If Lawyers worked like Doctors

Dr. Wes in a column from October 2009 writes a 'parody' on attorney billing. If you read it, you will chuckle....

I have a few other 'regulations' for attorneys.

Pass the Affordable Plaintiff and Defendant Act.

Establish legal preferred practice patterns

Establish evidence based legal decision making

Establish quality review and payment guidelines for outcomes.

Establish "never events" which allow clients to refuse payments to their counsel.

Incentivize attorneys to utilize legal information technology with decision making algorithms.

Encourage further the development of 'managed judicial organizations (MJO) and/or accountable judicial organizations (AJO)

Establish a sustainable growth rate formula (SGR).   This would include a built in 5% a year decrease in reimbursements, subject to a six month hold while waiting for congress to delay the changes.

Establish and publish on the internet a directory of all attorneys and a rating by clients. Call it "Legalgrades" Post uncorroborated complaints from clients about the attorney or the firm.

Establish 100 not for profit foundations and/or study groups to make recomendations to improve efficacy and safety of legal judgments. 

Establish a National Lawyer Database (NLB) to report the win/loss statistics and any disciplinary actions (to be posted on the internet) and other untoward events.

Require a search of the database prior to any legal actions posted by any attorney.

Require attorneys to become credentialled annually at the BAR for individual courts, and charge them annually for this privelege.

Washington and the Parasitic Economy

Following in the distinguished footsteps of Microsoft and Google, Apple is the latest innovative company to be targeted by politicians and regulators for being too successful. Will it be sucked into Washington's "parasite economy"?  Has medicine become a part of the government's parasitic economy?

David Boaz of the CATO Institute explores the history of success in America.

For more than a decade, Microsoft went about its business, developing software, selling it to customers, and — happily, legally — making money. Then in 1995, after repeated assaults by the Justice Department's antitrust division, Microsoft broke down and started playing the Beltway game — defensively at first.

Washington politicians and journalists sneered at Microsoft's initial political innocence. A congressional aide said, "They don't want to play the D.C. game, that's clear, and they've gotten away with it so far. The problem is, in the long run they won't be able to."

And Microsoft got the message: If you want to produce something in America, you'd better play the game. Contribute to politicians' campaigns, hire their friends, go hat in hand to a congressional hearing, and apologize for your success.

A decade later, it was Google. After a humble start in a Stanford dorm room, Google delivered a cheap and indispensable product and became the biggest success story of the early 21st century.

Politicians, seeing an opportunity to extend their power and rake in some campaign cash, are circling like sharks. When both Apple and Google declined to attend a Senate show trial on Internet privacy, Sen. Jay Rockefeller (D., W.Va.) growled, "When people don't show up when we ask them to . . . all it does is increases our interest in what they're doing and why they didn't show up. It was a stupid mistake for them not to show up."

And that's what politicians and regulators are costing America: The brilliant minds of Silicon Valley and Redmond, Wash., are going to waste time and energy on protecting their companies instead of thinking up new products and new ways to deliver them to consumer

 

Does any of this sound familiar? For the past fifty years our patients enjoyed the best of healthcare and incredible advances in science and health. The miracles of antibiotics, vaccines and advanced cardiac treatments have  extended life to the point where degenerative diseases have replaced infectious disease as the major end of life events leading to death (in an extended manner)

This measure of success is discounted and totally ignored as the source of increased expenses for health care in America.

In the past physicians have largely ignored this parallel in general business and health finances. However the interest in pandering to political expediency peaked during the past debate on health reform.  Medicine showed up at the hearings and for several decades have attempted to 'lease' representatives interest with PACs and lobbying efforts.

Well, medicine is now wasting it's time and energy protecting itself and patients. Brilliant minds are also leaving patient care and clinical research to pursue other less stressful and more innovative methods to treat  patients. 

This sounds very familiar with Dave Boaz's analysis of the " Beltway Game."

It would be interesting to find out how you think about this analogy??

Bad Medicine

In a white paper written by The Cato Institute, Bad Medicine...A Guide to the  Real Costs.....elaborates on the true cost of the health reform act, and it's secondary consequences:

Simply having insurance is not enough to satisfy the mandate.

More than 2/3 of companies could be forced to change their insurance coverage

Some of the mandated changes may have unintended consequences.

As many as a million workers could lose their health insurance coverage they have now.

Tennessee's experience with TennCare gives a precautionary tale.

The phase-out of these benefits imposes a high marginal tax penalty

All together these changes produce an enormous increase in the welfare state

Plans offered through the exchanges must meet minimum federal standards

President Obama has been hostile to consumer directed healthplans

The fate of HSA's depends upon ruling by the Sec'y of HHS.

THE CATO INSTITUTE 

The Cato Institute was founded in 1977 by Edward H. Crane. It is a non-profit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of libertarian pamphlets that helped lay the philosophical foundation for the American Revolution.

In order to maintain its independence, the Cato Institute accepts no government funding. Cato receives approximately 75 percent of its funding from individuals, with lesser amounts coming from foundations, corporations, and the sale of publications. The Cato Institute is a nonprofit, tax-exempt educational foundation under Section 501(c) 3 of the Internal Revenue Code. Cato's 2007 revenues were over $24 million, and it has approximately 105 full-time employees, 75 adjunct scholars, and 23 fellows, plus interns.

Mission

The Cato Institute’s nationally and internationally recognized Centers and Projects tackle a wide range of topics, including health care, education, environment and energy, foreign policy, and international human rights. Scholars in these Centers and Projects vigorously apply America’s founding principles to key issues of the day, and are committed to countering the continued expansion of government beyond its constitutional constraints, and to confronting escalating attacks on individual rights.

Center for Constitutional Studies

Center for Educational Freedom

Center for Global Liberty and Prosperity

Center for Representative Government

Center for Trade Policy Studies

Downsizing the Federal Government

Project on Social Security Choice

del.icio.us Tags: cato institute,medicine,health reform,tenncare,President Obama,HSA,HHS

Health Train Express Resumes Publishing

Things seem to be working again. I spent the greater part of the past two days getting things back up and running.

After my blog platform disappeared from my menus and a number of dead desktop icons, several freezes, virus scans, and other disconnected events, and after removing several programs, re-installing several programs, which failed to load, defragmentations, etc I did a restore to several weeks ago and all is fine. It interrupted my writing schedule and diverted my attention, worrying all the while if it could be fixed, how much data I would lose, etc and  even the fear of having to replace it with  a new system.  '

 

Fortunately for me I had a disaster plan....I had an external drive with backup and also an online backup.  My onsite backup runs automatically twice a week, and my online backup is continuous as needed. Onsite backup has it's own dangers, and at times fails. An online insurance backup is not expensive, (about $ 100/annum)

It is a great sense of comfort, and I lost no data.

I bring this up because it really relates to developing total dependence on electronics.  Sooner or later it will go 'south'

If  you are in a significant size group  you probably already have expert IT support, if you are solo or a small group it can be a challenge to keep backups and disaster plans implemented and more important used on a regular schedule.  It might even be worthwhile to have disaster drills, just like fire drills.

An EMR disaster abruptly changes the focus of the practice for the manager and the doctor.

I have had it happen to me, despite  best intentions.  My staff was not performing regular backups, my vendor was unreliable, and often unavailable.  I learned a lot about computers, software as a matter of necessity. Besides losing income and losing time, it created havoc in my mind. Having a system in place is the first step, testing and using it is also vital. In todays' much harsher reimbursement environment a small blip can rapidly unravel into disaster financially.

Many of us are being diverted by all the talk about 'incentives' and meaningful use for EMR.   Another important issue is  whether your system works for 'your practice' and if it is designed to be reliable,have fail safes and totally reliable tech support from your vendor or a reliable local source.

Remember, the introduction of EMR and HIE will mean more complication...eventually.

However I think the horse (or is it cow) has left the barn.

Non Publishing Notice

Due to technical difficulties Health Train Express will not be publishing for the next 48 hours.  I know you will all be broken up about missing one of my rants.   Blame it on 'Windows'.

Re-distribute the Wealth

 

Don Berwick's commandered appointment to be head of CMS seems to have only caused a flicker of congressional shock.

Some of this may have been their own reticence to start the confirmation process, because Max Baucus had not yet scheuled the hearings.  Perhaps the Republican leadership should learn that political stalling and meandering only lead to surreptitious acts. The Republicans are not alone in this form of political extortion and deal making.

Berwicks' candid and open opinion that health care  reform should 'redistribute wealth, and that is one of it's primary missions".  (See The Video, below)

That statement  is one that neither I nor most doctors have ever heard from a highly appointed M.D.  I can accept that health reform should 'transform, and perhaps open access to those who are not yet covered. "   If this is a true 'redistribution of health care, or wealth, then someone else will get less access or treatment.

Redistribution of wealth or health care is a euphemism for 'rationing'.....'with your eyes open'. 

Essentially Don Berwick has become the 'lap-dog' for the socialist agenda of Barak Obama.  Dr. Berwick has been a respected member and head of many organizations that are held in high esteem by the government for advice.  [the Institute for Healthcare Improvement (IHI)^[1], a not-for-profit organization]He has been awarded many  titles, and is a professor of pediatrics.

Obama's actions in health care is juxtaposed to his bail our of financial markets and the automotive industry.  In those cases the wealth was 'redistributed' toward the already wealthy barons of finance and industry.

Never before has the head of CMS (who is basically supposed to be an administrator, and not a policy maker), a function which should be left to the congress acted in such a manner.

The combination of the Affordable Patient Care Act and it's mandates for the Head of HHS to do certain things and the appointment of Don Berwick to CMS  are a double pronged attack on the freedom of patients and physicians to make choices. Make no mistake about it we all have lost much.

 

Hopefully when and if confirmation hearings do occur when the Congress resumes they will oppose the nomination.  Hopefully public opinion and backlash from those in the trenches will keep this issue in the headlines.  I doubt it....the attention span of the media today is about 24 hours.

A sad day for the American Dream

Richard Reece MD in his Blog Medinnovation asks;

"How should physicians respond??"

Team NY TIMES

Finally, a Medicare/Medicaid Chief

Published: July 7, 2010

The New York Times  Op - Ed, today

 

"President Obama made a sensible move Wednesday when he bypassed the Senate and appointed Dr. Donald Berwick, an expert on reducing health care costs, to oversee Medicare and Medicaid. Republican senators had made it clear that they would use confirmation hearings to distort his record and rehash their arguments against the recently enacted health care reforms, mostly to score political points for the November elections.

By using his power to make recess appointments while the Senate is on vacation, Mr. Obama put Dr. Berwick in a position of vital importance in implementing the new reform law. His appointment will run until late 2011, giving him time to get things moving before he would have to be renominated. The Centers for Medicare and Medicaid Services, which Dr. Berwick will run, has been without a permanent administrator since 2006.

The obscure but influential agency runs two huge public insurance programs that will play central roles in health care reform. The new law requires Medicare for older Americans and the disabled to become more efficient and to serve as a testing ground for innovations to improve the quality and lower the cost of health care, the core of Dr. Berwick’s professional interests. Reform will also entail a big expansion of the state-federal Medicaid program for the poor, requiring strong guidance and leadership from Washington.

Dr. Berwick’s major credential for the job is that he leads the Institute for Healthcare Improvement, a consulting group that promotes measures to improve the quality and safety of health care while reducing its costs. He has been enormously successful at getting health care professionals and institutions to work together to reform their practices — exactly what the agency needs.

His appointment is backed by the American Medical Association, the American Hospital Association and scores of other health organizations and patient advocacy groups. He has been endorsed by three predecessors who held the same job in Republican administrations.

Even so, some Republican senators have portrayed Dr. Berwick as a proponent of socialized medicine because he has expressed great admiration for Britain’s National Health Service. They also call him an advocate of rationing care and even suggest he favors “death panels,” a politically potent falsehood.

Yet Dr. Berwick spoke an obvious truth when he declared that “the decision in not whether or not we will ration care — the decision is whether we will ration with our eyes open.” Care is already rationed by insurance company decisions about what services to cover and by high prices that make insurance and medical care unaffordable to millions of Americans.

Senators jealous of their prerogatives in confirming presidential nominations are grumbling about being bypassed. But there is no telling when or whether the Senate would have been ready to confirm Dr. Berwick. The job is too important to leave open any longer. "

For the record, a serious conversation about Berwick’s qualifications and plans would have been worthwhile. I’ve heard even people sympathetic to Berwick question whether his administrative experience is adequate. But, again, it’s hard to have a serious conversation when one of the two political parties refuses to be serious.

The Dems were well within their rights to use the recess appointment mechanism (as the Bushies did hundreds of times in their day), just as they were to use the reconciliation mechanism to pass the healthcare reform bill. Of course, the GOP is now completely free to paint the Berwick appointment as unacceptably anti-democratic. Who’s right? Who cares? The voters will ultimately decide.

Some or all of the above may be true, but why the rush to the appointment.  Some of those recommendations come from previous temporary heads of CMS. So, why didn't they keep their job?

The American  People deserve to hear the questions from their elected representatives, and answsers from Dr. Berwick, both about positive and negative attributes of this highly achieved and touted academician.

It has been shown the AMA represents only about 115,000 physicians out of over 800,000 physicians, most are students,  and academicians.

Senators are not 'jealous of their prerogatives" they have the sworn duty to represent their constituents.

As  usual the NY Times is highly biased in favor of liberal social agendas, rather than expressing any discontent with President Obama's wanton disregard of procedural matters.

GML

Your Health on the Ballot Box

So, how are you going to like your health care on the ballot?

Would you like a Republican diagnosis, A Democratic diagnosis, or perhaps the Libertarian or Independent opinion?  Worry not, no matter what the decision it will take months to implement, if it is funded, at all.

The situation in Massachussetts is dire.

Mitt Romney signs health-care reform into law as Ted Kennedy (third from right) looks on, April 2006.

U.S. President Barack Obama (C) is applauded after signing the Affordable Health Care for America Act during a ceremony with fellow Democrats in the East Room of the White House March 23, 2010 in Washington, DC.

 And in large measure Obamacare is on the same path.

Rago of the Wall Street Journal has this to say:

 

President Obama said earlier this year that the health-care bill that Congress passed three months ago is "essentially identical" to the Massachusetts universal coverage plan that then-Gov. Mitt Romney signed into law in 2006. No one but Mr. Romney disagrees.

The state's universal health-care prototype is growing more dysfunctional by the day, which is the inevitable result of a health system dominated by politics.

In the first good news in months, a state appeals board has reversed some of the price controls on the insurance industry that Gov. Deval Patrick imposed earlier this year. Late last month, the panel ruled that the action had no legal basis and ignored "economic realties."

Sure enough, the five major state insurers have so far collectively lost $116 million due to the rate cap. Three of them are now under administrative oversight because of concerns about their financial viability. Perhaps Mr. Patrick felt he could be so reckless because health-care demagoguery is the strategy for his fall re-election bid against a former insurance CEO.

The deeper problem is that price controls seem to be the only way the political class can salvage a program that was supposed to reduce spending and manifestly has not. Massachusetts now has the highest average premiums in the nation.

Liberals write off such consequences as unimportant under the revisionist history that the plan was never meant to reduce costs but only to cover the uninsured. Yet Mr. Romney wrote in these pages shortly after his plan became law that every resident "will soon have affordable health insurance and the costs of health care will be reduced."

One junior senator from Illinois agreed. In a February 2006 interview on NBC, Mr. Obama praised the "bold initiative" in Massachusetts, arguing that it would "reduce costs and expand coverage." A Romney spokesman said at the time that "It's gratifying that national figures from both sides of the aisle recognize the potential of this plan to transform our health-care system."

Perhaps Mr. Obama never took Economics 101 at Harvard. He has certainly never run a business.

What do you think?

del.icio.us Tags: deval patrick,obama,romney,health care bill discussion,health train express,insurance caps,affordable Care and Patient Protection Act

Wellness Wiki.....What is?

About five years ago I was asked to participate in the founding of the "Wellness Wiki".  This was during the dawn of the age of HIT.

Several luminaries participated in this early talk about wellness, and health care transformation.

Welcome to the Wellness Wiki! We offer this wiki to help clarify the complex problems plaguing the U.S. healthcare system and develop sustainable ways to improve the health and well-being of all people. This virtual encyclopedia of the healthcare crisis and potential remedies. We welcome your comments! To become a contributor, please contact Dr. Beller

The program of which I was privileged to have my name put on it (with little real contribution, other than an enthusiastic "go for it" from me) now is on wiki.wellspaces.com  and is available for purchase at the web site.

It is well worth the read, from two experts well ahead of the curve.

Hospital Staff Priveleges:

Why I no longer belong to hospital staffs:

The Happy Hospitalist explains the byzantine maze required to see and treat patients.

A medical license has always been an earned privilege. We are given the privilege of hospital staff memberships. However things have taken a terrible turn for the worst. At this point the hospitals should consider it is their privilege to have me on their staff. I agree with Happy that there is now a lot of “crap” in the system. Someone has made or is making a lot of $$$ producing software, and/or meetings for medical staff offices to ‘automate” their credentialing system. A great deal of information requested is repetitive and could easily be stored in a central location for medical staff credentialing purposes.

 

 

In their own words;

“CAQH, an unprecedented nonprofit alliance of health plans and trade associations, is a catalyst for industry collaboration on initiatives that simplify healthcare administration. CAQH solutions promote quality interactions between plans, providers and other stakeholders; reduce costs and frustrations associated with healthcare administration; facilitate administrative healthcare information exchange and encourage administrative and clinical data integration. provides the same type of services for physicians to become credentialed by health insurance companies.”

It just keeps on getting crazier. Physician credentialing software is out of control. Physicians now pay hundreds of dollars a year in government regulatory licensure fees. Doctors pay thousands of dollars to take the test. The test is a board exam documenting the physician's expertise in a field of medicine so they can hang a certificate on their wall that most patients will never see.

Physicians who take the test are supposed to be certified as experts in their field of practice. So why are physicians forced to jump through miles and miles of expense and complicated credentialing processes for every hospital they would like to see patients at?

For physicians to do a hospital admission or daily visits or procedures inside a hospital they must first obtain hospital credentials. In other words, if there are five hospitals in town and a physician wants to be able to see patients at all five hospitals, they must apply for the right to practice medicine within all five hospitals.

* It's not good enough to pay your money to your state licensing authority every year for the right to practice medicine.

* It's not good enough that most states require physicians to complete at least 50 hours of uncompensated continuing medical education (CME) every two years just to apply for a state medical license.

* It's not good enough to pay $500 every few years to the federal government for the right to prescribe medications.

* It's not good enough to pay several thousand dollars and spend hundreds of hours of uncompensated study to get your board recertification every few years.

Nope, none of that is good enough. To practice medicine inside the walls of a hospital, the hospital must then grant you the privilege of seeing your patients at their hospital. Every hospital has their own set of rules. Every hospital has their own credentialing committee that meets to give the yeah or nay to new staff appointments. Every hospital has their own physician credentialing software that guides them in their search for red flags.

I recently applied for hospital privileges to another hospital. Happy's billing company takes care of all the credentialing requirements for insurance companies and hospitals. In this case, they sent me a packet of information almost 40 pages long. They mark everything I need to sign with tiny little sticky pads. About 10-15 tiny little sign and date here sticky pads dotted the hospital credentialing paperwork. Forty pages of legal mumbo jumbo.

A lot of this physician credentialing software delves into your past history. Where did you train? What are your previous practice experiences? What procedures can you prove proficiency in? What procedures would you like to be credentialed to provide? What are your last three residential addresses? Have you ever been charged with a crime? Have you ever been convicted of a drug or alcohol related offense? Have you ever been sued? Not lost a lawsuit, just sued. Have you ever been treated for depression? There is some pretty personal information that gets requested on these hospital credential applications. Next thing you know, they'll want to know my sperm count.

Imagine the legal fallout hospitals must be worried about by allowing doctors who have been sued from seeing patients? Could they be held liable for allowing a bad apple to practice medicine in their walls. A physician who has been licensed by the government and certified by their specialty society as an expert capable of providing excellent care?

There are many ramifications for settling a lawsuit because it's cheaper just to make it go away than to fight for what you believe in. Would that prevent you from obtaining hospital credentials or perhaps even cause a hospital to revoke them?

Physician credentialing software these days must be based on an overwhelming mountain of legal fear. One of my partners failed to disclose a minor in possession ticket (MIP) during her teenage years. After failing to disclose this ridiculously unimportant legal request, her hospital credentials were delayed for weeks, perhaps months in order to send letters and appear in committee meetings to explain herself.

One local physician even told me that another colleague at another hospital had failed to disclose that he got a ticket for fishing without a license. That's right folks. A ticket for fishing. When he failed to disclose this dastardly deed on his hospital credentialing paperwork, his approval was denied and delayed. Unbelievable.

This is what the legal environment of doctors and hospital credentialing has become. MIPs and fishing licenses. The fear in medical credentialing is out of control.

In a new one for me, physician credentialing software asked me how many children live in my home and if I'd ever lived with any children in the past. The title of the document I was to sign had to do with any previous allegations or arrests for child abuse or sexual assault. Now the hospitals want to know if I have any children in my home. What has this world come to?

With such a large volume of legal detective work being done on every physician credentialed at every hospital, one has to wonder how is it even possible for a bad apple to fall through the cracks. If you have a hospitalist seeing you at your hospital, you can rest assured their past has been raked through the coals and their history and credentials have been picked apart by government agencies, specialty societies and even the hospital you find yourself in. And absurdly so.

HAPPY HOSPITALIST, I hear your angst.........and there is hope

Credentialling Solutions

which offers this service.

Blogs | Reporting on Health

Blogs | Reporting on Health

Happy Independence Day

The freedoms to practice medicine...........................

It's that time again, the anniversary of the "birth" of our nation. The 4th of July means many things to many people. For our warriors away from home it memorializes what our country is all about. "FREEDOM" 

When I was younger I did not appreciate fully how challenging it is to establish and maintain "FREEDOM'  The seed must be planted in  fertile ground, watered and fertiilzed.  Neglecting the plant and not watering it will result in withering and death.

One of the best fertilizers for "FREEDOM" is the diversity, discourse, and  strong disagreements among it's citizens.  Just like the first law of thermodynamics, organizations tends to descend into chaos without  adding more energy. 'FREEDOM' will always require energy to maintain.

And while our economy is suffering, "FREEDOM" remains strong. It however is endangered by the crisies, real or manufactured.

Governments may be induced to suspend "FREEDOM" in the interest of public safety, and disasters.

Our leaders must be attentive to this emperative and not lose focus dealing with the daily challenge of meeting health care needs, fixing economic markets, and sustaining productivity.

Our founding fathers were true geniuses, establishing a tri-partite government, with each body carrying equal weight in the equation.  It is the duty of the congress to regulate and challenge the executive branch.  The Judicial branch serves to analyze and apply law to certain conflicts with it's opinion(s).

The President is supposed to lead the people,  but not the congress.  Congress is supposed to have a mind of it's own.

Freedom and health care go hand in hand. It's always been a lightening rod for disagreement in the United States, when governments steps in.

Are our leaders who are sworn to defend the constitution and our borders violating their oaths for political  purposes?

As we all enjoy our hamburger's hot dogs, ribs, chicken and other barbecue goodies,  think of the marinade as the "freedom" we have the fortune to live in. Think of the ketchup as the  blood shed to guarrantee our freedoms. Think of the mustard as the gold or riches of our freedoms.

God Bless America,  my home  sweet home.

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