Daily Healthy: doctor-patient

Who’s Afraid of the Medical Home?

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Obamacare is here to stay, and with it a host of initiatives small and large, some intended and some not so much so, targeting massive transformation of the health care delivery system. One of those initiatives involves the adoption of the principles of a <a href="http://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf" target="_blank">Patient Centered Medical Home</a> (PCMH) for primary care as formulated by the primary care medical associations, and to a large extent, as translated into operational processes by the <a href="http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx" target="_blank">National Committee for Quality Assurance</a> (NCQA). There are other implementations of the PCMH put forward by public and private organizations, but NCQA’s Medical Home recognition program is considered the gold standard for PCMH. The PCMH concept is also here to stay, and as is the case with Obamacare, the Medical Home model has its supporters, its detractors and all sorts of misconceptions and implementation missteps. 
 
If you randomly ask a primary care physician about his/her opinion on the Patient Centered Medical Home model of primary care, you will most likely get one of the answers listed below in order of increasing prevalence: 
<ol>
<li>Absolutely fantastic way to practice medicine. We’ve been doing this for a while and are a Level III recognized Medical Home. </li>
<li>The idea is good and we are currently making the transition and working on obtaining NCQA recognition. It’s not easy, but we are hopeful.</li>
<li>We are part of a PCMH pilot in our state. It’s a lot of work and I am not convinced that it will have any benefits for my practice.</li>
<li>I read about it, but I can’t afford to hire dieticians and social workers and spend time on all the paper work. </li>
<li>I don’t have time for this.  Just a bunch of government regulations that do nothing for patient care.</li>
<li>This is the final nail in the coffin of primary care. It’s going to drive all remaining independent physicians out of practice, which is what the government wants anyway.</li>
<li>My mother-in-law is in an assisted living facility, but other than that I don’t have any patients in nursing homes….. I don’t take Medicaid.</li>
<li>Say that again….?</li>
</ol>
Just like Obamacare is not something invented by overzealous socialists, but the brainchild of extremely conservative thinking, the PCMH is not a government invention, but instead it is based on a statement made by physician associations attempting to define good primary care and the need for insurers to pay more for such excellence. The devil of course is in the details. It’s been said that the “official” NCQA PCMH requirements consist of too many details, and that some of those details are bureaucratic in nature, burdensome, expensive and contribute little to patient care. It’s been said that true quality of care and practice transformation, whatever that may be, is largely independent of counting points, formal testing, certifications and recognitions.  Granted, all these contentions seem reasonable, but before deciding to walk away, how about a quick bird’s eye tour of what NCQA PCMH recognition really is? 
 
The six parts of formal NCQA 2011 PCMH recognition are called Standards. Let’s take a critical look at each one and note the order in which they are arranged. 
 
Standard #1 - Enhance Access and Continuity – Continuity here refers to people having a personal physician instead of seeing whoever happens to have time that day. I don’t know many practices where this is not the case anyway, but it’s hard to argue against the need to build a long term relationship between patients and their doctors, and it’s even harder to argue against this being the #1 foundational requirement of delivering high quality longitudinal patient care. Note that by definition solo practices are automatically set up to care for patients this way (just saying…). The second part of this Standard is a bit more problematic from a physician’s point of view, because it does require availability after hours and seeing patients the same day as much as possible. It is not an easy task to start tinkering with your schedule, if you are not currently offering same-day appointments, and done haphazardly, it may have serious financial implications to your practice. How about being available after hours, particularly for a solo or very small practice? How about your family and personal life? If you are one of the new concierge docs with a tiny panel of well-behaved patients, this is obviously not an issue. If you have 2500 patients, or so, on your panel, some creative thinking may be required. How would your patients react if, say, every Tuesday you’d start seeing patients from 12 pm to 8 pm? Or if you closed early on Wednesdays and twice a month you saw patients on Saturday mornings? Or if you had an arrangement with a couple of other practices to provide urgent care at odd hours on a rotating basis? 
 
A recent study in the <a href="http://annfammed.org/content/10/5/388.abstract?ijkey=&keytype2=tf_ipsecsha" target="_blank">Annals of Family Medicine</a> found that total health care expenditures were 10.4% lower for patients who had access to extended hours of care. This is great news for the “system”, but how about benefits to you and your practice? Whether you like it or not, you are now competing against business models with extremely low overhead, such as grocery store clinics and virtual tele-medicine clinics, offering pseudo-primary-care to your rushed and hurried patients for simple needs, leaving you to deal with complex visits that cost you a lot to deliver, but pay as much (or as little) as the simple ones. Unless you start thinking outside the box, your model of business is destined to become obsolete. Offering some electronic visits, providing hours for urgent care needs and collaborating with others on extended coverage may very well be a matter of survival. Interestingly enough, another recent <a href="http://jama.jamanetwork.com/article.aspx?articleid=1197012" target="_blank">JAMA</a> study, although limited to community health centers, finds measurable correlation between access and continuity and lower operational costs per unit of service. There should be very little doubt at this point that Standard #1 is the place to start work on the viability of any practice, or ignored at significant peril. 
 
Standard #2 - Identify and Manage Patient Populations – This one sounds onerous and a departure from individualized patient care, but is it really so? The “populations” term notwithstanding, all this Standard requires is that you document patient demographics and clinical information in the chart (seriously?), that you take good histories and that you send reminders to your patients to mind their chronic and/or preventive care needs. There is really nothing here that a good primary care physician doesn’t already do, and probably to a much greater extent than the NCQA standards specify. The one thing that may be different is that this Standard talks about proactive reminders to patients that don’t come in to see you on their own. Good for business and definitely good for patient care on an individual level. 
 
Standard #3 - Plan and Manage Care – Another statement of the obvious, but this standard uses terminology that may raise some eyebrows. For example, it asks that your care is evidence-based. Is your care not evidence-based? Surely you decide how to treat patients based on your education, what you learned along the years, books, articles and latest research, instead of throwing darts at a random treatments list hanging in your office. And this is really all there is to this Standard, other than practicing medicine, i.e. seeing patients, evaluating conditions, planning care, talking to patients, and generally speaking, being their doctor.  
 
Standard #4 - Provide Self-Care Support and Community Resources – This may sound like the new age fluff of patients taking care of themselves, and granted, there is some of that here, but the details are again pretty straightforward in their intent to have patients understand their conditions and do something about it. Primary care docs don’t usually fit the much publicized portrait of aloof and paternalistic doctors who won’t give you the time of day. It is the time constraints in fully loaded practices that may prevent some from fully engaging with their patients, and no certification process will change that without proper shift in reimbursement, or a change to a more direct practice model with smaller patient panels. This Standard’s feasibility is also highly dependent on patients themselves, but there are simple things you and your staff can do to better enable patients to take some responsibility for their own health (most of which you are probably doing already), and this is all this Standard is about. 
 
Standard #5 - Track and Coordinate Care – Do you send patients to specialists and then forget all about them? Do you order lab tests and don’t care if the results come in or not or if they are normal or not? Do you get calls from the hospital notifying you that one of your patients was admitted, and you hang up thinking that this is not your problem? No? Then you are tracking and coordinating care. Can you do more? Probably, but here you are largely at the mercy of specialists and hospitals in particular. You most likely already have tickler lists to help remind your staff about getting specialists notes and test results, but it is extremely difficult to have the hospital contact you if you are not admitting your own patients (and sometimes even if you do). There is effort (and costs) involved in better tracking and better coordination and payers are starting to take notice as evidenced by the latest care coordination CPTs added to the Medicare physician fee schedule. 
 
Standard #6 - Measure and Improve Performance – Here it is. This is the measuring, reporting and all administrating bag of requirements, complete with patient satisfaction surveys, sending data to payers and using electronic medical records. While most items here are optional, a medical home is required to set some improvement goals for clinical measures (just goal setting, not necessarily outcomes). So after doing everything outlined in previous Standards, this is where the assumption is implicitly made that a medical home should be able to continuously improve the care it provides. Perhaps you believe that you are already providing excellent care, and no doubt most of you do, but is there anything more you can do? This Standard is asking you to consider this question, and if you have an answer, begin acting on it. And yes, this too may take more time and more effort on your part, and thus be dependent on payments to support these efforts. 
 
Did I leave anything out? If your opinion of the PCMH was something along the lines of #6 above, you are probably wondering about some “strategic” omissions. How about all that “team care” and nurse practitioners? How about those case managers and dieticians? What of the need to buy, implement and use an expensive EMR? Well, for starters these things are optional in nature. Unless you are a team of one, you already have people helping you out with patient care and administration, and you are not required to use or augment your staff more than you are comfortable with. A good EMR should help, but it is not mandatory either. And yes, NCQA will recognize nurse practitioner led practices as medical homes, but this is reflective of legislation at State levels, and it should be appropriately addressed at a policy and legislative level as well. As to the infamous amounts of paperwork involved, yes, there is plenty of that, but there is also plenty of help out there and you just need to find it. 
 
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On the surface the NCQA PCMH recognition process is an administrative test for primary care, but if you look at it carefully, you can see that it is also a logically ordered roadmap for quality primary care and a tool for you to take a fresh look at your practice and position it to change with the times without having to sacrifice your ethics and your principles. Some things in this roadmap are at the heart of what you do every day, others are things that you may want to do if time and finances allowed, and few are in the realm of “forget it”. Unlike Meaningful Use, the NCQA PCMH “test” is not an all-or-nothing proposition and there is reasonable freedom for you to discard those “forget it” items, or postpone the wishful thinking for a better day. There should be financial benefits accruing from just doing some of the things on this roadmap (such as Standard #1), and there are financial incentives from payers for doing other things or from just “passing the test”. 
 
The medical home is a timeless model of care, repackaged for these troubled and technology driven times, and as such, it is also a business model for the future of primary care. You could approach the entire exercise as yet another payer and government mandated intrusion, or you could make this roadmap your own, and look at it as a means by which to refine and sustain an already excellent practice. It is ultimately all up to you. 
 
[Disclosure: I am the founder of BizMed, a company whose mission is to support the viability of independent medical practice, and to that end it offers free software tools to reduce administrative complexity in private practice in general, and PCMH recognition in particular]</div>

Obamacare is here to stay, and with it a host of initiatives small and large, some intended and some not so much so, targeting massive tr...

Why Doctors Will Never Ever Like EMRs and How to Change That

9:30 PM Meme Art Studio 0 Comment

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EMRs are not designed for patient care. Is there anyone working in health IT who can honestly say that he or she never heard this statement being made hundreds or thousands of times? Is there any clinician actually working with patients and EMRs who can state that such thought never crossed his or her mind? This includes health IT evangelists and physicians spearheading IT initiatives at the most excellent of centers of excellence. People complained that EMRs are not designed for patient care seven years ago, when the first EMR <a href="http://en.wikipedia.org/wiki/CCHIT" target="_blank">certification body</a> was created. They said the same thing four years ago when billions of dollars were made available for the purchase of EMRs. They kept insisting even as use of EMRs was becoming widespread two years ago, and the chorus remains unchanged today: EMRs are not designed for patient care. 
 
Seven years is an eternity in the world of computer technology. Seven years ago Motorola and Blackberry ruled the world and the iPhone was getting ready to be born. Seven years ago something called <a href="http://techcrunch.com/2006/07/15/is-twttr-interesting/" target="_blank">Twttr</a> was released and Facebook launched a high-school version of itself. Seven years ago Ken Jennings was undisputed king of Jeopardy and IBM’s Watson was wrong 85% of the time. We’ve come a long way, baby, but EMRs are still not designed for patient care. Why is that? The most common explanation is that EMRs were designed for billing and cannot be changed. But if a program designed to play Jeopardy can be expanded to practice medicine, surely seven years is more than enough to refocus EMRs on something other than billing. The second most common reason given for the inadequacy of EMRs is the inadequacy of those who build them; because we all know that all great programmers work at Apple, unless of course, they work at Twitter or IBM or somewhere in Verona, Wisconsin. More seriously, the third explanation for EMRs failure to help with patient care is the onslaught of government regulations for EMR design. 
 
Many, <a href="http://onhealthtech.blogspot.com/2013/09/alternative-health-information.html" target="_blank">including yours truly</a>, are arguing that EMR vendors are so busy meeting regulatory mandates that there are no resources available to make customers happy. On second thought though, are we saying that giants like GE that owns half the planet, or McKesson with its astronomic CEO compensation, or that one place in Verona, are unable to spring a few bucks for half a dozen developers to make EMRs better for patient care? Are we saying that a market chockfull of very wealthy customers railing for a solution cannot attract even one manufacturer willing to solve the problem and collect billions of dollars in return? Surely we are not saying that seven years is not enough time for writing an EMR that is designed for patient care. On September 12, 1962, President John F. Kennedy, in a <a href="http://er.jsc.nasa.gov/seh/ricetalk.htm" target="_blank">speech at Rice University</a>, officially launched the race to the moon. On July 20, 1969, Neil Armstrong and Buzz Aldrin <a href="http://airandspace.si.edu/explore-and-learn/topics/apollo/AS11/a11.htm" target="_blank">walked</a> on the moon. It took seven years. 
 
EMRs are not designed for patient care because our medical system is no longer designed for patient care. Our medical system is being redesigned to provide health services to consumers, and EMRs are morphing into superb tools for a service industry. 
<ul>
<li>EMRs are designed to collect increasingly detailed customer information.</li>
<li>EMRs are designed to facilitate market research.</li>
<li>EMRs are designed to standardize and automate transactional complexity.</li>
<li>EMRs are designed to smooth handoffs across the supply chain.</li>
<li>EMRs are designed to orchestrate and monitor production lines.</li>
<li>EMRs are designed to minimize production costs and maximize revenues.</li>
<li>EMRs are designed to provide quality assurance based on exact specifications. </li>
<li>EMRs are designed to prevent and quickly detect malfunction and non-compliance with specifications.</li>
</ul>
To be clear, most EMRs can’t do all these things just yet, but they are being redesigned along these lines, because these new EMRs are foundational to what <a href="http://scholar.harvard.edu/cutler/biocv" target="_blank">David Cutler</a>, a Harvard Applied Economics Professor and one of the most influential health care policy makers, calls the “information technology revolution”. In a surprisingly candid <a href="http://www.technologyreview.com/news/518906/why-medicine-will-be-more-like-walmart/" target="_blank">article</a> Prof. Cutler is describing the future health care system as designed by him and his distinguished colleagues, and as currently implemented by our government. The title of his article is self-explanatory: “Why Medicine Will Be More Like Walmart”. It is very possible that as EMRs are being carefully repurposed, they will also be made more intuitive, more iPhone like, glossier, faster, more colorful, and generally more appealing, because it is imperative right now that physicians use them consistently, and preferably without much turmoil. Why? Let’s hear from Prof. Cutler: “The introduction of information technology into the core operations of hospitals and doctors’ offices is likely to make health care much more like the retail sector or financial services. Health care will be provided by big institutions, in a more standardized fashion, with less overall cost, but less of a personal touch”. And, if I may respectfully add, increased convenience and instant consumer gratification to be balanced by lower quality, lower wages, rampant fraud and mass exploitation of both workers and customers. A veritable paradise for well-adjusted proletariat. 
 
Yes, physicians will be using EMRs in larger and larger numbers, but there is zero probability that today’s doctors will ever like using EMRs, because nobody goes to medical school (or any school) hoping one day to land a job at a Walmart lookalike. So the logical remedy for doctors’ dislike of emerging Walmart EMRs is very simple: get rid of doctors. Right now we are told that there is a looming shortage of physicians, so we must find ways to deliver medical services without doctors, and hence we must automate, computerize and delegate medical care. Very clever idea, because once we downgrade services and have people accept this new paradigm, we can make the circular argument that we need even fewer doctors. Indeed Prof. Cutler goes on to prophesize the demise of small independent practice and small hospitals along with most conventional doctoring, which will be replaced by computer-aided self-diagnosis and crowd sourced clinical advice (something to do with Amazon, I think…). He still sees a need for a few doctors here and there, mainly “to direct patients to the right specialized resources, to reassure those in need, and to comfort the terminally ill”, which we are told “is a noble calling nonetheless”.  Noble calling indeed, but it should not require an MD or fifteen years of preparation, and hence it will not command much attention or compensation. The Walmart “doctors” in David Cutler’s future of health care will be happy to like their EMRs, or whatever else they are told to like. 
 
Oh, by the way, no need for panic... I am fairly certain that they will have separate little venues serving Dom Perignon and Beluga caviar with Harvard Medical School educated physicians on the side.</div>

doctor-patient Why Doctors Will Never Ever Like EMRs and How to Change That

EMRs are not designed for patient care. Is there anyone working in health IT who can honestly say that he or she never heard this stateme...

The People’s Advocate at the Supreme Court Bar

1:11 AM Meme Art Studio 0 Comment

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<tr><td class="tr-caption" style="text-align: center;">H. Bartow Farr, III, Esq. </td></tr>
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The Patient Protection and Affordable Care Act (PPACA) has finally met its challengers in the highest Court in the land and following the three days showdown, there’s nothing left but watchful waiting for the Supreme Court to hand down its final decision. All media outlets from left, right and supposedly middle are covering the events and hundreds of experts are ready to make predictions based on the inflections in one Justice’s voice. I made a point to not read any of that, and if you are an informed citizen who still insists on making his/her own mind, the very impartial <a href="http://www.scotusblog.com/2012/03/scotusblog-health-care-and-a-few-things-you-might-have-missed/" target="_blank">SCOTUS blog</a> is the place to go for links to the audio and transcripts of all oral arguments and all briefs submitted to the Court. By this logic you should probably not read what follows below either, but if you do, this is an unorthodox (neither left nor right) look at the proceedings from a citizen's point of view, a perspective that struck me as lacking in the proceedings themselves. 
 
The main contenders were the Republican Governments of 26 States against a Federal Government controlled by a Democratic administration. There were also some private plaintiffs with a strong Libertarian argument, but their contribution to the subject is not clear to me, and is probably just a largely inconsequential sideshow. Generally speaking local governments were wrestling with central government in an outdated Federalist argument, where the people themselves have no standing. 
 
The <a href="http://www.supremecourt.gov/oral_arguments/argument_audio_detail.aspx?argument=11-398-Tuesday" target="_blank">main event</a> took place on Tuesday, March 27, where the constitutionality of the individual mandate, requiring every American to buy health insurance or pay a penalty, was argued, with the Federal Government arguing that its power to regulate interstate commerce includes the right to mandate that everybody buys health insurance, and if not, then the penalty should be viewed as a tax. The State Governments argued as expected that this gives the Feds unlimited power and a penalty is not a tax. The lively debate came complete with broccoli, burial insurance and babies being denied care at the hospital, hypotheticals. But here is what I found interesting: at the heart of the Federal Government argument was the contention that the uninsured are basically offloading their health care costs on the insured and society in general, therefore we must mandate that they buy insurance and pay their fair share. The States on the other hand, argued that forcing healthy people who don’t want to buy insurance to subsidize the sick is really not fair. Most Americans, as everybody agreed, are already purchasing health insurance, so who are these freeloading uninsured? 
 
Well, it seems that 68% of the <a href="http://www.statehealthfacts.org/comparecat.jsp?cat=3" target="_blank">uninsured</a> are under 140% of the Federal Poverty Level (FPL), and 95% of them are below 400% FPL. A full 45% of <a href="http://www.statehealthfacts.org/comparetable.jsp?ind=131&cat=3" target="_blank">poor adults</a> and 17% of <a href="http://www.statehealthfacts.org/comparetable.jsp?ind=128&cat=3" target="_blank">poor children</a> (under 100% FPL) are uninsured. Are these our freeloaders? Are these our interstate frequent travelers who impose huge uncompensated expenses on States where they don’t live? Are these poor people without insurance seeking out States that enacted guaranteed-issue and community rating insurance laws and move there en-masse? Is anybody else doing that? Do we even know what problem we are trying to solve? 
 
Another pearl from the March 27 arguments was the realization that the States concede that the Federal Government has the power to require that people pay for health care with insurance. They only differ on the timing of buying the necessary insurance instrument, with the State Governments insisting that a free citizenry should have the right to purchase insurance en route to the ER, if they so choose, and the Feds arguing that they must buy insurance the day they are born. Does that mean that one cannot pay for health care with cash, or chickens? Will they check to see if you have insurance and if so, cash payments will be disallowed? What do you do if you’re one of the penalized? Do you get to pay cash, or do you get some services in return for all those penalties you paid into the system? 
 
As interesting as the constitutionality arguments were, I found the session on <a href="http://www.supremecourt.gov/oral_arguments/argument_audio_detail.aspx?argument=11-393" target="_blank">severability</a> to be most enlightening. On Wednesday, March 28, the Court grappled with the next steps, if the individual mandate is by any chance found to be an unprecedented and unlimited expansion of Congress powers and thus ruled unconstitutional. The 26 Republican governed States argued that the Court should throw out the entire Obamacare legislation with the mandate, because everything else in the PPACA is either hinging on the offending mandate or is unimportant. This is not surprising, since the war on the individual mandate, which is the brainchild of an ultraconservative foundation, is just a battle in a much larger war to remove the current Democratic President from office. The Federal Government began its arguments by mentioning the millions of citizens that are not standing before the Court and how the Court should nevertheless give them consideration. That was beautiful, but it didn’t last long, because eventually it became clear that the Federal Government is asking the Court to strike down both guaranteed-issue and community rating clauses along with the individual mandate, if found unconstitutional. 
 
The Federal Government, true to form, was arguing on behalf of its insurance companies patrons. Unless the Feds can guarantee a certain number of customers, there is no way that insurers will agree to sell their wares in a non-discriminatory manner, because discrimination is how insurers make money, and no government should infringe upon basic rights of corporations. It fell to an attorney independently appointed by the Supreme Court to argue for the people, and (very eloquently) make the simple point that the purpose of the PPACA was not to provide customers to insurers, but to make health care affordable to all Americans, including poor and sick ones. The individual mandate is just one tool in an arsenal of tools to accomplish that end. It may be a very useful tool, but it’s not the only tool, and therefore if it is found unacceptable, it should be severed from the legislation and removed without throwing out the baby with the bathwater. 
 
So the People finally got their 15 minutes in Court, represented by Court appointed counsel, as paupers usually are. Whatever the Court decides in this case, I will forever be grateful to the Supreme Court of the United States, the nine unelected Justices, who saw fit to solicit someone to speak for the People, something that neither States nor Federal Governments seemed to be too terribly inclined to do. And I am grateful that the Court chose H. Bartow Farr, III, Esq. to represent us in this matter, since his oral arguments were second to none, and may God grant the Court the wisdom to do what Mr. Farr advocated that they do, and the People shall prevail.</div>

doctor-patient Matt Goldenberg minority mental health The People’s Advocate at the Supreme Court Bar

H. Bartow Farr, III, Esq. The Patient Protection and Affordable Care Act (PPACA) has finally met its challengers in the highest Court...

Call to Action: Organizing for Patient Care

9:54 PM Meme Art Studio 0 Comment

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By NIRAN S. AL-AGBA, MD and MARGALIT GUR-ARIE      </h4>
On November 8th America elected a President who ran on a promise to restore government of the people, by the people, for the people (among other things). However, we cannot expect such government to be given to us on a silver platter, no matter who resides in the White House. We must build it ourselves, by definition. Government of, by, and for the people requires the people to stand up and do more than just vote every four years, do more than author clever blogs, do more than compose brilliant tweets, post cynical quips or write constructive comments on the websites of power. Self-government requires informed citizens with a vision to organize, mobilize, and take purposeful action. 
For the last eight years we engaged in all of the former and none of the latter. We know many of you are in the same predicament. We are the everyday people and frontline doctors everybody in government is supposedly trying to help. We don’t entirely doubt the intent, but the end results have been so much less than we want, so much less than the American people deserve, so much less than we know is possible. We come from vastly different backgrounds. We have diametrically opposed political ideologies. We have a broad and dynamic spectrum of prescriptions for how health care in America should work. This is our strength. 
 
You may be elated by the 2016 election outcome; you may be on the fence, indifferent, worried, depressed or positively enraged. Whether you love it or hate it, you cannot deny that something extraordinary happened on November 8th. Whether you think disaster breeds opportunity or victory itself is the opportunity, let’s “seize the present; trust tomorrow even as little as you may” and try to gain some control over our personal and professional fates. 
<h4>
Call to Action</h4>
We would like to propose that we organize a workgroup of physicians and people with interest in health care to create evidence and consensus based guidance and recommendations for the new administration as it undertakes major changes in health care policy, legislation and regulation. Our initial thoughts are that we create an objective position paper to address the impeding changes to current health care legislation, free of political and partisan shenanigans. Our dreams are that this grows into a perpetual grassroots advisory group which brings real-world experiences, varied points of view and wisdom from the frontlines of medicine and from everyday life into the hallowed halls of government to inform the work of public servants. 
 
If you think the American people and their doctors should have a voice in governance, if you believe the welfare of your patients stands above politicking, if you want to amplify your voice and the voice of others, please join us. If you think you can contribute a small amount of time to such effort, we invite you to kick start this endeavor. You can remain anonymous if you so choose. You can contribute as much time as you have available. You can choose how, when and what. Let’s leave the actual details open and brainstorm together how best to move forward quickly. 
<h4>
Let’s Roll</h4>
Are you all in? Would you prefer to dip your toes in the water first? 
Email us today: mga111026 at gmail.com 
We will communicate via email to set up a conference call and take it from there. We will do the housekeeping, bottle washing and ashtray emptying to get us started. For those who already expressed enthusiasm (or guarded interest) on Twitter and elsewhere, retweet, spread the word and let’s make this happen. It’s time. 
 
<a href="https://drive.google.com/file/d/0B8BeVx5dHnjfZXVQc0VBVFpOQWs/view?usp=sharing" target="_blank">Download</a><a href="https://drive.google.com/file/d/0B8BeVx5dHnjfZXVQc0VBVFpOQWs/view?usp=sharing" target="_blank"> PDF version</a>. Please share freely. 
 
 
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doctor-patient health care Call to Action: Organizing for Patient Care

By NIRAN S. AL-AGBA, MD and MARGALIT GUR-ARIE On November 8th America elected a President who ran on a promise to restore governme...

Telemedicine, Here I Come!

2:54 AM Meme Art Studio 0 Comment

<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEObNy7Am_mjQgwoSGOB4r6KpQJwzK5rfiAGOyZA6VQbXq6BCCOasJuI3MfAVuOGl28EZiW8aQwhuZDJJdaVDi4Qe57p8uV6nG5we0u-7RFu-moTgp-csK2j_ImCWvfC3ocrTD3LIq_CkJ/s1600/telehealth.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEObNy7Am_mjQgwoSGOB4r6KpQJwzK5rfiAGOyZA6VQbXq6BCCOasJuI3MfAVuOGl28EZiW8aQwhuZDJJdaVDi4Qe57p8uV6nG5we0u-7RFu-moTgp-csK2j_ImCWvfC3ocrTD3LIq_CkJ/s1600/telehealth.png" /></a> <div class="MsoNormal" style="background: white; margin: 0in 0in 0pt;"> By <a href="http://www.psychiatry.org/mental-health/healthy-minds-blog-contributors" target="_blank">Hind Benjelloun, MD</a> <a href="https://twitter.com/hbenjelloun" target="_blank">@hbenjelloun </a> My decision to pursue a career in telemedicine was a long process. I had a comfortable, stable clinical position at a highly regarded academic center in a lively city. But I kept wondering if my career needed a boost. I found myself thinking, career development takes risk. Medicine is an ever-changing and growing field. I felt that I had to embrace some changes myself if I wanted to keep up. Telemedicine is a relatively new discipline. The idea of incorporating health care with technology, specifically the web, may have some rolling their eyes or shaking their heads. But, simply put, it is the future of healthcare; and it is certainly getting the buzz these days.</div> <div class="MsoNormal" style="background: white; margin: 0in 0in 0pt;"> The <a href="http://www.americantelemed.org/home" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">American Telemedicine Association</a> is rapidly growing and developing its services and its role in healthcare. Many medical and scientific organizations are recognizing the importance of the discipline as well. You can see it reflected in the number of publications, conference seminars, and available CME. Tech gurus are predicting that the recent acquisition of Oculus by Facebook will be a game changer in the tech industry and will further grow telemedicine’s influence. So I took the plunge into a field in its infancy. I went for it.  Telepsychiatry! After almost ten years at Georgetown University Medical Center, I drastically shifted gears to pursue a full time career in crisis telepsychiatry. In this career change, I have been labeled a pioneer among colleagues and friends. It feels wonderful to immerse myself in such an innovative healthcare movement. My healthy narcissism embraces it and it strengthens my confidence in what some may call a risky career decision. Today, telepsychiatry is revolutionary in the way it <a href="http://www.psychiatry.org/advocacy--newsroom/advocacy/government-relations/improving-access-to-mental-health-treatment" style="background-color: transparent; font-family: Arial, Helvetica, sans-serif;" target="_blank">enhances access to care</a>. And although right now telepsychiatry is primarily seen as a means of engaging the rural patient population, it will progress in the medical community as a future medical norm. The evidence is growing and continues to demonstrate the boom of telemedicine and its success.</div> <div class="MsoNormal" style="background: white; margin: 0in 0in 0pt;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjn4SDQASR_rY28Gl6K0YrrAWPJElWBhLlyNNMMOvcgvXnb-_tRlK2vHpDuljiSoMxtuuKz1AaphyaPE9dS0enOD0ICgYwlgdQWxWGPjHZ6VXYe4scAVoUAQVi-Bg_nKLH9SPPURwSGPfab/s1600/telepsychiatry.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="111" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjn4SDQASR_rY28Gl6K0YrrAWPJElWBhLlyNNMMOvcgvXnb-_tRlK2vHpDuljiSoMxtuuKz1AaphyaPE9dS0enOD0ICgYwlgdQWxWGPjHZ6VXYe4scAVoUAQVi-Bg_nKLH9SPPURwSGPfab/s1600/telepsychiatry.png" width="200" /></a>Still, taking the leap into telepsychiatry had its downsides. Because of its youth, telemedicine lacks a number of accessible mentors who can guide the process. There are few clinicians who have an “institutional” knowledge of telemedicine to share. This means that other than the anecdotal accounts that you may read in a journal or blog post about what it’s like to venture into the world of telemedicine as a provider, there aren’t many reputable sources to turn to.  I had trouble knowing what to expect. I started working with InSight, a national telepsychiatry provider company earlier this year. As a crisis telepsychiatrist with InSight, I have the ability to seamlessly transition between seeing patients at multiple hospitals in multiple states back to back. Today, I love my job. But the legislative hurdles I had to jump through to get going were a major headache. I was completely committed to offering services right away when I made the decision to start practicing telepsychiatry. I was ready to go. But I had no idea what kind of challenges I would encounter as I attempted to receive licensing from medical boards that all work independently of each other. After the first hurdle of becoming licensed, I thought I had passed the finish line. But to my surprise, I was back to waiting on privileges from hospitals that were scrutinizing my immunization records and testing my knowledge of their fire code. This all seems so frivolous and a waste of time, effort and money. Didn’t they understand that I would be seeing patients remotely? When I finally began working with a regular schedule, I found myself asking, why did it take so long for me to be able to actually see patients and provide care? The answer lies in legislation. The laws and regulations in place for telemedicine are significantly outdated. Why is my medical license in one state insufficient in another? Big changes are needed to reflect the advent of technology’s integration into medicine. And when it comes down to it, it’s the patients who suffer from these outdated practices the most. The shortage of psychiatric prescribers, as well as other types of providers in the United States is a growing problem. Telemedicine is an important way of addressing that shortage with the providers we already have. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiclMyiQGopCzsiPqO7NxQbQjKsU8tZ1mTGXqS4EAn0jaMZsqIA1IaU3ffFGuqmxOhmxeVYIwkvIzqxjZURj3iLbvgB49aoRjWJIy-ujkPNrnrszlD4_AS2PLhNWDKXQVs8buFkQgqlObds/s1600/FSMB.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiclMyiQGopCzsiPqO7NxQbQjKsU8tZ1mTGXqS4EAn0jaMZsqIA1IaU3ffFGuqmxOhmxeVYIwkvIzqxjZURj3iLbvgB49aoRjWJIy-ujkPNrnrszlD4_AS2PLhNWDKXQVs8buFkQgqlObds/s1600/FSMB.png" /></a> </div> <div class="MsoNormal" style="background: white; margin: 0in 0in 0pt;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiclMyiQGopCzsiPqO7NxQbQjKsU8tZ1mTGXqS4EAn0jaMZsqIA1IaU3ffFGuqmxOhmxeVYIwkvIzqxjZURj3iLbvgB49aoRjWJIy-ujkPNrnrszlD4_AS2PLhNWDKXQVs8buFkQgqlObds/s1600/FSMB.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a>Thankfully, there is yet hope. The Federation of State Medical Boards (FSMB) has recognized this unnecessary obstacle to patient care and the strain inflicted on telemedicine as an industry.  At its annual meeting at the end of April, the FSBM will vote on adopting the <a href="http://www.fsmb.org/pdf/fsmb_news_rrelease_multistate_compacts.pdf" target="_blank">federation’s Interstate Medical Licensure Compact,</a> a licensing option that would allow qualified physicians to expedite licensure in all states who participate in the Compact. Telemedicine as a field of practice would be transformed dramatically with the adoption of the Compact. Fingers crossed. I am enthusiastic about potential for growth of telepsychiatry and telemedicine. But I believe providers must take an active role in pioneering this new form of care, and pushing for its successful implementation for the people who need it—our patients. Bottom line—we are in this for our patients, and it is our patients who will benefit the most from telemedicine and a successful reevaluation of the legislation that regulates it.</div> <div class="MsoNormal" style="background: white; margin: 0in 0in 0pt;"> <o:p></o:p></div> <a class="twitter-share-button" data-count="horizontal" data-related="APAPsychiatric" data-via="APAHealthyMinds" href="http://twitter.com/share">Tweet</a><script src="http://platform.twitter.com/widgets.js" type="text/javascript"> </script>

American Telemedicine Association doctor-patient telemedicine Telemedicine, Here I Come!

By Hind Benjelloun, MD @hbenjelloun My decision to pursue a career in telemedicine was a long process. I had a comfortable, stable clini...

What’s Up Doc? Medicare Carrots and Sticks

6:35 AM Meme Art Studio 0 Comment

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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQyBiYo7fsSRxD3jWfgkFRmjHyIeZNE1uZ1k3ccoPbG7C6r7N6yY4vEkJhcKDaz2nb3OV_l26jYcy-tMjd6T3zuTyvqvmluofDi0KZ6DkL_gyEBfgoMfkfsyZUbtjG9c6AB8Q4MLxL6J4/s1600/bugsbunny.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQyBiYo7fsSRxD3jWfgkFRmjHyIeZNE1uZ1k3ccoPbG7C6r7N6yY4vEkJhcKDaz2nb3OV_l26jYcy-tMjd6T3zuTyvqvmluofDi0KZ6DkL_gyEBfgoMfkfsyZUbtjG9c6AB8Q4MLxL6J4/s1600/bugsbunny.jpg" /></a></div>
The Patient Protection and Affordable Care Act (PPACA) of 2010 mandates that certain administrative simplifications should be made to reduce overhead costs of health care. Since administrative complexity obeys the conservation laws of physics, for every bit of complexity that is removed, a new chunk of bureaucratic complexity must be added to the system. With that in mind, <a href="http://www.ama-assn.org/resources/doc/cqi/pcpi-032912-rapp.pdf" target="_blank">CMS has created</a> and is proposing to grow an array of <a href="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//EHRIncentivePayments-ICN903691.pdf" target="_blank">financial incentives</a> and penalties for health care providers. This collection of carrots and sticks is intended to be used as so many levers to control and fine tune the practice of medicine by encouraging adoption of health information technology, measuring processes and steering physicians to low cost treatment methods. 
 
Since confusion is abundant, and confusion leads to anger, fear and sometimes outright panic, which in turn causes folks to dump perfectly good private practices on the first hospital that knocks on their door, I thought it would be beneficial to clarify a few things and look at the situation from an objective mathematical perspective. Below are concise descriptions of the current CMS incentives and penalties programs, and a dollar amount evaluation of their possible effect on your bottom line. 
<h4>
 Electronic Prescribing</h4>
A bit outdated in the EHR era, the <a href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html?redirect=/ERXincentive" target="_blank">eRx incentive program</a> began in 2009 and is due to expire in its entirety by 2015, when no bonuses and no penalties will be assessed for this initiative. 
The Rules: Currently, 10 electronic prescriptions in the first half of the year will ward off the penalties for next year, and 25 electronic prescriptions during the entire year will get you the incentive next year. The prescriptions must be written for Medicare patients’ unique visits with associated E&M codes and a “qualified” electronic prescribing system must be used. Any eRx module in a certified Complete EHR will do and if you use a standalone system, make sure it states that it is “qualified” for CMS incentives. 
The Numbers: The incentives are 1% this year and 0.5% in 2013. There are no incentives available after that. Incentives are calculated as a percentage of the total Medicare Physician Fee Schedule (MPFS) allowable charges for the calendar year. The penalties are -1%, -1.5%, -2% in 2012, 2013 and 2014 respectively. There are no penalties after 2014. Penalties are applied as an adjustment to ongoing MPFS payments during the penalty year. Note that you cannot receive eRx and Meaningful Use Medicare incentives in the same year. You can do so for Medicaid EHR incentives. 
<h4>
 Physician Quality Reporting System (PQRS)</h4>
This is <a href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html" target="_blank">the successor</a> of PQRI (the “I” was for initiative) and it started in 2010 in its current format with no proposed expiration date. It is important to keep in mind that the contents of your PQRS reports will be made public on the Physician Compare website maintained by CMS. 
The Rules: You will have to report on at least three clinical quality measures, or one group of measure, for the reporting year. You may report your measures via claims, registries, EHR or a special group reporting tool. The reporting is limited to Medicare patients and although the registry option offers a 6 months reporting period, most other methods require that you report on 30% to 80% of pertinent patients for the whole year. If you choose claim reporting, make sure you don’t let charges entered close to year-end linger around, because CMS may not get them in time to calculate your incentive. Both Incentives and penalties are calculated and applied as they are for the eRx program. 
The Numbers: You could have gotten a 1% incentive in 2011, but starting in 2012 and through 2014, the incentive is a constant 0.5%. There are no incentives authorized after 2014. Penalties begin in 2015 with -1.5% and continue to -2% from 2016 and beyond. There is no end date for the penalties. PQRS incentives are independent of eRx and Meaningful Use and may be combined with either one. 
<h4>
 Maintenance of Certification (MOC)</h4>
The <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Maintenance_of_Certification_Program_Incentive.html" target="_blank">MOC program</a> is only available for those who successfully report PQRS measures and is available only through the incentives phase of PQRS. 
The Rules: You need to participate in a Maintenance of Certification program and complete a practice assessment more frequently than is required to qualify for or maintain board certification. Make sure that your board is indeed qualified by CMS for this program, since not all are. 
The Numbers: This is a very simple program that will pay an additional 0.5% of MPFS to what you already receive for PQRS reporting. The program expires after 2014 and there are no penalties associated with it. 
<h4>
 The EHR Incentives Program (Meaningful Use)</h4>
Saving the best for last, this is the big one and most advertised one. The <a href="https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html" target="_blank">Meaningful Use program</a> started in 2011 and is projected to continue indefinitely. It has been likened to an escalator, where the requirements become more comprehensive and more complex every two or three years. 
The Rules: You must buy an ONC Certified Complete EHR (or a collection of certified modules) and meet a set of required measures every calendar year. The measures are adjusted every two (or three) years, from the current Stage 1 to future Stages 2, 3 and presumably others. There are two tracks for this program, one for Medicare and one for Medicaid participants. Meaningful Use is a very comprehensive set of measures reaching into every aspect of medical practice and is inclusive of both electronic prescribing and the reporting of clinical quality measures. The EHR incentives program and the electronic prescribing program are mutually exclusive under Medicare incentives. 
The Numbers: The program offers 5 years of decreasing incentives followed by incrementally increasing penalties for non-participation. The maximum incentives under the Medicare track is $44,000, plus 10% of that if you practice in a designated health professional shortage area, and $63,750 for the Medicaid track. You can join the Medicare track as late as 2014 (you will lose about half the incentive) and the Medicaid track can be started as late as 2016 with no loss of incentives. However, in 2015 penalties, in the form of adjustment to your Medicare allowed charges, will begin to apply for those not participating in either track. CMS is proposing to backdate the penalties, so they apply in 2015 to those who have not become Meaningful Users by October 1st of 2014, effectively moving up the compliance date mandated by legislation. The penalties start at -1% of MPFS in 2014 and increase by 1% every year until they reach -5% in 2019 and continue at the -5% level indefinitely. 
<h4>
 Bottom Line</h4>
For illustration purposes, let’s say you see 10 Medicare patients every day, you work 5 days every week and 50 weeks every year in a health professional shortage area. Accounting for different E&M charges, you are looking at approximately $200,000 per year paid to you by Medicare, and clearly this is a best case scenario. Let’s further assume that the proposed reimbursement cuts and the proposed increases to primary care reimbursement balance each other out and your Medicare revenue stays flat in today’s dollars. How will the carrots and sticks affect your income? 
Scenario 1: You do all that is required and are rewarded with nothing but carrots between 2011 and 2020. In addition to your claims reimbursement, you will receive from CMS $57,400 over the current decade, which is $5,740 per year or $478 per month, totaling less than 3% increase in your average Medicare reimbursement. 
Scenario 2: You ignore all CMS programs and do your own thing, and stick with your decision through 2020. You will of course not get any incentives and you will lose a total of $72,000 over this decade, or an average of $7,200 per year, which is $600 per month, or the equivalent of 3.6% of your Medicare revenue over 10 years. 
 
It is important to note that, while the incentives are temporary, the penalties are applied indefinitely, converging to 7% MPFS, or $14,000 per year in our imaginary scenario. The sticks are larger than the carrots. These numbers do not bring into account costs of opportunities lost, such as performance bonuses and additional payments per-member-per-month that are becoming available from private and public payers for special endeavors such as medical homes and other quality improvements, and require the same infrastructure be exercised in the same fashion as the Medicare incentives programs described above. 
<h4>
 But wait, there is more: The Value Based Payment Modifier (VBPM)</h4>
If you are fortunate enough to practice in Iowa, Kansas, Missouri, or Nebraska, you are part of a preamble to <a href="https://www.cms.gov/PhysicianFeedbackProgram/" target="_blank">a new Medicare program</a> which proposes to add a modifier to your charges based on the ratio of cost to quality for services rendered to Medicare members. So far physicians of all specialties in the selected pilot States have received Quality and Resource Use Reports (QRURs) outlining their performance and costs based on 2010 claim submissions. The program is in its definition stage and there are no clear numbers associated with the proposed modifier, and no explanation on how such modifier would be calculated, but it seems that by far, this is going to be a much more significant stick or carrot than anything outlined above. The legislation mandates that this program goes into effect in 2015 and by 2017, most physicians paid under the MPFS will see the VBPM applied to claims they submit to Medicare. [More on the VBPM in a future post…] 
 
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<tr><td class="tr-caption" style="text-align: center;">CMS incentives and penalties proposed programs 2011-2020 (click to enlarge)</td></tr>
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 These are the visible carrots and sticks. Now it’s your turn to do the math and make your decision. Note that Scenarios 1 and 2 above are the extremes. You can always jump on the wagon at a later point, with less incentive and/or less penalties. The wagon, though, is accelerating pretty quickly.</div>