ACP Internist

Wednesday, March 17, 2010

QD: News Every Day--Health care reform amid rising consumer costs

As clashes continue over using a "deemed passed" procedure to avoid a formal vote on health care reform legislation, business groups are pressuring Democrats who are fence-sitting as party leaders shore up support. (New York Times, AP, Wall Street Journal)

Meanwhile, to offset declining Medicare reimbursement, one California cardiology practice instituted annual fees for unreimbursed items such as notification of test results. The practice instituted three tiers of service, ranging from $500 annually for in-office pro-time and warfarin adjustments and pacemaker follow-ups, $1,800 for priority appointments and e-mail communication, to a concierge option for $7,500. Patients who do not choose one of the three tiers will receive medically needed services, but have to schedule an office visit to discuss non-urgent test results, for example. Consumers face these and similar increasing extra health care costs more often. For example, Medicare's prescription doughnut hole affects seniors at a time when prescription prices are outpacing inflation. (Kaiser Health News)

Labels: concierge medicine, health care reform, medicare, QD, reimbursement

QD: News Every Day--Health reform vote by the weekend

A vote on health care reform could come this weekend, with the House members considering whether to pass the Senate's version and then a bill of budget changes. House members are leery of the upper chamber's following through. The Majority Whip is trying to ensure there will be enough votes for passage. Abortion, immigration and costs remain key sticking points. Both sides are applying pressure to those on the fence, and Republicans are trying to make sure Democrats pay a price for victory. (Wall Street Journal, Washington Post, Fox News, Los Angeles Times)

The impact from this weekend's vote will play out over the next decade. Primary care doctors will see a 10% payment boost from Medicare for their office, nursing home and other outpatient visits. Medicare also plans to pilot accountable care organizations that reward primary care doctors for managing multiple chronic illnesses. Doctors and hospitals would band together for payments, similar to a "Mayo Clinic model." (AP) [Editor's note: This post originally stated the legislation applies to rural and inner city physicians. It applies to all physicians for the three conditions stated above.]

Labels: health care reform, medicare, QD, reimbursement, rural medicine

QD: News Every Day--The end is in sight (until later)

The Senate voted today to delay until September 30 Medicare's 21% reimbursement cut. The legislation also extends federal financial assistance for state Medicaid programs for six months and COBRA and unemployment insurance benefits through all of 2010. (Modern Physician)

For the broader issue of health care reform, Democrats are trying to build a majority for the final push, while Republicans hope to capitalize on the divisions as well as create procedural roadblocks to the reconciliation process that might be used to pass it. (Christian Science Monitor, Washington Post, New York Times)

Labels: health care reform, medicare, QD, reimbursement

What if Other Parts of Life Were Like Healthcare?

Health care is bizarre. Anyone who spends significant time in its ranks will attest to the many quirky and downright ludicrous things that go on all the time. But I am not sure people realize just how strange our system is. Perhaps it would be interesting to see what it would be like if other parts of our lives were like health care.

1. Get up in the morning

The first thing that happens in your day is that your alarm fails to go off. Although you have major things happening, nobody ever has explained to you exactly what you are supposed to do and when. You watch the morning TV show and it seems that some experts say you should go to school while others say you should avoid school at all cost. You call a friend who says that she knows someone who went to school and it destroyed their liver. Another friend goes to school every day and is just fine.

Confused, you turn to the Internet and go to a Web site that explains that you should base your schedule on the pattern of tea leaves in a cup. This site claims that your normal schedule is actually fraught with secret appointments that will, unbeknown to you, make you have cancer. It states that those people in power are making you go through this dangerous schedule so they can make money off of you. They don't care for you like the people who made this web page (and for $400 you can have six months of magic tea leaves).

Finally, you decide that you are going to go with the majority opinion and go to school.

2. School

You go to your bus stop and wait. You keep waiting. You know that the bus was supposed to come at 8 a.m., but after an hour you begin to wonder if you missed it. Calling the bus service, you find out that the bus got caught up doing some extra routes. There is a shortage of buses, and so the ones that remain have to do twice as many routes as is feasible. After a two-hour wait, the bus finally arrives to take you to school.

The first teacher comes into the classroom and looks very distracted. She teaches general studies and is staring at a curriculum that contains a huge amount of subjects. As she is doing her lessons, she furiously takes notes on her own teaching so that she can submit documentation to the school board and prove that she taught you. This is the only way she gets paid.

In total, she teaches for about 15 minutes and documents her teaching for 45 minutes. You want to ask questions, but the bell rings and you have to move on to your next class before any can be answered.

The next teacher only teaches a small specialized subject. This teacher is paid four times more than the first teacher. Instead of teaching and answering questions, however, he is constantly making you take tests. Apparently, the school system pays a huge amount for making you take tests, but very little for teaching lessons that would make you do well on those tests in the first place.

School is finally over, but you don't feel like you got much out of it (except for taking a lot of tests and getting more confused). You decide that a trip to the store would perhaps make you feel better.

3. The grocery

Upon entering the grocery store, you notice something odd. There are very few different brands of items stocked on the shelves. Your choice is limited to only the brands that have struck the best deal with the grocery chain. These brands have to send the grocery store a large "rebate" check because they are carried exclusively in this store.

When you go to the meat counter and ask for some steak, the butcher asks you if you have first tried the ground beef. You may not purchase steak unless you have first tried and disliked the ground beef. The ground beef, of course, is actually ground turkey, but the butcher says that these two are basically interchangeable and so the substitution is permitted.

The grocer can't post prices because all customers have different negotiated prices. Posting prices, in fact, would be considered collusion since other grocers could find out exactly what this grocer is charging. Some congressman in California decided that grocers are all crooks and should not be allowed to share what they charge for things.

You go to the cash register to pay. The total is $380, but the cashier informs you that your negotiated price is only $150. A poor person behind you has not had the chance to negotiate a price and so must pay full price for everything.

There are a few people in the store who don't have to pay anything. They have had the price negotiated for them by the government, and so will come to the store very often. They sometimes come for real food, but are often coming for candy and cigarettes--all paid for by the government.

This experience leaves you more tired and confused, and so you decide to go home.

4. Home

Coming home, you notice that your house is under construction. There is a new wing being built that contains all sorts of the newest and fanciest gadgets, such as flat-screen TVs, the fastest computers, and wonderful new kitchen appliances. Going into the house, you notice that there is no running water or heat. Apparently, there are all sorts of grants and low-interest loans to pay for the fancy gadgets, and so contractors find it much more profitable to do that instead of fixing water or heating.

Your mother is in the kitchen trying to make dinner, but instead of cooking she is staring into a cookbook and at the ingredients you brought from the grocery store. You assume she can make do with what you brought, but she just sighs helplessly. Despite the fact that your mother is incredible at improvising meals, she is required to follow a cookbook that doesn't fit the ingredients that are available. This makes dinner taste pretty bad. Your mother, obviously angry about this, gives you a weak smile and tells you to finish what is on your plate.

After dinner, you settle down to watch some television. As you are finally starting to relax, a knock on the front door breaks your peace. At the front door stands a police officer. "You are only authorized to be in the house for two hours today, so I am going to have to ask you to leave."

You try to explain that two hours is not enough to get the rest you need, but the officer threatens a stiff fine and forces you to leave. Before you can get your necessary things, you are forced to leave without an explanation of how you are supposed to survive on the streets.

If it doesn't make sense in real life, how can it make sense in medical practice?

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: health care delivery, humor, medicare, primary care shortage, reimbursement, Rob Lamberts

QD: News Every Day--Health care reform's "endgame"

All the talk is of the endgame to health care reform. You'll find the word used repeatedly as the fourth column discusses the timeframe, strategy and roadmap how to finish the legislation. ACP Internist points out that even if passed, future legislators can continue the game year after year. It's the sport of kings.

Medicare pay cut
Primary care doctor William Schreiber, MD, broke down his practice expenses and figures the pending 21% Medicare pay cut would leave him with the equivalent pay of a minimum-wage job. The pay cut has been pushed back until the end of the month. (CNN)

Labels: health care reform, medicare, practice management, QD, reimbursement

QD: News Every Day--Medicare cuts delayed by 30 days

Medicare reimbursement cuts have been delayed for 30 days. (Nowhere else in our country's economy would someone's paycheck be bandied about like this.) The same legislation, actually a jobs bills, also extended the time that the federal government will pick up some of the tab for COBRA health insurance. (Health Leaders Media, Los Angeles Times)

As mentioned in yesterday's edition, the president plans to siphon off some Republicans by incorporating a few of their ideas. He might need them to counter Democrats who opposed health care reform legislation, but Republican leadership scoffed at the idea of breakaways. (ACP Internist, Washington Post, Politico)

H1N1 influenza
H1N1 influenza took an unexpected course in its timing and severity. Novel pandemics are different than seasonal flu outbreaks, explains those who tracked its course. And seasonal flu was mild this year, too. (Wall Street Journal, Pittsburgh Tribune-Review)

In case you missed it ...
W.G. Watson, MD, is a 100-year-old practicing obstetrician. One baby he delivered grew up to become his practice's partner, as a matter of fact. (CNN)

Labels: flu, H1N1, health care reform, health insurance, medicare, QD, reimbursement

QD: News every day--"Final act" for health care reform?

In a letter today to congressional leaders, President Obama said he is exploring four ideas proposed by Republicans at last Thursday's health summit, including using undercover clinicians to track down Medicare/Medicaid waste, allocating $50 million in federal funds to help states retool methods of dealing with medical malpractice lawsuits, increasing state Medicaid reimbursement to doctors, and expanding access to health savings accounts and high-deductible plans. The White House press secretary said today that the health care reform debate is in its "final act." President Obama is expected to release his revised health care plan tomorrow. (New York Times, Washington Post, LA Times)

Meanwhile, a jobs bill introduced in the Senate would put off Medicare cuts to physician reimbursement until August. (MedPage Today)

Labels: health care reform, medicare, QD, reimbursement

QD: News Every Day--Medicare holds claims to prevent pay cuts

Today's the deadline for a 21% cut in Medicare reimbursement. Congress didn't get a temporary fix pushed through in time, so Medicare is going to hold claims for 10 days to allow lawmakers enough time to act. Still, solo doctors and small practices worry that they will immediately feel the pinch. One internal medicine practice wrote its patients partly to warn them, but also to put pressure on lawmakers to act. Another warns that practices serving a large proportion of retirees are in even more trouble. ACP President Joseph Stubbs, FACP, remarked to Medscape that this has happened before, forcing some practices to take out short-term loans to meet payroll. (Health Leaders Media, The Daily Sentinel, TopNews.com)

It's going to be a busy week. Lawmakers can take up the issue of Medicare cuts later this week, but the White House is also going to signal its intentions on health care reform in the next few days. Both sides are taking sides, and talk about bipartisanship is being left behind. Democrats may have the votes to pass it without Republican support, but it's not a sure thing. Democrats counter that with 100 Republican amendments, the bill is bipartisan even if the final voting isn't. (New York Times, The Christian Science Monitor, Wall Street Journal, CNN)

In case you missed it ...
President Barack Obama received his annual check-up, and the results are online if you want to peek at the president's lab results.

Labels: health care reform, medicare, QD, reimbursement

QD: News Every Day--counting down to Thursday's summit

ACP Internist continues its look at Thursday's pending health care summit. The White House released its vision of health care reform yesterday to build party unity. But it drew immediate attack by the opposition. (ACP Internist, USAToday, The Christian Science Monitor)

With states feeling the pinch of Medicare and Medicaid spending--and rebelling in some cases--the federal government is using stimulus act spending to provide $4.3 billion to states to for prescription drug costs. Governors from New York and California say more is needed. (Health Leaders Media, Reuters)

In case you missed it ...
Drug companies contributed financial support to more than half the nation's internal medicine residency programs, even though three-quarters of residency directors said such aid is "not desirable." At issue are the pocket guides, meals, office supplies and drug samples given to doctors just as they gain the power of the pen. (New York Times, JAMA)

Labels: conflict-of-interest, drug companies, health care reform, Medicaid, medicare, QD, residency

QD: News Every Day--health reform smacks into health insurance

ACP Internist continues its look at health care reform efforts in the U.S. Reconciliation might be back. Not between Democrats and Republicans, but the procedural move that could attach health care reform to a budget bill that requires a simple majority in the Senate instead of a filibuster-proof supermajority. That's the stick the White House is wielding if the health care summit on Feb. 25 doesn't produce results. President Barack Obama will release details Monday about his plan for comprehensive reform. (AP, New York Times, Los Angeles Times)

It's a perfect storm for health insurance. The economy has driven record numbers of people to Medicaid. 15 million more people could be added, but states are cutting programs and reducing payments to doctors. Medicare Advantage premiums are rising and private insurance rates are climbing, too. President Obama is using the private insurance rates as a talking point to push his agenda. (Washington Post, New York Times, Los Angeles Times, Reuters)

Labels: health care reform, health insurance, Medicaid, medicare, QD

Primary Care Physicians Are All One Breath Away From Dropping Medicare

This post by Rob Lamberts, ACP member, originally appeared at Better Health.

I am going to state something that is completely obvious to most primary care physicians: I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business.

In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance. If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit. This is totally obvious to me, and I suspect to most primary care physicians. A huge part of our overhead comes from the fact that we are dealing with insurance. A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge. As it stands, the percentage of my collections that goes to overhead is between 50% and 60% (depending on the month). A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing and documenting. If I dropped insurance and charged a fixed amount, I could:

--cut my billing staff nearly to zero (someone would still have to do bookkeeping),
--increase my payment per visit, which would allow me to see fewer patients per day,
--document for the sake of patient care, and not for the sake of getting paid, and
--add extra services like e-mail access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

So why just single out Medicare and Medicaid (M/M)? Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me. There are several reasons why this is possible for insured patients:

--Insured patients generally have the option of filing for their own insurance (there are some that still don't allow this, but that number is dwindling with the decrease of HMO's); and
--Insured patients could choose to just pay me cash if they choose.

Can't Medicare/Medicaid patients do this? No, for several reasons:

--If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files;
--If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered). So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud; and
--If I drop M/M, I cannot sign up for it again for three years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still? Why would I continue to make my life so difficult? Two words: duty and calling. I view my seeing M/M patients as a social responsibility (especially Medicare). These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income. So far.

Plus, I just like to take care of the elderly and the poor. My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need. If I dropped M/M I would reject the calling for personal gain, which is something I can't do in good conscience at this time.

The fact that the only thing keeping me accepting M/M is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care. The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system. I am personally willing to continue on this course as long as (it doesn't get too much worse) but I have complete sympathy for primary care physicians (PCP) who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP's. PCP's keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital. The system is just holding on with the PCP's we have; decreasing that number would be devastating and perhaps fatal to the system. It's a very bad sign when the best business model for PCP's is to do something that, if done by all PCP's, would wreck the system. Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors! They have to earn less money! They have to actually have a conscience! What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle and live by my conscience. At this time, most PCP's accepting M/M are doing the same. But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish. Pushing down M/M payments for PCP's will make a bad situation worse.

That's bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: health insurance, Medicaid, medicare, primary care, reimbursement, Rob Lamberts

...and I Feel Fine

This post by Rob Lamberts, ACP Member, originally appeared at Musings of a Distractible Mind.

Primary care is dead. Long live primary care.

Wait a minute, I am in primary care. I am not dead. Not yet, at least.

Which reminds me of this Monty Python skit:

CART MASTER:
Bring out your dead!
[clang]
Bring out your dead!
[clang]
Bring out your dead!
[clang]

CUSTOMER:
Here's one.

CART MASTER:
Ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
What?

CUSTOMER:
Nothing. Here's your ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
'Ere. He says he's not dead!

CUSTOMER:
Yes, he is.

DEAD PERSON:
I'm not!

CART MASTER:
He isn't?

CUSTOMER:
Well, he will be soon. He's very ill.

DEAD PERSON:
I'm getting better!

CUSTOMER:
No, you're not. You'll be stone dead in a moment.

CART MASTER:
Oh, I can't take him like that. It's against regulations.

DEAD PERSON:
I don't want to go on the cart!

CUSTOMER:
Oh, don't be such a baby.

CART MASTER:
I can't take him.

DEAD PERSON:
I feel fine!

CUSTOMER:
Well, do us a favour.

CART MASTER:
I can't.

CUSTOMER:
Well, can you hang around a couple of minutes? He won't be long.

CART MASTER:
No, I've got to go to the Robinsons'. They've lost nine today.

CUSTOMER:
Well, when's your next round?

CART MASTER:
Thursday.

DEAD PERSON:
I think I'll go for a walk.

CUSTOMER:
You're not fooling anyone, you know. Look. Isn't there something you can do?

DEAD PERSON: [singing]
I feel happy. I feel happy.
[whop]

CUSTOMER:
Ah, thanks very much.

CART MASTER:
Not at all. See you on Thursday.

Now I would never suggest that the cart master who clubs the dead person represents, say, Medicare. It would not be in my nature to make such a suggestion.

But that is not the point of this post. While many complain of the death of primary care and declining reimbursement, some practices are experiencing quite the reverse: growth in income. I should know, because I am in such a practice.

We are not business geniuses in any stretch of the imagination, but we have been quite successful and raising our incomes substantially. Since I started 13 years ago, my income has doubled, and most of that increase has happened over the past five years, just the time that the death of primary care has been announced.

Our practice is almost totally outpatient (we still see inpatient pediatrics), and we earn very little at this point from labs and procedures. The vast majority of our income comes from regular office visits.

Here are some of the ways we have accomplished this:

We have focused on process. Using our electonic medical record, we try and find the most efficient ways to perform tasks in the office, involving the lowest possible number of staff. This has been a passion (see also: obsession) of mine.

We have focused on our patients. Our patients are our business, and so trying meet their needs (instead of the needs of the doctors) has resulted in a booming business. Here are some ways we have done this:
1. We have extended office hours. with a walk-in clinic (for acute problems only) every morning from 7:30-9:00 a.m. and every evening from 5:30-7:00 p.m. People don't get sick on a schedule and so we allow them to come in when they are sick. To do this, we had to drop most of our inpatient care (or have no life). This accounts for about 25% of our revenue that we would have otherwise lost to prompt cares or ERs.
2. We allow work-in visits. The patient likes to be able to see their doctor when they are sick (they get whoever is in clinic if they use our walk-in clinic). So even with a full schedule, I allow one "quick sick" visit every hour.
3. We do not tolerate patients being treated poorly. Doing so is considered a fireable offense. If a physician does so, they talk to the senior partner (which is me, but this really has not happened).
4. We strive for timeliness. Although we can never guarantee being on-time, we have done our best to have patients out the door within an hour of their arrival. This goal was modest enough to be possible, while allowing for the obvious emergencies.
5. We have a modified "open access" schedule. While I have too many chronic disease patients and scheduled follow-up visits to want to go completely open access, we do leave an hour of each afternoon open until the day of, so even complex patients can possibly be seen on the day they call.

We understand what is most important. While many practices focus on the complex higher-priced visits, we have understood from the start that the money we can earn per hour is much higher for ear infections and urinary infections. Plus, the majority of our patients are only going to use us episodically, so we want our office to cater to the larger population rather than the minority who are sick all of the time.

We are growing. My income went up when my share of the overhead went down. While our system worked fine for three physicians, it requires very few additional staff and space to run it with six. Adding new physicians and/or mid-levels has cut our overall overhead per provider dramatically.

We are planning. We know that pay-for-performance (P4P) and the "medical home" concept are probably going to happen. We have tried hard to keep our data good enough to be able to pounce on this once it is offered. So far, I have personally collected over $5,000 from P4P programs already, and their penetration is minimal. We know that once that wave starts, we will be in the front of it.

Quality is not compromised. We have done what we can to run the business well, but have tried not to forget that we are offering healthcare. The physicians in our practice agree to certain care standards and common practices. If we can all agree to what good quality care is, then we are far more likely to achieve it and we can engineer our process to accomplish it. For example, when National Committee on Quality Assurance certification became a means to increasing income, we were already exceeding the standards to become certified in diabetes care within a matter of weeks.

Admittedly, it has not been a smooth road to where we are now, and we are not without our problems (there is always a crisis somewhere), but from what I can tell, we have remained one of the less dysfunctional practices around. Given the unstable ground of U.S. health care, we certainly have no guarantees that this trend will continue, but I am doing my best to anticipate any trends in the system and set us up for capitalizing on this, rather than being caught off-guard.

Hopefully we are not facing any bridge of death in the near future. If we are, then perhaps we can start collecting shrubbery. I already have my electronic medical record programmed to say "Ni!"

Bonus points if you know the significance of the title. The answer is here.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: electronic medical records, humor, medicare, patient communication, patient-centered medical home, primary care, quality reporting, Rob Lamberts

QD: News Every Day--Health politics becomes health policy

ACP Internist's wrap-up of current events turns its attention toward health care reform, and how health care policy translates into health care delivery.

Health care reform
Congressional legislation will move forward with the least controversial elements of health care reform: solving Medicare's pending insolvency and closing a gap in Medicare Part D coverage. But Democrats and Republicans differ on how to accomplish such goals. (Wall Street Journal)

Medicare's reimbursement system has long stuck in the craw of primary care physicians. As a result, they don't always accept such patients, so one in three Medicare enrollees had trouble finding a primary care doctor when entering the Medicare population, according to a June 2008 report by the Medicare Payment Advisory Commission. The impact is shortening an already pressed primary care system. In Arizona, only three of that state's 15 counties have the appropriate ratio of primary care doctors to the general population. (The Arizona Republic)

Physicians aren't waiting for health care reform that may never come. They continue to leave community practice and delve into concierge care, which they say allows them to practice the thorough, hands-on medicine they'd envisioned when they graduated medical school. ACP Fellow David Grulke, MD, of Norfolk, Va., converted his practice to a concierge model in 2002. He charges $660 to $1,080 annually (unlike some practices that charge thousands or more) and describes it as a service for ordinary people who want a relationship with their doctor. In the same article, Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, tells the Virginian-Pilot such arrangements are the symptom of a broken care system. (Virginian-Pilot)

Haitian relief efforts
ACP Member Myriame Casimir, MD, was raised in Haiti. Today, she returns there on a medical mission comprised of her and 20 other providers from Rush University Medical Center in Chicago. (Chicago Tribune)

Also, an aid worker used a first-aid app on his cell phone to survive 60 hours trapped in the rubble of a building. (CNN)

In case you missed it ...
ACP Fellow Turi McNamee, MD, blogs about the "weekend effect" and concludes that, on Satursdays and Sunday, it's better to be shot than have a heart attack. She covers her local hospital's shifts on weekends and wonders what the impact will be on her facility's relaxed atmosphere if more research leads to an increase in weekend staffing. (True/Slant)

Labels: concierge medicine, disaster response, health care reform, medicare, primary care shortage, QD, weekend effect

QD: News Every Day--More internists arriving in Haiti

ACP Internist's wrap-up of current events follows MSNBC's chief health correspondent traveling through Haitian hospitals. He reports as they get up to speed on caring for patients in their facilities, they are also trying to coordinate care. Simple tasks, such as finding out who has space, are difficult. Relief efforts by many countries aren't fully coordinated with each other or with many of the nongovernmental efforts underway. Despite reports, logistical challenges are improving. (MSNBC, CNN)

Amid the logistics, independent medical teams are succeeding, such as a group from Christiana Care Hospital in Newark, Del. Reynold Agard, ACP Member, and Erin Meyer, ACP Associate Member, joined a team of 20 who travled to Jacmel, Haiti, a seaside town not far from the quake's epicenter, but that hadn't yet received help. Another team from Bridgeport, Conn., going to Jacmel was joined by Sangeetha Thiviyarajah, ACP Associate Member (pictured here). A team from Cooper University Hospital in Camden, NJ, has started surgical care, and physicians from Dayton, Ohio, set up a morgue, a decontamination area and showers for relief workers. And, the USNS Comfort received its first two patients by helicopter. It's now anchored off the Haitian Coast for an indefinite stay after upgrading to 1,000 hospital beds and more than 1,000 sailors. (Wilmington News-Journal, CTpost.com, Philadelphia Inquirer, Dayton Daily News, U.S. Navy)

The USNS Comfort anchored off the coast of Haiti and began receiving patients on Jan. 20.

Health care reform
Health care reform proponents look to salvage area of health care reform that were agreed upon throughout the legislative process, such as preventing insurers from canceling policies for people who fall ill. But many aspect of health care are related to one another, so a piecemeal approach has its own problems. Drug-makers, insurers and other health-related businesses are positioning themselves in the new landscape. So are medical societies, such as ACP. (free registration required) President Joseph Stubbs, FACP, explains. (Los Angeles Times, Wall Street Journal, MedScape Today)

In case you missed it ...
An internist in California was shocked when she saw the new Medicare schedule had cut reimbursement by 20%. Her overhead costs haven't fallen, so she's contemplating giving up that block of patients, even though she loves caring for them. (Los Altos Town Crier)

Also, LiveScience.com debunks seven common medical myths that even doctors believe.

Labels: disaster response, health care reform, medicare, QD, reimbursement

Losing Money on Medicare

Medicare, the government insurance company for everyone over age 65 (and for the disabled), pays fees to primary care physicians that guarantee bankruptcy. Additionally, 70% of hospitals in the United States lose money on Medicare patients. That's right ... for every patient over age 65, it costs the hospital more to deliver care than the government reimburses. That is why Mayo Clinic has said it will not accept Medicare payments for primary care physician visits at its Arizona facility. Mayo gets it. Nationwide, physicians are paid 20% less from Medicare than from private payers. If you are not paid a sustainable amount, you can't make it up in volume. It just doesn't pencil out.

Mayo lost $840 million last year on Medicare. Since Mayo is considered a national model for efficient health care, if they are losing money it doesn't bode well for the rest of us who are much less efficient and who have fewer resources for integrated patient care. Instead of Medicare payments for clinic visits, Mayo will start charging patients a $1,500 fee to be seen at their Glendale, Ariz., clinic. Much like a retainer, this fee will cover an annual physical and three other doctor visits. Each patient will also be assessed a $250 annual administrative fee.

Primary care physicians are on the front line of patient care and senior patients are the most time-consuming. The average Medicare patient takes 11 different medications. Just refilling and coordinating the medication can take up an entire office visit, without addressing other health concerns. I grant all Medicare patients a half-hour visit because I would be chronically behind if I didn't. After paying office overhead, I am broke with Medicare.

I do not welcome the 65th birthday of my patients, but I continue to see them because I love my senior patients. No kidding, I really love being their doctor. They are grateful and respectful and have interesting health conditions. I am able to see them because I make my income from my administrative position and I have other patients who pay outside of Medicare.

Sad but true--unless we have true payment reform that values primary care and pays for coordination of care, I fear Medicare patients will not find enough willing physicians who accept Medicare in the future.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: geriatrics, health care cost, medicare

QD: News Every Day--not the intended effect

ACP Internist's daily digest of news and events continues with backlash from an analysis of proposed health care reform legislation, voices from middle American and an ACP Fellow's controversial stance on just how much money is wasted in our current health care system.

Health care reform
Medicare's chief actuary reports that legislation in the U.S. House would raise health care costs by $289 billion over the next 10 years and reduce benefits and access to services. (The Hill, Washington Post)

Meanwhile, 43% of Americans oppose the health care plans underway in Congress, 41% approve, 15% are undecided, the latest poll figures show. But opponents are more strongly against it than supporters are in favor, say numbers provided in a study by Stanford University and the Robert Wood Johnson Foundation. (AP/Washington Post)

Peter Reiter, FACP of Ottumwa, Iowa, describes the need for health care in his community, while Robert Vautrain, ACP Member, of Springfield Il., asks for a public option specifically. (Ottumwa Courier of Iowa, State Journal-Register of Illinois)

H1N1 influenza
Airlines are chafing at CDC recommendations that they filter air for H1N1 influenza even while at the terminals. They say it's costly, but just 20 minutes on the ground is long enough to spread the virus. (CBS 11 of Dallas-Forth Worth)

Primary care shortage
Concierge medicine rankles some in communities already stretched by a lack of primary care providers. Read how the controversy is playing out in Waco, Texas. (Waco Tribune-Herald)

Medical education
To accommodate the arrival of the first baby boomers, the American Geriatrics Society is proposing that elder care be added to the list of medical education's six core areas. (Boston Globe)

In case you missed it ...
Richard A. Cooper, FACP, blasts the vaunted Dartmouth Atlas for its statement that one-third of the nation's health care goes toward wasted expenses. He counters that the analysis is unfair toward urban hospitals, which treat more poor who lack primary care. His critics are just as harsh. But Dr. Cooper is not afraid of taking strong, pro-primary care position. He's taken on concierge medicine (opens as 1-hour video) and The Mayo Clinic. (Kaiser Health News)

Is Medicare fraud getting worse, or are the documentation requirements just becoming more onerous? (Washington Post)

Labels: concierge medicine, geriatrics, H1N1, health care reform, medicare, primary care shortage, QD

QD: News Every Day--SGR cuts stalled

ACP Internist's daily digest of news and events continues with more on SGR cuts, and one physician who reformed health care in Oregon from the inside, as a legislator and later as governor.

SGR cuts
Legislation to permanently fix the annual threat of sustainable growth rate (SGR) cuts to Medicare physician payment formula has stalled. Some legislators balked on voting for it because the $247 billion price tag over 10 years wasn't offset elsewhere. Permanently ending annual SGR cuts were part of a quid pro quo deal between doctor's groups and Senate Majority Leader Harry Reid; eliminate the SGR in exchange for supporting overall health reform. The money would hold reimbursement where it is until Congress can create a better way to reimburse for Medicare.

Since political debate involves a lot of name-calling, one legislator compared the American Medical Association's position to prostitution for its support. The AMA promptly got all dolled up and released 22 "patient access hot spots" nationwide that the organization claims highlights the impact of Medicare cuts. The AMA analyzed state-level data on five access measures and declared hot spots are based on their ranking in the top 15 of at least two of five measures of access:
-- practicing physicians per 1,000 Medicare beneficiaries,
-- Medicare beneficiaries below 150% of the federal poverty level,
-- estimated underserved population living in primary care health professional shortage areas,
-- hospital emergency room visits per 1,000 population, and
-- percentage who hadn't seen a doctor in the past 12 months because of cost.

In case you missed it ...
A physician enacted health care reform in Oregon, first as president of the state's Senate and then as its Governor. The Oregon Health Plan prioritized medical services by value and the number of services covered was determined by how much money the legislature appropriated. It was radical and it worked. Kaiser Health News profiles the physician.

Meanwhile, ACP governors from Nebraska and North Dakota and a member from Green Bay, Wisc. chimed in their support for health care reform.

Labels: health care reform, medicare, QD, reimbursement

QD: News Every Day--One stolen laptop threatens all doctors' personal data

ACP Internist's daily digest of news and events continues with a stolen laptop's threat to physician's personal info, plus the Senate voting and voting and voting on physician payments, and the reasons why the public is so divided on the way they view public health issues.

Almost all U.S. physicians, 800,000 total, have been warned that a stolen laptop had their names, addresses social security numbers and provider identification numbers on it. An employee of the trade group representing Blue Cross insurance plans moved information to a personal laptop that was then stolen, which leave as many as 20% of all doctors vulnerable to identity theft.

H1N1 influenza
The World Health Organization urged prompt antiviral treatments in people with suspected H1N1 flu because it can lead to pneumonia so quickly in young, otherwise healthy people.

Physician payments
A bill that would increase Medicare payments to physicians will require three votes by the Senate--needing 60 votes each time--before the Senate can take a fourth vote. Greatest legislative body in the world, indeed. Oh, and the Congressional Budget Office estimated the $240 billion bill will actually cost $247 billion over 10 years.

Primary care shortage
A blog post explaining the reasons why there is a primary care shortage doesn't offer any new insight so much as it puts all the reasons in one easy-to-read place. These aren't esoteric issues; they play out in real life all across the country, as this profile explains what's happening in Omaha.

In case you missed it ...
Much of the disconnect on health care reform can be explained by political beliefs, researchers reported in the American Journal of Public Health. They tested a news article describing how a lack of sidewalks and presence of fast food were linked to type 2 diabetes. Republicans were less likely to believe junk food led to a diabetes epidemic than Democrats. Researchers told ABC News that the same message has to be framed differently to the two audiences to garner support.

Labels: H1N1, medicare, physician shortage, QD

QD: News Every Day--legislative tricks, treat the underserved and banning sick kids ... from hospitals

ACP Internist's daily digest of internal medicine in the news continues with a look at legislative tricks for health legislation, a medical school that sends students into poor neighborhoods as part of their training, and hospitals that are enacting bans on minor visitors to avoid spreading H1N1.

Health care reform
Senates are seeking a bill that increases Medicare fees by $247 billion in the next decade. Because it will raise the deficit, Senators are trying a two-bill approach, a bit of legislative sleight-of-hand, to let them claim that health care reform won't cost more. At stake is a 21% reduction in Medicare reimbursement that was is scheduled to take effect in January.

In another bit of having one's cake while eating it, too, seniors will pay more for Medicare Advantage when costs increase from an average of $32 to $39 per month next year. Insurers are cutting plans that have no premiums--a federal requirement. Also being scrutinized are the free perks meant to entice traditional Medicare patients into private Medicare Advantage policies. But free to patients means paid for by the government--or sometimes hidden as higher co-pays and additional fees.

Investor's Business Daily points out a looming fight between primary care and specialty medicine. Legislation in the Senate gives primary care doctors a 10% bonus if they work in a Health Professional Shortage Area and 60% of their services are primary care. Half of the funding for the bonus comes from across-the-board cuts for specialists, who are refusing support.

Primary care shortage
Federally qualified clinics could treat more than 20 million patients this year, 2 million more than last year, the AP reports. The increase comes at a time that states are cutting their health care budgets.

To serve this need, Florida International University curriculum will send medical students to poor neighborhoods as part of their training. TIME profiles the program (and quotes ACP president Joseph W. Stubbs, FACP in the process.)

Finally, an emergency room doctor wrote an open letter to President Obama, making the points that:
--people without health care head to ER for treatment,
--medical training is expensive and causes primary care shortages, and
--legislators would discuss the space program without involving astrophysicists, so it's time to get doctors involved in health care reform.

These are all familiar points, but the letter is worth a read.

In case you missed it ...
To avoid spreading H1N1 influenza, hospitals have begun banning visitors less than 18 years old. These are children's' hospitals, too. M.D. Anderson followed suit, as well.

Labels: flu, health care reform, medical education, medicare, primary care shortage, QD

QD: News Every Day

ACP Internist begins a daily digest of primary care in the news, debuting with an update on health care reform's messy reconciliation in Congress, good news about Medicare access (as health care currently stands) and what a national EHR network would look like.

Most recently for health care reform:
Two Democratic proposals to create a government insurance plan to compete with private insurers failed, while members of Congress turn their attention toward paying for abortion and insurance coverage for illegal immigrants. Now, Sen. Max Baucus is looking to revise a key financing provision after an analysis showed its tax burden would fall on seniors. In the wake of voting, amendments, provisions and alternatives are being slung left and right (politically, as well as figuratively.)

Since it's not a news cycle without something on H1N1, hundreds of New York state's health care workers protested a mandate that medical professionals get seasonal and swine-flu vaccines. But state health commissioner Richard F. Daines, FACP, told Gannett News Service, "This isn't the time to pump air into a completely deflated argument about vaccine safety."

Other issues internists should also be aware of include:
The Government Accountability Office found that less than 3% of Medicare beneficiaries had major problems accessing physician services, even while more people used the benefit and the number of services per beneficiary increased. More physicians are accepting Medicare, too. Unfortunately for Medicaid, it's far too easy to fraudulently access addictive drugs--65,000 instances costing of about $65 million in 2006 and 2007.

Finally, doctors' offices and hospitals are slowly, slowly moving toward electronic health records. Another view on the issue is instead of one national database, there'd be a "network of networks."

Labels: electronic medical records, H1N1, health care reform, medicare, QD

A job opening for an internist

It's clear that many of our blog's readers and at least one contributor are concerned about the way Medicare is being run. So maybe it will come as good news that the top slot at the agency is available, as the New York Times reported today. Did you know that there hasn't been a Senate-confirmed administrator at CMS since 2006? Time to brush off the old resume and show them how it ought to be done.

Labels: medicare

Mr. President, please fix Medicare

Dear President Obama,

I am in favor of health care reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.

But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever-expanding diagnosis codes, the excessive documentation rules and the poor payment to "cognitive, diagnosing, talking" physicians make the idea of expansion untenable.

May I give you one small example? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, 22 pages for a change of address. It is now mid-August and I still do not have the "approval" for my address change.

I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes half an hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests and treatments and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules I cannot submit a bill to Medicare because they have not approved my change of office address.

I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I sent the forms and information "overnight, registered" because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my "bank officer" and a utility bill from the office. Mr President, I don't have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients...but I certainly did comply.

I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.

I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for five months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patients or their supplemental Medicare insurance either.

Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.

Sincerely,
An internal medicine (read: primary care) physician

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: medicare

Still doing it the hard way

Medicare is probably not going to pay for virtual colonoscopies, according to a story in today's New York Times. The agency found insufficient evidence to support the alternative technology. Not surprisingly, the endoscopic gastroenterologists cheered, while supporters of the CT scans jeered.

Who's right? Hard to say, since no one knows exactly how many more people would sign up for colonoscopies if they had access to the virtual technology. But based on the preliminary CMS decision, it looks like we won't be finding out anytime soon. The agency is accepting public comment for 30 days before making a final ruling on the subject, which experts expect to be against virtual scans.

An article and video in ACP Internist recently assessed (and offered some solutions to) the challenges of getting patients to submit to colonoscopy.

Labels: medicare, screenings

ACP Internist hosted Grand Rounds on June 16, wrapping up the best of the medical blogosphere. Click here for the complete wrap-up.

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Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

Everything Health
EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Getting Better with Dr. Val
Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

HealthHombre
A roundup of health policy news drawn from a database of hundreds of Web sites.

Interact MD
Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

Kevin, MD
The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

LSUHSC-S Medical Library Evidence Alert
Major guidelines, systematic reviews, meta-analyses and/or major reviews by national and international organizations.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by a doctor.

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Wednesday, March 17, 2010

QD: News Every Day--Health care reform amid rising consumer costs

Monday, March 15, 2010

QD: News Every Day--Health reform vote by the weekend

Wednesday, March 10, 2010

QD: News Every Day--The end is in sight (until later)

Tuesday, March 9, 2010

What if Other Parts of Life Were Like Healthcare?

Monday, March 8, 2010

QD: News Every Day--Health care reform's "endgame"

Wednesday, March 3, 2010

QD: News Every Day--Medicare cuts delayed by 30 days

Tuesday, March 2, 2010

QD: News every day--"Final act" for health care reform?

Monday, March 1, 2010

QD: News Every Day--Medicare holds claims to prevent pay cuts

Tuesday, February 23, 2010

QD: News Every Day--counting down to Thursday's summit

Friday, February 19, 2010

QD: News Every Day--health reform smacks into health insurance

Wednesday, February 17, 2010

Primary Care Physicians Are All One Breath Away From Dropping Medicare

Friday, January 29, 2010

...and I Feel Fine

Monday, January 25, 2010

QD: News Every Day--Health politics becomes health policy

Thursday, January 21, 2010

QD: News Every Day--More internists arriving in Haiti

Wednesday, January 6, 2010

Losing Money on Medicare

Monday, November 16, 2009

QD: News Every Day--not the intended effect

Wednesday, October 21, 2009

QD: News Every Day--SGR cuts stalled

Friday, October 16, 2009

QD: News Every Day--One stolen laptop threatens all doctors' personal data

Thursday, October 15, 2009

QD: News Every Day--legislative tricks, treat the underserved and banning sick kids ... from hospitals

Wednesday, September 30, 2009

QD: News Every Day

Tuesday, August 18, 2009

A job opening for an internist

Friday, August 14, 2009

Mr. President, please fix Medicare

Friday, February 13, 2009

Still doing it the hard way

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