Primary Care and How it can Cut the Cost of Renal Failure

 

Telemedicine Can Cut Health Care Costs by 90%

by Vijay Govindarajan

Vijay Govindarajan is the Earl C. Daum 1924 Professor of International Business at the Tuck School of Business at Dartmouth. He is coauthor of Reverse Innovation (HBR Press, April 2012).

The title for the post is a bold one. It is a vague, sweeping declaration, certainly one we would all like to believe, an it grabs one’s attention to see how the conclusion has been derived by Dr Govindarajan.

If you've not yet heard of telemedicine or think that it's not a great  way to deliver quality health care, you may want to read this. Telemedicine, made possible by the availability of mobile networks, is revolutionizing health care. But not in the U.S.

You have to look to India, where telemedicine is already widely used in the delivery of health care — and is saving lives even in the most rural corners of the country. Nephrologists have developed a system that allows for peritoneal dialysis at home in  lieu of the more expensive hemodialysis with expensive devices in dialysis centers or in hospital. At home PD requires no vascular access ports, pumps or technical personnel. It can be accomplished by a trained patient with minimal if any supervision.

Dialysis Center                          At Home Peritoneal Dialysis

The major barrier in the acceptance of PD is concern that patients won't have proper access to a doctor — especially in geographically dispersed countries such as the United States. As a result, less than one in twelve ESRD patients are treated with PD. The net result? It costs over $170,000 to treat patients with ESRD in the U.S., using the more expensive HD.  HD requires a network of redundant hemodialysis centers scattered within travelling distance for a procedure necessary several times a week.

It doesn't have to be this way. The "distance" between the patient and the PD unit can be overcome, at a dramatically low cost, by efficient use of the internet, mobile phones, and a strong home visit protocol. To quote Dr. Nayak: "Our success can easily be replicated in the U.S. Conservatively, even if 15% of ESRD patients choose PD over HD, cost savings for Medicare and Medicaid will run into many millions of dollars every year."

After signing into the (secure) hospital website, patients and caregivers are directed to a personalized home page from which they can use the site to enter and share information. Health complaints made by patients receive immediate response. Remote monitoring is augmented by a home visit protocol that ensures that each PD patient's progress is followed up by a well-trained clinical coordinator (CC) on a regular basis. The CCs are trained to follow a set protocol and are equipped with a standardized checklist for a step-by-step assessment of patient well-being during each visit. All this information, together with a brief summary of the patient's most current laboratory results, is conveyed to the nephrologist by SMS from the patient's home. The CC is instructed to wait until the nephrologist responds (usually within 15 minutes), and then to counsel the patient accordingly. CCs also assess and advise patients on nutrition, psycho-social well-being, and physical fitness and rehabilitation levels.

Dr. K. S. Nayak, Chief Nephrologist at the Lazarus Hospital in Hyderabad, India, and his team are able to treat ESRD patients using PD, supported by  mobile phone short messaging service (SMS), inexpensive digital cameras, and the internet to address patient accessibility issues.

The hospital retrospectively analyzed 115 rural patients who had started PD using this remote monitoring technology. Amazingly, rural patients performed well on PD and had significantly better survival rates than did their urban counterparts.

What is the primary driver of this system-wide inefficiency and cost? Most health care providers would agree that it is physician "mindset:" higher physician reimbursement for HD than PD, and concerns about accessibility in a geographically vast country contribute to historically low use of PD in the U.S.

Author comments:  Gary M. Levin MD

In this now Patient-Centric health model in the U.S. a driving force for P.D. should be patient demands for quality of life issues and cost.

Primary care physicians should encourage nephrologists to make peritoneal dialysis a predominant form of dialysis if indicated.  In the coming changes in reimbursement not based on procedures, this may become a reality.  Most patients on ESRD (end stage renal disease) programs are already funded by a separate Medicare administrative system. Prior authorization for HD may become a routine to select HD in lieu of HD.

The "distance" between the patient and the PD unit can be overcome, at a dramatically low cost, by efficient use of the internet, mobile phones, and a strong home visit protocol.

To quote Dr. Nayak: "Our success can easily be replicated in the U.S.

Ref:  Health 2.0 News

 

Technorati Tags: dialysis,hemodialysis,peritoneal dialysis,telemedicine,reimbursements,primary care,nephrologist,dialysis center,Vijay Govindarajan center,esrd,medicare,medicaid,india dialysis

Brave New World

 

Author: G. M. Levin M.D., Attribution to the American Medical Association, AMED news

 

More details are forthcoming regarding ACO establishment and leadership. One of the key announcements is that 27 of the leaders of ACOs will be physician leaders. AMA Medical News announced that “Thousands of physicians will be among those coordinating patient care in the 27 accountable care organizations that were chosen in April to participate in the new Medicare shared savings payment model.”

Organized medicine was pleased to see that 21 of the 27 ACOs would be physician-run. The American Medical Association also noted that five of the approved groups will participate under an advance payment model, which provides up-front funding from Medicare to cover the costs of establishing the infrastructure needed to coordinate patient care. Advance payments make it possible for smaller groups of doctors to participate in the program in a leadership role, said AMA President Peter W. Carmel, MD. More than 50 organizations have applied for the advance payment option beginning July 1.

So far, CMS has received more than 150 applications seeking approval to participate in the second phase of the program, and the agency will announce the groups that qualify in July. Another round of applicants will be approved in January 2013.

The newest organizations to be chosen, which involve more than 10,000 physicians, have agreed to coordinate care for nearly 375,000 Medicare beneficiaries, the agency said during an April 10 briefing with reporters.

Safeguards are being put in place to insure equality with physician leadership and control

Plymouth Bay Medical Associates, Jordan Physician Associates and a number of specialty physicians from Jordan Hospital joined to form Jordan Community ACO in Plymouth, Mass. Physicians in the network will coordinate care for more than 6,000 Medicare patients.

The Vitruvian Man,  Leonardo Davinci, circa 1478 (Wikipedia)

The ACO is structured so that physicians and the hospital have an equal say in how the organization will operate and share in any savings. The pool of doctors, who mostly are primary care physicians, and the hospital each have one vote, and a majority is needed to move forward. That effectively means decisions must be unanimous or both sides continue negotiating.

This is unchartered ground so far, and the ACO will be looking for Medicare patients to be active rather than passive participants in the care model. “Patient education is paramount for any project to work,” Dr. Johnson said.

Accountable care organizations that provide higher-quality care and cut costs can earn bonuses from Medicare. Groups will be evaluated by their performance on 33 quality measures, their use of preventive health services and whether they improve care for at-risk patients. The 27 ACOs participating in the systemwide shared savings program as of April 1 will be joined by additional members in July.

But beneficiaries still retain the right to choose physicians outside an ACO.

 

Physician-led ACOs

• Accountable Care Coalition of Caldwell County, Lenoir, N.C.
• Accountable Care Coalition of Coastal Georgia, Ormond, Fla.
• Accountable Care Coalition of Eastern North Carolina, New Bern, N.C.
• Accountable Care Coalition of Greater Athens, Ga.
• Accountable Care Coalition of Mount Kisco, N.Y.
• Accountable Care Coalition of the Mississippi Gulf Coast, Clearwater, Fla.
• Accountable Care Coalition of the North Country, Canton, N.Y.
• Accountable Care Coalition of Southeast Wisconsin, Milwaukee.
• Accountable Care Coalition of Texas, Houston
• AppleCare Medical ACO, Buena Park, Calif.
• Chinese Community Accountable Care Organization, New York.
• Coastal Carolina Quality Care, New Bern, N.C.*
• Crystal Run Healthcare, Middletown, N.Y.
• Florida Physicians Trust, Winter Park, Fla.
• Jackson Purchase Medical Associates, Paducah, Ky.*
• Optimus Healthcare Partners, Summit, N.J.
• Physicians of Cape Cod ACO, Hyannis, Mass.
• Premier ACO Physician Network, Lakewood, Calif.
• Primary Partners, Clermont, Fla.*
• RGV ACO Health Providers, Donna, Texas*
• West Florida ACO, Trinity, Fla.

Nonphysician-led ACOs

• AHS ACO, Morristown, N.J.
• Arizona Connected Care, Tucson, Ariz.
• CIPA Western New York IPA, doing business as Catholic Medical Partners, Buffalo, N.Y.
• Hackensack Physician-Hospital Alliance ACO, Hackensack, N.J.
• Jordan Community ACO, Plymouth, Mass.
• North Country ACO, Littleton, N.H.*

 

*  These ACOs are receiving advance Medicare implementation funding.

Source: “First Accountable Care Organizations under the Medicare Shared Savings Program,” Centers for Medicare & Medicaid Services, April (cms.gov/apps/media/press/factsheet.asp)

TEDMED Social Media in Vivo

 

I admit it. T.E.D. 2012 from San Francisco CA was lost in the clutter on my radar screen this month by tax day and a myriad number of social media projects I am involved in. As an inadequate apology here is  TEDMEDs 2012 PROGRAM . TEDMED is well established as an annual affair and is well accepted as a source of information for the present and future. The speakers cross a wide divide of topics from social concerns to science and at times science fiction. Well respected, this year the TEDMED was carried by simulcast live at UCSF.  For the rest of us we will have to wait for the archived event to be published.\

“TEDMED is the only place where a Nobel Prize-winning neurobiologist has a conversation with a four-star general…where an opera singer (with a double lung transplant) chats with a NASA space physician…and where a ballet dancer talks to an exoskeleton designer,” according to the TEDMED website.

The Program Brochure adequately describes the events:

 

In the interest of not missing the event for 2013, please reserve April 16-19 2013 at The Kennedy Center in Washington, D.C. Apply To Attend  early. It usually sells out.

Speakers have not yet been formally announced, however 2012 Speakers will give you an idea of the energy, excitement and creativity at the TEDMEDs

Sherwin Nuland at TEDMED 2010

Distance between Physician and Patient Increase

As my title for today’s post indicates, TEDMED is THE Social Media Event, Live each year.

Technorati Tags: TEDMED 2012,TEDMED2013,TEDMED program,Sherwin Nuland,UCSF

When Doctors are called Providers

by Shara Yurkiewicz | in Physician

KevinMD featured this touching real story about physicians as caregivers and not providers.  A physician cannot provide health….he can direct traffic and guide patients to return to wellness or accommodate illnesses that cannot be cured or treated.

Here is the story,

“Impersonal and self-absorbed as Manhattan may be, it’s still embarrassing to cry on West 32nd Street.  I looked for a store, any store, and ducked inside.  The pace of my steps and angle of my head as I buried myself into a back corner, thumbing through pants twice my size, gave me away.  A store clerk walked over and asked if I was okay.  I knew I’d have to meet her eyes, unable to hide the tell-tale redness and puffiness of my own.  I asked if they had a bathroom I could use.

Being Manhattan, there was no customer bathroom, but the store clerk very gently led me to the staff bathroom and told me to take the time I needed.  After five minutes of some fairly heavy crying, I spent the next ten desperately trying to disguise what I had just done.  I scrubbed my face until it hurt and molded my expression back into that of stoic, aloof New Yorker.  My insides didn’t feel much better, but at least my outsides didn’t betray that anymore.   I emerged, thanked the clerk, and took comfort in the fact that I’d never see her again.

My little episode had only intensified the all-consuming ringing in my ears.  The tinnitus had started two years ago, suddenly and unrelentingly.  Five doctors and five clean bills of health later, I was left with the unchanging advice: “We’ve ruled out anything organic and tinnitus isn’t dangerous, so you’ll just have to get used to it.”  No follow-up appointment necessary.

I was left to my own devices–which included the Internet, snake oil supplements, and my own obsessive mind–and I wasn’t using them well.  Besides being sleepless, irritable, and depressed, the far more damning thing was that I was without any hope.  I couldn’t imagine being able to live happily in my body.

Thinking back, I still can’t figure out why it didn’t dawn on me to consider a psychiatrist instead of an ENT or a neurologist.  The idea to see him wasn’t even my own.

After getting to know me, the psychiatrist eventually suggested medications.  I wasn’t afraid of the side effects, and I began immediately.

A year and a half later, everything is much better, objectively and subjectively.  Though not gone, the auditory disturbances are manageable to the point where they hardly register emotionally.  I don’t much like talking about it, for reasons better articulated by Russell Crowe’s character in A Beautiful Mind:  ”I still see things that are not here. I just choose not to acknowledge them. Like a diet of the mind, I just choose not to indulge certain appetites.”

Of course, most times I go to the doctor, for any purpose, I am asked about the reasons I am on certain medications.  Usually my answer is acknowledged, and the appropriate empathetic response is conveyed.

Recently, I was surprised by one doctor’s version of empathy: “Oh, yes, tinnitus can make you literally want to drive off a bridge.”

Of course, this doctor doesn’t know that 18 months ago, I broke down in midtown Manhattan and wondered how I could live out the rest of my life at this rate.  She assumes by my demeanor that I am well-adjusted and perhaps always have been.  She doesn’t know that sometimes when I listen with my stethoscope for a patient’s heartbeat and I hear ringing, that familiar fear makes my own chest tighten.  Or that sometimes I “indulge” in anxiousness when a tinnitus spike occurs that I cannot ignore.  Or that the very condition she was treating me for was creating such a spike at that moment.

Regardless, I was in “no acute distress,” as the medical lingo goes.  I let it go.

I wasn’t even angry with her off-the-cuff remark.  I say silly things to patients on a weekly basis, and the only reason it isn’t more frequently is that I only see patients once a week.

What reminded me of her remark was a piece by Dr. Danielle Ofri in the New York Times, which was inspired by a New England Journal of Medicine article by Dr. Jerome Groopman and Dr. Pamela Hartzband.

All three doctors rail against the term “provider” instead of “doctor” for a number of reasons: the generic term connotes sterility, commodification, distance, and interchangeability.  ”The words we use to explain our roles are powerful,” Groopman and Hartzband explain.  ”They set expectations and shape behavior.”

This is all fair.  And, as a medical student, I should be in especially staunch agreement.  But I’m not. As a patient, I’ve seen far more “providers” than “doctors.”

I went to the doctor who made the unfortunate comment about my tinnitus because I had an unrelated problem.  She took me seriously, she diagnosed me correctly, she prescribed the appropriate medications, and I got better.  Technically, flawless.  She provided excellent care.

But, Groopman and Hertzband write when we use a term like “provider,” it ignores “the essential psychological, spiritual, and humanistic dimensions of the relationship.”

From a patient’s point of view, though, all it takes it one insensitive comment from the physician to lose that humanistic dimension.  When my doctor made that remark, I relegated her to the impersonal role of provider, someone incapable of understanding my experience but capable of treating my physical problem.  I just wanted to get better.  As Dr. Ofri writes, “It makes [physicians] feel like a vending machine pushing out hermetically sealed bags of ‘health care’ after the ‘consumer’s’ dollar bill is slurped eerily in.”  That is exactly how I saw my doctor.

Was I happy with the care I got?  Sure.  If I have another problem, will I see her again?  Probably.  Was I bothered by her remark?  A little.  Did I care?  Not really.  I didn’t care because I depersonalized her immediately after.  If I cared, the remark would hurt.  I don’t want to hurt.  Is that fair to the doctor?  Maybe not, but I care more about me.

This example is far from unique, for me and for others as well.  There are many reasons people dislike doctors, and many of these reasons are not particularly fair.  But when the same complaints are heard over and over again (“He doesn’t listen to me!”  ”I can’t believe she said that!”  ”He doesn’t understand!”), one has to wonder which came first–the term “provider” or the doctor acting like one.

I’m not dismissing the argument that “provider” is irksome or suggesting that we shouldn’t spend space discussing its consequences.  But I wanted to spend some space on rationalizing why patients may already think in these terms: on how in many cases physical provision of health care is exactly what doctors do, and on how depersonalizing doctors can actually protect patients when their emotional or humanistic care is lacking.  And the term “provider” sometimes fits, even if doctors don’t want to wear it.

“But words do influence us,” Dr. Ofri writes about what doctors are called.  Yes, they do.  Now let’s take those thoughts and apply them to what doctors say too.”

 

Technorati Tags: physicians,providers,primary care

Social Media and the Pot of Boiling Water

Social media, and blogging are a collective affair. Interesting and creative posts and ideas seem to take on a life of their own. It reminds me of the molecules in a pot of boiling water.  The water molecules vibrate faster and faster bouncing off one another until it reaches  100 degrees C.   Adding further energy (heat) creates a change in physical state absorbing more energy and if contained in a space pressure rises or escapes if it is an open vessel.

Social media is a bit like this analogy.The subject starts off slowly and if worthwhile others repost or write a similar blog.  At some point the post takes on a mind of it’s own, travelling through feeds, and aggregation sites.

It’s like that here at the Health Train Express where I want to thank Health Works Collective for it’s continuing and generous redistribution of my meager thoughts and ideas. Much of Health Train’s success is attributable to Joan Justice and her fine team.   Thank you.

 

Technorati Tags: health works collective,social media,blogging

Meaningful Use and Mobile Apps

 

Several sources are discussing the possibilities that EMRs will eventually require a mobile app interface and smart applications for phones and tablet PCs. to qualify as an approved EMR. Another meaningful use criteria to qualify for incentives from Medicare/Medicaid.  At first glance another governmental intrusion into health care, but upon closer examination perhaps the first ‘real’ M.U. for providers and patients, who are the center of ‘Patient Centric” healthcare.

New mHealth App Certification – The Next CCHIT Mistake  In order to qualify for M.U. CMS/HHS will likely require certification of mHealth apps

Happtique,  a healthcare-focused appstore, announced plans to create a certification program that will help the medical community determine which of the tens of thousands of health-related mobile apps are clinically appropriate and technically sound. The company has tapped a multi-disciplinary team to develop the “bona fide mHealth app certification program” within the next six months. The program is open to all developers and will be funded by developer application fees.

It will certify apps intended to be used by both medical professionals and patients

Why your Practice needs a Mobile Website Interface 

EMR  FDA and HIPAA  (how many more do we need?)

There is a challenge to avoid being called a ‘medical device’ in developing and marketing smart phones, and mobile apps.  The term invokes a whole new series of hurdles for approval by the regulators of medical devices. The Food and Drug Administration has a protocol for several classes of medical devices. Approval by the FDA also adds considerable expense for the approval process.

Relatively small medical mobile app developers dominate this niche and rely upon word of mouth to market their products for distribution via the iPhone Store or the Android Store, via the internet or cell network.

 

Technorati Tags: mapps,web portal,cchit,meaningful use

Jobs, Funding Related to Health Care Law at Risk

 

There’s little precedent for axing funding after a law is struck down.
 

Should Obama Care be rescinded by the constitutional conundrum and the decision of Supreme Court to throw out, it will take some time to unravel what has already taken place.

Sometime is better to cut your losses, and untold millions of dollars have already been spent forming new agencies and staffing them.

If the Supreme Court pulls the plug on health reform, winding it down could be almost as contentious as building it up in the first place.

And the hundreds of federal employees in the agencies created or expanded by the health law could find themselves at the center of a new round of fighting. Those positions rely on Affordable Care Act dollars that the court could take away by holding the whole law unconstitutional.

A lot could still be left up to the White House and Congress to work out — and the decisions would affect the new offices and agencies, the livelihood of the men and women who work in them and status of the multiyear contracts and projects they have embarked on.

It’s likely that some in the health reform workforce would get reabsorbed into other Health and Human Services offices, where a number worked prior to the health law’s passage two years ago. But some could end up without a job — and without their health benefits.

The offices created to implement the health reform law include the Center for Consumer Information and Insurance Oversight and the Center for Medicare & Medicaid Innovation. The consumer office is writing the health law’s new insurance rules and the Innovation Center is experimenting with different payment models for entitlement programs.

Neither Center for Medicare & Medicaid Services nor the White House would I have a comment for this story, but HHS records show about 500 people work for these two offices. A recent Senate Republican analysis of federal jobs data concluded that thousands more new HHS workers are busy implementing the health law, with about 3,000 new positions in the Office of the Secretary alone.

It’s complicated, and I find little satisfaction in the morass created by an irresponsible congress who did not take the time to read the law. It’s more than ‘I told you so.”  How much will it cost to take apart ‘Rubik's  cube ? 

Removing the freshly poured foundation, and filling a deep hole still seems far less complicated than figuring out procedure codes and how to link them with ICD diagnostic codes to submit a bill to patients, insurers and Medicare.  And the number of codes are about explode exponentially.

 

Technorati Tags: CPT icd,Obama Care,supreme court,unconstitutional,HHS

Combining all of these changes and near misses, Obama care, HITECH, ARRA, HIX, ACO, Pay for Performance, Outcome studies, Medical Meetings and implementing a new Electronic Medical Record system I may have to relinquish blogging and social media.

Big Data Part II Social Media

 

This article is a compilation of several sources, referenced at the end.

750 million users of Facebook, 100 million users of Google plus and an additional   users of Twitter, Myspace and Pinterest produces and enormous amount of data. How much of it is useful?  That depends upon who wants to know.

The same can be said for Health Information Systems. A conundrum is developing and will become an overriding issue as the Health Information Exchanges, regionally and nationally become operational.  There are substantial barriers financially and some reticence on the part of hospitals to invest. The initial construction will be heavily subsidezed by HITECH and ARRA.  When these grants expire the exchanges must be self supporting.  When and if completed HIX will gather enormous amounts of information. Will it gather dust unused? That will depend upon a second and even third generation of software.

It comes in “torrents” and “floods” and threatens to “engulf” everything that stands in its path. The sheer size of the pile (measured in petabytes, one million gigabytes, or even exabytes, one billion gigabytes) combined with its complexity has threatened to overwhelm just about everybody, including the scientists who specialize in wrangling it.

“It’s easier to collect data,” said Michael Franklin, a professor of computer science at the University of California, Berkeley, “and harder to make sense of it.”

Making sense of Big Data is, in fact, a holy grail of computer science these days — and technology companies, academic institutions and the federal government are investing heavily in the endeavor.

And with Google, Facebook, Twitter and many other leading data-heavy technology companies based in the Bay Area, many locals are on the cutting edge of Big Data research.

Last month, the National Science Foundation awarded $10 million to Berkeley’s A.M.P. Expedition, which stands for “algorithms machines people,” a team of Cal professors and graduate students who take an interdisciplinary approach in their drive to advance Big Data analysis.

The Berkeley group was founded in early 2011 and includes Google, SAP and Oracle as sponsors.

The grant is part of the Obama administration’s “Big Data Research and Development Initiative,” which will distribute $200 million. One of the more innovative aspects of the Berkeley group is its emphasis on the people part of dealing with Big Data.

Meanwhile, for every minute that it took you to read this article, 48 hours of video were uploaded to YouTube. According to the site, an overwhelming amount of material — about eight years of content — are added every day by users.

Big Data will play a role in ACOs, and Medicare’s budding plan to incentivize or penalize outcomes. Individual providers will be judged in the context of their “beneficiary community” and local providers.

 

Technorati Tags: big data,acos,medicare,incentive payments,outcomes,beneficiary community,hix,hie,google +,twitter,health information exchange

PAIN FOR PERFORMANCE

Attributed to Jonathon  Low  (from the blog “Lowdown”)

A Partner and Co-Founder of Predictiv and PredictivAsia, Jon specializes in management performance and organizational effectiveness for both domestic and international clients. He is an editor and author whose works include Invisible Advantage: How Intangilbles are Driving Business Performance.

“Medicare Starts to Tie Doctors' Pay to Quality and Cost

For all the data collected about medical care and health, the relationship between expenditures and results in the US remains stubbornly disconnected.”

Reimbursement from Medicare is going to become tricky with the imminent calculations regarding outcomes for your patients in your geographic location.

It appears that not only will your outcomes  affect your income, but the outcomes of your referring and referral providers will affect your practice income.

Jordan Rau (Washington Post) writes, “Making providers routinely pay attention to cost and quality is widely viewed as crucial if the country is going to rein in its health-care spending, which amounts to more than $2.5 trillion a year. It’s also key to keeping Medicare solvent. Efforts have begun to change the way Medicare pays hospitals, doctors and other providers who agree to work together in new alliances known as “accountable care organizations.” This fall, the federal health program for 47 million seniors and disabled people also is adjusting hospital payments based on quality of care, and it plans to take cost into account as early as next year.”

“Twenty-thousand physicians in four Midwest states received a glimpse into their financial future last month. Landing in their e-mail inboxes were links to reports from Medicare showing the amount their patients cost on average as well as the quality of the care they provided. The reports also showed how Medicare spending on each doctor’s patients compared with their peers in Kansas, Iowa, Missouri and Nebraska.”

“Efforts have begun to change the way Medicare pays hospitals, doctors and other providers who agree to work together in new alliances known as “accountable care organizations.” This fall, the federal health program for 47 million seniors and disabled people also is adjusting hospital payments based on quality of care, and it plans to take cost into account as early as next year.

Applying these same precepts to doctors is much more difficult, experts agree. Doctors see far fewer patients than do hospitals, so making statistically accurate assessments of doctors’ care is much harder. Comparing specialists is tricky, since some focus on particular kinds of patients that tend to be more costly”

Dr. Michael Kitchell, a neurologist and chairman of the board at the McFarland Clinic in Ames, Iowa, one of the state’s biggest multi-specialist practices, predicted the Medicare reports “will be a huge surprise to almost every physician.” That’s because the calculations of how much those doctors’ patients cost Medicare include not just the services of the individual doctor but of all the doctors that provided any treatment to the patient. Kitchell said his patients saw on average 13 physicians besides himself.

“You’re a victim or a beneficiary of your medical neighborhood,” Kitchell said. “If the primary-care doctors are doing the preventative screening tests, you’ll get credit for that, but if you’re in a community where the community doctors are doing a poor job, you’re going to look bad.”

Providers organized into a multispecialty medical group and/or accountable care organizations will have an easier time than those in solo, practice, or single specialty groups. These practices may require a redesign  They are at a distinct disadvantage caused by their local community provider network formal or informal.  It ups the stakes as to who you receive referrals from or to whom you refer.  The quality, efficiency and their outcomes will alter your reimbursement through incentives and/or penalties.  (Note that the metrics are determined by CMS, not your neighboring providers or you.)

Dana Gelb Safran, who oversees quality measurement for Blue Cross Blue Shield of Massachusetts, says she doubts it will be possible for the government to judge individual doctors. She predicts CMS will ultimately have to find ways to evaluate doctors as parts of groups — either formal affiliations as part of group practices or informal affiliations among doctors who refer to each other.

If you were an auto mechanic your brake repairs might be compared to a body shop, or engine mechanic that also worked on the same vehicle.  The brakes may be perfect, however your payment may be decreased by the condition or repairs on the rest of the vehicle

This may be an unprecedented change in payments for any services not only in health care but most industries.

Although the program is still being devised, it will become reality for many doctors starting in January, because CMS plans to base the 2015 bonuses or penalties on what happens to a doctor’s patients during 2013.

Medicare’s adoption of this approach would be “a game changer” in terms of making physicians directly accountable for costs, said Anders Gilberg, senior vice president at the Medical Group Management Association, which represents doctors groups. Medicare is “going to be shifting money from . . . physicians who are deemed to be high-cost relative to their peers to low-cost physicians. That’s going to create all kinds of new incentives in fee-for-service.”

Private insurers may follow Medicare’s lead, said Paul Ginsburg, president of the Center for Studying Health System Change, a Washington think tank. The formula Medicare ultimately designs to judge and pay doctors, Ginsburg said, could become “a valuable asset for private insurers, with a tool that will be somewhat bulletproof, that physicians won’t attack because they’ve been part of the process of developing them.”

“Patients are not behind this agenda. The public is very scared about managing costs.”

 

Technorati Tags: accountable care,medical home,cms benefits,medicare,pay for performance,quality,outcomes

Social Media in Healthcare—Where is it Leading Us?

 

The following selection is from the blog “Occupy Healthcare”

Do you remember when people had a family doctor that made house calls. I am one of the few physicians who can remember those days. Todays graduates in most locales would not think of this as a way to practice medicine. Perhaps in some rural areas (if there are any primary care physicians in those areas.)

When was the last time you heard of a medical home visit? Have you ever been seen in your home? What has changed in healthcare that we must go to a building in order to receive services? Why are services not coming to us? When did healthcare become removed from the community?

“20% of Americans or approximately 60 million people live in rural America. Those who live in rural communities are older, poorer and have more chronic diseases than the typical city dweller. The problem: few doctors choose to practice in rural America. And the doctors who are out there are getting older themselves and are close to retirement.”

 

Healthcare reform paid a significant amount of attention to expanding coverage for individuals who previously had no health coverage. In some rural areas, being able to have access to insurance means that you are now more likely to be seen than before. But what happens when there is no one there to see you? What happens where there is no workforce to address your healthcare needs? While the same can be said for urban areas too, the need is more apparent in our rural communities.”

 

Commentary:

Gary Levin M.D.

Are social media and telemedicine the first retro step in a journey to house calls? I believe we are just at the beginnings of the applications of remote monitoring and telehealth.  The perfect storm and convergence of smartphones, tablet computers, internet, cell phone technology and an exploding interest in Health 2.0 and 2012 has earned the year of mobile applications in healthcare.

Today computer technology allows for EKGs, Ultrasound examinations, Blood testing,  and video transmission of images. ‘Scopes” can be attached to video to be transmitted via inexpensive tele conferencing applications. The technology is now here, and only political and regulatory reform are necessary for the technology to become widespread. All of the above can be performed in a home environment, removing the inadequacies of home examinations and treatments.

While the concept today seems archaic to most current trainees there still remain physicians who remember the day when the diagnosis was made during the history taking, confirmed by physical examination, and laboratory data as the last resort.

Today young physicians seem to rush through the history and physical and resort to imaging as the first resort of an evaluation, be it abdominal pain, headache, or trauma.  I am not implying these relatively advanced technologies should be abandoned, rather selectively applied.  The medic-legal environment also sways our judgment in ordering these tests as they have become a ‘standard of care’ in most communities.

Government Poised To Provide A Huge Boost To Healthtech Startups

 

Attribution:  All of this article is attributed to

 

Dave Chase is the CEO and Co-founder of Avado, a Patient Relationship Management platform that automates interactions between an individual and their healthcare providers greatly reducing the administrative burden for healthcare providers and improving the patient experience. 

Currently, the federal government is poised to level the playing field for healthtech startups. An unprecedented wave of innovative healthtech startups has been developing over the last few years. You can see them at conferences such as Health 2.0, TechCrunch Disrupt, TEDMED and demo day events that Blueprint Health, Healthbox, Rock Health and Startup Health host. Nonetheless, the health sector may be the single most challenging arena for startups.

Fortunately, there are scores of innovative startups who are start up health,well positioned to address the patient engagement requirement. Look no further than the companies in startup incubators/accelerators or the scores of companies demonstrating at Health 2.0 conferences. These software developers from Silicon Valley, Seattle, Boston, New York and elsewhere have the skillset to address this critical requirement. They can assist healthcare providers directly or via their vendor partners.

Unfortunately, with little awareness of innovative healthtech startups, providers and legacy vendors are pushing back against the requirements proposed by the ONC. There is a major risk that the proposed requirements will be watered down based upon this feedback. What could be the biggest ever jumpstart to the healthtech startup community could become a missed opportunity. More importantly, the opportunity to make a huge difference in the health of our population would also be missed.

 

Note: The image accompanying this article is from Regina Holliday. As described on her Wikipedia page, Regina paints images that encapsulate her view and others in the e-patient community

Having high expectations for Patient Engagement will cause healthcare providers to rise to the occasion to solve this huge issue. Consider that three-quarters of healthcare spend is on chronic disease and decisions that drive outcomes are made by individuals (aka “patients”). It’s long been said the most important member of the care team is the patient. It’s time to transform that from a catchphrase to reality.

 

2012 TEDMED. During the event, they had a “Great Challenges“ contest. Not surprisingly, “The Role of the Patient” was a leading vote getter. This despite the fact that it didn’t begin to hint at the role patients can play if they’re equipped with information.  And that’s a major point of why patient and family engagement are proposed in Stage 2 Meaningful Use.  As support built for the challenge, it’s critical that your voice is heard on the proposed Stage 2 Meaningful Use requirements.

Voting for the petition is great to raise visibility, but the most impactful thing you can do is to comment on the government site

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I am taking a break today.....it's my birthday. 

Something In It for Everyone (to Oppose)

 

Health Train Express was derailed by a ‘near miss’ and had an unscheduled trip to my “Center for Excellence” in Heart Affairs.  I will report on that in my next blog post, but already have this one ready to go.

The Affordable Care Act is a rich target for almost everyone, employers, hospitals, physicians, patients. The only ones not opposed to it are the uninsured and disadvantaged, but they are suspicious as well.

If the Act itself is not sufficient there are annual budget proposals that will modify and tweak it further.

Let’s begins with

Chicoholley’s World

Military Tiering: Govt. wants retirees to pay for their health care according to retirement salary. These were earned benefits for all and shouldn’t be treated like a welfare program. It was a promise and part of the package for serving a minimum of 20 years.

The Presidents budget for FY 13 proposes “tiering” which is means testing based on retired pay.  This testing is for the health care we have earned through a full career.  These were promises made by the government.  The health care and  pay was earned through many years of service to protect our country. This certainly is discriminatory.  Means testing health care fees is rare in the civilian community.  The types of programs that are means tested for example are welfare programs.  Military retirees have earned their health care for a full career in the military.  Now, the government wants to break promises to all those who have served for 20 to 30 plus years.  Their word means nothing.  This is unfair to all those who have served and protected our country.  I am sure many of you out there have friends and family members who have spent years their lives being career military.  We need your help to tell congress and the president that this is unfair and discriminatory toward those who have served.  Thank you.  M. Moll  USAF Retired.

Employers are faced with providing insurance to all employees or face penalties. Many may opt out and pay a penalty which will be less costly to them than purchasing insurance coverage.

Employees

Providers will be affected by meaningful use requirements, HIT directives, reorganization of payment models using accountable care organization and elimination of procedure driven billing codes. and the burden of installing electronic medical records or suffer penalties in payments. Providers will have to chose carefully regarding Health Insurance Benefit Exchange Offerings, and completely review state Medi-caid plans.

Hospitals are faced with the expensive challenge of forming accountable care organizations to monitor and control cost, and outcomes. Nice new income source for attorneys

Insurance

Major changes in regulations regarding limits on profit, broad expansion of eligibles, changes to coding, payment models with formation of accountable care organizations.

Retired   Means testing and tiering are also being proposed for social security benefits, as well as increasing eligibility age for benefits.

State Health Departments will have to reassess their eligibility standards for state sponsored plans using Medi-caid as an administrative plan. Current standards are highly restrictive and make no sense as they are not based on any type of meaningful coverage nor consistency and are based upon month to month eligibility.  Medi-caid eligibility standards are retro based on poverty standards and meaningless maintenance requirements and size of household.  Standards are set for disqualifications such as household size and other factors.

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All of these complaints lead me to repost something I had posted in the past on Facebook. 

“The Donkey in The Well”

One day a farmer's donkey fell down into a well. The animal cried piteously for hours as the farmer tried to figure out what to do. Finally, he decided the animal was old, and the well needed to be covered up anyway; it just wasn't worth it to retrieve the donkey.
He invited all his neighbors to come over and help him. They all grabbed a shovel and began to shovel dirt into the well. At first, the donkey realized what was happening and cried horribly. Then, to everyone's amazement he quieted down.
A few shovel loads later, the farmer finally looked down the well. He was astonished at what he saw. With each shovel of dirt that hit his back, the donkey was doing something amazing. He would shake it off and take a step up.
As the farmer's neighbors continued to shovel dirt on top of the animal, he would shake it off and take a step up. Pretty soon, everyone was amazed as the donkey stepped up over the edge of the well and happily trotted off!
MORAL :
Life is going to shovel dirt on you, all kinds of dirt. The trick to getting out of the well is to shake it off and take a step up. Each of our troubles is a steppingstone. We can get out of the deepest wells just by not stopping, never giving up! Shake it off and take a step up.

 

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