Category: Physicians

POLICY: ACP reccomends UK system

The American College of Physicians is out with its proposals for a better American health care system

The paper recommends voluntary certification and recognition of primary care and specialty medical practices that use health information technology, quality measurement and reporting, patient-friendly scheduling systems and other "best practices" to deliver better value and improve care coordination for patients, especially those with multiple chronic illnesses.While the specific criteria for being listed as a qualified advanced medical home will be developed later, ACP envisions that qualified practices will have the following kinds of services in place.* Primary care physicians would be responsible for partnering with their patients to assure that all of their health care is managed and coordinated effectively. This will be a major improvement from the fragmented health care system that we see today. They would partner with, and educate patients with chronic diseases, like diabetes, to help them manage their own conditions and prevent avoidable complications that would inevitably occur without long-range attention. These complications of diabetes include amputation, blindness, heart attacks and kidney failure.* The practice would use innovative scheduling systems to minimize delays in getting appointments.* Electronic health records and other health information technologies would be used to store all clinical data and test results, which would be immediately available. Physicians in the advanced medical home would use computerized, evidence- based clinical decision guidelines at the point of care to assure that patients get appropriate and recommended care.* Patients would have access to non-urgent medical advice through email and telephone consultations. The practice would have arrangements with a team of consultants and other health care professionals to provide the full spectrum of patient-centered services.

Now I know those physicians are very clever and all that, and I also know that they’re very jealous of how much cash the surgeons and radiologists pull down, but hang on a minute. Haven’t we heard something like this before on THCB? All care managed by PCPs; use of IT to coordinate all care; Choose and Book-type systems for patients; Access for all patients to NHS Direct — they’ve hit on the perfect system. It’s called the UK National Health Service.

Perhaps their members will be slightly less keen when they discover the average income of a GP in the UK, although with the state of the dollar these days it’s not as bad as it used to be if you consider it in American money!

HOSPITALS/PHYSICIANS/POLICY: More data on specialty hospitals suggests the obvious

HSC is out with another study on local markets, and this time it’s looking at specialty hospitals. Not a new tune. HSC finds that purchasers in three local markets where there are plenty of specialty hospitals believe that the hospitals add to overall healthcare costs without improving quality. While purchasers may get lower prices from the new hospitals, they perceive that more procedures are recommended by physicians driving up their number of procedures and therefore overall costs. In addition, traditional community hospitals have been forced to compete by building new facilities, the costs of which get passed onto purchasers in the end, and have been raising their prices for services that specialty hospitals do not offer to compensate for their losses where the specialty hospitals have taken their business.

Yup, it’s all a scam. A war between docs and hospitals with the payers (and the taxpayer) picking up the tab. Of course, as discussed multotimes on THCB, if this was done within the context of some type of fixed budget, then maybe specialty hospitals or teams would be found to be the best way of delivering care. But in a FFS-based cost-unconscious system, they’re just adding to the death of health care affordability by a thousand cuts.

POLICY/PHARMA/PHYSICIANS/POLITICS: Some more publicity about the awful state of pain medication

Finally there is some word getting out about the reign of terror the DEA has been running against pain doctors and its awful impact. This article, called Let’s Get Serious About Relieving Chronic Pain picks up from the NEJM article I wrote about last week. We have known at least since the HHS report in the early 1990s that pain medication is massively under-prescribed. In this article, Jane Brody notes that :

"Pain is a common symptom in patients nearing the end of life," with up to "77 percent of patients suffering unrelieved, pronounced pain during the last year of life," Dr. Timothy J. Moynihan wrote in The Mayo Clinic Proceedings in 2003.

But the news is that the DEA, on its messianic quest to prevent us all going to hell or whatever the theocratic fascists think they’re doing, is not only wasting our time and money, and condemning innocent doctors and patients to prison.  They are also helping most people to suffer in their last year of life. Well I’m sure the DEA think it’s a deal worth taking, but I can’t believe any rational person does. If there’s one government agency that ought to be abolished and have all its employees sent to fill in prairie dog-holes in Nebraska (or wherever), it’s surely the DEA.

PHYSICIANS/POLICY/POLITICS: What else are they going to do?

THCB contributor, radio talk show host and occasional orthopedic surgeon Eric Novack (just kidding, Eric!) sent me this story about the problems that Medicare recipients will  be having getting access to doctors in California if the projected cuts in Medicare reimbursement for Part B actually materialize. So far the cuts for this year have been rescinded by the Senate and the arguing is still going on in the House. Eric has written on THCB recently about the possible bad effects on patient access from cutting physicians fees, and I do agree with him that it’s unjust that only physician fees get cut when hospitals and managed care companies get an increase.

But the problem physicians face is that they don’t really have an alternative. Sure some will retire early, some will move to cash only practices. But given that Medicare is about a third of the money in the system, realistically they can grumble all they like but they’ll end up taking it, and of course doing more things to those patients to make it up on volume.  And that’s not just my opinion, it’s the findings of this five year study by the HSC folks. After all, they went to medical school and residency for all those years, what else are they going to do? There’s only so much room on the poker circuit and only so many of them can run health plans.

That’s why I say that physicians should be figuring out how they collude with government to reduce overall spending while maintaining as good a position as they can. That’s what’s happened in other countries, and one day it’ll happen here. Of course there’s lots of time for gnashing of teeth and entrepreneurial end-arounds before then.

PHYSICIANS/POLICY/POLITICS: Is cutting Medicare Part B fees a good thing? by Eric Novack

THCB’s favorite orthopedic surgeon Eric Novack is grumpy about Medicare’s proposed cuts in physician reimbursement, which are still up in the air as I write. Not sure how much support he’ll get over here on THCB, but it’s ironic that $10 billion is being set aside for health plans and PBMs to reimburse them for possible losses for their role in Medicare Part D, and hospitals are getting a raise. If we are going to cut Medicare, wouldn’t an across the board cut be fairer? Here’s Eric’s thoughts:
Unless Congress acts in the next week, reimbursement to physicians for services provided to Medicare recipients will be cut by 4.4%. The government’s formula for determining the payment rate does not take into account the increasing costs of healthcare delivery. Rather it is based upon such factors as the cost of prescription drugs and general economic factors over which doctors have no control. The reduction is not merely a reduction in the rate of growth of spending. Payments of $100 will become $95.50. And if the Congress’s inaction continues, payment will be less than $75 by 2011. No adjustments for inflation or cost of living are included.
Is all Medicare spending being cut? No, only payments for outpatient services- Medicare Part B- are affected.
Hospital care, paid under Medicare Part A, will get a pay increase of about 4.8%. Managed care plans that get paid by Medicare for managing Medicare HMOs will also get a raise. In both cases, the government’s formula for payment is based upon the medical economic index, which takes into account the costs of health care delivery.
Other than doctors, why should anyone care that reimbursement is going down? What options do patients and physicians have? Doesn’t more affordable mean more accessible?
Nearly 97% of US doctors participate in Medicare. This means that the doctor has signed a contract to accept the rates that the government says it is willing to pay for services. Doctors cannot be selective. They must accept the rate for any and all services that Medicare offers. They cannot tell patients that they will accept the contracted rate for one service, but not another. For example, doctors are not allowed to accept the Medicare rate for knee replacements, but not for hip replacements. This is especially an issue when it comes to the care of very complex conditions, as the level of expertise, time necessary, and potential liability is significantly increased, whereas payment is often only minimally higher than for the care of much simpler cases.
Physicians have several ways to deal with the Medicare cuts. They can retire and stop practicing medicine. Some will. They can see more patients each day, spending less time with each patient. Some will. They can stop practicing medicine and pursue other careers. Some will. They can limit the number of new Medicare patients they will see. Some will. They can drop out of Medicare altogether, requiring Medicare patients to pay completely out of pocket for healthcare services. Some will.
Patients have few, if any, options under the current structure of Medicare. Seniors cannot opt out of Medicare and find private insurance to cover care.
Government fixing of healthcare prices below reasonable market rates will create the medical equivalent of the gasoline crisis of a generation ago. The planned and projected Medicare cuts will have exactly the opposite of the intended effect: seniors throughout the United States will have less access to doctors and healthcare services.

PHYSICIANS/PHARMA: Is academic medicine beyond salvage? by The Industry Veteran

Several people are concerned about the integrity of our medical leaders, and the latest Cleveland Clinic spat has upset a few people, notably local MD Medpundit. I have a more jaded view. I liken it to when I heard that lawyers have to take an ethics test but are only not allowed to practice if they fail it, I assumed that any lawyer passing an ethics test lacked the aptitude required for the job! However, making a welcome return to THCB, even the usually cynical-beyond-belief contributor The Industry Veteran appears a little concerned. He writes:

I had previously viewed the tussle between renowned cardiologist Eric Topol and his boss at the Cleveland Clinic, Delos Cosgrove, as principally an academic spat whose significance did not extend beyond the personal fortunes and the organizational power positions of the two principals. The Times’s article, by contrast, suggests the Cleveland bash reveals that the integrity of academic/high research medicine is fundamentally compromised. Instead of remaining disinterested researchers who help to develop and evaluate new medicines and technologies, big time researchers and their institutions own equity positions in the companies whose products they evaluate. The very notion that medical researchers are gatekeepers for the public, motivated by professional ethics and the search for scientific truth, remains a fool’s myth. Who guards the guardians?I recently asked a friend who teaches marketing ethics at his university to tell me his views about the recent editorial in the New England Journal of Medicine. That was the one where the Journal’s editors belatedly said they were shocked, shocked by the fact that Merck’s shills neglected to include three instances of myocardial infarction among a sample of Vioxx users. The specific issue for which I sought clarity concerned the relative responsibility of the academic physicians who authored the study (or, more accurately, whose names appeared above the study, since Merck’s medical writers doubtlessly wrote the paper) versus that of Merck, who sponsored the research. My friend’s pontifications assigned the lion’s share of blame to the physicians. They must reasonably be expected to know that the first and final interests of any corporation’s operators lie in obtaining profit to satisfy shareholders. In this particular case, the academic physicians would have been psychotically detached from reality not to have known that Merck’s pursuit of Vioxx profits included a thoroughly unethical inclination to twist and hide data. “If they were willing to accept research money and sponsorship from known crooks such as Merck,” he wrote, “then they had a responsibility to act with the very highest possible standards of ethics, and my guess is that they fell far short of that.” The Times article flicks off the lid to reveal that these kinds of self-aggrandizing conflicts are the routine condition of high powered, medical research.

POLICY/INTERNATIONAL/PHYSICIANS: It’s not just here that doctors fees are an issue

And from the THCB Japan bureau (well actually the Yomiuri Shimbun)….

It’s worth noting that the Japanese, who have one medical fee schedule for all of their multi-payers (and also a complex system of cross-subsidization between those payers), are about to cut fees and reallocate them. In Japan private doctors make lots and lots more money than hospital-based ones, and the government is slowly trying to move the incentives away from what’s traditionally been a system with a high-volume of office visits and prescriptions of dubious benefit.

We’re about to do the same here, calling it pay for performance. Like there it’s going to turn into a fight. Joe Paduda notes today that the AMA is having some success in its attempt to stop the 4% cut that’s scheduled to come into effect for Medicare at the end of the year. And is directly linking it with a demand to stop pay for performance.

The advantage that the Japanese have got is that there’s only one fee schedule to argue about. Here we have gazillions and no one really knows what they are

QUALITY/TECH: Bob Wachter on patient safety

Bob Wachter is probably the leading expert in the nation on medical errors and a great speaker.

He’s worried about the lack of budget for training, and that IT = Patient safety. But he does think that the IT/EMR movement is now tipping, especially as the disconnect between patient’s perception of being high-tech and what’s happening in the health care system is not tenable, and docs saying that they can’t do it is not credible even for the older docs

He talks a little bit about computer induced errors and problems. There’s a new literature replacing the Bates stuff about how great the Brigham’s system was, and now it’s all about how it’s going wrong.  It’s not a mistake to computerize but you need to go in with your eyes open. You need to think about the process improvements…including the easy ability to cut and paste H&T and continuing on mistakes. What happened when the computer goes down? As at Beth Israel Deaconess. And then in the example for Childrens’ Pittsburgh, does CPOE kill people? Well the chaos still goes on and CPOE clearly gets in the way in ICUs. The critiques of this study are that they "didn’t do it right" but that’s what an implementation looks like. Plus what looks good in the demo doesn’t work per se in your local community hospital. Or the experience of the Brigham is not transferable …unless your hospital also has a 1,300 strong IT department.

The Cedars Sinai story: They built their own and they built in some decision support. But the medical staff revolted. Too many alarms, reminders, too many screens, etc, etc. But not just that, also a story about control over medical care.  Cedars was exerting central control.

So the question is, who exerts control. He quotes Spiderman. "With great power comes great responsibility"  Now there are institutions that are going to have to wrestle with this problem, and if you push too hard the backlash is very tough.  get it implemented first, and do the control later…one little thing at a time.  It’s like the Right Stuff which changed the test pilot from being a cowboy pilot like Chuck Yeager to being a goody two shoes Astronaut like John Glenn….it got more boring, but mortality rates fell dramatically. So this shift is coming too, and will be a huge shift.

Add to this the emergency dislocation of medicine, such as late-night radiology reading in Bangalore. This means that the world gets wired and we start to figure out how to provide care very differently. eICU from VISICU is another reason, seeing a real time data stream and facilitating the care remotely. One of the most profound affect is going to de-tether the assay from its interpretation.

TECH/HOSPITALS: Mr HISTalk says “Does Cerner Millennium kill children? I don’t think so.”

MrHISTalk, who’s blog is fantastic, out-does himself in an article about the University of Pittsburgh Children’s hospital CPOE implementation, which has had so much publicity since the article was released on Monday.

His article is called, Does Cerner Millennium kill children? I don’t think so. It’s not betraying his anonymity to tell you that MrHISTalk is a hospital IT director with a great deal of experience in pharmacy. He’s an expert, so go read it.

I have little to add other than three quick thoughts:

1) The before and after study may have studied a period too early in the CPOE implementation. It takes time to get the new processes down, and things may have got better later. But not in the timeframe of this study, apparently.

2) Last weekend I heard a doctor complaining bitterly about having to use an EMR in the outpatient setting, claiming that it imposed secretarial tasks on him, and interfered with his relationships with his patients. I’d counter by saying that in ambulatory care the recording of what happens in the exam room and the presentation of information from there and other venues (labs, medication) etc matters more to the care of the patient than the information that the doctor actually imparts there, 90% of which the patient forgets about when they walk out the door — something physicians don’t on the whole realize. In the ICU, what happens in the room is often a matter of life and death, so the interference that the recording of the information puts in the way of the process may have a bigger impact.

3) IT implementations are not easy. Paper does kill. Of course it’s not just paper that kills, it’s poor processes with or without IT. But the option of ignoring IT is not an option.  The industry needs to do much more work about getting this right.


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