Wednesday, March 25, 2009

Ultrasound and Scope of Practice

A measure that would require women seeking an abortion to get an ultrasound exam and have the option to view the scan was revived Wednesday.
State law already requires sonograms for any abortion done more than three months into a pregnancy. The proposed bill would extend that provision to the first trimester, when most abortions take place.
Under the proposed law, doctors must allow the woman a chance to see the scan, unless she signs a waiver declining that option. Doctors also would be required to provide information on fetal development.
The bill provides exceptions to the ultrasound requirement in cases of medical emergencies or when the woman can provide documentation that she's a victim of rape, incest, domestic violence or human trafficking.
Proponents of the measure argue that the ultrasound provision helps women make informed medical decisions and helps doctors prevent complications.
Opponents argue the provision is a veiled effort to create an added hurdle for women. They say doctors -- not the Legislature -- should make the decision to perform an ultrasound.
Personally, I am surprised that organized medicine would support such a measure which clearly provides the legislator the authority to dictate how a doctor should practice medicine.
We struggle every year to prevent the expansion of the scope of practice.
Now,legislators WITHOUT medical training or license to practice medicine is telling us HOW to practice medicine?
I urge all of my colleagues to STOP this measure!
Contact your legislator and ask them NOT to support this legislation.

Posted on Thu, Mar. 19, 2009
Ultrasound abortion provision revived in Florida House

A measure that would require women seeking an abortion to get an ultrasound exam and have the option to view the scan was revived Wednesday, after the state Senate rejected a similar proposal last year in a dramatic 20-20 tie vote.
Following more than an hour of debate, the House Health Care Regulation Policy Committee cast a party-line vote in favor of the bill, with Republican supporters saying the ultrasound provision helps women make informed medical decisions and helps doctors prevent complications.

''I think that any time that anybody has more information when they're going in for a medical procedure I think that's a good thing,'' said Rep. Anitere Flores, a Miami Republican who is sponsoring the bill along with Rep. Rachel Burgin, R-Brandon.

Opponents argue the provision is a veiled effort to create an added hurdle for women. They say doctors -- not the Legislature -- should make the decision to perform an ultrasound.

''I think that this is a very difficult decision that women make and we should not continue to put hurdles up and chip away at current law,'' said Rep. Kelly Skidmore, D-Boca Raton, who voted against the bill along with Rep. Ari Porth, a Coral Springs Democrat.

State law already requires ultrasound scans -- also referred to as sonograms -- for any abortion done more than three months into a pregnancy. The proposed bill would extend that provision to the first trimester, when most abortions take place.

Under the proposed law, doctors must allow the woman a chance to see the scan, unless she signs a waiver declining that option. Doctors also would be required to provide information on fetal development.

The bill provides exceptions to the ultrasound requirement in cases of medical emergencies or when the woman can provide documentation that she's a victim of rape, incest, domestic violence or human trafficking.

Lawmakers in several other states also have proposed bills imposing various ultrasound requirements. Ultrasounds are currently required before all abortions in Alabama, Mississippi, Louisiana and South Dakota. This is the third year in a row that the Florida Legislature has debated similar ultrasound bills. The proposal cleared the GOP-dominated House in previous attempts but failed once because the Senate would not take up the issue, and most recently when seven Republican senators joined 13 Democrats to defeat the bill.

This year, Sen. Andy Gardiner, R-Orlando, is sponsoring the Senate version of the proposal.

Some of the bill's supporters believe the measure has a better chance of passing this session because at least one of the senators who previously voted against the bill has been replaced by a more conservative member.

However, the bill is set to pass through the Senate Health Regulation Committee, where five of the committee's eight members say they are opposed to the bill or have voted against it in the past.

Breanne Gilpatrick can be reached at

Thursday, March 19, 2009

South Florida Doctor Cares For The Uninsured

Attached some bad and good news regarding the situation of the Uninsured in Florida.

Whats the BAD news?

The Miami Herald today reported that according to recent Census Bureau report more than five million Floridians were uninsured for at least a month during 2007 and 2008.

That works out to 38.1 percent of residents under 65. Almost four out of five of those were uninsured for six months or more, the report said.

Those figures reveal that Florida is slightly worse than the national average of 33.1 percent uninsured at some point during 2007 and 2008.

Other information from the study about Florida:

• More than four out of five uninsured Floridians, or 80.8 percent, were in working families.''

• More than three-fifths, or 60.7 percent, were individuals or families with incomes below twice the poverty line -- $42,400 of annual income for a family of four.''

Hispanics and African Americans were much more likely to be uninsured than non-Hispanic whites: 54.4 percent of Hispanics, 42.5 percent of African Americans, compared to 30.2 percent of non-Hispanic whites.

The study was based on the most recent Census Bureau reports and the Agency for Health Care Research and Quality.

Whats the GOOD news?

Some doctors are doing something about it and one of them, a South Miami radiologist, was featured in the Miami Herald.
Congratulation Dr. Kallos and we should honor her as an outstanding doctor and humanist.

Posted on Thu, Mar. 19, 2009
South Florida doctors offer options for uninsured

With the number of uninsured rising daily, a prominent South Miami radiologist is offering free mammogram screenings for women who have lost their jobs and health insurance.
''In the spirit of Barack Obama, we need to volunteer to help our country,'' said Nilza Kallos, who operates the Breast Health Center and Diagnostic Ultrasound.

She challenged other physicians to make similar offers. ''This could be like an invitation to other doctors to step up,'' she said.

``I've heard surgeons say they don't have enough work. Well, how about helping those who need help?''

Kallos' offer comes as many financially pressed patients are curtailing care because they can't afford it. Some are insured and can't even afford the co-payments. Few doctors in South Florida are matching Kallos' free offer, but many in Broward and Miami-Dade are offering discounts to those who need them.

''The situation has reached the crisis stage,'' says Bernd Wollschlaeger, a North Miami Beach physician and president of the Dade County Medical Association.

``I think we need to do something.''

He says he and others are lowering their prices for their uninsured patients or giving them other help if they can't afford to pay. ''If you donate some of your time, it comes back to help you,'' because patients will remember helpful doctors when the economy improves.

Tony Prieto, president of the Broward County Medical Association, said in a statement: ``Patients need to understand that doctors have bills to pay, staff salaries, and office expenses, but we are compassionate, reasonable people who want to help our patients.

``Patients who have lost their insurance should know that most doctors are willing to work with their patients, set up payment plans and give cash discounts so that the patients can still have access to care.''

Those doctors include Barbara Martin, a Tamarac internist. ''In my office we are not charging for any visits to patients who are in bad situations,'' Martin wrote in an e-mail. ``Also we are trying to get them medications that they can afford at Wal-Mart, and samples at the office.''

''I would be happy to offer services discounted to anyone who has lost a job,'' wrote Richard Rubenstein, a Tamarac dermatologist, in an e-mail.

Some doctors note they have always offered help to the uninsured.

Alan Routman, a Fort Lauderdale orthopedic surgeon, said: ``I've been giving patients without insurance 30 percent discounts for cash or credit-card payments forever.''

The burden of more people seeking cheaper healthcare often falls on publicly-funded health centers, who take all patients regardless of whether they have insurance. Jennifer Capezzuti, a primary care doctor at Broward Health, notes that she has been spending ``excessive amounts of time evaluating patient's prescriptions and switching to generic alternatives.''

At the Breast Center in South Miami, Kallos has long been known as a doctor who reached out to help the community.

In 2008, she was honored as a ''Woman of Vision'' by the American Committee for the Weizmann Institute of Science.

''The worst thing,'' Kallos said, 'is when I hear a woman say, `Oh, I lost my job and my insurance. I'll skip my mammogram this year.' Well, this could cost her a life,'' if a cancer went untreated for a year.

Kallos said she might have to spread out the appointments over time if she is inundated by request for free services.

''If it's a regular mammogram, it can wait a little bit. But if she says she has a lump, we'll do that right away,'' she said.

Edited and Published by

Berdn Wollschlaeger,MD,FAAFP,FASAM
President,Dade County Medical Association

Sunday, March 15, 2009

Home Health Care Fraud

Miami - Dade county tops the list again.
Investigators of the Government Accountability Office (GAO) cited that:
> Unusually large share of diabetic patients receiving home healthcare in the county -- 50 percent. That's nearly triple the
average rate in all other major metro areas nationwide.
> The number of Medicare-licensed home healthcare agencies reached 8,463 in 2006 -- up from 6,553 in 2002. More than
half of that increase occurred in two states, Florida and Texas.
> In 2006 Medicare spent about $13 billion for homebound patients nationwide receiving skilled nursing, aide and other visits
-- up about 44 percent from expenses in 2002. Yet over that five-year period, the number of home healthcare patients
using Medicare home services grew by 17 percent.
> In Miami-Dade in 2007, home healthcare agencies received more than $550 million from Medicare for treating patients.
That was four times greater than all Medicare payments for similar services billed in Chicago, Dallas, Houston and Atlanta,
even though there are more people over age 65 in each of those metro areas, the report says.

What are the factors contributing to the problem?
> Unscrupulous business people who can open a home-health company without any background screening or proper vetting
> Unethical doctors who expect and receive CASH payment in brown bags (yes, its true) for each patient referral, even though
home health care is not indicated.
> Medicare outsourced home health administration to private contractors who are not being watched or being held
accountable for their services.

> Stop private contracting process(Moratorium)
> Freeze licensure of all home health companies in Dade County and review their business practices. Unfortunately, South
Florida politicians do not have the guts (or cannot afford being cut-off from a guaranteed money flow) to stand up to that
Home Health lobby.
> Revoke the license of each and every doctor who accepts kickbacks.

Radical solutions? Yes they are! But something has to be done to stop the bleeding!

PS: Please send all hate mail and threats to the State Attorneys office.

Posted on Fri, Mar. 13, 2009
Study blasts rampant healthcare fraud, especially in Miami-Dade

A U.S. government watchdog agency has singled out Miami-Dade County for acute fraud in the $13 billion home healthcare industry, in a newly released report that spotlights runaway costs due to suspicious Medicare billing.
The Government Accountability Office cited the unusually large share of diabetic patients receiving home healthcare in the county -- 50 percent. That's nearly triple the average rate in all other major metro areas nationwide.

GAO investigators blamed Medicare for poor oversight of home healthcare agencies, citing hundreds of millions of dollars in ''improper payments'' for fraudulent claims in Miami, Houston, Los Angeles and other metropolitan areas.

The findings of the report, which analyzed 2002-2006 Medicare billings, angered the ranking Republican member of the Senate Finance Committee. U.S. Sen. Charles E. Grassley, R-Iowa, warned top officials of the nation's health insurance program for the elderly that they must confront fraud as part of President Barack Obama's goal to reform Medicare.

''I regret to say that it seems to me that [Medicare] is out of touch with the home health benefit and has yet to recognize the vulnerabilities inherent in the system,'' Grassley wrote Medicare's acting administrator.

``In order to bring much needed integrity into this program, [Medicare] needs to stop dropping the ball.''

Several of the troubling findings in the GAO report -- including questionable Medicare billing by Miami-Dade home healthcare agencies for services either not necessary or not provided -- were disclosed in The Miami Herald last November. The story showed that the problem has continued beyond the five years covered in the GAO report, with billings reaching $16.5 billion last year.

Medicare officials said they have taken steps to stop fraud -- including suspending more than $100 million in annual payments to 13 home healthcare agencies in Miami-Dade last fall. They're suspected of overbilling for nurses treating homebound diabetic patients who don't need help injecting their insulin.

Medicare is also conducting audits of claims and payments to determine whether services were actually prescribed by doctors and provided by agencies.


But Medicare said it isn't screening home healthcare applicants for criminal backgrounds, as recommended by the watchdog agency.

The GAO report found that in 2006 Medicare spent about $13 billion for homebound patients nationwide receiving skilled nursing, aide and other visits -- up about 44 percent from expenses in 2002. Yet over that five-year period, the number of home healthcare patients using Medicare home services grew by 17 percent.

Overall, home healthcare spending was highest in California, Florida, Louisiana, Nevada, Oklahoma, Texas and Utah.

Another startling statistic: the number of Medicare-licensed home healthcare agencies reached 8,463 in 2006 -- up from 6,553 in 2002. More than half of that increase occurred in two states, Florida and Texas.


GAO investigators said that as those numbers have soared, so have fraudulent and abusive billing practices. Among them: ``upcoding -- overstating the severity of a beneficiary's condition.''

That practice is rampant in Miami-Dade, where home healthcare agencies are suspected of paying kickbacks to homebound patients diagnosed with diabetes who don't need nurses to inject their insulin twice daily.

The GAO report noted that in Miami-Dade in 2007, home healthcare agencies received more than $550 million from Medicare for treating patients. That was four times greater than all Medicare payments for similar services billed in Chicago, Dallas, Houston and Atlanta, even though there are more people over age 65 in each of those metro areas, the report says.

Saturday, March 14, 2009

Primary Care in Crisis

Dear Friends and Colleagues:
Attached a great article from todays Miami Herald focusing on efforts to boost primary care funding.
I wholeheartedly support such efforts but am concerned to direct the funding for community health center only!
Lets not forget that the overwhelming majority of primary care visits are being rendered in private doctors offices!
In order to adapt to the rapidly changing healthcare market place those offices need the following:

* Logistical support to form collaborative practice networks to leverage their purchasing power, reduce administrative overhead, optimize practice management, access to skilled and trained human resources etc.
* Educate physicians and staff on how to integrate their practices into the medical home delivery system
* Optimize practice workflow to reduce patient error, increase quality and ascertain outcome
* Install and implement state-of-the art medical information technology tools
* Continuous assistance and support in the transformation process

This requires financial incentives, loans and grants and the active participation of specialty societies and other physician groups.
We must double our efforts to increase the workforce of primary care physicians. The clock is ticking.

Posted on Sat, Mar. 14, 2009
Study: Florida would save money by boosting primary care
Legislators are expected to receive next week a research paper that concludes the state could save $700 million a year in healthcare costs by making sure Floridians had a place to go for primary care.

More basic screenings and preventive care would keep many people out of expensive trips to the emergency room, wrote four researchers from The George Washington University. At present, 3.8 million Floridians don't have insurance, the study reports, and eight million ``lack access to a regular source of primary healthcare.''

The report comes at a time when the Obama administration is pouring $10 million into Florida's community health centers as part of the stimulus package, and more money may be on the way.

The Florida Association of Community Health Centers plans to use the George Washington University study to make a case that the Legislature should double funding for public clinics next year -- from $15.3 million to $31 million. The group also favors a $1 per pack increase in cigarette taxes.

''We're not asking for a lot,'' said Andrew Behrman, president of the association. ``And it could do a lot to help Florida.''

Both Democratic and Republican policymakers say more emphasis on primary care is the best way to reduce overall healthcare costs, but finding the dollars to finance it has been a challenge.

Behrman's group advocates getting the $31 million from the billion-dollar Lower Income Pool, made up of federal and local tax dollars intended for institutions that do the most for the poor and uninsured, such as the large public hospitals.

Anthony Carvalho, president of the Safety Net Hospital Alliance of Florida, which includes the Broward and Miami-Dade public hospitals, said, ''We think primary care initiatives are good,'' but he wasn't certain whether LIP is the best way to fund.

At present an LIP council, led by large public hospitals, recommends to the Legislature how the pool money should be spent. The Safety Net group, whose members form the bulk of the council, favors its retention. The Health Centers group supports a bill to abolish the council.

Meanwhile, money is rolling in from Washington. The Broward Community and Family Health Centers in Hollywood is getting $1.3 million in stimulus money to expand operations.

Community Health of South Florida (was just informed by a federal agency that it could receive $995,000 to help its seven clinics assist the poor and uninsured.

CHI Chief Executive Brodes Hartley said the group's clinics treated 58,000 patients in 2007, 65,000 in 2008 and are expecting increased growth this year. Hartley said he hopes to use the new funds to hire another obstetrician-gynecologist to deliver babies in South Dade and for other matters.

Friday, March 13, 2009

Walmart and EHR

Great idea? Successful EHR integration boils down to three components:
Most companies do a good job to install and implement a system but hardly provide any service on how to use an EHR to reduce costs, maximize outcome and improve quality. Basic question: how do they help me to transform my practice to achieve ROI (Return on Investment) and utilize the collected data to improve my financial performance.
Walmart may sell the product but what's happening afterwards if you need individualized support?

March 11, 2009
Wal-Mart Plans to Market Digital Health Records System

Wal-Mart Stores is striding into the market for electronic health records, seeking to bring the technology into the mainstream for physicians in small offices, where most of America’s doctors practice medicine.

Wal-Mart’s move comes as the Obama administration is trying to jump-start the adoption of digital medical records with $19 billion of incentives in the economic stimulus package.

The company plans to team its Sam’s Club division with Dell for computers and eClinicalWorks, a fast-growing private company, for software. Wal-Mart says its package deal of hardware, software, installation, maintenance and training will make the technology more accessible and affordable, undercutting rival health information technology suppliers by as much as half.

“We’re a high-volume, low-cost company,” said Marcus Osborne, senior director for health care business development at Wal-Mart. “And I would argue that mentality is sorely lacking in the health care industry.”

The Sam’s Club offering, to be made available this spring, will be under $25,000 for the first physician in a practice, and about $10,000 for each additional doctor. After the installation and training, continuing annual costs for maintenance and support will be $4,000 to $6,500 a year, the company estimates.

Wal-Mart says it had explored the opportunity in health information technology long before the presidential election. About 200,000 health care providers, mostly doctors, are among Sam Club’s 47 million members. And the company’s research showed the technology was becoming less costly and interest was rising among small physician practices, according to Todd Matherly, vice president for health and wellness at Sam’s Club.

The financial incentives in the administration plan — more than $40,000 per physician over a few years, to install and use electronic health records — could accelerate adoption. When used properly, most health experts agree, digital records can curb costs and improve care.

But many, especially physicians in small offices, doubt the wisdom of switching to electronic health records, given their cost and complexity.

Only about 17 percent of the nation’s physicians are using computerized patient records, according to a government-sponsored survey published last year in The New England Journal of Medicine. The use of electronic health records is widespread in large physician groups, but three-fourths of the nation’s doctors work in small practices of 10 physicians or fewer.

Wal-Mart, however, has the potential to bring not only lower costs but also an efficient distribution channel to cater to small physician groups. Traditional health technology suppliers, experts say, have tended to shun the small physician offices because it has been costly to sell to them. Taken together, they make up a large market, but they are scattered.

“If Wal-Mart is successful, this could be a game-changer,” observed Dr. David J. Brailer, former national coordinator for health information technology in the Bush administration.

In the package, Dell is offering either a desktop or a tablet personal computer. Many physicians prefer tablet PCs because they more closely resemble their familiar paper notepads and make for easier communication with the patient, since the doctor is not behind a desktop screen.

EClinicalWorks, which is used by 25,000 physicians, mostly in small practices, will provide the electronic record and practice management software, for billing and patient registration, as a service over the Internet. This “software as a service” model can trim costs considerably and make technical support and maintenance less complicated, because less software resides on the personal computer in a doctor’s office.

Dell will be responsible for installation of the computers, while eClinicalWorks will handle software installation, training and maintenance. Wal-Mart is using its buying power for discounts on both the hardware and software.

Wal-Mart’s role, according to Mr. Osborne, is to put the bundle of technology into an affordable and accessible offering. “We’re the systems integrator, an aggregator,” he said.

The company’s test bed for the technology it will soon offer physicians has been its own health care clinics, staffed by third-party physicians and nurses. Started in September 2006, 30 such clinics are now in stores in eight states. The clinics use the technology Wal-Mart will offer to physicians.

“That’s where the learning came from, and they were the kernel of this idea,” Mr. Osborne said.

Thursday, March 12, 2009

Pain Clinics

Wednesday, February 11, 2009


Painless Choices: Cocaine Cowboys Version 2.0

“Cocaine Cowboys” is a 2006 documentary film, which chronicles the development of the illegal drug trade in Miami during the 1970s and 1980s with interviews of both law enforcement and organized crime leaders. The film reveals that much of the economic growth, which took place in Miami during this time period, was a benefit of the drug trade. As members of the drug trade made immense amounts of money, this money flowed in large amounts into legitimate businesses. As a result, drug money indirectly financed the construction of many of the modern high-rise buildings in southern Florida. Later, when law enforcement pressure drove many major players out of the picture, many high-end stores and businesses closed because of plummeting sales.
But drug dealers and their cronies do have learned their lessons and refined their approach. Their basic premise: why going underground if one can deal narcotics legally. What ingredients do you need? A medical office, a doctor’s license,a DEA number, on-site drug dispensing and plenty of advertisement space. All of the above results in a booming cash business in our midst, attracting clients from as far away as Alabama, Kentucky and Georgia. One street newspaper features a “Health & Wellness” section brimming with almost fifty (50) pain clinic ads strategically following the “adult business” section.
In those ads “renowned” pain “doctors” want you to “ get back the life you once knew”, to help you to “ break free from pain” and suggest that “in all this madness good doctors matter.” Naturally, most of those clinics are happy to provide you with any narcotics of your choice if you provide the “proof” to be in pain. An MRI indicating an abnormality suffices to qualify you as a legitimate pain patients. From then on one can receive a variety of narcotics of choice from their menu, dispensed on-site, and with an almost guaranteed refill option, otherwise their business model would suffer. In many cases these unscrupulous modern narco cowboys make millions of dollars a year in CASH!
I have had the “pleasure” encountering several of those “colleagues” who in many cases have no formal training in pain medicine, are semi-retired, had licensure problems, and appear to be board certified in predatory medicine.
The unprecedented concentration of those “pain clinics” in midst our community contributes to out-of-control opioid abuse, narcotic drug dealing and endangers the public health. In my opinion, several of those pain clinics are financed and operated by criminal gangs and the proceeds of their activities are being invested in local businesses, including real estate.It requires the concerted efforts of law-enforcement, political leadership and the medical community to root out his problem. Several steps can be taken right now:
1) Impose a moratorium of dispensing narcotics in physician’s offices, unless the prescribing physician is board-certified in anesthesiology and pain medicine and operates within a licensed and certified facility to be approved by a designated agency. This will immediately reduce the phenomenon of “ pill shoppers” who are pretending to suffer from pain, receive narcotics in numerous pain clinics and then sell those for a huge profit on the street.
2) Mandatory monthly inspection of all pain clinics in South Florida. Skilled inspectors can be trained to randomly audit charts, on-site pharmacies and monitor the patient flow at so-called pain clinics.
3) Criminal background checks of all operators and their financial backers to be reviewed and updated on a quarterly basis.
4) Implementation of a prescription drug monitoring system as a tool to identify drug-seekers and doctor-shoppers.
5) Requiring the Board of Medicine to suspend the license of any physician who violates the standards of care as it pertains to inappropriate prescription of narcotics.
I want to emphasize that the above proposed sanction DO NOT APPLY to most physicians in private practice who in almost all cases legitimately prescribe narcotics for pain. The “physicians” in questions in those pain clinics prescribe hundreds of powerful narcotics at a time to anyone pretending to be in pain! Their “standard of practice” does NOT equate our high standards of care. Les act together to rid our community from these narco cowboys. Lets protect our families, friends and patients from those predators.
Don’t be afraid to call them by their name: drug dealers in a white coat.

Health Care On Life Support

Wednesday, March 11, 2009


Health Care on Life Support: Challenges and Opportunities

By now, most of you have heard that every business in America is buckling under the increasing costs of healthcare expenses. Year after year, health care costs grow faster than the rest of the economy, straining families, businesses, and government budgets. The Center for Medicare and Medicaid Services reported this week that total health care spending rose 6.1 percent in 2007; slightly less than the growth of 6.7 percent in 2006. Even so, it continued to expand faster than the overall economy, which is contracting., reaching a total of $ 2.2 Trillion in 2007, or 16.2 percent of the gross domestic product (GDP). Americans will spend $2.4 trillion on health care in 2008, which is equal to $7,900 a person! Despite the record spending there are 46 million Americans (and growing) without health insurance. No industrialized nation in the world comes even close to the percentage of GDP America spends on healthcare. There is strong evidence that much of this spending does not contribute to better health. Americans spend twice as much per person as the average among other industrialized countries, and yet our life expectancy and infant mortality rates are below average. At least one-third of medical procedures have questionable benefits, according to the Rand Corporation. Based on a study of regional variation, Dartmouth researchers concluded that Medicare spending could be reduced by 29 percent without reducing effective care or affecting health outcomes. The finding suggests that the entire American health care system spends roughly $700 billion a year that does not improve health outcomes. On top of it, in Dade county alone billions of precious health care dollars disappear every year and wind up in the pockets of crooks and criminals. Many businesses also face unique challenges. They lack the negotiating clout needed to obtain favorable rates from insurance companies, and their inability to spread risk across a large group of employees means that the health problems of a single employee can drive premiums up to unaffordable levels. Without economies of scale, small businesses also face larger administrative costs for each worker covered. Small business owners and their employees account for an estimated 27 million of the 47 million Americans without health insurance. Some employers are dropping health insurance, while employment is growing more quickly in industries that are less likely to cover their workers. As a result, fewer and fewer Americans receive health coverage from work. The percentage of Americans covered by employers dropped from 62 percent in 2003 to 59 percent in 2008, the equivalent of 8 million people losing coverage. And for tens of millions of Americans ineligible for Medicare, Medicaid, or another public program, no viable alternative exists to employer-sponsored insurance. There are several issues that need to be fixed to address the health care cost explosion :
1) We must transform health care from a fragmented system into a coordinated and integrated delivery system utilizing information technology, thereby enabling healthcare professionals to measure cost, quality and outcome at the point-of-care.
2) Fundamental payment reforms that encourages doctors and hospitals to improve management of chronic diseases and adopt proven treatments. We have to shift from a volume-based to a value-based reimbursement system. This will reward doctors to spend time with their patients and to focus on the core value of patient care. Otherwise, we will use an entire generation of urgently needed primary care physicians.
3) Promote the application of business management principles in medical offices to help doctors to work smarter and NOT harder.
4) Emphasize the use of generic drugs that can provide equally or even more effective treatment at lower cost. Retail spending on prescription drugs rose only 4.9 percent in 2007, versus 8.6 percent growth in 2006, which is due to the increased use of generic drugs.

5) Stop the preferred funding for Medicare Advantage Plans leading to higher reimbursement and higher costs (115 percent of fee-for-service traditional Medicare). The only beneficiaries are commercial insurance companies which rake in higher profits per member and drain public coffers.

These are just a few ideas that should be assessed and evaluated. As doctors we should take a proactive position and start reshaping our practices. Many of us are stuck in the daily routine and are afraid to change. Organized medicine can and will play a greater role to leverage the risk and assist the individual doctors along the process of change. If we do not adjust to the changing market now, others will enforce painful solutions. Let’s be proactive and not reactive!

EHR Implementation

Medical Information Technology
Your Monthly IT Guide since 1995!

EHR Or Not EHR: That’s Still A Question?

By Bernd Wollschlaeger,MD,FAAFP,FASAM

Many doctors are still debating passionately the merits of an Electronic Health Record (EHR). Some claim that the government has no right to mandate its use, others are suspicious that such systems provide government with the tool to peek into their practice and that “big brother” should stay out of their office.
The majority of doctors I have spoken with are mostly concerned about the costs of the switch from paper to electronic record system. With the average traditional EHR systems running about $50,000 per physician, not including monthly maintenance costs, many docs are hesitant to sign-off on such an expense, especially in those challenging economic times.
Furthermore, doctors have been fed horror stories of EHR implementation failures and the fact that thirty percent of medical practices that adopt a full-fledged EHR system deinstall it later!
It’s also of interest to consider the detrimental short term impact of the stimulus package upon adoption of Electronic Health Records systems. Some have attributed an almost Kafkaesque quality to stimulus package because it will probably serve as a speed bump to EHR adoption until the details of the act have been spelled out. Up until the passage of the stimulus package, adoption of EHR systems has been proceeding slowly but steadily. However, the vaguely defined promise of $17 billion in reimbursements for EHR if unknown criteria are met could result in gridlock among purchasers, i.e. doctors and hospitals, in the short term while they wait for finalization of the provisions of the stimulus package’s Health Information Technology for Economic and Clinical Health Act (HITECH Act). At this point I can state with a high likelihood of certainty that our government will NOT provide financial support to doctors to purchase hard- and software but will incentivize their use. In plain English: you will get paid MORE for demonstrating and proving the “meaningful” use of an EHR system in your practice. This undefined description will likely deter healthcare organizations from rushing to purchase an EHR system.
Another speed bump of the HITECH Act pertains to the reimbursement modality which would only be provided if a certified EHR was implemented. However, the certification standard is to be developed by an office (ONCHIT) that has not been staffed yet, with a coordinator that has not been named yet and by the Secretary of HHS, who has just been appointed.
So what do I advise you to do?
1) Start preparing your practice for the switch toward an EHR. That requires thorough workflow assessment and the careful parsing of essential information out of your existing paper record. This will achieve two goals: a) that your future EHR will model your current workflow, b) that you can transfer the extracted patient information quickly into your new EHR system.
2) Do NOT focus on the big number ($50,000/per physician). This number pertains to the OLD legacy system on which most current EHR software is based. These systems require costly installation, maintenance, updates and can not be adjusted to your practice. Focus instead on the new technologies. The Web 2.0, or second generation of web development and design, aims to facilitate communication, secure information sharing, interoperability and collaboration on the Internet. Web 2.0 websites allow users to do more than just retrieve information. They can build on the interactive facilities of “Web 1.0” to provide the Internet as computing platform, allowing users to run software-applications entirely through a browser. Users can own the data on a Web 2.0 site and exercise control over that data. These sites may have an architecture of participation that encourages users to add value to the application as they use it. This will dramatically cut costs to ~ $6000/year/physician.
3) The new Web 2.0 technologies offer interactive web-based software application with modular design components. For example, you can use an appointment scheduler, a patient registry and lab module to manage your information flow and allow patient to choose their doctors appointment whenever and whereever they want to do it. I am successfully applying such a module for > 2 years and my patients are loving it.

Jumping on the EHR bandwagon NOW gives you a competitive edge and allows use to benefit from the multitude of additional reimbursement opportunities including e-prescribing, quality of care reporting and chronic disease management.
Don’t way and be proactive. Change does not offer only financial opportunities but will provide greater job satisfaction.
We will help you along the way!
Disclosure: The author is a practicing family physician, addiction specialist and computer consultant. In addition, he is a founder and managing partner of a medical IT company.

Monday, March 09, 2009

Health IT and Medical Economics

"It is very easy to scare people with lies. It is much, much harder to educate them with facts.
But effective persuasion does not depend entirely on facts. It also depends on credibility, honesty, simplicity, repetition, and organization. "

Attached two very interesting articles from "Health Affairs" dedicating an entire issue on Electronic Health Records
I highly recommend those articles to assist you in parsing out the myth and the facts.
Most industrialized nations USE EHRs but docs in the US still debating the issue based on perceived "facts" which resemble secular religious propositions that are not proved or demonstrated but considered to be self-evident.
Cooler heads must prevail. Rational thinking versus emotional knee-jerk-reflex reactions are required.
Its absolutely silly (and dangerous) to call those of us who support a coordinated health care delivery systems as "socialists" and "enemies" of the free-market system.
Any smart business man wants to control costs, ascertain quality and maximize outcome of the services rendered. Most docs don't seem to get this basic economic ABC and roll their eyes when I ask them about PL & cash flow& other financial performance statements.
We must adapt to a rapidly changing market place. If not we do not need a meteor impact to go extinct!

One great article is a must read:

* The Attack On Health IT And Comparative Effectiveness Research: A Warning For What Lies Ahead

Attached the abstracts of some other articles in the same issue:

Health Information Technology: On The Fast Track At Last?

A MAJOR ANOMALY OF THE Information Age is that a huge sector of the U.S. economy has been so lacking—and for so long—in its use of information technology (IT). As dozens of major industries retooled themselves in the 1980s around new means of conveying, processing, and analyzing information, health care largely sat on the sidelines. We all suffered. How many deaths or injuries have occurred because clinicians lacked the right information about the right patient at the right time—when much or all of it could have been acted upon through the use of health IT?
Just why health care lagged so badly in adopting IT is a complex story, deeply interwoven with much of the sector’s lingering cottage-industry nature. More than half of doctors still practice in groups of four or fewer physicians; not surprisingly, a survey published in the New England Journal of Medicine (3 July 2008) suggests that only about one in eight physicians have even a basic electronic record system. Despite the substantial growth of e-prescribing, as Maria Friedman and colleagues note in this volume, the vast majority of doctors still write out their prescriptions by hand.

In the classic terms of a vicious cycle, the fact that health IT hasn’t been broadly adopted has almost certainly reinforced these cottage-industry tendencies—not to mention the many other failings of our health care enterprise. If you can’t or won’t share information across health care settings, the system inevitably remains much as the Institute of Medicine’s Crossing the Quality Chasm report summed up in 2001: insufficiently centered on patients, error-prone, needlessly inefficient, uncoordinated, and delivering vastly inadequate value for the dollars expended.

Now the overall health IT environment is changing, if not fast enough, as this issue of Health Affairs makes clear. One measure of progress is that plans are afoot in Washington to incorporate substantial health IT investments into an economic stimulus package, in hopes of boosting the economy while building the backbone of a twenty-first-century health care system. There’s already ample evidence that these technologies can and will be enablers of massive restructuring of health care delivery. In this issue’s Report from the Field, our journalism partnership with Kaiser Health News, Carleen Hawn reports on how a small but growing corps of clinicians are tapping into social-media tools such as Facebook to communicate with patients and reorganize their practices. And as Caroline Chen and colleagues record, when Kaiser Permanente introduced comprehensive electronic health records, complete with secure e-mail messaging between clinicians and patients, primary care office visits dropped by 25 percent. Can we seriously contemplate redressing the supposed primary care shortage by adding thousands more physicians before we get similar IT systems in place nationwide?

As the papers in this volume make clear, we shouldn’t embrace the likely benefits of health IT without ignoring the risks or the considerable implementation challenges ahead. Jos Aarts and Ross Koppel remind us that adoption of computerized physician order entry (CPOE) systems has been associated in some instances with unintended consequences—including, counterintuitively, more adverse drug events, not fewer. Deven McGraw and Linda Dimitropoulos and their colleagues argue that it will be critical to build public trust in health IT by addressing privacy concerns. That will be no small matter, since the combination of an unwieldy federal regulation and myriad contradictory state laws makes overall national policy on the privacy of health information a complete mess.

As of this writing, even assembling a health IT piece of a stimulus package is having its problems. Years of talk about standard-setting still hasn’t produced a sure-fire path to interoperability among competing proprietary health IT systems. If the goal is to share information broadly for the public’s benefit, why should taxpayers be asked to invest more in systems that won’t talk to each other? Talk about Bridges to Nowhere, IT-style! Surely a nation that once agreed on a common standard for the width of railroad tracks ought to be able to agree on interoperability of electronic health information. But we’re not there yet.

As momentum for health reform builds in Washington, addressing such concerns should be deemed every bit as important as broadening health insurance coverage or focusing on prevention. We thank the funders who made this well-timed thematic issue possible: the Markle Foundation, the California HealthCare Foundation, and the federal Agency for Healthcare Research and Quality.

Susan Dentzer, Editor-In-Chief

The Promises And Pitfalls Of Health Information Technology

Successful innovators leave no doubt that health information technology (IT) can have a dramatic impact on care, despite the challenges of implementation and adoption. The papers in the sections that follow describe efforts all along the continuum from large health care organizations to small independent physician practices.
Catherine Chen and colleagues document how adoption in Hawaii of Kaiser Permanente’s new comprehensive electronic health record (EHR) system—complete with secure e-mail messaging and "e-visits" between physicians and patients—has reduced enrollees’ old-fashioned office visits for primary care by more than 25 percent in four years. Next, Anna-Lisa Silvestre and colleagues report survey results describing how Kaiser’s patients value the convenience of online appointment scheduling, e-mail contact with their doctors, and instant access to lab test results. Stephen Parente and colleagues report on EHRs’ impact on patient safety and find some evidence of positive effects. Farzad Mostashari and associates then describe state-backed efforts to implement health IT among independent physician practices in Massachusetts and New York City.

Carleen Hawn’s Report from the Field on social media in health care focuses on how various organizations, physician practices, and patients are making growing use of these tools. Personal health records (PHRs)—either stand-alone or as patient-oriented complements to EHRs—have important potential in such areas as promoting better self-management for patients with chronic conditions. However, as James Kahn and colleagues report, PHRs are unlikely to fulfill their promise without improved health literacy and computer competency for many patients. Joy Grossman and colleagues describe how health insurers are developing and promoting PHRs but are also encountering lack of trust and privacy concerns among patients, providers, and payers.

Medicare’s apparently sure-fire strategy of promoting electronic prescribing with payment incentives has hit snags as well, Maria Friedman and colleagues report. A comparison by Jos Aarts and Ross Koppel of efforts under way in the United States and six other industrialized countries to implement computerized physician order entry (CPOE) systems shows advantages—even though adoption is slow, systems are often poorly integrated, they’re producing new and different types of errors, and users are frequently frustrated.

The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care

Catherine Chen, Terhilda Garrido, Don Chock, Grant Okawa and Louise Liang


We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.

Health Information Technology And Patient Safety: Evidence From Panel Data

Stephen T. Parente and Jeffrey S. McCullough
The potential of health information technology (IT) to transform health care delivery has spurred health IT adoption and will likely contribute to increased investments in coming years. Although an extensive literature shows the value of health IT at leading academic institutions, its broader value remains unknown. We sought to estimate IT’s effect on key patient safety measures in a national sample. Using four years of Medicare inpatient data, we found that electronic medical records have a small, positive effect on patient safety. Although these results are encouraging, we suggest that investment in health IT should be accompanied by investment in the evidence base needed to evaluate it.