What: Johnson & Johnson, Allergen, Inc, venture capitalists, surgeons, and outpatient surgery centers have banded together to promote the use of silicon gastric bands to address problem of morbid obesity, defined as 100 pound overweight, and its myriad complications – diabetes, hypertension, catastrophic cardiovascular events, heart failure, sleep apnea, and osteoarthritis of knees Gastric banding exploded 50% last year to 200,000 procedures per year, up from 35,000 in 2000, a 6 fold increase.
Why: Gastric banding fills a huge niche (no pun intended) in elective surgery field. It is relatively safe, relatively non-invasive, relatively free of complications, cheaper than gastric bypass ($17,000 v. $25,000), can be performed in an outpatient setting, is easy for surgeons to learn, does not change the basic plumbing of the GI tract, may be as effective as bypass surgery, and lessens and may even cure the diabetes that accompanies morbid obesity, and addresses a gaping need – one 1% of morbidly obese people have undergone surgery.
When: Surgeons in Europe and Australia introduced gastric bands in the 1990s. In last two years, the number of procedures has expanded dramatically since Johnson & Johnson, Botox-maker Allergen, Inc, and venture capitalists have began heavily promoting its use through websites, direct consumer ads, surgeon-training programs, and capital provision. Gastric bands are also being marketed via roadside billboards, the Internet, radio, TV, and on “Dr.Phil” and “Oprah Winfrey” programs.
How: Surgeons make tiny incisions, snake in a camera, and through video manipulation, wrap a band of silicon around the upper stomach, limiting the stomach size as a receptacle for food. The band may be periodically adjusted depending on patient response and weight loss.
Where: Training sessions are conducted nationwide, but biggest markets to date have been in Texas and California, and other entrepreneurial-minded environments.
Who: The number of procedures has grown enormously since Medicare, the Blue Cross Blue Shield Association, TriCare, and other insurers have started paying for procedures. It is said avoidance of complications, drugs, and diets justifies cost.
Monday, March 31, 2008
Electronic Medical Records - The EMR Funk
I’m something of a combined wonk and a monk when it comes to EMRs. Experts proclaim EMRs as the answer to health care woes, yet physicians resist them. Why this funk? This is a question only a wonky monk like myself can answer.
The word “wonk,” my dictionary says, is someone who is boringly, narrowly, and obliviously preoccupied with something For some time, I have been boringly, narrowly, and obliviously preoccupied with EMRs and why they are in such a funk in the real world of medical practice.
This funk stuns a lot of people after all the EMR hype. You’d think doctors would flock to EMRs. Instead 80% to 90% of doctors don’t install these electronic marvels..
The word “monk” comes from an Old English word, meaning “alone.’ A monk contemplates and prays alone. I pray EMRs will succeed, I contemplate why they don’t, and I tend to be alone in my opinions.
Out of my meditations have come these thoughts.
• First, the unworkability of EMRs. EMRs may not work for physicians because of high costs, practice disruptions, productivity losses, opposition by staff or partners, harassments of data entry, miserable returns on investment, and paranoia among physicians that EMRs are for the benefit of health plans, rather than for the benefit of patients or themselves.. The data gathered, doctors fear, will be used against them to rank them and even tank them.
• Second, the irrelevancy factor. Every specialty has its own work and thought flow patterns. Many of these patterns share little in common. For some, throughput is most important; for others a comprehensive understanding is paramount. A chief information office of a large multispecialty groups pointed out to me dermatologists, obstetricians, and ophthalmologists, and other specialists have completely different electronic needs than generalists. For a dermatologist, whose interests are skin-deep, a comprehensive EMR may bring nothing to the practice. It is simply irrelevant.
• Third, lack of application of EMR information at the “inflection point.” An inflection point is that point in patient care when the patient and the doctor need information the most. For the patient, this may be when a cancer diagnosis is first made, what specialists to go to, what tests will ensue, what lies ahead. For the emergency room doctor, the inflection point may be when a patient enters the ER after being referred by a primary care doctor. What information do I have on this patient, and how can I get it quickly? A simple email from the primary care doctor will do and is preferable to a personal health record or an EMR download. A standard EMR does little to address inflection points.
• Fourth, the emphasis on documentation rather than doctoring. Doctors are trained to be doctors rather than data entry clerks or documentation experts. Doctors don’t give one whit about complete documentation, unless, of course, it results in getting paid. One model that may work is the worksite clinic, in which others enter the data, an EMR is on site, the EMR contains relevant best practice information, and the doctor can spend his or her time doing real doctoring rather than dealing with documentation details.
• Fifth, failure to appreciate the importance of chunking.
In an excellent book, Edgeware: Insights from Complexity Science for Health Care Leaders (VHA, Inc, 1998), its authors point out most effective decisions occur at the edge, the margins, of care. Striving for complexity can be the enemy of good care. The book talks of “chunking,” allowing complex systems to emerge out of the links among simple systems that work well and are capable of operating independently. Simple workable systems build confidence, and simplicity is something complex EMRs that try to be everything for everybody sorely lack.
• Sixth, failure to stress “readiness training” for EMRs, EMRs and health 2.0 enthusiasts have failed to recognize practices must be made “ready” for EMRs. Electronic practices and paper practices are different ballgames with different work flows and thought patterns. Paper practices don’t become electronic at the snap of a finger, or the click of a mouse. In electronic practices, patients often don’t have to be present at the point of care; doctors hesitate to do anything without examining the patient. The American Association of Family Physicians (AAFP) addresses this problem with a formal readiness program. The AAFP claims 37% of its 93,000 members have adopted EMRs and another 13% have signed contracts to have systems installed. This is two to three times the national rate of EMR adoption. Doctors are conditioned to think: Ready, Fire, Aim! This doesn’t work with EMRs.
The word “wonk,” my dictionary says, is someone who is boringly, narrowly, and obliviously preoccupied with something For some time, I have been boringly, narrowly, and obliviously preoccupied with EMRs and why they are in such a funk in the real world of medical practice.
This funk stuns a lot of people after all the EMR hype. You’d think doctors would flock to EMRs. Instead 80% to 90% of doctors don’t install these electronic marvels..
The word “monk” comes from an Old English word, meaning “alone.’ A monk contemplates and prays alone. I pray EMRs will succeed, I contemplate why they don’t, and I tend to be alone in my opinions.
Out of my meditations have come these thoughts.
• First, the unworkability of EMRs. EMRs may not work for physicians because of high costs, practice disruptions, productivity losses, opposition by staff or partners, harassments of data entry, miserable returns on investment, and paranoia among physicians that EMRs are for the benefit of health plans, rather than for the benefit of patients or themselves.. The data gathered, doctors fear, will be used against them to rank them and even tank them.
• Second, the irrelevancy factor. Every specialty has its own work and thought flow patterns. Many of these patterns share little in common. For some, throughput is most important; for others a comprehensive understanding is paramount. A chief information office of a large multispecialty groups pointed out to me dermatologists, obstetricians, and ophthalmologists, and other specialists have completely different electronic needs than generalists. For a dermatologist, whose interests are skin-deep, a comprehensive EMR may bring nothing to the practice. It is simply irrelevant.
• Third, lack of application of EMR information at the “inflection point.” An inflection point is that point in patient care when the patient and the doctor need information the most. For the patient, this may be when a cancer diagnosis is first made, what specialists to go to, what tests will ensue, what lies ahead. For the emergency room doctor, the inflection point may be when a patient enters the ER after being referred by a primary care doctor. What information do I have on this patient, and how can I get it quickly? A simple email from the primary care doctor will do and is preferable to a personal health record or an EMR download. A standard EMR does little to address inflection points.
• Fourth, the emphasis on documentation rather than doctoring. Doctors are trained to be doctors rather than data entry clerks or documentation experts. Doctors don’t give one whit about complete documentation, unless, of course, it results in getting paid. One model that may work is the worksite clinic, in which others enter the data, an EMR is on site, the EMR contains relevant best practice information, and the doctor can spend his or her time doing real doctoring rather than dealing with documentation details.
• Fifth, failure to appreciate the importance of chunking.
In an excellent book, Edgeware: Insights from Complexity Science for Health Care Leaders (VHA, Inc, 1998), its authors point out most effective decisions occur at the edge, the margins, of care. Striving for complexity can be the enemy of good care. The book talks of “chunking,” allowing complex systems to emerge out of the links among simple systems that work well and are capable of operating independently. Simple workable systems build confidence, and simplicity is something complex EMRs that try to be everything for everybody sorely lack.
• Sixth, failure to stress “readiness training” for EMRs, EMRs and health 2.0 enthusiasts have failed to recognize practices must be made “ready” for EMRs. Electronic practices and paper practices are different ballgames with different work flows and thought patterns. Paper practices don’t become electronic at the snap of a finger, or the click of a mouse. In electronic practices, patients often don’t have to be present at the point of care; doctors hesitate to do anything without examining the patient. The American Association of Family Physicians (AAFP) addresses this problem with a formal readiness program. The AAFP claims 37% of its 93,000 members have adopted EMRs and another 13% have signed contracts to have systems installed. This is two to three times the national rate of EMR adoption. Doctors are conditioned to think: Ready, Fire, Aim! This doesn’t work with EMRs.
Sunday, March 30, 2008
Managed Care - The Industry Everybody Loves to Have
In the Spring of 2007. 113 hospital and physician organizations completed a survey on their attitudes towards managed care- a common enemy.
The words used to describe managed care were, in no particular order.
• Inflexible
• Rigid
• Incompetent
• Arrogant
• Greedy
• Unresponsible
• Pushy
• Unethical
• Careless
• Clueless
The managed care loser, in order of enmity, were,
• United HealthCare, 91%
• WellPoint/Anthem, 48%
• Cigna, 47%
• Aetna, 37%
To improve relations, doctors and hospitals suggest,
• Honest P4P programs
• Data exchange
• Streamlines business practices
• Clarity
Emad Rizk, MD, president of McKesson Health Solutions, says managed care can improve by
• Pick geographic areas in which they have more than 15% market share.
• Select a disease or populations in which they want to improve their image.
• Target hospitals and doctors with which they want better relations.
• Agree upon clinical process.
• Agree on outcome goals you want to achieve.
• Share financial incentives you will give.
• Agree on how to share data.
* Summarized from “Managed Care Can Improve Relations with Providers,” Healthleadersmedia.com, March 19, 2008.
The words used to describe managed care were, in no particular order.
• Inflexible
• Rigid
• Incompetent
• Arrogant
• Greedy
• Unresponsible
• Pushy
• Unethical
• Careless
• Clueless
The managed care loser, in order of enmity, were,
• United HealthCare, 91%
• WellPoint/Anthem, 48%
• Cigna, 47%
• Aetna, 37%
To improve relations, doctors and hospitals suggest,
• Honest P4P programs
• Data exchange
• Streamlines business practices
• Clarity
Emad Rizk, MD, president of McKesson Health Solutions, says managed care can improve by
• Pick geographic areas in which they have more than 15% market share.
• Select a disease or populations in which they want to improve their image.
• Target hospitals and doctors with which they want better relations.
• Agree upon clinical process.
• Agree on outcome goals you want to achieve.
• Share financial incentives you will give.
• Agree on how to share data.
* Summarized from “Managed Care Can Improve Relations with Providers,” Healthleadersmedia.com, March 19, 2008.
Saturday, March 29, 2008
Hospitals and Doctors, future - The Future of Hospitals and Baby Boomer Physicians
This is not a good time to be a hospital CEO.
From the Bush Medicare budget request over the next five years comes this news.
• The largest amount of Medicare cuts, by far, will come from hospitals: $15 billion from an across-the-board reduction in the annual updates for inpatient care; $25 billion from special payments to hospitals serving large numbers of poor people; and $20 billion from capital payments for constructing hospital buildings and the purchase of equipment.
And from the mean streets come these pieces of news about baby boomer physicians.
• The urge for physicians to be employed by hospitals will surge. Younger and older baby boomer physicians want security, time off, regular hours, vacations, malpractice coverage, and relief from the risks of running a business. This makes hospital CEOs wary because they took a financial bath during the late 1990s when they acquired hospital practices. Still. doctors need intensivists, hospitalists, ER doctors, and even general surgeons – positions in which doctors can enjoy 40 hour work weeks. For hospitals, these doctors, often in short supply, do not come cheaply. It costs as much as $443,000 to recruit a cardiologist, $471, 000 an orthopedic surgeon, $263.000 an internist, and $246,000 for a family physician.
• At the same time, more physicians are seeking independence from hospitals. The shift to ambulatory care is in full swing, as doctors seek autonomy. Unfortunately, for the hospital CEO, many physicians seeking less dependency - orthopedic surgeons, cardiovascular specialists, proceduralists of every ilk – contribute the most to hospital bottom lines. The lure of being your own person of controlling your own destiny in terms of income and clinical practice is well nigh irresistible. This means hospitals must hire these specialists for internal coverage and external coverage.
• Conflicts over call coverage will haunt hospitals. Legally hospitals have to be open 24 hours a day and to accept all comers to the emergency rooms. This is tough when uninsured rolls are growing, and people tend to go to the ER rather than bother their doctor. Furthermore, specialists are reluctant to come in at all hours to treat patients they have never seen, who pose formidable malpractice risks, and who cannot afford to pay.
• The physician shortage is intensifying. The Council on Physician and Nurse Supply, an independent group of healthcare leaders based at the University of Pennsylvania, has called on the White House to convene a special conference to address an estimated 30% national shortage of physicians and nurses. The council estimates the U.S will be 150,000 to 200,000 short of physicians by 2020, and nursing schools must produce 30,000 more nurses a year to keep up with demand. This shortage places new economic demands for hospitals, who must pay more recruiting expenses or hire locum tenens physicians or traveling nurses to fill the gaps.
Small wonder hospital CEOs place physician relations and nurse shortages as number one and two on their agendas. The good news is that hospitals have been running record profits over the last five years and have a cushion to address these problems. The bad news for hospitals that no immediate solutions are in sight. They good news for doctors is that they are in greater demand and call the tune. The bad news for some, not all, is that they must become employees rather than independent practitioners.
From the Bush Medicare budget request over the next five years comes this news.
• The largest amount of Medicare cuts, by far, will come from hospitals: $15 billion from an across-the-board reduction in the annual updates for inpatient care; $25 billion from special payments to hospitals serving large numbers of poor people; and $20 billion from capital payments for constructing hospital buildings and the purchase of equipment.
And from the mean streets come these pieces of news about baby boomer physicians.
• The urge for physicians to be employed by hospitals will surge. Younger and older baby boomer physicians want security, time off, regular hours, vacations, malpractice coverage, and relief from the risks of running a business. This makes hospital CEOs wary because they took a financial bath during the late 1990s when they acquired hospital practices. Still. doctors need intensivists, hospitalists, ER doctors, and even general surgeons – positions in which doctors can enjoy 40 hour work weeks. For hospitals, these doctors, often in short supply, do not come cheaply. It costs as much as $443,000 to recruit a cardiologist, $471, 000 an orthopedic surgeon, $263.000 an internist, and $246,000 for a family physician.
• At the same time, more physicians are seeking independence from hospitals. The shift to ambulatory care is in full swing, as doctors seek autonomy. Unfortunately, for the hospital CEO, many physicians seeking less dependency - orthopedic surgeons, cardiovascular specialists, proceduralists of every ilk – contribute the most to hospital bottom lines. The lure of being your own person of controlling your own destiny in terms of income and clinical practice is well nigh irresistible. This means hospitals must hire these specialists for internal coverage and external coverage.
• Conflicts over call coverage will haunt hospitals. Legally hospitals have to be open 24 hours a day and to accept all comers to the emergency rooms. This is tough when uninsured rolls are growing, and people tend to go to the ER rather than bother their doctor. Furthermore, specialists are reluctant to come in at all hours to treat patients they have never seen, who pose formidable malpractice risks, and who cannot afford to pay.
• The physician shortage is intensifying. The Council on Physician and Nurse Supply, an independent group of healthcare leaders based at the University of Pennsylvania, has called on the White House to convene a special conference to address an estimated 30% national shortage of physicians and nurses. The council estimates the U.S will be 150,000 to 200,000 short of physicians by 2020, and nursing schools must produce 30,000 more nurses a year to keep up with demand. This shortage places new economic demands for hospitals, who must pay more recruiting expenses or hire locum tenens physicians or traveling nurses to fill the gaps.
Small wonder hospital CEOs place physician relations and nurse shortages as number one and two on their agendas. The good news is that hospitals have been running record profits over the last five years and have a cushion to address these problems. The bad news for hospitals that no immediate solutions are in sight. They good news for doctors is that they are in greater demand and call the tune. The bad news for some, not all, is that they must become employees rather than independent practitioners.
Friday, March 28, 2008
Insights - Healthleaders Magazine - Insiders’ Insights
The March glossy issue of Healthleaders Magazine just hit my desk. Healthleaders is a Massachusetts based publishing firm that has a website, healthleadersmedia.com, a research firm, a conference giver, and a book publisher.
Their March issue’s cover story is “Your Hospital, The Entrepreneur, How Funding Early-Stage Ventures Now Can Yield Health Returns Later.” It features a story on hospital innovation. It talks of Ascension Health and its venture capital fund, and Vanderbilt University and its venture fund.
At Vanderbilt, William W, Stead, MD, associate vice chancellor for strategy and transformation and chief information officer, leads its innovation team. Says Stead, “It takes a particular mindset to be an effective entrepreneur. And there are a limited number of academic teams, certainly academic ones, that understand entrepreneurial people well enough to know how to lead them.”
Innovation runs in the Stead family. William Stead’s brother, Eugene Stead, MD, headed Internal Medicine at Duke, while I was a student, and he pioneered and founded the concept of Physician Assistants after observing that medics returning from Vietnam had great skills but nowhere to apply them.
But that's another story. T
he March issue also contains two “Insider Insights”, two short pieces on what health insiders think. One piece quotes me as editor of Physician Practice Options Old Saybrook. Connecticut, and the other citss Vince Kuraitis, principal of Better Health Technologies, LLC, of Boise, Idaho.
Here are our respective comments:
Reece: Doctors are highly skeptical about IT relieving the burden of their practice for a couple of reasons. One, with electronic medical records, they don’t seen any return on investments. Two, it disrupts their practice. And three, it costs too much, especially when you include maintenance of technology. That is one of the principal reasons only 10 percent to 20 percent of doctors in small practices have gone to EMRs, and only 20% communicate by e-mail. E-mail communication, in their minds, is not part of their normal practice flow, so they have not adapted to that yet. Some health plans do reimburse for time spent e-mailing – it’s seen as a way of giving patients more options. It’s an evolutionary thing, however, and we are clearly in the early stages.
Kuraitis: The current system is one that is totally designed to provide in-person are – and that is what they system is reimbursed for. The assumption is that is how care is delivered, and in the days that was a valid assumption. But now we are changing the assumption that care has to be delivered and/or reimbursed in person. As a result, doctors will be doing more virtual care, and the other part of the equation is that they’ll also be getting paid for it. It will be a change in the work flow, abut I would say it is good because we are chaning the though process on what is the optimal way to deliver care. For a lot of things, you don't have to be in front of a doctor. The new technologies will improve patient care because they have the potential to make doctors more competitive.
Their March issue’s cover story is “Your Hospital, The Entrepreneur, How Funding Early-Stage Ventures Now Can Yield Health Returns Later.” It features a story on hospital innovation. It talks of Ascension Health and its venture capital fund, and Vanderbilt University and its venture fund.
At Vanderbilt, William W, Stead, MD, associate vice chancellor for strategy and transformation and chief information officer, leads its innovation team. Says Stead, “It takes a particular mindset to be an effective entrepreneur. And there are a limited number of academic teams, certainly academic ones, that understand entrepreneurial people well enough to know how to lead them.”
Innovation runs in the Stead family. William Stead’s brother, Eugene Stead, MD, headed Internal Medicine at Duke, while I was a student, and he pioneered and founded the concept of Physician Assistants after observing that medics returning from Vietnam had great skills but nowhere to apply them.
But that's another story. T
he March issue also contains two “Insider Insights”, two short pieces on what health insiders think. One piece quotes me as editor of Physician Practice Options Old Saybrook. Connecticut, and the other citss Vince Kuraitis, principal of Better Health Technologies, LLC, of Boise, Idaho.
Here are our respective comments:
Reece: Doctors are highly skeptical about IT relieving the burden of their practice for a couple of reasons. One, with electronic medical records, they don’t seen any return on investments. Two, it disrupts their practice. And three, it costs too much, especially when you include maintenance of technology. That is one of the principal reasons only 10 percent to 20 percent of doctors in small practices have gone to EMRs, and only 20% communicate by e-mail. E-mail communication, in their minds, is not part of their normal practice flow, so they have not adapted to that yet. Some health plans do reimburse for time spent e-mailing – it’s seen as a way of giving patients more options. It’s an evolutionary thing, however, and we are clearly in the early stages.
Kuraitis: The current system is one that is totally designed to provide in-person are – and that is what they system is reimbursed for. The assumption is that is how care is delivered, and in the days that was a valid assumption. But now we are changing the assumption that care has to be delivered and/or reimbursed in person. As a result, doctors will be doing more virtual care, and the other part of the equation is that they’ll also be getting paid for it. It will be a change in the work flow, abut I would say it is good because we are chaning the though process on what is the optimal way to deliver care. For a lot of things, you don't have to be in front of a doctor. The new technologies will improve patient care because they have the potential to make doctors more competitive.
Thursday, March 27, 2008
Physician Shortage - The Fix?
Suddenly, a chorus of voices are shouting - train more primary care doctors, pay them more, pay them as well as specialists, and empower them by giving them control over referrals.
“Let’s eliminate E & M codes. Let’s create financial incentives for serving as an ‘Advanced Medical Home’ Let’s pay primary care physicians for what they do – providing comprehensive and coordinated care for patients – rather than by fee-for-service for individual acts. Let’s tie this payment into the severity and complexity of the illness. Let’s encourage the primary care specialists to become involved in coordinating care with the specialists to whom they refer.”
Norbert Goldfield, MD, Internist, Springfield, Massachusetts, Head, 3M Informatics Group, 2007
“The Patient-Centered Primary Care Collaborative, a coalition of large employers and professional groups, has been advocating for changes in reimbursement and the roles of primary care physicians. By realigning the incentives, by using tools, data and programs to identify and manage risk at the level of primary care, and by enforcing downstream accountability from the primary care base, these models have the potential to reinvigorate primary care, and to drive tremendous new improvements in quality and efficiency, and to help re-establish health care stability and sustainability.”
Brian Klepper, PhD, health care analyst, The Doctor Weighs in Blog, March 27, 2008
“United States is in the throes of a deepening physician shortage, and will experience a shortfall of 100,000 to 200,000 physicians over the next 15 years. Closing this gap will require an expansion of both medical schools and graduate medical education (GME) positions at the nation’s teaching hospitals. The Council also called for GME capacity to be increased by 30 percent. The Council warned that lifting the current cap Congress has imposed on Medicare-based funding for GME, while necessary, will not be enough.”
Press Release, Council on Physician & Nurse Supply, University of Pennsylvania Leonard Davis Institute of Health Care Economics, and AMN, Inc, America’s largest heath care staffing company
“Even without health-care reform, the demand for family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians. That’s a 40% increase over the family physicians at work in 2006. The fact is that costs are too high for an economically viable practice in many areas. Payments from the government and large insurance companies don’t adequately cover expenses and the burden of educational debt. The cost of malpractice insurance to practice the full range of primary care medicine, including obstetrics, is untenable. How can anybody rationally expect to build up the nation’s health on that crumbling foundation”
Benjamin Brewer, MD, family physician, The Doctor’s Office, “Primary Health Care Needs Fixing Before Universal Care Can Work,” Wall Street Journal, March 26, 2008.
“Perhaps these retainer practices, if they continue to flourish, will stimulate a resurgence of outpatient internal medicine. We will be able to continue to train internists who understand the spectrum and complexity of disease, because the retainer model provides an option for those who prefer the outpatient setting but also want complexity and comprehensiveness. Whereas many critics are concerned with the finances of this model and worry about inequities, supporters emphasize the retainer physician's ability to provide the level of care and attention that patients deserve. The retainer model originated and is succeeding because of classic market forces. Physicians and patients find our current arrangements undesirable, thus this new alternative model gives them an interesting choice. Perhaps it will save outpatient internal medicine.”
Robert M. Centor, MD, Professor and Director of General Medicine, U. of Alabama, Birmingham. March 20, 2008, Medscape Business of Medicine“
An impossible dream? Not to every major industrialized country on the planet. This plan is called single-payer. You might have heard of it, perhaps when it's being disparaged by insurance and pharmaceutical companies. There are many controversial issues related to a single-payer healthcare system, but it is time for all of the stakeholders in medical care to realize that the consequences of our current quagmire of a healthcare anti-system are too important to remain intransigent to change. The work will be hard, and some sacrifices will have to be accepted on all sides. However, in the end, we will have a system that is not only fair and efficient but caring and personal as well.”
Charles Vega, MD, Associate Professor, Department of Family Medicine, U. of California, Irving, March 20, 2008, Medscape Business of Medicine
“Let’s eliminate E & M codes. Let’s create financial incentives for serving as an ‘Advanced Medical Home’ Let’s pay primary care physicians for what they do – providing comprehensive and coordinated care for patients – rather than by fee-for-service for individual acts. Let’s tie this payment into the severity and complexity of the illness. Let’s encourage the primary care specialists to become involved in coordinating care with the specialists to whom they refer.”
Norbert Goldfield, MD, Internist, Springfield, Massachusetts, Head, 3M Informatics Group, 2007
“The Patient-Centered Primary Care Collaborative, a coalition of large employers and professional groups, has been advocating for changes in reimbursement and the roles of primary care physicians. By realigning the incentives, by using tools, data and programs to identify and manage risk at the level of primary care, and by enforcing downstream accountability from the primary care base, these models have the potential to reinvigorate primary care, and to drive tremendous new improvements in quality and efficiency, and to help re-establish health care stability and sustainability.”
Brian Klepper, PhD, health care analyst, The Doctor Weighs in Blog, March 27, 2008
“United States is in the throes of a deepening physician shortage, and will experience a shortfall of 100,000 to 200,000 physicians over the next 15 years. Closing this gap will require an expansion of both medical schools and graduate medical education (GME) positions at the nation’s teaching hospitals. The Council also called for GME capacity to be increased by 30 percent. The Council warned that lifting the current cap Congress has imposed on Medicare-based funding for GME, while necessary, will not be enough.”
Press Release, Council on Physician & Nurse Supply, University of Pennsylvania Leonard Davis Institute of Health Care Economics, and AMN, Inc, America’s largest heath care staffing company
“Even without health-care reform, the demand for family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians. That’s a 40% increase over the family physicians at work in 2006. The fact is that costs are too high for an economically viable practice in many areas. Payments from the government and large insurance companies don’t adequately cover expenses and the burden of educational debt. The cost of malpractice insurance to practice the full range of primary care medicine, including obstetrics, is untenable. How can anybody rationally expect to build up the nation’s health on that crumbling foundation”
Benjamin Brewer, MD, family physician, The Doctor’s Office, “Primary Health Care Needs Fixing Before Universal Care Can Work,” Wall Street Journal, March 26, 2008.
“Perhaps these retainer practices, if they continue to flourish, will stimulate a resurgence of outpatient internal medicine. We will be able to continue to train internists who understand the spectrum and complexity of disease, because the retainer model provides an option for those who prefer the outpatient setting but also want complexity and comprehensiveness. Whereas many critics are concerned with the finances of this model and worry about inequities, supporters emphasize the retainer physician's ability to provide the level of care and attention that patients deserve. The retainer model originated and is succeeding because of classic market forces. Physicians and patients find our current arrangements undesirable, thus this new alternative model gives them an interesting choice. Perhaps it will save outpatient internal medicine.”
Robert M. Centor, MD, Professor and Director of General Medicine, U. of Alabama, Birmingham. March 20, 2008, Medscape Business of Medicine“
An impossible dream? Not to every major industrialized country on the planet. This plan is called single-payer. You might have heard of it, perhaps when it's being disparaged by insurance and pharmaceutical companies. There are many controversial issues related to a single-payer healthcare system, but it is time for all of the stakeholders in medical care to realize that the consequences of our current quagmire of a healthcare anti-system are too important to remain intransigent to change. The work will be hard, and some sacrifices will have to be accepted on all sides. However, in the end, we will have a system that is not only fair and efficient but caring and personal as well.”
Charles Vega, MD, Associate Professor, Department of Family Medicine, U. of California, Irving, March 20, 2008, Medscape Business of Medicine
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