Tuesday, March 30, 2010

Real Effects of the legislation.

I got this email from a friend who also works in the health policy arena. I thought is particularly poignant, and obtained his permission to post it here. It is sometimes easy to get lost in the data and statistics, and forget, that there are REAL people out there, and this will have REAL effects.

I turned on the television tonight and saw a newsflash that the last vote had been taken on health care reform. For some reason it hit me – the sheer magnitude of the events of the last week, the last few months, and the last few years.

It made me think of my dad. Born in 1952, he has lived his life with a form of muscular dystrophy that has deteriorated the muscles in his legs. He has lived his life as a hard working farmer, as the sole owner/operator of an auto body shop, and as the best role model I’ve ever known. Considering his medical condition and his line of work, he has always had to purchase his own insurance – and has never been able to afford it.

No insurance plan would ever cover my dad’s condition and he has never received the kind of therapy that he truly needs.

He has now applied for disability as he is no longer able to work, an incredibly difficult decision for a proud, hardworking man. He is only months away from spending the rest of his life in a wheel chair, and this would have been preventable if he only had access to medical care.

The work that we have done, and the work that we will continue to do, is important as it truly impacts people’s lives.

With the new health care reform legislation, my dad now qualifies for the immediate high risk insurance pool until he is eligible for Medicaid, and is approaching Medicare eligibility. But, more importantly, millions of individuals like my dad will now be able to afford insurance and seek high quality health care from the finest medical institutions in our great country, and never reach the point where they are on disability and have to give up their livelihood.

My sister, born in 1981, has the same muscular dystrophy as my dad, and is currently uninsured. She will now be able to afford insurance through the exchange and receive the type of therapy early in her life that my dad was never able to afford.

My family owes each of you a debt of gratitude, individuals and families across this country owe each of you a debt of gratitude, and I am proud of what this team has accomplished.

I am going to celebrate. You should celebrate. And we should celebrate this historic accomplishment together.

I honestly believe that every day of our lives is a momentous day, and considering how many individuals like my dad and sister who will truly benefit from this health care reform, this is especially true of our collective days over the last few years.

Thank you for all you’ve done and all you continue to do. And thank you for the continued dedication we will all carry with us as we enter a new era of health care reform.


Saturday, March 27, 2010

Healthcare Reform Talk....

Well, I had to give a talk at the national SEMPA meeting this past Wednesday on "Healthcare Reform: Where are we now?" It was quite interesting. I arrived in Tucson on Sunday evening to find many of the other providers I know surrounding a TV in, of all places, the bar. They were watching the vote, and when it passed, a cheer erupted, with a few simultaneous groans. The president of our organization turned and looked at me with a grin, and said, "Well, I bet you have a little re-write to do" Ummmm. Yep. I almost asked if security would be provided. Holed up in hotel room I proceed to re-write and amend my initial talk. I was prepared, ready for an intense, emotional, intellectual debate. Unfortunately, attendance was small. I think this is because many were either so happy, or so angry that hearing anything more about it would be too much.

The talk went well.

Tuesday, March 23, 2010

Healthcare Insurance Reform...

The most groundbreaking, and comprehensive reform in healthcare was signed into law by President Barack Obama today, less than 48 hours after the house passed it. One side is decrying the legislation and claiming the ruination and destruction of the known universe. The other side is claiming that healthcare reform has finally been achieved.

As usual, they are both wrong. There are three distinct and separate components to healthcare reform, and this only addressed one of them. By no means, am I trying to diminish the symbolism of this achievement, but would rather caution that this is but the first ten miles of a grueling marathon.

I noted that President Obama was careful with his language today, and called this the "most comprehensive piece of health insurance legislation ever passed".

We still need to address healthcare financing reform (ie; how do we PAY for healthcare?) which this does to a very partial degree, but only through subsidies that remain somewhat murky as to the details of their financing.

The biggest hurdle, is perhaps the most important one. We desparately need healthcare delivery system reform. We need to reform the way that care is delivered. We need to develop strong comparative effectiveness data. We need to reduce the primary care income disparity gap, and we need start paying for value. We don't do this now. We pay for volume. We pay for quantity, not quality.

So there is still much to be done, and I will be on the front lines, carrying the banner of the PA profession into the fray.

Tuesday, March 9, 2010

Recent Study by Macy suggest changes to PA legislation...

This was a good workforce study recently completed by the Macy Panel, which as part of their conclusion suggests:

Coupled with efforts to increase the number of physicians, nurse practitioners, and physician assistants in primary care, state and national legal, regulatory, and reimbursement policies should be changed to remove barriers that make it difficult for nurse practitioners and physician assistants to serve as primary care providers and leaders of patient-centered medical homes or other models of primary care delivery. All primary care providers should be held accountable for the quality and efficiency of care as measured by patient outcomes.

I like their conclusions....

The complete study can be found HERE

Interesting Ideas concerning PA evolution....

FROM a PA who went back to the Medical School, and became a physician. I don't see it happening, but interesting nonetheless.

PA’s are as diverse in personality, background and desires as the sands of the sea. A young PA will have differing opinions on various subjects than an older PA. Times change, exams change,people change but human beings are basically competative by nature. Anyone ever run a race to come in second place? My comments to you all are very contemporary, political but with “YOU” in mind. I recently spoke at a conference where a group of NP’s addressed a fellow DNP by the title Doctor. I was recently at a rural clinic where an older PA and a younger PA apparently had issues with a Doctorally trained PA using the titile “Dr.Jones the associate Physician” I didn’t have a problem with that but the two PA’s apparently did. My goodness the PA had a Doctorate degree in Public Health and 18 months of residency training under his belt and I as an MD would not insult this man, brush aside his skills and great bedside manner to consider him my assistant but rather my associate.

To the gentleman who erroneously states PA’s are not considered second class medical citizens check this out and then tell me what you think, then I will answer Daves question as to what the profession needs to do. I propose a scheme for PA’s that would answer the question of why some people got into the medical field and not the PA profession particularly. I think outside of the box so my proposals take into account the group that loves the assistant role and being supervised versus the group which recognizes the practice of medicine boils down to good training and a lot of experience, not a “HAZING” process of brutal medical school training with 3 years of inhumane residency slavery.

Proof that the medical community sees you as second class citizens.

The Michigan state medical board without letting you all know, listed podiatrists as supervising physicians of PA’s. How respected is the PA profession when foreign-trained doctors working in Federal facilities can get a PA license without any didactic or clinical training in a PA program? see


When a medical organization accepts a model of licensure that designates its practitioners as lifelong “interns/residents” needing supervision,(Post Graduate year 1/2 medical students). That profession is doomed to accept practice guidelines involving supervision by “any” independant healthcare professional, (podiatrist).

Statement by AMA to increase medical student seats to increase the primary care force. PA’s are not even considered a viable option. Physician workforce shortage: Yes, no, or maybe? e-mail story | print story In the March 2005 issue of the GME E-letter, we wrote, “It appears we are facing a national shortage of doctors. This shortage is currently confined to some regions and specialties, but the bulge of aging baby boomers threatens to widen the gap. “The Association of American Medical Colleges (AAMC) has called for a 15 percent increase in the number of medical school graduates by 2015--but that won’t solve the whole problem. We will need more GME positions as well. “To be feasible, this expansion will require removing the current caps on the number of federally funded residency positions as well as finding additional funding sources for GME. But how should these residency slots be distributed geographically and among the specialties? And how should we develop national policy on medical workforce issues such as these?”

So when a Doctor gets disciplined or has his/her license revoked and the state medical board publishes this statement;

“Dr. John doe was placed on 2 years probabtion and is prohibited from SUPERVISING PA’s and NP’s”

So when those PA’s/NP’s just lost their job because of the MD’s incompetence and the underlying tone of such statements imply that a PA/NP can’t function without the valid,unrestricted license of an MD I have 2 questions;

a) Why then do you have PA/NP licensing agencies?
B) Why take exams,do clinical rotations,take CME’s or even have conferences?

Dave it was a Doctor who created the P.A profession now the PA’s should move the profession forward by doing the following;

1) Change your title to “Associate Physician”. The word Assistant in 33 standard dictionaries means “Clerical”.

2) Create a Doctorate Associate Physician (DAP). Read the history of DO’s then you will see that this just follows an already established precedent. A DO colleague of mine once said that “MD’s may look down upon me because I am a DO but at least I’m not a PA” the DAP degree needs to be created and granted with completion of accredited postgraduate clinical residency training programs. This should be a clinical degree, and you should use a doctoral title. Optometrist,opthomologist,psychologist and psychiatrist don’t have a problem with an established precedent of “Degrees”. I suggest the following licensing scheme to keep all Associates and Assistants happy;

4 year degree, Bachelors, Associate Physician. (BAP)

7-8 Year degree,(bachelors and 3 years of additional
training) Masters, Associate Physician(MAP)

7-8 Year degree, with Post-Graduate training,
Doctorate, Associate Physician (DAP)

This would be the key in a licensing system as defined;

Distinction/educational level is clear in this scheme.BAP, MAP and DAP. The bachelors trained professionals
are the only ones that need to follow the current PA-Physician supervisory model. This would keep all the assistants happy. If you want to be an assistant then stay here. The MAP and DAP should be independant practitoners however. In this scheme a seasoned, experienced Associate Physician could actually move up the career chain after many years of practice if they choose, or 26-30 year olds fresh out of medical school residency training will become supervising Physicians of a 30 year practicing PA. Doesn’t make sense to me. I had to put a 1 year out of residency training Board certified 30 year old FP in his place because the 50 Year old PA of whom he was the supervising Physician was correct regarding the use of basal -vs- bolus insulin in a Diabetic patient. It was quite obvious this board certified rookie learned all this detail about Lantus but didn’t understand you don’t use basal insulin for Bolus random blood sugar elevations, the 50 year old PA his “assistant” knew however.

Why am I on here? I don’t want my fellow hardworking, intelligent and innovative colleagues to go through the “Hell” I went through to move away from the clinical handcuffing I went through as a PA, going through medical school, residency training only to end up doing the same thing I did day in and out but now with a title change. Now with a better income and incentive pay. With hospitalist, I don’t need to manage patients in the hospital etc.....Wake up my friends and move forward. The grass is green on your side please water it properly.

Interesting, and timely discussion....

Tuesday, March 2, 2010

Example of Cost Increases.....

So, some time ago, I had a younger, obese female patient present to the ED. She came with a complaint of a breast lump with skin discoloration. At first, I thought of potential mastitis, could she have a ductal abcess, something bad...right? Nope. This had been present for 2 months duration, and she had done a "lot of research on the internet". That is not usually a good statement to hear from your patient, primarily because there is just so much BAD information out there, and you often spend a great deal of time correcting misinformation, or even more often, MISINTERPRETATION of information. Anyway, she saw her local MD, who referred her to a breast physician locally. She was extremely concerned that she had Invasive Ductal Carcinoma. In fact, she had already staged herself, and was concerned that she had already progressed to stage II. Mind you, she had not seen a breast physician yet. She had been concerned, and had already called our breast clinic, for which she had an appointment in 2 days.

This was unacceptable apparently. The patient wanted an MRI (which we rarely ever do in the ED, and only in the instance of a severe emergency), or to have it biopsied in the ED. I explained to her calmly that I could not offer her either of those options. I explained some alternative ways that she could potentially move up her appointment.

A completely unnecessary visit, which cost hundreds of dollars, and added nothing to her care. I don't blame her. I blame the system in which this is encouraged. This is not even an unusual story, as there are dozens of patients who present every day with complaints that should have likely been seen in an outpatient clinic.

Wellpoint CEO....

Well, those of you who follow this blog, know that I don't have a lot of empathy for insurance companies, and some of their practices.

THAT being said, I agree with the CEO of Wellpoint Angela Braly's recent stance. She's right, while some of the insurance industries practices are a bit distasteful, such as recission, and denial of claims. The insurance industry is not the main reason costs are increasing. Hospitals, physicians, and other providers are raising rates. Add in a tumbling economy, and you get a risk selection bias as healthier individuals forego insurance, and an increase in COBRA enrollment, which is almost universally full of sick individuals. This creates a problem for the insurance company. While I am not going to say I feel sorry for Wellpoint, I believe that most people are missing the point of Ms Braly's comments.

She's right, we need more than simple health insurance reform. We need DELIVERY system reform, and right now, we're not getting it.

How about this idea. If we are going to mandate that all patients have insurance, and we are going to mandate that all insurance companies cannot deny pre-existing conditions, or cancel policies, and must have higher MLR ratios, then how about MANDATING that all providers accept Medicare patients. Tie it to their DEA number. If they refuse to see new Medicare patients, they lose their DEA number.

Providers need to have some skin in the game too.