By ANISH KOKA, MD

Like many cities, Philadelphia is a city defined by its neighborhoods.  I practice in two neighborhoods separated by a few miles but leagues apart in every other way.  One of the hospitals is a tertiary care facility in the heart of Center City – a well to do upcoming part of town – and the other is a small community hospital a few miles South.  The patients at the two locations are quite different, and the mechanism of health care delivery is also starkly different.  Medical care at the Center City campus is provided mostly by employed physicians, and care at the community hospital is provided mostly by private practice physicians.

The debate about employed physicians vs. private physicians was one that until very recently was thought to have been settled.  To the nascent Obama administration in 2008 charged with ‘fixing’ health care, it was obvious that health care delivery in the United States was of low quality and needed change.  Enamored by models like the Mayo Clinic, the Cleveland Clinic, and Geisinger the answer clearly was large clinically integrated networks.  And just like that, with little discussion, and no evidence, the Obama administration set into motion legislation in the form of the Affordable Care Act that brought private practice to its knees. Declining reimbursement and increased overhead costs from regulations meant that percentage of private practice physicians went from 57% in 2000 to 37% in 2013.
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By MARGLIT GUR-ARIE

Some wars are supposed to last forever. Lyndon B. Johnson started a war on poverty. Richard Nixon kicked off a war on drugs. Ronald Reagan initiated a war on terror. Poverty, drug use and terror are booming. It’s time to launch another good ol’ war. Let’s make it relevant, cool, hip and infinite. So how about a 21st century war on Cybertheft?  This may sound trifle by comparison to those other wars, but wars are rarely about the actual title we bestow upon them. The war on terror evolved into a war on people living under secular dictators, the war on poverty ended up being a war on poor people, and the war on drugs became a war on black people. The war on Cybertheft will be the war on all people everywhere.

The war on Cybertheft has been simmering since the banks decided to do business online. The threat of “identity theft” should have been a monumentally mobilizing battle cry. But it wasn’t. Oh sure, it spawned a bunch of fear inducing exposés and some mildly successful businesses, but all in all, it failed to generate the zombie apocalypse panic it was supposed to trigger. Luckily, our wise leaders decided to put all our medical information on the Internet. It’s one thing for a Romanian hacker to gain access to your checking account balance, and quite another if Marcel is suddenly able to peruse your history of vaginal yeast infections. It makes no sense really, but the latter seems like an unbearable and humiliating violation of who you are. Wars have been launched for much less than that.

Let me give you an example that is splashed all over the news lately. A nondescript bunch of hackers broke into Democratic Party servers, stole all sorts of documents and emails and provided them to WikiLeaks for publication. This incident proved to be an embarrassment for the global money cartel behind our democratic curtain, and at the same time a great opportunity to score some cheap points in this weird election while stoking the fires of war. Within 24 hours, and with ample assist from corporate media tools, the conversation moved from corrupt, political machinations to an alternate universe where the Kremlin is colluding with insurgents to overthrow the rightful rulers of America. Terrifying stuff.

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By SAURABH JHA, MD

To paraphrase Tolstoy, all competence is alike, but every incompetence is incompetence in its own way. Every time I think I’ve seen the horizon of incompetence, I’m dealt a surprise. The sun never sets on incompetence. In healthcare, incompetence can be found in odd places, such as three recent examples I encountered with third party payers.

Case 1: Downgrading Caviar to Boiled Salmon

A patient was referred for a CT angiogram run off – which is a CT scan of the arteries of the belly, pelvis, both legs and feet – a very detailed and costly study. The cardiologist suspected a pseudoaneurysm of the femoral artery. The exam was an overkill, I felt, as the femoral arteries could be covered in a CT angiogram of the abdomen and pelvis – you don’t need to image down to the toes. I was confident that a pseudoaneurysm in the femoral artery would not extend to the arteries of the feet – it would be a world record, if it did. I suggested we stop the exam in the middle of the thigh.

“That’s fraud,” warned the chief technologist, who was also an expert in billing.

“Why is it fraud to restrict the field of view to the area of clinical relevance?” I asked.

“You can’t bill for a CT angiogram run off and only do the abdomen and pelvis. That’s fraud.”

“Why don’t we bill just for CT angiogram of the abdomen and pelvis?” I asked.

“You can’t bill just for the abdomen and pelvis, the patient has been pre-authorized for a run off.”Continue reading…

By LEONARD D’AVOLIO

I was walking with colleagues debating the merits of the latest round of healthcare payment reforms when we came across the ultimate symbol of American entrepreneurialism.  A young girl had set up a lemonade stand with a sign marketing 25 cents a cup.

“I’ll take one” I declared and was impressed with how confidently the young entrepreneur announced my total.  As I settled my tab my colleague stated that he too would like a cup of lemonade and was willing to pay 30 cents.  Except, he would pay half now and the other half would arrive after the cup was emptied, assuming a list of 8 pre-determined criteria were met.  Before he could finish explaining the 30 possible criteria from which she could choose, the third companion announced his thirst.  He would buy lemonade for two of the three of us!  For this, he would offer a dollar.  The catch was that two of us would receive all the lemonade we required for this flat rate.  She eyed each of us up and down carefully, gauging our potential lemonade intake and asked which two were to be covered?  To which my colleague answered, “you will not know until you sign the contract.”

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By TAMARA ST. CLAIRE

Consumers know that their primary care doctors don’t talk to their specialists, who don’t talk to their pharmacists, who don’t talk to their insurance providers. The rise of consumerism in healthcare may be in its infancy, but according to research recently released by Xerox, a full 64% of consumers wish their pharmacist, healthcare provider, and insurance company were more connected regarding their health.

Consider your most recent travel experience. You probably used a website like Expedia.com to look up flights, hotels, and even rental cars. With all the relevant information displayed conveniently (and often beautifully) side-by-side, you were probably able to make an informed decision and instantly book the exact travel package that suited your needs.

Now imagine your most recent healthcare experience. Scheduling the appointment was probably a painful logistical balancing act, accompanied by terrible hold music. You likely had to find and present an insurance card, possibly even filling out another set of insurance forms and a health history for the thousandth time.

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By ROGER COLLIER

Dear Mrs. Clinton –

It’s probably good politics to suggest making Medicare available to some under 65s , just when Congressional Republicans are proposing to increase the Medicare eligibility age. Sometimes, though, good politics doesn’t produce good policy.

Medicare may be well-regarded by most Americans, but the program has four huge weaknesses that need to be fixed before considering any expansion.

Here’s what’s wrong.

Medicare is absurdly, insanely overcomplicated.  When Medicare was created in 1965, it consisted of just two components, Part A hospital care and Part B physician and other care, with the split made only to gain AMA support for the legislation. Fast forward to 2016: we now also have Part C (Medicare Advantage), Part D (prescription drug), and seven versions of dual Medicare-Medicaid eligibility (in turn dependent on 50-plus states’ and territories’ own Medicaid regulations). And that’s all before the thousands of pages regulating payments to providers. The complexity provides a lot of jobs for bureaucrats and consultants, but does little for beneficiaries.

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By CAITLIN BREANNE SMITH

What if I told you that tobacco use, poor diet, lack of activity and toxic agents are not the main causes of death in the United States, as conventionally accepted?

With ever-rising healthcare costs combining with often ineffective strategies to combat suffering from preventable diseases, researchers have increasingly dedicated a particular focus on identifying ways to optimize our ephemeral resources. They are finding that the true or underlying causes of death can be linked to the economic and social circumstances of the individual, such as her or his income, education and social connectedness.

The historically accepted morbidity and mortality factors are often actions and behaviors that are driven by socio-economic factors. Identifying and addressing the root causes of these tangled health webs is recognized as the most advanced methodology to create the highest impact at the lowest cost.

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By NIRAN AL-AGBA

Earlier this week , physicians in small private practices and rural areas breathed a collective sigh of relief.  There is a possibility the implementation of changes to physician reimbursement (known as MACRA) could be delayed.  Thank you, Mr. Slavitt, for listening.  I am grateful to Orrin Hatch (R-UT) and Ron Wyden (D-OR) for keeping our rural needs in mind.  We have a window of opportunity for rural health care to survive but we must communicate our needs as physicians and patients’ loud and clear.

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