Insurance companies aren’t doctors. So why do we keep letting them practice medicine? - The Washington Post

We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.

Physicians often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back. If the insurance company denies coverage, which occurs frequently, I have the option of setting up a special type of physician-to-physician appeal called a “peer-to-peer.”


Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few keywords to make sure the denial is reversed.


Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions, the “peer” reviewer is unqualified to make an assessment of the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.

 Some physicians dealt with this system from the patient side, as well. A daughter has a rare genetic disorder called Phelan-McDermid Syndrome, which causes developmental delay, seizures, heart defects, kidney defects, autism and a laundry list of other problems. She receives applied behavior analysis therapy, an approach often used for autism, and has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.

While I know what levers to pull from the physician's side, a patient’s options are completely unclear. I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective. A patient can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life get smaller.

Most likely the person evaluating the claim has a leaf book or now a computer with an algorithm that decides the decision by checking off any number of boxes in a flow diagram of yeses and nos to make a decision, without knowing the patient's history, or physical findings.

This sounds good, as most denials are related to specific provider choice or contractual issues, which are relatively easy to remedy (but a problem nonetheless). But other denials are a judgment of some test or treatment as “not medically necessary.”

Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction asks for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.

Some might argue that it makes sense to have two doctors discuss a case and then come to a consensus on the most cost-effective approach for an individual. That’s not what is happening. This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients insurance companies will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.  It also exists to save money for the insurance company. 
Transgender youth are at high risk for mental health morbidities. Based on treatment guidelines, puberty blockers and gender-affirming hormone therapy should be considered to alleviate distress due to discordance between an individual's assigned sex and gender identity. The goals of this study were to examine the: (1) prevalence of mental health diagnoses, self-injurious behaviors, and school victimization and (2) rates of insurance coverage for hormone therapy, among a cohort of transgender adolescents at a large pediatric gender program, to understand access to recommended therapy.

Case-study: An IRB-approved retrospective medical record review (2014–2016) was conducted of patients with ICD 9/10 codes for gender dysphoria referred to pediatric endocrinology within a large multidisciplinary gender program. Researchers extracted the following details: demographics, age, assigned sex, identified gender, insurance provider/coverage, mental health diagnoses, self-injurious behavior, and school victimization.

Results: Seventy-nine records (51 transgender males, 28 transgender females) met inclusion criteria (median age: 15 years, range: 9–18). Seventy-three subjects (92.4%) were diagnosed with one or more of the following conditions: depression, anxiety, post-traumatic stress disorder, eating disorders, autism spectrum disorder, and bipolar disorder. Fifty-nine (74.7%) reported suicidal ideation, 44 (55.7%) exhibited self-harm, and 24 (30.4%) had one or more suicide attempts. Forty-six (58.2%) subjects reported school victimization. Of the 27 patients prescribed gonadotropin-releasing hormone analogs, only 8 (29.6%) received insurance coverage.

Conclusion: Transgender youth face significant barriers in accessing appropriate hormone therapy. Given the high rates of mental health concerns, self-injurious behavior, and school victimization among this vulnerable population, healthcare professionals must work alongside policy makers toward insurance coverage reform.We can do better. If physicians order too many expensive tests or drugs, there are better ways to improve their performance and practice, such as quality-improvement initiatives through electronic medical records.

When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.

Insurance companies aren’t doctors. So why do we keep letting them practice medicine? - The Washington Post: To get access to health care, you don't just need insurance. You also often need to navigate all the hoops and hurdles of health plans.

Medicare to require new Medicare ID in lieu of Social Security number for Medicare Health claims

About a year ago CMS began mailing your new Medicare ID card with a unique identifying number.Due to increasing cyber intrusions in the health care records on many websites, Social Security numbers were increasingly being compromised.  The new ID number has a different format making it more difficult to crack using decryption algorithms.  Beginning January 01, 2019 health providers must use this number or your CMS claim will be REJECTED .


Depending on your age your current SS card will look like this

Your new Medicare ID card looks like this

Comparison of current card v. new card

Do not discard your current Social Security Card.  It will still be required for tax filing and all other financial documents, including IRS and state tax returns.  Other non-health related businesses, banks, credit cards, visas, passports, green cards, immigration forms, and many other applications, for employment, driver's license applications, social security benefits, veterans benefits, and many other things.


Other CMS and Medicare compliance announcements

Governor Signs Variety of Bills Affecting Californians’ Healthcare

HIV Prevention

California will be the first state to allow people to access HIV prevention drugs from pharmacies without a doctor’s prescription. Pre-exposure prophylaxis (PrEP) is a once-a-day pill for HIV-negative people that may keep them from becoming infected, and post-exposure prophylaxis (PEP) is a medication that can help prevent the virus from taking hold if they have been exposed to it. SB-159 by state Sen. Scott Wiener (D-San Francisco) will allow pharmacists to dispense a 60-day supply of PrEP or a 28-day course of PEP. Patients will need to see a physician to obtain more medication. The bill prohibits insurance companies from requiring patients to obtain prior authorization before obtaining the medication.

Abortion Pill

Students at California’s 34 California State University and University of California campuses will have access to medication-induced abortion — commonly known as the abortion pill — at on-campus student health centers by Jan. 1, 2023. Under SB-24 by state Sen. Connie Leyva (D-Chino), students who are up to 10 weeks pregnant will be eligible. Initial costs, such as the purchase of medical equipment, will be paid for with private, not state, dollars.

Maternal Health

Black women are three to four times more likely to die during childbirth and from other pregnancy-related causes than white women, according to the Centers for Disease Control and Prevention. SB-464 by state Sen. Holly Mitchell (D-Los Angeles) will require perinatal healthcare providers to undergo bias training with the goal of reducing preventable maternal deaths among black women. “The disproportionate effect of the maternal mortality rate on this community is a public health crisis and a major health equity issue,” Newsom said upon signing the bill.

Some new moms returning to their jobs who want to pump milk at work will face fewer barriers. SB-142 by Wiener will require employers to provide new mothers with a private space that includes a table, chair, electric outlet and nearby access to running water and refrigeration. Businesses with fewer than 50 employees may be eligible for an exemption. “Too many new mothers are unable to express milk at work or are forced to do so in a restroom or other unsuitable space,” Wiener said.                                                 

 


 Financial Abuse of Older Adults



Investment advisers and broker-dealers will be required to report suspected financial abuse of an elder or dependent adults. SB-496 by state Sen. John Moorlach (R-Costa Mesa) allows these financial experts to temporarily delay requested transactions, such as stock trades and disbursement of funds, when they suspect potential abuse. “With growing Alzheimer’s and dementia concerns, it is critical that we provide safeguards to prevent financial abuse for those in the beginning stages of a difficult life journey,” Moorlach said in a statement.

               

 Ban Smoking in State Parks



Californians will be prohibited from smoking or vaping at state beaches and parks, except for paved roads and parking areas. Violations of SB-8 by state Sen. Steve Glazer (D-Orinda) will carry a fine of up to $25. Similar efforts were vetoed by former Gov. Jerry Brown.

     

                                                                           


Nurse Staffing



State health officials who make unannounced inspections of hospitals will start reviewing nurse staffing levels. Some California hospitals disregard the state’s current nurse-to-patient ratio requirements, Leyva, the bill’s author, argued. SB-227 establishes penalties for violations: $15,000 for the first offense and $30,000 for each subsequent violation.

Medical Marijuana on School Grounds



Even though medicinal cannabis has been legal for years in California, it has not been allowed on school grounds. SB-223 by state Sen. Jerry Hill (D-San Mateo), will allow school boards to adopt policies that authorize parents or guardians of students with severe medical and developmental disabilities to administer medicinal cannabis on campus, as long as it is not via smoking or vaping. This allows students to “take their dose at school and then get on with their studies,” Hill said.

Dialysis Industry Profits


One new law could disrupt the dialysis industry’s business model. Dialysis companies often get higher reimbursements from private insurers than they do from public coverage. One way low-income patients remain on private insurance is by getting financial assistance from the American Kidney Fund, a nonprofit that receives most of its donations from the two largest dialysis companies, Fresenius Medical Care and DaVita Inc. AB-290, by Assemblyman Jim Wood (D-Santa Rosa), will limit the private-insurance reimbursement rate that dialysis companies receive for patients who get assistance from groups such as the American Kidney Fund.

Healthcare in Jails and Prisons

County jails and state prisons will be prohibited from charging inmates copays — usually $3 to $5 — for medical and dental services with the passage of AB-45, by state Assemblyman Mark Stone (D-Scotts Valley). Some states already prohibit copays in prison, but California is the first to eliminate copays in county jails.

Cancer Patients

Some Californians undergoing cancer treatment such as radiation or chemotherapy will have insurance coverage for fertility preservation treatments. Under SB-600 by state Sen. Anthony Portantino (D-La Cañada Flintridge), private health plans regulated by the state must cover procedures such as the freezing of eggs, sperm or embryos for patients who want to try to have children in the future.

Big Pharma,

The Democratic governor also signed what health advocacy groups deem this year’s biggest effort to lower prescription drug costs. AB-824 will give the state attorney general more power to go after pharmaceutical companies that engage in “pay for delay,” a practice in which makers of brand-name drugs pay off generic manufacturers to keep the lower-cost generic versions of their medications off the market.

SOURCE: Story By Ana B. Ibarra | Kaiser Health News.

Moonshots for Health Care

It sounds a lot like Star Trek's iconic statement, "Go where no man has gone before"

Paradoxically that is where we are at with health care, financially, technically and for access to care.

A strange coalescence of increasing needs, increasing elderly patients, and conflicting needs for financial resources has attracted investors, entrepreneurs to apply known and developing technologies across many disciplines ranging from biochemistry, genetics, material engineering, and artificial intelligence.

A Moonshot is, in the technology context at least, an ambitious, exploratory and ground-breaking project, normally undertaken without any near-term expectation of profitability, and without the full investigation of all potential risks and benefits to come further down the road.

Current Moonshots from Startup Health include supporting the U.N. Sustainable Development Goals for health and wellbeing by 2030 and a mission to improve the health of everyone on the planet by 2040.

Access to Care Today, healthcare is for the few, for those who live near more developed cities or towns, and for those with money. Fully half of the world’s population goes without needed healthcare. Lack of access to quality healthcare is a problem affecting billions of people across diverse economies in every corner of the globe. Access to care is about geography – is it a four hour drive to the nearest hospital? But it’s also about being able to afford the care once you arrive. To solve the access problem we’re building radical new solutions that address delivery, cost, geography, and technology. We will need to leapfrog legacy systems and dream up brand new ways of doing business.

Cost to Zero About 800 million people spend at least 10% of their household budgets on medical expenses, according to a 2017 report by the World Bank and WHO. That’s expensive enough to send 100 million people into extreme poverty. Mobile technology internet connectivity are flipping the cost of care paradigm. Telemedicine has dramatically lowered provider overhead. New population health startups are upgrading the way patients battle chronic illnesses, slashing costs. We’re on a moonshot mission to take costs from poverty- inducing all the way to zero. The only way that is going to be possible is for us to dismantle our understanding of health and rebuild the machine from the ground-up.

Cure Disease Heart disease. Cancer. Stroke. Obesity. Diabetes. Six in 10 U.S. adults have a chronic disease. These diseases, which accounted for tens of millions of deaths in 2016, are already within our power to treat or cure. Through basic apps run on smartphones, people can follow healthy diets and schedule recommended screenings. The bottom line: If a cure exists, it should exist for all, and health tech has the potential to be that democratizing ingredient. A moonshot to cure disease is about access, but it’s also about discovery. Groundbreaking advances in machine learning are increasing our capacity to understand the drugs we’re making, and how they will affect our bodies. This, in turn, is opening the door to faster cures and targeted medicines for rare diseases.

End Cancer Cancer claims the lives of millions, shattering families across every bracket of age, geography and economic status. By 2030, the number of new cancer cases per year is expected to top 23 million. Chances are, you know someone personally who has battled cancer. And if you don’t, you unfortunately most likely will. To defeat cancer once and for all, it is going to take true moonshot thinking. A global cancer moonshot is built on a level of collaboration we’ve never seen before. It’s going to require breaking down data silos between academic institutions, reaching across political aisles, and even sacrificing personal egos.

Women’s Health Being born a woman shouldn’t be a health risk factor. But in much of the world, it is. Achieving the Women’s Health Moonshot means widening the aperture on the definition of women’s health, focusing on issues that move beyond the current litmus test — sexual and reproductive health — to a standard of living well. This includes a women’s right to physical and mental health and wellbeing. According to the WHO, self-harm, including suicide, was the second leading cause of death globally among females, aged 15–29, in 2015. It means creating a world where individual women no longer have to shoulder the burden of advocating for themselves in order to get proper medical care, a world where they can rely on the medical system

Children’s Health  On one hand, we have cause to celebrate. Global annual infant deaths have been cut in half between 1990 and 2017. At the same time, we see massive opportunity for improvement. Every year more than 1.4 million children under five die of preventable environmental hazards like air pollution, hazardous chemicals, inadequate water, sanitation and hygiene. Nearly 100,000 kids under 15 die of cancer even though the vast majority of childhood cancers are potentially curable with existing treatments.

Nutrition & Fitness If we are what we eat, we’re a world of extremes, desperate for a healthy middle. On one end is hunger. According to UNICEF, in 2017 approximately 200 million children under the age of five suffered from malnutrition. Where malnutrition has been abolished, we’ve created an epidemic of excess. Obesity is now a primary cause of some of the world’s biggest killers, like heart disease, stroke and diabetes. Billions of people the world over are overweight, and 650 million are obese. Together we can create a world where all people have access to the foods they need to thrive, prevent disease, and stay healthy regardless of where they live. We also can build communities of support to help people control their weight and live healthy lifestyles.

Brain Health  With every new age has come startling, beautiful revelations about the human brain. How, like an intricate map, sections of the three pound mass can be tied to everything from speech to memory to personality. Yet the more we understand it, the less it appears like a map, and the more it opens up like an unexplored galaxy, full of mysteries and new frontiers. The Brain Health Moonshot means dismantling the old, siloed notions about basic neurology and searching its great depths to unlock its mysteries. No longer will we merely treat health challenges without connecting the brain to the solution. We will master the mechanisms of the brain in ways that will create new opportunities for health and wellness and then share them with the world.

Mental Health & Happiness  The DSM-5 tells us that there are approximately 300 mental disorders. We live in a world where 600 million people suffer from depression and an epidemic of loneliness threatens our elderly population. Advances in mental health research have shown us deeper and more nuanced ways of understanding how our chemistry and environments affect our brains, and our behavior. The Mental Health and Happiness Moonshot reimagines what it means to thrive, feeling whole inside and out. It means using telemedicine and smartphones to expand the reach of mental health services. It means gamifying healthy habits in a community of peers. And it means expanding our definition of happiness in ways that we can’t even fathom yet.

Addiction According to the National Survey on Drug Use and Health, close to 20 million American adults (aged 12 and older) battled a substance use disorder in 2017. What’s clear is addiction is no longer anonymous, like the sign at meetings suggests. Its cords are reaching into families everywhere, ripping at the fabric of our communities. The time is now to fight back, to radically alter our thinking about treating addiction and ending the opioid epidemic. It starts by rethinking what’s possible. Together, with a unified will, global collaboration, and innovative health treatments, we can create a world where addiction is a crisis of the past.

Longevity  The Longevity Moonshot is just as personal as it is technical. Where you live greatly impacts how long you live. What public health experts refer to as social determinants of health—think housing quality, access to fresh food, water and air quality—are thought to be among the most powerful influences on a person’s health. As more people live longer, we need the ability to scale senior care in a way that addresses both medical and mental health needs in this older population. We need smart solutions to improve injury recovery. We need support and accountability to adapt a preventative mindset when it comes to our health in order to detect diseases earlier.


The groups are not listed in terms of priority.  Behind each of these goals are people and companies already on their moonshot.

Present and previous moonshot companies have videos explaining their goals.


What is your Moonshot ?

   For those of us who like meetings, Startup Events are listed here





Startup Health is an internet driven organization whose purpose is to attract other high-minded entrepreneurs to health care as an investment opportunity.   We are all invited to join the effort.

Using CRISPR to edit eggs, sperm, or embryos does not save lives

Some scientists hail reproductive applications of CRISPR as potentially lifesaving and curative. That claim for CRISPR is mistaken and misleading.


This startling announcement by He Jiankui almost one year ago that he had created the first genetically modified human beings unleashed a torrent of criticism. It also brought to the surface common misunderstandings — even among scientists and ethicists — that reproductive uses of this genome-modifying tool have therapeutic value, will treat people with genetic disorders, will save lives, and will eradicate disease. None of those are true.

The twin girls that He helped create are publicly known as Lulu and Nana. Their father is HIV-positive. The scientist said he used CRISPR-Cas9 genome editing technology to disable a gene called CCR5 to mimic a naturally occurring gene deletion that appears to confer immunity against HIV.



In a recent publication, The  Journal of Bioethics the ethics and thinking behind this ill-advised experiment are viewed by another expert.

A major criticism from the scientific community, which has otherwise been generally supportive of advancing gene technologies, was that He did not use the technology to address a serious medical need. That criterion stems from a 2017 report by the U.S. National Academy of Sciences and the National Academy of Medicine recommending that, once the technology is ready and safe, genetic modification of embryos could be allowed when there is a “serious disease or condition” to be addressed and no “reasonable alternatives” exist.

IVF with pre-implantation genetic diagnosis is an existing alternative to CRISPR for preventing the transmission of genetic disease.

PHILIPPE LOPEZ/AFP VIA GETTY IMAGES

This scientific criticism of He’s experiment was on target: Although HIV infection is a serious disease, there are proven ways to prevent transmission of the virus from an infected father to his offspring, and later in life to prevent or treat the infection.

This act can be compared to the young child finding a gun and shooting itself because it did not understand what a gun does.  It's actions cannot be reversed....the genie is out of the bottle.

Careful consideration must be taken when designing and proposing gene editing using CRISPR or any other techniques which alter the 'germ line' of human and mammalian cells. We know so little about the long term effects of clipping out parts of the gene or adding snippets.  If there are other methods of treatment with known risks, they should always be used first. "primum non nocere" is one of the first things that medical trainees are taught.

Although we 'think' we know how genetics works and how DNA fits into programming protein manufacturing each year that goes by new surprises appear to disprove our theories.

CRISPR does offer a new tool for research in laboratory animals, bacteria, viruses.  Unique genes  can be inserted to use microorganism's machinery to manufacturer new drugs.

"Prime editing" is more precise and more efficient than CRISPR and could herald a new era of genetic manipulation.




Using CRISPR to edit eggs, sperm, or embryos does not save lives - STAT:

CMA to tackle four major issues at annual meeting

CMA physician delegates meet annually to establish broad policy on current major issues that have been determined to be the most important issues affecting members, the association and the practice o...

The 148th Annual Session of the California Medical Association (CMA) House of Delegates (HOD) will tackle four major issues when it convenes October 26-27, 2019, in Anaheim.

This year’s major issues are:

Augmented Intelligence: Technology continues to transform the way physicians serve patients, creating opportunities and exposing challenges that prevent quality, timely and affordable care. While CMA has adopted policies addressing telemedicine, electronic health records and interoperability, it’s time to explore pragmatic solutions that address medical decision-making, new liabilities and privacy concerns inherent with augmented and artificial intelligence. With few laws and regulations on the books, CMA needs to proactively develop new policy that keeps physicians at the center of health care delivery.

Cannabis: CMA has adopted extensive policies concerning cannabis use and regulation, including our 2011 white paper, “Cannabis and the Regulatory Void.” As the state’s legal cannabis industry continues to grow and evolve, CMA must continue to weigh in on pressing issues, including health impacts associated with cannabis use, public health protections, federal legalization, data and surveillance efforts, high-quality research, marketing and advertising practices, cannabis equity programs and more.

Homelessness: Physicians witness the homelessness crisis in emergency rooms, clinics and on the streets of our communities. The multi-faceted challenges of housing, case management, intervention programs and public health considerations require California’s physicians to weigh in on evidence-based solutions that address the health care and social needs of those at risk of or experiencing homelessness.

Adverse Childhood Experiences: When it comes to trauma-informed care, CMA supports efforts for data collection, research, and evaluation of screening for Adverse Childhood Experiences (ACEs), recognizing there is a growing need to increase familiarity on the what, when and how to incorporate ACE screening practices into routine care. California physicians need tools, resources and funding to address their patients’ cumulative ACEs, which has a strong correlation to numerous health, social and behavioral problems throughout their lives.







CMA to tackle four major issues at annual meeting:

The number of transplant physicians is dwindling. That's a problem - STAT

Over the past few years, applications for training fellowships for transplant physicians has been on a decline, even as the need for them is increasing.

By DAVID WEILLOCTOBER 17, 2019

As the need for organ transplants grows, the number of transplant physicians dwindles

At any given time in the U.S., about 120,000 people are waiting for the call that they’ve been matched with a donor for a new lung, heart, liver, or kidney. That number will continue to rise, but the number of doctors to take the 2 a.m. call that a donor has been found for their patient and perform the transplant is dwindling..

About eight years ago, while directing the lung transplant program at Stanford University, I began noticing a sharp decrease in the number of applicants for the transplant fellowship program — a requirement to become a transplant physician — even though we had the oldest and best-established lung transplant training program in the world. Typically, I’d see five to six applicants a year, but in recent years I haven’t seen any. In my current role as a consultant to major transplant centers around the country, I’ve learned that this wasn’t specific to Stanford, and there has been a noticeable decline in the number of physicians committing to the transplant field, regardless of organ type.

Most Americans probably aren’t aware of the decline in the number of individuals training to become transplant physicians and how it will affect the future of medicine. Neither are the 2020 presidential hopefuls, all of whom have policies they believe best provide health care coverage for Americans without acknowledging or calling attention to the fact that soon there may not be enough doctors to do the work once more people are insured. We need a plan for that.

Our most vexing challenges in medicine right now are twofold: attracting young people to the field and keeping them there. These challenges are even more acute in transplantation. I have 12 months to teach fellows to be proficient at organ transplantation. It’s not enough time, so I work them hard. Throughout the history of medicine, training has been characterized as a “grand bargain” in which trainees make personal sacrifices with the expectation of a better life once they are practicing physicians. But that’s a deal many don’t accept anymore.

Physician wellness is a major factor. Up to half of physicians experience anxiety, depression, insomnia, and poor interpersonal relationships. Things may be worse for transplant physicians, as many view this field as unstructured with few boundaries to the physical work and, more importantly, one that requires a huge emotional commitment. In essence, transplantation is seen as a sure path to physician un-wellness. So, while many think about training in the field, most ultimately pursue other options.

Fifteen years ago, a lung transplant center would be considered large if it performed 40 transplants a year. Now the largest centers perform nearly 100 lung transplants a year (sometimes more) without concomitant increases in staffing. Harried transplant physicians care for an increasing number of patients, all the while under pressure from hospital administrators to do more transplants and pressure from regulatory bodies and insurance companies to produce better outcomes.









The number of transplant physicians is dwindling. That's a problem - STAT

“Things Providers and Patients Should Question.”

The mission of "Choosing Wisely" is to promote conversations between clinicians and patients by helping patients choose care that is:

Supported by evidence
Not duplicative of other tests or procedures already received
Free from harm
Truly necessary

Beginning in 2012, national organizations representing medical specialists have asked their members to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed. This call to action has resulted in specialty-specific lists of  “Things Providers and Patients Should Question.”

The original list was compiled the American Academy of Family Physicians

Don’t do imaging for low back pain within the first six weeks, unless

red flags are present.

Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis

are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most

common reason for all physician visits.

Don’t routinely prescribe antibiotics for acute mild-to-moderate

sinusitis unless symptoms last for seven or more days, or symptoms

worsen after initial clinical improvement.

Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due

to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80

percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

Don’t use dual-energy x-ray absorptiometry (DEXA) screening

for osteoporosis in women younger than 65 or men younger than

70 with no risk factors.

DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients

Don’t order annual electrocardiograms (EKGs) or any other cardiac

screening for low-risk patients without symptoms.

There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health

outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential

harms of this routine annual screening exceed the potential benefit.

Don’t perform Pap smears on women younger than 21 or who have

had a hysterectomy for non-cancer disease.

Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety,

additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for

improved outcomes.

– Nine leading physician specialty societies have identified specific tests or procedures that they say are commonly used but not always necessary in their respective fields. Patient advocates are calling the move a significant step toward improving the quality and safety of health care.

 The lists include things to question such as:

Do patients need brain imaging scans like a computed tomography (CT) or magnetic resonance imaging (MRI) after fainting, also known as simple syncope? Probably not. Research has shown that, with no evidence of seizure or other neurologic symptoms during an exam, patient outcomes are not improved with brain imaging studies. (American College of Physicians)

Do patients need stress imaging tests for annual checkups? Not if you are an otherwise healthy adult without cardiac symptoms. These tests rarely result in any meaningful change in patient management. (American College of Cardiology)
Should patients going into outpatient surgery receive a chest x-ray beforehand? If the patient has an unremarkable history and physical exam, then no. Most of the time these images will not result in a change in management and has not been shown to improve patient outcomes. (American College of Radiology)

Do patients need a CT scan or antibiotics for acute sinusitis? Most acute rhinosinusitis resolves without treatment in two weeks and when uncomplicated is generally diagnosed clinically and does not require a sinus CT scan or other imaging. (American Academy of Allergy, Asthma & Immunology)

Should dialysis patients who have limited life expectancies and no signs or symptoms of cancer get routine cancer screening tests? These tests do not improve survival in dialysis patients with limited life expectancies, and can cause false positives which might lead to harm, overtreatment and unnecessary stress. (American Society of Nephrology)

Should women under 65 or men under 70 be screened for osteoporosis with dual energy x-ray absorptiometry (DEXA)? No, research has shown that in patients with no risk factors, DEXA screening is not helpful in this age group. (American Academy of Family Physicians)

Since 2012 when the list was established it has grown substantially and many common tests performed regularly are on it.  This by no means that those tests should not be done. They must be considered in a larger framework of history, family history, physical examination and some routine blood tests.


To help patients engage their health care provider in these conversations and empower them to ask questions about what tests and procedures are right for them, patient-friendly materials were created based on the specialty societies’ lists of recommendations of tests and treatments that may be unnecessary.

The choosing wisely list was compiled by a large number of medical specialty societies.

Note: Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.


The list has been duplicated and disseminated by numerous consumer oriented publications

Ref:  Choosing Wisely.

Nobody Wants a Waiting Room

With his nose buried in a binder full of specifications for standardized outpatient

clinics, the architect asked, “Where do you want your waiting rooms?”

“I don’t think anyone wants a waiting room,” came the earnest reply.

Chuckling, the architect persisted, “Yeah, you’re probably right, but let’s figure out

where they’re going to go in this building.”

“Actually, we’re not going to have waiting rooms. Nobody wants a waiting room.”

The room grew quiet, and a few people shifted uncomfortably. The architect,

sensing no jest in the exchange, looked up and gently closed his binder. “But

everyone has waiting rooms . . .”

Health Reform cannot take place only in the Digital Health Space, but also the physical space, we call our offices or clinics.  A twenty minute wasted time at the very beginning wastes a lot of patient time, and if we really want to be patient-centric we cannot ignore the patient's needs.

This initial conversation would be the spark for a series of struggles over the next 2 years as we attempted to establish a new model of care, with a service blueprint and an environment to enable it.

In the summer of 2015, as the new Dell Medical School at The University of Texas at Austin began planning for the launch of its specialty clinics, the school’s embedded Design Institute for Health was asked to assist in the design of both the service model and the physical layout of the clinic.

The possibility of eliminating waiting rooms represented one opportunity to transform the patient experience. For patients and family, the feeling of wasted time, alongside others who were ill, was a source of frustration and anxiety, and reinforced the prioritization of the system’s needs over the patient’s. We felt it was impossible to address these drawbacks, no matter how many amenities were included, and waiting rooms wasted valuable floor space

This concept produces a windfall of cascading improvement in patient satisfaction. While at first it may be disorienting to patients and staff the learning curve will be swift, in fact much quicker than the transition to electronic health records.

The possibility of eliminating waiting rooms represented one opportunity to transform the patient experience. For patients and family, the feeling of wasted time, alongside others who were ill, was a source of frustration and anxiety, and reinforced the prioritization of the system’s needs over the patient’s. We felt it was impossible to address these drawbacks, no matter how many amenities were included, and waiting rooms wasted valuable floor space

Nobody wants a waiting room, and no one needs a waiting room

“But I need a waiting room. Where else will I get my patients from?”

A clinical leader at the medical school, when told that we wouldn’t be building waiting rooms, insisted quite sincerely that the clinic wouldn’t be able to operate efficiently without a ready supply of patients at hand. The concern reflected a “factory” metaphor that is almost universal in traditional clinics paid on a fee-for-service basis.

The waiting room is nothing more than a temporary stock room, or intermediate warehouse for patients with billable conditions that feed exam rooms every 10–15 minutes, ensuring the unbroken stream of billable encounters demanded by RVU targets or other measures of productivity. No health care provider I know actually views patients as a packaged revenue opportunity, but the fee-for-service system has incentivized this warehousing behavior.

Rather than delivering patients serially to one exam room after another, each owned by a different provider, we made the patients the owner of their own rooms, and instead, circulated the providers to the patients.”

All of this is well and good if you are building out a new space or as leasehold improvements. But what about your office that is already built out.  How can you improve your space to make it more pleasant?

Enter the office:

Snack Bar

 The Concourse

The Boarding Pass

Open Office Concept

Here are some relevant sources:

https://www.accentoffice.com/five-ways-to-make-waiting-rooms-more-welcoming/

https://www.btod.com/blog/2017/02/01/the-best-colors-for-an-inviting-waiting-room/

http://www.digitalsignbuilder.com/adslide-medical-waiting-room

https://www.nuemd.com/news/2017/03/03/5-tips-making-your-medical-practice-more-inviting

https://www.careinnovations.org/resources/14-ideas-to-transform-your-waiting-room/

https://www.patientpop.com/blog/running-a-practice/6-strategies-turn-waiting-room-asset/

https://www.warehouse-lighting.com/articles/Lighting-for-Hospital-Waiting-Rooms

Remember that the modifications to your physical space can produce a return on investment in produdctivy with increased number of patients and improved staff and patient satisfaction.

Attribution: https://catalyst.nejm.org/nobody-wants-waiting-room/

Patients Eligible For Charity Care Instead Get Big Bills |

Nonprofit hospitals admit they sent $2.7 billion in bills over the course of a year to patients who probably qualified for free or discounted care.  When Ashley Pintos went to the emergency room of St. Joseph Medical Center in Tacoma, Wash., in 2016, with a sharp pain in her abdomen and no insurance, a representative demanded a $500 deposit before treating her.

Health Care Finance Bullying.

She said, ‘Do you have $200?’ I said no,” recalled Pintos, who then earned less than $30,000 at a company that made holsters for police. “She said, ‘Do you have $100?’ They were not quiet about me not having money.” But Pintos, a single mom with two kids who is now 29, told state officials St. Joseph never gave her a financial aid application form, even after she asked.

Pintos said she was examined and discharged with instructions to buy an over-the-counter pain medication. Then St. Joseph sent her a bill for $839. When she couldn’t pay, the hospital referred the bill to a collection agency, which she said damaged her credit and resulted in a higher interest rate when she applied for a mortgage.

Not many people talk about this despicable standard of care in some hospitals.  About 56% of American community hospitals have nonprofit status, which frees them of paying most taxes and allows them to float tax-exempt bonds. In return, they are supposed to provide community benefits including free or discounted care for patients who can’t afford to pay.

The IRS leaves it up to each hospital to decide the qualifying criteria. A comparatively generous hospital may give free care to people earning less than twice the federal poverty level — around $25,000 for an individual and $50,000 for a family of four — and may provide discounts for people earning up to double that.

For those who do not qualify, hospitals often offer payment plans. But they can turn to aggressive tactics if bills are not resolved. Patients can be pestered by debt collectors, and some hospitals sue them or try to garnish their wages. Medical debt can damage credit ratings — one study calculated Americans had $81 billion in collections in 2016 — and forces some people into bankruptcy.“

While some hospitals say they write off the debt of poor patients without ever resorting to collection measures, several hospitals whose practices were highlighted in news reports this year for aggressively suing patients admitted to the IRS they knew many unpaid bills might have been averted through their financial assistance policies. 

Analysis of Debt Process

Patients Eligible For Charity Care Instead Get Big Bills | Kaiser Health News: Nonprofit hospitals admit they sent $2.7 billion in bills over the course of a year to patients who probably qualified for free or discounted care.