Category: Uncategorized

Why Obamacare Helps Small Business – And What That Means For the Rest of Us

Jan 30, 2013• 23

By JAAN SIDOROV, MD

It wasn’t until I had read this Jan. 30 Wall Street Journal opinion piece that I realized that my “nano” corporate” status was packed with such futuristic potential. According to the editorialist, American companies should follow my lead and be “protean” by dropping old fashioned W-2 employees and substituting 1099 contract relationships. That way, everyone – including a single person “nano” – can enjoy the upsides of being a corporation and stay below Obamacare’s 50 employee pay-or-play $2000 penalty threshold.

Since I formed my own corporation more than 5 years ago, it has certainly participated in “protean” business relationships.

Once things get underway, I’ve discovered that of the many prominent organizations that it does business with really consist of a small core office populated by a few owner-founders, a single administrative aide and one or two payroll folks who oversee the outsourcing of everything else. While the term “protean” is certainly novel, distributed, adaptable and organic business networks have been around for years.

But the WSJ editorial opens a window into an underappreciated consequence of Obamacare and the underlying assumptions of the central planners who run Washington DC. I doesn’t necessarily think it’s bad, but it sure is interesting.

Read on.

While the Affordable Care Act (ACA) was intended to link employment and health insurance, what it has really done is handed many small nimble interlocked businesses another leg-up against their large traditional mainframe competitors. For example, one colleague pointed out to the that “new” pharma companies are really marketing departments that outsource manufacturing that, in turn, outsources supply management that outsources I.T. that outsources its cloud services. It’s the only way they can compete.

Quantified Death

Jan 28, 2013• 6

By John H. Schumann, MD

: Cause of death on this 1937 death certificate? “Senile gangrene.”

I’ve always had nagging doubts about filling out death certificates.

An excellent article in the trade paper “American Medical News” by Carolyne Krupa explores the “inexactitude” of the custom.

As Krupa points out, doctors are never taught how to fill out the documents. She quotes Randy Hanzlick, MD, chief medical examiner for Fulton County, GA:

“Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, ‘Fill this out.’ ”

That’s pretty much how it works. Though sometimes the person that comes calling with the death certificate is a hospital clerk. And she will make you fill out the form carefully, using only ‘allowable’ causes of death.

Of course, everyone dies from the same thing:lack of oxygen to the brain. But you can’t list that. Nor can you list common “jargon-y” favorites like “cardiopulmonary arrest,” “respiratory failure,” “sepsis,” or “multi-system organ failure.” All of which are true, but too inexact to be useful.

It’s intimidating to be the one to “pronounce” someone dead, and be the final arbiter of the cause. Isn’t that why we have medical examiners/pathologists?

We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change. That leaves interns and residents (at teaching hospitals) and community docs (in the real world) in charge of filling out these important statistical and historic documents.

The Healthy Crowd

Jan 28, 2013• 3

By Esther Dyson

BERLIN – I recently attended the JP Morgan health-care conference, the Davos of the medical world. And, like the World Economic Forum’s annual gathering of business leaders, the JP Morgan conference is a Rorschach blot: you find in it what you are looking for.

Personally, I am interested in how health-care business models are changing – not in a smooth trend line, but one example at a time. The change has less to do with health-care “reform” than it does with improved access to information beyond the traditional sources of clinical trials and medical billing systems. Now we can find out more about each individual patient (and ultimately aggregate data), about the use and performance of drugs and treatments out in the market (not just during testing), and even about outcomes.

In search of this theme, I met with a variety of start-up companies on the fringes of the event. (The formal program was mostly publicly traded companies talking about their earnings outlooks, with one section reserved for privately held companies.)

First, there was Andrew Brandeis of SharePractice, a doctor who used to run a high-end medical service called CarePractice in San Francisco, but saw a need for doctors to share information about how they treat patients. The industry standard for such information, Epocrates, offers a mobile app with information about pretty much every drug on the market, but neglects other kinds of treatments. (Brandeis also asserts that there is too much advertiser influence; in fact, only Epocrates’ educational content and sponsor messages are driven by ads. Make of that what you will.)

Brandeis’s idea is crowd-sourced information: Doctors will record for one another what treatments they actually use. He showed me his own cellphone contact list; most of the people on it are other doctors. He shares with them already; SharePractice will make it easy.

But will they want to share this kind of information? Yes, says Brandeis, because they already do, via text, email, and phone: “It’s a cumbersome process, the data are totally unstructured, and doctors wind up repeating themselves, because searching through six months of text messages makes no sense.”

OpenNotes: Drilling Down to Assure a Healthy Evolution

Jan 27, 2013• 14

By Tom Delbanco, MD and Jan Walker, RN

As the instigators of the OpenNotes initiative, we are thrilled that OpenNotes is being adopted by the VA. Prompted by Dr. Kernisan’s thoughtful post , the ensuing lively discussion, and our experiment with 100 primary care physicians and 20,000 of their patients ), we thought it useful to offer some observations drawing both on our experiences as clinicians and on ongoing conversations with clinicians and patients.

First and foremost, we don’t have “answers” for Dr. Kernisan. Our hope is to contribute to new approaches to these sticky questions over time. And, remember that patients’ right to review their records is by no means new. Since 1996, virtually all patients have had the right to access their full medical records. What’s new is that OpenNotes takes down barriers such as filling out forms and charging per page, while actively inviting far more patients to exercise this right in an easier and accessible way.

We think of open visit notes as a new medicine, designed like all therapies to help more than it hurts. But every medicine is inevitably accompanied by relative and absolute contraindications, and it’s useful to remember that it’s up to the medical and patient community to learn to take a medicine wisely as it becomes more widely available. A few specific thoughts:

Dementia and diminished physical capacity:

When a clinician notices symptoms or signs of dementia, chances are the patient and/or family has already been worrying about this for some time. Is it safe for the patient to live alone? What about driving? How and when could things get worse? They may actually be relieved when the doctor brings up these topics and articulates the issues in a note. Moreover, their worst fears may prove unfounded, and reading that in a note can be reassuring. But we need to consider the words we write so we don’t rush to label a condition as “Alzheimer’s.” Being descriptive is often better and more helpful than assigning one word definitions. In itself, OpenNotes reminds the health professional to choose words wisely. That doesn’t have to mean more work, but we believe it can certainly mean better notes that can be more easily understood by the patient. We urge colleagues to stay away from “The patient denies…,” or “refuses,” or “is SOB.”

Abuse or diversion of drugs, possible substance abuse, or unhealthy alcohol use:

These subjects are always tough, and what to write down has been an issue for clinicians long before they worried about open records. Over the course of our experiment in primary care, we have heard stories from patients about changing their attitudes and behavior after reading a note and “seeing in black and white” what their doctors were most worried about. Though substance abuse may seem like a particularly sensitive topic, at least one doctor in our study is convinced that some of his patients in trouble with drugs or medications did better as a result of reading his notes. And while some patients may reject our spoken (or unspoken) thoughts that we document in notes, experience to date makes us believe that more patients will be helped than hurt, and that it is worth the tradeoff.

Rob’s New Economics of Practice Management

Jan 27, 2013• 20

By Rob Lamberts, MD

It has always been my assumption that my new practice will be as “digital” as possible. No, I am not going into urology, I am talking about computers. [Waiting for the chuckles to subside]

For at least ten years, I’ve used a digital EKG and spirometer that integrated with our medical record system, taking the data and storing it as meaningful numbers, not just pictures of squiggly lines (which is how EKG’s and spirometry reports appear to most folks). Since this has been obvious from the early EMR days, the interfaces between medical devices and EMR systems has been a given. I never considered any other way of doing these studies, and never considered using them without a robust interface.

Imagine my surprise when I was informed that my EMR manufacturer would charge me $750 to allow it’s system to interface with a device from their list of “approved devices.” Now, they do “discount” the second interface to $500, and then take a measly $250 for each additional device I want to integrate, so I guess I shouldn’t complain. Yet I couldn’t walk away from this news without feeling like I had been gouged.

Gouging is the practice of charging extra for someone for something they have no choice but to get. I need a lab interface, and the EMR vendor (not just mine, all of the major EMR vendors do it) charges an interface fee to the lab company, despite the fact that the interface has been done thousands of times and undoubtedly has a very well-worn implementation path. This one doesn’t hurt me personally, as it is the lab company (that faceless corporate entity) that must dole out the cash to a third-party to do business with me.

Doing construction in my office, I constantly worry about being gouged. When the original estimate of the cost of construction is again superseded because of an unforeseen problem with the ductwork, I am at the mercy of the builder. Fortunately, I think I found a construction company with integrity. Perhaps I am too ignorant to know I am being overcharged, but I would rather assume better of my builders (who I’ve grown to like).

Yet thinking about gouging ultimately brings me back to the whole purpose of what I am doing with my new practice, and what drove me away from the health care system everyone is so fond of. If there is anywhere in life where people get gouged or are in constant fear of gouging, it is in health care. Continue reading…

Replacing Lance

Jan 26, 2013• 4

By JAMES SALWITZ, MD

We need heroes. Heroes show us light in the darkness, the way to the miraculous and ignite a fire in our soul to survive. They prove what is truly possible, through the fog of the impossible. We mourn the disgrace of Lance Armstrong because he seems to have achieved Pyrrhic victory. Let us not doubt; whatever his frailty as a man, Armstrong vanquished a terrible foe; moreover the path blazed is not bare, for everywhere are cancer heroes.

– The 45 year old RN raising her children while she works full time in a pediatric intensive care unit, celebrates her eighth year in remission from pancreatic cancer, treated with surgery, chemotherapy and radiation.

– The grandmother who ignored a breast mass for two years so she could care for four disabled grandchildren, and when the tumor grew to be massive, continues to take care of the children while receiving chemotherapy.

– The hospital chaplain who has suffered from cancer, sits at the bedside holding a hand, sharing a smile, saying a prayer that is heard deep in the heart and to the heavens above.

– The 71 year old with four different cancers, treated with a bewildering mix of surgery, radiation and chemotherapy, whose primary worry is the cardiac care of her husband.

– The 64 year old rescue squad volunteer while receiving chemotherapy and radiation for extensive lung cancer, assists 150 people to flee from their homes and escape the wrath of Sandy.

– The national lymphoma expert, who could be wealthy in his own clinic, instead devotes his life to teaching and research, believing he can save more lives by consulting and advising oncologists in communities around the country.

Lawyers, Guns and Doctors

Jan 25, 2013• 45

By David Mokotoff, MD

Recently both President Obama and the AMA have called for physicians to talk with their patients about gun ownership, especially if they sense mental health issues. This request sounds innocuous enough, but let’s explore the implications and the reality here.

First I need to issue a disclaimer. I am neither a member of the NRA nor do I necessarily feel that more gun laws and bans will reduce the recent tragedies in Newtown, Ct. or Aurora, Co. Gun safety should be of paramount importance to all gun owners. However, if I am going to ask all my patients about gun safety and ownership, then there are a few other dangerous things I need to engage them with as well.

“Do you own a pool?” (Quite relevant since we live in Florida.) “If you do, do you have small children at home or as guests? Do the neighborhood children come by? Do you have a pool fence and is it locked at all times? Have you thought about how many accidental drowning of children there are in Florida every year? Have you taken a course in pool safety?”

Or how about this topic: “Do you own a dog? What kind of dog is it? Were there any pit bulls in its family lineage? Do you have small children at home or grandchildren? Has your dog ever bitten anyone? (Okay, the mailman doesn’t count.) Have you taken a course in dog safety ownership?”

You see where I am going with this of course. First of all, I, and most doctors, don’t have the time to engage in this dialogue with my patients, since I am too busy asking about percentage of seat belt use, quitting smoking, updating medicine lists and system reviews, and filling out ridiculous “meaningful use” of EHR forms, just to get paid from Medicare. And even if I did have time, it is really none of my business. And if even if it was my business, asking this would not prevent a mentally aberrant person from finding weapons and using them in a hideous fashion.

About Time? Smokers Face Tough New Rules Under Obamacare

Jan 25, 2013• 105

By Dan Diamond

The Affordable Care Act contains a number of provisions intended to incent “personal responsibility,” or the notion that health care isn’t just a right — it’s an obligation. None of these measures is more prominent than the law’s individual mandate, designed to ensure that every American obtains health coverage or pays a fine for choosing to go uninsured.

But one provision that’s gotten much less attention — until recently — relates to smoking; specifically, the ACA allows payers to treat tobacco users very differently by opening the door to much higher premiums for this population.

That measure has some health policy analysts cheering, suggesting that higher premiums are necessary to raise revenue for the law and (hopefully) deter smokers’ bad habits. But other observers have warned that the ACA takes a heavy-handed stick to smokers who may be unhappily addicted to tobacco, rather than enticing them with a carrot to quit.

Under proposed rules, HHS would allow insurers to charge a smoker seeking health coverage in the individual market as much as 50% more in premiums than a non-smoker.

That difference in premiums may rapidly add up for smokers, given the expectation that Obamacare’s new medical-loss ratios already will lead to major cost hikes in the individual market. “For many people, in the years after the law, premiums aren’t just going to [go] up a little,” Peter Suderman predicts at Reason. “They’re going to rise a lot.”

Meanwhile, Ann Marie Marciarille, a law professor at the University of Missouri-Kansas City, adds that insurers have “considerable flexibility” in how to set up a potential surcharge for tobacco use. For example, insurers could apply a high surcharge for tobacco use in older smokers — perhaps several hundred dollars per month — further hitting a population that tends to be poorer.

Is this cost-shifting fair? The average American tends to think so.

Are Healthcare and Health IT in a Dysfunctional Relationship?

Jan 23, 2013• 26

By Edmund Billings, MD

What a week last week! First the disgraced cyclist confession and later the baffling college-football-player-and-his nonexistent-(dead)-girlfriend story, with the RAND report sandwiched somewhere in between. It’s positively a scandal-palooza.

What’s that? You don’t feel like the recent RAND report, which basically says that a 2005 RAND study financed by GE and Cerner was wildly optimistic in predicting about $81 billion in potential health care cost savings through widespread adoption of electronic health records, qualifies as a genuine hoax, controversy, scandal?

Me neither.

But it does neatly frame what is arguably a unique characteristic of the healthcare industry—a trait that extends to peripheral industries as well. Basically, healthcare is an interconnected environment. Call it the systems theory of healthcare, co-dependency … or just regular dependency. Call it what you want, but there is an interconnectedness in healthcare that we ignore at the expense of national wellness.

Witness key data points provided by the RAND report:

Modern health IT systems are not interconnected and interoperable, functioning “less as ‘ATM cards,’ allowing a patient or provider to access needed health information anywhere at any time, than as ‘frequent flier cards’ intended to enforce brand loyalty…”

Neither are they widely adopted, with an estimated 27 percent of hospitals utilizing a basic electronic record. Without broad adoption, interoperability is far less relevant.

Improvements in quality of care / patient safety and reductions in healthcare costs (which have grown by $800 billion since 2005) are not manifesting with EHR adoption, in part because hospitals and clinics are rushing to adopt mediocre solutions and garner federal funds.

The provision of care is the same as it ever was, even though EHRs are frequently promoted as the optimal tool for a different kind of care.

The reasons for these disappointing stats are readily apparent and unalterably interconnected.
Continue reading…

Six Awkward Concerns in My OpenNotes

Jan 23, 2013• 20

By Leslie Kernisan, MD

I found out this past weekend that the VA will be making clinician progress notes available for patients to view on the MyHealtheVet portal. In other words, the VA is going OpenNotes. (Note: I was a primary care provider in geriatrics clinic at the San Francisco VA from 2006-2010.)

My first reaction was to be impressed by this bold progressive move.

My next reaction was to feel mildly relieved that I’m no longer a PCP there.

Now, it’s not because I’m against transparency in healthcare, or am suspicious of patient engagement, or feel that patients shouldn’t see their health information without the assistance/gatekeeping/interference of a clinician. Far from it.

It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.

So whew, I find myself relieved that I don’t have to figure out how to document (or not document?) these concerns.

Instead, I’ll get to see how my friends at the VA handle these issues.

Wondering what they are? Ok, I will tell you but shh … don’t tell my elderly patients that I may be considering these topics as I care for them.

Six awkward concerns in geriatric primary care practice

· Possible dementia. As a geriatrician, I focus on an age group that has a high incidence of dementia. Which means that when someone starts to tell me odd stories (concerns related to poison are a popular theme, as well as reports that someone is stealing things repeatedly), I start wondering about possible dementia. Ditto if he or she starts floundering with the medications, or starts having other difficulties with IADLs.

Why it’s awkward: Patients and families really hate it when I bring up the possibility that there might be dementia. Many find the possibility of a disease such as Alzheimer’s truly terrifying, both because it’s perceived as a terrible disease, and because they worry about having to leave their homes or otherwise losing their independence. Note that if I’m considering the possibility of dementia, I usually let the patient know during the visit.