Primary Care--What are the Barriers?

Last week I was invited to join Hope Street Group 2.0 which is focused on economic opportunity for professionals and practitioners. It covers a variety of areas.  One of them is health care.

They posed this question:

Re: What do you think is the biggest barrier to innovation in primary care?

Aaron Doty and Sarah Steinhofer  enumerated the following: (Hope Street 2.0)

"It is possible to point to a  number of barriers that limit the spread of innovation in primary care  (see some examples below).

Examples  of barriers to innovation in primary care

• Variations  across states in scope of practice regulations
• Reimbursement  rules and lower earnings overall limit the attractiveness of primary  care specialties
• Current training and practice in silos does not  support team-based work
• Malpractice insurance rules discourage  part-time work, especially for retirees
• Inadequate  access/utilization of health IT – telemedicine, electronic  communication, EHRs – restricts access in rural/underserved areas
• Administrative  burden of care coordination
• Design of new payment models is  complex
• Payment models (such as pay-for-performance) may  incentivize shedding of sickest patients, or penalize those providers  with more chronic & complex patients
• Lack of data analysis  capacity

Barriers  to the spread of particular models:
Retail clinics – concern  about fragmentation of care coordination, concern about loss of revenue  by other providers, lack of shared electronic record with PCPs
Accountable  Care Organizations – limited number of demonstration projects – new and  unproven payment mechanisms, lack of consistent specifications,  antitrust: perceived risk of collusion in the guise of care  coordination, loss of revenue from emergency presentations.
Patient  Centered Medical Homes – lack of clarity about essential features to  ensure quality outcomes, sustainability of savings unproven –  quality-funding link not built into the model, access to well-trained  care coordinators.""

 

I also suggest these additional issues:

In order to address the problem, one has to evaluate and anlyze what has caused the dramatic shift from general practice to specialty care, issues as great as reimbursement are only one part of the challenge..

Most analysts enumerate the disparity between specialty care and primary care..in reimbursment, and  more administrative issues in primary care

I added these additional issues and challenges:

Several factors have been at work over the past fifty years.

1.The urbanization of America has caused a flight of young and old to the urban areas to seek out 'culture', diversity,access to health care and economic opportunity .  This has caused a well known  phenomenon of an economic shift from small towns to larger metropolitan areas.

2. Our challenges in primary care have followed this trend.

3..Some of these  problems involve the social and economic millieu in which highly educated professionals desire to work, live and recreate.

4. No one can challenge the fact that physicians are amongst the most highly educated members of society.  This is not just a technical skill, but by exposure to multicultural diversity, general fund of medical and social, political knowledge.  Physicians do want to serve, however are very reluctant to place their  families in areas that do not offer the best education or cultural opportunities.

4a.. Spouses generally drive where the physician choses to live in the long run. To do otherwise usually ends up in divorce.

5. Physician recruiting from rural and underserved areas is fraught with challenges, to attract bright inquisitve p eople who may be challenged by underachieving schools and other social and family barriers,both economic and other.  Many of these young potential physicians see education as a road out of their community, for many good reasons.It would be interesting to evaluate what percentage of physicians do return to their home to practice in their community in which they grew up.

6. Programs developed with economic incentives such as loan

 

forgiveness with contractual obligations provide some basis for supplying these areas, however what percentage of recipients remain when their time is up?

7..Although not as frequent in today's educational structure were those physicians who would practice general medicine for several years and then specialize.  The elimination of the  free standing internship with a possible break to work and perhaps look at a long term view of general practice has virtually destroyed this mechanism to produce general physicians

8. The well meaning elevation of family practice to a recognized specialty created the necessity to become board certified in family practice to be credentialled at hospitals and also insurance companies.Insurance companies are now 'driving this boat", Because specialty care pays so much better, one asks the question, why spend two to three years becoming eligible for a family practice credential, why not spend the same amount of time training to become 'specialty trained."

del.icio.us Tags: primary care,specialty medicine,urban,rural,hope street group

How Relevant is CCHIT in the HITECH era?

 

Chris Thorman in an article on CCHIT and HITECH elaborates on the 'new issues' posed by HITECH.

For nearly four years, the Certification Commission for Health Information Technology (CCHIT) has been the lone entity recognized by the federal government to certify electronic health record systems. Since being named a recognized certifying body by Health and Human Services (HHS) in 2006, CCHIT has awarded certifications to nearly 200 EHR software products based on CCHIT’s standards of functionality, interoperability, usability and security.

However, CCHIT’s role in the EHR market is changing. The Office of the National Coordinator of Health IT (ONC) and the Center for Medicare & Medicaid Services (CMS) announced in early March 2010 that they would name more than one organization to certify EHR software, countering previous claims that CCHIT would become the sole certifying body.

Read more at  http://www.softwareadvice.com/articles/medical/emr-ratings-how-relevant-is-cchit-certification-in-the-hitech-era-1061410/#ixzz0sLyLuNYQ

Take the SURVEY

 

This points out the difficulties of having federal intrusion into the daily working of medical care and technology.  He who signs the checks makes the rules.  Not only is that a factor, but the rules change.  Mandates are made and only a small percentage of these come to pass.  Pilot studies and demonstration projects are planned, implemented, and studied.   In a recent article

The Road to Wellville: Pilots and Demos?

By ROGER COLLIER

in The Health Care Blog  he states:

"Just how important are all these pilots and demos?   Harvard’s David Cutler, who served as a key advisor to the Obama administration in developing the reform strategy, clearly believes they are vital. Writing in the June Health Affairs, he stresses the need for rapid implementation of the pilots and demonstrations in order to help achieve eventual savings of “enormous amounts of money while simultaneously improving the quality of care..............The simple answer is that few providers will participate in a pilot or demonstration if it’s likely to cause their income to drop. As a result, CMS must attract “volunteers” with generous promises of shared savings or payments for additional services –essentially, bribes to compensate for lost revenue and the time-consuming process of dealing with CMS bureaucracy. So far, the bribes have outweighed the savings in almost every case. Worse still, and often overlooked in evaluations of pilots, participating providers are likely to be those most able to achieve savings—the “good guys,” rather than the typical—with resultant optimistic skewing of the results........................Results suggest that some of these programs may have modest effects on the quality of care and mixed impacts on Medicare costs, with most programs costing Medicare more than would have been spent had they not been implemented….

In almost all cases, the cost to Medicare of the intervention exceeded the savings generated by reduced use of inpatient hospitalizations and other medical services.”

 

Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies. He is editor of Health Care REFORM UPDATE [reformupdate.blogspot.com]

Chris Thorman came to Software Advice after working in politics and with international non-profit organizations. He's originally from Kansas City and has been blogging about the Chiefs at ArrowheadPride.com since 2006. His articles have been mentioned in the New York Times, Wall Street Journal, Washington Post, Business Week, Sports Illustrated, ESPN and NFL.com. Currently, Chris resides in Austin, TX, with his wife Nichole and dog Winston.

Read more: http://www.softwareadvice.com/articles/medical/emr-ratings-how-relevant-is-cchit-certification-in-the-hitech-era-1061410/#ixzz0sM53feyY

 

del.icio.us Tags: software advice,healthtrain express,pilot projects,demonstration projects,CCHIT,HITECH,EHR,Chris Norman

Amazing Technology

No doubt, health information technology is the "Penicillin" for the business and record keeping digital age.

Some of us seem to be 'allergic' to the technology, so they keep an ampule of epinephrine in the form of pens and pencils in their pockets to prevent anaphylaxis.

HIT, EMR, HIE are truly the amazing outgrowth of silicone wafers, printed circuit boards, integrated circuits, mosfets, microprocessors, RAM, ROM,hard drives, solid state drives, LCDs, LEDs, engineers, software, and cheap labor in Asia.

We have gone through several decades of explosive technology in diagnostics and therapeutics. Some of the latest 'gadgets" are outlined below, 

THE LAB ON A CHIP

A new microfluidic device from the University of Southampton, called single-cell impedance cytometer, is being reported in Lab on a Chip. The technology promises to perform a white blood cell differential count in a tiny package from a puny sample.

FIRE YOUR OPHTHALMOLOGIST or buy an eyePhone

Researchers at MIT have developed a method of using a basic cellphone coupled with a cheap and simple plastic device clipped onto the screen to estimate refractive errors and focal range of eyes.

Because of its simplicity, and the fact that soon just about everyone will have access to a mobile phone, eye exams may become available to the whole world at little to no cost.

WHICH IS BETTER?  ONE OR TWO? --- NEITHER

developed at the MIT Media Lab

ARTIFICIAL RETINA

 

ARTIFICIAL CORNEA  (This is a video of the procedure)

 

ARTIFICIAL EYE LENS  (INTRAOCULAR LENS)

The latest is a lens that focuses in the distance, and also allow reading at close range

JOINT REPLACEMENT

SHOULDER

HIP REPLACEMENT

 

CARDIAC DEVICES

PACEMAKERS

 

ARTIFICIAL HEART VALVES

HEART TRANSPLANTS---INFANTILE

 

AUTOMATED EXTERNAL DEFIBRILLATORS

 

ARTIFICIAL SKIN

 

INSULIN PUMPS & MONITORS--iMonitor-Bluetooth

 

REMOTE MONITORING TELEMEDICINE

 

ARTIFICIAL NERVES

Previous neuroprothesis worked through electric signals that triggered already existing nerves to release neurotransmitters like dopamine. However, the electric signals didn't discriminate between different types of nerve cells, which greatly reduced the fidelity and usefulness of the devices.

This new device utilizes the same neurotransmitters that natural nerves use. That allows the robotic nerve to target specific neural pathways, without the random side effects of electronic neural stimulation.

 

BIOPROSTHESIS

COCHLEAR IMPLANT

WHY TRANSPLANT A WHOLE BODY??

This is quite controversial, but possible, ethical? immoral?

Health Reform....Disappearing Ink

OP-ED  by John Goodman

  

 

President Obama with Erskine Bowles, left, and Alan K. Simpson, co-chairmen of the commission on debt reform, before speaking in the Rose Garden on Tuesday.

Will there be real health reform?? Why is that man on the left smirking? What is the man on the right saying?? How serious is this? Well here are the facts, based upon Wikipedia regarding Alan K. Simpson;

 

"The June 7, 1994, edition of the now-defunct supermarket tabloid Weekly World News reported that 12 U.S. Senators were aliens from other planets, including Simpson. The Associated Press ran a follow-up piece which confirmed the tongue-in-cheek participation of Senate offices in the story. Then-Senator Simpson's spokesman Charles Pelkey, when asked about Simpson's galactic origins, told the AP: "We've got only one thing to say: Klaatu barada nikto."^[5]

This was a reference to the 1951 science fiction classic film, The Day the Earth Stood Still, in which an alien arrives by flying saucer in Washington, D.C. Simpson also utters this phrase in a brief cameo in Men in Black."

The International Monetary Fund is warning that the U.S. national debt will exceed 100% of GDP within the next five years, and economists both here and abroad are expressing alarm. The debt problem is mainly an entitlements problem and the entitlements problem is mainly a health care problem. How serious is it?

Here’s the bottom line: Our entitlement problems all stem from the fact that these programs are run like Bernie Madoff chain letters. Since payroll tax revenues are spent rather than invested, workers are accumulating benefits that are not paid for. Implicitly, we are creating huge obligations for generations not yet born — people who never agreed to be part of the scheme and who will surely be worse off if they participate.

 

President Obama has appointed a commission on the federal debt (National Commission on Fiscal Responsibility and Reform), mainly focused on Social Security, Medicare and Medicaid. To signal his seriousness about this venture, the President has even gone so far as to put the newly passed health reform bill on the negotiating table — although the ink on the new law is barely dry.

Health Reform?  2000 pages of wet ink which is all a "MAYBE"

del.icio.us Tags: health train express,entitlements,international monetary fund,federal debt,erskine bowles,alan simpson

Eye Stimulus Package

 

One of my colleagues,  Alan Carlson MD, and ophthalmologist at Duke University offered some humor for physicians,   ophthalmologists and others here.

He also mentioned on a post on one of our specialty listserv, the fact that he was surprised to see how much political commentary appeared on this 'scientific forum'. 

I thought I would post here, his modifications of procedure to satisfy the requirements of health reform.  At the end I have added a few of my own quips.

During the 2008 pre-ARVO Advanced Surface Ablation meeting in Ft. Lauderdale, I was stimulated by Dr. Dan Durrie’s suggestion that LASIK is perhaps an outdated term. Noting that our patients deserve and expect an updated term, one that reflects several recent surgical advances, he ultimately proposed the term SBK, or sub-Bowman’s keratomileusis, rather than simply “thin flap LASIK.”

I confess that my first thought was that this new name had more surgeon appeal and less consumer attraction. Along with SBK, a number of other terms designed to catch our interest as well as that of our patients include: “Custom LASIK,” “iLASIK,” and “EYE-Q LASIK,” among others. New terms as descriptors should impart a quality or aspect of new information to the consumer.

 

• Obama LASIK begins by prescribing Restasis preop and explaining to the patient that this is part of their new tear stimulus package. During the actual procedure, the surgeon making the flap prefers looking at the laser monitor, which also serves as a high-definition teleprompter, rather than looking through the microscope oculars.

• Palin LASIK stipulates that any surgical procedure not fully approved by the FDA will no longer be called “off-label.” Instead, this procedure will be designated on the consent form as “going rogue.”

• Bush LASIK occurs when the surgeon is willing to take on the tougher cases, even without all of the data, but leaves open what defines a “successful” end result, indications for enhancement, and a strategy that defines completion.

• Cheney LASIK. This technique emphasizes intense irrigation under the flap clearing the interface of all debris in a technique known as “saline boarding.”

• Hillary LASIK recognizes that co-managed patient care extends beyond the surgeon and the optometrist. Rather, it takes an entire postoperative team, or village, to care for the patient.

• Pelosi LASIK. is quite cumbersome, with a 1,900-page brochure and consent form, but also recognizes that all future advances in the field of refractive surgery can only occur when wealthier patients start paying their fair share.

• Gore LASIK stresses that good, consistent surgical outcomes can only occur if the surgeon monitors temperature, humidity and environmental aspects surrounding the laser. Scientific evidence suggests that enhancement rates are increasing throughout the country resulting from a general warming trend in excimer laser rooms.

• The Rev. Jesse Jackson LASIK involves communication during the surgical procedure. Instead of the common reassurances of “perfect” and reminder to look at the flashing light, the surgeon intones short phrases that have a distinctive cadence and rhyming delivery, such as: “… I think it is basic, you’ll benefit from LASIK. Look at the light, and all will be right.”

We must not forget our commentators as well.

• Keith Olbermann LASIK addresses all negative outcomes and patient complaints by placing the blame on the patient’s eye-care provider for the previous eight years.

• Bill O’Reilly LASIK entails instructing the patient during surgery to avoid being cantankerous rather than asking him to look at the flashing light.

• Sean Hannity LASIK pronounces all satisfied LASIK patients as great Americans.

• Rush Limbaugh LASIK reminds all satisfied LASIK patients that the surgeon’s special talents are on loan from God.

• Lou Dobbs LASIK is generally limited to enhancements, but challenges the location and authenticity of the original LASIK procedure.

 Corneal

Aberration

Reduction

Laser

Surgery for

Optical

Neutrality

 

 

My own thoughts

Bill O'Reilly Lasik offers the 'No Spin Laser". With this technique the autotracker is disengaged and the flying spot software is also disengaged.  Pinhead or Patriot enhancements  are also available. The laser has been certified as 'fair and balanced'

Oprah Winfrey Lasik offers the best seller list as a benefit and value added feature.

Rush Limbaugh Lasik offers large amounts of pain management along with  a copy of his book, "See, I told you So".

 

Governor Mark Sanford Lasik offers a free trip to Argentina for both the procedure and post operative visits. An option is a free escort service.

General McCrystal Lasik offers a free trip to the United States with a refundable return ticket to Afghanistan (cannot be transferred). The procedure is pre-approved and in accordance with all DOD regulations, and is free of charge.

BP Lasik

wkrg_oil_spill on livestream.com. Broadcast Live Free

 

 

utilizes a mixture of homeopathic oil mixed with saline and a pinch of pelican feathers, oysters and shrimp, placed on the cornea at the conclusion of the procedure. The procedure also comes with a free grant application for financial aid.

Dr. Carlson's commentary regarding the level of political commentary is well taken.  Doctors are 'mad as hell' and aren't going to take it anymore.....

A prematurely retired ophthalmologist.......

Incentivization and Cautionary Tails

It seems  we will only do things with monetary rewards

Wander off to this website, dedicated to spending the tax payers money for the purpose of installing and using electronic health records in provider offices.  The rule making is only 169 pages long. The devil is in the details.

 

 

It is apparent that most providers want nothing to do with EMR, but have been convinced by 'others' that we must do it, because they know better than we do what is 'good for us'.

Another factor in the equation is that EHRs can be considered to be medical devices, or even 'biomedical equipment".  I think most  of you can see where this is headed.  The Food and Drug Administration (FDA)regulates medical devices as well as pharmaceuticals.

Consider this:  Biomedical equipment must be annually inspected and certified by the appropriate biomedical engineer to be used for patient care.  Devices usually are subject to a 'clinical trial' or reports, or an IDE (Investigative Device Exemption)

EMRs are intimately intertwined with patient care, and involve patient safety issues. 

Where the  feds are involved expect to see more bureaucracy, regulation and oversight.  The feds are just not going to incentivize without regulation. Build in more overhead for regulation.

 

Certification will not be the end of the story. Just as new drugs require approval by the FDA, so too will software upgrades. After all who knows what an upgrade might cause?

The Yo-Yo Effect

The past several months reveal how disconnected the plan for health care reform has evolved. There was little transparency regarding the evolution of the bill, except for political posturing. The present administration has no experience in business leadership, nor basic economic theory.

The fact that the flawed SGR formula, hastily conceived in the early 1990s, was not addressed in the health reform bill attests to the simple fact that cost is a major factor in the legislation. Universal care was never a top priority except to assuage the proletariat.  SGR was and is held out as a bargaining chip and as a diversion for most  physicians.

The effects of the SGR impact very severely on ophthalmologists, urologists, geriatricians, some internists  and somewhat on cardiologists and pulmonologists.  These practices serve a large medicare population, and the SGR impact as presently structured or not eliminated will be devastating.

Primary care physicians can select to minimize medicare or eliminate it all together from their business model, with much less impact on their practices.

Thus, some specialists will have little choice but to either quit entirely, or fire half their staff, and reduce the quality and accessiblity of their practices to senior citizens.  These practices will ill afford to acquire new technology.  The physical structures of medicine will decline, poor maintenance, bare floors, and peeling paint.

The past several months have been  a Yo yo  for physicians  with hope for resolution of the SGR fiasco, and then dashed as we are used as a political football.

del.icio.us Tags: yo yo effect,sgr,political footbal,bargaining chip,healthtrain express

Health Train Surfing on the Web

One of the great things about the internet is how rapidly one can research topics of interest.

Today's posting is a collection of interviews with a number of politicians.

Governor George Pataki on Health Care Reform from CMPI on Vimeo.

The Center for Medicine in The Public Interest, or CMPI hosts a large number of video interviews on their website.

This organization is very pro doctor.

The Clothesline

I don't know about you, but I and most physicians are fed up with being hung out to 'dry'.

Same old, same old.

Doctors with Medicare patients will start seeing a 21 percent pay cut this week after Congress failed to defer the cuts by two more years.

This Story appears today in the Washington Post.

• The Senate had until June 1 to avert the cuts. It is not expected to vote by Tuesday, when the Center for Medicare and Medicaid Services' temporary hold on Medicare claims expires.

Some members of the American Medical Association signed white lab coats instead of a petition to voice their displeasure on Sunday at the group's annual meetings in Chicago. The coats will be delivered to lawmakers in Washington on Friday, a spokeswoman said.

"The Senate's failure to act before June 1 made the 21 percent cut the law of the land," AMA President J. James Rohack said in a statement. "Physicians will start seeing a 21 percent cut in Medicare payments this week that will hurt seniors' health care as physicians are forced to make practice changes to keep their practice doors open."

Legislation to restore doctor's pay -- known as the "doc fix" -- is part of a broader aid package that includes jobless benefits and more financial aid for the states. In his Saturday radio address, President Obama called on lawmakers to avert the pay cuts, faulting Republicans for the delay. "After years of voting to defer these cuts, the other party is now willing to walk away from the needs of our doctors and our seniors," Obama said.

Republicans call the package fiscally irresponsible and said it would add $80 billion to a bloated federal deficit. Some moderate Republicans say they will vote for the package if the cost is offset by cuts elsewhere in the federal budget.

President Obama this weekend told us all how much he 'cares' about doctor reimbursement. 

 

What a sham.  

 

If that were the case there should have been room in the monstrous 1200 page heath reform bill to (link takes a while to load))include a permanent fix to the SGR (sustainable growth rate)

Better pony up and get some more clothespins....before they are all gone!!

The Shadow over Health Care

Will quality heath care survive "the eclipse"??

 

However, there is still hope.

Will EMR correct these entries in the medical record??

Are these "Never Events"?

Will "time-outs" prevent these misfortunes?

 

1 . The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

5. Patient has chest pain if she lies on her left side for over a year.

6. On the second day, the knee was better, and on the third day it disappeared.

7. The patient is tearful and crying constantly. She also appears to be depressed.

8 The patient has been depressed since she began seeing me in 1993.

9. Discharge status: Alive but without permission.

10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

11. Patient had waffles for breakfast and anorexia for lunch.

12. She is numb from her toes down.

13. While in ER, she was examined, x-rated and sent home.

14. The skin was moist and dry.

15. Occasional, constant infrequent headaches.

16. Patient was alert and unresponsive.

17. Rectal examination revealed a normal size thyroid.

18. She stated that she had been constipated for most of her life, until she got a divorce.

19. I saw your patient today, who is still under our car for physical therapy.

20. Both breasts are equal and reactive to light and accommodation.

21. Examination of genitalia reveals that he is circus sized.

22. The lab test indicated abnormal lover function.

23. Skin: somewhat pale but present.

24. The pelvic exam will be done later on the floor.

25. Patient has two normal teenage children, but no other abnormalities.

Is Help on The Way?

 

The issue of how much medical malpractice adds to the cost of healthcare in the United States has been on the front burner for physicians, yet legislators turn a deaf ear to this challenge. Medical malpractice adds to the cost of each patient encounter not only due to the premiums physicians pay, but the even more significant costs of practicing 'defensive medicine'.  This fuels the additional non medically indicated ordering of high tech laboratory and other expensive imaging and other tests.

 

By Katherine Hobson

Today the government begins to hand out $25 million in funding for demonstration projects attempting to find some fixes for the medical malpractice system, the WSJ reports. The one- and three-year grantees include projects focusing on alternative dispute resolution programs, rapid medical error disclosure and the development of guidelines to reduce lawsuits.

This project was initiated last year, in the heat of the health-care debate. But the overhaul bill that ultimately passed Congress included another $50 million in grants for states that want to explore alternatives to traditional tort reform proposals, American Medical News reported this week. (The paper is published by the AMA.)

Grant-winners haven’t been announced yet. But experts told medical liability insurers at a recent meeting about several different alternatives that might be funded as test projects, AMN says. Here they are:

Health courts: The notion of courts dedicated to medical malpractice has kicked around for a while and was endorsed in 2007 by then-presidential candidate Mitt Romney. The courts would have judges who specialize in medical-liability cases, as well as “neutral experts, preset timelines and compensation schedules,” which hopefully would produce a more predictable and efficient system, AMN reports.

Early offers: Just what the name indicates — a defendant could opt to pay economic damages and lawyers’ costs within 180 days of a claim, avoiding lengthy litigation. The patient, however, would have to skip non-economic damages.

Apology programs: The hope is that when doctors apologize for or at least communicate about errors with patients and family members rather than immediately lawyering up, the risk of litigation may decline. (Here’s a WSJ story on the subject.)

Medical review panels: Already used in many states, these nonbinding panels of medical and legal experts review suits before they go to trial to cull the most egregiously silly and advise plaintiffs and defendants on the merits of the evidence. (Here’s a 2009 AMN story about the concept.)

The AMN reports some caution on the second round of grants: Funds have to be appropriated by Congress, and by the terms of the program, test projects can’t limit the rights of plaintiffs and defendants to pursue claims through traditional means.

Some sucess has already occurred with "caps' on awards for punitive damages in several states.

The funding for this initiative has yet to be passed by the congress.