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Many physicians are wondering what that means, in the context of their clinical practice.
Here's my 'take' on the situation. 'It depends" on:
1. The day of the month.
2..What the feds and payors want to extract from your medical records.
It has nothing to do with your needs, or affordability
The latest insider information this week is posted by the HIT Policy Committee
So we have a moving target....and so do the software vendors.
For some specialties the term meaningful use is meaningless.
Four days from now the three ring circus begins (Dems, Repubs,and Obama) on Thursday and Blair House in Washington, D.C.
Finally (maybe)an attempt at transparency will take place. It's been over a year since these plans for health reform were 'reconciled' in closed room, with secret deals, and legislative trade offs.
I am sure it makes us all feel good to know our health care is now legislated in a back room.
I belong to several specialty group listservs and professional health care blogs. The tone on these forums has changed radically. One of these groups is an ophthalmology forum.
Many on this forum plan to announce this coming week they will no longer be accepting medicare patients in their practices. This, because of the March 1 deadline for a 21% cut in Medicare reimbursement. This figure is an accumulation of about 5%/ year which is the sum of the number of times this cut was delayed by last minute tack ons to legislation delaying the reductions.
Undoubtedly this will occur again, but only by an uprising of protest by physicians and patients.
They will all downsize, and shift their professional efforts toward elective non medicare reimbursements. Those who still have choices will make them according to responsible measures and 'balanced budgets. Unlike our federal government we cannot print money.
If you are like me, then you are fed up with hearing about “bipartisan support” for health care reform. Most of us would like to see non-partisan health reform. The recent pronouncement from on high is about the coming conference between Dems and Repubs regarding health care reform. A dollar late and a dollar short.
Most interested parties could care less about ‘bipartisan support’. This wraps the process in a shroud of chaos and cloaks what the people really want and that is MEANINGFUL change in our health system, not just another step in the path to federalized and/or socialized medicine. The TEA (party), which is not a political party, but a movement amongst both Democrats and Republicans who agree that our federal government is out of control, not just in health care matters, and also violating constitutional guarantees regarding the limits of federal power as conceived by some very smart folks such as Thomas Jefferson, Ben Franklin and others.
Case in point: The recent election of Scott Brown in Massachussetts surprised most dyed in the wool Democrats, however it bespeaks the deep distrust of politics as usual in the “Cradle of Liberty”, now an oxymoron. The citizens of Massachussetts are burdened with their “socialized medical system”, in a state where the longest wait times occur for primary care (over 50 days). It’s not hard to believe that now, a heavily Democratic stronghold given what the ‘people’ really think about government health care, and it’s intrusion into medical care.
Do you have your parachute on?
No, I am not speaking about the ‘golden one’ that many CEOs and financial wizards seem to deserve for their “financial wizardry”.
I mean the one that you will need when you are swept off the cliff by the ‘lemings’ cascading before the onslaught of insurance companies, Medicare, software vendors, EMRs, RHIOs, P4P, QA and hundreds of other eponyms. Even as I back-pedal my feet slip closer and closer to the cliff of doom.
Sid Schwab in his most recent blog post of Cutting through the Crap seems to nail the problem on it’s head. (posted February 11, 2010…UNWORKABLE). It goes far beyond healthcare and medicine. It is a problem we physicians have recognized two or more decades ago. Perhaps it is not because we are smarter or more intelligent than other citizens, but we do seem to be exposed to more human suffering and tragedy as well as a cornucopia of human experience, both good and bad. For the longest time we were privileged to be able to rise above the morass and observe, without personal threat or financial anxiety. It gave us the benefit of a certain altruism and privilege of caring for people, not out of financial necessity, but of moral compass and humanity.
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.”
Obama's lieutenants (Heads of Cabinet positions and Departments) seem to make outrageous statements that any simpleton can see through. The first egregious mis-step was on the part of Secretary Napolitano (her name reminds me of an ice cream, a mix of pink, white, and brown flavors (like Obama's mindset).
Her initial statement that all went well with DHS's methods of preventing terror attacks such as the one on a recent airline flight, was quickly retracted and modified into a politically correct statement.
The next misstep was by the head of the Department of Transportation, that everyone owning a Toyota should stop driving it until a fix can be accomplished. Obviously again retracted the next day. Has Obama hired a bunch of idiots based upon political correctness? Let's not even talk about our attorney general. Afraid to back down and turn the terrorist over to military police, he has spun this story into the success measured by events which took place prior to the detention facility at Guantanamo and the organization of military tribunals.
Can we afford these kinds of mistakes in general, and what will happen to health care? Whoops I didn't mean to give you the wrong diagnosis.
Certainly our adversaries have noticed these incompetencies. And where is congress? Buried in a dark hidden 'transparent' room masturbating over health care legislation. Strong words, not politically correct, nor tasteful, but true.......
Bill Gates (former Microsoft CEO) announced a 10 billion dollar grant from the Bill and Melinda Gates Foundation for the development and distribution of vaccines to combat malaria. Vaccines against diarrhea, pneumonia and tuberculosis would save millions of children in developing world countries.
Mr Gates will go down in history as another Carnegie, Robert Woods Johnson, or Howard Hughes, Warren Buffet, George Soros, Li Ka- Shing.
One of my favorite bloggers is Placebo Journal.
This is borrowed from Dr. Douglas Farrago. Laugh on Dougie......Doug can be found on his own web site @ http://www.placebojournal.com/ I laugh so hard my liver starts to ache !! Doug is from Maine, so that explains much of his 'common cents".
Sound Familiar? by Michael Gorback MD
By noreply@blogger.com (Placebo Journal Blog: Medical Humor with a Purpose!)
I don't know how many of you have heard the new buzz about ACO's -
accountable cost organizations. If you have been following discussions
about Massachusetts health care you have seen this suggested.
ACOs are groups of doctors that receive a fixed amount of money and then
provide all of a patient's health care needs. I guess they figure they
can glue together a pediatrician, a heart surgeon, a dermatologist, etc
and make a cohesive group that provides one-stop shopping for all health
care needs. If the patient needs an MRI, the ACO pays for it. Hip
replacement, same thing. Labs, xrays, the whole deal. Kind of like an
insurance company, except now the doctors are the insurance company
without having any insurance company experience. We take in fixed
premiums and pay out benefits.
Does this sound like back to the future?This is basically capitation
revisited.
The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok
The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok
for everybody but doctors) they can control costs this way. After all,
you'll think twice before you rip out that kid's tonsils if you have to
pay for it. Considering deliberately mismanaging someone's diabetes so
you can get $50,000 for a BKA? Not if it comes out of your own hide.
I think it will succeed, because if you stop paying people to "do
things" they will pretty much stop doing things. In my specialty the
general goal for most of us is to get a patient's pain under control
with minimal reliance on pain meds. Some of these modalities are
expensive. A spinal cord stimulator lead costs $1500, and the battery
about 10x that. An intrathecal pump is about $10,000. These are hardware
prices. they don't include O.R., anesthesia, etc.
So here I am in my new ACO office and a patient comes in with horrible
pain from failed back surgery that has been refractory to just about
everything.
* I know a stim could potentially help a lot.
* However, I also know that if I go around putting $15-20,000 worth of
hardware into people my partners are not going to be happy.
* I also know that writing a prescription is far easier and much better
for my health than spending an hour in front of a c-arm wearing a lead
apron under hot lights. And I will make MORE money that way. Plus, you can't surf the Internet while scrubbed.
So what's going to happen? They gave me an incentive to not do things
and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in
and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in
some Phenergan for you. No wait -- that might drop your WBC. That means
paying for lab tests. Try some flat ginger ale. That's what my mother
gave me for a tummy ache. Excuse me, time to check my email.
This didn't work when it was called capitation. I don't see how it will
work this time, and I can't imagine how they plan to get doctors to join
into diversified groups without killing each other. Maybe it will be
assigned seating like high school. Maybe they have figured out how to
herd cats. Maybe the CIA has secret pheromones that will make us
cooperate like ants and bees.
I want to know what will happen when a patient hates the group's
endocrinologist and wants to go "out-of-ACO". Can you do that, or do you
send the doctor and the patient to counseling to work it out? What if
the cardiologist you want is in another group?
What if you are a very popular or famous doctor, in big demand? Can you
threaten to go to another ACO if they don't give you more money? Will
there be a draft for doctors coming out of residency? When can you
become a free agent?
The ACO's are also supposed to help "coordinate care". This is the new
buzz word. The old buzz word, "preventive care", turned out to be not so
good after the data showed that it actually costs more to do tests on asymptomatic people. Not to mention that a PAP smear or colonoscopy is not preventive so much as early detection. Smallpox vaccine is preventive. Tetanus shots are preventive. Colonoscopies find what's already there. Anyway, it's not like we have any control over whether or not you eat a large pepperoni pizza every night, washed down with a 6-pack of beer, and then a few relaxing smokes. Nor can we prevent gallstones, broken ankles, cerebral aneurysms
aneurysms
or about 99% of the things that afflict people even if they all live like Dean Ornish in an isolation bubble. Healthy diet, a good night's sleep, exercise, don't smoke, watch your weight, and get lung cancer like non-smoker-vegetarian-yoga-enthusiast-transcendental-meditation-teacher-and-successful-actor/comedian Andy Kaufman, dead at age 35.
Do they think this will be like Boston Legal, where all the partners sit
around a conference table and discuss each case? How many of us call our
colleagues after every visit to discuss the patient? "I'm sorry, Dr.
Futznagle can't come to the phone to discuss Mrs. Balderdash. He's
already on the phone talking to Dr. Squigglemeyer and then he has to
return a call from Dr. Fussypants. Can he call you back next week after
he finishes returning last week's calls?"
Even the Europeans aren't that stupid. To really screw things up you
need the United States Congress, which seems to think that reinventing
the wheel by making a square wheel with a broken axle is the way to
decrease gas consumption.
Yes indeed, that's one way to do it.
(figure 1): Short list of small ambulatory practices EHR.
I thought I would take a step back in time to when I was writing about EMRs, RHIOs and interoperability. The roots of this blog were in the Riverside Health Information Organization.
Time has evolved EMRs from a primitive form of data collection and storage to a more sophisticated form of data storage and collection.
EHRs now have had the benefit of time, and some longevity to develop and critique their short comings. The results thus far show the front runners in the great race to automate and interoperate. The above figure is from an "independent study" of Group One Health Source, sent to me in a private emailing by Andrea Biddle.
(figure 2) Short list of large ambulatory practices.
The differences in these two charts is small and probably represents the different markets that vendors have chosen to target with their offerings.
Health Train Express January 5 2009
In which direction are we headed? The WSJ reported that health care spending growth had diminished to 4.2% in 2008. the slowest rate of growth over the past forty-eight years.
Despite the slowdown, national health spending reached $2.3 trillion, or $7,681 per person, and the health care portion of gross domestic product (GDP) grew from 15.9 percent in 2007 to 16.2 percent in 2008. These developments reflect the general pattern that larger increases in the health spending share of GDP generally occur during or just after periods of economic recession.
This makes logical sense, since health needs never go into a recession….they continue no matter what the economy is. If the general economy outside of medicine contracts then health care expenses would represent a greater portion of the GDP. What is critical here is that for the first time in 48 years the growth rate diminished from near 16.2% to 4.2%. Let’s see how that sounds on CNN, MSNBC and/or FOX News.
It was a very nice quiet New Years on the Health Train Express. Fill in anchors on the networks and cable 24 hour media events, and less about healthcare.
Congress will be back in session very shortly and the fires will be stoked up.
A colleague of mine sent this to me. Common sense, common values, and a real friend to physicians.
Mike Huckabee (click to go to media)
If this doesn't warm your heart in this cold January week perhaps a raise in our reimbursements would. We are in a world of negative reward. We feel good if we stop the cuts, we think we have won a battle.
We all need to take the Mayo Clinic route. Give up Medicare.
Tomorrow I return to what I like most about medicine, Patient care. The rest of it is there supposedly to help me do that better. (not a reality)
A place where no man has gone before.
This might be a timely metaphor from Star Trek.
A 'crack in the wall' as a result of proposed health reform has already begun to form. As reported in the Arizona Republic, Bloomberg News, and The Health Care Blog, The well known and venerated name "MAYO CLINIC' in Glendale Arizona has announced that effective today, Januray 1, 2010 they will no longer accept Medicare for Primary care (formerly known as your family doctor). While this only affects five physicians at that facility, Medicare reimbursement for specialty care and hospitalization will continue to be accepted.
The amount patients will now have to pay for primary care will be about 1500 dollars/year.
Whether or not this is a 'trial balloon for Mayo will remain to be seen.
This does not apply to private or employer based insurance plans. It may also open a new market for private insurance plans to offer an option for primary care only coverage.
This of course radically affects the referrals to Mayo Clinic specialty care. It also shifts a considrable load to area doctors for primary care. It is not clear whether those patients who chose to go elsewhere will be able to be referred to Mayo for specialty care. Given the reputation of Mayo Clinic for "specialized care", this will probably be the case.
My head hurts. Maybe it's my hangover???
HAPPY NEW YEAR from Health Train.
gml
