How many rules does it take to make a Ruler?

Matt Holt, last week proposed these two basic rules to guide us in health care reform:

Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.

Rule 2 A health care reform bill needs to limit the amount of GDP that is going to health care to its current level, with an overall aim of reducing the share of health care going to GDP.

This week Uwe Reinhardt expands a bit:

Writing in his blog in the NY Times, Uwe Reinhardt sets out three overarching goals of health reform

1. Financial barriers should not stand between Americans and preventive or acute health care that they sincerely believe will address concerns over a troubling medical condition, in a timely manner, before that condition grows into a critically serious illness.

2. Having received needed health care, no American family should be so financially devastated by medical bills that it cannot meet routine daily living expenses — for example, make utility or mortgage payments on time or finance the education of the family’s children.

3. The future growth in national health spending should be constrained to fall significantly below currently projected spending growth, which has the United States devoting about 40 percent of its G.D.P. to health care by mid-century.

All other goals are subordinate to these three overarching goals, as are the means to reach them.

How do we get from here to there?

SERMO AND MSNBC.COM

Another word for SERMO. Dan Palestrant (founder of Sermo) was on MSNBC.com for another ‘debate’ with “established’ organized medicine. This time it was with the head (/Dr. William Struck ) of the Bassett Hospital in Cooperstown, New York. The argument again was about ‘salarizing’ physicians as a means of cost containment.

Viewers of this ‘sound byte’ need to know about Bassett Hospital.. Bassett Hospital operates in a rural area of Northern New York. It is a pristine small community with a fairly large drawing area of a lightly populated region. Solo private practice in that communitiy would be untenable economically. Bassett Hospital also is affiliated with Columbia University School of Medicine, and has multiple training programs for residents from Albany Medical Center (over 100 miles distant) and also from Columbia University in New York City, over 200 miles distant.

This is a unique population of physicians and their practice setting. The presence of residents in training (who are salaried at a much lower level than attendings) shifts a great deal of work load, night call and physician administration, such as record keeping to junior physicians who are not yet qualified to practice independently..

Attending physician work load in this setting is diminished when compared to other settings. The lowered physician income does not decrease overall costs, and any benefit is shifted to the administrative staff, capital expenditures, and operating budgets. Physician income is a very small component of their budget. (so is income for physicians not in integrated health care systems.)

When asked, the CEO of Bassett hospital dodged the question from about how much savings there were by salarizing their physicians. I suspect this was because he either did not know, or would not admit there are “NO SAVINGS” overall.

Dr Struck contends that salarizing physicians removes the added administrative tasks from physicians and allow them to focus on their patient care. This begs the question and denies the culpability of the insurance industry and regulatory affairs that has imposed these tasks upon the physician. It puts the horse before the cart and attempts to make physicians responsible to reduce the cost of this burden imposed by insurance and government payors.

Dr. Palestrant and Sermo join other real physician advocates in their proactive and aggressive education program for the general public.

Summer Recess

As some of us prepare for the long awaited "August" vacation, remember that your elected congressman, senators are also spending time in their congressional districts.  Keep them busy at this critical time and voice your opinions on health reform. 

Things are reaching a critical mass, and this now has national attention, with everyone weighing in...Make our voices heard, fellow physicians and health care workers.

It is apparent that some beginning of health reform will take place. Most opinions revolve around increasing availability of primary care, levelling  reimbursements between primary care (family practice for you other dinosaurs) and specialty care.

 

Rather than over all revolution it seems that the insurance companies should be the focus of initial changes in regard to cherry picking,

 

increasing risk pools and universal coverage via market economics, not government intervention. Government should act to enable this to occur via present structures rather than inventing new government bureaucracy and restrictive regulations.

It seems the critical mass has boiled down to "

THE BAUCUS SIX".

 

del.icio.us Tags: health train express,max baucus,congressional hearing,vacation,red tape,health reform,cherry picking,primary care,reimbursements

Health Train Express and Calculus

Health reform created a weird calculus of outcomes, decision makers and political intrigue

by Catherine Rampell

Update | 2:11 p.m. List of states has been corrected.

My colleagues David Herszenhorn and Robert Pear had an article on Tuesday on the Baucus Six — the group of six senators tasked by their parties to hammer out a new health care package to be considered by the Senate Finance Committee (and then, presumably, the full Senate).

The senators are from Maine, Iowa, Montana, North Dakota, New Mexico and Wyoming. A colleague noted that it’s a somewhat odd group to be asked to design a new health care system, given their constituents.

Whom, exactly, do these senators represent?

They come from some of the country’s least populous states, with no true urban centers to speak of. None of their home states contains even one of the 20 biggest cities in the country. Forget that: Of the country’s 100 biggest cities, just one is in these states (#34, Albuquerque, N.M.).

These states represent less than 3 percent of the country’s population, and hold only 2 percent of the nation’s uninsured, according to Census Bureau estimates.

It makes sense to give the residents of Montana and Wyoming a strong say in the future of health care reform, which will likely affect residents of every state. But shouldn’t someone representing a state with a few big complicated cities also have an official seat at that table, which is trying to determine a compromise that works for (almost) everyone? The way health care functions varies greatly from region to region, in terms of things like patient needs, delivery systems and resources. A more metropolitan state with a few rich, research-oriented medical facilities will operate differently, with regard to everything from expenses to treatment options to patients, from a rural state with fewer resources.

There would be a similarly problematic imbalance if the senators asked to design a template for the future of American health care were all from California, New York, New Jersey and Florida, and excluded all the Iowans and North Dakotans from the table. The plan that resulted from some Bizarro-World, urban-state-only cabal would have altogether different blind spots, of course.

This problem transcends the issue of health care reform; there are surely many occasions when the actual representativeness of our “representative democracy” seems in doubt.

But in this case — where the richer, more populous states will likely disproportionately contribute the federal taxes used for any additional government involvement in health care — it seems especially curious, not to mention impolitic, to exclude a California or a New York from the current discussions.

The Baucus Conference Room:

Last week, there were chippers — chocolate-covered potato chips — described on a sign as “North Dakota Diet Food.” More often, there are Doritos, pretzels, Oreo cookies and beef jerky: fuel to get through hours of talks on topics like the actuarial values of private insurance plans or the cost-sharing provisions of Medicare.

The fate of the health care overhaul largely rests on the shoulders of six senators who since June 17 have gathered — often twice a day, and for many hours at a stretch — in a conference room with burnt sienna walls, in the office of the Senate Finance Committee chairman, Max Baucus, Democrat of Montana.

President Obama and Congressional leaders agree that if a bipartisan deal can be forged on health care, it will emerge from this conference room, with a huge map of Montana on one wall and photos of Mike Mansfield, the Montanan who was the longest-serving Senate majority leader, on the other.

The battle over health care is all but paralyzed as everyone awaits the outcome of their talks.

del.icio.us Tags: health train express,max baucus,montane,wyoming,north dakota,David Herszenhorn,Robert Pear

CAT scans for your cat

Tonight's 20/20 Exposes Single-Payer Health Care

ABC News "20/20" is planning to air a segment tonight with John Stossel about the health care systems of Canada and Great Britain. We understand our friend and colleague, Grace-Marie Turner of the Galen Institute, will be on the program. "20/20" airs tonight at 10 p.m. Eastern, but please check your local listings for the exact time.

Stossel gives us this teaser on his blog: "We did find places in Canada where patients have quick and easy access to cutting edge technology like CT scans, endoscopy, thoracoscopy, laparoscopy. The clinics make these treatments available 24 hours a day, seven days a week, so patients rarely have to wait. But patients have to bark or meow to get that kind of treatment.

"Do you want a CT scan? Canadian veterinary clinics, which are private, told us that they can get a dog in the next day. For people, the waiting list is a month."

The health care segment is scheduled to air toward the end of the program. Be sure to watch and let us know what you think.

For more information about the program, please visit the 20/20 Web site.

Now it's ACO

Dear Mrs Jones;

I am sorry that I no longer am responsible for your healthcare and you will not be able to pay me for services. I am now a member of the ‘accountable care organization’ of my regional health system.

After much studying and implementing mandatory health insurance coverage in Massachussetts (they discovered there were not enough doctors, nor enough funds to provide the coverage that was promised.

ACO was invented….this is a super large HMO.

1. The development of Accountable Care Organizations (ACOs). (Health delivery entities that can work as a team to manage the provision and coordination of care so that they are accepting responsibility for all - or most - of the care for their enrollees.)

2. Patient choice. Patients will be able to choose their primary care physician, and will not be restricted to only clinicians in their ACO - but may have to pay more for services outside of their ACO.

3. Patient-centered care and a strong focus on primary care. Each patient’s selection of a primary care provider will direct their insurer’s payments to their ACO, which will receive technical support to help develop/create medical homes.

4. Widespread adoption of the medical home model. (The Special Commission concluded that “medical homes overlaid on the current FFS system cannot achieve its vision for a high-value health care system.”)

5. Pay-for-performance (P4P) incentives to ensure appropriate access to care, and encourage quality improvement, evidence-based care, and coordination of care.

6. Sharing of financial risk between ACOs and insurers. ACOs will be held responsible for performance risk—including cost performance and meeting access and quality standards. Insurance companies, (and self-insured companies), will retain the insurance risk for the insurance contracts written to groups and individuals.

7. Strong and consistent risk adjustment. Global payments will be adjusted to reflect providers’ clinical and socioeconomic case mix, and, as appropriate, geography, so that ACOs will not be financially harmed by accepting high-risk patients with complex or chronic health care needs.

8. Cost and quality transparency. ACOs will report performance against common metrics measuring health care quality and access to appropriate care.

9. Participation by both private and public payers to ensure consistent alignment of care delivery incentives and to minimize administrative complexity and costs.

According to this well thought out proposal by legislators and higher ups in the food tree of health care administration, the ACO will provide the ability for global payments. (they don’t define what this is, nor how it is determined)

Real Reform in Massachusetts This report is generated from The Massachusetts Special Commission on Payment Reform recently issued its  recommendations for shifting the state’s health care system from Fee-For-Service (FFS) to Global Payments over a 5 year period.

It’ simple, really !!

So Mrs. Jones, the above diagram shows you how to obtain your health care. I see one box for health care providers on the lower right portion of the diagram. Where are you, the patient??

Wisdom on the Health Train Express

from 'GOOZNEWS'

Technology isn’t a quick fix. Just ask General Motors. In the 1980s, the auto giant spent $50 billion to automate and computerize its plants in an effort to compete with Toyota. Today, GM is emerging from bankruptcy while Toyota still leads in producing high quality, fuel-efficient vehicles.

What happened? “The Japanese have a great way of describing the error that General Motors made,” said Thomas Kochan, co-director of the Institute for Work and Employment Research at the Massachusetts Institute of Technology Sloan School of Management. “It’s workers who give wisdom to these machines.”

(underlining, mine)

The analogy between the auto industry and health IT is obvious.

Will the Obama administration’s $20 billion push to flood the nation’s physician offices and hospitals with electronic medical records (EMRs) suffer a similar fate?

“Technology doesn’t change lives,” Riley said. “It’s the process around the technology that brings results.”

I think this is what doctors are talking about in their reticence to accept EMRs into their practices. What is good for the goose, is not necessarily good for the gander.  Small practices (group, or otherwise) are different administrative animals than large and even huge integrated health care systems.

An easily observed manifestation of this is what I call the 'walkaround"   Walk around a typical small group or solo practice and compare the square footage in a smaller practice  dedicated to clinical care space, and administrative space.  Where is the administrative space? In these large entities, those with the nicest offices with a 'view' are the nurse case managers, heads of departments, and executive administrators.  This is obvious when one tours a VA hospital, Army, Navy hospital and Kaiser Permanente. 

Are these administrators 'evil people"?  No, however the pecking order and corporate culture encourage this development of space allocation, especially since administrators control the purse strings.  I have even heard practice managers discourage allotting a comfortable 'thought room" because doctors don't see patients in their "personal office space".

More on this in my next post. I have a patient waiting and have to leave my 'personal space' (100 square feet).

The Art part of Health Care Reform?

M.D.: Where Is the Art of Medicine in Health-Care Debate?

Abraham Verghese MD discusses the objective of tying reimbursement to the time involved with seeing a patient. Attempts at this were made with the development of Evaluation and Management coding. (E/M coding). Unfortunately the criteria for these codes do not include many factors in patient management that have no relevant coding measures. E/M coding is strictly limited by body system evaluations, and depending upon the clinical focus are inappropriate. The coding measures have always been insufficient. There are no codes that reimburse for coordinating patient care with other providers, nor for administrative time involved in justifying payments to payers, including medicare.

Everybody’s got something to say about health reform, but nobody’s speaking up for the art of medicine, Abraham Verghese argues today in a Wsj.com column.

Many doctors’ groups and academic medical centers are too deeply entrenched in the business of medicine to speak up for the field’s noblest intentions, writes Verghese, a novelist, Stanford prof and practicing physician.

And he makes a case that a payment system that encourages doctors to practice the kind of medicine that leads to real relationships with patients could be more efficient in the long run: “Our esteemed medical societies and academies aren't speaking for medicine; they are lobbyists, defending their financial self-interests, lining up for or against the latest bill being proposed. Our great academic institutions and our esteemed medical schools have historically spoken for the cause of medicine, but these days many medical schools are more like big companies with complex financial interests in large hospitals and clinical practices. What about the large foundations dedicated to health care, such as the Robert Wood Johnson Foundation or the Kaiser Family Foundation? I think their voices have become more potent as they seem largely free of the kinds of conflicts of interest that bind many of us, but they are not quite the voice of medicine.”

Howard Dean meets SERMO

The power of the internet has become apparent in national and local political decision making. Politicians use the internet and watch bloggers and social networking sites to measure carefully their decisions. No longer do groups have to use expensive s elf serving lobbyists to get their point across.

Yesterday SERMO participated in a nationwide forum (debate) with Howard Dean on CNBC. Sermo put forth the concept that the AMA does not represent either the majority of physicians, nor their opinions.

Howard Dean himself indicated that he does not belong to the AMA. It was  a very contentious meeting. Dan Palestrant who spoke for SERMO and it’s 110,000 members focused on the need for tort reform and reimbursement reform. Howard Dean expressed his belief that doctors on salary would do away with the demons of our present system. Palestrant focused upon level of reimbursement being adjusted for level of training. Dr. Palestrant indicated the AMA has a self serving interest in reimbursement since it holds important copyrights to the CPT (current procedural terminology), which all insurance companies and Medicare, as well as DOD, and VA system use on a daily basis. (ie,insurance companies pay the AMA for their right to use CPT codes.) The AMA garners a great deal of income from that source. The interview was too short, abbreviated, and neither participants had sufficient time to give a coherent presentation to lay audiences.

I think the most important take away was that a large group of physicians had a national platform other than the AMA. Hopefully Congress has paid attention.

SERMO and the AMA

Daniel Palestrant MD of Sermo discusses health reform issues with Howard Dean, former Governor of Vermont

Health Reform....is Health IT mandatory?

One of the greatest discoveries a man makes, one of his great surprises, is to find he can do what he was afraid he couldn't do. Henry Ford

 

[Shades of the Past!

 

Jeff Marion of  EHR watch .com shares this commentary from Shahid Shah.

Guest Article: Why do Doctors Hate EMRs???

There is also an audio cast on the web site, for those who like to multi-task, listening and /or reading content.

Some interesting quotes regarding the appraisal of typical EMR software.

How do we know doctors hate EMRs? Look at anemic adoption rates.

When such features as e-prescribing, e-visit, and PHR integration are considered, it is likely than less than half of physicians use their EMR for little more than their own templates and a few favorite features. The majority of physicians have voted with their feet.

In the business community it is common to hear doctors referred to as computer-phobic and “in denial” about the benefits of computing. That is wonderfully ironic when heard alongside chronic complaints that doctors are overly eager to use expensive technology: lasers, cryro-probes, fiber optics, MRI and PET scanners, stents, and implants. The fact is that doctors love high-tech.

They have reason to hate EMRs but not computers and iPhones.

Most physicians receive their first scars at the hands of hospital software. The truly unlucky have experienced a software installation with conversion from paper to EHR.

Physicians know that better exists. They have experienced Google, Amazon and e-Bay. Game lovers know that Electronic Arts’ “Tiberium,” now 15 years old, exceeds the capabilities of their professional health care software. They know from Yahoo and MSN the value of configuring a home page suited to delivering niche-information of their own preference. They know from using Word and Word Perfect that they can create precision documents merely by tweaking a template. They know they can use voice commands to make a phone call on their Blackberry.

They know that they can find drug information more easily on Google than proprietary software. They suspect that if their EHRs and EMRs had physician-specific home page functionality, that they could drop and drag orders, answer FAQs, dictate letters, and save time with templates with many fewer clicks. Ordering medications should be as safe and uncomplicated as using E*Trade.

Today most EHRs and EMRs are invasive both to workflow and finances. While high cost is a significant barrier to physician adoption, workflow disruption remains the killer deterrent.

An example demo patient, a return visit for an office visit, was typical enough: an obese, diabetic female smoker with a pulmonary problem. Everything was point and click: select, enter, click, read, post—again and again, over and over. The visit timed out at 30 minutes (their calculation, not mine) not including the time spent by a nurse’s clicks and front-office clicks. Allowing for physicians’ differing styles and based on difficulty, I’d expect this visit to take half that time. The record created was excellent. In private practice, at two patients per hour, and at this level of complexity—say 12 to 14 patients per day—one should expect bankruptcy. One would make a better living running a Dairy Queen.

A sign at a dry-cleaner’s shop reads: Low Prices, High Quality, Fast Service: Pick One. The point of EMR design is not to “pick one.” And, I am not advocating modeling medical practice after that in a remote mission clinic where the only record is a toe-tag, although I should recognize that mission outcomes are remarkably good. In the real world you get what you measure. If the metric is the chart, and you are willing to sacrifice time, then have at it. Also, in the real world, physicians are not usually on salary with no increment of production payment. Physicians do not hate high-tech and they do not hate computers. They hate wasting time; they cannot afford it, and neither can our health care system.

A Voice in the Wilderness

How many times do you or other specialists watch the current issues affecting medical care, and go back to seeing patients, either because of lack of interest, or more likely time pressures and patient care overwhelm your ability to deliver quality care to patients?

Specialists rely upon their societies to get the  news to the AMA via their specialty representatives or through their local and county medical societies and again through their state medical societies.  Is this effective?

CNBC Debate To Feature Sermo Physicians

Live survey results on CNN

Recently SERMO conducted a survey regarding physician opinions of the AMA's effectivenss in representing physicians. Does their public image and lobbying truly reflect the grass roots views.  SERMO's survey, although small seems to represent a far different view.  95% of the survey respondents said NO.  While there are some that this is  not a valid or scientific study, it does reflect a troubling issue brewing amongst physicians.  The study is biased toward physicians using "NEW MEDIA" , social networking and the internet.  Yet this is an important new vehicle which is more democratic than our previous organizational democracy. It also represents the young movers and shakers who will assume and be affected by health reform proposals.

For those of you unfamiliar with SERMO, it is a web based site with specialty sections.  It began with mostly clinical discussions about cases, and therapeutic interventions.   It grew over the past two years to include  practice mangement, political issues, ethics, philosophy, and medical issues. It is also a direct line to pharmaceutical companies, and others who can tap into the statistics developed from  comments on SERMO.

Be INFORMED, and render your opinions. !!

The Nitty Gritty

The following is part of a series of original guest columns by the American Medical Association.

by J. James Rohack, M.D.

Physicians started this month with some good news from the White House. After intense AMA education and outreach, the administration announced that it would remove physician-administered drugs from the archaic formula used to determine Medicare physician payment rates.

This important development will significantly lower the costs of a permanent repeal of the current payment formula that projects yearly payment cuts to all physicians. This is key. There is no debate that the current formula is broken, but the cost of permanent reform has stood in the way of long-term action. Instead, Congress has stepped in at the eleventh hour for the last few years to stop yearly cuts to physician payments that would harm seniors’ access to care.

Over the years, spending on physician-administered drugs ballooned from $1.8 billion to $9.1 billion, growing three times faster than spending on actual physician services. When government number-crunchers add those figures into the physician payment formula, known as the Sustainable Growth Rate (SGR), overall physician volume appears to go up. The growth target in the formula is then reached sooner, sending payment rates down.

The irony is that physician-administered drugs should never have been part of the formula in the first place. Payment rates for drugs are not determined by the formula, and utilization is primarily driven by pharmaceutical advances and government policies. The AMA has long argued that it is not equitable or realistic to finance the cost of these life-saving drugs through cuts in physician payments.

Permanent Medicare physician payment reform must be part of comprehensive health reform this year. Medicare payments should cover the increasing cost of providing care so that seniors can be assured of continued access to physician care.

Members of Congress on both sides of the aisle have stated that the Medicare physician payment formula is broken and should be repealed. President Obama’s administration has helped clear the way to Congressional action by removing drugs from the formula.

J. James Rohack is President of the American Medical Association.

Related Posts:

• The long road to health reform
• Medicare reform
• An article found on the road
• Voters versus lobbyists
• It starts with physician payment reform

Posted at KevinMD.com. Stay updated and subscribe or follow me @KevinMD on Twitter.

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