Monday, April 27, 2009

Symposium on Health Education Reform, Day One

WOW....surrounded by heavyweights...all of them.

Had breakfast with Polly Bednash, who is the Executive Director of the AACN, Darrell Kirch, the current president and CEO of the AAMC, and my friend, and colleague, VP of the AAPA Bill Fenn.

Attendees include:

President Emeritus AAMC
Chancellor Emory University
Director, Division of Undergraduate Medical Education, AMA
President and CEO of the Institute for Healthcare Improvement
Professor and Dean of Vanderbilt School of Nursing
CEO Henry Ford Medical Group
Senior VP of the American Board of Medical Specialties
CEO and Executive VP, American Colleges of Pharmacy
CEO Accreditation Council for CME
CEO National League Nursing
President and CEO ACGME
President American Association of Colleges of Osteopathic Medicine
Coordinating Producer ABC News Health Care Task Force

as well as NUMEROUS other deans and presidents of various medical schools.

It was a good day.

First session started with a review of the four cornerstones of health reform for the Mayo Clinic.

Discussion also focused around reforming medical student education to NOT teach disease treatment, but to teach healthcare delivery. There was a lot of focus on integrated classes for medical students, WITH MANY classes being taken with other health professionals. For example. Anatomy. There was discussion that medical students, nursing students, PT students, and PA students ALL TAKE THE SAME ANATOMY COURSES TOGETHER. There was talk about incorporating a course that would solely teach and focus on teamwork, and (sorry Happy) teaching the physician that they are an EQUAL with other members on the team, and not always in charge.

There was a lot of discussion about the Intermountain group, that manages 30,000 diabetic patients with only FOUR endocrinologists. HOW? They use non physician providers.

The next session was about Licensure, Accreditation, and Certification. There was a lot of debate about having a SOLITARY interdisciplinary certifcation process.

There was a talk about Professionalism, and having medical students NOT graded on individual exams to test medical knowledge that they won't remember, but to test them on the concepts, and the ability to find the answers when they need them. ALSO, to test them on HOW WELL THEY FUNCTION IN THE TEAM MODEL.

The next session included Realigning the Health Care Training System Toward Coordinated Patient Centered Care, again discussing the team model, and dramatically changing the current medical school structure.

Finally, we were asked to submit a singular answer from EVERY table as to HOW to best reform the health care system.

Then, we had dinner, and a discussion on Driving Change in Academic Medicine.

I'm tired now. A lot of information, a lot of very intense discussion amongst a group of highly accomplished and intelligent folks.

I will update you tomorrow with the findings at that time.

Here's some more information:

After the introduction, Denis Cortese, M.D., presented an overview of the Mayo Clinic Health Policy Center’s consensus-driven cornerstones for health care reform in America: create value, coordinate care, reform the payment system and insure everyone. He noted that medical education must play a crucial role in preparing individuals to provide high-value, coordinated care and introduced several issues for education professionals to consider, including specific curriculum designed to increase value, student selection criteria, instruction methods, assessment and financing.

Zoƫ Baird then introduced the panel and framed the discussion around how to train students to create a healthier America. All panelists agreed that the educational system must be redesigned to break down professional silos, creating an educational environment in which physicians, nurses, other allied health professionals, community health workers and family caregivers learn to work together on behalf of the patient.

“There is concern about a shortage of physicians today,” said Michael Johns, M.D. “I think if we gave allied health staff the ability to practice to the full extent of their skills, that shortage would be a lot smaller.

“We need the right person at the right time to provide leadership to the care team,” he continued. “Physicians need to be comfortable not being at point all the time. Every person is important.”

Panel members also noted that the curriculum must incorporate elements of engineering and health delivery science in addition to biological science.

Dr. Cortese commented that the current education system encourages learners to focus on accumulation of knowledge rather than innovative ways to deliver health care to individuals.

The group also called for the development of novel assessments – including measurement based upon patient outcomes, teamwork and individual performance.

“We need to move away from GPA and standard examinations as our primary or sole assessment tools,” said Jack Stobo, M.D. “There is no correlation between these tools and how students perform in practice.”

“We are in control of health professional education… it’s ours to win or lose,” he emphasized. “There currently is a mismatch with how we’re educating professionals and what society needs.”

10-11:30 a.m. – Licensure, Accreditation and Certification: Achieving Harmonic Resonance

Susan Wagner, Producer, Dr. Oz Show

Geraldine Bednash, Ph.D., Executive Director, American Association of Colleges
of Nursing
Claire Bender, M.D., Director for Education, Mayo Clinic in Minnesota
Richard Hawkins, M.D., Senior Vice President for Professional and
Scientific Affairs, American Board of Medical Specialties
Thomas Nasca, M.D., CEO, Accreditation Council for Graduate Medical Education

Moderator Susan Wagner provided introductions and began the discussion by asking the panelists to define licensure, accreditation and certification. Then, discussion revolved around identifying steps to change licensure, accreditation and certification standards/processes without a clear sense of what reforms will shape the care delivery system.

Geraldine Bednash, Ph.D., R.N., discussed efforts in advanced practice nursing to bring together the different standard-setting groups to agree on a common set of standards for certification and accreditation. Dr. Bednash noted that licensing occurs at the state level by government and is influenced more by political considerations instead of evidence of capability of providers.

Expanding sharing opportunities is an area that can be explored immediately, according to Claire Bender, M.D. Dr. Bender described new efforts at Mayo Clinic to bring different providers together in the same class when curriculum is applicable to both. It has been successful in demonstrating that different providers have and need different skills. The model also provides an environment that allows different health care professionals to become familiar with each other and respect the abilities of each type of provider.

Thomas Nasca, M.D., pointed out that it will be difficult to get hundreds of professional societies, accrediting bodies and licensure boards around the table, but that it may be possible to begin agreeing on unifying themes that move across discipline boundaries. It will be important to make sure that licensure, accreditation and certification standards don’t prohibit change, and reinforce core competencies that learners can carry forward as health care delivery systems evolve.

Richard Hawkins, M.D., discussed how assessments can be redefined to reinforce the principles of teamwork in a reformed health care environment. He suggested creating a feedback cycle from clinical care into the education and certification process.

Participants spent a portion of the session submitting ideas for changes in licensure, certification and accreditation to aid in transforming the educational system to support patient-centered, coordinated health care reform. The following actions received the highest endorsement.

Introduce team-based minimum standards for training and care models for both certification and accreditation.

Introduce team-based exercises as part of individual certification.

Certification should more closely mirror real-life clinical situations.

Consider use of a public/private entity, independent of Congress, to bring societies and professions together and adopt more common standards for training, certification and accreditation.

Noon-1:30 p.m. – Professionalism - The Critical Element in Health Care Education

If doctors falter in their professionalism, health care reform efforts will come up short, said Jordan Cohen, M.D., president emeritus of the Association of the American Medical Colleges and professor of medicine and public health at George Washington University.

“Professionalism is when physicians know the right thing to do and then do it,” he remarked in his keynote luncheon address. “It’s the behavior required of doctors in fulfilling their compact with society. They are honor bound on their own volition to work in patients’ best interest and use their knowledge and expertise to that end.”

Dr. Cohen said that nurturing professionalism is one way to advance needed changes in U.S. health care, and he recommended six ways for educators to promote professionalism:

Adopt and approve admission criteria. Few medical students fail to graduate and fewer still fail to get licensed. Educators have a fundamental role as gatekeepers to the profession.
Establish explicit learning objectives. Adults learn best when they have prospective understanding of what they are going to learn.
Address the rationale for adhering to the precepts of professionalism in the formal curriculum. Future physicians need to be mindful of temptations and ways to withstand conflicts of interest.
Be proactive and intentional in the informal curriculum. Educators need to model behaviors emblematic of professionalism. Informal curriculum is one of the most powerful influences on adopting the norms of the profession.
Articulate institutional expectations. “We need to be unabashed about communicating these expectations,” says Dr. Cohen.
Evaluate and reward behaviors that are emblematic of professionalism. Sanction and call out those who are not professional.

Americans long to trust their physicians and polls show that they largely do, Dr. Cohen added. And, trusting doctors is good for patients. “It increasing compliance and improves outcomes,” he remarked. “But that trust is earned, not owed. The surest way to lose that trust is to abandon professionalism.”

1:30-3 p.m. – Realigning the Health Care Training System for Coordinated Patient- Centered Care

Maggie Mahar, Ph.D., health care fellow, Century Foundation

Mark Kelly, M.D., Henry Ford Medical Group
Lindsey Henson, M.D., University of Minnesota
William Hersh, M.D., Oregon Health and Science University
Beverly Malone, PhD, RN, FAAN, National League of Nursing
Alyce Schultz, RN, PhD, FAAN, EBP Concepts

Today’s medical education system has holes that prevent the next generation of doctors, nurses and allied health professionals from learning how to provide patient-centered care.

That was the premise of moderator Maggie Mahar, Ph.D., health care fellow, Century Foundation, as she opened the session titled “Realigning the Health Care Training System for Coordinated Patient-Centered Care.”

She was joined by representatives from, nursing, medical education and medical center leadership to discuss how the core competencies identified in the Institute of Medicine’s 2003 report “Bridge to Quality” might fill those gaps.

Panel discussion centered on the core competencies, most taken from the IOM report, including:

Providing patient-centered care
Working in interdisciplinary teams
Using evidence-based practice
Applying quality improvement
Using informatics
Shifting culture toward professionalism

The discussion sparked more than 30 recommendations to keep patients at the center of coordinated care. The top-ranked recommendations encompassed common themes of teaching future providers how to work in teams and across disciplines. The recommendations challenged educators to find ways to increase learning opportunities in real world settings.

Participants ranked these recommendations as most important:

Introduce (early in training programs) team-based and reality-based standards and experiences that reflect all health care team members contributing at their highest level of training.

Establish an institutional/unit commitment to patient-centered collaborative care.

To understand patients, students should interface with the patients in their communities experiencing medical care through their patients eyes and experiences

Incentives for students (i.e. evaluation) must be aligned with team learning.

Health education schools need to work across disciplines to develop areas of shared curriculum to teach students team care delivery

Create a non-punitive culture for understanding and learning from mistakes and inefficiency

3:30-5 p.m. – Your Views Concerning Change – What is Required to Create the Health Care Workforce of the Future?

Event co-hosts Pat Mitchell and Dr. Cascino challenged participants to brainstorm ideas to answer the same question posed to MD Connector Competition participants:

“In order to create a health care workforce equipped to provide a high-value team approach to coordinated, patient-centered health care, what is the most important change required of the health care education system?”

The group spent an hour discussing potential changes, and submitted their consensus responses. Responses will be compiled during the evening, and participants will review and prioritize the recommendations during the opening session on Tuesday morning.

7-8 p.m. – Driving Change in Academic Medicine

Darrell Kirch, M.D., president and CEO, Association of American Medical Colleges provided perspective on the need for change in academic medicine.

Dr. Kirch emphasized the importance of focusing medical and health care education reform on the training of all professionals who work in the delivery of health care. Individuals who practice in any portion of care delivery are a vital part of the team approach to medicine and need to have a voice in the evolution of training.

Dr. Kirch noted that many buzzwords are associated with health care reform. One of these words is “change.” He focused on two degrees of change:

Incremental, which is usually considered good in academic settings, and
Revolutionary, which encompasses broad change

Dr. Kirch proposed the need for a middle ground in education: transformational change. This involves sweeping, fundamental change that recognizes the tremendous good in the current system – especially the dedicated people.

A primary barrier to change, he noted, is true culture shift in medical and health care education. Dr. Kirch cited the 1910 Flexner Report as the last true culture shift in medical and health care education. Flexner emphasized an academic culture which has medical research at its core. While this is a valid foundation, Dr. Kirsh said that this focus has led to competition among individuals in research and practice.

A New Culture
Dr. Kirch discussed that today’s patient expects teamwork in medicine. The current health care practice – which emphasizes individualism – is unsustainable, and there is broad recognition that teaching and learning have to be different. Health care professionals need to use information rather than retain information.

Dr. Kirch concluded his presentation by outlining five items for medical and health care education reform:

First, health care systems and educational systems need to be partners. This involves training organizations that are accountable for developing value in the health care system.

Second, the medical and health care training system needs to put aside culture and focus on training that meets the needs of patients.

Third, medical and health care education schools must be increasingly transparent with financial and tuition information.

Fourth, medical education must develop future leaders, building a bottom-up approach that focuses on teamwork and consensus.

Fifth, the health care system must examine the factors that drive medical and health care education training. This must include the concept of justice in the health care system. Dr. Kirch emphasized that the current health care system is unjust or fundamentally unfair, which is not a political issue but a core ethical issue.

Thursday, April 23, 2009

Honored Post of the Month.

Gotta tell ya, there are very few replies on here that just smack it....I mean, HIT IT OUT OF THE PARK....this one did. So I thought I would make it into a whole new post.

Anon 4:33, whoever you are. That was one of the most thoughtful, elaborate, well reasoned posts I have seen. NP's ARE great providers, and are my colleagues, at least to my consideration. But, some of the posts on here, well, they show either

A. DELIBERATE misinformation


B. Ignorance coupled with Misconception.

This is part of the problem, as I said yesterday, too many of us, BOTH PA's and NP's, are so friggin ready to attack at the slightest hint of someone impugning them, that they don't realize, that honest, and careful evaluation of BOTH our strengths AND our weaknesses will only make us BOTH better providers. Here is one poster's reply.

Anonymous said...
I never understand why this is even an argument. NPs are great practitioners in many respects and so are PAs. Physasst said nothing that isn't true, but several notions by the NPs here are. Let me enlighten everyone.

I'm a current Acute Care NP student that has started clinicals and finished didatics, so I can speak with great authority on current NP education. We don't need to recertify, a NP can go through a direct entry program and have no experience, NP education has no more slanted to the medical model than kindergarten has shifted to college, NPs are no more trained to practice independently that a PA, and there is one (hopefully so there will be more) clinical doctorate for PAs through Baylor.

Also the average PA has 4 years medical experience, has more basic science pre-reqs (From UAB PA program)

The following prerequisites:

3-4 semester hours of biology I (lab preferred)

3-4 semester hours of biology II (lab preferred)
3-4 semester hours of microbiology (lab preferred)
3-4 semester hours of human anatomy
3-4 semester hours human physiology (UAB BY 116 or BY 409)
8-9 semester hours of general chemistry (labs preferred)
3-4 semester hours of statistics (upper level, population, and/or health-related with lab preferred)
9 semester hours of psychology (general, developmental, abnormal)

They have higher requirements. This is from the Duke PA program and is representative of most Master's level PA programs.

The ranges of academic and experiential qualifications for the middle 50 percent of accepted applicants for Fall 2008 were as follows:

* Overall GPA: 3.3 – 3.7
* Natural science GPA: 3.1 – 3.6
* Total natural science credits: 47 –74
* GRE General Test scores:
o Verbal: 460 – 598
o Quantitative: 600 – 708
o Analytical Writing: 4.0 – 5.0
* Months of full-time patient care experience: 12 –60

, more advanced science in the didatic year (See UAB PA link above), and does 2000-2600 clinical hours total in the same medical rotations as doctors.

And since NPs have thrown down the gauntlet, let me take you down a peg.(See UAB's ACNP program) The Master's NP is a 18 month long program (24-37 part time which is what many choose to do). It contains a handful of science courses, and don't give me the "I went to nursing school" crap because I have a BSN and it didn't have but handful of sciences. Definitely no biochemistry or gross anatomy.The GRE is waved for students above a 3.2 GPA. The icing on the cake is they do a MINIMUM OF 675 CLINICAL HOURS! Vanderbilt only has 500 and their DNP doesn't add any clinical hours. Just look at the curriculum from the link above for Vanderbilt. How can you even argue that you have received more education.

Even if you somehow did, PAs can go on to post-graduate residencies and will have ~5000 clinical hours in a year. There are quite a few

And just because there were Midwives that practiced out long, long ago, doesn't mean that they somehow magically bequeathed knowledge to all future nurse practitioners.

Neither NP or PA practices "cook book" medicine. PAs can be very independent by owing their own practices or being 6 hours away from their SP. Yes, NPs have the "collaborative" practice which many have taken to mean independent, but it's really semantics. Just because PAs have "supervised" doesn't mean the MD goes through every chart and watches every thoracentesis the PA does. Even if there was a possibility for independent practice with absolutely no MD oversight, PAs don't want it. They know that the terminal degree to practice independently should be the MD/DO education.

I would like for someone to prove me wrong, but since I have links to actual school admissions and curriculum I doubt that you can.

P.S. I'm quitting NP school (sucks because I'm 2/3 through) to become a PA. I've seen both and researched both and find PA to be a better new grad (as long as the have health care experience), have more versatility in their profession (can switch specialties), and more opportunities for growth (PA residencies).

April 23, 2009 4:33 PM

Thanks for a wonderful reply, and no, before anyone goes into ATTACK mode, not because they are switching to become a PA, but because they posted valid, well reasoned logic, coupled with a lot of information. He/She could STILL become an NP, and I would have the utmost respect for this person.

Well played.

Wow, what does THIS mean?

SO, I'm at work earlier finishing up a paper that I am writing on the "Utilization and Deployment of PA's and NP's at Mayo Clinic", and I am in my office. I hear one of our chief residents out in the lounge area (my office is located off of the lounge area) start laughing. She's talking with one of the second years, and they are both pointing towards my office. I of course, curiosity piqued, ask what they are laughing about.

She looks, and says "You know, I finally figured out who you remind me of" I ask, "Ummm, okay, and who is that?"

She says "Dr Cox from Scrubs, your personalities are almost identical."

Then she left, and now I'm trying to figure out what the hell that means....

Was it a compliment, or a slam?

Enquiring minds want to know.

Wednesday, April 22, 2009

Interesting Patient.....

Had an interesting encounter not long ago. Some of you may know that I moonlight at a smaller, rural ER, which is staffed solely by PA's. No MD's onsite. I was there the other day and got a page from EMS. They were bringing in an elderly female that was over the age of 90, and was in acute respiratory failure with an SAO2 of 79% on scene, and a RR of 26. Apparently she had a history of chronic dementia, and had experienced an unresponsive episode five days earlier, where she remained unresponsive for about 5 minutes. The staff at the nursing home apparently thought that this was not important, as they did not send her in at that time. Since then, she has had a worsening cough, increasing confusion, and "choking" episodes with every meal.

Well, on the morning I saw her, she apparently had ANOTHER period of unresponsiveness that lasted about 3 minutes. She had a DNR order, but no DNI order.
I ask my nurse to draw up the 100 of sux, and 10 of etomidate. I grab the airway cart, and start organizing my things. I make sure we have BiPap ready too. She gets to the hospital, and EMS had placed her on a 100% non rebreather, and her sats were now about 89% or so. She was concious, talking, and a bit confused about what all the fuss was about. Her exam reveals an intact neuro exam, an irregular pulse, and rales in the right lower lobe. Otherwise within normal limits for age.

I get an EKG, hmmm. That's not good, she's had a history of intermittent paroxysmal AFib in the past, but now, or at least, sometime in the last two months since her last EKG, she has had a substantial anterolateral infarct. She has subtle ST depression, but inverted T waves in all of her anterior and lateral leads. Troponin= 0.16 (normal range at this lab-0.1) Creatinine is normal, so can't blame it on renal function. Certainly NOT an acute STEMI though.

Portable CXR shows a rather large RLL pneumonia. I order 750mg Levaquin.

I go out to talk to the family and discuss what happened, and what my findings are. We are discussing whether or not they might want a cardiology consult, and possible subsequent cath, when I get a panic value.

Sodium= 118

Okay. So I call up to the regional hospital, where the ER doc, listens to the presentation, and says "Well, sh*t, you've done the whole eval, can't we make her a direct admit?" My response was "Sure, but she'll need a unit bed".

I get on the phone with the intensivist, who, after hearing the report, says "You know, I'm wondering if this patient can just go to the floor".....

My response..."Seriously? Did you listen to ANYTHING I just said?" To which, she says, "Oh yeah, you did say she was in respiratory failure, and she's hyponatremic right?" Me...."YEAH". "Okay, yeahhhhh, I guess she could come to the unit?"

I mean, WTF? You guess? I know she's a DNR, and the nurses were a little freaked about her EKG, which BTW, wasn't even close to my biggest concern, but someone who is not on a DNI order, who is in respiratory failure secondary to a likely aspiration pneumonia, and is profoundly hyponatremic, needs a unit bed.

Just an interesing encounter. Last I heard, she's doing great.

NP issues....

Okay, so apparently some on here think that I have taken an "anti-NP" stance.

As usual, people have things backwards, upside down, and all over the place. I am far from being "anti NP". I actually advocate for BOTH PA's and NP's when I can, and am an outspoken proponent for both. The problem is, that NP's as whole hear the SLIGHTEST criticism, and they immediately attack. Which is too bad.

I have posted here in the past about the educational differences, and the differences in licensure and certification.

One commenter remarked that "phyasst, most of the PA programs are at Community Colleges not medical schools. I also agree with the last commentor that PA initial education is very basic and comparable to two year RN ADN programs, Respiratory Therapist and ect."

I don't know what to say to such ignorance. Of the 142 PA programs in existence that are accredited by ARC-PA, ONLY 3 are community colleges. These are remnants of the older days in the early seventies when PA programs WERE at community colleges. BTW, one of them actually grants a Master's degree now.

Please look here

I don't know if it's a reading comprehension thing, or just plain ignorance, but I AM FIGHTING FOR BOTH PROFESSIONS.......

Do I have concerns about NP education, and specifically the DNP degree and it's potentially negative effect on the supply of primary care providers in rural and underserved areas? Yes, I do. And BTW, so do MANY of the NP's I know and work with.

Do I have concerns about the PA education, and specifically the students that I have been seeing lately that are younger and younger with less and less real prior HCE? Yes, I do, which is why I am advocating mandatory residencies for PA's.

Do I have serious concerns about EITHER profession having programs betcha, and as of right now, I am not aware of a single PA program online, but if there was, I would decry it as loudly as I decry the NP ones.

Do I have concerns about the combined RN/NP programs where the student NEVER actually works as an RN prior to becoming an NP? Yep, and so do most RN's that I know and work with.

BTW, the PA profession has a "clinical doctorate" program too. The Baylor/Army EM residency program awards a DSc degree, and with 5600 clinical hours, and close to 700 didactic hours over a period of 18 months, I would most assuredly call it a "clinical" doctorate. Guess what, I would be JUST as opposed to graduates from the program using the title doctor in the clinical setting.

I am pro PA, I am also pro NP, NP's have been valuable colleagues, co-workers, and have filled a very valuable niche in the healthcare market by delivering low cost, high value care, especially in primary care settings.

Does this mean that I cannot question either profession? If so, then you have truly drank the kool-aid.

At the end of the day, after advocating for PA's and NP's, there is one group that I must advocate for, even at the expense of the above two....

The patient.

As Charles Mayo said. "That which is in the best interest of the patient, is the only interest to be considered".

Thursday, April 16, 2009

Internist shortages.....

I love this.

From Happy's blog...

So, midlevels aren't good enough.....blah, blah, blah. If Happy is only referring to practicing with complete independence, I would completely agree with him. But he's not.

I cannot speak for NP's, but PA's ARE educated in the medical model. We recieve between 2000-2600 clinical hours during school. NP's recieve far less. Like 600-800 for many programs. We are dependent providers that practice with a fair amount of autonomy, but not complete independence. We complete board examinations every 6 years, and 100 hours of CME every two years.

If Happy had his way, ONLY MD's/DO's would be able to practice medicine....too bad it's not possible.

HERE is a link from an article for the NY Times....

A little snippet for ya.

Two trends are converging: there is a shortage of internists nationally — the American College of Physicians, the organization for internists, estimates that by 2025 there will be 35,000 to 45,000 fewer than the population needs — and internists are increasingly unwilling to accept new Medicare patients.

Hmmm, 35-45000 fewer providers than needed. Per the ACP.....Where are these mythical MD's going to magically appear from? Who is going to pay for them?

PA's and NP's can manage a great deal of what comes through an ER or clinic on their own. I am working today. I've seen 12 patients, I've only involved the consultant on three of them, WHY?? Cause the others did not need physician evaluation.

OH, and BTW...the PA profession has 49 residencies, including Hospital Medicine, in fact, there are two!


Wednesday, April 15, 2009

Medicare for everyone?

As Bob Laszewski points out here.

This is just a bad idea on so many levels, and you need to stop and think about the implications. This means hospital reimbursements will crumble. Hospitals who are struggling will close. Hospitals who aren't, will still have to drastically reduce services offered. This pay cut won't just affect physicians. Hospitals will be faced with an unpleasant, and possibly unsafe choice.

1. Cut staff by 20-30%, not ideal, and could lead to patient safety issues.
2. Cut staff salaries by 20-30%...can we say revolt? Also, it's one thing to cut a spine surgeon's salary who is making 850k by 20%, but quite another thing to take an RN making 50k and cut her salary by 10 thousand dollars. And anyone who knows ANYTHING about hospitals will know that they will. They will do everything possible to keep the physicians happy and keep patients flowing through the doors, yet the nurses, and floor workers will get SCREWED.

Initially, the report indicates that reimbursements will only fall 5-7%, but that is only in 2010, as the program progresses, and more people switch to the "government" plan, and abandon private insurance, the reimbursements will fall even more. Private insurers will need to reduce their payments or raise rates dramatically to make up for the loss of volume. This will have an economic tsunami effect, and patients will suffer for it.

I understand Mr Obama's intentions, and I think they are admirable, but this is just not the right way to go about this. Cost controls need to be implemented, and those providers/institutions who are billing fraudulently, and/or providing unnecessary services SHOULD see their reimbursements cut, but this will create a blanket effect, that will affect everyone.

Basically, there are better ways to go about this.

Oh yeah, and Bob's right, what the hell is up with democrats wanting a two-tiered plan? I thought that was anathema to them?

The respected and non-partisan Lewin Group recently issued a report evaluating the idea, “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options.” It looks to me to be a credible job. They made the assumption providers would be paid at Medicare rates—a logical conclusion if the objective is lowering costs.

Among Lewin’s findings:

“If the public plan is opened to all employers…at Medicare payment levels we estimate that about 131.2 million people would enroll in the public plan. The number of people with private health insurance would decline by 119.1 million people. This would be a two-thirds reduction in the number of people with private coverage (currently 170 million people).”
The study also examined what the proposed plan might do to provider reimbursement rates. Lewin says that if current Medicare payment rates were to be used for a public plan option, physicians would see their net income drop by $33 billion (-7%), and hospitals would see their revenue fall by $36 billion (-5%) in just 2010.
“If Medicare payment levels are used in the public plan, premiums would be up to 30 percent less than premiums for comparable private coverage. On average, the monthly premium in the public plan for a typical benefits package would be $761 per family compared with an average of $970 per family in the private market for the same coverage.”
“If as the President proposed, eligibility is limited to only small employers, individuals and the self-employed, public plan enrollment would reach 42.9 million people. The number of people with private coverage would fall by 32.0 million people. If private payer reimbursement levels are used by the public plan, enrollment would be lower, with only 10.4 million people switching to the public plan from private insurance.”
Medicare premiums would be lower than private premiums because of the exceptional leverage Medicare has with providers. Medicare pays hospitals about 30 percent less than private insurers pay for the same service. Physician payments are about 20 percent less than under private coverage. Also, because Medicare has no allowance for insurer profits or broker/agent commissions, administrative costs for this population are about one-third of administrative costs in private health plans.

This is not a good idea. I am for a realignment in payment structures, and providing primary care physicians with better reimbursements. I am also for reducing the reimbursement for certain procedures which are obscenely reimbursed when compared to others, but a 20-30% reduction across the board will cause many struggling hospitals to simply close their doors. Physicians will bail en masse. It would not be pretty, and I'm afraid, would be unsustainable. It's one thing to talk about reducing ALL salaries by 2-5%, it's one thing to reduce outrageous reimbursements that allow some specialists to make 7 figures, but it's a whole nother thing to take a primary care physician who is making 150 per year, and tell them that their salary is going to drop by 30k per year.


Here's a link to the Lewin Report if interested.

Pay for Performance. (Frost and Sullivan)

With all of the talk of the "medical home" that is so common right now in Health Reform circles. We need to discuss "Pay for Performance". This paper here:

Frost/Sullivan White Paper

Ground breaking. I suggest strongly that EVERY provider, physician or otherwise take ten minutes to read the article. This type of system is already in use in many places, and will be coming out as a national initiative. I know of many physicians, and others who I have talked to, who are somewhat resistant to this effort. This is a mistake. We need to embrace this, learn about, change our practice parameters, and increase our patient satisfaction and outcomes.

Any thoughts?

Symposium on Health Care Education Reform

As a member of the Mayo Clinic Health Policy Center, I am going to post a short blurb on an upcoming event for the center. We are having a Symposium for Health Education Reform on 4-26 through 4-28.

What says the medical blogging community, Happy?

What changes would you like to see in medical student education?

NP/PA Education?

Nursing Education?

Any ideas?

This should be an outstanding event with leaders and educators from around the country gathering here in Rochester. Hopefully the information and discussion will yield some important recommendations from the Center itself. I know that one topic, at least, will be the reform of medical student education to more of a "Team" based model, rather than the traditional physician centric model that has been used for decades.


More info, HERE!!!

Monday, April 6, 2009

Fast Track Disasters....

Continuing with our ongoing series....this time. LISTENING to your patients.

Mr Smith (name altered) was a pleasant middle aged obese male who presented with a primary complaint of a sore throat. Triaged to Fast Track. Vitals demonstrated a normal temp, mildly hypertensive, normal pulse and respiratory rate. He appeared to be slightly disheveled, and his clothes looked to be stained and likely worn for several days. We discussed his sore throat, and the necessity for obtaining a strep test. He denied any associated nausea or vomiting, no body aches or chills, no fever, and no rash. He denied any change in the color of his urine. Exam showed some mild erythema in the posterior pharynx, and mild enlargement of his anterior cervical nodes. Otherwise the rest of the exam was unremarkable. AS I was finishing, his daughter enters the room. I explain my findings, and start to leave the room. I was about halfway through the door, when I hear the daughter say, "Dad, aren't you going to tell him about your urination problem". Feeling slightly annoyed, as I looked at the hallway full of blinking lights(New patients waiting), I turn back into the room. What urination problem I ask. The patient proceeds to tell me that for the past two months, he just has to go to the bathroom constantly. I ask him about any dribbling, urgency, etc.etc., and finally I ask him about his oral intake. His daughter starts to laugh, and says, well, "He's thirsty all the time. He's drinking soda constantly." Notwithstanding the sodium content in soda, I quickly order a BS. 1125 is the final diluted result from the lab. I order labs, urinalysis, and EKG, and then order the IV and initial Insulin protocol. I arrange to transfer him to the monitored area of our ER, and in order to help them, arrange for a bed and admit him prior to him going over there.

Just a little lesson on the importance of listening to your patient.

Friday, April 3, 2009

Creating Value

As a member of the Mayo Clinic Health Policy Center, I would like to take time to talk about creating value.

From our website, and one of the cornerstones of the MCHPC's recommendations:

Create Value
One of the four cornerstones of the Health Policy Center recommendations, creating value involves improving patient health outcomes and satisfaction with U.S. health care and decreasing medical errors, costs and waste. Creating value is the responsibility of providers, medical industry leaders and patients.

Specific recommendations
Develop a definition of value based upon the needs and preferences of patients; measurable outcomes, safety and service compared to the cost of care over time.
Measure and publicly display outcomes, patient satisfaction scores and costs as a whole. Create competition around results through pricing for appropriate bundles of services and quality transparency.
Increase support of health care delivery science, which allows providers to improve the care, efficiency and business processes that support the practice of medicine.
Create a trusted mechanism to synthesize scientific, clinical and medical information for both patients and providers.
Hold all health care sectors accountable for reducing waste.
High-value care delivery.
Develop care programs for patients who need intense, high-cost medical services, such as patients who have complicated diabetes or heart failure.

Quality and efficiency: Increasing support for health care delivery science (systems engineering) will allow for continual analysis of the outcomes and processes of care, a key step to improving quality, reducing waste and lowering costs.

Easier decision-making: Understandable, public reporting of outcomes, patient satisfaction scores and prices will arm individuals with the information required to make better value-based choices.

I've heard some physicians, especially those in primary care grumble about this concept, and especially the pay for performance. There is some concern, and rightfully so about managing a non-compliant patient population and then suffering decreased reimbursements because the patient is not following prescribed treatments. For example, the non compliant diabetic who continually forgets to take their medications, and therefore has an A1C score consistently in the mid 8's. This would indicate poor control, and the physician may likely spend MORE time with this patient in counseling, yet face decreased reimbursements.

I think that that is a legitimate complaint. However, we need to attempt to aggressively measure healthcare outcomes, and reign in spiraling healthcare costs.

What say you?

Healthcare Spending Control

This is a direct and real threat to the American Economy and the American way of life. When various stakeholders in the debate on health reform attempt to discuss pay for performance, and cost controls that are needed. It is a direct result of spiraling healthcare costs that have far exceeded GDP growth, even in good times.

How Much Does the U.S. Spend on Health and How Has It Changed? The U.S. spends about $7,400 per person on health care each year. Sixteen percent of the U.S. economy is devoted to health care. The United States spent $2.2 trillion on health care in 2007. Spread over the population, this amounts to about $7,421 per person (Figure 1). This $2.2 trillion represents 16.2 percent of the nation’s total economic activity, referred to as the gross domestic product or GDP. While these figures are themselves staggering, of principal concern is their rapid growth over time.

Health care spending is consuming an increasing share of economic activity over time.Health care grows faster than many other sectors of the economy and thus its share of economic activity has increased over time. For example, whereas the education, transportation, and agriculture industries may, on average and over time, grow at rates close to the economy as a whole, health care does not. In 1970, total health care spending was about $75 billion, or only $356 per person. In less than 40 years these costs have grown to $2.2 trillion, or $7,421 per person. As a result, the share of economic activity devoted to health care has grown from 7.2 percent in 1970 to 16.2 percent in 2007. By the year 2018, the Centers for Medicare and Medicaid Services (CMS) projects that health spending will be one-fifth of GDP (20.3 percent).

More here


Thursday, April 2, 2009

Reimbursement Shift

A topic I think worthy of some discussion. Should we decrease surgical and specialty reimbursements, or rather reimbursements for interventional procedures, and simultaneously increase payments for primary care?

Essentially, If I were health care "czar", my first action would be an across the board cut of 30% in payments (CMS) to surgical specialists and interventional radiology, cards, etc.etc.etc. And then increase reimbursements by 15% for primary care and hospitalist care. Emergency Room visits would remain stagnant, but not decrease. This would result in substantial health savings, and could start to address the issues in health reform that we face.

What say you?