HEALTH TRAIN EXPRESS Mission: To promulgate health education across the internet: Follow or subscribe to Health Train Express as well as Digital Health Space for all the updates for health policy, reform, public health issues. Health Train Express is published several times a week.Subscribe and receive an email alert each time it is published. Health Train Express has been published since 2006.
Bill Gates (former Microsoft CEO) announced a 10 billion dollar grant from the Bill and Melinda Gates Foundation for the development and distribution of vaccines to combat malaria. Vaccines against diarrhea, pneumonia and tuberculosis would save millions of children in developing world countries.
Mr Gates will go down in history as another Carnegie, Robert Woods Johnson, or Howard Hughes, Warren Buffet, George Soros, Li Ka- Shing.
One of my favorite bloggers is Placebo Journal.
This is borrowed from Dr. Douglas Farrago. Laugh on Dougie......Doug can be found on his own web site @ http://www.placebojournal.com/ I laugh so hard my liver starts to ache !! Doug is from Maine, so that explains much of his 'common cents".
Sound Familiar? by Michael Gorback MD
By noreply@blogger.com (Placebo Journal Blog: Medical Humor with a Purpose!)
I don't know how many of you have heard the new buzz about ACO's -
accountable cost organizations. If you have been following discussions
about Massachusetts health care you have seen this suggested.
ACOs are groups of doctors that receive a fixed amount of money and then
provide all of a patient's health care needs. I guess they figure they
can glue together a pediatrician, a heart surgeon, a dermatologist, etc
and make a cohesive group that provides one-stop shopping for all health
care needs. If the patient needs an MRI, the ACO pays for it. Hip
replacement, same thing. Labs, xrays, the whole deal. Kind of like an
insurance company, except now the doctors are the insurance company
without having any insurance company experience. We take in fixed
premiums and pay out benefits.
Does this sound like back to the future?This is basically capitation
revisited.
The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok
The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok
for everybody but doctors) they can control costs this way. After all,
you'll think twice before you rip out that kid's tonsils if you have to
pay for it. Considering deliberately mismanaging someone's diabetes so
you can get $50,000 for a BKA? Not if it comes out of your own hide.
I think it will succeed, because if you stop paying people to "do
things" they will pretty much stop doing things. In my specialty the
general goal for most of us is to get a patient's pain under control
with minimal reliance on pain meds. Some of these modalities are
expensive. A spinal cord stimulator lead costs $1500, and the battery
about 10x that. An intrathecal pump is about $10,000. These are hardware
prices. they don't include O.R., anesthesia, etc.
So here I am in my new ACO office and a patient comes in with horrible
pain from failed back surgery that has been refractory to just about
everything.
* I know a stim could potentially help a lot.
* However, I also know that if I go around putting $15-20,000 worth of
hardware into people my partners are not going to be happy.
* I also know that writing a prescription is far easier and much better
for my health than spending an hour in front of a c-arm wearing a lead
apron under hot lights. And I will make MORE money that way. Plus, you can't surf the Internet while scrubbed.
So what's going to happen? They gave me an incentive to not do things
and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in
and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in
some Phenergan for you. No wait -- that might drop your WBC. That means
paying for lab tests. Try some flat ginger ale. That's what my mother
gave me for a tummy ache. Excuse me, time to check my email.
This didn't work when it was called capitation. I don't see how it will
work this time, and I can't imagine how they plan to get doctors to join
into diversified groups without killing each other. Maybe it will be
assigned seating like high school. Maybe they have figured out how to
herd cats. Maybe the CIA has secret pheromones that will make us
cooperate like ants and bees.
I want to know what will happen when a patient hates the group's
endocrinologist and wants to go "out-of-ACO". Can you do that, or do you
send the doctor and the patient to counseling to work it out? What if
the cardiologist you want is in another group?
What if you are a very popular or famous doctor, in big demand? Can you
threaten to go to another ACO if they don't give you more money? Will
there be a draft for doctors coming out of residency? When can you
become a free agent?
The ACO's are also supposed to help "coordinate care". This is the new
buzz word. The old buzz word, "preventive care", turned out to be not so
good after the data showed that it actually costs more to do tests on asymptomatic people. Not to mention that a PAP smear or colonoscopy is not preventive so much as early detection. Smallpox vaccine is preventive. Tetanus shots are preventive. Colonoscopies find what's already there. Anyway, it's not like we have any control over whether or not you eat a large pepperoni pizza every night, washed down with a 6-pack of beer, and then a few relaxing smokes. Nor can we prevent gallstones, broken ankles, cerebral aneurysms
aneurysms
or about 99% of the things that afflict people even if they all live like Dean Ornish in an isolation bubble. Healthy diet, a good night's sleep, exercise, don't smoke, watch your weight, and get lung cancer like non-smoker-vegetarian-yoga-enthusiast-transcendental-meditation-teacher-and-successful-actor/comedian Andy Kaufman, dead at age 35.
Do they think this will be like Boston Legal, where all the partners sit
around a conference table and discuss each case? How many of us call our
colleagues after every visit to discuss the patient? "I'm sorry, Dr.
Futznagle can't come to the phone to discuss Mrs. Balderdash. He's
already on the phone talking to Dr. Squigglemeyer and then he has to
return a call from Dr. Fussypants. Can he call you back next week after
he finishes returning last week's calls?"
Even the Europeans aren't that stupid. To really screw things up you
need the United States Congress, which seems to think that reinventing
the wheel by making a square wheel with a broken axle is the way to
decrease gas consumption.
Yes indeed, that's one way to do it.
(figure 1): Short list of small ambulatory practices EHR.
I thought I would take a step back in time to when I was writing about EMRs, RHIOs and interoperability. The roots of this blog were in the Riverside Health Information Organization.
Time has evolved EMRs from a primitive form of data collection and storage to a more sophisticated form of data storage and collection.
EHRs now have had the benefit of time, and some longevity to develop and critique their short comings. The results thus far show the front runners in the great race to automate and interoperate. The above figure is from an "independent study" of Group One Health Source, sent to me in a private emailing by Andrea Biddle.
(figure 2) Short list of large ambulatory practices.
The differences in these two charts is small and probably represents the different markets that vendors have chosen to target with their offerings.
Health Train Express January 5 2009
In which direction are we headed? The WSJ reported that health care spending growth had diminished to 4.2% in 2008. the slowest rate of growth over the past forty-eight years.
Despite the slowdown, national health spending reached $2.3 trillion, or $7,681 per person, and the health care portion of gross domestic product (GDP) grew from 15.9 percent in 2007 to 16.2 percent in 2008. These developments reflect the general pattern that larger increases in the health spending share of GDP generally occur during or just after periods of economic recession.
This makes logical sense, since health needs never go into a recession….they continue no matter what the economy is. If the general economy outside of medicine contracts then health care expenses would represent a greater portion of the GDP. What is critical here is that for the first time in 48 years the growth rate diminished from near 16.2% to 4.2%. Let’s see how that sounds on CNN, MSNBC and/or FOX News.
It was a very nice quiet New Years on the Health Train Express. Fill in anchors on the networks and cable 24 hour media events, and less about healthcare.
Congress will be back in session very shortly and the fires will be stoked up.
A colleague of mine sent this to me. Common sense, common values, and a real friend to physicians.
Mike Huckabee (click to go to media)
If this doesn't warm your heart in this cold January week perhaps a raise in our reimbursements would. We are in a world of negative reward. We feel good if we stop the cuts, we think we have won a battle.
We all need to take the Mayo Clinic route. Give up Medicare.
Tomorrow I return to what I like most about medicine, Patient care. The rest of it is there supposedly to help me do that better. (not a reality)
A place where no man has gone before.
This might be a timely metaphor from Star Trek.
A 'crack in the wall' as a result of proposed health reform has already begun to form. As reported in the Arizona Republic, Bloomberg News, and The Health Care Blog, The well known and venerated name "MAYO CLINIC' in Glendale Arizona has announced that effective today, Januray 1, 2010 they will no longer accept Medicare for Primary care (formerly known as your family doctor). While this only affects five physicians at that facility, Medicare reimbursement for specialty care and hospitalization will continue to be accepted.
The amount patients will now have to pay for primary care will be about 1500 dollars/year.
Whether or not this is a 'trial balloon for Mayo will remain to be seen.
This does not apply to private or employer based insurance plans. It may also open a new market for private insurance plans to offer an option for primary care only coverage.
This of course radically affects the referrals to Mayo Clinic specialty care. It also shifts a considrable load to area doctors for primary care. It is not clear whether those patients who chose to go elsewhere will be able to be referred to Mayo for specialty care. Given the reputation of Mayo Clinic for "specialized care", this will probably be the case.
My head hurts. Maybe it's my hangover???
HAPPY NEW YEAR from Health Train.
gml
Arguments about the validity of Health 2.0 are moot. It is here!! Hundreds of thousands of patients and providers use the format in advocacy groups, using facebook, twitter, blogs, and search engines. Is Google a health 2.0 app?
The following story is well worth the read
THOUGHTS ON MEDICINE AND SOCIAL MEDIA (Regina Holliday)
On Wednesday, May 27, 2009 I met Dr. Ted Eytan. I was invited to present a patient and caregiver view of hospitalization at a small health 2.0 meeting. I saw Powerpoint presentations with bar charts and graphs. I sat patiently taking notes about the state of ehealth and social media. At around 3:15 I spoke. I described the horror of my husband being diagnosed with cancer and of terror of not being told what was going on. I spoke about the fight we had fought to get to get a copy of the medical record. I recounted the numerous times I had used the information in his record to improve his care. The record sat upon the table in a three inch thick binder. There was silence in the room. We were no longer speaking in the abstract about patients. They asked me to focus on what was the worst thing that had happened through this entire tragedy. I told them the worst thing we experienced was lack of access to my husband’s data.
We are hearing different reasons why we must pass this health reform bill. 1. There is a crisis and if we don't pass the bill, we will go bankrupt (things are unsustainable).
There are many hidden aspects to this bill, which is not being discussed in a transparent manner (which our esteemed President assured us.)"that things would be different in D.C. if he were elected"
2. If the bill is passed costs will go up as well, including increases in premiums of a significant amount to cover the new insured,, who were previously uninsurable, or excluded to due pre-existing conditions.
3. Additional taxes will go into effect several years before any benefits or changes will be made to coverage.
"Quick, pass the bill before anyone can read it and really understand the profound effect it will have not only on health care, but every business, and person who is insured. "What will be the ripple effect on health care costs, provider availability, and hospital survival?
THE PUBLIC OPTION
Let's think of some titles that will be more acceptable to the approximate 50% of voters who do not want a public option.
1. Alternative integrated universal choice for Health.
2..National Public Health, Inc. (NPH)
3. United Stated Federal Health Reserve USFR)
4. Federal Health Insurance Bank (FHIB)
5. U.S. Health Stimulus Choice (also known as USHC certified)
6. Federal United Care Combine (also known as FUCC) (sounds like Fuc@)
Or let's allow patients to 'Opt-out of the Public Option. This would be done on a state wide basis rather than as individuals. Depending on which state you live in. This great idea comes from those two Senators Reid and Pelosi who must smoke something for breakfast that is grown in the fields of either Afghanistan or Northern California.
Plans #1 through #4 could be funded by donations from patients who "care" for only pennies a day.
For those who want the public option....I hope you will like what you get...it won't be pretty. If you think you can't find swine flu now, when you need it, then consider that this is typical of any government program. The idea that the federal government is going to contract with private insurers copies what it does in most other areas of defense, manufacturing of medications such as vaccines (CDC), NASA, and others). They cannot do the job themselves, and contract it out to others who are either not supervised or unable to perform.
Our government easily promises what it cannot or will not deliver. The war on cancer, the war on drugs.
Yes, a a physician I know it is a disgusting fact that there are many uninsured needy patients who don't get health care. I also know that programs such as medicaid will pay for a surgery, but not the necessary post op physical therapy....why? Because the states are fearful that everyone on Medi-caid will run down and sign up for chiro-massage or manipulation. That philosophy runs rampant in most state and/or federal programs.
Government programs are always trying to make a brick float.
GML
Physicians no longer feel in charge for many things that occur during their daily clinical work. During our training years we are carefully monitored and have mentors who we can look to for advice, guidance and in some cases, even wisdom...For those in 'private practice' in a solo or small group practice 'autonomy' becomes a real issue, and blending this with the reality of patient care, risk, and medical politics becomes a narrow balance beam for most of us.
Health reform measures are a reflection of a conundrum. Will we be reformed from within, or without?? It is a mess. Even the informed, educated and well read can make little sense or aggregate the impact of the legislation presently being debated in congress. Driven solely by financial analysis the legislators pretend to develop a 'quality driven, consumer oriented health care policy', a real oxymoron in itself.
Kenneth Fisher, MD in his blog, Health Care Reform in America, states,
Dr Fisher and I are classmates and graudated from George Washington UniversitySchool of Medicine
"Indeed it takes more training to take care of seriously ill patients than to fly a jet liner. Yet it is inconceivable that a jet pilot when facing a problem, instead of using his experience and judgment, would have the passengers vote on what to do. However, unlike the pilot, in today’s medical practice it is common for physicians to place the task of medical judgment on the patient/family frequently resulting in irrational care. This often leads to patient suffering and the wasting of valuable resources.
This exaggerated sense of patient autonomy along with the fear of legal action has augmented medical consumerism. This problem has been enhanced by drug and device advertisements directly to the public and by the medical profession’s undue reliance on the legal system to decide what are, in effect, medical questions. Instead of our various medical societies forming referral mechanisms to help decide difficult issues, hospitals and doctors have abdicated this responsibility to the courts with the result being an ever-present fear of legal action.
It should be noted that till this day our medical societies have not answered this challenge. Again, in May, 1994 (New England Journal of Medicine) while discussing the Baby K court case, an encephalic baby with no chance of recovery, George J. Annas had a similar message. He commented that for medicine to avoid becoming a consumer commodity and thus unbearably expensive requiring control by payers, physicians will have to set standards and follow them. Again organized medicine did not and has not responded
A few weeks ago (November 2009) a talented second year resident told me that, in his opinion, American medicine is no longer about treating patients’ problems. It has become a hospitality industry focused on customer satisfaction regardless of the appropriateness of the medical plan.
For health care reform to be successful we have to insist that our medical societies set up procedures so that patients are treated as individuals, each with unique needs. At the same time mechanisms must be established so that we uniformly practice high quality medicine with evidence-based use of resources. We must have expanded peer review so that difficult situations and overuse can be quickly resolved using medical experts.
It Is obvious how the world of blogging.has displaced the coffee room and the water cooler as sources of inside information. In fact, blog sources are frequently the first place that relevant information appears.
In addition to classical newspaper and Journal sources these entities have their own blog section. Add to this, facebook, twitter, digg, my space and others yet to be determined the relationships become infinite.
Take for example, this posting on ‘Dr Wes’ blog:
On Dec. 3 the U.S. Senate voted to keep significant Medicare cuts in the health-care overhaul bill despite polls showing seniors are concerned about their benefits. Senators voted 50 to 42 to reject an amendment by Sen. John McCain, R-Ariz. that would have stripped more than $400 billion in Medicare cuts from the health-care bill. The measure would have sent the health-care bill back to the Finance Committee for redo
What this means for our seniors is Medicare benefits will be cut in important health-care programs. In my specialty, cardiology, this will mean draconian cuts to Medicare-dependent seniors in cardiology services.
The real deal is this”
A new survey of U.S. cardiologists indicates the following:
Practice effects
* 94 percent would be forced to reduce paid staff such as nurses and technologists.
* 80 percent would be forced to cut employee benefits.
* 67 percent would elect to retire earlier than planned.
* 59 percent would limit practice hours.
* 56 percent would be forced to sell their practice and merge with a local hospital.
* 45 percent would no longer perform imaging services such as nuclear stress testing or echocardiography.
* 25 percent would be forced to close their practices.
Patient effects
* 97 percent believe that Part B costs to Medicare will increase in their area because patients will have to receive imaging tests in the hospital setting where the Medicare reimbursement rate is significantly higher than under the Medicare Physician Fee Schedule (MPFS) for private practice.
* 92 percent believe patients’ co-pays will increase as much as 20 percent if they are forced to have imaging tests done in the hospital setting.
* 89 percent believe early detection of heart disease will be greatly reduced because of patients’ lack of access to cardiology procedure services.
* 76 percent would refer patients to the nearest hospital for imaging procedures.
* 79 percent believe current Medicare patients will no longer be able to have imaging done at private practice offices and would be forced to have imaging done only at the nearest hospital.
* 45 percent would no longer be able to accept Medicare patients.
With these cuts physicians may not be able to provide the services that patients have come to depend on and in the long run, if the current policies are not changed, cardiologists may be forced to close their doors to their patients.
The law is clear — our seniors will realize these cuts unless Congress acts. We all have seen the response to government studies which want to limit mammograms to women in their 40s. You have seen the outcry to this type of foolish rationing. The Senate just voted to reverse that ruling and provide mammograms through their insurance carriers.
These Medicare cuts are the first step in Medicare rationing of our seniors’ health care. We must stop these cuts to the Medicare system. Our seniors are living longer and in better health because of the Medicare system. We can keep current Medicare benefits if fraud and abuse are eliminated. There are good-practice guidelines which have been enacted by the specialties societies. Let us enforce these practices and let Medicare survive.
On the ‘street’ it looks very different from the view at 40,000 feet. Its about the same as President Obama receiving the Nobel Peace Prize.
Call and write to your senator today. Let him know how you his constituents feel about these proposed changes in health care.
Bottom line: The only way to get health costs down is when consumers are presented with a range of options in a truly competitive marketplace
*******************************************************
Another Observation:
Grace Marie Turner, The Galen Insitute, "More Nutty Ideas from the Senate," December 8
Two thousand seventy-four pages and trillions of dollars later, this bill doesn’t even meet the basic goal that the American people had in mind and what they thought this debate was all about: to lower costs.
Mitch McConnell, Senate Minority Leader, December 8, on Senate Health Care Bill
It’s beginning to look like health care consumers are going to have to take lowering health care into their own hands since no answers are coming down from above. "
My own thoughts on this matter (Health Train Express)
Add to the cost of insuring additional patients, the cost of the regulatory mechanism . We have already witnessed this with HMOs and Medicare Advantage. Add to this the costs of outcome analysis, preferred payment schedules for EMR usage, health information exchanges, etc and you will see that ‘savings’ are imaginary. Keep it simple, and accountable on the local level. "
Here are ten tips for lowering your costs.
One, encourage your employer to offer a health savings account with a high deductible. Encourage the employer to pay half the deductible. Your premiums will be much lower, and your employer will save up to 50% over current HMOs and PPOs.
Two, investigate a company called Simplecare. The SimpleCare story has appeared in U.S. News & World Report, in Forbes, and on NBC News. SimpleCare , a fee-for-service organization, accepts money for medical treatment without the bother and hassle of insurance forms, co-payments, and other third-party payment related procedures. SimpleCare has an alliance of doctors offering cash discounts. Itsmembership includes 38,000 patient members working with 1,500 doctors nationwide. Discounts range from 15 percent to 50 percent for patients paying in cash.
Three, ask your doctor if he or she accepts cash only. About 10 percent of doctors accept cash only. The idea is to pay for care at the time and point of care with cash, check, or credit card without the expense or trouble of going through an insurance company. Dealing with third parties creates a 50 percent to 60 percent overhead, and many doctors are finding they can charge less and make just as much or more money without going through a third party. Often the doctor’s fee is negotiable.
Four, find out if your doctor dispenses prescriptions in the office. Prescriptions dispensed in this way average 50 percent less. A company called Physicians Total Care has installed prescription systems in 30 states and is growing by 170 percent a year. For more information, google Physicians Total Care or read a chapter “Physician Office Dispensing Stages Comeback” in my book Innovation-Driven Health Care (Jones and Bartlett, 2007).
Five, fill your prescriptions at Walmart, Target, or discount stores. Walmart has more than 300 generic drugs and 1000 over-the-counter medications it sells at $4 for a 30 day supply and $10 for a 90 day supply. Fifty percent of Americans live within 5 miles of a Walmart or Target.
Six, ask your primary care physician if he or she performs common procedures like skin biopsies, abscess drainage, joint injections in the office. An organization called the National Procedures Institute (www.npinstitute.com) has trained over 15.000 primary care doctors to perform simple office procedures, and these can be done less expensively without waiting than in a surgeon or other specialist’s office.
Seven, consider visiting a retail clinic in drug store or discount outlet for minor ailments or immunizations. Nurse practitioners using protocols and electronic medical records run these clinics, which may have physician or hospital backups. The charges are listed are transparent and predictable. About 2000 of these clinics are now operating, and their locations may be found at conveniencecareassociation.com. The services of these clinics cost about half as much as a visit to a physician’s office but do not have a physician’s expertise and may miss serious underlying conditions.
Eight, if you work for a larger employer, ask executives if they are considering setting up worksite clinics. About half of the nation’s corporations with headquarters employing more than 100 employers on site are organizing these clinics, which offer the services of a primary care physician and staff, which may include a nurse, nutritionist, and other health professionals. Employees can receive free generic drugs and other treatments or advice on site, or may be referred to cost-effective networks of specialists off-site.
Nine, if you are uninsured or underinsured consider visiting a federally-qualified community health clinic. These were launched by President Bush as a Health Centers Initiative in 2002. These clinics, which are present in all 50 states, have 4000 locations and have served 15 million people. They are administered by Health Resources and Service Admistration (HRSA. Services include checkups when well, treatments when sick, complete pregnancy care, immunizations, dental, and mental care. To find a clinic near you, google HRSA – Find a Health Center.
Ten, in general low cost and convenient care is available at a local primary care physician. There is now a shortage of these physicians. Therefore, these physicians are now very busy, and you may have to wait for an appointment. Because of low reimbursements, some no longer accept new Medicare or Medicaid patients.
·
It becomes apparent that we should not expect ‘government ‘ to fix the problem . Initiatives from patients, employers and insurance companies are far better than throwing up our hands and relying on the government(s) to solve a problem that really has nothing to do with governing, or defending our country. It remains to be seen if patients,and employers can bring pressure to bear on insurers without governmental intervention and/or regulations.
Care for each other, your parents, your brothers and sisters, and relatives to the best of your abilities.
Bricks, Straw, or ? This is an interesting metaphor, and it may apply well to the current health debate.
Too big to fail? Health care reform, or Dubai?
Obama's 'glow" is diminishing, even amongst the 'faithful, and gullible.
Matt Holt and THCB quote"
There’s a big to-do about whether there are really any cost-saving measures in the House and Senate bill. Most people say that the answers are “no” and “sort of”.
But let’s not dwell on that. Instead let’s have some fun. Regular THCB readers will know that AHIP’s Karen Ignagni has told half-truth after half-truth after outright lie to protect the position of her members. All the while somehow holding together a coalition that really should have broken apart long ago (and may yet still do that). And she gets paid very well for that role.
But today in the WaPo she told the truth:"
Karen Ignagni, president of America's Health Insurance Plans, said the Senate bill includes only "pilot programs and timid steps" to reform the health-care delivery system, "given the scope of the cost challenge the nation faces." Unless lawmakers institute changes across the entire system, Ignagni said in a statement Wednesday, "Health costs will continue to weigh down the economy and place a crushing burden on employers and families."
