What does the Border have to do with Accountability?

 

as Posted on The Health Care Blog

Does This ACO Thing Really Mean We Need to be ‘Accountable’?

By VINCE KURATIS

Last month The American College of Physicians (ACP) released a well-reasoned and thorough position paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices.

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

At this time, implementation of the above principles within care coordination agreements represents an aspiration goal…

The care coordination agreements should be viewed solely as a means of specifying a set of expected working procedures agreed upon by the collaborating practices toward the goals of improved communication and care coordination — they are not legally enforceable agreements between the practices. [emphasis of “solely” is in the original document, not added]

Translation:

Don’t expect to hold us accountable….and don’t expect to be able to sue us if we don’t get it right

del.icio.us Tags: Kuratis,ACO,Patient centered,Medical home,accountable care organization,american college of physicians

Virtual Immigration Fence Failure – A Lesson for Medicine?  from Medical Innovation Blog

Richard Reece, M.D.

As Americans, we believe “virtual surveillance” techniques, drones over Pakistan, orbiting spy satellites, cameras on street corners and in stores, telemonitoring of patients with chronic disease with implanted sensors, e-ordering systems to control utilization of high tech medical technologies, virtual integration of doctors and hospitals to reduce care fragmentation – will make us more secure and healthier.
This may be, but we need to understand better what’s taking place on both sides of the technology fence.
The Techno sphere Versus Boots on the Ground
Technologies, no matter how sophisticated, can never replace boots on the ground, humans on the frontlines, police on the streets, or the human needs of populations you are trying to deflect, defeat, control, or serve.
The Virtual Arizona Fence
The “virtual failure” of the “virtual fence” on the Arizona border is the latest example of surveillance technology limits. This “invisible” fence, consisting of strategically and periodically placed high tech radar towers equipped with state-of-the-art monitoring gadgets has failed to stem the tide of immigration. Where there’s a will, there’s a way around the fence.
After 4 years of effort, construction of 50 miles of fence over the 2000 mile Mexico-US border, and a $1 billion contract with Boeing, the Obama administration is abandoning the fence.
High winds, tumbling tumbleweeds, weak cameras, slow software, blurry images that confuse cars with humans, and determined immigrants in search of a better life have combined to circumvent the fence.
In the words of a New York Times editorial,
“The ‘virtual fence’ was a misbegotten idea from the start, based on the faulty premise that controlling immigration is as simple as closing the border — and that closing the border is a simple matter of more sensors, more fencing and more boots on the ground. So long as there is a demand for cheap labor, a hunger for better jobs here, and almost no legal way to get in, people will keep finding ways around any fence, virtual or not.”

The Lesson
For information technology enthusiasts and for those who monitor patient health behaviors through web-based “consumer empowerment” techniques or “physician improvement” technologies, there is a lesson to be learned here.
You cannot control human behaviors at the level of patient-doctor interactions no matter how “sophisticated” your data mining or monitoring efforts. And you cannot do it without more “boots on the ground,” more physicians in the clinical trenches to critically appraise human needs, to prevent “immigration” towards bad health and high cost hospitalizations.  (underline mine) High tech fences will not keep immigrants out of the human garden. And you cannot weed the garden using high tech information sensors.

Posted by Richard L. Reece, MD at 12:24 PM

Future of Health Reform

 

Today on CSPAN the Robert Wood Johnson Foundation presented a summation of the current environment in congress and future possible modifications to the health reform law.

Dean Rosen, former assistant to Bill Frist, MD, the former speaker of the house, Norman Ornstein, resident scholar at the American Enterprise Institute, and  Ed Howard, from the Alliance for Health Reform each give their expertise on current events.

VIDEO PROGRAM  CSPAN

KevinMD hosts Health Train Express

 

Just a pat on my back (spraining my shoulder) and a thanks to KevinMD for hosting Health Train tomorrow—Friday.

Politicians know S %@*t about Health Care

 

A good friend and colleague sent me a link to a video.  I advise you that there is a lot of foul language in it.  I thought it was outrageously funny and exactly on point.  When I thought hard about it I thought, What the f#%!k .  If Obama doesn’t understand it or get it by now he never will). 

Thanks again to Xtranormal,  the do it yourself  internet Pixar of the  21st Century.

 

The White House Oval Office

 

One of our problems as physicians is that we rarely say no, or go to h#@l!  We are always so reasonable and accommodating, while we slowly are boiled.  So I don’t believe I need to be polite, or politically correct or even have good manners.  I and most of my colleagues have been wrung out and demeaned beyond belief. 

You will all think I have lost it, and I am ready to hear that as well. But the AMA and the rest of it have not done any better kissing a@s,

and pouring $$’s  into the cesspool we call congress.

del.icio.us Tags: obama,congress,profanity

Cleaning up The Health Train Express

 

In an effort to speed up loading the landing page of my blog I have deleted many links, ads, and unnecessary ‘noise’.  Hopefully this will speed up your access, reduce internet traffic between sites.  This is my effort to make the internet more green.  For the time being I have left the blog links alone.

I will be playing with the overall design in the coming week. Anyone who has a strong feeling or opinion can leave a comment.

 

GML

Video Game and Butchers, What do they Have in common?

 

The '” boys “  over at  The Healing Blade  and  Nerdcore Learning bring new multimedia strategy to the healing arts.

Turn on your wide screen HDTV and get your controllers ready!

 

Those  long hours in the video game room may be paying dividends in learning as well as improving surgical skills.

The Butcher does not have to code, the surgeon does, butcher does not need malpractice coverage, no CME, not on call, does not need hospital privileges.   If you like to cut, be a butcher.

Health Train caught in an Earthquake???

 

 

Hospital Seismic Safety Report  February 2010

 

We all know about the seismic risks to buildings in California, including health care facilities.  The California Healthline recently  reported the summary information available as of November 6, 2010.

Unfortunately, although mandates for seismic retrofit was established many years ago, the vast majority of hospitals have not been officially evaluated for potential collapse in a major seismic event.

California does not require hospitals to determine their collapse risks, but facilities can do so voluntarily. Hospitals also do not need to determine collapse risks for each of their individual facilities, making it difficult for some hospitals to determine which building to retrofit first.

Efforts To Assess Risk

In 2002, California compiled a list of 1,100 hospitals that could pose a risk of collapse during an earthquake. Of those, the state conducted complex evaluations of 370 hospital buildings and determined that 280 facilities had low enough collapse risks to qualify for the 2030 seismic safety deadline.

State authorities now are focusing on about 700 hospital buildings that were placed in the highest-risk category.

Of those, the state has determined collapse risks for only 90 facilities. Fourteen of those 90 facilities have been assigned collapse risks of between 10% and 32%, far higher than the 1.2% collapse risk that officials deemed reasonably safe.

 A map showing the location of hospitals with buildings that have a 10 to 32 percent chance of collapsing in an earthquake. Click on this link to see more information about the 14 buildings located at these hospitals.

What's left are about 700 hospital buildings in the highest-risk category that still face deadlines to make changes. Officials only know the collapse risk for about 90 of those buildings, which range from .75 to 32 percent.

del.icio.us Tags: earthquake,hospital safety,seismic standards

Medicine from 40,000 feet

 

Way back in the mid 20th century when I graduated from George Washington University with an M.D. degree I imagined that I had “arrived”.  I remember my classmates selecting different specialties and eventually going off to clinical training. I could not imagine doing anything other than clinical work, and perhaps dabbling in some clinical research.  Some of my friends were studying ‘epidemiology’ and a new field ‘public health’.  At that time, it mostly  was dedicated to ‘epidemics’, vaccinations, preventive medicine, and things that to me did not really involved patient care.

Turn the page, 50 or 60 years. This specialty has morphed into having an MPH (Masters in Public Health), and perhaps an MBA in health administration..  Previously these professionals had little to do with your clinical practice on a daily basis.  Now these people are the groundbreakers, movers and shakers throughout the medical world in which we all practice.

My school is now known as “ George Washington University School of Medicine and Health Sciences. The previous formal division of Medical Clinical pursuits from allied health and health business has become blurred at the educational level.  This blurring of distinction has also occurred in the clinical world with PAs. NPs, Advanced Degree nursing specialties and the like.

As a delayed and recent student of this field , and as a result of my blogging research I see that the topography has changed drastically.  Previously treated with disdain, MPHs, and MBAs, and MHAs increasingly have invaded our insular clinical world.  Many health reformers and policy makers delved deep into the social psychology of medical practice, medical group organization, quality measures, and even reimbursements.  All of this has evolved into an environment of MPHs having a huge influence on governmental policy makers.   Many MPHs have evolved into a new specialty of Political Influence.  Many practice medicine, not by treating patients or treating diseases, but by spreadsheets, algorithms, and formulating treating diseases from 40,000 feet….far removed from the implications of their edicts.

The flack is coming from we clinicians on the ground.

Gee, I wish I had gotten that MPH.

del.icio.us Tags: MPH,MBA,NP,advanced degree RNs,MD,health sciences,public health,epidiemiology

Disruptive Luddites

 

For Ophthalmology Times:

The past year has seen a rapid acceleration and implementation of electronic medical records in medical practices. While some ophthalmologists long ago installed EMR it was for the reason of establishing a reliable medical record, and also to improve the efficiency of their practices, improve reimbursement and eliminate paper. Most ophthalmologists lagged in EMR usage due to lack of affordable solutions and the fear of disruptive technology.

During the second and rapid phase of adoption of new technology we have gone beyond 'early adopters', and the remainder of ophthalmology is adopting for political/financial incentives or social influence. Social influence plays a large role in the selection process of the EMR. Ophthalmologists and many physicians rely upon social medical peers for their demonstrations and testimonials regarding EMRs.

Like it or not in the next two years most of us will have adopted EMR and HIE (health information exchange), and not for just financial reasons. Instead of investing in that 4^th generation OCT, or Wave front analyzer you will opt to buy an EMR, for which you will be at least partially reimbursed. (and most likely more than a charge for an OCT or Wave front calculation. The smart money will go toward EMRs. In most specialties the reimbursements are being bundled, and the ROI or recapture of investment will be much less than the incentive for purchasing an EMR.

We will increasingly see that referral sources require electronic communication with specialists, and will expect consultation reports to be sent electronically, via the health information network(s). This will take some time to establish, but it is inevitable.

Like my analogy on the Health Train Express....move over or get run over! It is a bit like the negative effect of not adopting a disruptive technology. By not adopting a growing technology you will be at a disadvantage in the market place, which will more than disrupt your practice than if you had adopted EMR.

John Hamlaka MD, who is the CIO at Harvard makes the following observations.

“The ONC is concerned about the success of meaningful use Stage 1, “and if it turns out much of America can’t achieve meaningful use Stage 1, then more rigorous criteria are not a good idea,” he said. The ONC is expected to further refine the requirements and do a second-quarter 2011 checkpoint to see how it’s going.
Stage 1 programs start in January, attestation will begin in April, and the first incentive dollars will be awarded in May, Halamka said. “The implication for many of us is that you better make sure you have the capacity to do all these quality measures January through March, 2011.

“In some ways, quality measures as they exist are process measures,” said John D. Halamka, MD, during his closing keynote HIMSS Virtual Conference presentation.

Stage 2 will see the introduction of outcomes orientation, and Stage 3 will move to outcome measures, which measure the wellness of a patient instead of how many tests were ordered for a given patient, said Halamka, an emergency room physician and CIO of Beth Israel Deaconess Medical Center and Harvard Medical School, chair of the U.S. Healthcare IT Standards Panel (HITSP) and co-chair of the

When Do We Get to The Next Stop?

 

Did I miss my station? 

I’ve been riding the Health Train Express for several years. I seem to have missed many stops and find myself at the end of the road. Somewhere in between I have vague recollection of stops along the way,  SGR, HMO, PPO, IPA, PQRI, ARHQ, CMS, HITECH, PACA,NHIN, HIE. EMR, RHIO,HHS.

What does it all mean?

Jane M. Orient, M.D., is an On Air contributor speaking on Healthcare Reform. Dr. Orient has appeared on NBC, MSNBC, ABC and many major broadcast venues throughout the US, as well and her Op-eds have been printed in hundreds of local and international newspapers, magazines and followed on major blogs. She has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. She received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. She is the author of Sapira’s Art and Science of Bedside Diagnosis; the fourth edition has just been published by Lippincott, Williams & Wilkins. She also authored YOUR Doctor Is Not In: Healthy Skepticism about National Health Care, published by Crown. She is the executive director of the Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. Complete curriculum vitae posted at www.drjaneorient.com. Additional information on health-related issues: www.aapsonline.org and www.takebackmedicine.com

Congress handed the Congressional Budget Office (CBO) some assumptions, the computers came up with the mix of adjustments needed to give a magic number under $1 trillion in 10 years, and the “Affordable Care Act” (ACA

Numbers are thrown about—but where’s a spreadsheet of the money flows? The President couldn’t exercise a line-item veto even if he had one because there aren’t any line items. For example, how can you budget for each of the new bureaucracies if you don’t even know exactly how many there are (159—more or less)? And are they counted in the $1 trillion cost?

This article by Dr Orient succinctly elaborates the incompetence of the ACA (Affordable Care Act) as she writes in The Health Care Blog.  It seems to have been written by a legal intern skilled at legalese without thought about a strategy for implementation. Each section is written with the assumption and without regard for the effects of a prior change in the health care system.

Her summation is chilling, and should be read by every American and our congressional representatives,  who should have read the bill before voting it’s approval.

PACA needs to be repealed and/or amended drastically. Let’s not give up and roll over.  Change is what he wanted, and change is what we will give  Obama.

del.icio.us Tags: affordable care,repeal,obama,Jane Orient MD,health train express,the health care blog,congress

Some Funny, Some Sad, Some Ridiculous

 

Todays’ post is a potpourri of health related blogs.

Medical care and Art by Ted Bacharach MD (retired)

3D CT scan of a 300-year-old pocket watch

by Vijay

ECRI Institute Receives Contract for Monitoring Health Care Technology

Billion Dollar Home In Mumbai by Indian Mukesh Ambani (Videos)

Cathy's Scarf Quilt

Major Victories In the War Against The Obese

Top 3 stories in health and medicine this morning, November 5, 2010

The Town hall

Raising our voices, throwing our weight

A Few Extra Bucks (the online doctor still meets the same patients)

Ask Not What Your Country Can Do For You, But What You Can Do for Your Patient

AARP Raises Insurance Costs for Employees

The Health Care Blog

Election day Aftermath

del.icio.us Tags: election,hmo,healthcare reform,obama care,constitution,redistribution,health train express

Here we are one day post election.  It was reported that 1.6 billion dollars was spent for the benefit of politicians and free spending businesses, lobbyists, and some well meaning citizens who buy into their lies, promises and grandiose ideology and plans for the republic. No doubt many of these companies, and individuals had some self serving sinister motives. Campaign financing laws are easily thwarted,  to attain these levels of spending a mid-term election.  There is a great deal of American Wealth at stake, your wealth as our politicians fight to obtain your money for their purposes, without regard as to whom elected them or pay their salaries. Media companies  flourish from our largesse,  disseminating half trues, and opinion, competing for advertising dollars and ratings.

“Take back our country”  should be re-stated as “Take back our Money”

I have always  been a moderate, paid taxes, contributing as much as I could when I was relatively well off, employing ten people, accountants, attorneys, insurance companies, not only for malpractice, but liability, disability, health insurance and more. I fueled several medical technology companies for diagnostic and surgical equipment as equipment became obsolete every five years, or less.  I created a ten year business plan investing a significant amount in equipment with a depreciation plan. 

All of my  planning and budgeting were sabotaged by the ‘threat of inflation’ and the projected insolvency of Medicare. During the late 1980s and early 1990s a plan was developed by some ‘hidden magical gurus of health care planning’ located within the D.C. Beltway.  HMOs, IPAs, Managed Care, PPOs and other eponyms were launched with the objective and promise of ‘cost containment’.

It is difficult to prove a negative but one naturally questions what would have occurred if these changes did not occur.  Medical care and the quality of care suffered greatly, administrative expenses soared with the multiple tiers of billing, review and organizational expense.   New positions were created for ‘executive directors’, added administrative expense and consultants in management. Most patients and physicians despised the system.

We were paid less, buying into the concept of ‘withholds’ which would be paid back if doctors managed well and thereby receive a rebate.  I witnessed one of our organizations hi-jacked by our board, using our funds to capitalize the  organization to sell it to Aetna’ managed care plan. This company and many others like it removed much of our income which formerly covered operating expenses and allowed for charity care for the uninsured, both in our private offices and hospitals. Whether there were cost savings remains very much open to question. Many of these organizations merged, failed or became insolvent. 

The  true definition of insanity is to repeatedly do the same thing, resulting in a bad outcome and then repeat it expecting a different outcome.

Our entire medical system has been manipulated and re-organized with devastating outcomes, the number of uninsured has soared, as government has become more involved in the process.  Rest assured our elected officials will fail to control their mandates for ‘Obama Care’.  That is evident from the law they passed without reading or understanding the full implication of the law.  They certainly did not plan the secondary or tertiary effects of the law and how insurers, employers and patients would “gain the system.”

Think about this…40 million citizens (and perhaps a fair number of undocumented aliens receive food stamps to survive. Some of them drive gas guzzling SUVs which have become less expensive to buy because others cannot afford these vehicles to drive to and from work any longer. (Another unintended consequence of a well meaning mandate for fuel economy and “green”. So the poor non working and some disabled can afford better things that hard working employed who have significant other cost of living expenses from their ‘declining spendable income.”

Not mentioned is the tremendous increase in cost of regulating and enforcement of these new laws. 

While you and I have little time to devote to being a ‘watchdog’ over administrators , politicians, we are paying their salaries to got to meetings to plan our destruction, not only of the earners  but the people’s freedoms who receive the ‘rearrangement’  and re-distribution of your property and wealth.

The election illustrates that physicians themselves are still trusted by the people.  Several physicians, one of whom is Rand Paul, MD (an ophthalmologist) were elected to the U.S. Senate. And despite being ridiculed by other candidates, and even some physicians his message rang true for the people of Kentucky. 

The forgers of our constitution were very brilliant in codifying our country’s foundational concepts.  Those concepts brought us through many crises, and it should not be decimated by “ convenience to businesses, decision makers, nor Presidents. It has already been significantly degraded and is in danger of being destroyed. 

 

Our republic was formed with the ability to reform itself through legal process codified in the US. Constitution.  Our peaceful  transition of ruling and power is peaceful despite significant and deeply entrenched diverse values of our peoples.

As long as these values of our legal citizens are respected as we move forward things should continue to flourish despite our current

del.icio.us Tags: constitution,health train exxpress,hmo,obama care,health care reform

difficulties. The Constitution was created for our present contingencies as an eternal document to be built upon ,just as the Magna Carta, and the Bill of Rights have served as part of our republic. 

Halloween on the Health Train

 

My friend and buddy for Halloween night.

If it doesn’t work out, there is always this,

Happy Goblins !!

A Haunting I will go