Health Train Express

For the next week or so I will not be posting at Health Train Express.  I will be over at my other blog  THE VIEW FROM HERE

Tank up, turn off, and tune in for rants about politicians,economists, and our esteemed leaders...

I will be posting daily..

 

Health Train Security Alert

 

Like all professionals, we physicians need to be policed. There are some of us  (not me)  who are impaired, drug dependent, and present a risk to patients.. Certainly today with 'transparency' as the new  buzz word it is now expected that consumers will have a seat on the medical board as reviewers and decision makers.

This blog is transparent and read by physicians, administrators, pundits and yes, even 'consumers' (I prefer patients).

In California the administrative functions of the Medical Board have changed drastically in the past year. Enforcement issues have been taken away from the Medical Board.  It was found that the 'diversion program'  for physicians who are impaired was flawed and inadquate to guarrantee patient protection. The diversion program has been terminated.

In California all licensed providers receive a quarterly report about disciplinary actions against providers, including podiatrists, allied health care licensed providers.  I don't see dentists, or optometrists on this list, so they are most likely policed by a different agency.  They are held to a different standard, although they now provide many medical functions dispensing medications.  Is the system prejudiced against MDs?

When this "brochure" arrives I rush to open it and scan it for people I know or have known. This month I was shocked to find two colleagues who I know fairly well.  One is an anesthesiologist who attended to almost all of my patients I operated on as an ophthalmologist for over 15 years.

I never had a problem with him, my patients in fact would always comment how he made them feel secure.  His anesthesia techniques were very good. If I had a problem or he had a problem he usually noticed it early on.  I know because I had a year or so of anesthesia training before I opted out to specialize in ophthalmology. (I was a late bloomer, who enjoyed it all, and could not make up my mind).. A problem for many students who are forced to chose early because our post graduate system no longer has flexible internships with exposure to general practice in the first post graduate year.  I digress.

Apparently after 30 years as an anesthesiologist he retired and took several years off.  He became a physician for the corrections department.  Of course his general medical skills needed updating.

After he was hired he was offered remedial training and also the opportunity to take an evaluation.  He was not told that his employment would depend on his passing this test.  As it turned out he did poorly on the  test and it was determined that his skills were not up to caring for prisoners....I do not know if he was offered supervision or time to have remedial CME.  His medical certificate was revoked.  I also noted that it is no longer called a 'license', but a certificate.

A second colleagues's name appeared in the list.  This doctor was a psychiatrist who I knew for over four years.

His back ground was impeccable, and he devoted his career to poor patients, either in the medi-cal system or indigent.  He dealt with patients who had serious mental illnesses, ranging from bipolar disorder, to psychosis, alcoholics, and drug dependent patients. Among his patients the ones in question were among the most ill, with poor outcomes and chances of improvement.  They were very time intensive. He developed a social and sexual relationship with one patient, and expert testimony determined that this was not a predatory behavior for him, but a circumstance that developed out of this patient's serious physicial illness.  The event ocurred out of the office, and he was seduced during a period of extreme stress arising out of a recent divorce, severe financial problesm from a failed investment in an imaging center.

He was also accused of keeping poor medical records.

This psychiatrist trained in the days where psychiatric history's were sacrosanct. Psychiatrists were taught to be very careful in what they documented in the patient's chart. This was a habit he carried with him throughout his career.  He practiced in a private setting as well as a county mental health center for many years without this being an issue.  It became an issue for 'the system' when he was supervising an 'intern' who complained about 'inadequate record keeping'.. (who was supervising who?)

He was also accused of not giving adequate informed consent.

 

Informed consent implies that a patient can understand what he is told or reads.   The times I saw him as a patient to deal with my own stresses he gave me a yellow sheet which outlined the reactions, side effects, and drug interactions.  Even as a physician, I had difficulties understanding some of the material.

Was this determination based upon a patient complaint, or what was not in the chart?

How would an impaired psychotic or drug dependent patient understand and be truly informed??  Dr P worked with severely ill patients,  in a very busy mental health clinic with time constraints limited by the 'system'  He barely had time to evaluate a patient, document the visit, write the prescriptions, give informed consent and get it signed.  He had minimal if any assistance, and most of the  time did not have a psychologist to deal with issues he did not have time to complete.  The county however, had no difficulty providing administrators and clerks to process financial paper work for billing and other issues.

Perhaps he should have complained to his supervisor or the county.  He would probably have been terminated.  Government never accepts their portion of accountability for anything.

The county, state or federal system lives on bureaucracy and paper work.  Many of these patients are on ten or more medications for medical conditions as well as psychotropic medications. Physicians are policed and reviewed to be certain their records are complete, so why wasn't this caught well before he faced administrative or board discipline?

Yes, physicians need to be accountable and live up to a higher standard than 'ordinary people'.  Physicians have the duty to put their patient's welfare before their own.  At times this places them in a compromised position.

These issues become more critical and more prevalent with the increase in rationing, decreasing reimbursement, increased patient loads and the real world time constraints resulting from the growing crisis in health care delivery.

 

del.icio.us Tags: medical board,enforcement,diversion,informed consent,bureaucracy,addiction,psychotic

Why is Healthcare so Expensive

This, found in Planet Money as a feature on NPR.

Today, NPR featured this video which simplifies the problem(s)

Planet Money explains further.......................

Health Train Express has found that there are many prolific writers from the likes of the WSJ, NPR, and many other sources in the media and the business world who  are addressing healthcare financing.  In some cases they seem to have a better grasp of the big picture while we physicians flail about just trying to survive and earn our daily bread.  Despite that none or few of these writers  have ever had the day to day and night to night responsibilty for human lives they seem to or think they have all the problems accounted for..  Yet their solutions do and would have enormous collateral 'damages' to health care as we know it.

The laws of unintended consequences, and perhaps some of the laws of intended consequences must come into play.

Other weblog stuff:

John Hamlaka explains the demise of  AHIC and it's replacement by   a new organization

John D. Halamka, MD, MS, is Chief Information Officer of the CareGroup Health System, Chief Information Officer and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE (the Regional Health Information Organization), Chair of the US Healthcare Information Technology Standards Panel (HITSP), and a practicing Emergency Physician

What are the ERs doing about Overcrowding?

PLACEBO JOURNAL VIDEO

Some are wondering what effect the looming credit crisis is having on health care

del.icio.us Tags: credit crisis,ahic,standards

Health Train Overload

ALL ABOARD THE HEALTH TRAIN

Health Train Engineer Ratings

e-Patients.net today had an interesting topic about the value of doctor rating sites on the internet.  John Grohel and Ruth Given elaborate on the worth, value, and the economics of these web sites as sources of valid and credible information for patients.

Some of these sites should have their title "Buy  your Grades"...These sites are not even secure...what is to stop hacking in to the 'teacher's"  grading books??  The whole issue seems a bit sophomoric.

1. It is not unbiased

2. Who reviews and rates the comments

3. Is there any credibility and accountability for ratings and/or comments.

4. Do the rated physicians have the ability to offer answers to criticisms??

1.true

2 ??

3.no

3.no

'nuff said?

Health Train Reports

Pay for Performance:  It's a no way street, since medicare has failed to live up to it 's promise.  Providers are struggling to determine what went wrong...Not a win-win situation, and a loser for both sides.  The experiment to improve outcomes by requiring coding for certain behavior on the part of providers and rewarding them for the same is flawed fundamentally by a rigid set of parameters to measure, which in the long run will most likely evolve with time.  It's going to be the dog chasing it's own tail.   Most providers do not have the time or resources for this unless it is a substantial size group.  2 percent  incentives for hiring administrators and software to perform this function is offset by increased overhead.  This amounts to negative reinforcement if payers and CMS decide to penalize those who do not conform to a very questionable mandate.

The effects of medical group practice and physician payment methods on costs of care.

AMA survey results:This study indicates that payment methods at both the medical group practice and physician levels influence the cost of care.  However, the methods by which that influence is manifest is not clear.

Many doctors are still trying to figure out what went wrong with the 2007 PQRI.

Confidential physician feedback reports from last year's initiative, which for the first time offered Medicare bonuses for successfully reporting quality measures, became available to participating practices starting in August. Since then, many participants have been struggling to make sense of the information that they received -- if they were able to access it at all.  Only about 20% of 408 physicians surveyed in September by the American Medical Association were able to download their 2007 feedback reports, which told each doctor whether he or she reported enough measures to qualify for a bonus. Nearly 60% of those who sought assistance from the Centers for Medicare & Medicaid Services in accessing the confidential reports said they received little to no help from the agency.

In the interest of efficiency CMS has contracted with new companies to process payments.

Never you mind that the new companies are unable to perform.

How will CMS deal with increasing complexity of coding, transition to ICD 10, and vendors who are ill prepared to assume the responsibility for payments to providers?

And how will CMS deal with audits and repayments by providers?

HEALTH TRAIN CONTRIBUTES TO THE ECONOMY

A long time ago in a distant past my parents told me that if I became a physician I would always have work to do. They also told me I would probably never be a rich man.  I did not pursue medicine as a 'job'  My very worth is embedded in being a physician and surgeon... Like most physicians I wonder what I could do if I    could no longer care for patients. 

At times while it is exhausting and saddled with many 'duties' such as becoming a secretary filling out forms, entering data and patient histories into an electronic health record.  While most clerical personell earn about 10-15 dollars/ hour my pay grade is far above that figure.  For me it is a good deal. The downside for providers is less ability to see an increasing number of patients..For payors and medicare it is  poor economics to pay the physician  to do secretarial work.  As medicare and payors increase the bureaucracy and regulatory requirements there reaches a rate of diminishing return.

An analogy to this is what Hubbert calls "Peak  Oil".  named after Dr. M. King Hubbert, Geophysicist.

This eponym describes the phenomenon where it takes more energy to pump oil out of the earth than  what it yields in energy.  This is due to the necessity of pumping water into the well to force crude oil to the surface, drilling deeper, and drilling further offshore and in remote locations (cost of transportation)

Add to that, the political, ecologic, and economic aspects of legislative hurdles, environmental protection, and building infrastructure.

We are now entering the era of "Peak Medicine".

Dr. Phil Roth, unknown to me has already described this phenomenon in his blog, Peak Oil Medicine.

Peak Oil is well described in this video.

I think there are many parallels between Peak Oil and what is occuring in medicine and health care.

The emphasis has been to control costs by ratcheting down reimbursements, increasing bureaucracy and regulation, while at the same time ,demand is increasing due to aging, and increasing;y expensive  technology.

Health care employment is one area of the economy that continues to enjoy steady growth. Health finance experts tell us that medical care is increasingly a larger percent of the GDP. Is this because the remainder of the GDP is contracting due to outsourcing, an automobile industry in shambles, exporting production of telecommunications, electronics, and NAFTA.  Are the statistics skewed?

 

del.icio.us Tags: peak oil,peak oil medicine,hubbert,physician making a living,medicare,payers,regulation,GDP,NAFTA

Health Train Motorcycle Detour

 

David Kibbe MD a family practice physician joins us here courtesy of Matthew Holt of The Health Care Blog....Dave is a well known writer on the subject of health IT.  In this particular episode he takes us on a cross country tour produced by Scribe media.org   I think  you will like the music as well. Enjoy!

And now Heeeeere's Dave !!

Health Train Transfer

GREAT QUOTES

The overriding theme of the recent campaign season was and is “CHANGE”. The sea of jubilant Americans, young, older, all races, and backgrounds celebrating this victory of Obama for America demonstrates the power of democracy. Yes, democracy is more powerful than capitalism (run amok) and socialism.

We tend to think of black and white. Either left or right. During the campaign at times it was difficult to analyze the real deep meaning of either candidates proposals. There were many who feared this outcome, however the majority has ruled. It is obvious many of us have been left behind.

The outcome is not the death of capitalism, nor the onset of socialism, it is however the demonstration that capitalism and free markets have exceeded their inherent ability to balance the equation. One can argue that creeping entitlements have led us into this “dead end”. The normal market pressures have become dysfunctional.

George Bush’s policies and decisions ended when we invaded Iraq. We were caught up in a perfect storm of global events and economic turmoil.. and terrorism was the overriding theme for us.

Americans had never been attacked in the underbelly, or the heart of the nation’s highest peak (the World Trade Center). The events of 911 symbolized and unknowingly foreshadowed the events of the past several months. In reality these events were ongoing for considerable time. Our recent financial collapse has been blamed on the supreme mortgage meltdown. This is a smokescreen for what has been ongoing for the past ten or twenty years in real estate, credit markets, the consolidations of enterprises, the greed of the stockmarket, insurance industry, technology whether it was for the good, or for mindless entertainment among increasingly idle Americans, who had lost their direction.

We should have learned that actions should not always be based upon fear. We should also remember not to depend upon one person to lead us and/or save us from ourselves.

At the onset of the crisis I said “look in the mirror, there is the culprit”. Even those of you who are relatively successful depend upon inequality, and greed. How big a house, and how many do you need? How big a vehicle do you want? Is it based upon your life’s needs, or some other motivation. Some families with 2-4 children do need a larger vehicle. Why has the foreign car market exploded? Why have we had to export and/or outsource many of our vital functions?

I am not going to give answers here. I don’t know all of them, But we all, patients, payers, providers, and yes government need to assess what we have done. It has not been done to us. Look in the mirror.

While we have been counting the casualties, worrying about health care financing, the gradual and relentess increases in the cost of energy, and the innumerable eco- disasters the perfect storm arose and devastated capitalism as we knew it.

Our new leader is largely unknown, however he is extremely bright, a brilliant orator and politician. This inexperienced man defeated a powerful political machine, overturning the democratic party, just like a boat in the perfect storm. We must all row the boat together as a team to insure our success. We don’t expect a miracle, but more people now have hope.

No capitalism is not dead, nor is socialism taking over. It is not black and white.

President Obama is the perfect combination for our country, a man of color and white, an immigrant, a man who came out of nowhere, from a very modest background, raised by a single parent and grandparent. How familiar does that sound to you? It is not the American dream, but it is the American Reality.

Hope must come before prosperity. There is no prosperity without hope.

As I drive to work through endless homes

I always wonder, what is going on in each of those homes. Are they healthy? Do they have jobs? How many are living from paycheck to paycheck, unable to save or follow the advice of financial wizards? How many are sad?   How many have dysfunctional families? How many alcoholics and drug dependent people are in those homes? How many don’t have insurance? How many live in fear of losing their homes and/or their transportation. How many have latchkey children?

There are many more questions than answers. Statistics don’t tell the real story. They indicate the enormity of our problems, however as I drive through the neighborhood I feel the pain.

We as providers face these situations on a daily basis, unable to respond effectively for our patients, unable to commit sufficient time to analyze problems of poor health based on economics, family structure, anxiety and/or depression, limited income in a country with supposedly unlimited financial resources. In truth it has not been this way for many years.

Democracy gives us Hope

 

del.icio.us Tags: election,obama,capitalism,socialism,health financing,free market,hope,prosperity

Health Train Transfer

GREAT QUOTES

The overriding theme of the recent campaign season was and is “CHANGE”. The sea of jubilant Americans, young, older, all races, and backgrounds celebrating this victory of Obama for America demonstrates the power of democracy. Yes, democracy is more powerful than capitalism (run amok) and socialism.

We tend to think of black and white. Either left or right. During the campaign at times it was difficult to analyze the real deep meaning of either candidates proposals. There were many who feared this outcome, however the majority has ruled. It is obvious many of us have been left behind.

The outcome is not the death of capitalism, nor the onset of socialism, it is however the demonstration that capitalism and free markets have exceeded their inherent ability to balance the equation. One can argue that creeping entitlements have led us into this “dead end”. The normal market pressures have become dysfunctional.

George Bush’s policies and decisions ended when we invaded Iraq. We were caught up in a perfect storm of global events and economic turmoil.. and terrorism was the overriding theme for us.

Americans had never been attacked in the underbelly, or the heart of the nation’s highest peak (the World Trade Center). The events of 911 symbolized and unknowingly foreshadowed the events of the past several months. In reality these events were ongoing for considerable time. Our recent financial collapse has been blamed on the supreme mortgage meltdown. This is a smokescreen for what has been ongoing for the past ten or twenty years in real estate, credit markets, the consolidations of enterprises, the greed of the stockmarket, insurance industry, technology whether it was for the good, or for mindless entertainment among increasingly idle Americans, who had lost their direction.

We should have learned that actions should not always be based upon fear. We should also remember not to depend upon one person to lead us and/or save us from ourselves.

At the onset of the crisis I said “look in the mirror, there is the culprit”. Even those of you who are relatively successful depend upon inequality, and greed. How big a house, and how many do you need? How big a vehicle do you want? Is it based upon your life’s needs, or some other motivation. Some families with 2-4 children do need a larger vehicle. Why has the foreign car market exploded? Why have we had to export and/or outsource many of our vital functions?

I am not going to give answers here. I don’t know all of them, But we all, patients, payers, providers, and yes government need to assess what we have done. It has not been done to us. Look in the mirror.

While we have been counting the casualties, worrying about health care financing, the gradual and relentess increases in the cost of energy, and the innumerable eco- disasters the perfect storm arose and devastated capitalism as we knew it.

Our new leader is largely unknown, however he is extremely bright, a brilliant orator and politician. This inexperienced man defeated a powerful political machine, overturning the democratic party, just like a boat in the perfect storm. We must all row the boat together as a team to insure our success. We don’t expect a miracle, but more people now have hope.

No capitalism is not dead, nor is socialism taking over. It is not black and white.

President Obama is the perfect combination for our country, a man of color and white, an immigrant, a man who came out of nowhere, from a very modest background, raised by a single parent and grandparent. How familiar does that sound to you? It is not the American dream, but it is the American Reality.

Hope must come before prosperity. There is no prosperity without hope.

As I drive to work through endless homes

I always wonder, what is going on in each of those homes. Are they healthy? Do they have jobs? How many are living from paycheck to paycheck, unable to save or follow the advice of financial wizards? How many are sad?   How many have dysfunctional families? How many alcoholics and drug dependent people are in those homes? How many don’t have insurance? How many live in fear of losing their homes and/or their transportation. How many have latchkey children?

There are many more questions than answers. Statistics don’t tell the real story. They indicate the enormity of our problems, however as I drive through the neighborhood I feel the pain.

We as providers face these situations on a daily basis, unable to respond effectively for our patients, unable to commit sufficient time to analyze problems of poor health based on economics, family structure, anxiety and/or depression, limited income in a country with supposedly unlimited financial resources. In truth it has not been this way for many years.

Democracy gives us Hope

Health Train Express stops at the Voting Booth

I have to give Barak Obama and John McCain a great deal of credit for their ceaseless energy in campaigning.  Whether you agree or disagree with either of them, admit that they have 'charged' the electoral process.  For the first time in my memory we have a real choice.

This column does not pretend to be unbiased, either in my pronouncements or opinions. It is the culmination of 65 years on the third rock from the sun, and as a physician for 40 years. There are many of you out there that are older, younger, but few wiser than me.  I admire Barak Obama for energizing his "base"

I did not like the  way Obama at the last minute decided to  waive campaign financing in lieu of fund raising.  He obviated the careful thinking about removing finances from the equation. Most of us pay one dollar to fund campaigns.  So  much for Obama being the voice of the  people  HYPOCRISY

I admire John McCain for his life and experience.  Young politicians can be gifted and wise beyond their years. Obama's lie story is compelling and appeals emotionally to many,  but his real world experiences are limited....He is much like the academic who is smart, but has limited real world experience and speaks from two polar opposites....academia and the poor of Chicago. I am suspicious of his origins in Chicago, his affiliations, his glib statements, and his denial of being a very left politician. 

He cannot extract a list of accomplishments compared to McCain. He is not even a proven academic. Where is his list of papers. What happened during his college years?  Being head of the Harvard Yale Law does not prove much unless he practice law and perhaps it allow him to be in a certain circle of elite friend in the law.

It has been said he will govern from an oligarchy of four associates.

John McCain did not have the 'handlers' nor the organization of Obama...He also started too late. Obama was at this fully committed for two years.  McCain all but dropped out a year ago.

Political handlers do not run our country, they stage Roman festivals, go door to door (paid to do that).  Tell the candidate where and where not  to go.  Obama  has kept his handlers well hidden. I don't see him as having any original thought...great oratory in a hypnotic manner of delivery.

Yes, I have a bad feeling.  There is a great deal of emotion and anger in Obama and his wife.  His wife and friends harbor these feelings, which may be justified. He is supported by millions of disenfranchised citizens.

Anyone who would use the phrase, "my program will allow you to buy more of those 'iTune' songs says it all. 

For a presidential candidate what cultural and sociologic or even true inspirational aspects are present??

 

My vote does not depend upon either candidate's proposals for healthcare reform...There are much bigger issues to consider.

I have a MCCAIN-PALIN bumper sticker on my car in a heavily OBAMA neighborhood.  My son, age 22 told me I should take it off if I don't want my windows smashed.  The fact that he felt some intimidation surprise me.  He however is much more in touch with young people.  I took it off....he is a very good judge of character.

SO I WILL VOTE FOR JOHN MCCAIN, AND IF YOU HAVE SOME LOGIC AND REASON YOU WILL SEE THAT OBAMA PLAYS TO OUR EMOTIONAL NEEDS....IF YOU VOTE FOR OBAMA TODAY YOU WILL GET WHAT YOU DESERVE...LOSS OF FREEDOMS,much higer taxes, more entitlement programs and further movement of businesses to foreign countries.A SLAVE TO THE 'PEOPLE'....SOUNDS LIKE MARXISM, SOCIALISM AND THE DREAD WORD WE HATE TO SAY "COMMUNISM"

YOUR VOTE HAS BEEN BOUGHT BY MILLIONS OF DOLLARS, AVERAGED OUT TO 18.75 DOLLARS PER VOTE.

 

SORRY SID, YOU ARE BEING PLAYED BY SOMETHING THAT SOUNDS WONDERFUL  BE CAUSE YOU ARE SUCH A GREAT GUY, PHYSICIAN AND CARE SO MUCH FOR PEOPLE.

Forty eight hours and counting....VOTE, VOTE VOTE

Here is how the last minute polls show the Presidential Race::::How will America go??

Obama McCain Health Train Comparisons

All commentary is taken from The Heritage Foundation

 

Obama: 

 

McCain:

It's been some time since we have had such a clear choice in our selection for our President and the leader of what we call the free world.

Obama---black, young,liberal,inexperienced,

McCain--white, old,conservative, experienced

Both men tempered by their life's stories, both credible, neither with a good plan for our present crises, which are ECONOMIC, NOT POLITICAL.  The same pertains to HEALTHCARE.