Is Laughter the Best Medicine??

How important is blogging? Well, according to our American Academy of Medical Bloggers, it is essential to the survival of medical care as we would like it to be. (The AAOMB has just been founded by myself). The membership has expanded rapidly in the past week from 0 members to 1 member. Board certification is NOT required, and would actually place one at a disadvantage. I am the sole voter, and hold immediate veto powers over myself. I am inviting you to a tea party, during which I hope to be overthrown.

Were it not so serious our present condition is laughable. If laughter is the best medicine, (Norman Vincent Peale) would be hard pressed to apply our situation to better health.

AMA flip-flop

As I stated in one of my recent blogs, The American Medical Association recently did a 180 degree turnabout to support HR 3000. The American College of Surgeons today sent a letter also supporting HR 3000 .

The text of it’s support:

The American College of Surgeons has endorsed the House’s healthcare reform bill, joining the American Medical Association in backing the Democratic initiative.
“On behalf of the more than 74,000 members of the American College of Surgeons,” Executive Director Thomas Russell wrote in a letter, “I write to express the College’s support.”

What is not apparent in their letter of support is:

The house of medicine is far from unified in support of the House Democrats’ bill, however.
The American Association of Neurological Surgeons and Congress of Neurological Surgeons issued a statement opposing the legislation, citing their stances against the creation of a government-run health insurance plan and in favor of medical malpractice reform measures rejected by Democrats.
Likewise, a letter opposing the House Democratic bill is circulating among state-based medical societies. The missive could land in Capitol Hill inboxes on Monday. Apparently the “grass roots” is fed up with being mis-represented by their ‘societies’. Perhaps this too is a sign of the populaces’ opinions of their congressional representatives, who are so busy they don’t have time to read the very bills they vote upon.
Like the American Medical Association, the surgeons’ support is strongly tied to provisions in the House bill that would replace the formula that calculates how much Medicare pays physicians. This very narrow focus of the ‘societies’ would imply that physician interest is mainly tied to their pocket books.

Like so many issues the ‘devil is in the details:

“The current Medicare payment system, universally regarded as flawed, has called for pay cuts every year for nearly a decade, forcing Congress to enact short-term fixes. For 2010, the formula would establish a 21.5 percent cut without legislative intervention.
“One of the greatest threats to our health care system is the uncertainty facing physicians in Medicare, and H.R. 3200 takes important steps to address the problems posed,” Russell wrote in a letter delivered Thursday to House Ways and Means Committee Chairman Charles Rangel (D-N.Y.), House Energy and Commerce Committee Chairman Henry Waxman (D-Calif.) and House Education and Labor Committee Chairman George Miller (D-Calif.).
The new physician payment formula in the House bill would cost up to $300 billion over 10 years. The Senate Finance Committee is not considering a permanent fix to the payment issues, meaning that physician groups' endorsement of the House’s bill does not necessarily mean they will support the final healthcare legislation.”

1 x 10 to the ninth

A trillion here, a trillion there. In the words of Governor Bobby Jindall of Louisiana fame,

“This here is a fine pot of gumbo”.

He continues in his comments for the WSJ

“I honestly do not know one single individual who is happy with this situation. Not one. Not a Republican, a Democrat or an independent. These actions are all problematic individually, but taken as a whole, they are devastating. So against that backdrop, we enter the health care reform debate. I honestly do not know one single individual who is happy with this situation. Not one. Not a Republican, a Democrat or an independent. These actions are all problematic individually, but taken as a whole, they are devastating. So against that backdrop, we enter the health care reform debate. I know a little something about health care policy, and I can tell you exactly the game that is currently afoot. If the House Democrats’ plan were to become law, the president’s statement that “if you like your health care now, you can keep it” will not be true. This is not an opinion, this is a fact.”

Plagiarism

I could not resist plagiarizing this from Dr Wes' blog.

An Open Letter To Patients Regarding Health Reform

By DrWes

Dear Mr. and Ms. Patient,
It has come to my attention that in order for you to enjoy success as patients in the new era of health care reform, you must start working now to prevent illnesses that might befall you. Do not, under any circumstances, eat or drink too much. Fast food might as well be considered illegal. Exercise three, four, five times a day, even if it means take time off from work. It goes without saying that you should not smoke. The government has data that demonstrates how you have become fat, lazy, and a huge burden on our health care system. Your non-compliance threatens the very fiber of our economy. Even employers realize this, and are using calculators to figure your financial burden to them.
Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term "leper colony" mean anything to you?
Rest assured, if you fall into one of the areas studied under the guise of comparative effectiveness research and I apply all of the 153 quality care measures deemed necessary, according to the President I will not receive a cut in pay and you will receive exemplary care. Further, my nurse coordinator will be more than happy to answer your calls, see you in the hospital, answer all your questions and service your symptoms. After all, Mr. Peter F. Orszag, an economist and Director of the Congressional Budget Office feels they are equivalent to my specialist care and will serve as "productivity enhancements," saving $110 billion. See how patriotic you'll be?
Also, do not be a surgical case that has any risk of failure. After all, "Complicated Patient" is the new scarlet letter as we work to cut even more costs. Fortunately, thanks to the new multitudes of guidelines for care that we must follow, I will be carefully interviewing you to assure that you fit into one of several pre-determined renumeration bins called "bundles." Please don't confuse me with more than one major disease since there is currently no way to handle this circumstance. I would suggest you pick the disease that bothers you most.
Unfortunately, after years of clinical practice I have observed several clever patient stunts, like failure to respond to medications, unusual unforeseen infections, having an rare disease, and the like. I strongly recommend against these shenanigans as we move forward. It is in your best interest to not require long hospital stays, dear patient, or else.
I wish you the best as we move forward in this exciting time. Please feel free to contact my automated pool of nurse coordinators if you have questions. They'll each open your message, play a little "hot potato" with each other, and then contact you as our information technology system streamlines communication.
Stay healthy!

Erratum

This post has been deleted.....

Senator Tom Coburn's Bill SB 1099

I received an email from my good friend and colleague this morning. Jim Rowsey MD, a now retired academic physician (fellow ophthalmologist) has been working with Senator Tom Coburn (Okla), also a physician for the past several years. Dr. Rowsey, in response to one of my recent blog posts refreshed my memory on alternative proposals spearheaded by Dr. Coburn for health reform. It is published below:

“I am still teaching every state medical society that I can reach, or their Board of Trustees, and the subspecialty societies the value of Tom Coburn, MD's legislation Senate Bill 1099, (and House companion bill 2025) which covers tort reform, Medicaid reform, HSA, and a Patient Driven Health Care system. It the the point of action for physicians to take back control of health care. Jim Rowsey, MD cell 727-642-7017”

The WSJ Blog has this to say about reform:

Is closing military bases the model for health care reform?

 

Massachussetts has some “ less than original ideas”

Obama-care

Last evening I watched the whitehouse news conference, during which President Obama outlined his 'vision" for healthcare in America.  Unfortunately his speech had little specifics other than how wonderful life would be with his reform measures.

As in most political campaigns the message was what would happen if we did not adopt these changes. Surely the sky would fall. It sounds a bit like "Chicken Little".

The message from Congress is becoming quite clear. SLOW DOWN!

Providers, both in small practices and in large integrated health care organizations, such as the Mayo Clinic have exposed some basic flaws in reform measures being considered in Congress.

This from the WSJ Health Blog:

Mayo Clinic CEO: Medicare Payment Model Is a ‘Catastrophe’

Mayo Clinic, along with 18 other health care organizations around the country, sent an open letter to Congress on July 22.

Posted by Jacob Goldstein

Denis Cortese, the doc who runs the Mayo Clinic, swung by the Health Blog’s office today to talk health reform. His bottom line, which he’s been repeating in public in the past few days: The big health-care bill unveiled last week in the House of Representatives misses a key opportunity to change the way Medicare pays for health care.

What’s more, Cortese argued, adding a new public plan that covers more people and pays for care the same way as Medicare won’t work, because the rapid rise in health costs will …continue. “A Medicare model is a catastrophe,” he said.

The basic argument Cortese and the Mayo Health Policy Center have been making for a while now is a variation on a familiar theme: Doctors and hospitals should be paid on the based value they provide rather than simply paid a fee for every procedure they do. Those who have better outcomes with less risk and fewer costs to the system should be rewarded.

Yes, it’s tough to value care for some conditions, but there are others where there are solid, risk-adjusted measures to evaluate patient outcomes. And Medicare could go a long way by starting with a few common conditions, such as diabetes and heart disease, Cortese said.

“Why don’t we give instructions to the Health and Human Services Secretary to start value-based purchasing right now in Medicare?” he said.

The message is clear: We must fix medicare first.  Any reform is doomed to fail based upon the flaws in medicare payment methodology.  Who  regulates medicare?  Congress supposedly does with advice from a number of groups, some  physician groups and many others such as AHRQ.   If medicare is any indication of how well Congress makes decisions. ?????

HR 3200

My conclusion regarding health reform was confirmed by the congressional budget office today. With the present plan there will be no savings. The plan as proposed does nothing to eliminate the parasitic bureaucratic insurance environment, nor the regulatory environment, In fact the plan would merely transfer these costs to the government. Unfortunately the AMA in an effort to boost it’s credibility came out today to support the House Bill. No surprise there….just when most sensible people rose up and told congress it’s too expensive.

Obama is creating a ‘health care crisis’ much as he did with the fiancial markets promising to pull it out with ‘stimulus funding’. Congress is begiing to say “enough is enough’.No one is going to be panicked into a hasty decision. Obama wants all or nothing at all.

It seems saner heads are prevailing, as well as the skeptical response of the public in general.

Unfortunately health care will have to wait further to see just how our economy will (if) recover. As evidenced by the state of affairs in California even those well established programs such as SCHIP are being curtailed or eliminated, and this in the largest and perhaps most affluent state in the country.

Nevertheless changes do need to be made, and sooner rather than later. The cry of ‘emergency’ and crisis are beginning to sound like crying ‘wolf’. That only goes so far….banks, equity firms, mortgage crisis, credit crisis, and financial scandals . Obviously all those responsible were not playing with their ‘own money’ This too would be an enormous problem with a universal, or public program.

The most imminent medical issue is that there are a lot of providers who are about to quit, retire, or find some other less stressful financial vehicle, even if it means living under a bridge.

The Death of the SGR

Way back in the early 90s the Sustainable Growth Rate was introduced to us by Congress and Medicare.  This would result in an annual reduction of physician's fees annually, unless congress took action to either eliminate that year's adjustment or postpone it until the next fiscal year.  After 4 years of 'deferrals' the amount  pending is 20%. In the midst of heated congressional examination and proposals for health reform, this 'adjustment' has not publicly been discussed.  It however is a major bone of contention amongst providers of medicare services.  It becomes more important in the face of other payors who base their reimbursements upon Medicare's fee schedule.

The SGR  includes the costs of drugs and other items billed by the      provider, and also the payments made to ambulatory surgery centers. These numbers are included in the calculation of provider expenses. Claims that provider payments have increased are largely due to these two amounts.  As we all know ambulatory surgery centers have literally exploded in volume, and pharmaceutical expenses have risen sharply as well.

In the past, not much has been made of this item.

HR Discussion Bill

I began reading the 850 page draft discussion bill for health care reform that the House of Representatives is now considering.

The bill is now in committee.

The contents of the proposal are frightening, and impacts not only reimbursements but also how, and what type and numbers of residency programs will be offered.  It usurps the role of established specialty boards and overides the goals of program directors. Every academic physician must read this document, and react immediately.  The content of the entire bill  goes beyond my limited time to discuss it's entirety here, but can be found at:

HR discussion Draft. Considerable length is given to the formation and administration of a "Health Care Exchange".  The extent of regulation and enforcement dwarfs the already present insurance company bureaucracy.  It is difficult to surmise how this will play out in terms of costs to the taxpayers of the United States.

del.icio.us Tags: health care bill discussion,health reform,health insurance exchange,HHS

Order your Edsel

 

The past two weeks seems to further elaborate on the issues creaging a  tightening of the Gordian Knot of Health care which

threatens to overwhelm and bring our healthcare system and even our economy to a grinding halt.

Physicians are rightly frustrated and outraged at the incursion of well meaning pundits, experts, health policy gurus and others, who have meddled with the patient doctor relationship. It may never be restored. 

The new wave of HIT and EMR adoption foists upon not only providers but misguieded taxpayers who are being sold a bill of goods akin to the "Edsel" of the 1960s.

Rick Weinhaus MD  writes in The Health Care Blog about the folly of today's unproven CCHIT certified EMRs. Here are some excerpts from his letter to David Blumenthal, ONCHT .

am writing to you on the need for user-friendly electronic health record (EHR) software programs. As a practicing physician with first-hand experience with hard-to-use CCHIT-certified EHR software, I would like to share with you a solution to this vital issue.

The CCHIT model for EHR software certification is fatally flawed because it mandates hundreds of required features and functions, which take precedence over good software design.  This flawed CCHIT model takes valuable physician time and effort away from patient care and leads to increased potential for errors, omissions, and mistakes.

As a clinician, I have had first-hand experience with a top-tier CCHIT-certified EHR.  Despite being computer literate and being highly motivated, after a year and a half of concerted effort, I still cannot effectively use this CCHIT-certified program.  The poorly designed software constantly intrudes on my clinical thought process and interferes with my ability to focus on the needs of my patients.

Just this year the National Research Council report on health care IT came to a similar conclusion. The report found that currently implemented health care IT programs often

provide little support for the cognitive tasks of the clinicians or the workflow of the people who must actually use the system.  Moreover, these applications do not take advantage of human-computer interaction [HCI] principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks

It is astounding that physicians would be willing to accept inferior technical tools for administration and record keeping when we insist upon medical diagnostic and therapeutic equipment that must pass muster and require regulation by the FDA, and other healthcare regulatory organizations.

We absolutely need standards for data, data transmission, interoperability, and privacy. There is no need, however, to specify the internal workings of EHR software. To do so will stifle innovative software designs that could improve our health care system. If CCHIT is allowed to mandate the meaning of the term “certified-EHR,” the $17 billion allocated for EHR adoption and use will largely be wasted.

HL 7 guy explains our current conundrum:

There are real and tangible reasons why Information Technology as it exists is of very little help to many clinicians.

Gathering the information to feed into the systems is obtrusive and disruptive to the clinicians workflow.

For an hour of clinician and patient interaction there is approximately an hour of data input as most EMR applications are currently built. This is extremely inefficient.

Clinicians aren't secretaries or clerks that can be typing away all day. They have to cure and save the lives of their patients.

Frustrations imposed by improperly built software have created an apathetic attitude from most clinicians towards technology.

Until technologists understand this and start building solutions based on use cases and that fit seamlessly into the clinicians workflows, adoptions will be scarce and the failure rate will be high.

 

LiveJournal Tags: healthtrain express,gordion knot,ehr,cchit,blumenthal

The Final Frontier---where no man has gone before

 

For those of you in the know, this week is a critical time in health care reform. The Sentate’s Health, Education, Labor, and Pension committee, chaired by Senator Ted Kennedy is analyzing and weighing the various bills being proposed in Washington, this week. NPR is carrying a good portion of the proceedings. There is a lot at stake. Not only will proposed changes make immediate impacts, but in the future these changes will have unintended consequences. This happened with Medicare, the HMO act of 1971, Congressional budget regulations regarding sustainability (SGR) adjustments each year, and others. The federal government is slow to act, and slower to re-act. Legislation cut in stone is often in the end counterproductive.

Some of the proposals lead to well intended false hopes and promises. A major flaw regarding a public health program is that it would stimulate competition in the private market. That is highly doubtful, based on common sense. It’s like the 800 pound gorilla competing with a 150 pound chimpanzee. The federal government has many built in advantages, such as contracting, freedom to set rates arbitrarily, sheer overwhelming market presence, and force. Will government competition include predatory premiums way below market values? Will payments be locked in, and will it be prohibited by providers to charge less than the public health program? These are serious questions, considering how CMS has acted in the past. Are we going to see more credentialing restrictions for providers? Will this open a door to a ‘federalized medical license’? (maybe that is a good thing)

Even though this appears to be a critical year in terms of interest and action hasty actions can and will lead to unintended consequences and disaster.

These are the members of the committee:

COMMITTEE MEMBERS

Democrats by Rank

Edward Kennedy (MA)
Christopher Dodd (CT)
Tom Harkin (IA)
Barbara A. Mikulski (MD)
Jeff Bingaman (NM)
Patty Murray (WA)
Jack Reed (RI)
Bernard Sanders (I) (VT)
Sherrod Brown (OH)
Robert P. Casey, Jr. (PA)
Kay Hagan (NC)
Jeff Merkley (OR)

Republicans by Rank

Michael B. Enzi (WY)
Judd Gregg (NH)
Lamar Alexander (TN)
Richard Burr (NC)
Johnny Isakson (GA)
John McCain (AZ)
Orrin G. Hatch (UT)
Lisa Murkowski (AK)
Tom Coburn, M.D. (OK)
Pat Roberts (KS)

There is one MD on the committee, Dr Tom Coburn of Oklahoma. Of note are also several ‘powerful deal makers on the committee, including Ted Kennedy (Chairman) Chris Dodd, Barbara Mikulski, Orin Hatch. There are also several ‘young senators’.

Will the ‘old wise men’ make the right decisions for the younger generation of Americans?

Now is the time to put in your two cents. Despite the overwhelming feeling amongst physicians of futility and despondence it is vital you make your voice(s) heard NOW. Without physician input and support any systemic changes will be hampered and doomed just as they have in the past 25 years.

During these committee hearings, NPR points out that looking around the room behind the cameras are the 268 seats filled with special interest lobbyists.

LiveJournal Tags: health train express,ARRA,congressional hearing,health,labor,pension

A Political Message and Agenda

The final key to HIT adoption may lie with the beleagured physician (provider) as he attempts to deliver the best (healthcare), science based medicine to his patient (consumer).  The names and titles may change, but the challenges remain the same.

The simultaneous arrival of financial crisis, healthcare crisis, ARRA, and Health Information Technology adoption seems to be the 'perfect storm' for political meddling with medical care.

This statement appears at the introduction of the 'HIT Certification Course" sponsored by an unamed group using the term HIT Certification and a web site   'healthitcertification.com '

The web site does have a contact us link.  There appear to be many pundits or 'experts' on healthcare policy', a few physicians, and lots of titles listed as: faculty and advisors.

In it's opening statements, I quote:

"While some would have approached the current recession in a different manner, President Obama reflects upon the activities that helped spur growth after the Great Depression of the 1930s with spending for jobs that will modernize aging infrastructure and hopefully restore the middle class way of life in the U.S."

Accompanying this statement is the following illustration

I don't quite get the association between FDR and HIT. Is there a not so hidden agenda with this connection?  How can anyone cast negative aspersions on a program associated with FDR, the defeat of Nazi Germany, The Japanese Empire, The New Deal, Social Security, and all while sitting in a wheel chair and smoking cigarettes with a cigarette holder?? I am not certain however he would authorize his likeness in support of Obama's opportunism in regard to health care.  Create chaos and dysfunction and jump into unravel the mess.

I took some of my valuable patient time to read through some of the certification courses (offered free as a bait for the 'real course' which participants pay mightly to register.

It struck me as peculiar that a federal program would require 'consultants' physicians, and others to take a course which they must pay  for to obtain information regarding federal funding.  Why would the government even allow this, when they are funding billions of dollars to develop the training and infrastructure. (This is all nicely outlined in ARRA and HITECH)

So, all of you who have money to burn....go ahead, and throw some at me.

I'd rather be seeing patients. (especially without an EMR).But then again, I am rapidly becoming obsolete (and fossilized).

LiveJournal Tags: obama,hitech,hit,fdr,healthtrain express,political agenda,ARRA,health it certification