Saturday, December 17, 2011

ER, Dental Care and Medicaid

I recommend reading an article published in today's Sun Sentinel titled "More patients turning to ERs for dental care" summarizing the findings of a study by the Florida Oral Health Coalition which found that more than 115,000 people went to the hospital last year for dental care that could have been prevented or done at a much lower cost in a dentist's office. That's up 9 percent since 2008. More than 15,500 of them were children. ERs charged $88 million for that dental care last year — $30 million to Florida's state-federal Medicaid program , the study found. Hospitals not reimbursed for the care likely pass on the cost to other patients through higher charges. The reliance on ERs for tooth care was even heavier in South Florida, with the number of ER visits up 32 percent in Broward County since 2008. To tackle the problem, the group suggests expanding services that can be offered by dental hygienists, raising Medicaid payments to attract more dentists, having Medicaid cover adult dental care, and expanding county health department dental clinics. But the recommendations would require more tax money at a time when state officials are trying to shrink the Medicaid budget.

Florida Medicaid Pilot

On Thursday the federal officials agreed to extend Florida's five-county Medicaid managed-care experiment to 2014 but required the state to make significant improvements to the program. They include the denial of the medical-loss-ratio waiver requiring the participating private health plans to spend 85 percent of funds on patient care and the denial to cap benefit levels for Medicaid beneficiaries preventing the termination of Medicaid services because recipients had already met their $500,000 maximum for the year. These requirements will protect patients from arbitrary insurance service denials and will force private health insurance plans to manage taxpayers dollars efficiently and responsibly. Meanwhile, we should continue to oppose any expansion of the pilot project UNLESS the State of Florida can provide solid and indisputable data that the pilot project improves access and enhances the quality of care for all  Medicaid enrollees. So far I have not found any evidence to substantiate Governor Scott's claim that "we've seen higher quality in administration of care, produced cost savings and consumers in the pilot have found improved access for Medicaid recipients." Looking forward to your feedback. Yours Bernd For more information see:

Saturday, November 19, 2011

The Sick Business of Medicine

Attached a link to an interesting article by John Dorschner published in the Miami Herald titled "Finances strain the marriage between Jackson and the University of Miami" which details the increasingly strained relationship between Jackson Memorial Hospital and the University of Miami. At the center of the dispute are insured patients seeking medical care at Jackson Memorial hospital. UM critics claim that UM physician direct these patients to the UM hospital across the street, and that Jackson Memorial hospital is left with treating the uninsured patients. Miami-Dade taxpayers pay Jackson Memorial $330 million a year to treat uninsured people who seek treatment in the county-owned Jackson system. As part of the system that has evolved over the years, Jackson also pays UM when its doctors treat the uninsured at Jackson. UM critics also claim that once an uninsured patient gets insurance UM doctors are shifting their care to the UM hospital, which then receives the Medicare reimbursement money. UM calls that patient choice. Jackson counters that its paying patients shouldn’t be siphoned off to UM facilities. What troubles me is that patients are being considered as milkable cash cows and once they are loosing their production value they are being pushed back into Jackson Memorial Hospital. Its a sick system which encourages overutilization of medical services and drives up healthcare costs even further. Yours Bernd

Sunday, November 13, 2011

Health Care Cost Control

"Unfortunately, few people really understand how much we spend on health care,how much we need to spend to provide quality care, and the difference between the two." The New York Times published three articles by Ezekiel Jonathan Emanuel,MD PhD focusing on how to control the escalating health care costs in the United States. I highly recommend reading the articles published so far and have attached the links to each article below. The following bullet points represent an excerpt of the arguments made in his articles: How much do we spent on health care in the United States? In 2010, the United States spent $2.6 trillion on health care, over $8,000 per American.The United States spends on health care alone what the 65 million people of France spend on everything: education, defense, the environment, scientific research, vacations, food, housing, cars, clothes and health care. In other words, our health care spending is the fifth largest economy in the world. For more than 30 years, health care costs have been growing 2 percent faster than the overall economy. That means every year we spend ever more on health care and therefore have to spend less on other things — or borrow money to pay for the extra health care. If we continue at this rate of growth, health care will be roughly one-third of the entire economy by 2035 — one of every three dollars will go to health care — and nearly half by 2080. This level of spending on health care is high, but is it worth it? Does it make us healthier? The United States spends around 20-30 percent more per person than the next highest-spending countries, Switzerland and Norway BUT the United States is not getting 20 or 30 percent better health care or results than other countries! As a country we are actually doing worse than a number of countries, like France and Germany, that spend considerably less! How do we spent our health care dollars and how can we start saving? In health care, you have to be talking about tens of billions of dollars before you are talking about real money. A useful threshold for savings is 1 percent of costs, which comes to $26 billion a year. Anything less is simply not meaningful. Cutting health insurance companies profits? Last year, health insurance companies did rack up big profits, but it turns out that the combined profits of the country’s five largest for-profit health insurance companies — United, WellPoint, Aetna, Humana and Cigna — were $11.7 billion, only 0.5 percent of total health care spending. Even confiscating every penny of those profits would add up to less than half of the cost-saving threshold. Cutting drug companies profits? Between 2004 and 2009, generic drug use rose from 57 to nearly 75 percent of all prescriptions. Paradoxically, over those same years, the total amount Americans spent on drugs actually increased by 31 percent — the same rate as overall health care expenditures. Even the best estimates suggest that savings from expanding generics’ use even further are, according to the Department of Health and Human Services, “likely to be small relative to total spending on drugs.” Pharmaceutical costs account for roughly 10 percent of total health care spending, some $260 billion in 2010. Importing brand name drugs from abroad would cut about 2 percent from that — $5 billion per year. Another cost control disappointment. Malpractice reform is the solution? In 2009, the Congressional Budget Office did a comprehensive assessment of the potential cost savings from medical malpractice reforms. Its conclusions: A package that included a $250,000 cap on noneconomic damages, a $500,000 cap on punitive damages and a one-year statute of limitations for claims by adults would save about $11 billion a year — 40 percent from reduced malpractice premiums and the rest in the form of fewer defensive procedures like M.R.I.’s. Frankly, $11 billion is not insignificant BUT at less than half the $26 billion threshold, malpractice reform is certainly not a cost savings magic bullet either. Restrict health care spending on exorbitantly expensive patients? An unpublished analysis of nearly 20 million commercially insured patients(provided to the author of the article) showed that there were only 255 patients who consumed over $1 million in 2010. Together they spent 0.5 percent of all costs — a very large number for so few patients, but just half the 1 percent threshold for cost-saving that matters. And not all of those costs could be saved. Are administrative services one of the biggest money wasters in our health care system? Administration accounts for roughly 14 percent of what the United States spends on health care, or about $360 billion per year. About half of all administrative costs — $163 billion in 2009 — are borne by Medicare, Medicaid and insurance companies. The other half pays for the legions employed by doctors and hospitals to fill out billing forms, keep records, apply for credentials and perform the myriad other administrative functions associated with health care. The range of expert opinions on how much of this could be saved goes as high as $180 billion, or half of current expenditures. But a more conservative and reasonable estimate comes from David Cutler, an economist at Harvard, who calculates that for the whole system — for insurers as well as doctors and hospitals — electronic billing and credentialing could save $32 billion a year. And United Health comes to a similar estimate, with 20 percent of savings going to the government, 50 percent to physicians and hospitals and 30 percent to insurers. For health care cuts to matter, they have to be above 1 percent of total costs, or $26 billion a year, and this conservative estimate certainly meets that threshold!!! How do we get to these savings? First, electronic health records would eliminate the need to fill out the same forms over and over. An electronic credentialing system shared by all hospitals, insurance companies, Medicare, Medicaid, state licensing boards and other government agencies, like the Drug Enforcement Administration, could reduce much of the paperwork doctors are responsible for that patients never see. Requiring all parties to use electronic health records and an online system for physician credentialing would reduce frustration and save billions. But the real savings is in billing. There are at least six steps in the process: 1) determining a patient’s eligibility for services; 2) obtaining prior authorization for specialist visits, tests and treatments; 3) submitting claims by doctors and hospitals to insurers; 4) verifying whether a claim was received and where in the process it is; 5) adjudicating denials of claims; and 6) receiving payment. Substantial costs arise from the fact that doctors, hospitals and other care providers must bill multiple insurance companies. Instead of having a unified electronic billing system in which a patient could simply swipe an A.T.M.-like card for automatic verification of eligibility, claims processing and payment, we have a complicated system with lots of expensive manual data entry that produces costly mistakes. The Affordable Care Act requires the Department of Health and Human Services to develop operating standards for electronic eligibility determination and payment — steps one and six — in the next few years, but we need to go further. We need the standard operating rules to encompass authorizing tests and treatments, submitting claims, verifying where in the process a claim is and the real-time adjudication of denials. And we must accelerate the process, covering all steps by 2015. Finally, the government needs to require that all parties — doctors, hospitals, insurers, government agencies — use the electronic systems. This platform of electronic eligibility, claims and payment would — in addition to saving billions of dollars in paperwork — facilitate anti-fraud measures like those used by credit card companies. It would ease the administrative burden on doctors, letting them do the work that really matters — treating patients. Finally, it could improve care through built-in guidelines; if a doctor tried to schedule a stent implantation for a patient with stable heart disease, the system could tell him to try medication first; if he tried to order an M.R.I for a patient with normal back pain, it could tell him to prescribe physical therapy first. We have to realize that there are no " magic bullets" to solve our health care cost crisis.Any solutions offered so far to provide universal health care coverage will fail UNLESS they are being combined with meaningful and sustained cost control measures. This requires a total reform of our reimbursement system transforming it from a quantity to a quality focused service industry utilizing state-of-the-art information technology tools. Unless we are not willing to change, we are going to be forced to further ration medical services. What do we prefer? Yours Bernd Links: Spending More Doesn’t Make Us Healthier, Less Than $26 Billion? Don’t Bother., Billions Wasted on Billing,

Thursday, November 03, 2011

Personhood Amendment

On November 8th Mississippi voters will be asked to decide on a proposed amendment to the state constitution, which would define as a person “every human being from the moment of fertilization, cloning, or the functional equivalent thereof.” For most voters it sounds like a good idea and it will most probably pass. Therefore, several other states, including Florida, are preparing similar constitutional amendments. Florida Senate Majority Leader and former US Senate Candidate Mike Haridopolos recently signed the FL Personhood Amendment!! The ambiguous language in the Florida and Mississippi 'personhood' amendment are intentionally not being represented properly by the proponents of this ballot initiative. A recent New York Times article correctly points out the following problems: "First, what does “fertilization” mean? As embryologists recognize, fertilization is a process, a continuum, rather than a fixed point. The term “fertilization” — which is sometimes considered synonymous with “conception” — could mean at least four different things: penetration of the egg by a sperm, assembly of the new embryonic genome, successful activation of that genome, and implantation of the embryo in the uterus. The first occurs immediately; the last occurs approximately two weeks after insemination (or, in the case of embryos created through in vitro fertilization that do not get implanted, never). Thus, on some reasonable readings of the amendment, certain forms of birth control, stem cell derivation and the destruction of embryos created through in vitro fertilization would seem impermissible, while on other equally reasonable readings they are not." Following the "logic" of the "personhood" advocates doctors can be charged with manslaughter or even murder by prescribing morning after pills, because it can irritate the lining of the uterus (endometrium) so as to inhibit implantation of a fertilized egg, i.e. "killing a person." A doctor could also be criminally charged by inserting an IUD because it adversely affects a new embryo as it enters the uterus, thus preventing it from implanting in the uterine lining . Again, according to the "personhood" advocates this constitutes the "killing of a person." Even though, abortions are still being protected by federal law women may still face criminal charges according to state law. Other unintended consequences include the question if the treatment of an ectopic or a molar pregnancy requires first a court order to overrule a "personhood" amendment in the respective state constitution. Needless to mention that any delay of these time-sensitive treatment decisions may harm the mother and even jeopardize the life and well-being of a women. I urge all of you to speak up against any such ballot initiatives, to protect the physician-patient relationship and to guard against further state intrusion into our lives. Yours Bernd

Sunday, October 30, 2011

Drug Treatment Instead Of Prison

Attached a link,0,3676874.story to an interesting editorial published in today's Sun Sentinel titled " State prisons need drug treatment alternative." The Sun Sentinel Editorial Board supports legislation — CS/HB 177 and SB 448 — which intends to establish a re-entry program for nonviolent offenders that offers intensive substance abuse treatment, adult education courses and vocational training as alternatives to long prison sentences. The idea is to reduce recidivism, which is essential if state officials want to get a handle on the costs of incarceration. The bills are sponsored by State Sen. Ellyn Bogdanoff, R-Fort Lauderdale, and State Rep. Ari Porth, D-Coral Springs. The two lawmakers are trying to pass needed, positive legislation to help the state of Florida reduce the costs of operating its prisons. In my opinion we should support this legislation and begin lobbying members of the Florida House and Senate. E-mail, twitter, mail or call your representative because " Unlike prison privatization and the more controversial ideas to cut state prison costs, the re-entry program is a simple solution that promises both savings and a much-needed reduction in the state's ongoing recidivism problem." Yours Bernd

Substance Abuse Counseling and Preventive Health Care

Attached a link to an interesting article titled "Counseling on alcohol helps patients and is billable" published in AMA News and posted on October 17th, 2011. Several highlights:

* Since early 2011, many commercially insured patients have been able to receive alcohol counseling paid at 100% with no co-pay or deductible, and the same is expected to be true for Medicare beneficiaries as of Jan. 1, 2012.
* Just asking about alcohol abuse will not necessarily lead to reimbursable payment, but treating those who screen positive most probably will. In addition to the usual fee-for-service, other incentives on the table should further make dealing with the issue more financially feasible for practices and make it more likely that patients will enter treatment.
* Tracking the percentage of adolescents and adults with new episodes of alcohol or other drug dependence who initiate treatment is on the list of eligible professional measure specifications from the Centers for Medicare & Medicaid Services.
* Information should be noted in the patient's chart, along with the time spent on this task. Counseling sessions longer than 15 minutes are billable, but shorter ones are not.
* On July 19, CMS issued a proposed decision memo stating that, as of Jan. 1, 2012, Medicare will cover annual alcohol misuse screening. (A final decision has not yet been made.) Under the proposal, Medicare would pay for four brief, face-to-face behavioral counseling interventions a year. The American Medical Association and other medical societies support his move.
* In addition, alcohol misuse screening and counseling is on the list of preventive services that non-grandfathered health plans must cover at 100% with no deductible or co-pay, according to the Patient Protection and Affordable Care Act. Grandfathered health insurance plans are those that have not changed since the health system reform law was enacted. Non-grandfathered ones are new policies issued after Sept. 23, 2010, and must cover a recommended list of preventive services with no cost-sharing with patients.
* When billing private insurers, the CPT codes are 99408 for an intervention lasting 15 to 30 minutes. An intervention longer than 30 minutes should be coded 99409. H0049 is the code for alcohol and drug screening of Medicaid beneficiaries. H0050 can be used for every 15 minutes of intervention. The services can be provided by a nurse practitioner or physician assistant as well as a physician.


Wednesday, October 26, 2011

Drug Testing Halted

Attached a link to another article titled "Florida's welfare drug testing halted by federal judge" reporting that A federal judge in Orlando on Monday temporarily blocked Florida’s controversial law requiring welfare applicants be drug tested in order to receive benefits. Judge Mary Scriven issued a temporary injunction against the state, writing in a 37-page order that the law could violate the Constitution’s Fourth Amendment ban on illegal search and seizure.Gov. Rick Scott, who signed the measure into law on May 31, touted it as a way to ensure taxpayer money isn’t “wasted” on those who use drugs. “Hopefully more people will focus on not using illegal drugs,” he said then.
But, in her order, Scriven issued a scathing assessment of the state’s argument in favor of the drug tests, saying the state failed to prove “special needs” as to why it should conduct such searches without probable cause or reasonable suspicion, as the law requires. “If invoking an interest in preventing public funds from potentially being used to fund drug use were the only requirement to establish a special need,” Scriven wrote, “the state could impose drug testing as an eligibility requirement for every beneficiary of every government program. Such blanket intrusions cannot be countenanced under the Fourth Amendment.”
Fortunately, our legal system still provides protection against the growing government intrusion in our lives spearheaded by a conservative majority in our legislature. We need to continue to push back the growing number of bills threatening not only the practice of medicine but also the freedoms each and every citizen is entitled to.

Florida Prescription Drug Monitoring Program

Attached a link to an interesting article in USA Today titled "States target prescriptions by 'pill mills'" highlighting the Florida painmill problem, the actions taken to combat this issue which include the Prescription Drug Monitoring Program ( PDMP) . We should be ware that the death rate from oxycodone in Florida increased 265% from 2003 to 2009, the CDC found. By 2009, the number of deaths involving prescription drugs was four times the deaths involving street drugs, the CDC said in a July report. Hopefully, the number will decrease but this requires our active participation and support INCLUDING our use of the just recently launched PDMP, or E-FORCSE.
I am using this program now for the last week and am pleased to report that it truly works! For example, I have implemented a protocol which requires that the prescription record of each and every patient who receives a controlled substances has to be crosschecked with the medication listed on E-FORCSE.
I have already discovered that several of my patients did not inform me that they visit different physicians to receive controlled substances. One patient who is currently being treated with Suboxone received prescriptions for a total of 360 Hydrocodone pills from another MD "specializing" in pain management. I called her and she was very surprised to find out that I knew what she was prescribed. She tried to convince me that she only fills these scripts for "psychological reasons" but is not taking but hoarding them at home. I asked her to come to my office for a follow-up visit including drug testing but she never showed up. I suspect that she may sell, or share this medications with others.
I urge you to obtain your username and password and to incorporate this valuable tool into your practice.

Saturday, October 01, 2011

The number of Uninsured continue to soar!

Attached you find a link to an excellent article article by John Dorschner published in today's Miami Herald titled " More in S.Florida going uninsured" focusing on the soaring numbers of uninsured even in middle-class suburbs." The facts are indeed stunning and sobering:

"The data shows that almost a third — 31.2 percent — of adults aged 18 to 64 in the Kendall area, a middle-class suburb, were uninsured in 2010, up from 19.6 percent in 2008.
Those grim numbers reflect South Florida’s recent economic struggles that have driven up unemployment and forced many small employers to drop insurance coverage, said Steven Ullmann, a health policy expert at the University of Miami. The figures are part of a larger trend of growing numbers of uninsured and shrinking alternatives for the poor throughout Miami-Dade and Broward counties."

"The Kendall uninsured numbers — 50 percent higher than national figure for the same 18-to-64 age group — are “a reflection of everything the economy has been through,” Ullmann said. “It’s becoming an issue nationwide, but it’s reflected even more so in our local economy.”

"The Census data, released last month, shows 31.8 percent of Miami-Dade’s residents of all ages were uninsured in 2010. In Broward, it was 24 percent. In Monroe County, 32 percent — compared with a national average of 16.3 percent."

"A stunning 57 percent of Hialeah residents in that age group were uninsured in 2010, up from 53 percent in 2008.
In the City of Miami, 50.4 percent of 18-to-64-year-olds were uninsured, compared to 45.8 percent in 2008. In Deerfield Beach, 48.5 percent were uninsured, compared to 33.6 percent in 2008. In Miami Gardens, it was 39.9 percent, compared to 35.2 percent in 2008, while Miami Beach registered very little change, with 35 percent, compared to 35.8 percent in 2008. Weston continues to be the place in South Florida with the lowest rate of uninsured residents in the 18-to-64 age group, with 17.9 percent, compared to 13.8 percent in 2008."

The poor are also getting squeezed, says Ullmann. Many of them can qualify for Medicaid, the state-federal program for the poor, but Ullmann notes that as the state’s budget shrinks, legislators have been trying to reduce the program by lowering payments and forcing patients into health maintenance organizations."

Unfortunately, these numbers are not going to change and may even worsen. Many of those who are lucky enough to find a job are NOT offered health insurance because health insurance premiums for employer-provided health insurance jumped 8-9 percent in 2011, passing $15000 for family coverage!
As a result more people seek health care in emergency rooms driving up the costs even further, because those with insurance are paying the share for those who don't, or cannot, pay. Meanwhile, politicians are still engaged in trench warfare to fight off "Obamacare."
We must face reality and find solutions to this problem. One of them would be a countywide effort to create a network of primary care clinics offering a Patient-Centered Medical Home (PCMH) coordinating medical care. Such a network could be financed by grants and federal subsidies. The costs of such care would be substantially lower compared to the emergency room services provided. For example, one of my asthma patients has utilized the emergency room 2-4 times per month for treatment and medication refills. He is now enrolled in a chronic disease management program and has used the ER only once in two years.
I hope that common sense will prevail. Otherwise, we are going to face a very bleak future.

Monday, September 26, 2011

The Legality of Online Health Care Discounts

Attached you find a link,0,6420216.story to an interesting article titled "Are Groupon discounts for medical treatments illegal?" highlighting an important issue: Those big discounts on health care treatments offered on websites like Groupon may be illegal, medical law experts say. Not for the patients but for the medical professionals giving them.
"The law is very strict. This seems like a problem," said Michael Segal, a South Florida health-care lawyer. "I would urge [practitioners] to be very careful. You don't want to find out there's a concern after you have done it."
A number of national and local medical associations, including the Palm Beach County Medical Society last month, have warned members because the issue is still in doubt. Florida regulators said they have not discussed it. Medicare has taken no position. Nor has the American Medical Association or other medical trade groups.


Sunday, September 18, 2011

Hospital Performance

Attached a link to an interesting article titled "Report Finds Improved Performance by Hospitals," reporting that in the latest advance for health care accountability, the country’s leading hospital accreditation board, the Joint Commission, released a list on Tuesday of 405 medical centers that have been the most diligent in following protocols to treat conditions like heart attack and pneumonia. Almost without exception, most highly regarded hospitals in the United States, from Johns Hopkins in Baltimore to the Mayo Clinic in Rochester, Minn., did not make the list!

"With evidence-based ratings gaining prevalence, and a strengthening link between quality and payment, the Joint Commission report raised questions about how consumers should best use the data newly available to them. Increasingly, one component of that inquiry may be whether hospital reputations are deserved or mythologized."

"As an example, none of the 17 medical centers listed by U.S. News & World Report on its “Best Hospitals Honor Roll” this year are on the Joint Commission’s list of 405 hospitals that received at least a 95 percent composite score for compliance with treatment standards. About one-third of a hospital’s score in the U.S. News methodology is based on its reputation as gauged by a survey of physicians...the Joint Commission list of top performers included a disproportionate share of small and rural hospitals, as well as 20 Veterans Affairs medical centers. About 14 percent of roughly 3,000 eligible hospitals made the cut."

"As it is, both private and government health insurers are beginning to tie hospital reimbursements to quality measures like infection rates and readmissions. Next year, compliance with procedural standards will become even more consequential, as the Joint Commission plans to withhold accreditation from any hospital that posts a composite score below 85 percent."

This report serves as a reminder that payers will use this data to strengthen the link between quality and payment.
Therefore, physicians should consider adjusting their treatment protocols and quality measurements accordingly.



Wednesday, September 14, 2011

Wollschlaeger et al vs. Farmer et al

Court Grants Preliminary Injunction Against Physician Gag Law

Since Taking Effect, Unconstitutional Gag Law Had Chilled Speech by Florida Doctors

The Florida chapters of three national medical organizations, along with six physicians, applauded the decision of a federal district judge today to immediately block enforcement of the new state law that bars healthcare professionals from asking patients if they own guns and have them stored properly. These questions are a key element in the practice of preventive medicine.

The groups, along with individual doctors, had asked Judge Marcia Cooke of the U.S. District Court for the Southern District, Miami Division to issue a preliminary injunction because the new law has already curtailed the First Amendment rights of physicians across the state to speak with their patients about gun safety. A preliminary injunction is an order that prevents a party from pursuing a particular course of conduct until a case has been decided. To grant a preliminary injunction, the court must find that plaintiffs have a substantial likelihood of success on the merits of the case.

Lisa A. Cosgrove, M.D., FAAP, President of the Florida Chapter of the American Academy of Pediatrics (Florida Pediatric Society) said: “Pediatricians simply want to do what they do best: protect children. We hope that now we will be able to get back to working with parents to maintain their guns, pools and poisons to keep kids safe."

Dennis Mayeaux, MD, Chair, Board of Directors, Florida Academy of Family Physicians said: “The impact of this law has already caused serious rifts in physician-patient relationships. Casual conversations with patients often bring other medical issues to light, and erosion of these opportunities also erodes the quality of care. The preliminary injunction will now allow us to talk to our patients again about firearm safety.”

Stuart Himmelstein, M.D., American College of Physicians Governor for Florida, stated: "Reversing this law is essential in order to preserve the sanctity of the doctor -patient relationship by keeping the government out of the exam room. The preliminary injunction will preserve free speech between both doctors and patients as protected by the Constitution and which is necessary to obtain the highest of quality care that every citizen deserves."

Physicians and other healthcare professionals routinely provide their patients with information about a variety of health risks in the home and broader environment. Such preventive counseling has become a cornerstone in the practice of medicine and is recommended by numerous professional medical societies. In the course of practicing preventive medicine, healthcare professionals routinely ask and counsel patients about firearm safety.

The state chapters of the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians collectively represent more than 11,000 healthcare professionals in Florida. On June 24, 2011, these organizations, along with six individual physicians, filed papers asking the court to enjoin the law because it substantially curtailed their First Amendment rights to exchange information with patients about gun safety.

The lawsuit challenging the Physician Gag law was originally filed on June 6, 2011, shortly after Governor Scott signed it into law. Prior to filing suit, the physician groups urged the Governor to veto the legislation since it infringes the First Amendment rights of healthcare professionals throughout Florida.

The organizations and individual physicians in the lawsuit are represented by Ropes & Gray (lead counsel), Astigarraga Davis (local counsel), and lawyers from the Brady Center to Prevent Gun Violence’s Legal Action Project.


Saturday, September 03, 2011

PDMP goes online!

Attached a link to an article from today's Miami Herald titled " Fla. prescription database goes into operation" highlighting the fact that as of September 1st Florida's prescription drug tracking system finally was up and running. That means that dispensers and pharmacies must upload their prescription data for Schedule II to IV to the database. Rebecca Poston, the system's program director in the Department of Health said that "Everything is working wonderful, I have not heard of any glitches related to the dispensers registering or uploading information in the system."
The Department of Health will not begin registering doctors and pharmacists until Oct 1, nor will they be able to get information out of the database until Oct. 17. In my opinion the registration and training process should start now and be phased in either by region, or other criteria to be determined by the Department to allow for a smooth transition and to motivate doctors to use the system. Its not too late to do that but leaving it until October 1st is cutting it too short.

Thursday, September 01, 2011

United Health On The Move

Attached a link to an article titled" UnitedHealth Buys California Group of 2,300 Doctors" reporting that United Healthcare will acquire the management arm of Monarch HealthCare, an Irvine, Calif., association that includes approximately 2,300 physicians in a range of specialties. This will establish United's Optum health-services unit as a formidable presence in California. Optum had previously taken over the management arms of two smaller southern California groups, AppleCare Medical Group and Memorial HealthCare Independent Practice Association.This serves as an example of how lines are blurring between insurance companies and health-care providers.
What can we do? Consider forming cohesive primary care and/or multi-specialty associations, utilizing EHR technology and based on the Patient-Centered-Medical-Home Model to compete in the rapidly changing healthcare marketplace.
We cannot ignore the writing on the wall. Change is inevitable!

Pill Mills Under Pressure

Attached a link to today's New York Times front page article titled "Florida Shutting ‘Pill Mill’ Clinics."
The article highlights the accomplishments made despite the initial resistance by the current administration in Tallahassee.:

As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.
One indication that law enforcement officials are choking the supply of prescription drugs sold illegally in Florida is that the price of Oxycodone on the streets here has nearly doubled from last year, to $15 per pill from $8.
On Commercial Boulevard, a major street in Broward County, the number of pain clinics has fallen in the past year from 29 to one.
The fallout from the tougher laws may include an increase in pharmacy robberies, a problem that has been worse in Florida than any other state since 2007 (there were 65 armed robberies of pharmacies here last year).

As of today any health care practitioner who has dispensed a Schedule II-IV controlled substance, as defined in section 893.03, F.S. (i.e., OxyContin®, Percocet®, Vicodin®, Klonopin®, Xanax®, and Valium®), is required to report dispensing information to the Prescription Drug Monitoring Program’s database within seven (7) days after dispensing, in accordance with section 893.055, F.S. This includes pharmacies licensed under chapter 465, F.S., and dispensing health care practitioners licensed under chapter 458, 459, 461, 462, or 466, F.S
Now we must push to start educate physicians on how to use the PDMP and to encourage accessing the database to identify "doctors shoppers."
I am optimistic that we can achieve our goals.

Saturday, August 27, 2011

Drug Testing for Welfare Recipients

Attached some food for thought regarding the mandatory drug testing for welfare recipients:

When Florida Gov. Rick Scott (R) signed the law requiring welfare recipients to pass annual drug tests to collect benefits, he justified the likely unconstitutional law by saying it would save the state money by keeping drug users from using public money to subsidize their drug habits. Drug use, Scott claimed, was higher among welfare recipients than among the rest of the population.According to preliminary results from the state’s first round of testing, however, has seemingly proven both of those claims false. Only 2 percent of welfare recipients failed drug tests, meaning the state must reimburse the cost of the $30 drug tests to the 96 percent of recipients who passed drug tests (two percent did not take the tests). After reimbursements, the state’s savings will be almost negligible, the Tampa Tribune reports:
Cost of the tests averages about $30. Assuming that 1,000 to 1,500 applicants take the test every month, the state will owe about $28,800-$43,200 monthly in reimbursements to those who test drug-free.
That compares with roughly $32,200-$48,200 the state may save on one month’s worth of rejected applicants.
Net savings to the state: $3,400 to $5,000 annually on one month’s worth of rejected applicants. Over 12 months, the money saved on all rejected applicants would add up to $40,800 to $60,000 for a program that state analysts have predicted will cost $178 million this fiscal year.
This should serve as an example that our government in Florida seems to base its decisions on ideological assumption instead on rational thought and consideration.


Bernd Wollschlaeger,MD,FAAFP,FASAM
16899 NE 15th Avenue
North Miami Beach,FL 33162
Phone: (305) 940-8717
Fax: (305) 940-8871
Web Site:

Saturday, August 20, 2011

Primary Care Defunded

Attached you find a link to an article by John Dorschner titled "Clinics for poor threatened by cuts" pointing out that " federal support of clinics [ community health centers] took a big hit in the recent deficit reduction deal in Washington and may be taking an even bigger one when Congress starts a new round of budget-cutting in the near future. At the same time, some free clinics in South Florida that also help the poor — often with little or no government support — are running out of funds and are in danger of closing."
Dorschner further reports that the creators of the federal healthcare reform act considered primary care such an important way to cut costs that the act authorized $11 billion to bolster care at “federally qualified health centers,” which include nine clinics with more than 30 locations in Miami-Dade and Broward. Congress authorized $1 billion for new federally qualified facilities or expansions of existing ones this year. But the $1 billion allocation was slashed to about $90 million for new facilities during the recent budget cuts. Only 67 of 2000 applications for new federally qualified centers were funded. More cuts may be coming as a new congressional deficit reduction committee gets under way.
In my opinion cutting primary care services is a penny-wise and pound-foolish decision . Now, those uninsured will be left with no other choice but to use the emergency rooms of local hospitals for their care resulting in far higher costs, poor care coordination and no continuity of care.
How can we talk sense to politicians who seem to ignore those facts? Are they really so detached from reality, or is is just about scoring points for their re-election campaigns? We must speak up and defend the rights of those who now do not have anyone left to speak up for them. Both parties in congress are at fault and our president doesn't dare to rock the boat. Enough is enough!!

Wednesday, August 17, 2011

Health Insurance Policy

Attached a link to an interesting article published in today's WSJ reporting that as part of the health-care overhaul law federal regulators are expected to unveil on Wednesday the proposed health insurance policy summary form of health insurance policies , that will lay out the details of each policy, from deductibles to how much it might cost to have a baby. The requirement is supposed to take effect next March. Currently, states mandate certain disclosures from health insurers, but they vary by state. The information often comes as part of a document known as the certificate of coverage or evidence of coverage, which can run to dozens of densely written pages and is often supplied ONLY AFTER a consumer has signed up for a policy. Employers offering coverage typically provide materials to their workers, but these also don't follow any common national format.
The proposed new summary is expected to closely follow a draft version from a committee convened by the National Association of Insurance Commissioners, people with knowledge of the matter said. Health and Human Services is expected to finalize the form after a public comment period. Insurers said they were concerned about the potential cost and administrative burden of the new requirement, particularly if they have to create different iterations of the form for every possible plan design a consumer could explore and for every single employer.
Of course they are concerned because for the first time the policies will be readable, comparable and can form the basis of rational decision making in a complex market place. Who does understand his/her current health care policy? I don't !! I still struggle to understand how much my insurance will cover for a colonoscopy and how much I have to budget for this procedure. If we want a free market place then we should allow for measures that create accountability and transparency. Currently, insurance companies will make every effort to maintain the status quo, which disenfranchises the consumer. We should support these new federal regulation and to express our opinions during the public comment period. Let's not miss this opportunity.

Monday, August 15, 2011

The Blues Treatment For Mental Health Providers

Attached a very troublesome article I just received today reporting that on July 27, 2011 Blue Cross Blue Shield of Florida began notifying ALL of their mental health providers (licensed social workers, licensed mental health counselors, psychologists, and psychiatrists) that effective November 30th, 2011 they would be terminated, without cause.
They were also notified that that if providers would like to join the new company they are partnering with, New Directions, so that they can provide services to their patrons, they would need to complete a new contract (sent under separate cover) within 15 days and agree to significant cuts (35-55%) in reimbursement rates, as well as other disturbing clauses such as only being able to refer to in-network providers, etc.
Since BCBS is considered to be one of the largest providers of insurance for mental/behavioral health in Florida, this termination could potentially place hundreds/thousands of providers in a position of being underemployed and/or unemployed, and worse, leave thousands of patients without coverage or access to mental health/psychological treatment.

CNN producer note
iReport -
On July 27, 2011 Blue Cross Blue Shield of Florida began notifying ALL of
their mental health providers (licensed social workers, licensed mental
health counselors, psychologists, and psychiatrists) that effective Nov 30,
2011 they would be terminated, without cause. That is, they will no longer
be providers for BCBS-FL. In this notice, current providers were also
instructed to notify BCBS subscribers/patients of this coming termination
directly and on behalf of BCBS-FL.

BCBS-FL also indicated that if providers would like to join the new company
they are partnering with, New Directions, so that they can provide services
to their patrons, they would need to complete a new contract (sent under
separate cover) within 15 days and agree to significant cuts (35-55%) in
reimbursement rates, as well as other disturbing clauses such as only being
able to refer to in-network providers, etc.

Interestingly, New Directions appears to be a subsidiary of BCBS-FL. So, as
if it isn't horrible enough that ALL of the mental/behavioral health
providers have been "fired" at the same time and patients will likely find
themselves with poor quality care or no care at all, it appears that they
(the same company-BCBS-FL) fired its contractors and then offered them the
oportunity to reapply for rehire within the same week, but only if they
agree to sign a new contract, with entirely different terms.

This action (termination of providers only in one area) also seems to be a
possible violation of the Federal Mental Health Parity Law which protects
against the discrimination of mental health services. It does not appear
that any of the other healthcare providers or "medical" providers had their
contracts terminated.

Since BCBS is considered to be one of the largest providers of insurance for
mental/behavioral health in Florida, this termination could potentially
place hundreds/thousands of providers in a position of being underemployed
and/or unemployed, and worse, leave thousands of patients without coverage
or access to mental health/psychological treatment.

The ripple effect of these actions by BCBS-FL could be deadly to the people,
communities, and businesses throughout FL. leaving many unable to make a
reasonable living and thousands (including Seniors with BCBS as a secondary
policy) unable to access and/or pay for mental health treatment and
psychological services.

Bernd Wollschlaeger,MD,FAAFP,FASAM
16899 NE 15th Avenue
North Miami Beach,FL 33162
Phone: (305) 940-8717
Fax: (305) 402-2989
Web Site:
Twitter: @dadedoc

Wednesday, August 03, 2011

Florida Turns Down Federal Money

Attached a link to a recent article published in the NYT pointing out that despite having the country’s fourth-highest unemployment rate, its second-highest rate of people without insurance and a $3.7 billion budget gap this year, the Florida has turned away scores of millions of dollars in grants made available under the Affordable Care Act. And it is not pursuing grants worth many millions more.
Although Florida is the fourth most populous state, it ranks 12th in the amount of money received from health care act grants, according to the government’s grant-tracking Web site. The law has directed $46.4 million to the state out of $1.98 billion awarded nationally. Much of the money has gone directly to local governments, community groups and medical providers. The Florida government even went so far to deny funding for community health centers! Three of four grants to expand community health clinics in Florida went to medical centers that are beyond the reach of the governor and the Legislature. The fourth was to the Osceola County Health Department, which under Florida law is effectively a unit of state government. The Legislature used its power to not authorize a grant won by the county to expand two health centers and build a third.
This represents not only irresponsible ideology driven behavior but it also threatens the fragile health of our communities.
Its time to raise our voices and to act as responsible citizens of our great state of Florida.


Wednesday, July 27, 2011

Iraqi Healthcare

According to data analyzed by various think tanks the United States of America, i.e. taxpayers like you and me, spent (or wasted) almost ONE TRILLION DOLLAR in Iraq!! Among the many "gifts" we provided was our financial and logistical support for an Iraqi constitution.
It's of interest to note that Article 31 of the Iraqi Constitution, drafted by the U.S. administration in 2005 and ratified by the Iraqi people, includes state-guaranteed (single payer) healthcare for life for every Iraqi citizen!! Article 31 reads: "First: Every citizen has the right to health care. The State shall maintain public health and provide the means of prevention and treatment by building different types of hospitals and health institutions. Second: Individuals and entities have the right to build hospitals, clinics,or private health care centers under the supervision of the State, and this shall be regulated by law."
There are other health care guarantees, including special provisions for children, the elderly, and the handicapped elsewhere in the 43-page document.
So let me make it clear: Our taxpayer money was used to draft a constitution which contains state-guaranteed healthcare for life for every citizens BUT the same rights are being denied for the very same U.S. citizen who paid for this constitution??!!
Naturally, all of our legislators enjoy guaranteed state-funded healthcare, state-guaranteed pensions, state guaranteed salaries etc. BUT the same legislators want us to believe that all state-funded activities are evil and must be cut or eliminated! Naturally, excluding those benefits they enjoy!!
Churchill once said that " The inherent virtue of socialism is the equal sharing of misery." Maybe this is now a virtue of our democracy and our legislators want us to share the misery and allocate the benefits of freedom to those they choose.
Its up to us to let them do that.

Thursday, July 21, 2011

Child Abuse Prevention in Florida

The Miami Herald reports in today's edition that Florida lawmakers have rejected more than $50 million in federal child abuse prevention money because its is being offered through the Affordable Health Care Act which lawmakers oppose for  "philosophical", i.e. ideological,  reasons. The money would have paid, among other things, for a visiting nurse program run by Healthy Families Florida, one of the most successful child-abuse prevention efforts in the nation. And because the federal Race to the Top educational-reform effort is tied to the child-abuse prevention program that Healthy Families administers, the state may also lose a four-year block grant worth an additional $100 million in federal dollars!!
Its of interest to follow the "reasoning" of a key lawmaker, State Senator Joe Negron, opposed to Healthy Families Florida. State Sen. Joe Negron, who chairs his chamber’s Health and Human Services Appropriations Subcommittee, said he long has been philosophically opposed to Healthy Families, which he views as an intrusion into the private lives of parents.“I believe in providing basic information to parents at hospitals and medical settings,” said Negron, a Palm City Republican. “I am not persuaded that it is a good idea to show up at a family’s home year after year giving advice and guidance. I do not think that is a core, essential function of government.”
According to his "logic" its OK for government to censure  doctors free speech and to figure out by themselves, and under the threat of punishment,  what  basic information to parents at hospitals and medical settings is relevant to prevent child abuse.
Its also of interest to note that nobody wants to take responsibility for the rejection of federal funds.
On Wednesday, leaders of the state House and Senate and the governor’s office all insisted they had nothing to do with rejecting the money.“The grant was included in [the state Department of Health’s] legislative budget request, but beyond that, the executive branch never advocated for it and a budget amendment was not submitted,” said Katherine Betta, spokeswoman for Republican House Speaker Dean Cannon of Winter Park. Brian Burgess, a spokesman for Gov. Rick Scott, said Scott did ask for the money. Burgess produced a budget request that has the proposal. “If there is to be finger-pointing,” he said, “it should be directed elsewhere.”
In contrast to previous posturing the Governor and Republican lawmakers seem to be odds at whom to blame (or to cheer) for rejecting the grant money.
Meanwhile, more children will suffer and some may even loose their lives.
As physicians we are obligated to speak up!!


Wednesday, July 20, 2011

United Health Care Profits Rose 13%

Today's New York Times article entitled " Profit Up 13%, United Health Raises Outlook" reports that The United Health Group one of the nation’s largest health insurers, reported its second-quarter results on Tuesday, and the good news for the industry appeared likely to continue. UnitedHealth announced a double-digit increase in profits and raised its estimates for 2011 earnings. Its net income rose 13 percent, to $1.27 billion, or $1.16 a share, compared with $1.12 billion, or 99 cents a share, one year ago. And revenue increased 8 percent, to $25.23 billion. UnitedHealth was the first of the big insurers to report this quarter, and once again, the high profits appear to be partly the result of more budget-consciousness by their customers, even as the insurers ask for higher premiums. As they have for many months now, Americans seem to be putting off or forgoing medical care because of the weak economy and the increasing amount they are required to pay in medical bills as their deductibles and co-payments climb. In late spring, many health insurers said it was too soon to tell whether utilization would eventually rebound to the same levels as before the downturn. They argued that they could not count on the demand for medical care staying at relatively low levels.So the company continued to benefit from consumers making fewer doctor visits as they try to save money in the tough economy.
Following the logic of a free market economy, they should lower their premiums to entice consumers to "buy" healthcare services. But these rules DO NOT apply to the so-called "healthcare market" which is controlled by a few monopolies, in which only one seller faces many buyers who have no choice but to buy the product regardless of price.
Unfortunately, these monopolies also are acting as monopsonies, in which only one buyer faces many sellers. In this cases providers of health care services (doctors, hospitals etc) have no choice but to sell their services to a large insurance company because its buying power dwarfs the remaining market.
Ironically, the Patient Protection and Affordable Care Act will inadvertently exacerbate this situation because for-profit insurance companies play an essential role in the provision of services.
Who will suffer? The consumer who is forced to buy these expensive insurance products and the doctors whose negotiating power has been curtailed by regulations.
In this context a single-payer system, or a model based on not-for-profit insurance companies (i.e. Germany), may serve as a solution.
Unfortunately, we are doomed because we swallowed the "free market" ideology bait with hook, line and sinker and in the end have no choice but to stick with the worst solution anyone can offer.



Friday, July 15, 2011

Graduate Medical Education

Federal Budget Cuts Threaten Graduate Medical Education:

In their efforts to reduce the federal deficit the partisan negotiators seem to agree on one issue only: drastic cuts of the Medicare subsidy for postgraduate medical education and funding reduction for advanced equipment that teaching hospital require to train young doctors.

The recommendations made by the National Commission on Fiscal Responsibility and Reform, currently under consideration, would cut about $5.8 billion in graduate medical education funding from the nation’s teaching hospitals. This represents a 53% cut compared to the current $10.9 billion in payments!! The Simpson Bowles Commission, which advised President Obama on debt and deficit reduction called in December 2010 for reducing “excess” payments to hospitals for medical education. The commission said the payments could be brought in line with the costs of medical education by limiting the direct subsidy to 120 % of the national average salary paid to residents. A second, indirect subsidy, which pays for intensive services and advanced equipment should also be reduced.

The proposed draconian cuts will jeopardize the sorely needed expansion of graduate medical education in the U.S . and exacerbate the looming physicians shortage. Who will care for the baby boomers seeking medical services? Who will provide primary care physicians once millions of Americans gain access to healthcare coverage in 2014?

The proposed measures are based on penny wise and pound foolish approaches to cover our federal deficit and ignore the long-term investments needed to protect our crumbling healthcare service infrastructure in the U.S. The suggestions were developed by politicians with a limited political life cycle instead by healthcare planners who are being tasked to develop policy and not politics.

I suggest to review thoughtful proposals such as the Nineteenth Report by the Council on Graduate Medical Education (COGME) entitled “ Enhancing Flexibility in Graduate Medical Education” before throwing out the baby with the bath water.

The future of our healthcare is at stake and politicians must step aside to let experts take charge.



Sunday, July 03, 2011

When Ideology Trumps Compassion

When Ideology Trumps Common Sense and Compassion:

In the past week, Florida lawmakers turned down a $2.1 million federal grant that would pave the way for the state to receive $35 million in federal funding that would move elderly and disabled patients from nursing homes to their own homes during the next five years. With the help of this federal funding elderly people could be moved out of nursing homes to independent-living facilities or to support care at home with their families resulting in less money to be spend on nursing-home care. Republican legislators defended their refusal of the latest federal grant, known as the Money Follows the Person funding. "Not only would accepting the Money Follows the Person grant go against our policy of implementing federal health-care reform, but it would be redundant to the multiple efforts that Florida has already made to improve the delivery of long-term care," said Rep. Denise Grimsley, R-Sebring, chairwoman of the state's House Appropriations Committee.
Grimsley said the federal grant came with "significantly higher administrative costs that have been unnecessary" because Florida already has been successful at moving people from nursing homes. Nan Rich, Leader of the Senate Democratic Caucus, disagrees. In a letter to the editor published in todays Miami Herald she argues that “ the funding would have garnered Florida $35,7 million in federal funds over the next five years.” She is correct stating that “ Florida's share of the federal funds will go to another state whose leaders aren't willing to shortchange their elderly and disabled for the sake of ideology.” The remainder of her letter speaks for itself and is worthwhile reading in its entirety:
“It just doesn’t make any sense for Florida to refuse the “Money Follows the Person” funds. The grant covered 100 percent of the staffing and administrative costs. The federal Medicaid match for this program would have increased from about 56 percent to almost 78 percent for the first year, and we would have been under no obligation to continue the program after that. Even if we did, however, we’d still save money by moving more eligible people out of nursing homes. Our state’s seniors, disabled people and taxpayers deserve better than the short-sighted political posturing that we saw last week.”
Is there any hope that rational thought will prevail in Tallahassee?

Saturday, July 02, 2011

Drug Testing for Welfare Recipients

Drug Test Law May Face Costly Legal Challenges:

Attached a link,0,5410762.story to an article published in today's Orlando Sentinel pointing out that a new state law requiring welfare applicants to be drug-tested goes into effect today.

The law stipulates that parents with minor children who request temporary cash assistance must undergo a drug test. The average benefit check per family is $240 a month with a lifetime limit of 48 months.

About 4,000 Floridians each month may be affected by the new law. The 93,000 state residents already receiving such benefits would not be affected unless they reapply. In addition all parents who test positive for drugs — including legal drugs not prescribed for the parent — will be reported automatically to the state's abuse hotline. Applicants will have to pay for the drug tests themselves, though those who test negative will be reimbursed in the first benefit check they receive. Those who test positive also would have the chance to get a second, more-sophisticated screening — at their own expense of up to $100 — and have an official medical review of the testing (MRO) . It is still unclear whether those expenses would be reimbursed if the applicant is ultimately cleared. The law may violate the constitutional standard requiring that the government must have reason to believe an individual is using drugs before demanding a test. Michigan, the only other state to pass a similar law, had it struck down in court. Therefore, it most probably will face a costly legal challenge on taxpayers expense!! Furthermore, by implementing this policy the state government should have provided drug treatment options for those welfare recipients with children who test positive for drugs. The new law falls shot of this option, too.

In my opinion this new law is a bad idea which will face a long and costly court battle and will further divert scarce state resources from more important issues such as drug use prevention and treatment programs.

Happy 4th of July,



Thursday, June 30, 2011

Counterfeit-Proof Prescription Pads

Just want to remind all of you that as of tomorrow, July 1st, 2011, counterfeit-proof prescription blanks MUST be used by all physicians for prescribing of ANY controlled substances. A list of approved vendors of counterfeit-proof prescription pads can be found on the Department of Health web site at is also important o know that approved vendors are required to provide monthly reports to the DOH, documenting who purchased the prescription pad or blanks and how many were purchased.
Have spoken today with one of the vendors and was assured that they make every efforts to expedite deliveries of counterfeit-proof prescription pads.


Monday, June 27, 2011

Mystery Shoppers

Attached a link to today's New York Times article reporting that the federal government plans to deploy  mystery shoppers who will call doctors in nine states to try to schedule an appointment first posing as someone with private insurance and another time as someone with public insurance. The goal is to ascertain access to care issues ,  especially as the healthcare system braces for millions more Medicaid patients in 2014.
Already doctors are lining up in opposition to these "snooping" tactics. In response Christian J. Stenrud, a Health and Human Services spokesman, said: “Access to primary care is a priority for the administration. This study is an effort to better understand the problem and make sure we are doing everything we can to support primary care physicians, especially in communities where the need is greatest.”
So shall we oppose in principle all tactics that are aimed to assess the scope of the primary care shortage and related access to care issues? Are there any meaningful alternatives to the proposed "snooping" tactics deploying mystery shoppers to doctors offices? What role can we play not only to highlight the problem but to offer solutions?
I look forward to your responses and comments.

Saturday, June 18, 2011

Medicare Claims Show Overuse For CT Scans


Attached a link to an interesting article published in today's New York Times entitled “Medicare Claims Show Overuse for CT Scanning.”

The authors highlight that according to Medicare claims data some hospitals overuse chest CT scans and, thereby, needlessly expose patients to radiation by scanning their chests twice on the same day. The Medicare agency distributed the data to hospitals last year to show how they performed relative to each other and to encourage more efficient, safer practices. The review of that data found more than 200 hospitals that administered double scans on more than 30 percent of their Medicare outpatients — a percentage that the federal agency and radiology experts considers far too high. The national average is 5.4 percent. The figures show wide variation among states as well, from 1 percent in Massachusetts to 13 percent in Oklahoma. Overall, Medicare paid hospitals roughly $25 million for double scans in 2008. Added revenue may not be the reason dual scans are ordered. But the absence of treatment protocols may explain the variation of CT Chest use among physicians.

Possible solutions should include standardized, evidence-based diagnosis and treatment procedures according to which physicians can tailor their approach to patient care accordingly.

I hope that Medicare will open its database for researchers and health economists to help all of us to make educated and smart medical care decisions which will benefit our patients, too.



Thursday, June 16, 2011

Support Doctors in Bahrain

Attached a link to an AMA press release encouraging America's physicians to write to Bahraini officials, using a sample letter from the AMA website, and join the world's medical community in urging the fair treatment of the health care professionals detained in Bahrain.
Please participate because your support counts.

Governor Scott Suspends Drug Testing Order

Attached a link to an article from today's Sun Sentinel,0,6797555.story reporting that Governor Scott has suspended the order he signed earlier this year requiring random drug tests of all state employees in light of an ACLU law suit. The governor had signed the order for so-called "suspicion-less" drug tests – so termed because all state employees would be subject to them, regardless of their job or whether they were suspected of using drugs – in March. He also successfully urged the Legislature to require drug tests of all new applicants for welfare assistance, which the ACLU is also expected to challenge.
I encourage all of you to speak up loudly against the mandatory drug testing of welfare recipients which will be challenged in court, too.

Tuesday, June 07, 2011

The Big Rip-Off

In today's Miami Herald John Dorschner points out a painful truth: healthcare consumers are being ripped off every day by healthcare service providers.
According to Alan Sager, a healthcare policy expert at Boston University,  “Anytime I’ve read reports of patients or journalists seeking comparison pricing, they’ve encountered the same inconsistency, confusion, frustration and often misleading information,” he said. “When we go into a big supermarket, we all pay the same price for a gallon of milk. In healthcare, there are multiple prices in the same place.”
I myself have a hard time to find out the REAL costs of my own healthcare needs. Recently my daughter had to do undergo laboratory testing for which I was charged a $900 co-pay. I tried to appeal and as a result my case was immediately referred to a collection department. I barely saved my credit rating and paid. Its outrageous! The profit margins are beyond belief exceeding 1000 percent!! The so-called "free-market" argument is a joke!! An article in today's Wall Street Journal points out that in a survey of 1,000 British Medical Association members - all doctors - 80% of those surveyed were "mostly or very unwelcoming" towards the idea of privatization of the National Health Service. Meanwhile, American doctors and politicians continue to support the private health care market model. There is NO health care market but an aggregation of monopolies suffocating the average health care consumers. 
Its time to fight back! We should demand a single-payer system with uniform and transparent pricing structure.

Saturday, June 04, 2011

Governor Scott Signs Pill Mill Bill into law

After initially fighting one of its key provisions, Gov. Rick Scott signed a bill Friday aimed at cracking down on clinics that frivolously dispense pain pills, feeding a nationwide prescription drug abuse epidemic. The bill tightens reporting requirements to the database from 15 days to seven days, a change critics said the program needed to make it more effective. The measure also increases penalties for overprescribing Oxycodone and other narcotics, tracks wholesale distribution of some controlled substances, and provides $3 million to support law enforcement efforts and state prosecutors. It also bans most doctors who prescribe narcotics from dispensing them, requiring prescriptions to be filled at certain types of pharmacies. Scott has been under pressure from elected officials throughout the country to do something about the proliferation of so-called "pill mills" in Florida that attract people from other states seeking easy access to highly addictive, powerful painkillers.
We should now urge the Department of Health to provide education and training programs for physicians and other healthcare professionals on how to use the Prescription Drug Monitoring Program and to fund those necessary efforts.

For more information see

ACLU Sues Governor Scott Over Drug test Rule

ACLU Florida has filed a lawsuit against Gov. Rick Scott over his executive order to force drug testing on state employees. The suit argues that Scott's order is an unreasonable search of the government that violates the Fourth Amendment of the U.S. Constitution.The ACLU maintains that the mandatory random drug testing Scott has ordered on about 100,000 workers is only allowed under special circumstances, such as workers who carry firearms or railroad workers involved in accidents.
I urge all medical professionals involved in federal workplace drug testing procedures to await the outcome of this lawsuit BEFORE deciding on their participation in the proposed state wide drug testing for state employees.

For more information and the complete text of the law suit see

Physicians Challenge Florida Goverment

Attached an article highlighting an issue which is going to be resolved in court. Unfortunately, Governor Scott signed HB 155 into law which will bar physicians from asking patients about gun ownership. Florida is the only state in the nation to have such a law which was pushed by the NRA.
Sadly, the Florida Medical Association does not oppose the new law exposing its members to charges of harassment if they "dare" to provide their patients information about gun safety. Any alleged violation of the new law will expose physicians to disciplinary action and even license revocation!
Now its time to stop government intrusion into the patient-physician relationship.
I encourage doctors to pay attention to this issue and to take action.


Palm Beach Post Staff Writer

Updated: 10:58 p.m. Thursday, June 2, 2011

Posted: 8:19 p.m. Thursday, June 2, 2011

Three groups of doctors are suing Gov. Rick Scott over a bill he signed into law Thursday restricting health care workers from asking patients questions about guns.

Lawyers representing members of Florida chapters of the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Physicians asked Scott last week to veto the measure (HB 155) and threatened to sue if he signed it into law.

The Florida Medical Association does not oppose the new law.

Bruce Manheim of the Washington-based Ropes & Gray law firm said Thursday he would file the lawsuit immediately after Scott signed the law.

Doctors say the law infringes on their First Amendment constitutional right to free speech by barring them from asking about gun ownership, something they say is necessary to do their jobs.

It will "have a muzzling effect on doctors" who routinely ask parents and teenagers about swimming pools, dangerous drugs, bicycle helmets and car seats as well as about firearms in the home, pediatrician Tommy Schechtman said.

Under the law, doctors and other health care professionals will face sanctions including fines and losing their licenses if they ask patients about guns in the home without a direct belief that the inquiry is relevant to the patient's safety or health.

"It is my job. It is my responsibility. I have a moral obligation, an ethical obligation to be doing this," said Schechtman, who has offices in Palm Beach Gardens, Jupiter and Boca Raton.

But Scott spokesman Lane Wright said the first-term governor is confident he is on solid legal ground by signing the bill.

"Others would argue it would be an infringement of a citizen's rights who owns a gun to have a doctor ask those questions," Wright said. "Why should any law abiding citizen have to report to a doctor that they have a gun?"

Florida is the only state in the nation to have such a law, according to National Rifle Association lobbyist Marion Hammer, a former president of the gun rights organization.

Hammer said some health care professionals are pushing anti-gun messages to their patients under the guise of home safety questionnaires. The measure was prompted by complaints from gun owners following an incident this summer in which an Ocala-area physician told a couple to find another pediatrician after they refused to answer questions about whether they owned a gun and how it was stored.

The NRA and other supporters don't object if doctors routinely distribute safety brochures to all patients that give instructions on swimming pools, firearms or other safety-related issues, Hammer said.

"But doctors should not be spending the time that patients are paying for to talk to them about matters they're not there for. They come to doctors for medical care and medical treatment, not to have politics in the examining room and not to be lectured on firearms. They are medical doctors; they are not firearms instructors," she said.

But Mannheim said the new law is so vague about when questions are permissible that it would have a chilling effect on health care practitioners fearful of having to defend themselves before the Board of Medicine.

"Questions about firearm safety, as innocuous as they may be to the ordinary person, could be construed by someone as constituting harassment by a physician and simply on the basis of that judgment a physician could be taken through these disciplinary proceedings," he said. "It immediately chills the speech of our clients and their members and accordingly we intend to move very quickly with a lawsuit."

Schechtman said the new law won't stop him, however. More than 1,500 children die each year from household gun-related injuries, he said.

"Some of us won't shut up. Sometimes you have to decide to do the right thing which is what I will do. It's not going to stop me from doing anything," he said.

But other physicians may feel it's not worth the risk.

"It will have its intended effect. That's the thing that's scary to me. And that's why I think we have to take this off the books. I think it's sending a wrong message that people shouldn't have to worry about guns," Schechtman said.

Sunday, May 08, 2011

Gun Law and Physicians

The new gun law makes Florida the first state in the nation to prohibit doctors from asking patients if they own guns. HB 155 entitled "Privacy of Forearm Owners" passed the Florida House and will be signed into law by Governor Scott. NPR featured this law in a recent story Having read the entire bill I am trying to understand what I am allowed to ask my patients and how I can protect myself from those who exercise their constitutional right to carry guns. Here are the some of the problems the bill presents us with:

* The bill states that “A health care practitioner licensed under chapter 456 or a health care facility licensed under chapter 395 may not intentionally enter any disclosed information concerning firearm ownership into the patient's medical record if the practitioner knows that such information is not relevant to the patient's medical care or safety, or the safety of others."

Question: How do I know whats relevant to the patients safety? Actually, I was taught to be concerned about "anticipatory guidance" — teaching parents how to safeguard their children against accidental injuries. Like pediatricians family doctors ask about bike helmets, seat belts, and GUNS. That means I cannot counsel a parents how to secure a gun to prevent accidental injury and death? Shall I delete those questions from my patient intake form? Shall I NEVER ask those questions? Will I be disciplined if I dare asking those questions?

* But in the next paragraph the bill also states that " Notwithstanding this provision, a health care practitioner or health care facility that in good faith believes that this information is relevant to the patient's medical care or safety, or the safety of others, may make such a verbal or written inquiry."

Question: So what is correct and prevents my exposure to disciplinary action? Shall I adhere to a don't ask, don't tell policy?

* The bill contains other confusing language such as " A health care practitioner licensed under chapter 456 or a health care facility licensed under chapter 395 shall respect a patient's legal right to own or possess a firearm and should refrain from unnecessarily harassing a patient about firearm ownership during an examination."

Question: What if a gun owner claims to feel "harassed" by a doctor and files a complaint with the Board of Medicine then a physician has to answer and file a response. That requires legal advice and consultation which costs $$$. Facing such a dilemma precludes ANY questions about guns. That's what the NRA wanted, the legislators did and the FMA endorsed!

* The bill goes further stating " A health care provider or health care facility may not discriminate against a patient based solely upon the patient's exercise of the constitutional right to own and possess firearms or ammunition."

Question: What if the patient has a concealed weapon permit and carries a concealed weapon in the medical office and I discover such a weapon during the exam? It happened to me several times!! Can I ask the patient to leave and return without the weapon without him/her claiming that I harass them? Can I establish a policy prohibiting patients to carry guns on my premises?

* Furthermore, the bill contains an entire paragraph about patients rights BUT NOT a single sentence about physicians rights and safety!! That's what the NRA wanted, the legislators did and the FMA endorsed!


Friday, May 06, 2011

Solutions From The Inside

Attached a link to an interesting article entitled " Solutions from the Inside." In the article the author, Martha Baker- President of the SEIU Local 1991- , points out that " We must transition to a cost-effective, preventive, patient-oriented, primary-care-focused system." It still baffles me that the focus of hospital administrators remains on expanding specialist driven care to maximize the volume of reimbursable medical services instead on primary -care based medical services with the focus on quality, safety and population oriented care. The latter approach would also provide access to increased Medicare and Medicaid meaningful use reimbursement and performance-based incentive payment.
As family doctors we should be responsible for relentlessly pointing out these shortcomings which eventually will only increase healthcare costs and will force us to ration care.
The choice is ours to make.

Friday, April 22, 2011

Medicaid and Managed Care

Reform Medicaid to maintain access:

Re the April 21st letter by Michael Garner, President and CEO,Florida Association of Health Plans. Mr. Garner claims that for-profit managed care companies will contain Florida's rising Medicaid costs by care coordination and quality improvement.
But a recently published study of the managed care pilot program taking place in Broward, Baker, Clay, Duval and Nassau counties concluded that there is insufficient evidence to verify claims of cost savings. The study concludes that instead of rushing to implement this unproven and ill-advised pilot program statewide, more reliable cost-saving alternatives should be considered. For example, Massachusetts is trying to contain rising health care costs by supporting the development of accountable care organizations (ACO's). These are networks of physicians, practices and hospitals that will share in any cost savings they generate by better coordinating and integrating patient care without adding unnecessary administrative overhead generated by managed-care companies. Geisinger Health Systems in Pennsylvania is using its networks to try out a model similar to patient-centered medical homes and high-risk care management programs. Sutter Health in California has focused on engaging its doctors on quality and efficiency programs. Before we turn over billions of dollars to private for-profit managed care companies we should seriously explore other methods and modalities to contain health care cost, improve the quality of care and to maintain access to medical services for all of those in need.

Bernd Wollschlaeger,MD,FAAFP,FASAM
Board Certified Family Physician & Addiction Specialist
16899 NE 15th Avenue, North Miami Beach, FL 33162
Phone: (305) 940-8717

Thursday, April 21, 2011

The Valentine's Day controversy

It's Time For An Attitude Adjustment

According to a recent New York Times article the president-elect of the American College of Surgeons resigned his position Sunday after weeks of controversy surrounding a Valentine’s Day editorial he wrote touting the mood-enhancing effects of semen on women during unprotected sex. Dr. Greenfield, 78, was the editor in chief of Surgery News when the editorial was published but resigned that position in the wake of the controversy; the entire issue of the newspaper was withdrawn. He is an emeritus professor of surgery at the University of Michigan School of Medicine. The editorial cited research that found that female college students who had had unprotected sex were less depressed than those whose partners used condoms. It speculated that compounds in semen have antidepressant effects.
Dr. Colleen Brophy, a professor of surgery at Vanderbilt University, submitted a letter of resignation from the surgery association during the controversy and said Sunday that she had no intention of reversing herself now that Dr. Greenfield has resigned. “The editorial was just a symptom of a much larger problem,” Dr. Brophy said. “The way the college is set up right now is for the sake of the leadership instead of patients.”
I hope that members of our profession distance themselves from those who still believe that their professional status renders them immune to public criticism. The change of attitudes within our profession must progress by large jumps instead of small increments.


Wednesday, April 20, 2011

Controlled Substances

In an interesting article entitled “US Seeks To Rein in Painkillers” the authors report that the Obama administration seeks legislation requiring doctors to undergo training before being permitted to prescribe powerful painkillers like OxyContin. This appears to be the most aggressive step taken by federal officials to control both the use and abuse of the drugs. Among the drugs that would most probably fall under a stricter licensing measure are OxyContin, fentanyl, hydromorphone and methadone. They are considered critical to pain treatment. But they also have been associated in recent years with a national epidemic of prescription drug abuse and addiction and thousands of overdose-related deaths. Proponents of the training argue that it would help doctors better identify patients who would benefit from treatment with long-acting narcotics, and help them unmask patients feigning pain to get drugs they then abuse. Opponents say a training requirement will reduce the number of doctors prescribing pain drugs and hamper patient care. The F.D.A. released new regulations on Tuesday that would require the makers of long-acting or extended release painkillers to provide training to doctors but would not require doctors to take such courses. This proposal is similar to the one rejected as too weak in last year’s debate. Dr. Janet Woodcock, who heads the F.D.A. Center for Drug Evaluation and Research, indicated that the new agency rules were effectively a placeholder until legislation was passed or were to be used if a relevant bill failed.

In my opinion additional education and training requirements for controlled substances prescribing are long overdue! Most physicians have no, or very limited knowledge, of the appropriate indication, pharmacology and adverse drug interactions of controlled substances. I often see patients who were prescribed Methadone, a long-acting opioid, at a four-times daily dosage schedule. These physicians seem to be clueless about the fact that Methadone metabolism rates vary greatly between individuals, up to a factor of 100! These metabolism rates can range from as few as 4 hours to as many as 130 hours, or even 190 hours. This variability is apparently due to genetic variability in the production of the associated enzymes. Ignoring these pharmacological facts can lead to accidental overdose and death.

Additional training requirements should be implemented to protect our patients and our families.



Thursday, April 14, 2011

Fla. House panel OKs compromise pill mill bill

Finally, the future for a prescription drug monitoring program is looking better every day. According to an April 12th Miami Herald article compromise legislation designed to combat "pill mills" that supply prescription painkillers to drug dealers and addicts cleared a House committee Tuesday after the panel took out Gov. Rick Scott's proposal to repeal Florida's prescription monitoring system. The revised bill (HB 7095) instead would strengthen the database by giving pharmacies only seven days rather than 15 to submit prescription information to the state. Unchanged from the original legislation is a ban on dispensing controlled drugs by most doctors. That means patients would have to get prescriptions filled only at pharmacies. Doctors who violate the ban would face up to five years in prison. The House Appropriations Committee unanimously approved the revised bill. It next goes to the House floor. House Speaker Dean Cannon, R-Winter Park, also pushed for the database repeal, arguing that a ban on dispensing by doctors would be more effective, but Bondi said he's also supporting the compromise and helped bring it about. Bondi and Senate President Mike Haridpolos, R-Merritt Island, have been strong supporters of the tracking system, and the Senate's pill mill bill (SB 818) did not include the repeal.
I urge you to continue pushing your legislators to support the House ( HB7095) and Senate bill (SB818).
The battle is not over yet !!

Friday, April 08, 2011

Florida Medicaid Reform

Friday, April 8th 2011

Letter To The Editor:

Managed Care is not the solution to rising Medicaid cost:

David Pollacks's letter to the editor suggests that moving Medicaid beneficiaries into managed care is the most effective solution to Florida’s Medicaid woes because managed-care organizations in Florida and across the country have a track record of improving outcomes while reducing costs. But is that true? A Georgetown University Health Policy Institute study of Florida's Medicaid Managed Care pilot program questions the use of for-profit managed care companies to reduce Medicaid costs. 
The Georgetown study analyzed the impact of the pilot program taking place in Broward, Baker, Clay, Duval and Nassau counties. The study concluded that there is insufficient evidence to verify claims of cost savings and also raises questions about patient access to medical care, particularly turnover among private plans that disrupts the patient-provider relationships. The study finds that some companies hoping to profit from providing Medicaid managed care services have not achieved the success they envisioned and sometimes choose to leave the program with little notice, causing a disruption for patients. In terms of managed care costs savings, the Georgetown study found "insufficient data available to draw conclusions," adding that reductions in expenditures may actually be due, in part, to patients being denied care. Furthermore, no encounter data, and no up to date data on cost savings are available to substantiate the claims made by proponents of the Medicaid HMO plans. Encounter data measures what services and medications patients are receiving and which ones are being denied - accountability that health advocates say is critical to ensure for-profit HMOs aren't lining their pockets at patients' expense.
The study concludes that instead of rushing to implement this unproven and ill-advised pilot program statewide, more reliable cost-saving alternatives should be considered such as such raising the generic prescription drug dispensing rates and pushing for adherence programs that produce better health outcomes.
So why do we want to turn over billions of dollars to private for-profit managed care companies?

Bernd Wollschlaeger,MD,FAAFP,FASAM
Board Certified Family Physician & Addiction Specialist
16899 NE 15th Avenue, North Miami Beach, FL 33162
Phone: (305) 940-8717

Sunday, April 03, 2011

Governor Scott and Mandatory Drug Testing

Governor Scott and Mandatory Drug Testing:

A recent article published in the Miami Herald reports that Governor Scott signed an executive order last week that requires drug testing for many current state workers and job applicants. According to the article “Scott’s order applies to all employees and prospective hires in agencies that answer to the governor, and could affect as many as 100,000 people. Scott also supports a state Senate bill that requires all cash-assistance welfare recipients over the age of 18 to pay for and receive a drug test, a policy that could affect about 58,000 people.”

But is this executive order legal?

* In April 2000 U.S. District Court Judge Kenneth L. Ryskamp ruled that governments cannot require prospective employees to take drug tests unless there is a “special need,’’ such as safety. Ryskamp’s ruling led other South Florida cities, such as Pembroke Pines, to abandon their policy of drug testing all job applicants.
* Random drug-testing of current government workers also has been limited to those in jobs that affect public safety and to cases where a reasonable suspicion of abuse exists, according to a December 2004 federal court ruling in a case that involved Florida’s Department of Juvenile Justice. In that case, U.S. District Court Judge Robert Hinkle ruled that the DJJ violated the Fourth Amendment in ordering random drug-testing of all the agency’s 5,000-plus employees.
* State agencies already are allowed, but not required, to screen job applicants for drugs, under the Florida Drug-Free Workplaces Act. The law allows state agencies to test employees if there is a reasonable suspicion that workers are on drugs. But that suspicion must be well-documented and employees must be informed of the policy prior to testing.
* Howard Simon, executive director of the ACLU of Florida, said Scott is taking a “simplistic” approach to the law, pitting the public’s expectation of a “right to know” against each individual state worker’s right to privacy.

The article concludes that though no legal challenge to the governor’s order has been filed, one will be forthcoming.
I urge all of you to support the ACLU of Florida in their efforts to fight back against government intrusion into our lives camouflaged in the shroud of transparency.


Friday, April 01, 2011

Malpractice Reform

Attached you find a very interesting and thoughtful article regarding professional liability reform. In last month’s budget proposal, the Obama administration offered a solution: a plan to encourage evidence-based medicine by limiting the professional liability of doctors who adhere to clinical practice guidelines.
The author points out that the proposal will not achieve the noble goal of providing quality care at a reasonable cost because the current guidelines, written by nonprofit medical groups and for-profit insurance companies, are not good enough.
The author then suggests that "instead of nonprofit groups producing free guidelines, or insurance companies producing ones that serve their own interests, the government should require health care providers to buy or license guidelines from what I call private regulators, for-profit companies with expertise in evidence-based medicine. Doctors would have immunity from malpractice cases if they followed the guidelines. However, the private regulators themselves would be liable if their guidelines were found to deviate from optimal care."
Unfortunately, the malpractice reform debate is often reduced to a ONE SOLUTION ONLY issue: cap non-economic damages.
The proponents of those caps often forget that the non-economic damages among those patients who were harmed can often never be properly assessed. Non-economic damages, or quality-of-life damages,compensate injuries and losses that are not easily quantified by a dollar amount and are difficult to measure.
Therefore, we should pursue other solutions such as the application of evidence - and standards-based care to protect patients and our families who may fall victims to malpractice.

March 28, 2011

A Market Solution for Malpractice


Austin, Tex.

IT’S been a year since health care reform was signed into law, and since then both Republicans and Democrats have been trying to address one item it left out: medical malpractice reform. In last month’s budget proposal, the Obama administration offered a solution: a plan to encourage evidence-based medicine by limiting the malpractice liability of doctors who follow clinical practice guidelines — in effect, granting them immunity.

Doctors love this proposal, and patients should too: When doctors follow good guidelines they are less likely to order too many or too few tests or to prescribe the wrong treatment.

Unfortunately, the proposal will not achieve the noble goal of providing quality care at a reasonable cost because the current guidelines, written by nonprofit medical groups and for-profit insurance companies, are not good enough.

First, they often conflict with one another. Recommendations for when and how frequently to give women mammograms, for instance, notoriously vary depending on which group is giving them.

In addition, there are conflicts of interest. Guidelines produced by insurance companies sometimes put their interests first. Malpractice insurers, for example, may recommend yearly mammograms, even if they are not necessary, because they bear the costs of lawsuits for late diagnoses of breast cancer — and not the costs or health risks of the extra mammograms. Moreover, the nonprofit groups behind many other guidelines have traditionally depended on pharmaceutical and medical device companies to finance their work. Last year, the Council of Medical Specialty Societies issued a new code of conduct seeking to stop these industries from sponsoring the development of guidelines, but there are still too many loopholes, and thousands of guidelines produced before the reform are still in circulation.

Most troubling of all is that the groups behind the guidelines bear no liability for producing bad ones. No matter how poor the care they prescribe, it is the doctors who depend on them who are punished.

Mr. Obama’s proposal to limit the liability of doctors who follow these flawed guidelines (included in a $250-million plan for overhauling states’ malpractice systems) is clearly not the way to better care. Immunity is a good idea. It’s just that we need to create the incentives necessary for the production of optimal guidelines first.

This is no secret — last week the Institute of Medicine put out a report listing new standards for promulgating guidelines. I was a consultant on the report, which goes a long way toward improving the system, but I worry about the extent to which these standards will be followed. I have a different proposal for improving the guidelines:

Instead of nonprofit groups producing free guidelines, or insurance companies producing ones that serve their own interests, the government should require health care providers to buy or license guidelines from what I call private regulators, for-profit companies with expertise in evidence-based medicine. Doctors would have immunity from malpractice cases if they followed the guidelines. However, the private regulators themselves would be liable if their guidelines were found to deviate from optimal care.

The profit-seeking forces of the market on the one hand and legal accountability on the other would help private regulators strike the right balance between patient safety and cost of care. Private regulators would discourage the overuse of expensive medical procedures because doctors, under pressure from insurance companies to keep costs low, would be unlikely to invest in guidelines recommending unnecessary procedures. But if the guideline-makers failed to recommend an appropriate procedure, they’d be held responsible for the patient’s health.

Just as they can now, doctors could deviate from the guidelines when required. Their discretion and autonomy would be preserved. But in most cases, when guidelines apply, doctors could follow them without having to worry about being held liable, and more important, about getting bad advice.

Such a system may not be too far off: medicine is already moving toward for-profit guidelines. UpToDate, First Consult and eMedicine are just a few new databases compiled by for-profit companies in the business of making technical, evidence-based medicine more accessible to doctors. This is certainly exciting, but to provide doctors with the peace of mind they deserve, these companies need to be held accountable for the advice they give.

Almost every other product Americans encounter is subject to laws that guarantee that the producer suffers when its product is subpar. There’s no reason medical guidelines should be any different. With the proper incentives, these private regulators could help President Obama carry out the health care reform he signed into law a year ago.

Ronen Avraham is a professor at the University of Texas School of Law.