Tweet this: patient consultations?

Can – and should – doctors, hospitals, and medical institutions use Twitter for more than networking with others in the field?

It seems many docs on Twitter are keeping their 140-character updates to interesting links, day-to-day minutia, and thoughts completely unrelated to medicine. Others have said it helps build community among physicians or even help bring in new patients.

But when it comes to Twitter and medicine, the micro-blogging tool may have more uses. How about clinical data and alerts?
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Now some doctors, hospitals, and health agencies are disseminating medical data via tweet, according to a USA Today story that details a report in the journal Telemedicine and e-Health.

The journal lists 10 medical uses for Twitter:

1. Disaster alerting and response
2. Diabetes management (blood glucose tracking)
3. Drug safety alerts from the Food and Drug Administration
4. Biomedical device data capture and reporting
5. Shift-bidding for nurses and other healthcare professionals
6. Diagnostic brainstorming
7. Rare diseases tracking and resource connection
8. Providing smoking cessation assistance
9. Broadcasting infant care tips to new parents
10. Post-discharge patient consultations and follow-up care

Do you think some of these medical uses are possible? Would you be willing to communicate such information to staff and patients via Twitter? Any risks here?

Get a better life

I am sitting in a lecture hall at PriMed NYC. The session: Changing Your Career. The chairs are full.
Physicians are looking for a change from rushed patient visits and victimization.
Wish you were here? Physicians Practice will bring Michael Greenberg, MD, to New York in October to lecture about how he revamped his dermatology career.
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He decided to cut back on patients and pursue a radio career. Now he practices at a much slower pace and has a show on XM radio. He is back to being happy.
What stories do you have about finding joy in medicine?

Medicine in the age of Facebook

Do you have a Facebook page? If so, you may have already encountered the dilemma detailed by physician Sachin H. Jain in a recent New England Journal of Medicine essay. A former patient requested to be in his network of friends, which he accepted, forcing him to grapple with whether he should have blended his personal and his professional lives on the social networking site.

He writes, “The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium.”
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Indeed as social media sites like Facebook and Twitter have gained popularity, users - including physicians – have had to determine how to deal with those barriers. A couple docs I talked to about Twitter for a recent podcast said they make a point not to discuss specific patients or divulge any identifying information.

The benefits of such sites are the enhanced networking, ready communication with those who share similar interests or who want to rally around the same cause.

But as Jain notes, the new medium exposes users’ personal photos, blog, posts from friends to their “walls.” This can be particularly hairy for clinicians. Jain lists a couple examples: “The MICU nurse who blogs about her experiences in dealing with a difficult patient, forgetting that one of the patient's family members — a recent addition to her network of friends — has access to her blog. Or the dermatology resident who is asked on a date by a clinic patient after he learns from her online profile that she is single — information that he would have hesitated to draw out of her in person.”

As with online rating sites, the Internet can expose both the good and the bad – and it all must be managed. Certainly, those who choose to participate in online social media should take a closer look at their profiles and set parameters for what they post and who they accept as friends.

Are you on Facebook? Ever encountered a request from a patient or had some details get you in a bind?

It's Your Turn to Blog

You've been reading our posts here at Practice Notes: The Physicians Practice Blog for the better part of two months now, and some of you have shown an interest in having your own voices heard.

Perhaps it's time, then, that YOU become the blogger.

If you've ever had an interest in blogging, or you already have a blog but would like some additional exposure, or you've never thought much about it but suddenly you're getting the itch, then read on for your opportunity to become an official Practice Notes blogger.

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Here's the deal: we're looking for a handful of opinionated, witty, worldly physicians who have the time and the desire to write one or more blog posts weekly on healthcare-related topics of your interest. Want to comment on reform efforts or other healthcare-business news items? Offer insight about how you handle sticky problems at your own practice, or share an interesting anecdote? Discuss how you balance work with the rest of your life? It's all good.

All political persuasions welcome, too, as are the apolitical. Younger or older, male or female, conservative or liberal or in between: We don't care about your ideology as long as you have a unique point of view on healthcare and life in practice.

If you're a physician (MD or DO) who's able to commit to at least one weekly post of about 300 words, and you're willing to keep your posts clean and relevant, then we're interested in trying you out as a Physicians Practice blogger. For more information and/or to express interest, just send me a note, along with a sample blog post and a way of contacting you at:

bob.keaveney@cmpmedica.com.

I look forward to hearing from you.

Sen. Kennedy, healthcare champion

It seems appropriate today to devote some space to Senator Edward Kennedy, who died last night at age 77 after a battle with brain cancer. Kennedy, D-Mass., had his hand in nearly every major piece of healthcare legislation during his tenure and was a central figure in the debate. Read more

A longtime advocate for universal healthcare, Kennedy dubbed healthcare the “cause of his life,” and “a defining issue for our society,” according to the Washington Post. Last May, Kennedy made a dramatic visit from the hospital to the Senate floor to vote for legislation preventing cuts in Medicare payments to doctors.

The WSJ notes: “Mr. Kennedy died with one of his lifelong goals, universal health care, tantalizingly within reach yet struggling on Capitol Hill. Some advocates have said his absence has hurt the chances for legislation, and hope Mr. Kennedy's passing will give new momentum and emotional force to his favored cause.”

Kaiser Health News put together a nice compilation of major news outlets’ references to Sen. Kennedy and healthcare.

Wyden-Bennett Redux

David Leonhardt of the New York Times, makes the case, for the umpteenth time, for the Wyden-Bennett idea of reforming healthcare by giving everyone, not just those who are currently uninsured, access to affordable health insurance options. This point has been made so often, including by me, that I hesitate to again point it out.

But perhaps more usefully, Leonhardt also explains why the current proposal for reform is so weak that, in practice, it would amount to no change whatsoever for the vast majority of Americans. Those who currently have (or are eligible to access) insurance through their employer, or through a government program such as Medicaid, would be ineligible to join the public option. The public option plan is designed to protect the status quo, not eliminate it.

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Fortunately, it's possble to fundamentally change the way the health insurance industry works -- so that it works more like other kinds of insurance -- without instituting a single-payer plan. You just need to create incentives so that people can choose affordable, individual-market health insurance plans through a regulated, but free, marketplace. This would force insurers to actually compete against each for individual consumers, as opposed to competing for large-group business. Unfortunately, all such proposals have been rejected outright as "too radical" by the defenders of the status quo, including the president and most Republicans.

That's why I oppose the current proposals on the table -- not because I oppose reform but because I'm for it. I'm hoping these lame reform ideas go down in flames because if they do, it's possible (unlikely, but possible) that in the near future the administration will take a different tack and, who knows, maybe propose actual change.

Gardasil Promotion Out of Line?

This week's JAMA includes criticism of education for Gardasil.
According to The Washington Post's coverage, Merck gave $199,000 to the American College Health Association, $300,000 to the American Society for Colposcopy and Cervical Pathology, and $250,000 to the Society of Gynecologic Oncologists for education around the vaccine.
That would be OK except that the education followed Merck's PR spin that the vaccine is really a vaccine against cervical cancer, not genital warts.
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That's not incorrect, really, the warts may lead to cervical cancer. But there is no doubt that focusing the conversation around cancer instead of a sexually transmitted disease makes the vaccination more socially and politically palatable. It's spin. Spin that impacts care. I've heard tell of payers covering girls for Gardasil (they can get cervical cancer) but not boys (even though they can get the warts and give them to girls).

One might hope physicians and medical associations and society could be above the moral and cultural politics. But science is part of culture and capitalism, after all. And arguments that medicine should or ever can be above it all seems niave to me. I think the criticism from JAMA is true but silly. How else do we think the conversation will happen? Where else would the medical societies get enough money to educate physicians about anything at all?

How the public option died

Like a lot of people on both sides of the healthcare reform debate, I've come to the conclusion that the so-called "public option" is dead, politically. The president is in a real bind: He can't satisfy the left without the public option, which has come to be seen as a litmus test for liberal bona fides. He probably can't get anything through the House that lacks a public-option provision. Nancy Pelosi has said as much. But he can't get the public option through the Senate without that body abandoning its 60-votes-to-pass-anything tradition, a move even the Republicans (when they controlled the Senate) contemplated only in the context of judicial appointments, and even then never actually went through with.

In other words, there's real doubt now that the president will get anything through Congress.

You know you're in trouble when the liberals and conservatives have more or less stopped fighting over the substance of your plan and are now fighting over how you lost the argument, but that's pretty much where things stand as the Obamas vacation on Martha's Vineyard. Political scientist Thomas Schaller offers his analysis from the left and Peggy Noonan supplies hers from the right.

If I were advising the president, I'd tell him to forget the dealmakers who want him to accept some half-baked basket of modest, easy regulatory updates that won't affect real change in healthcare but would are instead designed to allow him a way of claiming victory. That would truly be disastrous.

Personally, I'm against the public option but I would nevetheless tell him that he no longer has anything to lose by throwing his full weight behind it. If he wants it, he might as well go for it. Serious reform is probably unattainable this year so he may as well go down fighting for what he really wants. If by some miracle he gets his public option through the Senate, he wins. (He may not like the spoils of victory, but that problem is for another day.) If not, he'll at least be able to say to his left that he tried. Then, after the midterms, he can come back with a proposal that has a decent shot at passing both chambers -- one that shows he's able to not only think outside the box but come right back to an issue even after losing, and be better, sharper, more effective. Shove the Waterloo comment right down Jim DeMint's throat. Now that would be leadership.

Health reforms doctors want

Last week on this blog, Bob Keaveney asked you what your plan was for fixing healthcare. A few of you weighed in, and no doubt many more have your own thoughts on what to do.

In fact, we asked this question in our first-ever Great American Physician Survey. The story and results from the survey will run in our October issue, but for the September issue's The List, we thought we'd give you an idea of what physicians said when asked "What health reforms would you like to see?"
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By far the most frequent response was tort reform, followed by financial incentives for young docs and quality-of-care initiatives.

We also received dozens more suggestions for reforms, from narrowing the pay gap between primary-care docs and specialists to creating a national electronic health record system. Some called for the government to get out of medicine completely; others want a sing-payer system.

There were also a few cheeky responses:
- "Offer rewards for patients who actually follow my advice."
- "Bring humanity back."
- "Put a leash on the insurance companies."

Click here to read our list of 10 health reforms, and please comment below about some of the health reforms you would like to see.

Are Doctors the Villains?

Can I get an amen for Marshall Ackerman, a Washington DC-area surgeon, for his defense of physicians in today's Washington Post?

Lamenting that physicians seem to have been "cast as the villains" in the healthcare debate, greedily ordering up unnecessary tests and other services to line their own pockets, he says:

"How many physicians who are not radiologists own their own MRI machine, CT scanner, PET scanner or other sophisticated diagnostic equipment to which they refer their patients? Why would President Obama blast pediatricians for doing tonsillectomies for profit, when any intelligent person knows that pediatricians do not do surgery? They care for sick children and refer them to ear, nose and throat specialists when surgery is needed. Why does no one seem to be aware that surgeons have functioned under a "global reimbursement" system for more than 35 years? Surgeons are paid a set fee for the care rendered for surgery or fracture care for a fixed period (frequently 90 days) regardless of how often they see a patient or how long the patient remains in the hospital."

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I don't entirely agree with Ackerman's apparent conclusion that the entire reform effort is a sham, or that the system would be better left alone. Although he says we should "start considering the real flaws and strengths of our system and how to improve it," he offers no specifics along these lines so I don't know what he thinks we should do.

But his defense of physicians is dead-on. He notes that he was was paid $1,000 for a total knee and hip replacement is 1971, when he began practice. Today, 38 years later, he is paid $1,600 for the same procedure. That's a loss of $3,659 on an inflation-adjusted basis. Meanwhile, "our staff has doubled over the past 40 years to enable us to handle the growing stream of government and insurer mandates." Maybe THAT'S to blame, just a wee bit, for the high cost of care?

We're heading straight for oblivion if we do nothing about healthcare. So something must be done. But I wonder how many of you -- whatever side of the debate you're on -- are feeling unfairly blamed for healthcare's costs. There was a lot of debate in this space when I took the president to task for his ill-phrased attack on pediatricians. Even beyond that, though, have you noticed examples of physicians being "cast as villains" in this debate -- either in public statements or in your own encounters with friends, patients, whomever. To what extent to people seem to misunderstand the nature of healthcare, as a business?

A "statistically valid" physician rating site?

Another physician rating site has joined the din of online patient forums, but this one is taking a different approach.

The creator, Consumers’ Checkbook, says this site brings a more balanced assessment of each doc. Read more

Physician rating sites abound, and many of them just have a few entries from patients, making it easy for a couple rants or raves to skew the picture. Many docs say these sites are a disservice to patients – and a headache for the physicians – because the sample size isn’t statistically significant and can encourage patients to pick doctors based on factors other than quality of care. (Read more here about the sites – and how to defend yourself against this public forum.)

Consumers’ Checkbook (which AMNews notes here is the same group that in 2006 unsuccessfully sued the government for access to raw Medicare claims data for individual physicians) has completed pilot programs in Denver, Kansas City, and Memphis. The nonprofit consumer organization says their efforts show the approach can be scaled up nationwide.

Consumer Checkbook’s site relies on “scientifically valid surveys” of patients on information such as how well their doctors communicated, made themselves available, and arranged for a courteous staff - information the group says is "medically important."

They take a statistically significant number of surveys per doctor – such as an average of 58 completed patient surveys per doctor for more than 700 physicians in the Kansas City area.

“The rigorous survey design has enabled us confidently to identify real differences among doctors,” President Robert Krughoff said in a release on the group’s Web site. The group plans to do the survey in New York City this fall.

Does this sound like a more balanced approach to physician rating sites? Ever run into problems with rating sites, or do you have a solution to dealing with them?

Eat your veggies reform?

Only 10 percent of early deaths are the result of substandard care. The biggest contributor? Behavior. Things like overeating and smoking kill 40 percent of those who die early. This all according to The New York Times Magazine, in turn citing J. Michael McGinnis from the Institute of Health.
So, one wonders, do we need health reform for physicians and payers? Or do we need better, well, health?
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What if instead of creating a bigger national payer, we invested in making fruits and vegetables affordable? What about government grocery stores in inner cities stocked with more than Coke and jerky?
Of course, stopping early deaths is not really the focus of health reform. That is focused on getting better care, less expensively, to those who are still alive. If patients die early, so much the cheaper.
Still, it's pretty clear that physicians, no matter how they are paid or how well they adhere to guidelines can only do so much for a diabetic patient who won't control their diet or monitor their glucose.
I have been hearing quite a bit from physicians frustrated by the lack of attention being paid to the patients' role in all this.
That, to be sure, is even a harder problem to solve than getting more coverage for the uninsured.

Public option could be dropped?

It’s looking like Obama’s public health insurance option could get dropped from the reform plan.

Amid growing skepticism for a plan to compete with the private sector, Obama administration is saying it would compromise and consider a Senate proposal for a nonprofit health cooperative. Read more

Officials are now saying the public option is “not the essential” element of the reform push. Obama called it just “one aspect” of the reform. Lawmakers, pundits, and citizens will continue to debate plans to fix healthcare over the next few weeks in anticipation of a vote next month.

Liberal Democrats weren’t too happy about the idea that the public option could be dropped, but Obama administration officials said what’s “important is choice and competition,” and the plan will have that. Under the co-op proposal, insurance would be offered through a nonprofit, nongovernmental entity run by its members.

What's Your Plan?

Tis the season for multistep plans for fixing healthcare. Everybody's got one: There's the usual pundits on the right and on the left naturally. It seems we're always just a few steps away from a healthcare utopia, if only we'd kill all the lawyers, eat our veggies, and either get the government completely out of healthcare and let the private market work its magic, or get those greedy, evil insurance companies out and let the benevolent government take care of us. Heck, even I've been touting a plan, although I make no claim to inventing it.

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So here's my question: In three steps or less -- extra credit for doing it in three -- how would you fix healthcare? What are the three things you'd do, if we made you healthcare dictator for a week, to remake the system.

Go.

Comparing old and new drugs

Should drug labels include information on how the meds compare with other treatments for same conditions?

That’s a question a group of Stanford University Medical School researchers are asking, and they are calling on the FDA to require that information -- even if there is no evidence that the new drug is more effective than older treatments. Read more

The idea, they say, is patients and insurers would be less likely to pay for newer treatments without evidence of improved outcomes.

Considering the new treatments are more costly than the older generics, would this comparative data help reduce healthcare costs?

With the FDA approving hundreds of medications a year, it's hard for physicians to know where to get reliable information. And considering the debate on how to reduce costs in the system, this seemed like an interesting item.

What do you think?

Your practice and the recession

Rising operating costs, declining reimbursement, and implementing an EHR are the top three challenges for running a group practice, according to an MGMA member survey out this week.

Not much of a surprise, and in fact, those same three concerns topped the list last year as well. But new in fourth place this year was collecting from self-pay patients and those with high-deductible health plans and health savings accounts. Perhaps a sign of the recession.

MGMA’s survey also asked members specifically about how they recession was affecting their practices. Read more
Here’s how many practices said they are dealing with it:
- 36.6 percent said they have postponed capital expenditures;
- 34.7 percent are seeing a rise in uninsured patients;
- 34.5 percent have implemented a staff hiring freeze;
- 33.9 percent have cut operating budgets;
- 33.3 percent have improved billing and collections processes; and
- 33.1 percent have witnessed a decrease in revenue.

In our recent technology survey (coming up in our September issue), we asked how the recession was affecting tech purchases, and nearly 41 percent of respondents said they were putting off purchases.

Earlier this year, we offered a guide on how to survive the downturn, including controlling overhead, collecting co-pays while patients are in the office, and offering patient financing.

How is the recession affecting your practice? Are you doing more than belt-tightening?

Make your own pay for performance program?

This morning I conducted a webinar about pay for performance programs: plans under which providers who meet certain quality metrics get paid more.
Most of these programs focus on primary care practices. But some specialists have been able to play, too.
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Some specialists get involved by picking low-hanging fruit from the ever-expanding list of PQRI metrics from Medicare. PQRI isn't perfect, but it is evolving.
Others are going direct to payers, pointing out how e-prescribing or other easily measured steps are improving performance, and asking for better pay.
We'd love to hear about your experience and concerns about pay for performance.

And now a few words about death panels

An interesting point in today's Washington Post about why the two sides of the health reform debate can't seem to do anything but shout at one another. One side, on the left, is answering charges about "death panels" and Candadian-style healthcare by referencing the bills' stated goals. As written, there is no death panel. There is no single-payer system expressly contemplated in any of the bills. But that response is unsatisfactory to those who are arguing about what they see as the inevitable consequences, intended or not, of the current health reform plans.

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Or as Danielle Allen, a Princeton academic puts it:

"One can't answer them by saying: 'These policies won't ration; there will be no death panels.' If these reforms do either of these things, they will do so as a matter of unintended consequences. The appropriate answer, therefore, is to explain the institutional checks that will prevent the emergence of such unintended consequences."

Right. There actually are some institutional checks, but the administration doesn't want to talk about them for fear of angering a left that's already suspicious it's being "punked." The biggest check against a government takeover is the limit on who's eligible for the proposed "public option." The public option is unliley to be an option for anyone who already already has (or is elgible for) Medicare, Medicaid, or insurance through his job (assuming this insurance meets new federal standards). Only those who are currently uninsured or are buying their own coverage on the individual market -- AND who have no access to an existing government program or to coverage at work -- is likely to be eligible. If private insurers wanted to go after that market, there's been nothing to stop them -- and they haven't -- so it's hard to see how the government offering coverage to a group of people unattractive to business will bankrupt private insurance. Indeed, the new individual mandate to buy insurance will do more good for the insurance industry than the public option would do harm.

This does not mean the public option is a good idea. Only that to the extent it's a bad idea, it's not because it will necessarily lead to Canadian healthcare and/or "government rationing." Most serious advocates of single-payer don't believe that.

No, the public option is a bad idea because it will be very expensive and won't fix what's really wrong with healthcare: A lack of transparency in pricing and coverage; costs that are rising at an unsustainable rate; a severe gap in the supply of service providers to meet the demand of those who want and need services; and a canyon-wide difference between what people expect to get from their healthcare, and how much they expect to pay for it. Effective reform needs to address those issues, and the public option doesn't.

I wish the "death panel" debate could, similarly, be put in a more reasoned framework but the whole issue seems to be the work of Sarah Palin and her Facebook post. It is true that most healthcare dollars are spent on the elderly. It's also true that one of the stated goals of healthcare reform is to "bend the cost curve." And it's further true that at least one of the bills does envision paying doctors to counsel Medicare patients about end-of-life issues. I suppose if someone puts that together they might imagine death panels in some science fictiony way. But honestly, people. Physician counseling hardly represents death panels. It merely would reimburse physicians for having discussions with people that make sense to have.

Town Hall on Healthcare

Sen. Claire McCaskill, a Missouri Democrat, is holding a townhall meeting on healthcare today, and CNN is covering it live. You can watch online. Just a couple of thoughts on what I'm seeing:

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1. As important an issue as healthcare is, is there any doubt that CNN would not be covering a townhall meeting if it wasn't hoping that a riot would break out or that someone would burn the poor senator in effigy? Such is the state of our media. Unfortunately for cable ratings, everyone (at this writing) is behaving.

2. Here's a quote from McCaskill, a moderate Democrat in a red-leaning state: "You all understand what happened with Medicare [Part] D? I wish the anger that’s being ginned up right now would have been there for Medicare D. They gave $6 billion a year to the pharmaceutical companies. It wasn’t means-tested. You all are paying for Warren Buffett’s healthcare. It doesn’t make any sense to me. … And it wasn’t paid for. They just put it on the credit card. They just put it on the credit card."

She's referring to Medicare's prescription drug program. To their credit, Dems tried to empower the government to negotiate with pharmaceutical companies on drug prices but were voted down by Republicans, whose fiscal conservatism led them to insist that taxpayers pay any price for drugs that the pharma companies set. Still, McCaskill isn't suggesting doing away with Medicare Part D. In fact, earlier in the session, in a reference to the "doughnut hole" -- the hole in coverage that comes between a basic amount of coverage and before a patient spends a great deal on drugs -- she said: "We're gonna fill the doughnout hole." Meaning, government will start paying for ALL of seniors' prescriptions. So we'll be paying even more.

And the White House apparently brokered a deal with the pharmaceutical industry to block any Congressional effort to allow for drug price-negotiation, though it is now giving a runaround as to whether it actually meant to do so, and whether it will stick to its agreement. (My guess: In the end there will be drug price negotiation on any bill that passes.) Anyway, the drug benefit still won't be means-tested.

Gift bans going too far?

Will a free lunch, a speaking engagement, or a trip to a conference influence what you prescribe your patients? That’s the idea behind several states enacting laws banning gifts to doctors from drug- and device-makers (and Congress considering a push for more transparency in these relationships).

But now, a group of doctors say these moves are going too far. Read more

According to an American Medical News story, a recently-formed group called the Association of Clinical Researchers and Educators say the rules impede collaboration and hinder research and consulting. And others have said the restrictions assume docs are easily influenced and need to be regulated.

Does accepting these gifts create a conflict of interest or undermine your credibility? Do the bans affect research and collaboration?

Should there be a limit, and if so, what?

Compensation survey: We want to hear from you

We've got some great data from our fourth annual Physician Compensation survey, and I am looking for some doctors willing to weigh in on some of the issues raised around income and practice viability. (Here's last year's coverage.)

Have you taken steps - and succeeded - to boost your revenue?
Are you planning a major change in how you practice?
Have you managed to negotiate for a higher salary?
Got something to say about physician compensation?

If you're up for being interviewed for a story, please send me an e-mail!

Concierge care for all?

Are you considering concierge medicine?

In our recent Great American Physician survey (which will be fully revealed in our October journal issue), we found that 6.7 percent of respondents were considering or already practicing under such a model, where a small number of patients pay an annual fee for extensive access to the docs.

Another 34 percent said it might be worth trying if it makes sense economically, while 42 percent said such a model isn’t right for them, but they don’t mind if others do it.

But a full 17 percent said it was bad for the healthcare system or unethical.

Why? Read more

Perhaps because of the high retainer fee patients pay for such service? The annual fee is often $1,500 or even much more, which puts its out of reach for many patients.

In a blog post this week at Better Health, primary-care physician Alan Dappen explains how his practice is an alternative to the high-cost concierge care. Instead, he says, most of his patients pay closer to $300 a year for the same kind of access and care.

Here’s how:

“Practices like ours expect to be busy, have to take care of many people of all ages and socioeconomic status, maintain active panels of patients approaching 2000, don’t expect to make tons of money while trying our hardest to give you the best service at the best price we can. We love primary care, want the best for our patients, and this is why we do it.”

Dappen says it’s not hard to get affordable, quality primary care once you shed the layers “interfering” with the relationship between doctor and patient.

His model is rare. But is it possible? Can concierge care be available to everyone?

It's RAC time

Medicare’s Recovery Audit Contractor (RAC) program has started with Connolly Healthcare, the RAC for a large part of the southern U.S., posting the first set of issues eligible for review.

Although the issues are approved for providers in South Carolina, get ready, providers. Experts say it’s likely RACs in other jurisdictions will pick up on them and consider them for review. Read more

There are few things you need to know about RACs, CMS' audit police, as explained in a recent PEARLS column:

1. If you bill Medicare, you can be audited.

2. RACs are more likely to look at high-dollar services and aberrant billing patterns.

3. Don’t rush a response to a RAC request. You’ve got 45 days to review your coding and documentation.

4. You should appeal a RAC decision if you feel it was incorrect.

For five more things you should know about RACs, finish reading the PEARLS column and check out Pamela Moore's recent column on the topic.

Tips for Tweeters

For our podcast this month, I interviewed two doctors on how and why they use Twitter.

They had some interesting things to say about what to tweet - and what not to tweet - and how they find time to build a network through this social media platform.

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Have a listen and please weigh in. Do you tweet? If so, what do you tweet about? What are those you follow tweeting about? Are you using it to share valuable information, to build relationships among docs, or even market your practice?

United acquires HealthNet in Northeast

Providers in the Northeast are starting to feel uneasy. In late July, UnitedHealthCare announcedsubsidiaries that it has agreed to acquire HealthNet's in Conn., NY, and NJ. It plans to renew the members in those states as United members when their memberships run out.
Why does it matter to physicians?
Well, if you participate with United and HealthNet in the Northeast, you'll likely begin to see patients switching to United. And you'll get paid under their rates. United will just take over the provider contracts.
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That might not matter to you if HealthNet and United pay you about the same. In fact, accoridng to Physicians Practice data, United might be a bit easier to work with than HealthNet.
But the shift will matter a lot to your practice if United pays you significantly less.
Plus, there is an issue of monopoly-like behavior when it comes time to renegotiate your contract with United. If you had 20 percent of patients with United and 20 percent with HealthNet, once this deal closes, you'll have 40 percent of your patients with one payer. It's hard not to renew that contract no matter what the terms.

Trouble in Massachusetts

The Massachusetts 2006 health reform is a model for national reformers: Implement an individual obligation to get insurance, expand the social safety net for low-income people, develop a mechanism for making it easier for people to compare plans and purchase insurance on the individual market, and pay for it all with new taxes.

It has succeeded in its basic objective of lowering to near zero its rate of uninsured citizens. It's struggling on every other measure. And now one of Boston's major providers of care to the poor is suing the state, arguing it is owed $127 million.

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One problem: There are too few physicians in the state to provide services effectively to all of the newly insured, even though Massachusetts is one the most physician-dense states in the union and it's pre-reform uninsured rate was among the nation's lowest.

Second problem: A plurality of the state's formerly uninsured say they've been more harmed by the mandates and expenses of the new system than helped by its services and subsidies. Something's amiss when the main beneficiaries of a new service say they were better before.

Third problem: The state is now having trouble paying for its largesse and has been looking for cuts. Hence the lawsuit by Boston Medical Center, a major provider of services to Medicaid patients.

Massachusetts got most everyone covered. Now it is finding that access to insurance is not the same thing as access to healthcare.

Does preventive care really save money?

Obama has made a lot about preventive care in his push for healthcare reform. Physical exams and screenings will help prevent disease and save money in the long run. Right?

Well, it turns out the Congressional Budget Office hasn’t found any savings in any of the health proposals that can be attributed to increased preventive efforts.
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In an interview with NPR this week, former CBO health analyst Joe Antos, now at the American Enterprise Institute, says preventive services, in fact, often cost more. For cancer screenings, for example, millions of people are screened, and both true positives and false positives are picked up. Then, all of those patients have to be followed up, which costs even more, he said. So the screening doesn’t work unless you narrow it down to the right patient population.

Perhaps. But what about other less costly preventive services? Other health advocates say strategies such as those aimed at reducing expensive health problems such as obesity, diabetes and high blood pressure, are proven to work, but need to be more broadly deployed.

All of this seems like a philosophical debate when you consider most primary-care doctors are saddled with increasing patient loads and declining reimbursements. Is preventive care even possible?

In our recent article exploring preventive medicine, we found it may still be possible with some serious organization, using the right and often forgotten preventive care codes, and streamlining patient communication.

What do you think? Is preventive care possible? Will it wind up saving money, or is it more a matter of the right way to approach healthcare?