Reform ? or Revolution !

From my post here you may discern that I was in the 'self pity' mode, last week, something which I like to do once in awhile...'why me?"

Well, I am over that now and into:

'I am mad as hell, and I am not going to take it anymore"  My next swing will be into "charge ahead...Don't look back".  I am sure (or at least hope) most of your can identify with this evolution of mood.

For the past 14 months I have been a civilian contractor for the U.S. Army...I have been 'laid off'....A consequence of the financial crunch facing state and federal governments. Unfortunately I was not the beneficiary of all that "stimulus' money". 

The health reform debate, continues in D.C., in the media, and around town. 

I could 'pull a week's worth of all nighters studying the bills and come away not knowing much more about what would work, and what would not work. 

Frankly as any working physician knows this is very complicated, and in a tight balance financially....changing one aspect would create ripples in the health care economy. 

Promoting the enormous changes in our present Health REFORM  bill would be 'revolutionary, probably counterproductive, and even REVOLUTIONARY.  Not bad, if it brings more freedom, more incentives, and rewards for efficiency.  Measuring outcomes is a slippery slope.  With rapidly evolving medical technology where do we set the bar? 

Health Train Slows Down

Things are a bit slow this morning. A welcome respite. I spoke to wifey, who is still on the "left coast' tending to our adult children, who seem a bit reticent to step off into the world we are leaving them. I thought I would be retired by now, or at least tending to an alternate career, reading, writing, sitting on the park bench playing chess....or on the beach....not so. At times I thought I had my whole life well planned and structured, fool me!!!.
This post is going to be mostly a long ramble...that's what happens when I have a few unstructured moments. For five years or more I have blogged on a variety of subjects, ranging from health information exchanges, EMRs, health reform, generalized sarcasm and humor as well as commentary on my fellow bloggers meanderings.
I often wonder how some of these "overworked" and underpaid younger brethren' have time to write so many blogs. (Do they have 'ghost bloggers' ??).
Some of my favorite medical social media sites are KevinMD,DrWes,Medinnovationblog,The Health Care Blog, WSJ Health Blog, Cutting Through the Crap (written by the former publisher of Surgeon's Blog), Buckeye Surgeon, DistractibleMD, and more.
My guiding light platform is bloglines.com

Like my blog ramble today, things turn on a dime. Just found out I will be 'retiring' on April 2, 2010....that will give me a lot more time to blog. Happy Hospitalist, watch out....you too DistractibleMD.

Hal Scherz will be happy that I have more time to dedicate to Doctors 4 Patient Care.

Perhaps I can find a position in government (I hear they are hiring with all the stimulus money)...

Anyone need an ophthalmologist? ....will work for food !! Pity

Health Train at Blair House

 

Between patients yesterday I managed to watch the health reform forum at Blair House.  Thanks to the power of video streaming I was able to follow most of it.

The conversation seemed to present most of the issues, and even malpractice reform was brought up (at a late hour).  President Obama did not respond directly to that issue but it was estimated that the savings would run into billions of dollars, not from premium reductions, but the secondary effects of  'defensive medicine'...This brought no response from President Obama. He seemed more intent upon pushing his own vision of health care.

There were some central core issues that  both sides seem to agree upon.

1. Elimination of exclusions for insurance coverage (Universal coveragw)

2. Expanding medicaid would be very foolish, since it is a system that does not work, and not credible for quality care.

3. DEms want to push on with this bill, Republicans want to start over. 

Stay tuned...

Meaningful Use of EMRs

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.

The Circus

 

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.

Bi-Partisan???

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. 

Parachutes (and balloons)

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.

How Much is a Trillion Dollars

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.”

You Lie, and Too Many mis-statements

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.......

Charitable Largesse

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.

Out of Office

I did not realize it's been ten days since I last posted here. Had to take an emergency trip to the 'left coast', but should be back in several days. Wouldn't you know it, I return to California not to sunshine but a big El Nino...5 days of pouring rain, mud watches and high winds.

A Cents of Humor

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.

Back to the Future??

(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.