I saw an item on hospitalist board certifications that got me thinking about board certification in general. According to a recent study comparing the three major certifying organizations' requirements by medical specialty, all board certifications for hospitalists are equal.
I understand there has been some debate over hospitalist board certification. This also really made me wonder what board certification really means. Does it matter? Is it a true measurement of clinical qualifications?
Read more
It’s a topic we will be exploring in the journal next year. It’s also something the nonprofit advocacy group Consumer Checkbook has explored. As I understand it, there are two dozen medical specialty boards, and each one develops their own exams and policies for recertification.
Some 90 percent of American physicians are board certified. But does it matter for patient outcomes, and is it a true indication of knowledge and qualifications? I am interested to hear if physicians believe the certification is worth the time and money; And why get certified, or why not?
Wednesday, September 30, 2009
Tuesday, September 29, 2009
Are you happy being a doctor?
Are you happy with your job?
It’s one of the questions we posed to physicians in a recent survey in which we tried to get a handle on just who is the modern American physician. It turns out, for the most part, you are pretty content — even considering the headaches of long hours and declining reimbursements, for starters.
Read more
We found that more than 80 percent of respondents agree or strongly agree with the statement that they like being a physician. Nearly half of you reported being “happier and better adjusted than most people.” When asked to rate happiness on a scale of 1 to 10, 78 percent of you ranked yourselves at seven or above.
Similarly, a survey by the think tank Center for Studying Health System Change, found that 39 percent of docs were “very satisfied” with their careers and 43 percent said “somewhat satisfied.” Hey that’s not so bad given the current state of affairs.
To be clear, frustrations abound. I am working on a story for the November issue based on our annual Physician Compensation Survey. Perhaps not surprisingly, many physicians are struggling with flat or declining practice income and looking for ways to bring in more money. (More on that soon.)
But it seems that the overall satisfaction level often gets overshadowed as the country slogs through the healthcare reform debate, and physicians scramble to keep up with new regulations, all while trying to keep the practice humming. It can be easy to forget why you got into medicine in the first place. Yet, when asked to reflect, you all are a fairly happy bunch.
A wealth of fascinating information emerged from our Great American Physician survey. Read the full story on the survey, and check out October’s The List column where we compiled 10 things doctors want to tell their families. (One example of a statement to a spouse: “I will be late today. I have to finish some paperwork.”)
It’s one of the questions we posed to physicians in a recent survey in which we tried to get a handle on just who is the modern American physician. It turns out, for the most part, you are pretty content — even considering the headaches of long hours and declining reimbursements, for starters.
Read more
We found that more than 80 percent of respondents agree or strongly agree with the statement that they like being a physician. Nearly half of you reported being “happier and better adjusted than most people.” When asked to rate happiness on a scale of 1 to 10, 78 percent of you ranked yourselves at seven or above.
Similarly, a survey by the think tank Center for Studying Health System Change, found that 39 percent of docs were “very satisfied” with their careers and 43 percent said “somewhat satisfied.” Hey that’s not so bad given the current state of affairs.
To be clear, frustrations abound. I am working on a story for the November issue based on our annual Physician Compensation Survey. Perhaps not surprisingly, many physicians are struggling with flat or declining practice income and looking for ways to bring in more money. (More on that soon.)
But it seems that the overall satisfaction level often gets overshadowed as the country slogs through the healthcare reform debate, and physicians scramble to keep up with new regulations, all while trying to keep the practice humming. It can be easy to forget why you got into medicine in the first place. Yet, when asked to reflect, you all are a fairly happy bunch.
A wealth of fascinating information emerged from our Great American Physician survey. Read the full story on the survey, and check out October’s The List column where we compiled 10 things doctors want to tell their families. (One example of a statement to a spouse: “I will be late today. I have to finish some paperwork.”)
Monday, September 28, 2009
Some state lawmakers want ban on insurance mandate
Another interesting item in the NY Times: Several state lawmakers are pushing amendments to the state constitutions that would ban a mandatory health insurance clause.
Some say the moves are symbolic and wouldn’t hold up in court, but others believe the bans could create legal clashes that would delay federal healthcare changes.
The idea has been introduced in at least 10 states (some before the health reform debate began in Washington) and four others are planning similar measures. In Arizona, lawmakers have already will place the amendment on its ballot in 2010.
Some say the moves are symbolic and wouldn’t hold up in court, but others believe the bans could create legal clashes that would delay federal healthcare changes.
The idea has been introduced in at least 10 states (some before the health reform debate began in Washington) and four others are planning similar measures. In Arizona, lawmakers have already will place the amendment on its ballot in 2010.
EHR subsidies from hospitals
Like the federal government, large hospitals are beginning to offer incentives for physicians who adopt EHRs. In New York, the North Shore-Long Island Jewish Health System is planning to offer its 7,000 affiliated docs subsidies of up to $40,000 each over five years, the NY Times reports. That’s on top of the up to $44,000 available from the stimulus bill.
This hospital’s size is unique (13 hospitals and a $400 million investment), but many hospitals are beginning to help affiliated docs adopt EHRs. And it appears hospitals are motivated by more than improving healthcare delivery.
Read more
Of course, the investment aims to improve coordination of care, reduce unnecessary tests, and cut down on medical mistakes. But the effort is also a way for hospitals to “tighten the bonds,” the story says, between docs and hospital groups. Hospitals are competing for affiliated physicians, so this could solidify those relationships and potentially influence consolidation in the local markets.
North Shore may also benefit from the data from the EHRs, creating a database of evidence for treatments and procedures. The subsidy is up to 85 percent for physicians who agree to share data on patient measure that include glucose levels for people with diabetes and procedures and meds for heart patients. (The subsidy is 50 percent of the total cost for docs who install EHRs that link the office, hospitals, and labs.) Analysts say this move will be closely watched and hospital groups across the country will be rethinking their own plans.
This hospital’s size is unique (13 hospitals and a $400 million investment), but many hospitals are beginning to help affiliated docs adopt EHRs. And it appears hospitals are motivated by more than improving healthcare delivery.
Read more
Of course, the investment aims to improve coordination of care, reduce unnecessary tests, and cut down on medical mistakes. But the effort is also a way for hospitals to “tighten the bonds,” the story says, between docs and hospital groups. Hospitals are competing for affiliated physicians, so this could solidify those relationships and potentially influence consolidation in the local markets.
North Shore may also benefit from the data from the EHRs, creating a database of evidence for treatments and procedures. The subsidy is up to 85 percent for physicians who agree to share data on patient measure that include glucose levels for people with diabetes and procedures and meds for heart patients. (The subsidy is 50 percent of the total cost for docs who install EHRs that link the office, hospitals, and labs.) Analysts say this move will be closely watched and hospital groups across the country will be rethinking their own plans.
Friday, September 25, 2009
Melissa Young, MD: The Search for the Perfect EMR
OK, I know and you know there’s no such thing as the perfect EMR. But then again, there are EMRs that just don’t make getting an EMR worth the expense, effort, and loss of hair and sleep. On the other hand, I truly believe that finding an EMR that works for you and your practice can make you more efficient and can help you provide better care.
At least, I sure hope so. Just the thought of not having to thumb through 20 pages of paper to find the original sheet that had the patient’s past medical history, and of not having to rewrite their 20 meds down on a progress note, and of not having to hand write prescriptions for said meds makes me want to do the EMR happy dance.
Read more
But although it was easy enough to decide that I wanted an EMR, it was much harder to choose the “right” one. My old practice had tried two, and had hated two. Part of the problem was the implementation. The other part was the EMRs themselves. As far as implementation, the physicians and nurse practitioners were asked to start entering progress notes in the EMRs without the benefit of being able to use the prescription modules or the filing modules.
As I see it, the attractive parts of having an EMR are the ability to print or fax prescriptions or to e-prescribe, and to file labs and other data into the system. Let’s face it, when you’ve written your notes the same way for five, 10, or 15 years, learning to enter data in a computer is a challenge. So to do that, and then still have to write prescriptions, fill out lab slips and billing slips, and hunt around the paper chart for information, really made this more of a chore than an advancement.
As far as the EMRs themselves, they just weren’t built for subspecialists. The history data points, the templates, were really geared towards primary-care physicians, or other specialties where patients come in with a particular somatic complaint, specifically pain. Location, radiation, onset, precipitating and alleviating factors just don’t work when the patient is coming in for a consultation for a Graves’ disease or an adrenal incidentaloma. And if the history and physical exam questions (and their possible answers) have to be the same for every provider in the practice…well, you can imagine how long and animated the discussions got.
Once again, I did my research. I looked at reviews of the various EMRs. On the AAFP Web site, on Physicians Practice. I looked at which ones were most appropriate for a small practice. Which ones were highly rated by other docs for ease of use and which came from companies highly rated for customer service. Which ones were in a price range I could afford. I narrowed it down to four or five. Then I scheduled demos for each one. Most of the demos were done online, one was done in person. I had them walk me through a full patient visit, starting from scheduling the appointment, entering a history and physical, and billing.
I thought my head would explode. I downloaded an inexpensive EMR that seemed pretty easy to use, but it didn’t have a practice management system. After all the demos, I narrowed my choices down to two. I scheduled site visits for each one. I asked to go to endocrine practices because I wanted to see how it worked in a situation similar to mine.
That was a bit of a problem. There are so few endocrinologists, therefore, there are so few who use EMRs, so finding a practice within a reasonable distance who use the exact EMRs I want to look at was difficult. I had to drive about an hour each way to visit the practices.
What happened at each place deserves a post all its own.
Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.
At least, I sure hope so. Just the thought of not having to thumb through 20 pages of paper to find the original sheet that had the patient’s past medical history, and of not having to rewrite their 20 meds down on a progress note, and of not having to hand write prescriptions for said meds makes me want to do the EMR happy dance.
Read more
But although it was easy enough to decide that I wanted an EMR, it was much harder to choose the “right” one. My old practice had tried two, and had hated two. Part of the problem was the implementation. The other part was the EMRs themselves. As far as implementation, the physicians and nurse practitioners were asked to start entering progress notes in the EMRs without the benefit of being able to use the prescription modules or the filing modules.
As I see it, the attractive parts of having an EMR are the ability to print or fax prescriptions or to e-prescribe, and to file labs and other data into the system. Let’s face it, when you’ve written your notes the same way for five, 10, or 15 years, learning to enter data in a computer is a challenge. So to do that, and then still have to write prescriptions, fill out lab slips and billing slips, and hunt around the paper chart for information, really made this more of a chore than an advancement.
As far as the EMRs themselves, they just weren’t built for subspecialists. The history data points, the templates, were really geared towards primary-care physicians, or other specialties where patients come in with a particular somatic complaint, specifically pain. Location, radiation, onset, precipitating and alleviating factors just don’t work when the patient is coming in for a consultation for a Graves’ disease or an adrenal incidentaloma. And if the history and physical exam questions (and their possible answers) have to be the same for every provider in the practice…well, you can imagine how long and animated the discussions got.
Once again, I did my research. I looked at reviews of the various EMRs. On the AAFP Web site, on Physicians Practice. I looked at which ones were most appropriate for a small practice. Which ones were highly rated by other docs for ease of use and which came from companies highly rated for customer service. Which ones were in a price range I could afford. I narrowed it down to four or five. Then I scheduled demos for each one. Most of the demos were done online, one was done in person. I had them walk me through a full patient visit, starting from scheduling the appointment, entering a history and physical, and billing.
I thought my head would explode. I downloaded an inexpensive EMR that seemed pretty easy to use, but it didn’t have a practice management system. After all the demos, I narrowed my choices down to two. I scheduled site visits for each one. I asked to go to endocrine practices because I wanted to see how it worked in a situation similar to mine.
That was a bit of a problem. There are so few endocrinologists, therefore, there are so few who use EMRs, so finding a practice within a reasonable distance who use the exact EMRs I want to look at was difficult. I had to drive about an hour each way to visit the practices.
What happened at each place deserves a post all its own.
Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.
Thursday, September 24, 2009
New Pay System For Docs Likely
Two things have caught my attention this week on the health reform front:
1. Sen. Max Baucus says he plans to increase the subsidies available to lower-income individuals who would be hit hardest by his plan. As it stands, a person making as little as $32,500 a year (300% of the federal poverty line) would have to spend about $4,224 of personal income, pretax, out of pocket, before being eligible for any subsidy. And even then the subsidies are paltry. I haven't seen the details of what Baucus now proposes, and the New York Times is pulling the old "not immediately clear" business, so we'll see what he comes up with. But he told the paper "that he wanted to reduce the maximum amount that moderate-income Americans would have to pay in premiums ... to less than 12 percent of income." Not much; still incredibly unfair to lower-income people to force them to buy something they can't afford. So let's not get too excited. But at least it's a start.
Perhaps more interestingly ...
Read more
2. An amendement from Sen. Maria Cantwell would change how physicians are paid -- dramatically and in unspecified ways. As Sara Michael noted in her post yesterday, the Cantwell amendment "would incorporate a quality measure" that would penalize doctors for "low-quality" care. But what does that mean? Beats me. There's no definition for it in the amendment; Cantwell would assign the HHS secretary to define it. By 2014, the secretary would "provide, to the extent feasible, information to physicians about the value of the care they provide," according to the amendement. If I'm reading this right, all physicians who take Medicare would get a letter in the mail in 2014 telling you whether you're any good or not. A report card, basically. Before then, expect FURIOUS lobbying over the details.
I agree in principle that the volume-over-quality method of paying physicians is nonsensical. I think most physicians would rather work in a system where they are paid for the quality of care they provide -- the better the care, the higher the pay. Ken Terry has some interesting news to report on the subject of phyician-payment, too.
But the devil has always been in the details. Who decides what "quality" is? How does that translate into higher pay? Are physicians providing better quality, by deifnition, if their patients are healthier? Of course we can all see the flaws in that line of thinking. There is also evidence-based medicine and most pay-for-performance programs pay doctors for demonstrating that they have followed evidence-based medicine protocols. But that raises questions, too, about how physicians would make that demonstration and which protocols to use. The results of Medicare's new P4P program were decidedly mixed, and that was only a small pilot.
So here is my question, folks: Do you agree that physician payment models need reform, and if so, how would you do it? Are specialists paid too much? Primary care too little? How do you crack the volume vs. quality problem -- or do you disagree that it is a problem. How should quality be defined, and by whom?
1. Sen. Max Baucus says he plans to increase the subsidies available to lower-income individuals who would be hit hardest by his plan. As it stands, a person making as little as $32,500 a year (300% of the federal poverty line) would have to spend about $4,224 of personal income, pretax, out of pocket, before being eligible for any subsidy. And even then the subsidies are paltry. I haven't seen the details of what Baucus now proposes, and the New York Times is pulling the old "not immediately clear" business, so we'll see what he comes up with. But he told the paper "that he wanted to reduce the maximum amount that moderate-income Americans would have to pay in premiums ... to less than 12 percent of income." Not much; still incredibly unfair to lower-income people to force them to buy something they can't afford. So let's not get too excited. But at least it's a start.
Perhaps more interestingly ...
Read more
2. An amendement from Sen. Maria Cantwell would change how physicians are paid -- dramatically and in unspecified ways. As Sara Michael noted in her post yesterday, the Cantwell amendment "would incorporate a quality measure" that would penalize doctors for "low-quality" care. But what does that mean? Beats me. There's no definition for it in the amendment; Cantwell would assign the HHS secretary to define it. By 2014, the secretary would "provide, to the extent feasible, information to physicians about the value of the care they provide," according to the amendement. If I'm reading this right, all physicians who take Medicare would get a letter in the mail in 2014 telling you whether you're any good or not. A report card, basically. Before then, expect FURIOUS lobbying over the details.
I agree in principle that the volume-over-quality method of paying physicians is nonsensical. I think most physicians would rather work in a system where they are paid for the quality of care they provide -- the better the care, the higher the pay. Ken Terry has some interesting news to report on the subject of phyician-payment, too.
But the devil has always been in the details. Who decides what "quality" is? How does that translate into higher pay? Are physicians providing better quality, by deifnition, if their patients are healthier? Of course we can all see the flaws in that line of thinking. There is also evidence-based medicine and most pay-for-performance programs pay doctors for demonstrating that they have followed evidence-based medicine protocols. But that raises questions, too, about how physicians would make that demonstration and which protocols to use. The results of Medicare's new P4P program were decidedly mixed, and that was only a small pilot.
So here is my question, folks: Do you agree that physician payment models need reform, and if so, how would you do it? Are specialists paid too much? Primary care too little? How do you crack the volume vs. quality problem -- or do you disagree that it is a problem. How should quality be defined, and by whom?
Wednesday, September 23, 2009
Baucus addresses physician payment changes
Even before lawmakers started the debate, Senate Finance Committee Chairman Max Baucus already revised his healthcare bill, incorporating dozens of the 564 amendments proposed.
Baucus also addressed physician payments. In his opening remarks yesterday he said: “On one point, I want to acknowledge up front that we did not do as much to correct the payment of doctors under the incredibly misnamed "Sustainable Growth Rate." The SGR needs to be fixed permanently. I look forward to going further as the bill progresses through the process.”
His changes to the bill don’t include a long-term solution to the SGR, but it does at least appear to be among the items on the table for discussion.
UPDATE: The bill now also includes a provision that would incorporate a quality metric into determining how physicians are paid for treating Medicare patients, according to MedPage Today. By 2015, low-value care would be penalized, and by 2017, all docs would be paid based on quality-of-care factors. HHS would still have to define those quality factors.
Baucus also addressed physician payments. In his opening remarks yesterday he said: “On one point, I want to acknowledge up front that we did not do as much to correct the payment of doctors under the incredibly misnamed "Sustainable Growth Rate." The SGR needs to be fixed permanently. I look forward to going further as the bill progresses through the process.”
His changes to the bill don’t include a long-term solution to the SGR, but it does at least appear to be among the items on the table for discussion.
UPDATE: The bill now also includes a provision that would incorporate a quality metric into determining how physicians are paid for treating Medicare patients, according to MedPage Today. By 2015, low-value care would be penalized, and by 2017, all docs would be paid based on quality-of-care factors. HHS would still have to define those quality factors.
Tuesday, September 22, 2009
Expanded data breach rules to take effect
Expanded health data breach notification rules are set to take effect this week.
The rules, which were required under the stimulus bill, apply to HIPAA-covered entities and their business associates, requiring them to provide notification in the case of breaches of unsecured protected health information.
Read more
Under the rule (here’s HHS’ interim final rule), health care providers must now alert patients to data security breaches, and imposes penalties for such breaches. If the breach involves more than 500 individuals, the provider must report it to HHS and the media.
The rule is also broader than previous regulations because it also applies to business associates of the providers. (If it involves encrypted data, the providers don’t need to notify customers.)
Business associates, which includes any entity that provides services, such as consultants, third-party administrators or managers, claims processors, attorneys, accountants and software providers, must ensure that any electronic health information that is created, maintained, and transmitted for the covered entity are protected, according to an American Medical News story. They must report any breaches to the provider.
Your business associates need written policies and safeguards to protect the information. We provide a sample form for a business associates agreement, but we are working to update it to reflect the changes and welcome any input.
The rules, which were required under the stimulus bill, apply to HIPAA-covered entities and their business associates, requiring them to provide notification in the case of breaches of unsecured protected health information.
Read more
Under the rule (here’s HHS’ interim final rule), health care providers must now alert patients to data security breaches, and imposes penalties for such breaches. If the breach involves more than 500 individuals, the provider must report it to HHS and the media.
The rule is also broader than previous regulations because it also applies to business associates of the providers. (If it involves encrypted data, the providers don’t need to notify customers.)
Business associates, which includes any entity that provides services, such as consultants, third-party administrators or managers, claims processors, attorneys, accountants and software providers, must ensure that any electronic health information that is created, maintained, and transmitted for the covered entity are protected, according to an American Medical News story. They must report any breaches to the provider.
Your business associates need written policies and safeguards to protect the information. We provide a sample form for a business associates agreement, but we are working to update it to reflect the changes and welcome any input.
Monday, September 21, 2009
Melissa Young, MD: A medical waste permit?
So as I said in my previous post, I probably know more about running a practice than most physicians I know. I have read books about starting a new business and starting a new practice. I read about personnel management, financial risk management and marketing. I learned about captives, the accrual method and HCPCS. I talked to physician friends. I read blogs. I asked questions on physician bulletin boards. I scoured the Web.
And yet, I still found surprises along the way. One week, I started asking fellow MDs who they used for medical waste pick-up. A couple of docs gave me the names of the companies they use. Two had me ask their office managers. But it was the administrative assistant of one of them who asked me if I had applied for my waste permit.
My what?!?!
Read more
This wasn’t in the books! This wasn’t in the four dozen articles I had read. And no one else had mentioned this before. I figured she must be wrong. If I needed this permit, surely someone else would have mentioned this along the way. So I asked my doctor friends. None of them had any idea what I was talking about. They were going to “check with the office.” Turns out, yes, I do need a medical waste generator permit. And yes, I do need to pay the government for the privilege of generating said waste.
Just like I have to pay for the privilege to perform a waived test. I had always figured that when you say something is a CLIA waived test that you didn’t need to apply for anything. But, nooooo…You need to apply for a waiver. And they don’t even tell you ahead of time how much you have to pay. You need to tell them what test you plan to do and how often, then they tell you what the fee is. This is another tidbit of information I discovered on my own.
What other little surprises await? I guess we’ll find out.
Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.
And yet, I still found surprises along the way. One week, I started asking fellow MDs who they used for medical waste pick-up. A couple of docs gave me the names of the companies they use. Two had me ask their office managers. But it was the administrative assistant of one of them who asked me if I had applied for my waste permit.
My what?!?!
Read more
This wasn’t in the books! This wasn’t in the four dozen articles I had read. And no one else had mentioned this before. I figured she must be wrong. If I needed this permit, surely someone else would have mentioned this along the way. So I asked my doctor friends. None of them had any idea what I was talking about. They were going to “check with the office.” Turns out, yes, I do need a medical waste generator permit. And yes, I do need to pay the government for the privilege of generating said waste.
Just like I have to pay for the privilege to perform a waived test. I had always figured that when you say something is a CLIA waived test that you didn’t need to apply for anything. But, nooooo…You need to apply for a waiver. And they don’t even tell you ahead of time how much you have to pay. You need to tell them what test you plan to do and how often, then they tell you what the fee is. This is another tidbit of information I discovered on my own.
What other little surprises await? I guess we’ll find out.
Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.
Friday, September 18, 2009
Is There a Doctor in the House?
Last week I was at the Pri-Med conference in Princeton, NJ, the day after the President pitched his healthcare proposal to Congress. To Obama’s credit, he didn’t let a thousand pages of internecine squabbling deter him, and he gave a fairly clear-headed vision of his goal. But selling a vastly complicated healthcare package to a jittery lay public amid vicious political opposition is a Sisyphean endeavor. Just ask Hillary.
Over coffee I asked one of the attendees — a primary care physician in a 3-doctor practice outside of Trenton — what he thought of Obama’s speech. He said it was a nice speech, eloquent as always. “But what bothered me was that the President spoke at length about patients and payers. I felt left out. Where were the providers in his speech? Community doctors are at the frontlines of medical care and our perspective was never mentioned. We’re pushed to the margins of this debate.”
Read more
And, he opined, when Obama talks about creating an independent Commission to eliminate waste in the system it really says to hard-working doctors across the country that government-driven practice guidelines are on their way. Overutilization of your services is the iceberg the American healthcare system is headed for! So take it or leave it.
The AMA gave a tepid endorsement of Obama’s plan(s). But, as my overly-caffeinated doctor pointed out, the surgeon-heavy AMA represents only about 20 percent of American doctors; and a lot of the primary cares docs out there are developing a Rodney Dangerfield I-don’t-get -no -respect complex. “Soon there won’t be enough docs to treat patients. That’s reform? Our best and brightest are thinking twice before going into medicine. Can you blame them,” he said with a shrug.
I got all this over a quick cup of coffee.
Over coffee I asked one of the attendees — a primary care physician in a 3-doctor practice outside of Trenton — what he thought of Obama’s speech. He said it was a nice speech, eloquent as always. “But what bothered me was that the President spoke at length about patients and payers. I felt left out. Where were the providers in his speech? Community doctors are at the frontlines of medical care and our perspective was never mentioned. We’re pushed to the margins of this debate.”
Read more
And, he opined, when Obama talks about creating an independent Commission to eliminate waste in the system it really says to hard-working doctors across the country that government-driven practice guidelines are on their way. Overutilization of your services is the iceberg the American healthcare system is headed for! So take it or leave it.
The AMA gave a tepid endorsement of Obama’s plan(s). But, as my overly-caffeinated doctor pointed out, the surgeon-heavy AMA represents only about 20 percent of American doctors; and a lot of the primary cares docs out there are developing a Rodney Dangerfield I-don’t-get -no -respect complex. “Soon there won’t be enough docs to treat patients. That’s reform? Our best and brightest are thinking twice before going into medicine. Can you blame them,” he said with a shrug.
I got all this over a quick cup of coffee.
Saying "no" to patients
Whether for financial reasons or because it's in the best interests of the patient, sometimes physicians just have to say "no." And these days, more docs are saying "no" to patients.
So how do you do that without losing patients? For starters, come from a position of caring and mutual cooperation, rather than frustration, says Pamela Moore, who writes about this in her column in the October issue. Read more here, and join the conversation in the comments below: Are you saying "no" more?
So how do you do that without losing patients? For starters, come from a position of caring and mutual cooperation, rather than frustration, says Pamela Moore, who writes about this in her column in the October issue. Read more here, and join the conversation in the comments below: Are you saying "no" more?
Do payers support tort reform?
Lucien Roberts is an administrator and member of our advisory board. He had some comments about payers and tort reform, and the following post is his column.
Do payers support tort reform? On the surface, perhaps, but in the trenches, not at all. Here’s my litmus test.
You, dear doctor, are confronted in the exam room by a patient demanding a head MRI. Said patient went online last night and learned that headaches are the primary symptom of brain tumors. The MRI is not warranted by the patient’s history and physical. Further, the best practice clinical guidelines used by the payer do not support the MRI. You do not order the MRI, despite the patient’s protestations.
Six months later, the patient is diagnosed with a glioblastoma.
Read more
She is that one in however-many-thousands. She sues you, and your career as you know it will never be the same. You will order more MRIs, for discretion will never again be the better part of your valor.
Where was the payer as this unfortunate case unfolded? Good question. If the payer truly supported tort reform, it would stand both behind and beside you in this scenario. The payer would affirm that your actions were clinically appropriate and ask that the lawsuit be dismissed. After all, you were following the dictates of the payer — and not the insistence of the patient — in not ordering the MRI.
Unfortunately, this scenario plays out every week. Patients are not widgets, and even the broadest clinical practice guidelines will not catch every anomaly. Until payers stand behind their clinical practice guidelines and beside physicians, they are not substantively supporting tort reform. That is my solid opinion.
To their credit, the board of directors of the America’s Health Insurance Plans (AHIP) proffered a December 2008 proposal that included the following affirmation:
“The nation should also explore approaches for replacing our medical liability system with a new dispute-resolution process that is fair to patients and protects physicians against liability if they follow best-practice standards.”
AHIP estimates potential savings of $45 billion over the next five years. Unfortunately, their press releases in recent months have not emphasized, much less mentioned, this key element. This last statement is important. If AHIP truly supports tort reform as a critical piece of the healthcare reform puzzle, it must keep the dialogue on the front burners.
How many payers in your market will stand behind you when something bad happens while you follow their clinical practice guidelines? I suspect the answer is “zero,” and that is most unfortunate. Best practice guidelines, in the absence of payer support of tort reform, are but cloaks to hide payers from patient litigation. They guide and restrict the way you practice, but do nothing to protect you.
If AHIP and its members want to make a real statement about tort reform, they must replace their rhetoric with action. Now. Give a backbone to best practice guidelines and have the courage to support physicians who follow them. So, do payers truly support tort reform? Not yet, but this would be a great way to start.
Lucien Roberts, III, MHA, FACMPE, is executive director of Neuropsychological Services of Virginia. He also consults with medical groups and health systems in areas such as compliance, physician compensation, negotiation, strategic planning, and billing/collections. He may be reached at lucien.roberts@yahoo.com.
Do payers support tort reform? On the surface, perhaps, but in the trenches, not at all. Here’s my litmus test.
You, dear doctor, are confronted in the exam room by a patient demanding a head MRI. Said patient went online last night and learned that headaches are the primary symptom of brain tumors. The MRI is not warranted by the patient’s history and physical. Further, the best practice clinical guidelines used by the payer do not support the MRI. You do not order the MRI, despite the patient’s protestations.
Six months later, the patient is diagnosed with a glioblastoma.
Read more
She is that one in however-many-thousands. She sues you, and your career as you know it will never be the same. You will order more MRIs, for discretion will never again be the better part of your valor.
Where was the payer as this unfortunate case unfolded? Good question. If the payer truly supported tort reform, it would stand both behind and beside you in this scenario. The payer would affirm that your actions were clinically appropriate and ask that the lawsuit be dismissed. After all, you were following the dictates of the payer — and not the insistence of the patient — in not ordering the MRI.
Unfortunately, this scenario plays out every week. Patients are not widgets, and even the broadest clinical practice guidelines will not catch every anomaly. Until payers stand behind their clinical practice guidelines and beside physicians, they are not substantively supporting tort reform. That is my solid opinion.
To their credit, the board of directors of the America’s Health Insurance Plans (AHIP) proffered a December 2008 proposal that included the following affirmation:
“The nation should also explore approaches for replacing our medical liability system with a new dispute-resolution process that is fair to patients and protects physicians against liability if they follow best-practice standards.”
AHIP estimates potential savings of $45 billion over the next five years. Unfortunately, their press releases in recent months have not emphasized, much less mentioned, this key element. This last statement is important. If AHIP truly supports tort reform as a critical piece of the healthcare reform puzzle, it must keep the dialogue on the front burners.
How many payers in your market will stand behind you when something bad happens while you follow their clinical practice guidelines? I suspect the answer is “zero,” and that is most unfortunate. Best practice guidelines, in the absence of payer support of tort reform, are but cloaks to hide payers from patient litigation. They guide and restrict the way you practice, but do nothing to protect you.
If AHIP and its members want to make a real statement about tort reform, they must replace their rhetoric with action. Now. Give a backbone to best practice guidelines and have the courage to support physicians who follow them. So, do payers truly support tort reform? Not yet, but this would be a great way to start.
Lucien Roberts, III, MHA, FACMPE, is executive director of Neuropsychological Services of Virginia. He also consults with medical groups and health systems in areas such as compliance, physician compensation, negotiation, strategic planning, and billing/collections. He may be reached at lucien.roberts@yahoo.com.
College Kids Boo Baucus
President Obama has not full-thoatedly endorsed the Baucus healthcare reform plan, and I don't think his appearance yesterday convinced anyone on his staff that he should. When he mentioned the Baucus plan to a crowd at the University of Maryland, they grumbled. (Some are saying they "resoundingly booed." That's not what I saw. Anyway, they were not happy.)
This was an invitation-only liberal crowd of Obama supporters. These are the people who are responsible, more than any other, for getting him elected. Young idealists. So, this crowd's negative response to a bill that the president is willing to sign (I believe) right now, today, is not a good sign. The whole point of the Baucus effort was to devise a plan that satisfies moderates and maybe a Republican or two, while meeting the president's deficit-neutral objective.
Now, to be clear, the Baucus bill will be amended greatly over the next few weeks, but as it stands the president's own plan is not that far off from Baucus'. (Even he says, in the clip, that "each bill has its strengths and there a lot of similarities between them.")
Read more
So the president has a problem. My advice: Come out on Monday in favor of Sen. Ron Wyden's proposed amendment to "let everyone choose [the president's] health insurance plan."
Wyden wants everyone to have at least some choice in our health insurance options, not by killing employer-based coverage, as he has proposed in the past, but by requiring employers to offer "their employees a choice of at least two insurance plans, one of them a low-cost, high-value plan. Employers could meet this requirement by offering their own choices. Or they could let their employees choose either the company plan or a voucher that could be used to buy a plan on the exchange. They could also simply insure all of their employees though the exchange, at a discounted rate."
This is such a wonderful idea that I have every confidence it will go up in flames.
This was an invitation-only liberal crowd of Obama supporters. These are the people who are responsible, more than any other, for getting him elected. Young idealists. So, this crowd's negative response to a bill that the president is willing to sign (I believe) right now, today, is not a good sign. The whole point of the Baucus effort was to devise a plan that satisfies moderates and maybe a Republican or two, while meeting the president's deficit-neutral objective.
Now, to be clear, the Baucus bill will be amended greatly over the next few weeks, but as it stands the president's own plan is not that far off from Baucus'. (Even he says, in the clip, that "each bill has its strengths and there a lot of similarities between them.")
Read more
So the president has a problem. My advice: Come out on Monday in favor of Sen. Ron Wyden's proposed amendment to "let everyone choose [the president's] health insurance plan."
Wyden wants everyone to have at least some choice in our health insurance options, not by killing employer-based coverage, as he has proposed in the past, but by requiring employers to offer "their employees a choice of at least two insurance plans, one of them a low-cost, high-value plan. Employers could meet this requirement by offering their own choices. Or they could let their employees choose either the company plan or a voucher that could be used to buy a plan on the exchange. They could also simply insure all of their employees though the exchange, at a discounted rate."
This is such a wonderful idea that I have every confidence it will go up in flames.
Thursday, September 17, 2009
The Baucus Blunder
In the wake of the outrageously unfair-to-the-working-poor "reform" plan offered yesterday by Sen. Max Baucus, and the furious response to it on the left, I must admit I'm feeling a tad vindicated.
Some readers of this blog have gotten the mistaken impression that I'm a far-right Glenn Beck-o-phile because my criticism of the various reform proposals, and of some of the president's rhetoric, has often been heated. (I'm a moderate, left-of-center Democrat with occasional libertarian tendencies and an allergy to conventional thinkers, if you'd like to know.) But now that Baucus has promised something fairly similar to what President Obama has proposed, and liberals have come to realize how bad it is, I have to say, "Welcome, progressives, to the realization that it's possible to find this reform plan distasteful without being a 'birther,' a 'deather' or a believer in some other delusion."
I know. You're thinking, "But wait. The Baucus plan stinks because it's a big giveaway to insurance companies and other interests, and it kills the public option." Well, yes, Baucus is even more generous in his largesse to industry interests than the administration had initially planned to be, but the White House started cutting deals with industry groups in the spring. As for the public option, the president has been signaling since last month that he'd be happy to sign a bill without it, so its death was a fait accompli.
I'm not sure why the left is surprised by what Baucus is proposing. Baucus is making a disappointing bill odious, but he's not destroying a good bill.
Read more
To be clear, the Baucus plan is more than a mere giveaway to insurers. By including the individual mandate to purchase insurance, combined with its stingy subsidies AND its death blow to the public option, Baucus is selling out millions of vulnerable Americans. He's forcing people who make as little $32,000 a year to spend as much $4,200 a year to purchase overpriced, underregulated insurance plans, and that's JUST for premiums. It doesn't include copays, drug prices, etc. These folks would be ineligible for subsidies. They'd be ineligible for Medicaid. And if their employer offers insurance, they'd be ineligible to shop for a plan on the public exchange. They would, in other words, be REQUIRED TO BUY their employer's insurance option, almost regardless of their ability to afford it.
So I get how bad the Baucus plan is. What I don't get is why the left thinks it is so much WORSE than what was originally proposed. Every proposal on the table included an individual mandate. None included subsidies for folks earning more than three times the federal poverty line. Industry groups had already cut deals protecting them from most of the provisions that might have had a chance to actually cut the cost of care.
My basic objection to even the most generous reform plans -- even, say, the House plan -- is that they would do nothing to encourage the creation of a competitive insurance marketplace for those of us who already get coverage through work. That's the vast majority of Americans. I want ALL OF US to have access to the same kind of insurance "exchange" that would, under every proposal I've seen, exclude everyone except uninsured American citizens with no other alternatives. That means 5% of us would be eligible for the insurance exchange and/or public option. And that's the plan that the PRESIDENT has endorsed. No wonder the president has been saying that the public option is not that important -- as he proposes it, it's NOT that important.
I say kill the current employer-based insurance system and replace it with a properly regulated individual market where every citizen can purchase insurance, using subsidies and their own money. Forcing health insurers to compete for individuals, instead of competing for large employer groups, would encourage a customer service culture within the companies that would do far more to protect consumers than any list of promises from Congress. It would also encourage cost control since people would better understand the relationship between what they want from healthcare, and what they pay. I'd also add tort reform, a powerful Medicare Payment Advisory Commission -- and, if necessary, a public option.
Individual mandate? I'm for it, but only under the right circumstances. I'll have more soon on how lower-income individuals would fare the Baucus plan's mandate. Sneak preview: not good.
Some readers of this blog have gotten the mistaken impression that I'm a far-right Glenn Beck-o-phile because my criticism of the various reform proposals, and of some of the president's rhetoric, has often been heated. (I'm a moderate, left-of-center Democrat with occasional libertarian tendencies and an allergy to conventional thinkers, if you'd like to know.) But now that Baucus has promised something fairly similar to what President Obama has proposed, and liberals have come to realize how bad it is, I have to say, "Welcome, progressives, to the realization that it's possible to find this reform plan distasteful without being a 'birther,' a 'deather' or a believer in some other delusion."
I know. You're thinking, "But wait. The Baucus plan stinks because it's a big giveaway to insurance companies and other interests, and it kills the public option." Well, yes, Baucus is even more generous in his largesse to industry interests than the administration had initially planned to be, but the White House started cutting deals with industry groups in the spring. As for the public option, the president has been signaling since last month that he'd be happy to sign a bill without it, so its death was a fait accompli.
I'm not sure why the left is surprised by what Baucus is proposing. Baucus is making a disappointing bill odious, but he's not destroying a good bill.
Read more
To be clear, the Baucus plan is more than a mere giveaway to insurers. By including the individual mandate to purchase insurance, combined with its stingy subsidies AND its death blow to the public option, Baucus is selling out millions of vulnerable Americans. He's forcing people who make as little $32,000 a year to spend as much $4,200 a year to purchase overpriced, underregulated insurance plans, and that's JUST for premiums. It doesn't include copays, drug prices, etc. These folks would be ineligible for subsidies. They'd be ineligible for Medicaid. And if their employer offers insurance, they'd be ineligible to shop for a plan on the public exchange. They would, in other words, be REQUIRED TO BUY their employer's insurance option, almost regardless of their ability to afford it.
So I get how bad the Baucus plan is. What I don't get is why the left thinks it is so much WORSE than what was originally proposed. Every proposal on the table included an individual mandate. None included subsidies for folks earning more than three times the federal poverty line. Industry groups had already cut deals protecting them from most of the provisions that might have had a chance to actually cut the cost of care.
My basic objection to even the most generous reform plans -- even, say, the House plan -- is that they would do nothing to encourage the creation of a competitive insurance marketplace for those of us who already get coverage through work. That's the vast majority of Americans. I want ALL OF US to have access to the same kind of insurance "exchange" that would, under every proposal I've seen, exclude everyone except uninsured American citizens with no other alternatives. That means 5% of us would be eligible for the insurance exchange and/or public option. And that's the plan that the PRESIDENT has endorsed. No wonder the president has been saying that the public option is not that important -- as he proposes it, it's NOT that important.
I say kill the current employer-based insurance system and replace it with a properly regulated individual market where every citizen can purchase insurance, using subsidies and their own money. Forcing health insurers to compete for individuals, instead of competing for large employer groups, would encourage a customer service culture within the companies that would do far more to protect consumers than any list of promises from Congress. It would also encourage cost control since people would better understand the relationship between what they want from healthcare, and what they pay. I'd also add tort reform, a powerful Medicare Payment Advisory Commission -- and, if necessary, a public option.
Individual mandate? I'm for it, but only under the right circumstances. I'll have more soon on how lower-income individuals would fare the Baucus plan's mandate. Sneak preview: not good.
Wednesday, September 16, 2009
Does Medicare Advantage Stink or Rock?
Today, America's Health Insurance Plans (AHIP) released data showing that Medicare Advantage enrollees in Nevada and California had fewer inpatient days per patient, lower readmission rates, and lower rates of avoidable hospital admissions then Medicare B enrollees. Can (commercial) Medicare Advantage really be better for patients and cheaper than plain old vanilla Medicare?
Read more
Well, a contradictory report released by the Commonwealth Fund, says Advantage plans are paid $1,140 more per enrollee than providers would have gotten under regular Medicare.
Read more
Well, a contradictory report released by the Commonwealth Fund, says Advantage plans are paid $1,140 more per enrollee than providers would have gotten under regular Medicare.
So are Part C plans more efficient (and cheaper) or not?
There are several possible explanations for the data disconnect:
1. Data does what you want it to do (hardly satisfying).2. Medicare Advantage plans kept patients out of the hospital but because they get paid 110% of Medicare they STILL cost American taxpayers an extra $1,140 per patient.
3. The states studied made the difference.
Regardless of the big picture, it's still pretty clear that Medicare Advantage plans stink for providers who want to get paid.
COBRA claims hassles?
The recession has likely meant your practice has been dealing with a jump in the number of uninsured patients paying out of pocket or unable to pay their bills. It looks like there may be another hassle for doctors’ offices: COBRA claims.
COBRA, the program that allows laid-off employees to keep their employer-based insurance temporarily, has created problems for physicians’ offices, according to an American Medical News story. The stimulus package included subsidies for the premiums, which lead to a spike in enrollment.
Read more
The enrollment rules create complications, and there’s often a gap in health insurance coverage as a former employee is notified of the option and enrolls, which could leave physicians taking a hit. A patient may say he’s covered, but records may show the coverage was terminated.
So, one consultant says to just treat the patient as self-pay and bill him directly. Another said to set the bill aside and wait for the system to catch up. Another piece of advice is to have your practice’s COBRA policy visible and accessible. Informing patients may cut down on the hassles.
Has your practice experienced any troubles because of COBRA?
COBRA, the program that allows laid-off employees to keep their employer-based insurance temporarily, has created problems for physicians’ offices, according to an American Medical News story. The stimulus package included subsidies for the premiums, which lead to a spike in enrollment.
Read more
The enrollment rules create complications, and there’s often a gap in health insurance coverage as a former employee is notified of the option and enrolls, which could leave physicians taking a hit. A patient may say he’s covered, but records may show the coverage was terminated.
So, one consultant says to just treat the patient as self-pay and bill him directly. Another said to set the bill aside and wait for the system to catch up. Another piece of advice is to have your practice’s COBRA policy visible and accessible. Informing patients may cut down on the hassles.
Has your practice experienced any troubles because of COBRA?
Tuesday, September 15, 2009
Poll: Most docs want public option
A majority of physicians – 63 percent – would support a health reform plan that included a public option and traditional private insurance, according to a study in the New England Journal of Medicine funded by the Robert Wood Johnson Foundation.
And just 27 percent would support a plan that doesn’t include the public option, and instead provides subsidies for low-income residents to buy private insurance. Nearly 60 percent of docs also support expanding Medicare to people between the ages of 55 and 64.
Thoughts?
And just 27 percent would support a plan that doesn’t include the public option, and instead provides subsidies for low-income residents to buy private insurance. Nearly 60 percent of docs also support expanding Medicare to people between the ages of 55 and 64.
Thoughts?
Monday, September 14, 2009
Another blow to the public option
It’s more bad news for the so-called public option.
Even though Obama made a case for it during his address to Congress last week, the push for a government-sponsored health insurance option has appeared doomed for a while. And now a poll out shows that many people would be more amenable to reform if that piece were dropped.
Read more
The public has been skeptical of healthcare reform efforts, to say the least. But the Washington Post is reporting that opposition may be easing somewhat, according to a Washington Post-ABC News poll.
I thought Obama made a pretty concise and compelling arguement in favor of the public option - as well as a concession for opponents, stating that people with private insurance wouldn't be eligible for the public option. But he did also hint that that portion wouldn’t be what stands in the way of passing a bill.
The poll found that if the public option was removed, opposition to the overall package drops by six percentage points. Without the public option, 50 percent back the changes and 42 percent are opposed.
Further, if it is indeed limited to those unable to get private insurance, support would rise to 76 percent.
But I have to agree with Bob on this one: Why not extend the choice and competition to all Americans? Why not let us decide if we want to opt for the public option? Well, it might all be a moot point now.
Even though Obama made a case for it during his address to Congress last week, the push for a government-sponsored health insurance option has appeared doomed for a while. And now a poll out shows that many people would be more amenable to reform if that piece were dropped.
Read more
The public has been skeptical of healthcare reform efforts, to say the least. But the Washington Post is reporting that opposition may be easing somewhat, according to a Washington Post-ABC News poll.
I thought Obama made a pretty concise and compelling arguement in favor of the public option - as well as a concession for opponents, stating that people with private insurance wouldn't be eligible for the public option. But he did also hint that that portion wouldn’t be what stands in the way of passing a bill.
The poll found that if the public option was removed, opposition to the overall package drops by six percentage points. Without the public option, 50 percent back the changes and 42 percent are opposed.
Further, if it is indeed limited to those unable to get private insurance, support would rise to 76 percent.
But I have to agree with Bob on this one: Why not extend the choice and competition to all Americans? Why not let us decide if we want to opt for the public option? Well, it might all be a moot point now.
Introducing our Newest Blogger
Folks, allow me to introduce our newest Practice Notes blogger, Melissa Garduno Young, MD.
Dr. Young is an endocrinologist in New Jersey who is about to embark on a solo practice and has agreed to blog about her experiences in starting out on her own. Her first post is below.
If you, too, are a physician interested in blogging for Practice Notes, e-mail me at bob.keaveney@cmpmedica.com and let me know. We're looking for physicians able to commit to at least one blog post a week about your own experiences in practice, observations about the state of healthcare, your efforts to have a balanced life, etc.
Dr. Young is an endocrinologist in New Jersey who is about to embark on a solo practice and has agreed to blog about her experiences in starting out on her own. Her first post is below.
If you, too, are a physician interested in blogging for Practice Notes, e-mail me at bob.keaveney@cmpmedica.com and let me know. We're looking for physicians able to commit to at least one blog post a week about your own experiences in practice, observations about the state of healthcare, your efforts to have a balanced life, etc.
Melissa Young, MD: Why I'm going solo
I am embarking on a new adventure. Or what some are describing as a suicide mission. You see, for the last eight years, I have been an employed physician at a community hospital that is an affiliate of a major university hospital, and I am going into solo private practice. No, there was no major falling out, no catastrophe, nothing obvious that set this into motion. Why then, you may ask (everyone else has), am I leaving the security of employment for the uncertainty of a new practice?
Is it the need for autonomy? Is it to be five minutes from my kids’ school instead of 25? Is it because I am tired of being pulled in three directions every day? Is it temporary insanity? It is probably a combination of all of these, as well as some other annoyances I’d like to avoid and some dreams I’d like to pursue.
Read more
Being employed definitely has its advantages. For the last eight years I have enjoyed a decent salary, good benefits, paid vacation time, and conference time. I have not known nor cared to know how much it costs to keep a roof over my head, a secretary at the desk, or paper in the copier. As part of a faculty practice, I was surrounded by peers I could bounce ideas off, curbside about patients, and complain to about the administration ( uh, I’m talking about the government, I would never complain about the hospital administration). Teaching residents and students kept my mind fresh, and I had ample opportunity to receive CME credits.
So why, oh why, am I leaving? Part of it is purely personal. My new office will be closer to home and closer to my kids’ school. And part of it is because I think it’s time for me to start calling the shots. I want to be able to choose what EHR I want to use (a subject for another post), to fire a staff member I think is incompetent, inconsiderate to patients, or just downright freaky, and to have hours during lunch or after five so that patients who work can come in. And also because, while I wanted to do a little bit of everything when I started, over the years I have been asked (a little more adamantly each time) to 1) see more patients, 2) set aside more dedicated time for teaching, 3) and commit to doing research. And while multitasking is one of those talents every doc must have to some degree, there are only so many hours in a day.
It was not an easy decision. It took more than two years of research and soul-searching. I read books, blogs, and e-newsletters. I attended practice management conferences, webinars and telephone conferences. I talked to family and friends in and outside of medicine. And while I am somewhere between excited and terrified, I think I probably know more about running a practice than most docs I know.
Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.
Is it the need for autonomy? Is it to be five minutes from my kids’ school instead of 25? Is it because I am tired of being pulled in three directions every day? Is it temporary insanity? It is probably a combination of all of these, as well as some other annoyances I’d like to avoid and some dreams I’d like to pursue.
Read more
Being employed definitely has its advantages. For the last eight years I have enjoyed a decent salary, good benefits, paid vacation time, and conference time. I have not known nor cared to know how much it costs to keep a roof over my head, a secretary at the desk, or paper in the copier. As part of a faculty practice, I was surrounded by peers I could bounce ideas off, curbside about patients, and complain to about the administration ( uh, I’m talking about the government, I would never complain about the hospital administration). Teaching residents and students kept my mind fresh, and I had ample opportunity to receive CME credits.
So why, oh why, am I leaving? Part of it is purely personal. My new office will be closer to home and closer to my kids’ school. And part of it is because I think it’s time for me to start calling the shots. I want to be able to choose what EHR I want to use (a subject for another post), to fire a staff member I think is incompetent, inconsiderate to patients, or just downright freaky, and to have hours during lunch or after five so that patients who work can come in. And also because, while I wanted to do a little bit of everything when I started, over the years I have been asked (a little more adamantly each time) to 1) see more patients, 2) set aside more dedicated time for teaching, 3) and commit to doing research. And while multitasking is one of those talents every doc must have to some degree, there are only so many hours in a day.
It was not an easy decision. It took more than two years of research and soul-searching. I read books, blogs, and e-newsletters. I attended practice management conferences, webinars and telephone conferences. I talked to family and friends in and outside of medicine. And while I am somewhere between excited and terrified, I think I probably know more about running a practice than most docs I know.
Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.
Thursday, September 10, 2009
Tort Reform Demonstration Projects?
Last night the president said:
"Finally, many in this chamber -- particularly on the Republican side of the aisle -- have long insisted that reforming our medical malpractice laws can help bring down the cost of health care. I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs. So I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine. I know that the Bush administration considered authorizing demonstration projects in individual states to test these issues. It's a good idea, and I am directing my Secretary of Health and Human Services to move forward on this initiative today."
What is this "range of ideas"? The president may have been referring to efforts, in 2006, to fund health courts in the states. This is a good idea but don't get too excited, tort reformers.
UPDATE: It looks like the administration won't even go as far as health courts. The Post has some details. Still, I think health courts are worth exploring below.
Read more
Health courts are special courts designed to deal with med-mal claims.
In the meatime, here's what I can tell you. Though health courts can be set up in different ways, in most cases:
* The judges would be specially trained in medical issues.
* The medical experts would be neutral -- appointed by the court, not hired by the parties.
* There would be no jury. Findings of negligence, if any, would be made by the judge.
* Awards would be based on a "schedule" -- not a hard, one-size-fits-all cap, but awards would be predictable based on the nature of the injury. Like your fee schedule.
There is no doubt that such a system would go a long, long way toward injecting sanity back into the process of compensating injured patients while protecting doctors against abuse. So you can imagine how the Trial Bar feels about them.
I called the American Tort Reform Association. Here's what its spokesman, Darren McKinney, told me:
"We fully support the notion of health courts, or administrative boards that could fairly and consistently compensate people for the good-faith mistakes that people in every industry sometimes make." He said it's "not a bad thing" if the administration is moving even a little in this direction but he's skeptical that "demonstration projects" are anything more than smoke. "If health courts were to become the law of the land in every state -- hell, we'd be popping the champagne corks. But a few demonstration projects in a handful of states is like kissing your sister."
I have to say that I share his skepticism. But I'm open to being surprised.
"Finally, many in this chamber -- particularly on the Republican side of the aisle -- have long insisted that reforming our medical malpractice laws can help bring down the cost of health care. I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs. So I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine. I know that the Bush administration considered authorizing demonstration projects in individual states to test these issues. It's a good idea, and I am directing my Secretary of Health and Human Services to move forward on this initiative today."
What is this "range of ideas"? The president may have been referring to efforts, in 2006, to fund health courts in the states. This is a good idea but don't get too excited, tort reformers.
UPDATE: It looks like the administration won't even go as far as health courts. The Post has some details. Still, I think health courts are worth exploring below.
Read more
Health courts are special courts designed to deal with med-mal claims.
In the meatime, here's what I can tell you. Though health courts can be set up in different ways, in most cases:
* The judges would be specially trained in medical issues.
* The medical experts would be neutral -- appointed by the court, not hired by the parties.
* There would be no jury. Findings of negligence, if any, would be made by the judge.
* Awards would be based on a "schedule" -- not a hard, one-size-fits-all cap, but awards would be predictable based on the nature of the injury. Like your fee schedule.
There is no doubt that such a system would go a long, long way toward injecting sanity back into the process of compensating injured patients while protecting doctors against abuse. So you can imagine how the Trial Bar feels about them.
I called the American Tort Reform Association. Here's what its spokesman, Darren McKinney, told me:
"We fully support the notion of health courts, or administrative boards that could fairly and consistently compensate people for the good-faith mistakes that people in every industry sometimes make." He said it's "not a bad thing" if the administration is moving even a little in this direction but he's skeptical that "demonstration projects" are anything more than smoke. "If health courts were to become the law of the land in every state -- hell, we'd be popping the champagne corks. But a few demonstration projects in a handful of states is like kissing your sister."
I have to say that I share his skepticism. But I'm open to being surprised.
Wednesday, September 9, 2009
About the Speech
It was a good speech, a fine speech, an Obama speech, and in some ways a surprising speech. The president just finished speaking, so here are some thoughts off the top of my head:
1. What is this he's proposing on tort reform? Honestly, I have no clue. Vague talk of "demonstration projects" in several states. I'm confident that it's not the pain-and-suffering caps that most doctors want but I promise we'll find out what he's talking about. My column next month is on the lack of any tort reform whatsoever, so I'd like to thank the president for making me rewrite that on Thursday.
UPDATE: From the American Tort Reform Association, I found a reference to an effort in 2006 to provide funding for demonstration projects for health courts -- special courts just to handle malpractice cases. ( Having trouble linking it but here's the URL -- it's a PDF: www.mema.org/cmspages/getAttch.php?id=355)
If that's what the president is talking about (and I think it probably is), well, health courts are a good idea but they hardly qualify as tort reform, nor do they need special funding from the fed to create them. States have every right to create them; all you need to is set the rules and provide special training for judges.
2. Who was that twit who shouted "YOU LIE!" when the president said, correctly, that the bill will not provide services to illegal immigrants? That was truly outrageous. We have sunken to a new low, America. I assume the jerk will be on Hannity tomorrow and eventually get his own radio show.
UPDATE: It was Joe Wilson, R - S.C.
3. I like that the president called the death panel thing "a lie, plain and simple." Take that, Sarah.
4. I thought the president's defense of a public option was well-made and more vigorous than I expected. He also signaled that he's willing to sign a bill without it and told the left to just get over it, so the public option is dead. But here is what bothered me the most:
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If the president truly believes that "my guiding principle is and always has been that consumers do better when there's choice and competition", then why not provide ALL Americans with choice and competition? Why is it "too disruptive" to provide those of us who already have insurance through our jobs the opportunity to join any private insurance company, or if we prefer, the public option? Why not allow my employer to pay a fee equal to the amount it is paying for my insurance premiums, which then would be passed through back to me (by way of tax credits), allowing me to buy my own insurance? The president called this concept "too disruptive." (He also called it a right-wing idea, which it is not.) Too disruptive? You're trying to fix one-sixth of the economy -- you bet it's disruptive, and why shouldn't it be? Has this reform effort been going smoothly so far?
5. Finally, his comment on abortion: "Under our plan, no federal dollars will be used to fund abortions." Hmm, really? Is that right? I'm pretty lefty on cultural issues, so I'm all for funding abortions. But my understanding is that under the bill as written, the secretary of Health and Human Services would decide whether abortion is covered by the public option, if there is a public option. Is he promising the public option won't cover abortion?
1. What is this he's proposing on tort reform? Honestly, I have no clue. Vague talk of "demonstration projects" in several states. I'm confident that it's not the pain-and-suffering caps that most doctors want but I promise we'll find out what he's talking about. My column next month is on the lack of any tort reform whatsoever, so I'd like to thank the president for making me rewrite that on Thursday.
UPDATE: From the American Tort Reform Association, I found a reference to an effort in 2006 to provide funding for demonstration projects for health courts -- special courts just to handle malpractice cases. ( Having trouble linking it but here's the URL -- it's a PDF: www.mema.org/cmspages/getAttch.php?id=355)
If that's what the president is talking about (and I think it probably is), well, health courts are a good idea but they hardly qualify as tort reform, nor do they need special funding from the fed to create them. States have every right to create them; all you need to is set the rules and provide special training for judges.
2. Who was that twit who shouted "YOU LIE!" when the president said, correctly, that the bill will not provide services to illegal immigrants? That was truly outrageous. We have sunken to a new low, America. I assume the jerk will be on Hannity tomorrow and eventually get his own radio show.
UPDATE: It was Joe Wilson, R - S.C.
3. I like that the president called the death panel thing "a lie, plain and simple." Take that, Sarah.
4. I thought the president's defense of a public option was well-made and more vigorous than I expected. He also signaled that he's willing to sign a bill without it and told the left to just get over it, so the public option is dead. But here is what bothered me the most:
Read more
If the president truly believes that "my guiding principle is and always has been that consumers do better when there's choice and competition", then why not provide ALL Americans with choice and competition? Why is it "too disruptive" to provide those of us who already have insurance through our jobs the opportunity to join any private insurance company, or if we prefer, the public option? Why not allow my employer to pay a fee equal to the amount it is paying for my insurance premiums, which then would be passed through back to me (by way of tax credits), allowing me to buy my own insurance? The president called this concept "too disruptive." (He also called it a right-wing idea, which it is not.) Too disruptive? You're trying to fix one-sixth of the economy -- you bet it's disruptive, and why shouldn't it be? Has this reform effort been going smoothly so far?
5. Finally, his comment on abortion: "Under our plan, no federal dollars will be used to fund abortions." Hmm, really? Is that right? I'm pretty lefty on cultural issues, so I'm all for funding abortions. But my understanding is that under the bill as written, the secretary of Health and Human Services would decide whether abortion is covered by the public option, if there is a public option. Is he promising the public option won't cover abortion?
A dose of reality for med students
A group of University of Washington medical students spent their summer getting a glimpse of some of the healthcare system's ills – and learning what many physicians already know: the reimbursement system needs to be fixed.
According to The New York Times story: “The students learned not only to deliver babies and suture wounds, but also to order unnecessary tests as protection against law suits, to hector specialists into seeing Medicaid patients, to match patients with prescriptions on Wal-Mart’s $4 list.”
Read more
The rising second-year students, who spend a month providing care in rural and underserved areas in the Northwest, saw firsthand some of the ills of the profession, like doctors only spending five minutes with each patient and burn out on 13-hour nonstop days.
They were dispatched to perhaps some of the areas most in need, dealing with some of the harshest realities of the system, but my guess is these issues and sentiments are shared to varying degrees across the country. Perhaps unsurprisingly, some students said they didn’t want to pursue primary care, and many said they saw the dire need for healthcare reform.
“I often wondered what we were actually doing to help people,” one student told the NYTimes.
Lest this be a downer post, I'll end by reminding you (and letting any doubting med students know) of one of the top 10 reasons to be happy you're a doctor: You make a difference. Despite the specter of denials, malpractice, and overwork, you still have a job that provides a genuine service to the public, with tangible results and healthier patients.
According to The New York Times story: “The students learned not only to deliver babies and suture wounds, but also to order unnecessary tests as protection against law suits, to hector specialists into seeing Medicaid patients, to match patients with prescriptions on Wal-Mart’s $4 list.”
Read more
The rising second-year students, who spend a month providing care in rural and underserved areas in the Northwest, saw firsthand some of the ills of the profession, like doctors only spending five minutes with each patient and burn out on 13-hour nonstop days.
They were dispatched to perhaps some of the areas most in need, dealing with some of the harshest realities of the system, but my guess is these issues and sentiments are shared to varying degrees across the country. Perhaps unsurprisingly, some students said they didn’t want to pursue primary care, and many said they saw the dire need for healthcare reform.
“I often wondered what we were actually doing to help people,” one student told the NYTimes.
Lest this be a downer post, I'll end by reminding you (and letting any doubting med students know) of one of the top 10 reasons to be happy you're a doctor: You make a difference. Despite the specter of denials, malpractice, and overwork, you still have a job that provides a genuine service to the public, with tangible results and healthier patients.
Friday, September 4, 2009
H1N1 rap
The H1N1 virus has many practices developing plans to handle the influx of patients needing vaccines or care.
With that in mind, I thought this video posted on Kevin Pho MD's blog was worth sharing:
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This is Dr. John Clarke, medical director of the Long Island Railroad, rapping about H1N1.
"Hand sanatiza, I advise ya get it, why, it makes germs die when you rub and let it dry."
With that in mind, I thought this video posted on Kevin Pho MD's blog was worth sharing:
Read more
This is Dr. John Clarke, medical director of the Long Island Railroad, rapping about H1N1.
"Hand sanatiza, I advise ya get it, why, it makes germs die when you rub and let it dry."
Thursday, September 3, 2009
CMS will pay for H1N1 vaccines
Medicare will pay for administration of the H1N1 vaccine, though not for the vaccine itself, which it expects providers will get for free.
There is a new HCPCS code for the H1N1 vaccine itself (G9142, Influenza A (H1N1) vaccine, any route of administration), while G9141, Influenza A (H1N1) is for immunization administration (includes the physician counseling the patient/family).
There is a new HCPCS code for the H1N1 vaccine itself (G9142, Influenza A (H1N1) vaccine, any route of administration), while G9141, Influenza A (H1N1) is for immunization administration (includes the physician counseling the patient/family).
Wednesday, September 2, 2009
A case for retail clinics?
Retail clinics have posed a potential threat to primary-care offices for years, and now a new study bolsters the case for these walk-in medical clinics.
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Retail clinics, like those found in big-box chain stores, provide a “good standard of care for sore throat, ear infections, and urinary tract infections,” according to a HealthDay story that ran in U.S. News and World Report. The findings are from a study in the Sept. 1 Annals of Internal Medicine by Dr. Ateey Mehrotra.
Mehrotra compared data from clinics, doctors’ offices, urgent care centers and emergency departments. He found that standards of care in the retail clinics were consistent with accepted medical guidelines for those three ailments. Plus, they are cheaper, and about one-third of Americans live within a 10-minute drive of these minute clinics.
Of course, critics of the clinics say the patients don’t benefit from the comprehensive and expert care of their primary-care docs. And the clinics are treating the less-expensive, minor ailments, making it hard to really measure their quality.
This debate is becoming increasingly important in the context of lowering healthcare costs and expanding access.
As retail – and now worksite - clinics continue to multiply, practices are finding ways to collaborate and learn from them, rather than view them as competition. For starters, practices can look to these clinics for patient referrals, or ease their own patient load by sending patients to the clinics for minor treatments like flu shots.
Read more
Retail clinics, like those found in big-box chain stores, provide a “good standard of care for sore throat, ear infections, and urinary tract infections,” according to a HealthDay story that ran in U.S. News and World Report. The findings are from a study in the Sept. 1 Annals of Internal Medicine by Dr. Ateey Mehrotra.
Mehrotra compared data from clinics, doctors’ offices, urgent care centers and emergency departments. He found that standards of care in the retail clinics were consistent with accepted medical guidelines for those three ailments. Plus, they are cheaper, and about one-third of Americans live within a 10-minute drive of these minute clinics.
Of course, critics of the clinics say the patients don’t benefit from the comprehensive and expert care of their primary-care docs. And the clinics are treating the less-expensive, minor ailments, making it hard to really measure their quality.
This debate is becoming increasingly important in the context of lowering healthcare costs and expanding access.
As retail – and now worksite - clinics continue to multiply, practices are finding ways to collaborate and learn from them, rather than view them as competition. For starters, practices can look to these clinics for patient referrals, or ease their own patient load by sending patients to the clinics for minor treatments like flu shots.
Tuesday, September 1, 2009
Life after clinical practice?
Have you ever considered a career outside of clinical practice? Ever wondered what kinds of jobs are out there for doctors wanting to leave medicine?
That’s the topic of this month’s podcast.
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I spoke with Michelle Mudge-Riley, a doctor who now works as director of wellness and medical management at a brokerage firm. She is also a consultant for physicians looking to enhance their careers or transition out of medicine and into other jobs.
She wrote a series of essays on her experiences for Physicians Practice in 2006 called the Ex-Doctor’s Diary. The five stories explored job satisfaction, knowing what you don’t know, embracing uncertainty, lessons in leadership, and whether physicians who leave medicine are still physicians.
Listen to our conversation and join the discussion below.
That’s the topic of this month’s podcast.
Read more
I spoke with Michelle Mudge-Riley, a doctor who now works as director of wellness and medical management at a brokerage firm. She is also a consultant for physicians looking to enhance their careers or transition out of medicine and into other jobs.
She wrote a series of essays on her experiences for Physicians Practice in 2006 called the Ex-Doctor’s Diary. The five stories explored job satisfaction, knowing what you don’t know, embracing uncertainty, lessons in leadership, and whether physicians who leave medicine are still physicians.
Listen to our conversation and join the discussion below.
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