By JIM PURCELL

A message to health insurance CEOs, COOs, and CFOs.  I believe there to be a fundamental disconnect between typical health insurer provider reimbursement strategies and the long term good of our healthcare delivery system and its financing.

Let me give you some examples which I know, as a former health insurer COO and CEO, to be true.

• Insurers still pay primary care physicians far less than most specialists.  That perhaps was a function of the RBRVS system adopted by Medicare to “measure” the demands of specific physician activities and pay accordingly.  Specialist activities were rated higher than primary care activities.  They were deemed more complex, often involving surgery and fancy equipment with more training needed, etc.  The gap between primary care and specialist reimbursement grew and grew.  And what happened?  Predictably, the best and brightest are avoiding low paying primary care.  Consequences?

• Shortage and aging of primary care physicians who are needed to keep us from requiring the much more expensive specialist and hospital care

• Oversupply of specialists resulting in overuse, because if you build it they will come

• Keeping the focus on sick care, which is what most specialists specialize in, rather than well care

• Devaluing E&M (evaluative and maintenance) activity, which is the heart and soul of the practice of medicine, requiring observation, patient knowledge, and perception

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By DAVID INTROCASO

The intent of Title I of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) is to improve care quality and reward value. 1  Tying an increasing percent of Medicare fee for service payments to quality or value through alternative payment models such as Accountable Care Organizations (ACOs) is also Department of Health and Human Services Secretary Sylvia Burwell’s goal. 2  However, in the proposed MACRA rule published in May, CMS will measure and score quality and resource use or spending independently. 3  CMS will not measure outcomes in relation to spending.  CMS will not measure for value.  If value is left unaddressed in the final rule the agency can neither meet MACRA’s goals nor Secretary Burwell’s.  CMS cannot also reasonably expect providers to continue to enter into, and succeed under, risk based contacts if they do not know if they are incrementally improving quality or outcomes relative to spending. Continue reading…

By KIP SULLIVAN

One of the privileges of being a managed care advocate is that you never have to discuss the unpleasant question of how much your proposed intervention will cost. Whether your proposed intervention is HMOs, report cards, pay-for-performance, ACOs, “medical homes,” or electronic medical records, you never have to estimate what your bright idea will cost. With this privilege comes another: You are free to criticize doctors and hospitals for being “cost unconscious.”

Over the last decade, CMS has become a proponent of this double standard – cost consciousness for doctors and hospitals and cost unconsciousness for the health policy illuminati
. Beginning with the Physician Group Practice Demonstration, which ran from 2005 to 2010, and running through today’s ACO and “medical home” demos, CMS has assiduously avoided reporting the costs that clinics and hospitals incur to participate in these demos. Jeff Goldsmith and Nathan Kaufman  have described CMS’s behavior as “sunny obliviousness to provider economics.” [1]Continue reading…

By RONALD WYATT, MD

Civility is a system value that improves safety in health care settings. The link between civility, workplace safety and patient care is not a new concept. The 2004 Institute of Medicine report, “Keeping Patients Safe: Transforming the Work Environment of Nurses,” emphasizes the importance of the work environment in which nurses provide care.¹ Workplace incivility that is expressed as bullying behavior is at epidemic levels. A recent Occupational Safety and Health Administration (OSHA) report on workplace violence in health care highlights the magnitude of the problem: while 21 percent of registered nurses and nursing students reported being physically assaulted, over 50 percent were verbally abused (a category that included bullying) in a 12-month period. In addition, 12 percent of emergency nurses experienced physical violence, and 59 percent experienced verbal abuse during a seven-day period.²

Workplace bullying (also referred to as lateral or horizontal violence) is repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators.³ Bullying is abusive conduct that takes one or more of the following forms:³

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By KAREN SIBERT, MD

When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.

When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.

Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.

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