Showing posts with label physician. Show all posts
Showing posts with label physician. Show all posts

Friday, May 30, 2014

Physician Abdication of Power



Background:

During the last two decades physicians have abdicated their role to CMS and payers fo policing each other. Resident physicians are closely supervised and gradually given more responsibility for decision making as they proceed from PGY 1-PGY4.  As a chief resident they are responsible for much of the activity of junior residents. Surgical and/or medical residents in certain specialties have their proposed surgical cases reviewed by either a chief resident, or director of the training program prior to scheduling.

During the first year of practice or if the MD change hospitals medical staff regulatons require providers to have a  proctor during a certain number of cases to insure proper judgment and  competence.

Following this period they are allowed to operate alone.  Further proctoring is usually not necessary unless there is a complication or a death. Usually this takes place in a departmental meeting for review. This often serves as a learning experience and is not a punitive affair. If the difficulties persist the physician will be required to obtain further training or more supervision until he demonstrates competence.  The entire process is physician led. It is private and confidential and not discoverable by non-physicians.

During the last two decades physicians have been lax in many regards, and have not required chart reviews prior to surgery nor review of treatment protocols unless there is an untoward event resulting in a morbidity or mortality and after the fact.

Current:

The review and authorization procedure now is conducted by insurers for prior authorization by a non-physician or a medical director for a payer.  This occurs away from the clinical setting when the physician submits the case  history, and proposed procedure.  The intensity of the review by CMS and payers is usually determined by the level of cost and number of procedures that are done.  The ultimate goal is not patient safety, nor quality of care. It is to reduce cost.  Their benchmark for what is reviewed is a simple algorithm.   #of cases X cost/case = total cost. Cases that are done in high volume, or high expense will require prior authorization. Such cases or diagnostics include Cataract removal, Hysterectomy, Spine surgery, Interventional cardiology. Many of these are surgical or advanced medical interventions. Many of the reviews are for expensive imaging, such as MRI or CT imaging.
There has been a gradual erosion of self determination and  pre-surgical review by physicians and surgeons, allowing CMS and payers to intrude into physician-patient relationshiphs.

Future:

Physicians will reclaim the role of ascertaining quality control and prevention of abuse and fraud by peer-review of  expensive and high volume procedures prior to procedures, both diagnostic and Invasive.  It will be required that all pre-surgical cases be reviewed by another member of the department prior to scheduling (except for emergent or urgent need.) The insurance company should not have any role in  prior authorization.  That will be the purview of medical staff, much like PQRI was performed in the late 1980s for cataract removal.  

This system will allow peer and case review for the medical staff and immediate feedback for non-compliant providers.

The insurance system will be simplified.   Delays and/or denials could be eliminated for review, authorization and payments.  Administrative expense could be reduced. This will require some additonal time and effort by physicians.  That is the price for professional freedoms.  Freedom takes effort to maintain.

Is this an idealized vision for the future, or will it come to pass?  Only you and I can decide.

The time has come to draw a red line in the sands of health care.





Tuesday, February 18, 2014

Doctors now Taking Payments from bitcoin


Some  say physicians are IT luddites, however there are some indications that a select few are examining other payments that border on bartering.  Bitcoin is bartering in the internet age, where privacy and security have bcome a thing of the past.



Bitcoin is a virtual currency which offers total privacy and anonymity in payments. Explaining how and why it works goes beyond the scope of my blog, other than to offer it's positive impact it may have in this time of health reform, and new business models such as concierge or direct payment models. It remains to be seen whether it is a 'fad' or will become an alternative form of payment, such as PAYPAL.

Lower transaction costs, increased privacy protections lead some practices to accept controversial e-currency.

But it's also getting strong positive attention, especially from Internet thought leaders, because the Bitcoin system, which depends on no centralized authority but rather a loosely affiliated community of techies, offers some key breakthroughs in the areas of information exchange – particularly between parties unknown to each other – and digital cryptography.

The legal status of this so-called cryptocurrency is in flux worldwide, as various policymakers, monetary bodies and tax agencies get up to speed on its true ramifications.

In the meantime, curious people can still educate themselves and explore this new payment alternative without fear and in relative safety. Doctors who have taken bitcoins have found that doing so is both simple and relatively "unmagical," as San Francisco physician Paul Abramson, MD, put it.

Abramson, founder of My Doctor Medical Group, is a former software programmer and trained electrical engineer with a significant personal interest in privacy.

Bitcoin will only be attractive to 'techies' for the time being. and there are caveats for users intent on the new system of bitcoin.

Bitcoin has been a subject of scrutiny due to ties with illicit activity. In 2013, the US FBIshut down the Silk Road online black market and seized 144,000 bitcoins worth US$28.5 million at the time.[9] The US is considered Bitcoin-friendly compared to other governments, however.[10] In China, new rules restrict bitcoin exchange for local currency,[11] and the European Banking Authority has warned that Bitcoin lacks consumer protections,[12] Bitcoins can be stolen, and chargebacks are impossible.[13]
Commercial use of Bitcoin, illicit or otherwise, is currently small compared to its use byspeculators, which has fueled price volatility.[14] Bitcoin as a form of payment for products and services has seen growth, however, and merchants have an incentive to accept the currency because transaction fees are lower than the 2–3% typically imposed by credit card processors.[15]

There are many unanswered questions about the new "currency"

Many bitcoin enthusiasts  are particularly excited about the existence of a relatively secure currency that is not controlled by a government or other central authority.

Rather, the Bitcoin system is managed by software and mathematical principles, and is made possible by a peer-to-peer network that shares the burden of tracking bitcoins to ensure nobody counterfeits any, or spends the same bitcoin twice.