Fueling the Health Train Express

Quote of the day:
Where all think alike, no one thinks very much. - Walter Lippmann

Home health agencies, hospice services are feeling the effects of rising fuel prices, and in some cases workers and agencies are considering withdrawing from far flung rural locations that requiring long drives.  In some cases companies issue pre paid gas cards to employees as a perk.  Mileage allowances by the IRS now are far outdated, and medicare reimbursements for home health care do not consider regional differences nor the expense of transportation for home health care workers.

ALBANY, N.Y. (AP) — Stethoscope? Check. Bandages and medications? Check. Money for fuel? Uh-oh.

U.S. home health care workers, particularly those in rural areas, are suffering from financial headaches caused by the escalating cost of transportation, forcing some to borrow cash from co-workers in between paychecks and others to consider leaving the industry altogether.

Providers of home care in New York, California and other states are doling out prepaid gas cards, rental cars and other perks in an effort to retain their workers, who care for roughly 12 million elderly and disabled patients nationwide and drive an estimated 5 billion miles a year, according to a recent study by the National Association for Home Care and Hospice.

The industry is also contemplating abandoning uneconomical home visits in far-flung locations, and increasingly checking patients' blood pressures, heart rates, blood-sugar levels and other vital signs via remote monitoring systems, which many companies previously deemed too expensive.

Industry officials said they had not heard of any instances where a patient's care was compromised by the high cost of getting a health care professional to their home, though they are worried it could happen. After some home health providers threatened earlier this year to cease operations in rural parts of South Dakota, Democratic Sen. Tim Johnson said he would push Congress to revamp the Medicare payment system to account for the industry's rising fuel prices.

Donald Wagoner, a nurse who travels up to 100 miles a day traversing New York's Adirondack region, said his newest professional challenge these days is simply not running out of fuel. "I've come close a couple of times," said Wagoner, who drives a Saturn Vue SUV that gets around 25 miles to the gallon

These new economic pressures may allow remote monitoring information technology a more competitive edge.

For its part, the Home Care Technology Association of America is lobbying Congress for changes in Medicare to allow companies that use remote monitoring systems to get reimbursed for it — a major reason more companies haven't embraced the technology

Home Health Care figures

Each year, U.S. home care workers...
• Care for about 12 million patients.
• Make 428 million visits.
• Drive nearly 5 billion miles, a distance about the same as going 192,920 times around the Earth

Too many Cars on the Health Train??

Quote of the Day:
Injustice is relatively easy to bear; what stings is justice.
--H.L. Mencken

I go to my CVS pharmacy quite often because my wife, myself and one of children have chronic medical conditions. My son has cystic fibrosis, and that is another story in itself.

About 8 months ago several aisles were cleared near the pharmacy and a sign went up.  "Minute Clinic coming to serve you, soon."  The space remained vacant for several months.

Eventually construction crews arrived, taking about two months to build the clinic, with two rooms and a computer kiosk at the entrance for patients to register, and enter a brief intake history.

Several months later it opened for business.  In the interim there were multiple newpaper ads, cable news ads, and mailers sent to the neighborhood.  There were even five or six chairs set up in the pharmacy as a waiting area.

I will give them this....my CVS is located in an area with plenty of doctors (in Southern California).

I observed their operations from a distance and noted that 90% of the time there were no patients in the clinic, and a lone NP,, usually reading the computer.  On three occassions there were two NPs present, with no patients, and one time one NP was examining the other one.

After about six months on one day it seemed unusuallly busy. As I walked by there were five people in one room.  All of them had laptops, PDAs and/or cell phones.  One had an obsolete yellow legal pad and a yellow number 2 pencil. Three of them were "suits".  This was obviously their semi-annual review and performance reports. 

My estimate is that they perhaps saw two patients a week. Not a bad investment of at least 100,000 dollars in tenant improvements, computers, equipment and personell costs. I guess CVS needed a write off.

Perhaps in some rural communities this new paradigm might have something useful to offer, but not in a typical urban or suburban area. 

Maybe I could open a lipo or vein and tattoo removal service. I hear the space is up for rent.

What's your opinion??

Part II RHIOs Progress and Evolution

Quote of the day:
The nice thing about standards is that there are so many of them to choose from. - Andrew S. Tanenbaum

Opinion: Physicians' Resistance to EHRs Could Be Changing

Health care has lagged behind nearly every other industry in transitioning to computer record keeping, St Louis Post-Dispatch columnist Mary Jo Feldstein writes.
Physicians have been reluctant to invest in electronic health record systems because of the cost, integration challenges and concerns about the technology becoming obsolete, according to Feldstein. However, "waves of successful early adopters" could be "changing [the] tide," she writes.
A recent New England Journal of Medicine survey found that of the 83% of physician respondents without an EHR system, 16% said they had purchased a system but had yet to implement it and 26% said they planned to purchase an EHR system in the next two years.
Scott Anderson -- president of KIG Healthcare Solutions, an EHR vendor -- said he believes that most physicians are "over the hump" and know they need to invest in EHRs (Feldstein, St. Louis Post

E-Prescribing Provisions

The new law will provide Medicare physician incentive payments of 2% for e-prescribing in fiscal years 2009 and 2010, 1% in FY 2001 and 2012, and 0.5% in FY 2013. In addition, Medicare payments to physicians who do not e-prescribe will be reduced by 1% in 2012, 1.5% in 2013 and 2% in subsequent years.
The new law also requires the reporting of e-prescribing quality measures established under Medicare's physician reporting system.
The e-prescribing provisions only apply to physicians participating in Medicare, but other health plans often follow Medicare's lead and implement similar policies, according to Health Data Management.  At the same time there was a 'veiled threat", that those providers who did not adopt e-prescribing would be penalized.  The AMA cautioned that standards for e-prescribing were not yet solidified, which would delay implementation of e-prescribing.

FINANCIAL DISINCENTIVES IN PLAY

In most cases, the U.S. health care system does not provide incentives for physicians or hospitals to share clinical data with other health care providers, raising barriers to widespread adoption of the technology, Computerworld reports.

Charles Jaffe -- CEO of Health Level 7, which develops data standards for health care organizations -- said, "The problem we have in this country is a lack of business reasons for integrating." He added, "What is the business case for two competing hospitals to share data? None."
For example, five major hospitals in San Diego held a series of meetings about three years ago to consider sharing information stored in their respective EHR systems.
However, the hospitals decided not to pursue the plan because economic benefits were inadequate.
Joshua Lee, medical director of information services at the University of California-San Diego Medical Center, said, "The financial and oversight responsibility would fall on the medical centers, even though it's a very intangible benefit to the medical centers."
Although studies show that EHRs, computer physician order entry and other technology applications can improve the quality of health care, health care providers generally are not compensated for improvements to care, according to John Quinn, chief technology officer for HL7.

John Halamka, CIO at Harvard Medical School and Beth Israel Deaconess Medical Center, said, "The provider bears the cost, but most of the benefits accrue to other parties," particularly insurers and other health care payers.  Shaun Grannis, a medical informatics researcher at the Regenstrief Institute in Indianapolis, said that Regenstrief is working to develop an economic model for health information exchanges that would be sustainable over the long term, but he said that such projects continue to rely on "a patchwork of funding" (Mitchell

RHIO Progress

Quote of the day:
For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled. - Richard Feynman

At times I have been disappointed in the slow progress of NHIN and RHIOs.  However I think about the development of other communications systems. Our national and international telephone networks evolved over many decades, using now obsolete switches, wiring and non digital systems. 

The most recent reports reveal some progress and growth of functioning RHIOs even though about seven became defunct in the same time period. 

WASHINGTON - Regional health information organizations and health information exchanges may not be the answer to a nationwide network, according to David Westfall Bates, MD, an internist at Brigham & Women's Hospital in Boston who teaches at Harvard Medical School.

Bates, who serves as medical director of clinical and quality analysis of information systems for the Partners Healthcare System (of which Brigham & Women's is a part), says the process of creating and sustaining statewide and regional exchanges has been too slow.

Will RHIOs be able to fulfill the vision of electronic health information exchange across the country? That I think remains to be seen. I think the model is working, but I think the successes have been modest," he said.

Bates spoke Thursday at an online forum organized by eHealth Initiative, a not-for-profit organization that promotes quality care through use of IT. Technology companies 3M and ICW, which work with data exchange organizations, sponsored the forum.

The discussion highlighted early findings of eHI's 2008 survey on health information exchanges. The survey compares the state of exchange organizations in 2007 with 2006.

Jennifer Covich Bordenick, vice president of eHI, told the audience the survey shows there were 32 operational organizations across the country in 2007 compared with 26 in 2006.

Fully operational organizations exchange data on outpatient episodes, lab results, inpatient episodes, radiology results, information on enrollment and eligibility, dictation and transcription, pathology and emergency department episodes.

"There's really exciting stuff happening in these mature organizations," Bordenick said.

The data exchange organizations also reported on the most difficult challenges. At the top of the list - as in 2006 - is developing a sustainable business model.

Most organizations - 53 percent - are receiving funding from hospitals. Forty-four percent say they have funding from the federal government, and 43 percent from state government. Thirty-two percent derive some funding from payers, and 31 percent from foundations and other philanthropic organizations.

Start-up funding is usually less than $200,000.

"Hospitals continue to be a big funder," said Bordenick."They continue to step up and play a major role here."

Westfall said it's possible that hospital funding could "slow things down."

"Enabling clinical data exchange could hurt them competitively," he said.

West raised the possibility of providing more public funding, since RHIOs and HIEs are being created for the public good.

"More organizations are sustaining themselves," Bordenick said. "It's definitely a positive trend. It's slow, though."

next issue:  funding for RHIOs and sustainability

Prayer for The Day

Each morning when I arise the first thing I do is go to my home page to read the "prayer for the day".  I do this no matter what urgent thing of the day is happening....be it a crisis bill to be paid, a sick wife, child, patient or something else deemed to be the most important item of the day by someone else. Having accomplished this, I can move on to the rest of the day with renewed energy and faith to carry on.

Quote of the day:
When you look at yourself from a universal standpoint, something inside always reminds or informs you that there are bigger and better things to worry about. - Albert Einstein

There used to be a time when one thing was fairly certain,  your doctor and his caring manner and most of the time the ability to support you through whatever it was you were going through, emotionally, physically and otherwise. And these were during times when things were much more uncertain. The government, nor the payors are our problem.  To these folks it is always about the bottom line, not your  health or welfare. They will manipulate the system to  make their books balance and/or have a budget item that the OMB can justify.  Not only are we fighting a "war on terror" and a "war on  drugs" as well as a "war on illegal immigration".  During a Presidential election year is a very bad time to make a long standing decision about our health  care system. Believe it or not, those in decision making roles know bupkas about healthcare.

This is why it is critical for all physicians to become active in setting policy and aggressively as individual advocates for our  patients.

The Health Care Blog, written by Matthew Holt, describes several issues that are current.  He quotes Bob Laszewski in his BLOG about the SGR and the 18 month hold of fee reductions, only to rear it's head in 2010 with a 21% fee cut. Sounds like poker to me...."double or nothing".

As Bob describes it is the SYSTEM, not the fees and this is an issue only physicians can work out....this cannot be a 'divide and conquer' issue for  us. Without going into great detail here check out my links.

Passing of Michael Debakey M.D.

Quote of the day:
The beginning of knowledge is the discovery of something we do not understand. - Frank Herbert

Dr. Michael Debakey, a true pioneer of cardiac surgery, statesman, innovator and teacher passed away yesterday.

His memories and stories will linger amongst his students.

Michael Debakey records of accomplishments, honors, and humility stand alone.

The world has lost a great human being.

Special Trains for Special People

Quote of the day:
Everyone is as God has made him, and oftentimes a great deal worse. - Miguel de Cervantes

Today on California Healthline, the following information:

Prison Health Receiver Moves Ahead on Plans for Three New Facilities

On Thursday, the court-appointed receiver for California's prison health care system signed construction design documents to commit the state to spending $2.5 billion on three new health care facilities for inmates with chronic medical and mental health conditions, the Ventura County Star reports.
J. Clark Kelso was appointed by Federal District Court Judge Thelton Henderson to bring the state's prison health care system up to constitutional standards after a class action lawsuit found that state officials failed to improve conditions at the facilities.
Kelso said he filed notices under the California Environmental Quality Act to evaluate the construction projects at two planned facilities in San Diego and Stockton. He said he has not yet filed notices for a third site, potentially in Camarillo.
Each of the three health care facilities will contain 1,500 inmates.

Now I am not against adequate health care for incarcerated patients, and adequate facilities for prisoners. I imagine these prisoners might qualify as part of the 'underinsured'  It is interesting that the state may be willing to spend 2.5 billion dollars in capital alone to build the new hospitals. Factor in cost overuns and the eventual operating expenses, new salaries and it will probably run into more billions of dollars for tax payors.

This comes at a time when our Governor terminator is attempting to cut billions of dollars of insurance coverage for poor or uninsured citizens of the state.  We live in a egalitarian society...where health care for prisoners overides healthcare for children, and people who cannot afford health insurance for one reason or another.  I think I will go out and rob a bank.......three squares a day, health insurance and a nice bed....I may even get some tatoos.  And besides I can dance!

Compensation Packages for CEOs

I found that one of my posts here did not appear. Must have something to do with the 4th of July.  Or perhaps it is much like our disappearing reimbursements.  This week we are facing the lastest 'crisis' contrived by our inadequate incompetent legislators and administrators.  They never seem to be in sync.

It now appears that many physicians have announced they will not be accepting new medicare patients as of July 1st. This is the annual battle of the SGR formula. If you don't know what that is, I am sure you can google it. That would be a better learning experience than my giving the answers away here.

The lastest evaluation of CEOs reimbursement packages  for Payors revealed the following

 

When: 2007
How: Based on analysis of compensation of top executives of S&P 500 companies. Median total compensation was $8.8 million for executives overall, and $9.1 for CEOs of six publicly traded health plan CEOs.

Where: Everywhere there is concern among stockholders that compensation may have no relationship to performance. So far in 2007, publicly traded HMO stocks are up about 15%, from a mean of 53 to a mean of 61.

Who: Total compensation is said “not to be out of line by Wall Street standards,” and included the following health plan CEOs.
• H. Edward Hanway, Chair and CEO, Cigna, $25,839,777
• Ron Williams, Chair and CEO, Aetna, $23,045,834
• Dale B. Wolf, CEO, Coventry Health Care, $14,889,823
• Stephen Hemsley, $13,164,529
• Mike B. McCallister, President and CEO, Humana, $10,312,557
• Angela F. Braly, President and CEO, Wellpoint, $9,094,771
• Jay M. Gellert, PRESIDENT AND ceo, Health Net, $3,686,230

 

The WSJ states that these figures are not out of line when compared to other industries.  So medical and hospital care is just another industry.  Personally I cannot compare a pencil pusher that sits at meetings, gives speeches and worries more about his companies profit figures and equate it with a surgeon's worth, or a primary care provider's abilities to care for patients.

Next time you want your hernia repaired or your cataract removed, or your heart defibrillated....make an appointment to see the payor's CEO.....(don't trip over the golden parachute on your way in.

Physician Signatores of the Declaration of Independence

Quote of the day:
Character is what you have left when you've lost everything you can lose. - Evan Esar

The 4th of July seems a good time to reflect upon our liberties and also to reflect upon what physician's contributed as well

Matthew Thornton practiced for years in rural New Hampshire. When he went to Philadelphia for the Continental Congress, he had himself innoculated against smallpox and wrote of the ensuing ordeal. His satire described a Dr. Cash (”we saw no more of him, till I paid his bill of 18 dollars”); Dr. Critical Observer (”told me he would critically observe every stage … came once in two or three days, and stayed about a minute”); and Dr. Experience (”a merchant, who had the Small Pox, visited us every day, and gave a much truer account of the Small Pox, than all the doctors.”)

Josiah Bartlett was a practicing physician who became governor of New Hampshire and was one of the framers of the Constitution. But the practice of medicine remained important to him. In 1793, two years before he died, he wrote a letter to the New Hampshire state medical society (which he helped charter) expressing his hope that the group would crack down on quackery by “discouraging ignorant & bold pretenders from practizing [sic] an Art which they have no knowledge.”

Lyman Hall worked as a minister until, for reasons unknown to history, he was charged with “immoral conduct” and dismissed. He became a doctor, left his native Connecticut and ultimately landed in Georgia, where things seemed to improve for him — in 1783, he became governor of the state.

Oliver Wolcott was the son of a Connecticut governor who trained as a physician and may have practiced briefly, but spent most of his life in public office. For a while, he held the appealing sounding title of “high sheriff” in Litchfield County.

from the WSJ  July 3, 2008

That's My Opinion

Quote of the day:
Look for the ridiculous in everything and you will find it. - Jules Renard

 

It's the 4th of July, so I am kicking back, firing up the barbecue, putting on the sun block and writing today's episode.

It is only early July and my wonderful spouse just told me she has heard enough about the Presidential candidates. I guess that means no more newspapers, FOX news, MSNBC, CNN, etc etc. I will take those off my FAVs on the cable remote.

We live right by a national cemetery and there will be a procession of cars, and flags.  Living here it does not take a special day to remember how our country was won, and how it has been maintained.  Yes, we are guilty of many atrocities, stealing lands and lives from native Americans as our country expanded westward. Liberals will be quick to point that out, but they forget their ability to speak out has been bought with the blood of their fellow Americans.  I can see both sides of this argument, however when compared to the rest of the world I leave the final judgment open.

At one time I was a liberal, some new things and some changes are for the better, and some things are better left alone. The liberal establishment has left the tracks.  Conservatives too, have left the tracks.  Both sides seem to be missing the point.

I digress here (too many beers, I suppose).

We may examine and compare our health system to other countries reflecting on statistics which must be placed in the framework of our culture and history.

I do not believe important decisions regarding our health system should be made during an election year. We don't need medical decisions influenced by black and white  yes's or no's. Health care is too important to mix it in with liberal vs. conservative issues, national defense, the price of oil, mortgage crises., gay marriage, tax cuts and/or tax increases.   Politicians will be pandering to their constituents to become elected. Do you really want a politician making your  healthcare decisions?

 

I leave you with this:  Happy Fourth of July

Stars and Stripes Forever

We got their Attention

Quote of the day:
Finance is the art of passing money from hand to hand until it finally disappears. - Robert W. Sarnoff

Congress knew in advance that GWB would intervene prior to the new session of congress, by executive order.  GWB ordered that the 10% medicare fee reductions be suspended.  HHS Secretary Mike Leavitt also took administrative action to place a hold on changes as well.

"WASHINGTON (AP) - The Bush administration said Monday it is freezing a scheduled 10 percent fee cut for doctors who treat Medicare patients, giving Congress time to act to prevent the cuts when lawmakers return from a July 4 recess.

Physicians have been running ads hinting that as a result of the cuts, patients may find doctors less willing to treat them. The administration's delay in implementing the cuts spares lawmakers from having to use the recess to explain to seniors why they didn't do the job before leaving town.

Kevin Schweers, a spokesman for the Department of Health and Human Services, said Monday the Centers for Medicare and Medicaid Services will hold doctors' Medicare claims for services delivered on or after July 1. Claims for services received on before June 30 will be processed as usual, he said.

Congress, not willing to face millions of angry seniors at the polls in November, will almost certainly act quickly when it returns to Washington the week of July 7 to prevent the cuts in payments for some 600,000 doctors who treat Medicare patients. The cuts were scheduled because of a formula that requires fee cuts when spending exceeds established goals.

HHS Secretary Mike Leavitt had promised Friday that his agency "will take all steps available to the department under the law to minimize the impact on providers and beneficiaries." On Monday, the department used its administrative tools to delay implementing the scheduled 10.6 percent cuts."

 

It seems that outrage expressed byAARP and the projections by physicians that this could be a near final blow to the economiic survival of providers, both large and small.

It seems an opportune time for physicians to group together other high priority items for the upcoming new congressional session.

Personal Health Records and the Markle Foundation

Quote of the day:
Nothing is as simple as we hope it will be. - Jim Horning

 

Today I need to get down to more serious issues. I inject humor from time to time to maintain equilibrium.  I have had some commentary that my mind is "blown".  That may or may not be true......Nevertheless, here we go.

Medinnovation has a very comprehensive analysis of what and where medicine has gone and will go further, if the current entrenched medical power complex starts thinking out of the box.

Personal Health Records have been promoted in the past couple of years as a means of maintaining personal and family medical history for future provider visits.  The issue of privacy and confidentiality are probably a bigger issue here than in institutional settings.  Some people will want the personal security of using a hand carried  memory stick in one form another to carry in to their doctor's office. 

Others will want to rely on one they have available from their employer. 

HIPAA rules  may or may not apply to these PHRs.  The Markle Foundation has developed a 'Common Framework for Networked Personal Health Information', and how it would apply to a PHR, and a comprehensive view of their vision is at Connecting Consumers.

This is a good thing provided it is enforceable. A number of large organizations are endorsing it, and they can be found in the 'Common Framework'

However Matthew Holt   makes some cautionary remarks about this whole area of regulation as to how it applies to PHRs.

"There is, though, one tricky problem regarding disclosure of health information, and that is of course the impact it has on your wealth. So I asked the tricky question. They have AHIP, Aetna and BCBS Association (and Dossia) on their list of endorsers. They also have a separate policy about Discrimination and Compelled Disclosures (PDF is here). But as I asked, given that insurers (and some employers) already do discriminate based on health history, and thereby greatly impact people's wealth and their own of course, what’s the point in them saying that they won’t go fishing in the PHR. The answer is in the policy document (and to be fair it’s all they can say.)"

Well, my head is beginning to hurt, again.

Don't Stop Thinking about Tomorrow

Or never look back!!

Quote of the day:
The only paradise is paradise lost. - Marcel Proust

 

HMOs and where it all began..