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SUSTAINABLE GROWTH RATE: FORMULA REPEALED AFTER 17 YRS

The Sustainable Growth Rate which was established in 1995 has been a 'trojan horse' lurking and waiting to strike each year at budget time. The SGR caused severe angst to providers and hospitals each year distracting health care providers with a ghost law.

HISTORY--Doc Fixes Began With "The Biggest Backroom Deal"

Congress created the SGR formula in 1997 to put the brakes on Medicare spending for physician services. The formula sets annual spending targets based partly on changes in the gross domestic product. If Medicare spending comes under the target, physician payment rates go up the following year. But if spending exceeds the target, rates are reduced to make up the difference.

The formula became a definite nemesis of organized medicine in 2002 when SGR math yielded a 4.8% pay cut. Another 4.8% dip followed in 2003, and on February 13 of that year, Congress enacted the first of its doc fixes, replacing the 4.8% cut with a 1.4% raise.

The first doc fix was a backwater provision in an omnibus appropriations bill that one lawmaker called the "biggest backroom deal" in the history of Congressional spending, according to the New York Times. It was a 338 to 83 vote in that House that day, 76 to 20 in the Senate.

The history of the SGR and it's real meaning became apparent this year.  The Sustainable Growth Rate was never mean to sustain growth, nor to be enforced. The SGR was designed to be used as pawn in the trade of eliminating the onerous clause  in return for approval of the Pay for Value rembursement system presently in development by CMS.

For years, organized medicine warned that a rate reduction on the magnitude of 21% would drive physicians out of Medicare and leave seniors in a lurch. Likewise, medical societies constantly chastised Congress for postponing past SGR-triggered pay cuts — kicking the can down the road, they called it — instead of repealing the formula outright. Such "doc fixes," in Congressional parlance, caused the cuts to accumulate into the monster that came to life on April 1.

Organized medicine now has its SGR victory, but not everyone is sanguine about the future of Medicare reimbursement. Last week, the chief actuary of CMS issued a report saying that under MACRA, annual Medicare raises for physicians would not keep pace with rising practice costs in the long run. By 2048, the gap between payments and practice expenses would be greater than if Congress had let the SGR formula take effect, according to the report.

Breaking News on April 14, 2015

Congress Repeals Medicare SGR Formula

After 17 previous Congressional holding actions going back to February 13, 2003, the Senate today clinched the approval of a bipartisan bill that finally repeals Medicare's sustainable growth rate (SGR) formula for physician compensation and averts a 21% pay cut this year.

The Senate vote was 92 to 8.

The House overwhelmingly approved the bill, called the Medicare Access and CHIP Reauthorization Act (MACRA), last month. Now the legislation goes to President Barack Obama, who has promised to sign it.  Buried within the law (H.R.2 - Medicare Access and CHIP Reauthorization Act of 2015) are many fine points about calculations, bundled care, and giving the Secretary of  HHS unbridled powers to determine physician and hospital fees.

The bill will freeze Medicare rates at pre-April levels through June, and then raise them 0.5% in the second half of the year. They will continue to increase 0.5% each year from 2016 through 2019. At the same time, MACRA will shift Medicare compensation from fee-for-service to pay-for-performance.

Add to this formula the effects of the Affordable Care Act

The IFTTT is the swap between SGR and conversion to a pay for value system of reimbursement.

The Secret to Physician Engagement? It's Not Better Pay

Lena J. Weiner, for HealthLeaders Media , March 7, 2014

It takes more than money for hospitals and health systems to motivate and retain employed physicians, says a senior executive at Catholic Health Initiatives.

More doctors are leaving private practice for positions in hospitals and health systems—and they report the new model of doing business looks promising. The benefits of being of an employed physician are anticipated to include "improved communication, greater transparency, better physician job satisfaction and a more patient-centered focus," says a survey by the American College of Physician Executives.

"It's the reality, and healthcare needs to accept this reality," said Peter B. Angood, MD, CEO of the ACPE. "Everything is moving in the direction where physicians want to be employees…I'm not a zealot of it, but it's a phenomenon that's happening, and we need to embrace it."

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Intelligence Report: Physician Alignment in the New Shared Risk Environment

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A 20-question survey sent to 10,000 members of the ACPE was completed by 617 respondents. Of those, 59 percent said that at least 50 percent of the physicians in their healthcare organization were directly employed—and 18 percent of the respondents said all physicians in their organization were directly employed.

Not Like the 1990sThis isn't the first time the healthcare industry has trended away from private practice and toward hospital-employed physicians. In the early 1990's, physicians began flocking to healthcare organizations as a part of the Managed Care trend, which later fizzled out amidst a consumer backlash citing decreased quality of care and allegations of withholding necessary medical procedures to cut costs.

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See Also: Don't Underestimate Emotional Intelligence

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Angood says the current push toward employed physicians is different. "It seems both the physician workforce as well as healthcare systems are committed to not having the same issues pop up as did in the early 1990's," he said, adding that many of this generation's physicians are happy to take advantage of focusing on treating patients and to take advantage of the improved work-life balance that working for a hospital or other organization offers.

"It's getting harder and harder to manage your own practice. Smaller groups don't have the capital, and banks don't want to lend money for these things," T. Clifford Deveny, MD, Senior Vice President, Physician Services and Clinical Integration at Catholic Health Initiatives, said.

In addition to freeing themselves of duties related to finances, marketing, and other administrative physicians frequently find benefits packages in large organizations superior to anything they could obtain in private practice, with traditional benefits such as paid time off, competitive health insurance and retirement savings programs, and in some instances, "boutique" benefits such pet health insurance or concierge services.

Tradeoffs
"Traditionally, a physician is trained to be an independent thinker and do what they think is best, but integrated systems are there for the benefit of the patient, not the practitioner," Deveny said. "I've always been cautious to say whether employing physicians will improve their jobs."

Deveny also expressed concerns about physicians feeling like they were simply a cog in a machine, rather than a doctor actually treating patients. "When the IT guy or finance person doesn't meet your needs, you get frustrated," he commented. 

The Changing Health Care World: Trends To Watch In 2014

Susan DeVore

February 10, 2014

While today’s news is bombarding us with headlines about Healthcare.gov, the Affordable Care Act isn’t just about insurance coverage. The legislation is also about transforming the way health care is provided.  Consequently, it has ushered in new competitors, services and business practices, which are in turn generating substantial industry shifts that affect all players along health care’s value chain. Following are some of the top trends that our alliance is preparing for in 2014:

Chronic Care, Everywhere. It’s no secret that providers are moving quickly to implement accountable care organizations (ACOs). Recently, the Premier healthcare alliance released a survey of hospital executives projecting that ACO participation will nearly double in 2014. As providers work to improve their way to shared savings payments, look for a more intensive focus on the biggest health care consumers: those with multiple chronic conditions.

Since each chronic condition increases costs by a factor of three, managing this population is the sweet spot for the ACO, and the deepest pool from which to pull savings. To do it, an increasing number of providers will deploy Ambulatory Intensive Care Units (A-ICUs) or patient centered medical homes as part of their ACO, which will be charged with better managing chronic conditions exclusively within a clinically integrated, financially accountable primary care practice. As part of the approach, providers will develop care pathways for better managing chronic conditions and behavioral health needs, with an eye toward lowering hospital utilization, including inpatient bed days, length of stay, admissions, readmissions, and ED visits.

Put Me In, Coach. As an outgrowth of the need to manage chronic conditions, we expect new forms of health care employment in 2014. For instance, early adopters of the A-ICU care model report that their biggest asset in the effort to manage chronic conditions isn’t a nurse or a doctor, it’s a health coach.

Health coaches function like a personal trainer in a gym; they’re there to motivate, challenge, inspire, and listen. They complement medical professionals providing care; they get to know the patient one-on-one and keep clinical staff apprised of issues that wouldn’t come up in a doctor’s appointment, including financial struggles, problems with housing, family concerns, or any other obstacle that could stand in the way of someone following a prescribed care plan. And because the position does not necessarily require a medical degree, health coaches can be drawn from a diversity of settings.

Health Care at Home. We may have thought the days of the house call were over, but increasingly, they are coming back into fashion. Marketing firm BCC Research predicts that the market for remote monitoring and telemedicine applications will double from $11.6 billion in 2011 to about $27.3 billion in 2016. Much of the interest is being fueled by the people expected to become insured through the Affordable Care Act, a surge of new consumers that our system simply can’t treat in person.

Also driving the growth is the need to make care more convenient, particularly for those with chronic conditions, so patients can be monitored and coached to health anytime, anywhere. And there’s a cost component to the trend as well. “Hospital at Home,” a program designed by Johns Hopkins that provides acute care services in the homes of patients who might otherwise be hospitalized, has been demonstrated to increase the quality of care patients receive, improve their satisfaction, and reduce costs by at least 30 percent.

Last, technology-enabled at-home health care is increasingly solving an access issue for patients. According to a recent survey, almost half of rural hospitals use virtual care or telemedicine to connect with patients who may be too far away for an in-person visit, allowing them to close the gaps in care that arise due to geography.

On-the-Job Health. If you don’t already work for a company that offers incentives for healthy behaviors or penalties for non-compliance, that’s likely to change in 2014. This trend is being driven by two forces, both spurred by the ACA: the ability for employers to increase the dollar value of wellness incentives from 20 to 30 percent of total coverage, and increased private insurance costs.

When considering the wellness incentives, employers are responding with both free health tools and financial incentives. On the tools front, this can include free pedometers or FitBits to monitor activity, or free subscriptions to wellness web sites such as iFit or HealthyRoads. In terms of incentives, these can take a variety of forms, too. Whole Foods, for instance, offers its healthiest employees deeper store discounts. Others provide gift cards or extra paid days off for wellness behaviors such as joining a gym or participating in health screenings.

To address the cost issues, employers are addressing lifestyle choices that lead to higher health care consumption and corresponding costs, including tobacco use and obesity. Some employers, including Alaska Airlines and Hollywood Casinos, have hiring bans for employees who test positive for nicotine use. Others charge higher premiums or impose financial penalties for employees that fail to meet minimum health standards, such as a 40-inch or less waist circumference or a body mass index under 35.

Changes in the Exchanges. Insurance exchanges aren’t just for the public markets. In fact, a growing number of employers are considering comparable, private exchanges for their employees. Private exchanges allow employers to contract with a benefits provider offering hundreds of competitive health plans from dozens of insurers. Individuals are given a defined contribution from their employer to purchase coverage, allowing them to select the form their benefits will take, including the amount devoted to health, dental, vision, life or disability insurance, as well as the risk they accept via co-pays and deductibles.

Our expectation is that private exchanges will continue to grow in popularity in 2014, as they give employees an opportunity to customize coverage and provide a predictable amount of spend for the employer.

War of the Words. Mid-term elections will have politicians out in full force trying to re-prosecute the case on health reform. But anyone anticipating big changes to the ACA before 2017 will be disappointed; although the bellyaching will be at fever pitch, there will be no viable pathway to repeal and replace the law this year.

However, there will be opportunities for health policy changes this year. A few areas we see getting traction include a permanent fix to the sustainable growth rate (SGR) method for calculating physician payments. There is an SGR fix on the table, and members of Congress could come to a compromise on the path forward, complete with “pay fors” to fund it, by March. A permanent SGR fix will put physicians on the value-based purchasing (VBP) track that hospitals adopted years ago, with a significant portion of their income tied to quality and cost improvement, as well as incentives to pursue alternative models such as bundled payment and shared savings.

Along with SGR, we expect to see CMS adjust their two-midnight rule (which has already been further delayed until after September 30). This would help ensure that medical decision making is left in the hands of the physicians and not an arbitrary timetable. And we expect there could be changes to the hospital-acquired conditions (HAC) policy, which today penalizes hospitals up to three times for the same conditions. Ultimately, we believe CMS will recognize this policy is in effect arbitrary and unfair and replace it by moving HACs into the VBP program.

Data Liberation. The big buzz in health care is Big Data. From electronic health records to clinical measures and decision support tools, providers are inundated with new technologies that enable them to automate processes and capture new types of clinical data. However, these systems are limited in their potential because they don’t “talk” to one another; they’re the equivalent of an email system that only allows you to send messages to people in your own company, or a phone plan that only allows you to make calls in your house.

As long as data remains captive behind proprietary walls, we won’t be able to unlock its true potential. Inherent in the Big Data revolution of 2014 will likely be a provider-led push to liberate data by making application programming interfaces open source tools that developers can use to design creative, new applications that make use of all the data, and turn it into something providers can truly leverage. It’s sort of the iPhone approach to health care technology — Apple owns the operating system, but anyone can design an app that leverages it to deliver programs and services that the user truly values.

Recognizing the trend, some EHR vendors and insurers are making more systems open for innovation. But industry players can look for 2014 to be the year that the push for transparent data assets reaches a boiling point.

Partners R Us. We’ve already started to see unusual partnerships across health care designed to deliver care in new ways. Some of the more interesting moves in 2013 involved drug chains partnering with physician groups to create ACOs based around retail clinics. But in 2014, look for the trend to include community-based groups, including social service agencies, area gyms, and other non-health care service providers.

To give an example, Mount Sinai Hospital in Chicago serves a highly indigent population, where the poorest residents have a diabetes rate that is three times the national average.  There, Sinai partnered with a local grocery store to offer healthy food and classes on how to prepare it. Encouraged by the success they had working with 300 patients, Sinai expanded the program to local schools, day-camps, and youth programs.

As more providers look to provide “whole person care,” we expect many more of these kinds of unconventional approaches, and anticipate more formal arrangements with community churches to provide group care sessions, nature centers to provide outdoor exercise opportunities, taxi services to provide free or reduced price health care transportation services, and many more.

Patients to Have Right to Access Lab Test Result Data

Patients to Have Right to Access Lab Test Result Data

The lab test result data access rule is finally final.

See the HHS presser and the final rule, which is scheduled to be published on Thursday.

What does this mean? In a nutshell, patients in all 50 states are now guaranteed the right to access the results of tests conducted by freestanding labs. (The right to test results from labs within hospitals, other health care facilities and physician offices has already been in place under HIPAA, and a handful of states have already guaranteed direct patient access to freestanding lab test results.) The compliance date for the rule is eight months out, in early October, in order to give labs time to put necessary processes into place.

What exact changes were made to the regs? This was a surgical strike. The Clinical Laboratory Improvement Amendments (CLIA) regulations were revised to permit labs to provide results to patients, and the HIPAA regulations were revised to eliminate lab test results from the (very short) list of records not covered by HIPAA's patient access rule. Thus, if a patient asks, CLIA permits and HIPAA requires that a lab provide the results.

Is this significant? Yes, it is. This is a notable development because it was prompted not by legislation (the usual culprit when it comes to regulatory revisions) but by persistence on the part of patient advocacy groups and evolution in thinking within government. The final regulation has been a long time coming. It was originally published as a proposed rule more than two years ago. While it has been supported by many interested parties, including the Society for Participatory Medicine, there was significant opposition to the rule from organized medicine on the grounds that unmediated information could be misinterpreted by patients and could otherwise be problematic. The rule was held up in the final stage of review -- at OMB, which reviews the projected cost burden of proposed regulations -- for five months (that's at least 2-3 months longer than expected).

Under HIPAA, health care providers have up to 30 days to respond to patient requests for health care records, and freestanding labs will now join imaging centers, physician offices, hospitals, clinics and other providers in complying with this requirement. Labs, like other providers, may charge patients for the cost of providing records. Given the 30-day response period, there should be plenty of time for physicians to contact patients directly about potentially worrisome test results. Since most, if not all, of the data at issue here will be stored and transmitted electronically, it is possible -- and perhaps even likely -- that many test results will be transmitted to patients in less than 30 days.

Some of the health care organizations that already facilitate delivery of this sort of information do it automatically and electronically. That's the vision of the future for the engaged patient: frictionless sharing of information. Coming soon to a lab near you.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

A version of this post first appeared on e-patients.net, the blog of the Society for Participatory Medicine. David Harlow chairs the Society's Public Policy Committee.

Barefoot Doctors of China

Barefoot doctors (Chinese: 赤脚医生; pinyin: chìjiǎo yīshēng) are farmers who received minimal basic medical and paramedical training and worked in rural villages in the People's Republic of China. Their purpose was to bring health care to rural areas where urban-trained doctors would not settle. They promoted basic hygiene,preventive health care, and family planning and treated common illnesses. The name comes from southern farmers, who would often work barefoot in the rice paddies.

Lessons from the East

At first glance, China might seem unlikely to offer useful health care lessons to many other countries. Its health system exists within a unique geopolitical context: a country of more than 1.3 billion people, occupying a huge, diverse landmass, living under authoritarian single-party rule, and making an extraordinarily rapid transition from a Third-World to a First-World economy.

But first impressions can be misleading. Since its birth in 1949, the People's Republic of China has undertaken a series of remarkable health system experiments that are instructive at many levels. One of the most interesting lessons from the Chinese experience concerns the value of an institution that many countries take for granted: medical professionalism.

Because the changes in China's health care system have been so rapid and profound, it is helpful to briefly review its recent history.1 What might be seen as the first of four phases began when the Chinese Communist Party took power in 1949. The new government created a health system similar to those of other communist states such as the Soviet Union and its Eastern European allies. The government owned and operated all health care facilities and employed the health care workforce. No health insurance was necessary, because services were nearly free. A distinctive accomplishment of this phase was the system's successful use of community health workers, so-called barefoot doctors, to provide basic public and personal health services at the village level. Between 1952 and 1982, China's infant mortality rate fell from 200 to 34 per 1000 live births, and age-old scourges such as schistosomiasis were largely eliminated.2

In 1984, a second phase began: China turned its health system on its head, almost as an afterthought to dramatic free-market reforms in the rest of its economy. Led by Communist Party leader Deng Xiaoping, China converted to a market economy and reduced the role of government in all economic and social sectors, including health care. Government funding of hospitals dropped dramatically, and many health care professionals, including barefoot doctors, lost their public subsidy. The government continued to own hospitals but exerted little control over the behavior of health care organizations, which acted like for-profit entities in a mostly unregulated market. Many health care workers became private entrepreneurs. Physicians working for hospitals received hefty bonuses for increasing hospital profits.

As they responded to these new economic imperatives, Chinese physicians had little history or tradition of professionalism or independent professional societies to draw on. China had transitioned from a society organized according to Confucian principles (which did not envision the existence of a modern, independent profession such as medicine) to a communist country (in which clinicians were state employees owing their primary allegiance to the Communist Party) to a quasi-market environment. At no point along this journey did physicians have the opportunity or support to develop the norms and standards of medical professionalism or the independent civic organizations that could promote and enforce them. Indeed, the Chinese language has no word for “professionalism” in the Western sense.

To make China's experiment with free-market health care even more dramatic, the Chinese reforms left the vast majority of the population uninsured, since the government did not provide coverage and no private insurance industry existed. As of 1999, a total of 49% of urban Chinese had health insurance, mostly through government and state enterprises, but only 7% of the 900 million rural Chinese had any coverage.2 Thus, a population largely unprotected against the cost of illness confronted a health care delivery system intent on economic survival and a health-professional workforce that had never had the opportunity to develop as independent professionals. Indeed, prevailing new economic rules and incentives strongly encouraged physicians to operate like entrepreneurs in a capitalist economy.

The government kept its hand in one major aspect of health care: pricing. Presumably to ensure access to basic care, it limited the prices charged for certain services, such as physicians' and nurses' time. However, it allowed much more generous prices for drugs and technical services, such as advanced imaging. The predictable result: hospitals and health care professionals greatly increased their use of drugs and high-end technical services, driving up costs of care, compromising quality, and reducing access for an uninsured citizenry.

By the late 1990s, this market-reform experiment had resulted in public anger and distrust toward health care institutions and professionals, and even in widespread physical attacks on physicians. Discontent with lack of access to health care fueled public protests, especially in less affluent rural areas, that threatened social stability and the political control of the Communist Party.

Recent events:

In 2003, a third phase began, when the Chinese government took a first step toward mitigating popular discontent with health care by introducing a modest health insurance scheme covering some hospital expenses for rural residents. The focus on hospital care reflected the fact that hospital services were expensive and therefore drove many patients into poverty.

But this hospital orientation also reflected limitations in the leadership's understanding of the critical role that competent primary care plays in managing health and disease and controlling the costs of care. Chinese authorities were also preoccupied with relieving the financial burden created by much more expensive hospital services. Not surprisingly, the 2003 reforms proved insufficient to ameliorate China's deep-seated health care problems.

By 2008, China's leaders had concluded that major reforms in both insurance and the delivery system were necessary to shore up the system and ensure social stability. In a fourth and ongoing phase of evolution, they officially abandoned the experiment with a health care system based predominantly on market principles and committed to providing affordable basic health care for all Chinese people by 2020. By 2012, a government-subsidized insurance system provided 95% of the population with modest but comprehensive health
coverage 

Selected Characteristics of the Health Care System and Health Outcomes in China. and case histories; to compare this country with others, see the interactive graphic).3 China also launched an effort to create a primary care system, including an extensive nationwide network of clinics.3

Though China's extensive 2008 reforms are still in process, a number of problems, mostly concerning tertiary hospital care, continue to challenge its leadership. First, many of the country's publicly owned but profit-driven tertiary hospitals successfully resisted the latest reform efforts — a reality that probably reflects the hospitals' power within China's political system. As a result, frustrated authorities sought to use market forces once again to bring the hospital sector into line. In 2012, the leadership announced that they would invite private investors to own up to 20% of China's hospitals by 2015, double the preexisting rate.4

Second, major inequities continue between the health care available in poor rural areas and that in more affluent cities.5 Third, China continues to struggle with creating a high-quality, trusted, professionalized physician workforce. One legacy of China's market experiment is a widespread perception that physicians put their economic welfare ahead of patients' interests.

Though China's health care system is still rapidly evolving, several potentially useful lessons emerge from its recent history. The first is that in low-income countries, and perhaps high-income ones as well, community health workers such as China's barefoot doctors can significantly improve the health status of local populations.

Second, relying largely on markets to fund and distribute health services creates risks that need careful consideration. Though government price setting created market distortions, these do not fully explain the problems with quality, access, and cost that China experienced in the second phase of its recent history. Health care is subject to serious market failures. Asymmetries in information between patients and health care providers make it difficult for patients to make sound choices in free health care markets, and patients' lesser knowledge may be exploited by clinicians. Patients' resulting vulnerability, resentment, and distrust can be socially destabilizing — and may intensify when patients are heavily exposed to the costs of care, as they were until recently in China.

Third, physician professionalism may be underappreciated as a foundation for effective modern health care systems. The inculcation of professional norms during and after training and the existence of professional institutions that reinforce these norms certainly do not guarantee that professionals will act only in the interest of their patients and the public. But there seems little question that the lack of a widely shared tradition of professionalism has complicated China's efforts to create a health care workforce that its leaders and the public trust to do the right thing.

Is any of this relevant given the current state of health reform in t he United States.?....Probably not since east-west cultural differences formed the basic foundations of each system.

Why Google Could Punish Your Healthcare Website on April 21st - Howard J. Luks, MD

Why Google Could Punish Your Healthcare Website on April 21st - Howard J. Luks, MD

The Quantified Self and Patient- Centered Medicine

Ali Khan, MD, MPP is a clinician-innovator at Iora Health and a clinical instructor of medicine at Yale. He currently serves as the chair of the American College of Physicians’ National Council of Resident/Fellow Members. Leah Marcotte, MD is a senior medicine resident at the University of Washington. As a medical student at Penn, she served as a fellow at the Office of the National Coordinator for Health Information Technology. Among her varied policy pursuits, she serves as an associate editor for the journal Health Care. In a recent article ALI KHAN, MD and LEAH MARCOTTE, MD discuss Ezekial Emanuel' pronouncement that the annual physical examination is worthless. (worthless for what and to whom ?) The Wellness Revolt What Zeke Missed on the Annual Physical Are we being reduced to a series bits and bytes ? Can patients be distilled into a series of numbers, or symbols wnich requires a huge overlay of technology? Can human beings be defined and judged by electronic devices, computers and sensors ? The wave of HIT, mobile health,and health data exchanges bring this question to the forefront. It's not a new question, however one that is bold-faced by current events, cost, and still questionable value. We have been using bits/bytes for several decades with MRI, Ultrasound,ekg,pacemakers, implantable devices and sensors. Without these things we could not be delivering high quality care as we do now. Note that physicians definition of quality has nothing to do with length of stay, nor readmission to hospitals. Zeke,(Ezekial EmanuelM.D.) as he is called, one of the country’s foremost health experts threw a presumptive grenade into the national discourse: "the annual physical is worthless". As we watched the initial burst of reactionary fervor following his New York Times opinion piece, we weren’t quite sure what to think. Dr. Emanuel who is respected speaks from a far away place, somewhere between the NIH (National Institutes of Health and other well known Institutions. My comments are not related to the high) esteem in which I hold "Zeke" He is a welcome additon and possible heir to the ideas of another bio-ethicist, Dr Arthur Kaplan N.D. Then we realized why: in our training and burgeoning careers in primary care, neither of us has ever scheduled an “annual physical” for a patient. To us, the notion of such a visit – for scheduled, non-urgent care, and one not specifically for chronic disease management – is already dated. Given current trends in American health care delivery and professional training, we argue it is one that may well soon be obsolete. Many physicians would argue that opinion. But does that obsolescence change the value of that time – whether 15 minutes or 60 – with a patient, on a regular interval? Our perspective from medicine’s emerging front line offers a resounding no. Furthermore the indications for annual exams should be based upon diagnoses of the individual patient. One cannot extrapolate the necessity for annual physical examinations without a frame of reference. The most obvious argument for regular primary care visits is preventive care. Dr. Emanuel bases much of his argument on the validity (or lack thereof) of annual physicals. Drawing off that same evidence base, the U.S. Preventive Services Task Force sets recommendations for evidence-based screening in various populations. Even the young and healthy benefit from cervical cancer screening, initiated at 21 years of age and continued every three years provided negative results until the age of 30 (when the recommendations change slightly). Patients with higher risk earn further screenings, based on whether they smoke, their weight, their age and their family history.

Healthcare by Schmucks

There must be some intelligent people in government. They are hard to find,and if they rise to the top it is not infrequent they will last perhaps one term or even one year. When one is promoted to a position above the glass ceiling it is at first a rush to have been elevated to a place where you are seen,sometimes listened to maybe respected, and an easy target for those who think they know better about leading. It is not unique to healthcare. Only 17% of physicians are in solo private practice. What this means is a loss of economic freedom, the loss of integrity and honesty as an individual. Perhaps physicians are really not so unique as I once thought. Admittedly this was a primary reason for my entering the field of medicine. My other reasons are buried somewhere in a space where my MRI shows that my brain has shrunk. My physician (neurologist) showed me the MRI The ventricles were slightly enlarged, but the condition is 'stable' (what condition ?) Imagine that ! A former ophthalmologist with a shrunken brain). Perhaps I can use that as a marketing tool. "Lasik Surgery by a former pioneer and early user of Lasik" A one year special for $--.00/ Prices subject to change and we don't guarrantee results. 50,000 cases. All proceeds to go to the Alzheimer Foundation. My former patients took some solace in having a surgery by laser. It must be better...it's not surgery. It does not take much physical skill to perform lasik other than to affix several robotic tools which make the laser cuts according to a pre-determined algorithm. The skill and over-riding is judgment honed, and carved out from years of experience, a qualitative measure almost impossible to measure metric other than the length of a career. Perhaps it can be measured by the amount of brain shrinkage as indicated by an MRI. I digress, which is often the case discussing things not relevant to the theme of my paper. Back to health care by schmucks ( I love that word. I don't think it can truly be translated, summing up many people who are highly educated, trained and just don't quite get it.) They often are elected to positions of high esteem and leadership. Personally I have found in my career a certain resistance to following many of them. Perhaps it is my lack of respect for authority, a bit like my feelings for the IRS. They just don't get it, and they are led by Congress, and whoever is sleeping in the Lincoln bedroom, or in the bathroom of the oval office. No matter, usually they move on to a 'highly respected group of foundations (all non-profit, of course), such as the IOM, AHRQ, the Institute for Quality Improvement, and others. All of this brings me to the topic of today's article by Richard Amerling M.D. He is the current leader of the AMA. This position supposedly represents most or all of physicians. I don't know him personally, but he is trying to do a good job. Unfortunately Dr. Amerling does not represent any majority of U.S. physicians. I am sure he goes to sleep every nite tossing and turning thinking how truly powerless he is against HHS, CMS, the SGR and an alphabet soup of 'authorities'. Poor Richard (sorry,Dr. Amerland no disrespect intended) There seems to be no other way, so we live with compromise, the story of life, except perhaps for the Ayotollahs and those who cannot think for themselves a skill rarely taught in school these days. The article in the AMA has caused my brain to shrink even more. It is time to have a followup MRI for which I will wait two weeks to do, and then another two weeks to have a result, all while knowing that my brain is either shrinking or over-inflating with fluids. (does anyone need a spinal fluid infusion or replacement) I am willing to donate my spinal fluid for free, tested for STDs, Prions, and other infectious diseases. I cannot promise that you wont get Alheimer's or suffer the same process I seem to be going through now. I have had an epiphany about aging. I am surprised it took me this long. I have treated thousand of people over the age of 65 and I had no idea of what they were experiencing. After all they and I use denial to survive. It has taken me ten years to realize what I am experiencing. My spouse, who was an R.N. and 7 years younger than I am seems to know the story of aging. In my next article I will venture into what my cognitive powers have rendered. Scientific description with vocabulary that most people do not understand whether young, educated or not is not adequate to the task. It is a bit like watching black and white TV, never having seen color TV (that should summarize how old I am. My earliest recollection of TV is Howdy Doody and Dave Garroway. No one was capable of taking over NBC and they are still at the helm or Dave is directing NBC from wherever he may be. I would look at my elderly patients and observe forgetfulness in some, missing appointments, not complying with medication instructions and being unable to remember what they had for breakfast. My neurologist gave me a short mental status examination. ie, count backwards by 7s from one hundred while standing on one foot, or on my head. Who is the President of the U.S now. My answer was 'No one' My answer resulted in his retiring the next week,and he is ten years younger than I am. Sorry Dr. F, I meant no disrespect. i have known Dr. F all my career, and he has an excellent reputation, even if he works for a competing multi-specialty group. Damn I wish I had gone into that group when I came to town. But no I wanted to own my own practice and prove that I was 'better'. . I guess that makes me the 'ultimate schmuck' I did not mean it as a joke, however I will contribute that to the new man at the helm for Jim Colbert. However after blurting out what I thought was an original thought and now I realie just how funny it was. They say that great comedians are fast on their feet, a bit like Robin Williams R.I.P., Steve Martin, Jackie Gleason and Bob Hope R.I.P. If you are still with me and have not sucumbed to internet inattention by jumping to another site I will reward you with fact from those who I think may be schmucks but know their 'stuff' (no disrespect to my esteemed colleague Dr. Amerling, who I know would think the same things. That is what is so good about physicians, it' the 'elevator or doctor's lounge talk. That is, if it has not been turned into an administrator's office to crunch numbers to save money. I do miss those hospital sponsored lunches with filet mignon, lobster, fine wine, ice creams with fudge before going back to my office in a state of euphoria, refreshed, somewhat somonolent and content with my plight. Missing From the Debate Over The Medicare Sustainable Growth Rate: Sanity Click here to read online and comment. A popular definition of insanity---doing the same thing over and over and expecting a different result---could well be applied to the Sustainable Growth Rate. Understanding the origins of this failed policy is highly instructive as to the effects of government price controls in the Medicare system. Costs within the Medicare system started to rise faster than predicted as soon as the program was instituted. This should have come as no surprise. Millions of seniors were handed an entitlement to medical services, which of course increased the demand for these services. Physicians were allowed to charge their “usual, customary, and reasonable” rates and did so. Concern over rising costs led to various responses from the Health Care Financing Administration (HCFA, the bureaucratic precursor of the Center for Medicare and Medicaid Services), to rein in spending. These mostly took the form of price controls on physicians’ services. On its face, this is stupid policy, as payments to doctors were between 10 and 15% of total program spending. Cuts in this sector couldn’t reasonably be expected to produce much in the way of savings. And of course, going back to the dawn of civilization, price controls have never worked and have more often than not been disastrous. In 1983, HCFA began a fee freeze on Medicare payments to doctors. This was extended through 1986. Total Medicare spending increased dramatically during this period. Why? Doctors, to maintain income, increased the volume of services provided. The more patients seen, the more tests, prescriptions, consultations, and hospitalizations occur. Limiting the payment for an office visit invariably leads to less time per patient encounter. This must result in loss of quality. In 1989, HCFA moved away from paying doctors based on their UCR charges to the Resource Based Relative Value System, a socialistic construct that assigned dollar amounts to the myriad services provided by doctors. Balance billing of wealthier patients (not all seniors are poor) was severely restricted. Non-participating physicians could only charge a bit over the Medicare “maximum allowable charge.” Since they were also penalized with a lower payment rate, this increased the physician Medicare participation rate. The net result was another big pay cut to physicians, which was again followed by a major increase in total Medicare spending. It also brought larger numbers of doctors into the Medicare system, where they became highly sensitized to the dictated pricing. In 1997, the Medicare Modernization Act introduced the SGR. The idea was to base Medicare physician fees on total program performance the prior year. If total Medicare spending were above a certain target, payments to physicians would be frozen or cut in the current year. But pay cuts to doctors predictably cause total spending to increase. The Medicare Payment Advisory Commission (MedPac) recently reported that from 2002-2012 Medicare spending on physician services per beneficiary increased by 72%. A 9% increase in rates during this period was dwarfed by the growth in volume of physician services, including lab tests (91% increase), imaging (79% increase), and other procedures (up 68%). If SGR doctor pay cuts had been allowed to take place, doctors would now be getting paid pennies to see Medicare patients! This would have forced many doctors out of Medicare completely, creating a shortage (the legacy of most price controls). The SGR meets the definition of insanity. As it is, the net effect of pay cuts and freezes has been to force many physicians out of private practice, and into hospital systems, where costs are much greater. From 2002-2012, Medicare fee-for-service rates increased 9%, while the cost of operating a practice increased 27%. What’s the solution? The bill just passed by the House of Representatives and awaiting Senate action does away with the SGR, but enshrines Medicare price controls and an arbitrary update formula guaranteed to be substandard. It also furthers the push away from fee-for-service payment in favor of newer forms of managed care, such as the Accountable Care Organization. These, despite the bells and whistles, are doomed to fail. Since much of the current Medicare disaster can be traced directly to the effect of price controls, and direct payment of doctors through mandatory assignment, we should do away with these. Congress should insist that Medicare physician payments go through patients, and restore to physicians the right to balance bill. This would include being able to provide care for free to a truly indigent beneficiary (a practice that is now illegal). This would stem the flow of doctors exiting Medicare, and private practice, improve quality of care, and empower patients. Payments to physicians would likely remain flat, as volume of services would immediately decline. And this would moderate total program spending. Richard Amerling, MD (New York City) is an Associate Professor of Clinical Medicine and an academic nephrologist at Mount Sinai Beth Israel in New York. Dr. Amerling received an MD from the Catholic University of Louvain in 1981. He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania. He has written and lectured extensively on health care issues and is President of the Association of American Physicians and Surgeons. Dr. Amerling is the author of the Physicians' Declaration of Independence and is a seasoned speaker and on-air contributor.

Pain Managment ? The Role of Nutrition

Hoping to avoid medications? Try these natural options.

The answer may be in your kitchen pantry, and not in your medicine cabinet

Attributed to : Healthline

Turn to Nature

If you’re suffering from a toothache, backache, or any other type of pain, your first impulse might be to reach for a pill. Many people rely on medications, but they come with the risk of side effects, drug interactions, and the possibility of becoming habit forming. 

You may find the relief you need from a variety of natural painkillers instead.

Many herbs and spices can treat inflammation and other related conditions. These plant-based options fall under a category of medical treatment known as complementary and alternative medicine, which also includes acupuncture, yoga, reiki and other practices. When it comes to pain relief, you may be surprised at what might help you feel better.

Part 2 of 7: Willow Bark

Willow Bark

People have been using willow bark to ease inflammation (the cause of most aches and pains) for centuries. The chemical salicin, which is similar to the main ingredient in aspirin, is found in the bark of the white willow.

Originally, people chewed the bark itself to relieve pain and fevers. Now willow bark is sold as a dried herb that can be brewed like tea. It also comes as a capsule or liquid supplement. It can be used to treat headache, low back pain, osteoarthritis,and many other conditions.

However, willow bark can cause stomach upset, may slow down your kidneys, and can prolong bleeding time, just like aspirin. It should only be used by adults. It could be poisonous to children, just like aspirin can be poisonous when taken in large quantitates.

If you’re sensitive to aspirin, or if you are taking any over the counter anti-inflammatory drugs (e.g., aspirin, ibuprofen, naproxen) you should avoid willow bark. You should also avoid taking it if you are taking warfarin or other anticoagulant treatments, as salicin could increase the risk of bleeding.

Part 3 of 7: Turmeric

Turmeric

Turmeric is a spice that gives curry, an Indian dish, its yellow color and unique flavor. It contains the compound curcumin, an antioxidant that helps protect the body from free radical molecules that can damage cells and tissue.

Turmeric is used for the treatment of many conditions, including indigestion, ulcers, stomach upset, psoriasis, and even cancer. Some people with osteoarthritis turn to turmeric as a natural pain reliever because it helps relieve inflammation.

Part 4 of 7: Cloves

Cloves

Whole cloves are often used to spice up meat and rice dishes. Ground cloves are used in pies and many other foods. As a medicine, cloves can be found in capsule or powder form. Clove oil is also available.

Like other herbal supplements, cloves are used to treat a wide range of conditions. Cloves may help ease nausea and treat colds. They may also help relieve the pain associated with headaches, arthritic inflammation, and toothaches. Cloves can also be used as part of a topical pain reliever.  A study indicated that cloves could be used to treat fungal infections but further research is needed.

The active ingredient is eugenol, which is a natural pain reliever and is also used in some over-the-counter pain rubs. Rubbing a tiny amount of clove oil on your gums may temporarily ease toothache pain until you can get to a dentist. But too much undiluted clove oil may actually hurt your gums, so discuss this approach with your dentist before trying it at home. 

People with bleeding disorders or who are taking blood-thinning medication should be careful when consuming clove products. Clove oil can increase the risk of abnormal bleeding.

Read More: Is Clove a Cure-All?

Part 5 of 7: Acupuncture

Acupuncture

This ancient Chinese medical practice seeks to relieve pain by balancing the body’s natural energy pathways. The flow of energy is known as qi (pronounced CHEE). Acupuncturists place tiny, and very thin needles into your skin. The location of the insertion is related to the source of the pain. But, based on the qi, a needle may be inserted far from the part of the body experiencing pain. Acupuncture may relieve pain by causing the body to release serotonin, a “feel good” chemical that eases pain.

A study published in JAMA Internal Medicine found that acupuncture helped relieve pain associated with osteoarthritis, migraines, and various locations of chronic pain.

Related News: Researchers Find Proof That Acupuncture Blocks Stress

Part 6 of 7: Heat and Ice

Heat and Ice

Among the most common home remedies is applying heat and ice directly to sites of pain. While these may not seem like “surprising” pain relievers, not everyone is clear on exactly when to use ice or heat.

A strained muscle, tendon, or ligament may feel better after applying an ice pack to reduce swelling and inflammation, shortly after it is injured. Interestingly, once the inflammation has disappeared, heat may help reduce the stiffness that comes with strains and sprains.

A cold pack used briefly on the head may also help take away the pain of a headache.

But, if the painful problem is arthritis, moist heat applied to the affected joint will help more than ice. Moist heat packs that can be warmed in the microwave and used many times, making them easy and effective to use. If you get injured, talk with your doctor or pharmacist about how to use heat or ice to help ease the pain.

Part 7 of 7: Be Careful

Be Careful Managing Pain

The natural painkillers described above may only be effective for specific causes of pain. It’s possible that not all of the suggestions on this list will work for you. However, these natural alternatives to prescription or over-the-counter medications may at least give you some decent options to try before you turn to pharmacological solutions.

Remember, pain is the body’s signal that something is wrong. It may be temporary, such as a strained muscle. But pain can also mean you have a serious health problem that needs a professional medical evaluation. Don’t hesitate to seek out a healthcare provider to diagnose the source of your pain, and then discuss some natural options for treating it.