Tag: primary care

The Penguin Problem

Nov 22, 2010• 11

By VINCE KURAITIS, JD

Remember the penguin problem described by economists?

No one moves unless everyone moves, so no one moves.

Overcoming the penguin problem has a lot to do with creating expectations. A recent writing by Dr. James O’Connor in Physician Practice expresses a voice from the physician community that I’ve never heard before. His essay is entitled “Meaningful Use — Doctors Have No Choice”.

Physicians Have No Choice Other Than to Adopt EHRs?

Dr. O’Connor argues that physicians are effectively being forced into adopting EHRs. He cites facts and reaches a powerful conclusion:

1. CMS penalties begin in 2015.
2. What if you won’t or don’t accept Medicare/Medicaid patients (13 percent of practices in 2009, up from 6 percent in 2004? In August, four major insurers (Aetna, Highmark, United Health Group, and Wellpoint) announced that, at a minimum, they will link their pay-for-performance programs to federal meaningful use criteria. Other insurers are likely to follow.
3. Do you run one of the increasing number of “boutique” or VIP practices that work on a cash-only basis? The American Board of Medical Specialties (ABMS) released a statement in August saying that they intend to link meaningful use of health information technology into the ABMS Maintenance of Certification© program.
4. You don’t care about being board certified? (Sound of crickets chirping.) The Final Rule gives states the authority to impose additional requirements that promote compliance with meaningful use. As reported in Physicians Practice, the state of Massachusetts may take away your license to practice medicine in 2015 unless you demonstrate meaningful use of an EHR system. In Maryland, private insurers will be required to build incentives for acquisition of EHRs and penalties for not adopting them into their payment structure.

OK, so technically, we do have a choice. We could stop taking Medicare and Medicaid patients, accept cash only, give up our board certification (and thus usually hospital privileges), and move to a state (or country) that doesn’t impose EHR requirements. But is that really a choice? No.

Health IT and the Other Disparities

Nov 22, 2010

By MARGALIT GUR-ARIE

On October 18 2010, Dr. Blumenthal published a letter to EHR vendors titled "Health IT and Disparities" urging them to “include providers who serve minority communities in their sales and marketing efforts”. Reiterating the assumed benefits of Health IT to both quality of care and efficiency of care delivery, the National Coordinator for Health Information Technology stressed the importance of EHR vendors working together “to provide EHR adoption opportunities for physicians and other healthcare providers working within underserved communities of color”. This is obviously an important and welcome appeal. Physicians who provide care for impoverished minority communities usually lack the means to purchase EHRs and perhaps some EHR vendors will heed Dr. Blumenthal’s request and make special arrangements for these doctors and their clinics. The stimulus incentives may also help. But how about those who serve equally impoverished populations and are practically barred from incentives?

In my home State of Missouri there are about 350 Rural Health Clinics (RHC) serving a state which with very few exceptions is one big Medically Underserved Area/Population (MUA/MUP) which is a geographical area or a population designated by the Health Resources and Services Administration (HRSA) as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. For the uninitiated, RHCs are designated by CMS and have to meet certain requirements. The practice has to be located in a rural area and it has to provide team care, which is all the rage now, meaning that a Nurse Practitioner or a Physician Assistant and a Certified Nurse Midwife have to be on premise and team up with the physician in providing patient care. RHCs can be independent practices or they can be owned by rural hospitals. Either way RHCs are paid by Medicare differently than a practice without RHC designation. RHCs are required to submit reports of their operational costs and their total number of visits. Based on these two parameters the reimbursable cost per visit is calculated by Medicare. The entire process is complex and subject to rules, regulations and caps. The main point here is that RHC providers are not reimbursed according to the regular Medicare physician fee schedule and therefore will be unable to receive EHR incentives under Medicare. A few RHCs may qualify for Medicaid incentives, but in most cases they don’t have the prerequisite 30% Medicaid patients.

The Seduction of Primary Care

Nov 18, 2010• 83

By ROB LAMBERTS, MD

Hey there, big, smart, good-looking doctor….

Are you tired of being snubbed at all the parties? Are you tired of those mean old specialists having all of the fun?

I have something for you, something that will make you smile. Just come to me and see what I have for you. Embrace me and I will take away all of the bad things in your life. I am what you dream about. I am what you want. I am yours if you want me….

Seduce: verb [ trans. ]

attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .

(From the dictionary on my Mac, which I don’t know how to cite).

If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor. What you see there will tell you a lot about our system and why it is in the shape it is. Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.

“You can code this as CPT-XYZ and get $200 per procedure!”

“This is billable to Medicare under ICD-ABC.DE and it reimburses $300. That’s a 90% margin for you!”

This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit – something that is poorly reimbursed. Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically. The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.

Rating the Raters: Physician Compare

Nov 18, 2010

By NAOMI FREUNDLICH

Let’s say you’ve enrolled in a new health insurance plan and need to find an internist who participates. How do you decide which doctor to choose? My (long deceased) grandmother made her choices by using the following criteria: She looked for a male doctor with a Jewish-sounding last name who graduated from an American medical school—preferably one located in New York City. Nowadays her narrow (and culturally biased) criteria would have excluded some of the most esteemed practitioners around.

If you are like most people, you don’t depend on your grandmother’s advice to find a physician, but rather ask friends, colleagues or other doctors for recommendations. But taking one person’s experience with an internist or surgeon as a signal that he or she is “really good” is still far from the optimal way to choose a practitioner.

Over the years, several commercial websites like HealthGrades and Angie’s List have cropped up that provide such consumer-friendly information as the distance a doctor’s office is from the patient, and whether foreign languages are spoken there. They usually include ratings that reflect consumers’ personal experiences with the practitioner. For people who want to dig deeper, most state medical boards collect data that can be searched to find out where your doctor went to medical school, where he did his residency and what board certifications she has. In some states you can also search to see if the doctor in question has received disciplinary action or been sued for malpractice.

This is a lot of on-line legwork for the average person—a task that even professionals can find difficult. Chip Amoe, assistant director for federal affairs at the American Society of Anesthesiologists told a group recently, “When I tried to go find a primary care physician, I couldn’t. You know, it was very difficult. I had to go on several different Web sites to be able to find [one].”

Alzheimer’s Disease: The $20 Trillion Enemy We Must Not Forget

Nov 12, 2010• 10

By LISA SUENNEN

In the last several weeks I lost my phone (recovered), my iPod (gone) and even a piece of jewelry (I am pretty sure the cat is guilty). I was at the airport when I couldn’t remember where I parked my car for long enough to wonder if I actually did drive myself there. (Don’t judge me; I know you do it too.)

All of us are prone to losing objects and forgetting appointments and struggling for that word on the tip of our tongue that we definitely should know. Sometimes we even forget the names of people who live in our house just for a second; admit it: how many times have you called your child by the dog’s name?

Those momentary lapses of memory can be amusing or frustrating, but they usually don’t slow us down much. We laugh it off and say, “wow, I must be getting old” and move on to the next task. An op-ed I read recently in the NY Times, however, made me realize we don’t long have the luxury of humor when it comes to this issue.

Authored by Supreme Court justice Sandra Day O’Connor (ret.), Nobel Laureate neurologist Dr. Stanley Prusiner and Age Wave expert Ken Dychtwald, and entitled The Age of Alzheimer’s, the article pointed out these astonishing facts:

Starting on Jan. 1, our 79-million-strong baby boom generation will be turning 65 at the rate of one every eight seconds. That means more than 10,000 people per day, or more than four million per year, for the next 19 years facing an increased risk of Alzheimer’s. Although the symptoms of this disease and other forms of dementia seldom appear before middle age, the likelihood of their appearance doubles every five years after age 65. Among people over 85 (the fastest-growing segment of the American population), dementia afflicts one in two. It is estimated that 13.5 million Americans will be stricken with Alzheimer’s by 2050 – up from five million today.Continue reading…

Doctor Patient

Nov 10, 2010• 13

By ROB LAMBERTS, MD

I did a little “self care” earlier this week. I did it by not caring for myself.

I went to the doctor.

I was sitting in the waiting area for my appointment and saw the mother of one of my patients. ”Why are you here?” she asked.

“I have a doctor’s appointment.”

She got a curious look on her face, asking, “Don’t you doctors just take care of yourselves? I thought that was what doctors did.”

We do take care of ourselves, in fact we do it far more often than we should. Being your own doctor allows for a lot of denial. When you spend your day advocating healthy lifestyles after you had trouble finding pants would fit in the morning, denial is necessary. Do as I say, not as I do.

I realize that this is hypocrisy; that is why I was at the doctor on Monday. My patients have noticed my expanding waistline, commenting on it more than I would wish. Certainly my pants get in the way of denial as well, not forgiving the fact that I have been under a whole lot of stress. Pants don’t accept excuses.

The Electronic Medical Home

Nov 4, 2010• 4

By JOHN HALAMKA, MD

In previous blog posts, I’ve mentioned an idea deserves its own dedicated post.

Over the weekend, I keynoted the eClinicalWorks National User’s Conference in Florida. One of the attendees emailed me the following question:

“I have a number of questions regarding certain types of patient-level data that might cause us problems in the future of HIE. No one, to date, has been able to answer these and I thought I might ask you.

The first, and easiest, is how we we going to handle the following situation:

1) I am seen in Boston as a child and my mother says that I am allergic to Penicillin (or pick your drug of choice). The nurse-practitioner asks a few questions of my mother, who isn’t terribly forthcoming with information but insists that I am allergic. While he/she has reservations, they record it as an allergy in their eclinicalworks EMR. It goes to the Massachusetts HIE.

Losing Patients With Insurers

Oct 29, 2010• 70

By ROB LAMBERTS, MD

We are losing patients. Certain insurance companies are trying to “play hardball” with doctors, unwilling to negotiate with us over their outlandishly low rates. We have lost patience.

So the signs went up in the exam rooms today:

As of the start of the year, we will only accept X, Y, and Z Medicare advantage plans, and we are presently negotiating with A and B insurance companies. Please consider this when enrolling in plans.

It is highly likely we will drop one of the insurance plans altogether, and we are one of the last practices in our town to accept them.

Patients are distraught. Some of them who have seen us for years are now going to have to go elsewhere, while others that just joined our practice because their previous doctors dropped out of the plan will once again have to find a new doctor. Patients aren’t mad about this, just sad. The conversations go like this:

“So you are dropping X insurance?”

“We will if they don’t change. They are paying us significantly less than other plans.”

“That’s crazy. We just left a doctor because of the same thing. Now we have to move on.”

“Yeah, I am very sorry about that. I just want to see patients; I don’t want to do this kind of thing.”

“Well, I don’t blame you. They pay $1000 for an ER visit for an ear infection, and they won’t pay you what you charge?”

So That’s How The Rates Are Set

Oct 29, 2010• 9

By PAUL LEVY

The Wall Street Journal published a very important article this week. Written by Anna Wilde Mathews and Tom McGinty, it is entitled, “Secrets of the System: Physician Panel Prescribes the Fees Paid by Medicare.

Here’s the lede:

Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement.

Yet the influence of the secretive panel, known as the Relative Value Scale Update Committee, is enormous. The Centers for Medicare and Medicaid Services, which oversee Medicare, typically follow at least 90% of its recommendations in figuring out how much to pay doctors for their work. Medicare spends over $60 billion a year on doctors and other practitioners. Many private insurers and Medicaid programs also use the federal system in creating their own fee schedules.

Crossing the ROAD to Real Reform

Oct 25, 2010• 3

By ALI KHAN, MD, MPP

“So, why didn’t I take the ROAD again?”

It’s a question that I regularly hear from many of my co-residents in internal medicine – and no, we’re not questioning our travel routes to the hospital.

We all know why we chose internal medicine: the intellectual challenges inherent in treating across organ systems, the excitement of primary scientific investigation and diagnosis and the like. As we struggle through the rigors of primary care training, however, it’s hard not to look wistfully at our colleagues in such lucrative, ”lifestyle” specialties as radiology, ophthalmology, anesthesia and dermatology – the “ROAD” to riches in modern medicine – and wonder exactly how green the proverbial grass on the other side might be.

In the wake of the Affordable Care Act’s [ACA] passage, conventional wisdom suggests that we’re about to find out. After all, with the ACA’s passage comes the influx of more than 30 million new customers to American primary care offices and hospitals. In a health care marketplace where just two percent of all graduating American medical students will pursue careers in general medicine (according to a 2008 JAMA study), an exponential jump in supply will mean a requisite increase in demand – with a boost in wages for primary care docs surely close behind.