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Congress has officially approved of CMS’ decision to implement P4P. I recently read somewhere that CMS would increase physician reimbursements (and hospitals, too I suppose) by 300 million dollars with this incentive (if providers are able to conform to their requirements) I also read that physicians such as myself will not face the 5% annual SGR reduction in CMS payments. This has been massaged into the politically correct phrase as a “raise in reimbursements” (the lord giveth and the lord taketh away). So we are given back that which was taken from us and then told it is a “raise”.
Let’s face it, decision makers in Washington and some state capitols as well as legislators are out of touch with reality. Placing more administrative burdens on an already very dysfunctional barely functioning healthcare system is “insane”, and so are those that make these proposals, and then vote them into effect to placate a worried electorate about whether they will be able to afford another doctor visit or hospitalization.
Many physicians I know have retired in their mid 50s to sell soap or enter MLM businesses, sell real estate or go into other businesses, which tells you a great deal about the stressors on physicians.
I can find hundreds of consulting groups, and health care foundations that study everything to death, make more recommendations which increase further the cost of health care, couching their recommendations in terms such as quality initiatives, pay for performance, etc etc. There is a whole new lingo out there that most physicians do not comprehend, but must learn.
I am not optimistic about our health system in the United States. IT and RHIOs are a small part of what we need. If you are very rich or dead poor in poverty your health care is assured. The large mass of diminishing middle class are at great risk, if they lose employment, and/or their group health policies, have pre-existing illnesses, the quickly join the uninsured. Even those fully employed and insured are soon priced out of full insurance coverage.
HSAs are a joke, I tried one last year and found that it takes quite a while to meet the deductible, and the policies are worded in such a way for a family that the deductible for a family is what counts, not the individual users. You also cannot use it unless you fund the HSA upfront. If you have chronic illness and have high expenses from day one….you may not be able to save . I suspect the IRS will expect accounting through the HSA and not direct payments out of pocket. HSAs are a great deal for the banks and the insurers. It will not save healthcare dollars, nor reduce utilization. When people get sick, they seek medical care.
This year I became unemployed for a time and went onto COBRA, about a month later at the end of the year I finally reached my 4800 dollar HAS deductible. One week later it was January and the deductible started over again. True the premium was lower with the HAS but we had medical drug expenses of about 650 dollars that month….we cancelled our COBRA, went bare and are now forming our own group to obtain group health insurance. Individual coverage is out of the question. Now why is that? Seems to me all the individuals who are not in a group could be put into a group of “the individuals who are not in a group”
And now GWB is proposing tax law changes to “make healthcare more affordable”.
And another thing, when you sign up for insurance you are given an effective date which may be any part of the year, yet your deductible rolls over at each calendar year, whether it’s been six months, four months or eight months since you signed up. The contract is for one year…..so why are you cancelled if you miss one payment? Seems to me it is all weighted toward the insurer, not the patient.
As I write this article I am seeing this from the patient (now known as a consumer) aspect; let alone the physician provider side. The billing and coding aspects of reimbursement have turned into a high stakes poker game with a new industry spun off…..the reimbursement consultant who charges anywhere from 500 dollars to 3000 per year to update the practices on insurance billing practices and codes which change from year to year. It’s a bit like poker. And if you make a mistake you are accused of fraud and a buse, fined, or worse kicked out of a program.
I have been practicing over 30 years since I finished medical school. My the world has changed.
Insurance companies control everything. Recently I moved practice locations back to a community where I first started off as a young ophthalmologist. I discovered that my home hospital had disbanded the ophthalmology department and there were several outpatient centers that did all the eye surgery.
Now, insurance companies usually require the physician to have hospital staff priveleges to be on their provider list…..how does one go about that one? Some doctors already on the hospital staff are now paid to take ER standby call…..they are grandfathered in as staff members, but there is no way for new ASC doctors to be proctored in a hospital setting unless the ASC is part of the hospital. Worse than that some ASCs are privately owned and owners will not allow open access thereby eliminating competition in their geographic area. In my next article I will further details the requirements and administrative bureaucracy that has been generated to “protect” patients (from whom?)

Report from the IERHIO Annual Summit Meeting

Inland Empire Regional Health Information Organization held it’s annual summit meeting this week in Riverside California under the auspices of the RCMA and SBCMS. A live meeting web conference had presenters from Canada, Pennsylvania and Northern California. The group was quite eclectic with different approaches to the challenge of health information data input, storage and exchange. The Department of Public Health of Riverside County was also represented by Janis Neuman M.D. and and Geoffrey Leung M.D They discussed their ongoing projects and needs. Dr Leung recently returned from Taiwan and stated that he wished the U.S. was on a par with Taiwan in regard to health IT. Laura Landry represented the Long Beach Initiative. Their non profit has been funded and they have selected a vendor. They have excellent support from grants as a result of the expertise of P.H.F.E.
The attendance and support of area and regional hospitals was non-existent, although we have heard each hospital and IPA are investigation EMR solutions. Also present were Dr. Ron Bangasser from Beaver Medical Clinic and Dr. Edward Hess, formerly from Kaiser Permanente. Commentary was heard regarding the Kaiser experiences and their usage of “Epic”.
A presentation was made by Sabatini Montatesti, who is the CEO of ES Enterprises Inc. ES Enterprises is building out a non profit health data exchange for northeast Pennsylvania including Geisinger Medical Center and surrounding hospitals, clinics and physicians. This rural area has unique challenges in that there are a great number of uninsured patients. Funding for the non profit was through charitable donations and hospital contributions. The depth of his knowledge and architecture for the health data exchanges is impressive.
We also heard from other vendor solutions. Clinical Integration was represented by Mark Crespin, Steve Leider and Paul Bessingminder who presented from Vancouver, B.C.
Practice Fusion presented their proposed solution as well. The vendors had an opportunity to answer some challenging questions from our steering and advisory committee.
Ellen Badley represented the California Department of Health representing Cindy Ehnes. She spoke briefly about the Governor’s proposal for health IT and his “Universal Health Care for California” The “takeaway message” for her was the importance of reducing the chasm between state health care and private health care, and that health IT for each is not mutually exclusive.
Our group is obviously biased toward developing some form of integrated health information system.
There was much philosophical and hypothetical discussion about several models both financially and technically.
There was a great concern that our dysfunctional health care system would consider starting another venture in IT regardless of our motives. The group also discussed the inadvisability of a political state ment of universal health care without a major overhaul of the IT infrastructure to support increased numbers of insured in the system. We certainly cannot provide more care for less money and not without a revolution in our health data system.
While some believe a non-profit organization offers some advantages it is the opinion of this writer that is a more expensive and time consuming entity to form and attract users.
My belief is that a sound private entrepreneurial model with a private placement and subscription service would offer greater efficiency and less cost to develop. Because of the intense capital investment to plan, build and maintain an enterprise level solution and/or small practice solutions initial start up cost is critical.
Mission critical items include time to implement, reliability, vendor experience and availability. Jeff Rose of Health Alliant discussed time to implement and train a system in Riverside County at one week per installation which added up to 900 weeks for the provider and hospital base in our region. (which is over ten years)
As a result of two years of independent study, meetings, and information gathering I have developed some opinion on what our region can accomplish in a cost effective and expedient manner.
A proposal will be forthcoming in the next several weeks.
Thank you to all who have attended these meetings, donating valuable time, effort and much expertise for the benefit our our health care system and our patients.

Gary Levin M.D.

SUMMIT MEETING IERHIO RIVERSIDE CALIFORNIA

DATE: TUESDAY JANUARY 23 2007
TIME: 6:00 PM
PLACE: RIVERSIDE SAN BERNARDINO MEDICAL SOCIETY HEADQUARTERS


LIVE WEB CONFERENCE: MICROSOST OFFICE LIVE MEETING

Attendees have received email invitation. If you have not received an email invitation and wish to attend send email request to:
gmlevinmd@gmail.com

House Keeping Notes

Some of you may have noticed that Health Train Express now has an RSS Feed. The Icon which is orange and located on the right sidebar allows you to "subscribe" to the feed. If you click on the icon (orange) it will pop up the option to subscribe directly to your browser favorite folder, or whatever feed you use. Any time you use your browser you can find and click "Health Train Express" and see the short summary of the latest posting, without remembering urls.

If you wish please make comments on the blog. If you have problems doing so, please email me directly at gmlevinmd@gmail.com I have not been getting any commentary since I converted to the new blogger and new title. Perhaps it is a glitch.

I look forward to the meeting on January 23 2006. Contact me with suggestions at my email as well, or leave a comment here.

The meeting will be interesting with new participants from around the country via web feeds and audio conferencing.

Which Locomotive are you in Front of?

This article in Southern California Physician in early January seemed to juxtapose with the title of my blog. Lytton Smith M.D. categorizes five different locomotives in the "health train express" which threaten to either derail or provide synergy in converting our present health care non-system into an efficient one focused on optimal patient care and outcomes.

With his permission I have copied a few key remarks:

After 30 years in healthcare, I think of these payment conflicts as locomotives of varying size and power. Each train carries a different constituency.Locomotive No. 1 represents the health plans. Thinking they drive the healthcare train, they charge ahead. Focusing on profits to maintain their stock value causes them to ignore the economics of actually paying for the care they expect from physicians and hospitals.Locomotive No. 2 includes hospitals. They carry the EMTALA burden as best they can. Despite complaining about being underpaid, many thrive by billing high charges for basic services. Health plans ignore the hospital charges because they are contracted. The hospitals with poor payer mixes and poor contracts close their doors or sell to alleviate their burden.Shoveling coal in Locomotive No. 3, the physicians rattle down their track. Due to antitrust rules and their own sense of independence, physicians have trouble coordinating the function of their train. With so many internal conflicts--group practice vs. solo practice, primary care vs. specialties--who has time to watch where the train is headed?In flashy Locomotive No. 4, a scenic rail car, are the legislators. With their top-rated medical insurance and VIP status, they protect themselves from the vicissitudes of medical financial struggles by passing laws to assure themselves that all will be well. Locomotive No. 4, fueled often by the engineers of Locomotive No. 1, looks sleek and rumbles along, trying to avoid seeing Locomotive No. 5.Locomotive No. 5 is the longest train of all, containing patients. With many classes of service, it consumes enormous energy as it moves down the track. Like No. 3, No. 5 has no focused leadership. But because of its enormous size, this train has the most potential momentum. No. 5 occupies the most important track as all the other trains exist to serve it.If Locomotives No. 1, 2 and 3 cannot resolve "fair and reasonable" vs. "usual and customary" issues, I fear that Locomotive No. 5 will push Locomotive No. 4 into crushing the others. The resulting collision will create a force for a single-payer system. The drive for all parties to "get their fair share" may result in an oligarchy in which no one is well served. In this environment, mavericks like Dr. Reddy will surely need to look elsewhere for financial satisfaction.Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Jude Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at editor@socalphys.com.


Perhaps the advent of social health care blogs and the entry of consumer driven plans and opinons will become the "caboose"

www.socalphys.com

Amazing factoids from 2006

Brought to you with permission of the AMA. Comments are most welcome.

http://www.ama-assn.org:80/amednews/site/facts06.htm

The Cusp of 2006

As we end 2006 I want to thank Dimitriy for involving me with The Medical Blog Network.
For the past two years my involvement with a RHIO and Health Information Technology have given me the opportunity to meet and learn from other professionals about improving healthcare.
A fresh outlook is always a good thing. I am convinced that patients must have involvement and ownership of their healthcare "system"; it is in fact an essential element to move forward.
Government alone, nor payors nor employers can perform this great task alone.

So I wish all of you a happy and health 2007, and hope that we all do not "pay for performance".

I invite you to read my further comments at healthtrain express www.healthtrain.blogspot.com

Gary Levin

Good Bye to 2006

Year 2006 entertained new developments in medical social blog networks. This has provided new and "out of the box" resources for communication and discourse amongst diverse and at times historically adversarial components of our "health system". Consumer driven advocacy and health savings accounts have been introduced with varying results. Whether any or all of this will lead to reduced costs is very open to question, but it will certainly provide new resources for providers, payors, and patients as consumers to plan future developments.

RHIOs are experiencing serious difficuties in funding, and EMR promulgation although highly touted is also lagging due to financial constraints upon providers. CMS reimbursement cutbacks have also affected EMR acquisition by practices.

As a coordinator for a RHIO 2006 has been a year of quiet observation and study.

Personal health records will be supported by payors and employers. Whether they will be universal and/or interoperable remains to be seen. To be truly effective PHRs should be exportable or importable to any EMR to be useful. Perhaps employers will be enticed to provide the hardware as an employee benefit. (actually quite inexpensive at about 20 dollars for a usb flash drive, which is ubiquitous. I don't see a need to develop a new smart card or readers when everyone carries around a key chain and the device can be encrypted with u3 technology.

Many projects which have been mandated for health care have been sidelined due to the war on "terror". Personally my "terror" is the aspects of accessing health care and maintaining health insurance.

I wish you all a happy and healthy 2007.

Gary Levin MD

Fantasy Reimbursements

There are now many proposals by CMS regarding health information and their ability to gather data from EMRs, claims information and other sources from both hospitals and medical practices.

Not many of these have been worked out financially for the providers or the hospitals. Most of the proposals require software changes or running a parallel system to track the information they are requesting. For physicians this will cost far greater than the 1.5% proposed increase CMS is proposing as an "incentive". Most practices don't even have EMRs at all. Those without the digital EMR will be forced to workout a paper trail that again increases the paperwork burden to providers.

Here are some of the particulars. (from Health IT News, via iHealthbeat.org

According to Thomas B. Valuck, MD, medical officer and senior advisor for the Centers for Medicare & Medicaid Services, CMS will administer the recent legislation providing a 1.5 percent incentive to physicians who participate in a new pay-for-performance plan, patterned after the one already in place for hospitals.

Valuck said it is going to be difficult to estimate the impact the incentive will have on physicians given the number of variables in the revenue picture: “The problem with the 1.5 percent incentive is that doctors will raise the question, ‘does $1.50 on $100 of billing cover the costs of reporting? ’”

Congress on Dec. 9 passed legislation that would increase physicians' pay -- beginning in the second half of 2007 -- if they voluntarily submit quality data measures to CMS using IT.

Time MAN OF THE YEAR

I made it, in case you have not already read......you and I as bloggers and web communicator beat out Cheney, Rumsfield, and Amadinajab (if that is how you spell it) for this annual award!

You will read all about it in the next week or so

So sit back and enjoy your fame....it is fleeting.

Is Pay for Performance Illegal???

Today’s news from CMA clips, The New York Times and other reliable sources reveals an impending tsunami, or at least a sea-change in the way medicare proposes to reimburse providers. Pay for performance and also Pay for Population Health care as quoted in some recent journal articles opens a whole new bag of worms. While some insurance carriers and private payors have done some initial studies and give groups incentives for following certain practice guidelines, there are serious questions and doubts amongst physicians, the AMA, CMA and even some senators and congressmen who have typically been pro-active about regulating reimbursement using a stick rather than a carrot.
Headlines read “Government will offer a carrot, rather than a stick” to control rising medical costs.
First of all the original Medicare law passed in 1964 expressly forbids Medicare from passing laws as to how medicine is to be practiced. ““Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine.”
Mr. Moffit of the Heritage Foundation said the new initiative was “a backdoor attempt to repeal” this guarantee.
“It’s pay for compliance, not pay for performance,” Mr. Moffit said. “Doctors will be financially pressured to comply with government guidelines and standards. The integrity and independence of the medical profession could be compromised.”

Medicare in the past ten years has struggled to contain costs by using a flawed sustained growth rate formula (SGR) attempting to cut physician reimbursement by 3 to 6% each year. This was built into law about ten years ago, and each year at the 11th hour congress must struggle with modifying or eliminating or postponing the fee cut.
Pay for performance offers a “carrot” of 1.5% increase for providers to report their “compliance” with a practice pattern derived by their specialty organizations, or some other benchmark provided by a heath insurance carrier. The amount of paperwork, or computer investment to provide these numbers far exceeds the increase in payments. Perhaps there are some groups large enough who already have such systems in place. They were given special grants to develop these as “pilot programs”.
Representative Stark said, “Doctors and others who like pay-for-performance have to remember that it’s a zero-sum game.” As a result, he said, most doctors will have to accept lower fees if Medicare is to pay bonuses to the best performers.
What Medicare is doing may be “illegal”. I am surprised that this has not been challenged in the courts. Previous actions by medicare merely provided lack of payments and restricted benefits to reign in costs.
Providing incentives is definitely an inducement to “practice differently”
Other strong arguments are that practice patterns, pharmacology change fairly rapidly. Keeping up with the codification and timely documentation will remove assets from patient care to provide more bureaucracy.
As a believer in “open source” and development of regional health information organizations some are attempting to use P4P as an incentive for RHIO funding and development. I believe this is a very bad idea…the flow of private patient information even if “stripped” of identifying information should not be conveyed by RHIO data infrastructure. Open source refers to “code” and computer language, not patient information.
Later this week
The demise of HMOs, , PPOs and their replacement by “consumer drive plans”
Gary L

Web Seminars from Microsoft

As I have traveled along the health highway several trains have either run over me or passed me by.
In some cases all is well, but in others I have been caught on the track and unable to “get out of the way”
In today’s world one has to be a visionary with an open mind to see all the possibilities that are on the horizon or already quietly developing without your knowledge. Knowledge is power and the limiting factor on gathering important knowledge for you as a physician is critical.
It is as important to know what not to read as it is to read the sources that are credible and reliable. One also has to have discernment to differentiate between them. Time is wasted reading the wrong material, time that would be better spent relaxing.
In your daily activities operating, seeing clinic patients, overseeing business affairs, and keeping up with CME, licensure, credentialing requirements, legal affairs and business plans it is no wonder you may be tired and/or fed up by the end of a day. Balance is key to medical practice success as is location is to real estate.
Are you an entrepreneur and own your practice, or does it own you? Almost all physicians see themselves as entrepreneurs, but they are not. We as physicians set up our own businesses but are truly just “technicians”, be it medical or business. Entrepeneurship is entirely different…..requiring visionary thinking, not replicating something already in existence.
Have you read “E-Myth” by Michael Gerber, or his new book “The Dreaming Room”? Mr Gerber gave an eloquent and exciting presentation via Microsoft Live Web Conference on Tuesday December 5 2006. This web presentation is now archived. Judging from this initial presentation sponsored by Microsoft, and Intel the remainder of the series will also be dynamite. The series can be found at:
· Michael Gerber, December 5. 'E-myth' author kicks off Office Live seminar series. Register now.
· Stephen Covey, December 12,=. Get free small business advice from Stephen Covey. Register now.
Microsoft Office Live Seminar: The Age of the Alpha Dog with Donna Fenn https://msevents.microsoft.com/cui/r.aspx?t=2&c=en-us&r=1287133118
Microsoft Office Live Seminar: Lessons of The Natural Entrepreneur with Andrè Taylor
https://msevents.microsoft.com/cui/r.aspx?t=2&c=en-us&r=1287133041


Microsoft Office Live Seminar: Effectively Influencing Up with Marshall Goldsmith
https://msevents.microsoft.com/cui/r.aspx?t=2&c=en-us&r=1287133099

Microsoft requires that you have a “Passport Account”. If you have a hotmail email or msn email you already have a “passport”. If not it is simple to acquire one.

I was surprised at the quality of these webinars, totally not technical in nature and of interest to all who are in business or the professions.
So, the health train is about to leave the station ..Will you be on it??

Web 2.0 Applications for Medicine

Some of you may have heard about what is now called Web 2.0. This is another term for .asp solutions that run over the internet. Businesses in other sectors are now using this more and more rather than investing in expensive software and hardware that often require upgrading and expensive maintenance contracts. This portion of the expenditure for IT is often not appreciated and can run up to 20% of the investment in IT. Many medical practices utilize this method to transition to inhouse EMR.

Several applications are now becoming available for RHIO development, and may be the best solution not only in the short run but in the long run as well. The scalability of this solution is enormous and fits both small, medium and large practice needs. It does not require affiliation with a group, IPA or institution, although this solution would do well in all of these practice settings.

Privacy and security are issues that concern most health care providers, however secure and certificated web sites already are robustly protected, and backed up. They are run by IT professionals in a professional IT environment. Often they are mirrored and run on multiple servers geographically separated. My own personal experience with an .asp solution for prescription writing has been excellent, with no outages for a year's worth of use, as opposed to our in house EMR which goes down about once a month.

I would like for each of your to look at Practice Fusion for your input and analysis. www.practicefusion.com

The next Inland Empire RHIO meeting will take place in mid-January. The announcement will be sent via email and posted to the blog(s)

Happy Holidays to everyone

Gary Levin
gmlevinmd@gmail.com