Mom's on the Health Train Express

This past month I turned 67 years old. Today is Mother’s day in America. Mother’s are the strongest and deepest bonds we experience in life. They are our first and lasting imprint on our minds, auditory, visual and sensory. Fathers are important, however Mothers are crucial to sons, and daughters.

My mother passed away five years ago at age 89. Her last three years were spent in an assisted living facility and towards the end she knew not my brother or myself. She became less lucid as the end approached. My brother lived near her and made sure her needs were met as to where she lived and he became the executor for her personal financial affairs. I lived some distance from her and had many of my own responsibilities, a disabled wife and very ill son. I will never forgive myself for not making time for her.

During the last few years of her life I would speak with her on Mother’s day and apologize for not being there with her. She would respond saying it’s okay you have your own family now, it’s enough you remembered me…it’s enough…..

It’s enough rings in my ears to this day. No, it was never enough and that clarified itself on these past mother’s day when my first and lasting thought  was to call her. It was not a thought, it was a deep emotional reflex, lingering throughout the day.

So Happy Mother's Day to all you Mom's....and boys and girls don't forget 'the mom".

del.icio.us Tags: mothers day,moms,bonds,sons,daughters

Today's Post on Health Train Express

I was up very early this AM and set off on my daily surfing of health blogs.  There seems to be a division of those who focus on patient encounters and clincal care isssue, both humorous, commonplace and very sad stories.  The other end of the axis are those blogs focusing on health IT, health policy and reform.

Matthew Hold on the Health Care Blog always seems to have a reservoir of important health policy wonks emoting good stuff.

I envy the guy for creating Health 2.0  meetings all over the world. What a gig!!

Anyway today he has

 

  David Kibbe,

ePatent Dave, and

Vince Kuraitis

all well known writers on a number of health blogs, discussing disruptive changes in health care.

ePatient Dave  brings this approach to our challenge:

"It’s possible to look at the patients issue from a moral or ethical perspective, or from a business planner’s ecosystem perspective. In this post we’ll simply look at it pragmatically: is our approach going to work? It’s our thesis that although you won’t see it written anywhere, the stage is being set for a kind of disruption that’s in no healthcare book: patient-driven disruptive innovation."

ePatient Dave's comments at the Meaningful Use Workgroup of the HIT Policy Committee revolve about the potential for Consumer and Patient Involvement

We assert that to disrupt within a non-working system is to bark up a pointless tree: even if you win, you haven’t altered what matters. Business planners and policy people who do this will miss the mark. Here’s what we see when we step back and look anew from the consumer’s view:

1. We’ve been disrupting on the wrong channel.
2. It’s about the consumer’s appetite.
3. Patient as platform:
   • Doc Searls was right
   • Lean says data should travel with the “job.”
   • “Nothing about me without me.”
4. Raw Data Now: Give us the information and the game changes.
5. HITECH begins to enable patient-driven disruptive innovation.
6. Let’s see patient-driven disruption. Our data will be the fuel.
We don’t hear it often in healthcare, but disruption Is driven by shifts in buyers’ appetites over time. As products improve, some buyers reach a point where “more” is no longer attractive.

If you view your health data as a modular component in the “health web of the future,” you see that today it’s tightly integrated – with your provider. That prevents you from seeking care elsewhere, and it prevents you from adding value to your own data by applying innovative tools. To us that’s harm. It’s not just restraint of trade, it’s restraint of health.

At one time in the not so distant past it was posssible for the patient and the provider to get the consultation from whomever the consumer and provider wanted.

 

Raw Data Now: Give us the information and the game changes.

People often ask, “If we give you your data, what are you going to do with it?” We don’t know – that’s the point: innovators haven’t gotten their hands on it yet!

Twenty years ago Tim Berners-Lee invented the Web. In his TED talk a year ago he told why: he worked in a fascinating lab, and people would bring fascinating and useful information on all sorts of computers. “I would find the information I wanted in some new data format. And these were all incompatible. The frustration was all this unlocked potential.” He proposed the Web: linked data.

It can be hard to see huge potential in a simple change. After Tim’s boss died, the original proposal was found in his papers. In the corner he’d written, “Vague, but exciting.”

Tim’s next big vision says today’s internet stops short: it lets us see other people’s interpretations of datasets, not the data itself. So his 2009 TED talk agitates for change. By the end of the talk he had people chanting,

“Raw Data Now.”

 

Healthcare in America

 

What do you think about healthcare in America? This question was poised by

Deloitte in a recent survey

Survey Highlights

• 76 percent of consumers grade the system as “C” or below.
• 48 percent believe that more than half of health care money is wasted.
• Less than a quarter (23 percent) of consumers believes they understand how the health care system works.
• 42 percent of consumers surveyed support government-required health insurance compared with 38 percent who say they are against it.
• However, 42 percent say they would choose an employer-sponsored plan over the government’s (25 percent), all other factors being equal. Among the uninsured, a government-sponsored plan is favored (38 percent vs. 28 percent).
• One in three consumers believes that the market needs 10 or more insurance companies competing to ensure consumer choice.
• 7 out of 8 consumers believe themselves to be in "excellent," "very good" or "good" health yet, more than half (54 percent) have been diagnosed with one or more chronic conditions.
• Only one in five (22 percent) participates in a wellness program.
• A quarter (24 percent) of consumers remain confident about managing future health care costs, but of the people who skipped care when sick or injured, 4 out of 10 did so due to cost.
• More consumers are seeking alternative or natural remedies before seeing a physician (17 percent in 2010 compared with 12 percent in 2009) and more consumers are supplementing their current regimes with alternative remedies (20 percent in 2010 vs. 16 percent in 2009).
• One in five consumers rates their interest in accessing their health records by a secure Internet connection as high, would switch physicians to obtain access and would be very likely to use a mobile communication device to maintain them. However, only 10 percent report having a computerized personal health record (PHR).
• 15 percent of all consumers say they used a retail clinic in the past 12 months.

HIMSS and HIE

 

The playing field in health information data exchanges amongst vendors is beginning to look a lot like EMR offerings several years ago.  However, today there appears to be a de-facto standard set by CCHIT.  It remains to be seen if the feds will mess this up, too in their quest for 'higher standards' such as NIST.

The recent offerings were displayed and discussed at HIMSS 2010, which can be found here...............

As the marketplace continues to gain calories, a number of vendors in EMR, and even mobile platforms are jumping into the fray

You can take at some of these offerings here:

Inter

Systems Healthshare

inFrame (Medecison)

Axolotl

Medical-Data-Exchange Verizon

CONNECT  (NHIN Open Source)

KLAS is a reputable consulting company that evaluates software and certification standards.  They offer a white paper regarding EMRs and HIE offering for both providers, consultants and vendors.  They offer an overview and analysis of the current state of data exchanges throughout the United States.

State Run High Risk Insurance Pools

 

The date has passed for states to notify the Feds whether they will accept additional responsibilities for uninsured patients.

The New York Times reported on Friday,

"Friday is the deadline for states to tell the Obama administration whether they want to run the high-risk insurance pool for uninsured people with pre-existing conditions, or whether they will leave the task to Kathleen Sebelius, the secretary of health and human services."

 

Some states such as California already have a Major Risk Insurance Board, and some funding for the uninsured through the Major Risk Insurance Program. The coverage is not inexpensive, has a low cap, but does subsdize the plan using not Medi-cal, but programs such as Kaiser Permanente, Bllue Shield, and others depending on the region of California.  If one can afford it, it does work well, and is transparent to providers. ie, it looks like private insurance.  (meaning the provider does not have to be a medi-cal provider.

"Democratic officials in Montana, Pennsylvania, Washington and Wisconsin, among other states, said they intended to operate the program under contract with the federal government. They were joined by Gov. Arnold Schwarzenegger of California, a Republican, who gave a rousing endorsement of President Obama’s health plan at a news conference."

 

 

"But Republican officials in Georgia, Indiana, Nebraska and Nevada turned down the opportunity to run the high-risk pool, as did at least one Democratic governor, Dave Freudenthal of Wyoming."

More...........

del.icio.us Tags: new york times,major risk,medi-cal,uninsured,sibelius,HHS,California,Georgia,Schwarzenegger

Primary Care....What is THE Problem?

Now that health care reform has been passed, attention is being given to the shortage of 'primary care'.  What is the problem?

1. The new "politically  correct term 'Primary Care' Provider,rather than family physician, or general practitioner. This lumps MDs in with NPs. PAs, MedicalCorpsmen, and who knows what else.  (would you go through 4 years of college, 4 years of medical school, and 3 or 4 years of serfdom as a resident to be 'lumped in '

2. The enormous amount of non clinically related administrative tasks and secretarial work to be done each day. A recent article by Richard Baron MD in the NEJM chronicles the day in the life of an internist.  This publication is a MUST READ for anyone in pre-med.  It gives an accurate appraisal of what to expect if one selects to become a general internist or family physician.

In addition to the daily acts of diagnosis, treatments, and minor procedures, these generalist internists did the followng:

• Made 24 telephone calls
• Refilled 12 prescriptions (a vast underestimate of the daily refills, since a) the number reported in the study doesn't count refills done during an office visit, and b) the study counted the act of refilling 10 meds for a single patient as one refill)
• Wrote 17 e-mails to patients
• Looked at 11 imaging reports, and
• Reviewed 14 consultation reports.
• Beyond what happens during the 18 patient visits, the docs perform nearly 80 acts of data exchange and review each day. After Rich’s practice analyzed this workflow, they re-defined a “full-time physician” as one with 24 scheduled visit-hours per week, embedded in a 50 hour work-week. In other words, docs in Rich’s practice can expect to spend half their time on office visits with patients, and the remaining half on non-visit paper/computer/telephone work.

I would say that the number of patients these physicians see is very very conservative.  From my experience it is much more like 25-30 patient encounters a day.

Now I am NOT saying this is a bad thing.  Many young aspiring students go into medicine for this vision of their careers.  In fact most go into medical school, either undecided, or want to become a family physician either because of a personal experience with their own family's physicians or a personal life experience from an illness or that of a family member.

 

3. The fatal flaw of the CPT procedural coding system aligned with performing procedures rather than the extent of complexity and cognitive work for the event.  This results in an enormous disparity of income for generalists and specialistss.

4.

Military Medicine Funding for Regional Extension Center

Continuing this week's summary news Better Health created a series of video interviews at HIMSS.  You will find it here. Thanks to Val Jones, MD and Dr. Anonymous.  The range of interviewees extends from Sprint to Epocrates.

Increases in Health-Care Costs Even Worse in Military

The military’s latest enemy: rising health-care costs.

The Governor's Healthcare IT Conference

How Smartphones are Changing Healthcare for Physicians and Providers

 

New Regional Extension Centers Might Lack Proper Funding, Staff

from today's iHealthbeat:

Regional extension centers might be too understaffed and underfunded to provide the help health care providers need in adopting electronic health record systems, according to a recent study in the journal Health Affairs, American Medical News reports.

The 2009 federal stimulus package includes about $640 million to establish regional extension centers to help small health care practices become meaningful users of health IT.

HHS has awarded funding to establish a total of 60 centers throughout the U.S.

Study Findings

The study, funded by the Commonwealth Foundation, reviewed 29 existing programs that aim to help health providers with EHR adoption.

The study authors concluded that those working at the extension centers should have direct experience with small practices and technical knowledge -- a combination they say is difficult to find.

The researchers noted that many health care practices have difficulty selecting an EHR system and that extension centers are not providing adequate assistance in that area.

Researchers also warned that regional extension centers might be unsustainable due to inadequate funding. They noted that similar projects in Massachusetts and New York spent on average 10 times as much per targeted physician than the stimulus package funding provides (Lewis Dolan, American Medical News, 4/28).

Is  it possible that this will be an unfunded mandate?  Will state governments or university systems have to foot the rest of the bill, and will they?  Certainly this may fuel a new wave of employees, but who will pay them?  The 40,000 dollar incentive per physcian says nothing about the cost of selection, implementation, or operational and maintenace costs.

google Tags: commonwealth foundaton, HITECH, regional extension centers, federal stimulus package, ehr

Nouns or Verbs??

The infusion of information technology is not unique to health care. Technology is not a standalone black box sitting in the corner of the office or in a closet.  Those in the technology industry are now recognizing the importance of integration and to bring 'game changing ideas' to the market place.

Is technology a noun or a verb?  I think you will find this speech by Anish Chopra, the Chief Technology Officer for the United States. interesting.

Does eHealth technology such as email lighten the burden for physicians or does it impose additional responsibility upon them whether they are reimbursed or not?

A study published in the New England Journal reveals this counterintuitive finding. Simple is as simple does; More time on EMR or EHR, less time with patients, not the reverse.  Tell that one to the policy makers.  Okay I can spend an additional 90 minutes a day filling in the boxes and checking off the drop down menus and see 6 or 7 fewer patients.  That will really increase the shortage of PCPs.  And what about the  nonsense of coding for email and telephone calls.  Please, how is

the nation going to pay for that, not that MDs do not deserve to be reimbursed for their time.

The leaders of our government have a very strange thought process, or they are liars and have a hidden agenda.

And now something we as MDs have always realized, the not so hidden cost of sending a bill to the patient and the payor.

Another study performed at the Massachussetts General Hospital and published in Health Affairs (abstract)  (full pdf article), explains how  " The U.S. system of billing third parties for health care services is complex, expensive, and inefficient. Physicians end up using nearly 12 percent of their net patient service revenue to cover the costs of excessive administrative complexity"

 

Table 1:   Financial Cost of Administrative Complexity

Table 2:  

Administrative Complexity Burden In A Physician Organization’s Professional Billing Office

 

 

google Tags: information technology, primary care, ehealth collaborative, new england journal of medicine, email

Meaningful Use, ONCHIT

Today's  offering is a collection of web reference sources, and video keynotes regarding the Office of The National Coordinator for Information Technology.

 

 

Electronic Health Records Critical to Effective Reporting of Quality Measures Says ACP

 

David Blumenthal MD on Meaningful Use of EMR. Dr. Blumenthal is the National Coordinator for Health Information Technology His Keynote Speech is 20 minutes into the video.

 

A Parallel Universe  David Hesse, CEO Sprint/Nextel

Dramatic Challenges and Changes in Health Communications

Mobility Technology and it's use at the Point of Care

Compelling Health Information Solutions

4G, What's in it for me?

HITECH ACT------THE BILL-----PHYSICIAN INCENTIVES

There is much buried in this legislation....a worthwile  read, even if only a quick scan

Competition for Certification Authority

CCHIT

DRUMMOND GROUP----THE COMPANY

 

????  During the last four years EHR vendors have formed the alliance called CCHIT, to establish the standards for interoperability of disparate electronic health records.   A large number of vendors have already complied with this standard.  In fact many potential users have taken a wait and see attitude because of the lack of a standard.

ONCHIT had recently announced that it would seek out other potential certifying bodys (ie, COMPETITORS) before adopting one standard.  Thus far there has been only one other competitor (THE DRUMMOND GROUP).

Growth and Consolidation of the EMR Industry

 

The passage of the ARRA and HITECH Act creates a mandate of 19 billion dollars to the health IT industry.  This creates fierce competiton amongst HIT vendors for these dollars.  Mandates are not the same as actual funding.  We see this in many other situations.  Let's hope the government will be capable of following through on the congressional mandate.  It's a bit like California's situation, or the year end delayed or non payment of medicaid bills each year. The government  is free to back out of mandates from congress unless all hell breaks loose.

Vendors will be quick to offer their solutions, even if deficient, inefficient for physicians to implement and use.  Feedback from physicians remains critical, otherwise solutions will remain stagnant if they can continue to market and sell poor software. There will be no driving force to improve with research and development.

Physicians and hospitals must vote with their pocketbooks, rather than aceeding to government mandate to 'buy something' whether it suits our needs  or not. In my opinion if caution and deliberation are bypassed much of the investment will be a total waste.  The time frame for implementation fits someone elses needs not that of the health care industry.

 

Austin Merritt points out the current state of affairs amongst the software companies .

• NextGen – One of the “biggest names” in EHRs, NextGen focuses on medium to large enterprises. However, its system is certainly able to scale down to smaller practices. While it is often too expensive for groups with less than ten physicians, it has a strong position in the sweet spot of the market. Its .Net-based system is sold both directly and through a channel network, so NextGen is a good fit for Microsoft.
• GreenWay – GreenWay has a nice product, but is toward the smaller end of the companies on this list. It sells primarily directly and has some channel partners. PrimeSuite 2008, its EHR and practice management sytem, is .Net-based and is popular among small and mid-sized groups. Microsoft could leverage its resources and Greenway’s technology to become a major force in the industry. Moreover, Greenway doesn’t come with any legacy of old architecture or acquired customers.
• Pulse – Pulse has quickly climbed its way into the ranks of bigger EHR vendors and will likely stay here for some time. They were one of the first vendors to achieve 2011 CCHIT certification and are receiving a lot of buzz as a result. While the system is scalable and .Net based, Microsoft would likely want to pursue bigger fish for now.
• Aprima – Aprima (formerly known as iMedica) has focused on its .Net framework and N-tier architecture from the beginning. As a result, its modern platform and interface make it widely received among physicians across a broad range of specialties. While Microsoft would likely focus on larger companies first, Aprima could be a nice additional partner to champion .Net.
• AllScripts/Misys – A large brand and a publicly-traded company, it is a logical first place to look. After all, the company claims to have 160,000 physicians using its products. However, the 2008 merger between AllScripts and Misys presents the usual integration challenge, which might keep this firm busy for quite a while. Although we think the future of AllScripts/Misys is very promising, Microsoft probably wouldn’t get involved at this point.
• eClinicalWorks – This system is probably the most ubiquitous of the list, especially among smaller practices. The recent deal to sell eClinicalWorks through WalMart will definitely increase its brand recognition and share of the market. However, the system is built in Java, an open programming language that is the traditional enterprise alternative to Microsoft .Net. Microsoft would most likely rather acquire a pure .Net system or one that is at least close to it, especially with Oracle, IBM and SAP all embracing Java.
• Eclipsys – Eclipsys acquired MediNotes in 2009 in an attempt to move users to its Peak Practice EHR. While Eclipsys is fairly popular among hospitals, Peak Practice has not achieved similar success among small to mid-size outpatient practices. Existing MediNotes users are not thrilled about being forced to purchase Peak Practice and we’ve seen quite a few seeking a new solution from a new vendor. We think the success of the MediNotes deal is unclear and Microsoft would steer clear for now.
• Athena – The youngest company on this list, Athena’s product offering is slightly different from the others. Its system is offered via software as a service (SaaS) and is combined with outsourced billing and revenue cycle management services. This offering is indeed unique, but not a suitable target for Microsoft due to its SaaS offering and labor-intensive service component.
• Epic – This company possesses an interesting niche in the market. It has only 190 clients, but 150,000 physicians using its products. This is due to its focus on only the largest healthcare organizations in the United States. While this focus is great for Epic, it wouldn’t be effective for Microsoft. Epic will never be able to achieve the ubiquity in the small to mid-sized market where Microsoft dominates. It also sells direct, contrary to Microsoft’s traditional indirect sales mode.
• Cerner – Cerner’s cash cow is Millenium, a product designed primarily for hospitals. PowerWorks, its outpatient EHR, does not possess the market share among physician practices that Millenium enjoys among hospitals. While Cerner is a recognized name, few practices consider PowerWorks. It is also an older system. Cerner would need to improve its PowerWorks offering before becoming a suitable target for Microsoft.

His analysis was based upon a possible acquisition strategy by Microsoft

Back to The Future

 

 

Sorry for the absence. It's been a bit hectic while the Health Train travelled from Georgia to Southern California. (from green to brown)....from bugs to lizards and snakes.

I am on a sabbatical and expect to post much more from here.

I now have an internet connection and am able to catch up on some of my favorite bloggers,  KevinMD, Dr Wes, Edwin Leap, Medinnovation, and more, most of whom are listed on sidebar, with their links.

I admit I have been blog and healthcare reform fasting. I am not totally in 'remission' yet. I am weighing whether to continue my avid interest and advocacy for continuing health reform. I feel I need to contribute to bettering our health system.

The next ten years will see radical changes in health care delivery.

Some of what was once thought of as 'unethical' by practitioners will become commonplace.

The rise of retail medical clinics will continue unabated, and the scope of their practice will extend to management of hypertension, diabetes mellitus in addtion to other common maladies of body and spirit.

To survive, primary care practices will need to adopt electronic information systems, not just to increase efficiency, but to satisfy insurance and governmental requirements to obtain complete reimbursements, without penalties.

Retail medical clinics already employ these systems and are an integral part of their operations.

Physicians will either adapt or be swept aside. We must prepare the next generation for what they will deal with once they are finished with medical school.

Medical education itself is undergoing a transformation in funding.  The federal government has bypassed private banks for funding undergraduate medical education.  This will allow the federal government to specify who will get financial assistance,as well as  possible later waivers on loan repayment.  Medical students may be required to sign a contract agreeing to serve in underserved communities or less desirable practice locations. Perhaps it may be year for year.  These students will become civil servants.  They will be required to develop multi-cultural skills, and to demonstrate their literacy and verbal skills in Spanish.

The lack of enrolling minority groups, African American and/or Latino will encourage the federal government to aid schools by forcing them to accept lesser qualified candidates for acceptance to medical schools.  This does not appear to be a problem for Asian students who mostly excel in secondary and undergraduate colleges.

The "cell" generation will generate a strong market pressure to allow developers to build EMRs that will run on smartphone, such as the iPod.  These systems will integrate almost seamlessly with the office EMR  and/ PM systems.

Patients will no longer use a yellow page listing to find providers, they will utilize the internet, and at times find poor providers. Ths will drive state and federal officials to require documentation to be listed on internet search engines.  Commercial web sites such as healthgrades will not be a credible source for paid listings.

Despite the evolution EMR and Health IT, it will be found to not  save money or enable providers.  In fact it will reduce provider efficiency unless they are radically designed to be user friendly as a priority over meaningful use.  The term meaningful use will have been discarded, to be replaced with "Specialty specific Design. Meaningful use with be specific for each specialty.

Remote telemedicine and monitoring will become commonplace. The Federal and State governments will adapt their reimbursement method to pay for most of these costs when an analysis reveals that remote monitoring reduces inpatient admissions drastically,  and reduces the number of outpatient visits. 

All  of the home devices will be wireless and connect automatically to the home network and the specified instrument monitoring service. For those without broadband, dial up will be an alternative.  Just as providers now are required to have a national provider identification number, patients will also be assigned one at birth or on the occassion of their next birthday. The number will be unique to the medical system for a number of important security issues, and prevention of fraud.

Written signatures for consents, hospital admission and discharge and medical office registraton will be supplanted by biometric identification, either infrared fingerprint recognition or iris recognition.  It will no longer be necessary to provide an insurance identification card to a provider or hospital. 

Freedom of choice will be reduced for most patients.

 

google Tags: wireless, home medical, home telemedicine.

Health Insurers Investment in Fast Food

Food for Thought??  from The WSJ Health Blog

Should life and health insurers be investing in the stocks of fast-food companies?

Researchers at the Cambridge Health Alliance, which is associated with Harvard Medical School, say no, citing the downside of fast food — associations with obesity and other health problems, heavy marketing to kids and the the chains’ environmental impact. Insurers, however, do have a responsibility to share- or policyholders to maximize returns, and that may include investments in companies that don’t share their health-promoting mission, they say.

Sensing that potential disconnect, the Cambridge researchers set out to find out the value of major insurers’ investments in the five leading fast-food companies:

 

Jack in the Box, McDonald’s, Burger King, Yum Brands and Wendy’s/Arby’s. Based on shareholder data from the Icarus database, they calculated the insurers’ combined fast-food holdings totaled $1.88 billion as of last June. Their findings, including a breakdown by company, are published today in the American Journal of Public Health.

However, as with a similar analysis last year of tobacco stock holdings by insurers, companies disputed the numbers. MassMutual spokesman Mark Cybulski says the study’s calculations of $366.5 million were “absolutely incorrect.” In an email, he didn’t give an alternative number for June, but said that as of Dec. 31, the insurer’s fast-food related holdings were $1.4 million in a portfolio totaling $86.6 billion in cash and invested assets.

Northwestern Mutual held $422.2 million in fast-food stocks, according to the study; spokeswoman Jean Towell says that number is in error. At the time the data was collected the company had less than $257 million in holdings, about 0.19% of its general portfolio, and now that’s down to about $248 million, or 0.17%, she says.

Prudential Financial spokesman Bob DeFillippo said he couldn’t verify if the study’s $355.5 million calculation was accurate, and added that Prudential never talks about individual holdings, anyway. And, he says, many of the stocks are likely held in index funds for clients, meaning the insurer didn’t select the stocks but held them usually only because the stocks were index components.

Study author J. Wesley Boyd, an attending psychiatrist at CHA and assistant professor at Harvard, defends the numbers, saying according to the database they were correct. He says the U.S. companies studied were primarily life insurers and don’t sell health insurance per se, but that some of the Canadian and U.K. companies covered in the study do sell health insurance.

Why should we care whether a life or health insurer invests its money? “They’re profiting directly off the people who eat fast food, and if that leads to obesity or cardiovascular disease, they’ll charge you more for premiums if you have some of those conditions,” says Boyd. “They’re making money in either case.” The researchers say another option besides divestment is becoming activist investors in fast-food companies to push for changes such as lower-calorie menu options or different marketing policies.

Choosing a career

I remember chosing medicine as a career because I wanted to use whatever talent I had to help patients with their health and lives. At that time I was studying engineering. I was one of those people that could not make up their mind what I would do with the rest of my life. I would pick a topic, master it, and then move on to the next interest. Even after I earned my medical degree it took some time for me to pick a specialty. I stopped for a bit of time to direct an emergency medical group and practiced general medicine for several years. It was very interesting and stimulating. Perhaps I learned as much in those four years as I did in medical school and internship. I had no problems in finding specialists to manage problems that went beyond my relative inexperience to help my patients where I left off.

I left emergency medicine because at that time it was not a recognized medical specialty, and only after I left was the specialty formalized with board certification. I was one of the founders of the American College of Emergency Physicians. However I did not see a 'future' for me in ER medicine. There was little if any long term patient involvement.

I rarely had any follow after the patient was discharged from the ER, unless they were admitted. I also found out quickly that ER physicians do not have hospital privileges. (perhaps this has changed). Surgeons, orthopedists, internal medicine doctors openly looked down on ER doctors as those who did not or could not finish specialty training. Becoming an ER doctor had a negative implication on your intelligence and capability..

In those days it was a challenge to have a specialist come in to see an ER patient. Many were uninsured, and less than socially desirable patients. (things have not changed very much), although more patients, and even those with insurance resort to the ER when their physicians are not available. It has always functioned as a pressure relief valve or safety net for those otherwise unable to see a primary care doctor.

There are many reason why medical students chose not to enter general medicine..

The status of nurse practitioners and physician assistants has been elevated to the point where they can diagnose and/or treat 90% of common problems, and they do not have to have hospital staff privileges. Throughout medical school, unless one is fortunate enough to have a family medicine or clinic rotation the general consensus is that the best and brightest do not enter primary care medicine. Those who chose this field are looked askance at and trivialized as not requiring advanced clinical skills. The training programs are top loaded for gaining skills not at medical school, but later in postgraduate training, beyond the internship.

The reimbursement equation has not favored primary care, pediatrics, or internal medicine. The American system is based on procedural coding, not cognitive time or processing. Even the codes presently in existence for evaluation and management are inadequate, especially for time intensive issues. There are no codes for administrative time, medical record keeping, telephone consultations, telemedicine, or patient education time, hence it is either left to medical assistants or worse, ignored entirely.

Health reform will not alter the science of medicine. It will obstruct the smooth flow of our activities, and create time wasting administration which physicians will pay for as an operating expense, whether in private practice, group or government medicine. Administrators have and will control executive functions and physicians

Physicians will continue to care for patients, do research, do surgery, have good and bad outcomes regardless of fines, audits, quality assurance, pay for performance, EMR, incentives, penalties or other nameless ideas.

google Tags: medical careers, specialty medicine, general practice, family practice, cpt codes, bureaucracy, cardiology