CAeHQ---The Status of Health Information Exchanges in California

 

California is large enough to be called a ‘nation-state’ with 35 million citizens, it is larger than many sovereign states in the world.  The diversity of it’s demographic is challenging not only for health systems and providers, and with social engineers as well.

The development of health information exchanges in California is a microcosm for what must take place nationally in regard to health reform and ObamaCare.

Early study and planning for HIX began in 2004 with a major impetus by the newly formed Office of the National Coordinator for Health Information Technology (ONCHIT). Rather than forming one monolithic organization a model for regional information exchanges evolved over time.

Simultaneous interoperability standards were developed to ensure a common system of harmony between disparate EMR system, laboratory systems, pharmacy systems and more.

Federal incentives in the form of the HITECH Act has fueled significant growth in HIT since 2009.

The most recent meeting of the CAeHQ nicely summarizes the progress of health information exchanges, and it’s relationship to the national plan. It is anticipated that as the system matures individual HIOs may vanish to be replaced by the national HIE.

The development of each individual health information exchange has been sporadic and dependent upon local interests and the development of sustainable business models. Other items include trust agreements among the users of the exchanges.

Whilst some HIXs are working well, each one delivers different data fields and the comprehensiveness of it’s data. Some are simple messaging functionality, some allow transmission of continuity of care records, while  others are more complete.

As yet there is little if any transparency from an electronic medical record. Rather than true integration of the data into a trusted partner’s EMR a separate portal must be engaged to retrieve patient data.

The ONCHIT Direct program remains a national infrastructure, while each region has it’s own network.  There is no uniformity of size.  The current size appears to be guided by the hospital systems and the individual state. Few cross state jurisdictions except for a few.

The CAeHQC recent stakeholder meeting took place on July 18,2013 via a webinar.

The slide deck of the meeting (24 slides) is linked here. (may take a moment to load)

ref: CAeHC Webinar July 18,2013  Recorded TBA available at www.ehealth.ca.gov

 

Technorati Tags: caehq,onchit,rhio,hix,california hix,emr.interoperability,hitech act,trusted framework

HIPAA NEVER EVENTS

Never events refer to hospital mishaps in procedures and patient identification which often lead to severe complications, loss of a limb and/or death. Perhaps the term should also be applied to privacy rules:

It is forbidden:

The Privacy Rule allows a covered entity to de-identify data by removing all 18 elements that could be used to identify the individual or the individual's relatives, employers, or household members; these elements are enumerated in the Privacy Rule. The covered entity also must have no actual knowledge that the remaining information could be used alone or in combination with other information to identify the individual who is the subject of the information. Under this method, the identifiers that must be removed are the following:

1. Names.
2. All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP Code, and their equivalent geographical codes, except for the initial three digits of a ZIP Code if, according to the current publicly available data from the Bureau of the Census:
   1. The geographic unit formed by combining all ZIP Codes with the same three initial digits contains more than 20,000 people.
   2. The initial three digits of a ZIP Code for all such geographic units containing 20,000 or fewer people are changed to 000.
3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older.

4. Telephone numbers.
5. Facsimile numbers.
6. Electronic mail addresses.
7. Social security numbers.
8. Medical record numbers.
9. Health plan beneficiary numbers.
10. Account numbers.
11. Certificate/license numbers. **
12. Vehicle identifiers and serial numbers, including license plate numbers. **
13. Device identifiers and serial numbers. **
14. Web universal resource locators (URLs).
15. Internet protocol (IP) address numbers.
16. Biometric identifiers, including fingerprints and voiceprints.
17. Full-face photographic images and any comparable images.
18. Any other unique identifying number, characteristic, or code, unless otherwise permitted by the Privacy Rule for re-identification.

These categories are subject to fines, and penalties and in some cases prison sentences for violations (if repeated, and uncorrected)

It extends to insurance agents, insurers, Medicare, providers, hospitals and other health care entities, including health information exchanges,health benefit exchanges, government web sites (CMS, Medicaid), Social Security Records,social media, blogs, including archived storage media, cloud storage, and the Internal Revenue Service should they act as an enforcement agency for the terms of the individual mandate (subject to final rulings of the  affordable care act.

In essence HIPAA extends privacy rules to anyone in contact with digitized or written information about patients, INCLUDING NAVIGATORS. Let us anticipate they will be trained in HIPAA regulations.

Covered entities may also use statistical methods to establish de-identification instead of removing all 18 identifiers. The covered entity may obtain certification by "a person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable" that there is a "very small" risk that the information could be used by the recipient to identify the individual who is the subject of the information, alone or in combination with other reasonably available information. The person certifying statistical de-identification must document the methods used as well as the result of the analysis that justifies the determination. A covered entity is required to keep such certification, in written or electronic format, for at least 6 years from the date of its creation or the date when it was last in effect, whichever is later.

 

 

Technorati Tags: hipaa,privacy,confidentiality,navigator,cms final rule,medicare,hipaa fines,social security records,never events

What is a “Navigator”?

 

 1581: Francis Drake, having completed the first circumnavigation of the world a few months earlier, is knighted by Queen Elizabeth aboard his ship, the Golden Hind

Do we need navigators on the high turbulent seas of the Affordable Care Act ?

The Department of HHS as part of the Affordable Care Act mandated a Navigator program to help people enroll in insurance plans.  Why they did this is no mystery.

They estimated that licensed insurance brokers would ‘gain the system’ to their  advantage. I wonder what the evidence is for that?

There is much evidence which justifies  these concerns found on the internet just by searching for “Medicare enrollment”.  A search will take you to many sites for health insurance, besides Medicare….most seem to be profit driven Medicare advantage of private insurance companies of varying credibility.  The actual CMS or Medicare.gov sites are buried several pages down in the search results.

CaliforniaHealthLine   ( A publication of the California Health Care Foundation) reports:

Individuals who work in the Affordable Care Act's "navigator" program for the law's health insurance exchanges must be affiliated with certain community organizations, such as churches. The workers must undergo at least 30 hours of training to before they can be qualified as a "certified application counselor," the rule issued by CMS states

CMS Releases Final Rule for Affordable Care Act's 'Navigator' Program

Under the ACA, exchanges that will be operated solely by or in partnership with the federal government are required to have at least two certified navigator entities, one of which must be a not-for-profit. HHS has allocated $54 million in funding grants to train and pay navigators in the 37 states with federally run exchanges.

Navigator workers must provide "fair, impartial and accurate information that assists consumers with submitting the eligibility application, clarifying distinctions among [qualified health plans] and helping qualified individuals make informed decisions during the health plan selection process." They also must provide additional assistance to:

• Consumers with disabilities, limited proficiency in English; or
• Consumers who are unfamiliar with health insurance.

Lawmakers in recent months have raised concerns about the workers' level of training and access to consumers' personal and potentially sensitive data. In particular, some GOP leaders have stepped up their scrutiny of the navigator program and a separate "in-person assisters" program in states that will operate their own exchanges. The ACA prohibits federal funding for the assisters program because it does not have to meet the same criteria as the navigators program..

More Details of Final Rule

Under the final rule, traditional insurance agents cannot be selected and trained as navigator workers, who must not be affiliated with the insurance industry ("Healthwatch," The Hill, 7/12). Navigator workers and in-person assisters can provide information only about specific topics.

• The exchanges' qualified health plans and insurance affordability programs;
• The tax implications of enrollment decisions;
• Eligibility for premium tax credits; and
• Cost-sharing reductions.

 

Jones, Groups See Fraud Potential in Covered California Enrollment

California Insurance Commissioner Dave Jones (D) and consumer advocacy groups are concerned about the potential for fraud and identity theft when individuals enroll in the California Health Insurance Exchange .

Privacy, Fraud Concerns

Jones and consumer groups say that the exchange is not doing enough to ensure that people hired as enrollment counselors -- individuals who will provide consumers with in-person assistance in signing up for health plans -- are adequately screened and monitored.

The network of more than 21,000 enrollment counselors could have access to consumers' personal and financial information, such as ID cards and medical histories.

According to Jones, the exchange does not have a plan for investigating any complaints that could arise once the counselors begin their work.

Jones said that it will be possible for the counselors to "obtain information that will allow them to build the trust they have with the individual they're working with and potentially sell them all manner of bogus products, steal their identity, gain access to certain assets they might have ... The list is virtually endless."

He added, "We can have a real disaster on our hands." Unless the navigators are certified as HIPAA compliant entity

 

Technorati Tags: hipaa,aca,affordable care act,covered california,navigaator's program,cms final rule,chcf,healthline,medicare cms

Alice in Medicareland

 

                   

Lewis Carroll's Alice in Wonderland, because Medicare's original  policy has "morphed into madness."

"But I don't want to go among mad people," Alice remarked.
"Oh, you can't help that," said the Cat:
We're all mad here. I'm mad. You're mad."
"How do you know I'm mad?" said Alice.
"You must be," said the Cat,
"Or you wouldn't have come here."

Would anyone believe that a well intentioned law (Affordable Care Act) would wreak havoc with an already dysfunctional health system?  That is about to happen.

The discord is not just a partisan issue, Republican vs. Democrat. Neither side gives a damn about reality, or budgetary constraints. 

Haste will make waste, and the implementation  of the ACA must be put on hold, for several years.

 

Technorati Tags: affordable care act,alice,wonderland,lewis carroll,madhatter

Anytime I begin to think about writing about the affordable care act, Al ice in Wonderland comes to mind.

Obama Administration Doles Out Yet One More Contract to Help With Eligibility Infrastructure And to Operate One Massive Mail Room-With Insurance Exchanges - Serco The Biggest Company You Have Never Heard Of ~ Medical Quack

Obama Administration Doles Out Yet One More Contract to Help With Eligibility Infrastructure And to Operate One Massive Mail Room-With Insurance Exchanges - Serco The Biggest Company You Have Never Heard Of ~ Medical Quack

OUTRAGEOUS: HHS Outsourcing data needs to SERCO, a foreign company...let's bring home the BACON

(Bring American Contractors ONline.

Thanks to Ducknet !

Is this Population Health ?.

 

In the past several years the Epidemiology has been replaced with ‘Population Health”.  I never hear about epidemiology anymore.

Some could look  upon  the Affordable Care Act as a plan for improving health by ‘guaranteeing health insurance to all.   This however does not take into account the myriad complexity and reality of health and disease.

In 2010 the Affordable Care Act was passed into law. The law was passed unanimously by the democratic majority in Congress without Republican support. Due to our congressional structure roughly 1/2 of the country was disenfranchised in regard to decisions on health finance reform..

This produced much discontent which has gradually increased and even effected the supporters of the bill.

Many of the specific mandates are schedule to become effective on January 1, 2014.

White House delays employer mandate
Bending to criticism that requirements were burdensome and complex, the Obama Administration announced late Tuesday it would delay until 2015 a key provision in the healthcare reform law -- the requirement that businesses with more than 50 employees must offer them insurance. This portion of the ACA would force employers to offer health coverage to all full time employees, and require businesses with more than 50 employees to meet certain other requirements of the ACA.

Secondary consequences of the ACA are considerable, increased unemployment, increased part time work force, decreased hiring and loss of entrepreneurial spirit. The ACA increases the risk and cost of expanding a business.  All of these changes will be put on hold until January 2015.

This is only one of many issues that have become apparent. The Employer Mandate is the tip of an iceberg which also includes 1. The Individual Mandate 2. The  regulatory and enforcement activity by the IRS of the ACA.   3.Serious concerns by the health care system, hospitals and doctors.  

Physicians remain concerned over the future of U.S. healthcare, a new survey reveals. Among the survey’s findings, most physicians think EHRs and the ACA will adversely affect the quality of patient care, and nearly two-thirds anticipate that quality of healthcare will worsen over the next five years. 

The Physician Sentiment Index (PSI), conducted by Watertown, Mass.-based Athena health and Cambridge, Mass.-based Sermo, collected responses from 500 physicians who represented a diverse range of specialties and practices sizes. 

This year's PSI tells a story of over-burdened physicians who are deeply concerned about where the healthcare industry is headed. The data suggests the leading distractions affecting physicians' ability to provide the optimum care for patients center on government intervention, increased utilization of and frustration with EHRs and administrative burdens. All told, these distractions have diminished physicians' optimism around their ability to deliver quality care and remain viable, profitable practices. 

4. The sweeping tax supported incentives which include electronic medical records, health information exchanges, and training grants for health IT workers to implement HIT.

EHRs – more purchased, more in use, but what do docs think?

• 73 percent said EHRs are a distraction to doctor-patient interaction, up 12 percentage points from 2011.

• The number who purchased an EHR jumped 10 percentage points between 2011 and 2012 (from 70 percent to 80 percent). – Yet, very favorable opinions did not move in line –18 percent fewer voiced a very favorable opinion of EHRs (from 39 percent in 2011 to 32 percent in 2012).

• 36 percent more say they believe EHRs somewhat or significantly worsen patient care (from 11 percent in 2011 to 15 percent in 2012). 

• The majority (44 percent) says that the EHR was not designed with physicians in mind versus 32 percent in 2011

 

Doctors skeptical of regulation

 

• Over half (in 2012 and 2011) say that government involvement in regulation will not yield lower costs and better outcomes, with slightly more pessimism on display this year.

• A growing number concerned about the ACA’s impact on the quality of care:  Nearly one-third (29 percent) say they still do not understand the details and implications, compared to 22 percent in 2011.

• 16 percent said they'd like to see the ACA remain 'as is' (versus 11 percent in 2011).

• 53 percent report the ACA will have a detrimental effect on their ability to provide high quality care, versus 50 percent in 2011 – 43 percent more believe the ACA will be very detrimental to the delivery of quality of care (from 14 percent in 2011 to 20 percent in 2012).

• 26 percent want to see the entire ACA repealed (versus 21 percent in 2011).

• Three-quarters report that the meaningful use process is at least somewhat difficult and/or cumbersome.

• The ACO model draws concerns: More indicated ACOs as having a negative impact on quality of care (39 percent in 2012 versus 26 percent in 2011) and profitability (63 percent in 2012 versus 48 percent in 2011

 

Technorati Tags: meaningful use,aco,aca,emr,hit,irs,hhs,population health,psi,physician sentiment index,sermo,athenahealth,employer mandate,individual mandate

The Day After Independence Day

 

I thought of several ways to title this post. 1. Changes in Battlefield Medicine 2.Educational opportunities on line at MYVEHU. 3.What non-VA physicians should know about VA and/or Military Medicine.

This post seemed timely as we have just celebrated our freedoms and liberties defended by our warriors some of whom become severely wounded and challenged from their wounds. It also may explain the increased number of multiple limb amputees and how their mortality  has been drastically reduced, and how advanced technology is brought to the battlefield hospital for intervention during the window of opportunity within one hour of the injury. This is no accident and is due to carefully orchestrated teamwork of the involved professionals on the battlefield

There is a lesson to be learned for civilian medical care, both acute and chronic. ln our present system the majority of MDs practice in a relatively isolated clinic environment. Most of their professional organization takes place in the hospital as a member of the medical staff and their specialty department.  There is little opportunity to engage other specialists not in their own field. The individual excellence of each physician is in a silo (much like health information)

Civilians medicine is in the process of transitioning from the old model into one of integrated systems, and accountable care organizations, capable of using military models of care.

With this introduction, let’s move on to some specifics about the VA system, and also the medical departments of the armed services.

The Veteran’s Administration Health System offers continuing medical education for physicians and care-givers online, similar to many offerings for CME from universities and accredited programs.

MYVEHU is a source for VA personnel that also features topics relevant to the reorganization of civilian systems

 

Technorati Tags: battlefield medicine,myvehu,va medicine,va health system,military medicine,integrated system

A Message from Health Train Express

 

We interrupt our regularly scheduled posting to bring you a much more  Important message.

On this 4th of July I cannot think of anything more important nor seminal for us here in the U.S.A.

Take these images to heart.

 

Technorati Tags: july4,freedom,liberty,4th amendment,surveillance

The Impact of Pharma on Health Care Practice

 

Why Medical Marketing is Dangerous To You And Your Kids

You may find this sentiment paranoid, but the pernicious influence of Pharma money on unscrupulous doctors is a noted menace to public health, from the top of medical academia.

Harvard Medical School, the alma mater of Drs. Miller and Christakis, itself has a notorious history of influential psychiatrists paid by drug companies, disseminating dangerous practices. The psychiatrist Joseph Biederman--in 2007, ranked the second-highest producer of high-impact psychiatry papers--popularized attention deficit meds, as well as antipsychotic drugs as a treatment for "pediatric bipolar disorder." Kids' bipolar is a controversial diagnosis, since many psychiatrists believe the disorder's symptoms aren't detectable before adolescence--and yet the number of kids treated for bipolar increased 40-fold from 1994 to 2003, no doubt due in part to Biederman's influence. Rules by the National Institutes of Health (NIH) limit a doctor to taking no more than $20,000 from a drug company whose drug he is funded by the NIH to research. Yet the New York Times revealed in 2008 that Biederman had taken $1.6 million in consulting fees from drug companies over 8 years, while researching and promoting their drugs, without disclosing to the NIH or to Harvard. In 2011, Harvard and Massachusetts General Hospital denounced three psychiatrists, including Biederman, for taking secret Pharma pay for drugs they researched and promoted.

 

Doctor-Network Mapping: Propaganda-Machine, Healthcare Enabler, or Both?

Not that any of this is the fault of Drs. Miller and Christakis at Activate Networks, Inc. Their analytics tools seem likely to do good for medicine--promoting good health practices, from exercise to nutrition, not only in hospitals but also in corporate structures and communities. Outside of hospitals', doctors', and corporate networks, the company has applied its methods to the population of a whole city (Manhattan Beach, California), for a public health initiative by Healthways, a Tennessee-based "well-being company," using census data and publicly available address and co-ownership data to determine links between citizens, and to identify the community's most influential members to target for outreach.

But the market-forces of Big Pharma will lead inevitably to heavier pressures on doctors to sell out--to over-prescribe meds whose efficacy is supported mostly by industry-funded studies. And, because data-mining is a value-neutral tool, and Activate Networks is happy to get business from whatever customers want to pay (and Big Pharma is a deep-pocketed client)--the most influential doctors should be prepared to be bombarded with the full force of medical marketing. Docs, please, hold your ground.

 

Technorati Tags: healthways,big pharma,big data,joseph biederman,harvard medical school,christakis,medical marketing

Tales of the Zombie Apocalypse !

 

Alternate title:  How it only took 4 years to turn me into a zombie !!

 

By now you realize your medical education did not fully prepare you for life as a doctor

Our friend and colleague Zdogg was honored at a recent TEDMED presentation. His rap has made a mark in social media with a long list of YouTube videos.

Most physicians and providers need a dose of his hip hop and rap.

I share his video with you….there is not much more I can add.

Thank you Z   TEDMED will never be the same….

The Happy MD, are you out there"?

 

Technorati Tags: zombie,apocalypse,zdogg,tedmed,las vegas,primary care physicians,physician burnout,medicine

The Affordable Care Act, or IRS Tax Code 101

      

The Affordable Care Act is not really about Health Reform. It is about restructuring health service revenue cycles and the business of health payments. It also requires significant amendment to the IRS tax codes.

There is much more about IRS involvement than the ACA individual mandated insurance coverage. The extend of the change will be outlined below, one  the most intrusive is under ‘Collecting Information” and forms a close inter-relationship between IRS and HHS.  Little has been disclosed about this connection either by the HHS, CMS, nor media outlets.

Health Reform actually takes place with mandated change specified in the ACA and a second law, (much less known)....as

Through a series of manipulations, robbing Peter to pay Paul a series of tax increases take place up front and additional premiums will fund some of the later ACA implementation.

Further burdens include significant increased taxes, and major modifications to the IRS Tax Code, and the immediate secondary impact of increased tax reporting, administration, legal and accounting fees.

 

Charitable Hospital Tax:

Codification of the “Economic Substance Doctrine”:

Black liquor” tax hike:

Tax on Innovator Drug Companies

Blue Cross/Blue Shield Tax Hike

Tax on Indoor Tanning Services:

Medicine Cabinet Tax:

HSA Withdrawal Tax Hike:

Surtax on Investment Income:

Hike in Medicare Payroll Tax:

Tax Hike in Medicare Payroll Tax

High Medical Bills Tax

Flexible Spending Account Cap

Retiree Rx Drug Coverage Tax Hike:

Compensation Limit:

PCORI Fee

Individual Mandate Tax

Employer Mandate Tax

Tax on Health Insurers

Excise Tax on Health Insurance

Distributing subsidies

Early Retiree Subsidy

Nonprofit Tax Exemption

Reinsurance Tax Exemption

State Exchange Tax Credit

Cost-Sharing Subsidy

Small Business Tax Credit:

Small Business Tax Exclusion

Indian Tribe Tax Exclusion:

Therapeutic Discovery Tax Credit:

Adoption Tax Credit:

Tax Exclusion for Dependent Coverage:

Advance Tax Credit and Cost-Sharing Reductions:

Health Care Services Loan Tax Exemption:

Collecting Information

1. State Exchange Information Reporting:

2. Exchange Participation Requirement:

3. Taxpayer Information Disclosure

4. Insurance Provider Information Reporting:

5. Large Employer Information Reporting:

6. Medicare Beneficiary Information Disclosure:

Enforcing compliance

Health Plan Penalty:

New Group Plan Penalty

Group Plan Compensation Discrimination Prohibition

Nonprofit Indicator System:

Small Business Exemption for Cafeteria Plans:

Corporate Tax Advance

Credit to Ryan Ellis and Americans for Tax Reform for their research on this list.  www.atr.org

1. “Patient Protection and Affordable Care Act: IRS Should Expand Its Strategic Approach to Implementation.”  Government Accountability Office, June 2011. http://www.gao.gov/new.items/d11719.pdf

The GAO report list 47 new IRS powers in Obama Care, but one has been repealed since the report was issued – the employee voucher requirement.  It would have required employers to provide free choice vouchers to certain employees who contribute over 8 percent but less than 9.8 percent of their household income to the employer’s insurance plan.  The voucher could have been used by employees to purchase health insurance though an exchange.

 

Technorati Tags: irs,hhs,ppaca,patient protection and affordability act,irs tax code,gao report,health reform law,cms,aca,blue Shield,hsa,individual mandate,exclusions,credits,penalties

Truthiness in Health Care

 

Contributed by Rob Lambert MD

This post is going to be a compilation of quotes from physicians who are far more articulate than I am, and who are also still in the trenches of the battle between providers, and CMS.  Sadly the very organization that was formed to insure health care to seniors (and others) has been corrupted by unknown forces (ie, too numerous to mention.

I can only sit here in my ‘lofty position’ either at the top or the bottom of the system.

My main advantage is I no longer have to look at my checkbook and decide what to pay first, or if at all. 

IRS, State Franchise Board, Payroll (probably the most important since my staff depends upon this for their very survival) (God bless them they must be more motivated (or in a self survival mode) than I ever was. Include also my accountant, attorneys, consultants, HIT vendors, Membership dues to 5 or six professional societies, including three separate medical society dues, County, State and the AMA. State Licensing fees ( a total rip off, outmoded, obsolete, underfunded )(our state fees are supposed to pay to run these organizaions)…However that money is probably been sequestered or is going to pay off some bonds to build a road.

Medical Staff dues (for three hospitals)  Malpractice premiums, property and liability, worker compensation premiums.

That is enough about me ,  on to some other thoughts from those in the trenches.

Rob Lamberts is one of those innovative leaders in practice management he was into EMRs and HIT long before the dawn of medicine by the byte. Now he is breaking new ground in direct pay revenue cycle. However that is a misnomer since there is no ‘cycle’  People actually pay at the door, in return for a substantial discount due to the decrease in overhead of not using IT, nor billing services, nor being at the mercy and whim of CMS and countless other insurance companies whose prime goal (despite the glowing marketing press releases) is to deny payment. This requires multiple billing cycle and more overhead.

 

Rob Lambert

“I’m Rob and I am a recovering doctor.  Yeah, I am recovering…doing a lot better, actually.  Things are tough, but they are a lot better since I left my destructive relationship with Medicare, Medicaid, and insurance companies.  I’ve had to learn how to manage my own money (now that I can’t count on them to bail me out any more), but things are looking a lot better.  I am beginning to see how much better it will be to be on my own.”

The key was when I realized that the system wasn’t going to change no matter how much I accommodated its unreasonable requests.  I felt that if I only did what it asked of me, however unreasonable, it would stop hurting me and, more importantly, my patients.  But I’ve come to see that all the promises to take care of me and my patients were written in sand, and that it couldn’t resist the temptation to cheat on me.  I tried to do what it asked of me, but as time went by I couldn’t take how dirty it made me feel.

But I can’t sit around and wait for the system to change any more.  My patients were getting less and less of my time, and I was getting to the breaking point.  I know there are a lot of other doctors who are willing to do whatever the system asks, but I can’t sit around and watch it self-destruct.  It’s not what’s best for the system, for us doctors, and for our patients.  Sometimes the best thing you can do for someone is to let them self-destruct and pray that they finally take responsibility and learn the hard lessons.  I just hope that happens soon.”

Dr Lambert comes from the perspective of a group medical practice which he founded years ago as a solo doctor. Time and events corrupted his basic model despite and efforts to halt the steady deterioration in the group culture.  He resigned from the very group that he formed decades ago.

“But I don’t want to brag.  I’m no saint, and the system I’ve built to this point is far from perfect.  I’ve still not taken a paycheck, (HOW DOES HE DO THAT?) and that can’t go on too much longer.  Things could still go wrong.  But my decision to no longer try to live in my dysfunctional and destructive relationship has been worth the pain and uncertainty.  I miss the patients I had to leave behind, and I am sad to hear about the care they are getting.  I hope I can build something good enough that lets me offer to them what my new patients have, something I’d given up on: hope for the future of health care.”

Rob made a radical change to no longer take Medicare, nor private health insurers and accept only cash. He refuses to deal with insurers and any agreements are between patients and their insurer.  Dry Rob gets paid by  patients, and they bill their insurance companies.  That is the way it always worked until CMS and HHS entered the room.

That’s all I’ve got for now.  Thanks for listening.  One day at a time.

 

Logo attributable to “Musings of a Distractible Mind” 

Thoughts of an odd, but not harmful primary care physician.

 

LiveJournal Tags: rob lamberts md,distractible mind,cms,hhs,direct pay,concierge medicine,dr rob,emr,hit,seniors,medicare,irs scandal,accountant,attorneys,consultants,HIT vendors

Health 2014

We are at the half-way mark in 2013. In slightly more than five months, January 2014 many of the steps in the Affordable Care Act are mandated to launch.

Anyone able to read is keenly aware that not a minute or hour goes by unannounced without some breaking news about the future affordability of health reform, it’s consequences on your health and pocket book.

No doubt 2014 will be an adventure for patients, providers, hospitals, insurers and the Dept. of Health and Human Services.

Blame not these changes on the bureaucrats, nor President Obama. Many of these features were developed during the earliest parts of the Clinton Administration, when William Jefferson Clinton charged Hillary Clinton with forming a national health plan. That was almost 20 years ago, near the end of the last century.  Somewhat like a  wine fermenting in a bottle, the temperature should be constant and moderate, and not subject to light, or physical stresses. 

Health Reform fills some of those metrics, however it certainly has been subject to physical stresses.  Light has not been a problem, since most of the negotiating and meeting were done in the dark. So dark that congressmen did not read it prior to their irresponsible and negligent passage of the bill.  Not one Republican voted for it, even the most liberal ones.

Fearful of being left behind and/or penalized financially all states are rushing to implement the ACA, with minimal losses and/or expense.  While the new system is taking root, the federal government will prop financing with subsidies. Self sustaining financing will not kick in for several years as the uninsured find their way into the system of eligibility.  Rather than employing already existing resources in health insurance agencies and experts, HHS has deemed it fit to employ and train “Navigators”, twenty thousand and something.  It is not clear to me how long they will be employed, nor why the feds chose this route.  It was a move that completely bypassed existing organizations, and has not endeared the affordable care act to that segment of the present system.

Here are some of the examples

A Louisville Clinic Races to Adapt to the Health Care Overhaul

A feature common to all is the lack of specifics financially on eligibility and/or the premiums and benefits..There is a website, discussing the ACA, and Health Benefit Exchanges, however most patients and even providers have been unable to grasp just how it will all flow together.  One of the biggest issues will be if physicians will accept patients from a health insurance exchange, and expanded Medicaid, and the ‘strings” attached to the program.  It certainly does not appear to decrease paperwork and bureaucracy, rather it increase it.  One example is the HHS requirement that providers re-apply for Medi-caid  privileges.  There is no grandfather clause.

The County Board of Supervisors in my city met with the administrator of the Regional Medical Center. The administrator has a 25 year history of running the  busy medical center. About 20 years ago it was moved from a dilapidated structurally unsound building to a brand new structure certified to withstand a 9.0 earthquake,  It is located just adjacent to the San Andreas Fault less than five miles to the east.

The Supervisors had some excellent advice from consultants (from back east) and one of the supervisors owns an interest in a pharmaceutical company.  He seemed to have a substantial knowledge base in how the system has worked, or not worked as the case may be.

A significant problem in the United States is that there is a Polymorphic system, each with it’s own models  for reimbursement and a very different corporate culture.

City hospitals, county hospitals, federal hospitals, native American hospitals and community medical centers all have a unique cohort of patients, with vastly different sources of revenues. The patients who  use each system are segregated economically from each other.

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The county’s President of the Board proposed integrating private sources into the patient model of the county hospital that predominantly patients who are assisted by the Department of Social Services. He proposes that the County Hospital enter the market place to compete with standard insurance companies, and operate as it’s own Accountable Care Organization (ACO).  The facility is modern and will be staffed by trainees from the new University of California’s Riverside School of Medicine

Riverside has a significant number of uninsured.  The funding for the school , with it’s new buildings has been dicey during the recent years as a result of the state’s ongoing budget crises.  However local stakeholders, local private hospitals, medical groups, chambers of commerce, and business leaders have donated millions of dollars to offset state shortages.

Medcaid is controlled by counties who rely on the state for control and funding of their budgets.  They have little real interest in the health of their ‘clients’. Their true function is to minimize reimbursements to providers, hospitals and medical equipment companies in an adversarial role,not a supportive role.  In the current California system there are pockets of Managed care which function much better than FFS.  However the only Medicaid patient who can receive managed care in the current system  are the ones who have a zero share of cost.  Since share of cost in month to month the reality is that if an eligible person is eligible in one month due to limited income, if the income exceeds a set limit the next month they lose their managed care, and most likely their primary care M.D.  Few MDs participate in both programs since Medi-caid requires providers to be either FFS or prepaid and capitated.

It is truly chaotic and dysfunctional.  What is the ACA going to do about this process? Medi-caid will be inadequate as it is now structured and the promise of eligibility for insurance for this population is questionable without significant reform.  It may just be a mandate that will not work.

 

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