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Senator Tom Coburn's Bill SB 1099

I received an email from my good friend and colleague this morning. Jim Rowsey MD, a now retired academic physician (fellow ophthalmologist) has been working with Senator Tom Coburn (Okla), also a physician for the past several years. Dr. Rowsey, in response to one of my recent blog posts refreshed my memory on alternative proposals spearheaded by Dr. Coburn for health reform. It is published below:

“I am still teaching every state medical society that I can reach, or their Board of Trustees, and the subspecialty societies the value of Tom Coburn, MD's legislation Senate Bill 1099, (and House companion bill 2025) which covers tort reform, Medicaid reform, HSA, and a Patient Driven Health Care system. It the the point of action for physicians to take back control of health care. Jim Rowsey, MD cell 727-642-7017”

The WSJ Blog has this to say about reform:

Is closing military bases the model for health care reform?

 

Massachussetts has some “ less than original ideas”

Obama-care

Last evening I watched the whitehouse news conference, during which President Obama outlined his 'vision" for healthcare in America.  Unfortunately his speech had little specifics other than how wonderful life would be with his reform measures.

As in most political campaigns the message was what would happen if we did not adopt these changes. Surely the sky would fall. It sounds a bit like "Chicken Little".

The message from Congress is becoming quite clear. SLOW DOWN!

Providers, both in small practices and in large integrated health care organizations, such as the Mayo Clinic have exposed some basic flaws in reform measures being considered in Congress.

This from the WSJ Health Blog:

Mayo Clinic CEO: Medicare Payment Model Is a ‘Catastrophe’

Mayo Clinic, along with 18 other health care organizations around the country, sent an open letter to Congress on July 22.

Posted by Jacob Goldstein

Denis Cortese, the doc who runs the Mayo Clinic, swung by the Health Blog’s office today to talk health reform. His bottom line, which he’s been repeating in public in the past few days: The big health-care bill unveiled last week in the House of Representatives misses a key opportunity to change the way Medicare pays for health care.

What’s more, Cortese argued, adding a new public plan that covers more people and pays for care the same way as Medicare won’t work, because the rapid rise in health costs will …continue. “A Medicare model is a catastrophe,” he said.

The basic argument Cortese and the Mayo Health Policy Center have been making for a while now is a variation on a familiar theme: Doctors and hospitals should be paid on the based value they provide rather than simply paid a fee for every procedure they do. Those who have better outcomes with less risk and fewer costs to the system should be rewarded.

Yes, it’s tough to value care for some conditions, but there are others where there are solid, risk-adjusted measures to evaluate patient outcomes. And Medicare could go a long way by starting with a few common conditions, such as diabetes and heart disease, Cortese said.

“Why don’t we give instructions to the Health and Human Services Secretary to start value-based purchasing right now in Medicare?” he said.

The message is clear: We must fix medicare first.  Any reform is doomed to fail based upon the flaws in medicare payment methodology.  Who  regulates medicare?  Congress supposedly does with advice from a number of groups, some  physician groups and many others such as AHRQ.   If medicare is any indication of how well Congress makes decisions. ?????

HR 3200

My conclusion regarding health reform was confirmed by the congressional budget office today. With the present plan there will be no savings. The plan as proposed does nothing to eliminate the parasitic bureaucratic insurance environment, nor the regulatory environment, In fact the plan would merely transfer these costs to the government. Unfortunately the AMA in an effort to boost it’s credibility came out today to support the House Bill. No surprise there….just when most sensible people rose up and told congress it’s too expensive.

Obama is creating a ‘health care crisis’ much as he did with the fiancial markets promising to pull it out with ‘stimulus funding’. Congress is begiing to say “enough is enough’.No one is going to be panicked into a hasty decision. Obama wants all or nothing at all.

It seems saner heads are prevailing, as well as the skeptical response of the public in general.

Unfortunately health care will have to wait further to see just how our economy will (if) recover. As evidenced by the state of affairs in California even those well established programs such as SCHIP are being curtailed or eliminated, and this in the largest and perhaps most affluent state in the country.

Nevertheless changes do need to be made, and sooner rather than later. The cry of ‘emergency’ and crisis are beginning to sound like crying ‘wolf’. That only goes so far….banks, equity firms, mortgage crisis, credit crisis, and financial scandals . Obviously all those responsible were not playing with their ‘own money’ This too would be an enormous problem with a universal, or public program.

The most imminent medical issue is that there are a lot of providers who are about to quit, retire, or find some other less stressful financial vehicle, even if it means living under a bridge.

The Death of the SGR

Way back in the early 90s the Sustainable Growth Rate was introduced to us by Congress and Medicare.  This would result in an annual reduction of physician's fees annually, unless congress took action to either eliminate that year's adjustment or postpone it until the next fiscal year.  After 4 years of 'deferrals' the amount  pending is 20%. In the midst of heated congressional examination and proposals for health reform, this 'adjustment' has not publicly been discussed.  It however is a major bone of contention amongst providers of medicare services.  It becomes more important in the face of other payors who base their reimbursements upon Medicare's fee schedule.

The SGR  includes the costs of drugs and other items billed by the      provider, and also the payments made to ambulatory surgery centers. These numbers are included in the calculation of provider expenses. Claims that provider payments have increased are largely due to these two amounts.  As we all know ambulatory surgery centers have literally exploded in volume, and pharmaceutical expenses have risen sharply as well.

In the past, not much has been made of this item.

HR Discussion Bill

I began reading the 850 page draft discussion bill for health care reform that the House of Representatives is now considering.

The bill is now in committee.

The contents of the proposal are frightening, and impacts not only reimbursements but also how, and what type and numbers of residency programs will be offered.  It usurps the role of established specialty boards and overides the goals of program directors. Every academic physician must read this document, and react immediately.  The content of the entire bill  goes beyond my limited time to discuss it's entirety here, but can be found at:

HR discussion Draft. Considerable length is given to the formation and administration of a "Health Care Exchange".  The extent of regulation and enforcement dwarfs the already present insurance company bureaucracy.  It is difficult to surmise how this will play out in terms of costs to the taxpayers of the United States.

del.icio.us Tags: health care bill discussion,health reform,health insurance exchange,HHS

Order your Edsel

 

The past two weeks seems to further elaborate on the issues creaging a  tightening of the Gordian Knot of Health care which

threatens to overwhelm and bring our healthcare system and even our economy to a grinding halt.

Physicians are rightly frustrated and outraged at the incursion of well meaning pundits, experts, health policy gurus and others, who have meddled with the patient doctor relationship. It may never be restored. 

The new wave of HIT and EMR adoption foists upon not only providers but misguieded taxpayers who are being sold a bill of goods akin to the "Edsel" of the 1960s.

Rick Weinhaus MD  writes in The Health Care Blog about the folly of today's unproven CCHIT certified EMRs. Here are some excerpts from his letter to David Blumenthal, ONCHT .

am writing to you on the need for user-friendly electronic health record (EHR) software programs. As a practicing physician with first-hand experience with hard-to-use CCHIT-certified EHR software, I would like to share with you a solution to this vital issue.

The CCHIT model for EHR software certification is fatally flawed because it mandates hundreds of required features and functions, which take precedence over good software design.  This flawed CCHIT model takes valuable physician time and effort away from patient care and leads to increased potential for errors, omissions, and mistakes.

As a clinician, I have had first-hand experience with a top-tier CCHIT-certified EHR.  Despite being computer literate and being highly motivated, after a year and a half of concerted effort, I still cannot effectively use this CCHIT-certified program.  The poorly designed software constantly intrudes on my clinical thought process and interferes with my ability to focus on the needs of my patients.

Just this year the National Research Council report on health care IT came to a similar conclusion. The report found that currently implemented health care IT programs often

provide little support for the cognitive tasks of the clinicians or the workflow of the people who must actually use the system.  Moreover, these applications do not take advantage of human-computer interaction [HCI] principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks

It is astounding that physicians would be willing to accept inferior technical tools for administration and record keeping when we insist upon medical diagnostic and therapeutic equipment that must pass muster and require regulation by the FDA, and other healthcare regulatory organizations.

We absolutely need standards for data, data transmission, interoperability, and privacy. There is no need, however, to specify the internal workings of EHR software. To do so will stifle innovative software designs that could improve our health care system. If CCHIT is allowed to mandate the meaning of the term “certified-EHR,” the $17 billion allocated for EHR adoption and use will largely be wasted.

HL 7 guy explains our current conundrum:

There are real and tangible reasons why Information Technology as it exists is of very little help to many clinicians.

Gathering the information to feed into the systems is obtrusive and disruptive to the clinicians workflow.

For an hour of clinician and patient interaction there is approximately an hour of data input as most EMR applications are currently built. This is extremely inefficient.

Clinicians aren't secretaries or clerks that can be typing away all day. They have to cure and save the lives of their patients.

Frustrations imposed by improperly built software have created an apathetic attitude from most clinicians towards technology.

Until technologists understand this and start building solutions based on use cases and that fit seamlessly into the clinicians workflows, adoptions will be scarce and the failure rate will be high.

 

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