CPI in Medicine: Change Management in Clinical Practice

"The health care industry could be on the verge of an efficiency revolution,
because it is currently so far behind in applying operations management methodologies"

Attached a very interesting article from today's NewYork Times highlighting the advantages and benefits of applying continuous performance improvement (CPI) in hospital management.
These principles should not be restricted to inpatient care but should apply to the entire healthcare system. Therefore, physicians need to be taught how to apply CPI in their own offices to improve the quality of care, reduce costs and ascertain outcome of the treatments rendered. I hope that within organized medicine more enlightened leaders may emerge who challenge our profession to change. Unfortunately, ideological grandstanding and political cheerleading will not contribute to resolve the pressing healthcare financing and reimbursement issues we are facing. The translation of comparative effectiveness research into the clinical practice and the application of proven business management principles are of great value to maintain the practice of medicine. I hope that you can support and promote these issues.
Yours
Bernd

New York Times, Sunday, July 11th, 2010

Efficiency Comes to the Hospital

By JULIE WEED

SEATTLE

TWO years ago, the supply system at Seattle Children’s Hospital was so unreliable that Susanne Matthews, a nurse in the intensive care unit, would stockpile stuff — catheters in the closet, surgical dressings in patients’ dresser drawers and clamps in the nurse’s office. And she wasn’t the only one.

“Nurses get very anxious when we can’t get our hands on the tools we need for our patients,” Ms. Matthews says, “so we grabbed them when we saw them, and stashed them away.” This, in turn, made the shortages more acute.

On a busy day last month in the I.C.U., it took Ms. Matthews just a few seconds to find the specialized tubing she needed to deliver medicine to an infant recovering from heart surgery. The tubing was nearby, in a fully stocked rack, thanks to a new supply system instituted by the hospital early last year following practices typically used in manufacturing or retailing, not health care.

There are two bins of each item; when one bin is empty, the second is pulled forward. Empty bins go to the central supply office and the bar codes are scanned to generate a new order. The hospital storeroom is now half its original size, and fewer supplies are discarded for exceeding their expiration dates.

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

Manufacturers, particularly in the auto and aerospace industries, have been using these methods for many years. And while a sick child isn’t a Camry, Seattle Children’s Hospital has found that checklists, standardization and nonstop brainstorming with front-line staff and customers can pay off.

“It turns out the highest-quality care also is the most cost-effective because we make fewer mistakes and create better outcomes,” says Patrick Hagan, the hospital’s president.

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital, from the time they arrive in the parking lot until they are discharged, to see what could work better for them and their families.

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle. So many others have called for advice that Seattle Children’s put together a two-day workshop, presenting it to more than 200 medical workers and health care leaders from the United States and Europe.

“Some people think they have to choose between quality of care and saving money,” said Dr. David Chand, who attended the training and now uses C.P.I. methods at Akron Children’s Hospital in Ohio. “C.P.I. improves both patient outcomes and the hospital’s bottom line.”

To increase the number of surgeries the hospital could perform, Dr. Chand’s team spent about $20,000 overhauling the process to sterilize instruments, avoiding a $3.5 million expenditure to expand that department. More efficient scheduling in the M.R.I. department reduced the average waiting time for non-emergency M.R.I.’s from 25 days to 1 to 2.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward.

Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information.

“The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

On June 10, Ms. Munn helped lead a one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods. “We felt the cuts created an unsafe environment for patients,” she said. The nurses’ contract was settled on July 1, with no increase in staff levels.

Brian Lucas, a spokesman for Children’s Hospitals and Clinics of Minnesota, says the lean efforts have been used to reduce unnecessary tasks and have not resulted in lower nurse-to-patient ratios. “To the contrary,” he said, “they have allowed nurses to spend more time delivering care to patients.”

Techniques like C.P.I. may indeed be hard for many hospitals to put into effect, says Mark Graban, a senior fellow at the Lean Enterprise Institute, a nonprofit research, education and publishing company. The process takes a large amount of time and requires a culture shift that many hospitals may not be able to accommodate or sustain. “If the leadership tries to force new ways of doing things, the staff may chafe under the successive changes,” he says.

And George Lebovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Physical layouts can also interfere with changes that hospitals want to make, like reducing the distance a chemotherapy patient has to walk. And the techniques can fall short of their potential if they are used in just one area of a hospital, because a patient typically moves through many different departments.

At Seattle Children’s Hospital, Dr. John Waldhausen, the division chief of pediatric general and thoracic surgery, acknowledges that he and other doctors weren’t initially very enthusiastic about C.P.I. because they thought it would take some decisions about patient care out of their hands.

Over time, he changed his mind, and he is now a vocal advocate of C.P.I. “When you look closely, C.P.I. is the same scientific method we learned in medical school, including hypotheses, data collection and analysis,” he says. “It is not opinion and conjecture — it is data-driven.”

TEN years ago, Seattle Children’s set a goal to become the top hospital of its type in the country, and hired Joan Wellman & Associates, a process improvement consulting firm in Seattle, to help it get there. Ms. Wellman, who had worked with Boeing on its lean-manufacturing processes, suggested that the hospital apply similar principles.

Mr. Hagan says he became enthusiastic about lean manufacturing and C.P.I. after doing research and visiting local manufacturers. He directed the hospital staff to examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory.

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

The hospital staff has been rolling out the program in stages over the last decade. “We have probably made over 1,000 small changes, and frankly it never ends,” says Mr. Hagan.

In his C.P.I. training, Dr. Bryan H. King, director of the department of psychiatry and behavioral medicine, was one of the first Seattle Children’s staff members to visit Japanese manufacturers. He learned that “waste” could be viewed as any action that didn’t add value to the customer.

Turning to his psychiatric inpatient unit, he and his team worked to pinpoint the goal of each child’s stay and to communicate daily with families. They also made other changes, like starting to arrange outpatient resources as soon as children enter the unit, rather than waiting until they are ready to leave. These kinds of changes increased satisfaction ratings from families and helped cut the average time in the hospital from 20 days to 10. The unit can now accommodate 650 children a year instead of 400.

Changes like these are celebrated by the hospital administration. “Their support fosters the idea that everyone can make positive changes to their departments,” Dr. King said.

Dr. Howard E. Jeffries, the hospital’s medical director of C.P.I., is a fan of visual aids. One favorite is a white board at the entrance of the cardiac intensive care unit. A map of the rooms, labeled with patient names, provides a quick status report on how full the unit is and how ill the patients are. Stick-on stars indicate a patient who needs to be in isolation; a blue circle shows a patient on a ventilator.

“At a glance, staff coming in for their shift can get an idea of what’s going on and what to be aware of,” Dr. Jeffries says.

The same types of visual cues are used for inventory levels or inspection status in factories.

Another of his favorites is the “Days Without Infection” poster, like a construction site’s “Days Without an Accident” sign. “It keeps our new safety protocols top of mind for people,” he says.

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.

Dr. Lynn D. Martin, director of the anesthesiology and pain medicine department, says changes previously were instituted only when existing systems failed. Using C.P.I., teams can now make changes any time they think they can improve a process. When the operating room team saw that a tonsillectomy procedure involved filling out 21 separate forms, it sat down with the print vendor to remove duplications — and cut the number to 11.

The staff doesn’t have to wait for the perfect solution, Dr. Martin says, just a better one, because they can “keep making improvements year after year.”

Using C.P.I., the hospital has reduced the waiting time for many surgeries from three months to less than one. Recently, the bottleneck was not the surgeons’ time, but a lack of available inpatient beds for recovery. Examining the hospital’s census, administrators saw that there were empty beds on weekends. They realized that by scheduling more surgeries on Fridays, patients could recover over the weekend, when more beds were free. The change also benefited parents and patients who would miss fewer work and school days.

Lack of space in the recovery room was another logjam, and the hospital planned a $500,000 renovation to enlarge it. But a C.P.I. team saw that if a child’s parents went to a common waiting room during surgery, instead of an individual recovery room, more surgeries could be scheduled. Parents were given beepers to alert them when their child would arrive in the recovery room — and maps and colored lines on the walls helped point the way. Plans for the expensive renovation have been scrapped.

IN the hospital’s largest C.P.I. project yet, Lisa Brandenberg, the chief administrative officer, used the method to design a new $70 million clinic and surgical facility in Bellevue, Wash., just east of Seattle.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness.

The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building, which is to open July 20.

“We can’t wait to see it in use,” says Ms. Brandenberg.

Use of Synthetic Marijuana on the Rise:

Attached you find an article from today's New York Times highlighting the increasing use of synthetic marijuana (K-2) and the efforts to curb the metastatic spread of these substances. A food store next to my office sells it as incense to teenagers and I have tried convincing the shop-owner to stop its sale. Her argument " if I stop selling it the kids go to the other guy around the corner and I loose customers."
I urge you to read this article and to consider what actions can be taken. I would NOT wait for the FMA to step in because government regulation is not part of their political agenda. This is an urgent public health issue and we need to act fast.
Looking forward to your comments.
Yours
Bernd



New York Times, Sunday, July 11, 2010:

Synthetic Marijuana Spurs State Bans
By MALCOLM GAY

ST. LOUIS — Seated at a hookah lounge in the Tower Grove district, Albert Kuo trained his lighter above a marbleized glass pipe stuffed with synthetic marijuana Inhaling deeply, Mr. Kuo, an art student at an area college, singed the pipe’s leafy contents, emitting a musky cloud of smoke into the afternoon light.

Mr. Kuo, 25, had gathered here with a small cohort of friends for what could be the last time they legally get high in Missouri on a substance known popularly as K2, a blend of herbs treated with synthetic marijuana.

“I know it’s not going to kill me,” said Mr. Kuo, who likened the drug’s effects to clove cigarettes. “It’s a waste of time, effort and money to ban something like this.”

On Tuesday, Gov. Jay Nixon, a Democrat, signed a bill prohibiting possession of K2. Missouri is the nation’s eighth state this year to ban the substance, which has sent users to emergency rooms across the country complaining of everything from elevated heart rates and paranoia tovomiting and hallucinations.

Investigators blame the drug in at least one death, and this month, Gov. Mike Beebe of Arkansas, a Democrat, signed an emergency order banning the substance. Similar prohibitions are pending in at least six other states, including Illinois, Louisiana, Michigan, New Jersey, New York and Ohio, according to the National Conference of State Legislatures.

“It’s like a tidal wave,” said Ward Franz, the state representative who sponsored Missouri’s legislation. “It’s almost an epidemic. We’re seeing middle-school kids walking into stores and buying it.”

Often marketed as incense, K2 — which is also known as Spice, Demon or Genie — is sold openly in gas stations, head shops and, of course, online. It can sell for as much as $40 per gram. The substance is banned in many European countries, but by marketing it as incense and clearly stating that it is not for human consumption, domestic sellers have managed to evade federal regulation.

“Everybody knows it’s not incense,” said Barbara Carreno, a spokeswoman for the federal Drug Enforcement Administration. “That’s done with a wink and a nod.”

First developed in the lab of a Clemson University chemist, John W. Huffman, K2’s active ingredients are synthetic cannabinoids — research-grade chemicals that were created for therapeutic purposes but can also mimic the narcotic effects of tetrahydrocannabinol, or THC, the active ingredient in marijuana.

In a statement, Mr. Huffman said the chemicals were not intended for human use. He added that his lab had developed them for research purposes only, and that “their effects in humans have not been studied and they could very well have toxic effects.”

Nevertheless, pure forms of the chemical are available online, and investigators believe that many sellers are buying bulk quantities, mixing them with a potpourrilike blend of herbs and labeling the substance K2.

“It’s not like there’s one K2 distributor — everybody is making their own stuff, calling it K2 and selling it, which is the most unnerving aspect,” said Dr. Christopher Rosenbaum, an assistant professor of toxicology at the University of Massachusetts who is studying the effects of K2 in emergency room patients.

The American Association of Poison Control Centers reports that so far this year there have been 567 K2-related calls, up from 13 in 2009. But investigators add that no one is really certain what is in K2, and people are arriving at emergency rooms with symptoms that would not normally be associated with marijuana or a synthetic form of the drug.

“I don’t know how many people are going for a box of doughnuts after smoking K2, but they’re sure getting some other symptoms,” said Dr. Anthony Scalzo, a professor of emergency medicine at the St. Louis University who first reported a rise in K2-related cases and is collaborating with Dr. Rosenbaum in researching K2’s effects. “These are very anxious, agitated people that are requiring several doses ofsedatives.”

Dr. Scalzo, who is also the medical director for the Missouri Poison Control Center, added that although tests had found cannabinoids in K2, it was unclear “whether the reaction we’re seeing is just because of dose effect, or if there’s something in there we haven’t found yet.”

That question remains at the center of an investigation into the death of David Rozga, an Iowa teenager who last month committed suicideshortly after smoking K2. Mr. Rozga, 18, had graduated from high school one week earlier and was planning to attend college in the fall.

According to the police report, Mr. Rozga smoked the substance with friends and then began “freaking out,” saying he was “going to hell.” He then returned to his parents’ house, grabbed a rifle from the family’s gun room and shot himself in the head.

“There was nothing in the investigation to show he was depressed or sad or anything,” said Detective Sgt. Brian Sher of the Indianola Police Department, who led the investigation. “I’ve seen it all. I don’t know what else to attribute it to. It has to be K2.”

But many users say they are undaunted by reports of negative reactions to the drug. K2 does not show up on drug tests, and users say that while they would like to know what is in it, they would take their chances if it means a clean urine test.

The Missouri ban, which goes into effect Aug. 28, prohibits several cannabinoids that investigators have found in K2 and related products. Nevertheless, investigators and researchers say that bans like the one in Missouri are little more than “Band-Aids” that street chemists can sidestep with a slight alteration to a chemical’s molecular structure.

“Once it goes illegal, I already have something to replace it with,” said Micah Riggs, who sells the product at his coffee shop in Kansas City. “There are hundreds of these synthetics, and we just go about it a couple of them at a time.”

Investigators say that a more effective ban might arise once the Drug Enforcement Administration completes its review of cannabinoids, placing them under the Controlled Substances Act. Currently, however, only one such substance is controlled under the act, though the agency has listed four others as “chemicals of concern.”

“It’s hard to keep up with everything,” said Ms. Carreno of the D.E.A., adding, “The process of scheduling something is thorough and time consuming, and there are a lot of gifted chemists out there.”

Meanwhile, states are largely on their own when it comes to controlling this new breed of synthetic cannabis, which often comes down to a game of cat-and-mouse where law enforcement agents, politicians, users and their families must formulate new responses as each iteration of a drug comes to market.

“Where does a parent go to get answers?” asked Mike Rozga, who said he learned of K2 only after his son’s death. “We talk to our kids about sex. We talk to our kids about drugs, and we talk to our kids about drinking and being responsible. But how can you talk to your kids about something you don’t even know about?”

Electronic Health Records and Privacy

Attached two very interesting articles from today's Miami Herald highlighting the issue of EHR usage in South Florida and privacy issues.
I am actually more concerned about the uncontrolled mailing and faxing of medical records between doctors offices and hospitals WITHOUT adherence to privacy rules. Just today I was castigated by a front-desk clerk who took issue that I had the audacity requesting a medical record release before releasing the records of one of my patients.
Using an Electronic Health Record for > 12 years I can attest to the very basic privacy features in EHRs: 1) audit trail- I can document who has accessed a specific record and when it happened,b) prevent access through passwords, c) can encrypt and secure stored files. NONE OF THESE FEATURES are available in paper records!!!
Anybody can open and read a paper record, doors to the record room are often unlocked, and stored paper records cannot be encrypted or secured except with mechanical locks. So why are we talking about privacy issues? Because of the FEAR of the UNKNOWN!!! A fear stoked by those who often do not want to change and prefer to adhere to past and obsolete procedures. Many of my colleagues belong to this group too. I do have hope though that we can overcome this fear because nobody avoids using his/her ATM of computer to manage their financial transactions.
Looking forward to your comments.
Yours
Bernd


Posted on Tue, Jul. 06, 2010
Medical records go online, but at what cost to privacy?

BY FRED TASKER
ftasker@MiamiHerald.com


MARICE COHN BAND / MIAMI HERALD STAFF
Allison Grisham learns how to navigate her medical records with help from Dr. David Seo, a cardiologist at University of Miami Miller School of Medicine.
You're a South Florida resident on vacation in Boise or Bogotá. You suffer stomach pains and visit a local doctor. You whip out your BlackBerry, punch in your access code and show the doctor a list of your medications, allergies, past illnesses, tests, surgeries and advice from your physician back home.
Electronic medical records, or EMRs, are quickly becoming a reality for doctors and hospitals in South Florida and beyond.

If EMRs work, they'll be high-tech marvels -- letting patients access their own medical records on their home computers, helping doctors coordinate tests with each other to avoid duplication, giving medical researchers access to millions of medical records.

Nearly every major South Florida hospital and many doctors are joining a push by the Obama administration to spend $19.2 billion in federal stimulus money to help create a national EMR system by 2014.

Allison Grisham of Miami Beach just got her own EMR from her doctor at University of Miami Hospital, which is spending $100 million on a new Epic brand system. She hopes it can help end medical errors like one she barely avoided a few years ago.

``I was in a hospital once and the nurse tried to give me the wrong medication. We only stopped it because my mother and I refused to let her put it in the IV,'' she said. ``It could have been serious.''

There are drawbacks. Patient advocates worry that EMRs could pose a threat to privacy. Doctors and hospitals say they're not being given enough time to set up the complex electronic systems or enough financial help to pay for them. The systems can cost $50 million to $100 million for hospitals and $15,000 to $50,000 for private doctors.

But the potential pluses outweigh those complaints, many doctors and hospitals believe. The new systems are voluntary, but federal financial incentives for using them and penalties for failing to do so have most medical officials at least resigned to making the change.

Here's what else EMRs will do:

You're a university medical researcher and you suspect a popular diabetes drug is causing heart problems. On your PC, you study the records -- with patient permission, and without their names -- of all the millions of people taking the suspect drug and compare them to those who aren't.

``A researcher could access the records of nearly every patient in the country and solve problems quickly,'' said Dr. Pascal Goldschmidt, dean of the UM Medical School.

Or you're a hospital CEO, and EMRs help you communicate better and faster with other hospitals and doctors around the country -- something most hospitals can't do today even if they have older, simpler electronic medical records.

DUPLICATION

``That would eliminate a lot of duplication,'' said Linda Quick, president of the South Florida Hospital & Healthcare Association. She cited an example: an acquaintance had an EKG from his private doctor, was sent to the hospital next door for follow-up and was given another EKG 90 minutes later.

``Patients will take control of their own records. Exchange of information will be very fluid,'' said Tom Gomez, head of a Florida International University initiative promoting hospital information sharing.

``When we have the whole system, it will be as easy as using an ATM card,'' said Quick.

Still, experts predict years of hard work getting all the new EMR systems -- Epic, Cerner, Seimens and other brands -- to communicate with each other.

``This is going to be complicated,'' says Gomez. ``And we're in the very early stages. It's probably 10 years away.'' There are problems. Private doctors, especially in small practices, say they lack the money and technical staff to implement EMRs -- buying computers, hiring techs to run and repair them, taking time for the training to operate them.

``It's the wave of the future, fortunately or unfortunately,'' says Dr. Tony Prieto, a sole-practitioner family medicine physician in Plantation. ``I agree it's needed. I'm not saying I can afford it.''

Even some big hospitals say the program is moving too fast.

``The goal is noble, but the timeline is unrealistic,'' said Mimi Taylor, Baptist Health South Florida's vice president for IT. ``You have to give hospitals time to do it right.''

Baptist Health's six-hospital, 2,000-doctor system will spend $96 million by 2013 to install a Siemens Soarian system to meet the new federal requirements. An informal Miami Herald survey of 26 South Florida hospitals found every one is putting in a new system or upgrading an old one. In addition to UM Hospital and Baptist Health, hospitals installing new or upgraded systems include Broward's six-hospital Memorial Healthcare System, Tenet's 10-hospital chain, Miami Children's Hospital and Mount Sinai Medical Center.

At UM Hospital, six clinics already have begun offering patients a personal electronic medical record called MyUHealthChart. By July, all clinics on the Miller School campus are to have them. By December, patients will be able to schedule appointments and pay their bills electronically. Even Jackson Health System, with its financial woes, is upgrading its current Cerner EMR system as part of the federal push.

``We have to do it to remain competitive,'' said Fernando Martinez, Jackson's chief information officer.

The Obama administration is using both carrots and sticks to persuade hospitals and doctors to put in EMRs. The president set aside $19.2 billion from the American Recovery and Reinvestment Act of 2009 to subsidize the systems. Doctors who start implementing EMRs by 2011 can get up to $44,000 in extra reimbursements from Medicare or $63,000 from Medicaid.

REIMBURSEMENTS

Hospitals will get bigger reimbursements, although their financial officers can't say how much yet. Local administrators estimate federal subsidies will repay 20 percent to 50 percent of the cost of an EMR system.

The problem, said Prieto, the Plantation physician, is that the expense is up front for the EMR system, but the reimbursement is after the fact.

``I have 26,000 patient charts. I can't imagine what that will cost me.''

The reimbursement ``won't even be close'' to the expense, he said.

``If you're a solo practitioner, you have to go out and buy a new system and educate your staff to use it,'' said Cynthia Peterson, head of the Broward Medical Association. The stick: Doctors and hospitals that don't comply by 2015 will see their Medicare and Medicaid payments reduced by 1 percent in 2015, 2 percent in 2016 and 3 percent in subsequent years.

A Congressional Budget Office report predicts 90 percent of hospitals and doctors will have EMRs by 2019.




Posted on Tue, Jul. 06, 2010

In online medical records, worries about privacy breaches

BY FRED TASKER
ftasker@MiamiHerald.com

If millions of patients across America have electronic medical records they can access 24/7 by punching a code into a home computer or BlackBerry, how safe are those records from identity thieves?
Even today, even without a nationwide data-sharing electronic medical record system, attempts to steal medical records are alarming.

Actress Farrah Fawcett, who died of cancer in 2009, in her final days helped expose an employee of a Los Angeles hospital who was paid to leak her medical records to a tabloid magazine.

Won't putting the records online make them even more vulnerable?

``I would never say a system can't be hacked,'' said Sam Butler, spokesman for Epic Systems, which is creating a $100 million EMR system for University of Miami Hospital. ``But we're not aware that our medical records have ever been violated.''

A typical new EMR system has security programs similar to those for ATM cards or other bank records. Patients get 20-digit personal IDs and must answer questions such as date of birth or mother's maiden name to access their records.

Many users are resigned to some risk.

``Today if you have a paper record, you don't know who sees it,'' said Jacquelyn Liberto, executive director of strategic operations at UM Hospital. ``With Epic it's more secure,'' she said, because nurses or assistants will be able to access only the parts of a patient's records needed for their duties.

In the push for nationwide EMRs, Congress has tightened privacy rules, increasing penalties for leaking information, requiring immediate notification of patients if their records are leaked.

It's not enough, argued a 2009 editorial in The Journal of the American Medical Association that said the law still does too little to protect patients' records and is too restrictive in giving legitimate access to medical researchers.

``The result is that patients' medical records are not well protected, and researchers cannot effectively search for important discoveries,'' the editorial said.

Some patients are afraid insurance companies or potential employers might use their medical conditions to deny them coverage or jobs. Others fear that lawyers might demand to see their records.

In 2003, Florida prosecutors subpoenaed medical records of radio host Rush Limbaugh, who was charged with improper doctor-shopping after he acknowledged he was addicted to painkillers. The Florida Supreme Court gave some of the records to prosecutors but kept others private.

``Electronic records are wonderful tools for research, but there's so much concern about protecting privacy that it becomes a challenge,'' says Liberto.



Read more: http://www.miamiherald.com/2010/07/06/v-print/1716656/in-online-medical-records-worries.html#ixzz0sxiKTTmX

Medicare Payment Reform

Attached a very interesting article published today on the HEALTH AFFAIRS web site.
It contains a thorough and very readable analysis of the Medicare payment and SGR quagmire.
Several important quotes stand out:

* "Eliminating the SGR targets and permanently freezing Medicare physician fees at the 2009 level would cost $276 billion between 2011 and 2020."

* "The SGR system was supposed to give physicians incentives to practice more efficiently and thus gain higher fee increases, or at least avoid decreases. But the incentives don't work for individual physicians."

* "Medicare has a total cost problem, not just a physician cost problem."

The proposed solutions in my opinion could boost the role of primary care physicians:

"Whatever happens to the SGR targets, there is general agreement that long-range savings will require other reforms in the current payment system. Incentives for physicians are driven not just by the overall level of Medicare prices, but also by the prices for specific services. MedPAC and others have contended that certain services are "overvalued": The price is too high relative to the difficulty of providing the service or the physician's overhead costs.

Because overvalued services can be profitable, physicians have incentives to furnish more of them, while the system discourages the delivery of primary care and other undervalued services. Over time, misaligned incentives can even affect career choices, driving physicians into specialties with the most profitable services. CMS has been taking action on its own to correct some of these pricing problems, and further changes are mandated in the new health reform law.

Many observers argue that Medicare needs to move beyond the basic idea of paying physicians for each service that they provide to each patient. Paying service by service may encourage the fragmentation of care and the delivery of unnecessary services.

There are numerous proposals for payment changes that would promote integrated care delivery and encourage cost-effective medical treatment. One option is the bundled payment, a single payment to a provider for all services related to a specific disease or condition during some fixed period. Another is to encourage the development of accountable care organizations (ACOs), networks of physicians and other providers that would accept responsibility for the overall care of a population of Medicare patients, perhaps in return for a fixed per capita payment."

As family physicians we must realign and recalibrate our medical practice and learn to collaborate to meet the demands of integrated healthcare delivery.
The use of electronic health records and the development of a PCMH is one important step in this process.
Its just a matter of time until fee-for-service will be replaced by bundled payments. Escaping from the reality is not a solution and organized medicine seem to do just that.
Happy 4th of July.
Yours
Bernd

Paying Physicians For Medicare Services
06/25/2010

It is widely agreed that the existing payment system is broken. Congress has again enacted a short-term fix to a long-term problem that it will have to revisit.

What's the issue?
Congress has voted to halt and delay for six months a scheduled 21.5 percent cut for physician fees under Medicare that had gone into effect in June 2010. The change gives physicians a 2.2 percent rate increase retroactive to June 1. But unless a longer-term solution is found, this short-term "doc fix" will expire November 30, 2010, at which point the previously scheduled reduction will kick in.

This latest episode represents the fourth time this year that scheduled Medicare fee cuts to physicians have been averted at the last moment--or even later. A longer-term repair is needed, but will be costly for U.S. taxpayers.

A Broken System: There is widespread agreement that the existing system for paying for physician services under the Medicare program is broken. Under current Medicare rules, intended to restrain growth in spending, payments to physicians have been subject to supposedly "automatic" cuts for a number of years. However, Congress has consistently postponed those cuts and instead raised physician fees or held them constant.

The latest scheduled cut for physician fees was the 21.5 percent reduction that took effect in June. In May, the House passed a proposal to provide rate increases in 2011 and 2012, followed by an even sharper 35 percent rate cut in 2012. But the Senate was unable to pass similar legislation, contained within a long-stalled bill to extend unemployment benefits and provide Medicaid assistance to the states. Instead, the Senate approved the six-month, 2.2 percent rate increase in late June.

The Centers for Medicare and Medicaid Services (CMS) was for a time holding June bills, pending possible congressional action, but as of June 18 it had begun paying doctors' bills at the reduced rates required by current law. When it became clear that the Senate would not be able to approve the longer-term House bill, members in the House voted on June 24 to adopt the shorter Senate version, and President Obama signed it on June 25.

The Problem Is Money: A permanent "doc fix" that would override both pending and expected automatic cuts in future years could add as much as $276 billion to federal spending over the next decade. There is no agreement in Congress on how best to make the fix or on how to pay for it, whether by raising taxes, cutting other federal spending, or simply adding the amount to the federal deficit. This brief describes the likely options for congressional action in the months and years ahead.

What's the background?
Medicare pays physicians using what is called a fee schedule, or list of prices. This list sets a fixed maximum price for each type of service, such as an office visit, a particular surgical procedure, or a specific diagnostic test. Current law requires CMS to update these prices each year.

In computing the annual update, CMS starts with an estimate of inflation but then adjusts this amount upward or downward, depending on how rapidly overall spending for physician services has been growing. If spending has stayed within set targets, physicians get a bonus--a price increase greater than inflation. But if spending has exceeded the targets, the updated prices may rise more slowly than inflation or even be reduced.

The current system of spending targets was put into place by the Balanced Budget Act of 1997. The aim was to give physicians an incentive to restrain the growth in the number of services they furnished to patients, and to discourage them from providing higher-price services in place of lower-price ones.

The spending targets are set using a "sustainable growth rate" formula, often referred to as the SGR. The formula is complicated, but its basic goal is to keep spending for each beneficiary from growing faster than the per capita increase in the gross domestic product (GDP). GDP growth is included in the formula on the theory that it is not sustainable for Medicare physician spending to grow faster than the national economy.

Hope Not Realized: The expectation that this payment system would control spending was not realized. In the first few years under the 1997 rules, physician spending did stay within the targets, and physicians were rewarded with price increases greater than inflation. For 2002, however, the update formula in the law required a reduction in physician fees of almost 5 percent. Congress allowed the reduction to take effect. But when the formula dictated a further reduction for 2003, Congress overrode the Balanced Budget Act rules and approved a small fee increase.

That action set a precedent that has continued to this day. In each year since 2003, although the statutory formula would have led to a fee cut, Congress has instead granted an increase or at least frozen the rates and prevented a decrease.

Although Congress has repeatedly intervened to prevent rate cuts, it has never changed the formulas that dictate these cuts. Each time it has set the fee increase, Congress has specified that fee updates for later years should be computed as if it had not acted. What's more, Congress has never modified the SGR targets themselves.

Meanwhile, the number of services that physicians provide has been growing steadily, and the services are increasingly costly and complicated. That means that there has been a widening gap between actual spending each year and the amount allowed by the targets. Under the law, this ballooning deficit is supposed to be recouped by even steeper automatic rate cuts in the future.

Payment Cuts Kick In: In November 2009, CMS announced that under the formula, physician fees for 2010 would be 21.5 percent less than 2009 levels. The cut would have been even larger except for two factors. First, CMS on its own made some changes in the methods used for setting the targets. Second, the law limits how much fees can be reduced in any one year. However, cuts not made in 2010 would simply carry over into future years. Unless the law is changed, by 2014, rates could be about 40 percent less than 2009 levels.

Why has Congress consistently acted in this "Perils of Pauline" fashion, overriding automatic cuts on a short-term basis nine times so far? The answer is that a longer-range fix could greatly increase the federal deficit. Congress relies on the Congressional Budget Office (CBO) to measure the budgetary impact of proposed legislation. The CBO establishes a "baseline," projections of future spending and revenues that assume all current laws will be enforced. The baseline includes all of the physician cuts scheduled to take effect in future years, which will produce substantial savings for Medicare.

As a result, legislation that overrides future cuts would be "scored" by the CBO as increasing the deficit, in contrast with the current baseline. Eliminating the SGR targets and permanently freezing Medicare physician fees at the 2009 level would cost $276 billion between 2011 and 2020.

Postponing the cuts month by month or year by year, as Congress has done, has a smaller apparent budgetary impact. Yet even the six-month rate increase most recently passed by the House and Senate was scored as costing more than $6 billion, although the bill included savings provisions to offset that amount. Unless something is done before the end of this year, Congress will, once again, encounter pressure to avoid even bigger rate cuts in 2011 and later years.

Fixing The "Doc Fix": Few members of Congress wish to see physician payments slashed, and many would prefer to see some permanent "fix" so that they would not have to revisit the issue. Yet there are also mounting concerns about the overall size of the future federal deficit. In this context, many members on both sides of the aisle are reluctant to enact a costly fix without finding some way of paying for it.

What Are The Longer-Range Options?
Now that another short-term fix has been passed, Congress has several longer-range options. It could do nothing and let future cuts take effect. It could drop the SGR system and simply freeze future rates or let them rise with inflation. It could keep the current system but adopt various proposed modifications. It could adopt other fee schedule changes that might help slow spending growth. Or it could develop entirely new ways of paying for physician services.

Do Nothing: Congress could simply allow scheduled fee reductions to take effect. Without a fix, physician payments would drop as much as 40 percent from 2009 levels over the next several years. Although the government would save money, there are concerns about the potential impact that such large cuts would have on Medicare beneficiaries' access to health care. If Medicare rates fall too far behind those paid by private insurers, physicians might turn away current Medicare patients or stop accepting new ones. That would be more likely to happen if physicians have enough non-Medicare patients to make up for the income losses. The best guess is that physicians' ability to replace Medicare patients with those who have private insurance is likely to vary by geographic area and physician specialty.

Another possibility is that physicians would make up for lower Medicare fees by increasing the volume or intensity of services furnished to Medicare beneficiaries. However, it is unlikely that such "behavioral" changes could offset a 40 percent fee cut.

Whatever the potential effects of rate cuts might be, some people contend that the entire SGR approach has proved unworkable. The SGR system was supposed to give physicians incentives to practice more efficiently and thus gain higher fee increases, or at least avoid decreases. But the incentives don't work for individual physicians.

The problem is that if some doctors provide extra services, they will make more money in the short term than those who don't--yet the resulting penalties fall on everyone. Because of these perverse incentives, critics contend, aggregate spending targets may never be workable and should be replaced by more-focused cost containment methods.

Abandon The Sustainable Growth Rate System: Congress could decide to eliminate the formula that ties fee updates to trends in spending growth. Those who favor this step argue that since Congress is unlikely ever to allow the full scheduled rate cuts, it would be better and arguably more honest to take the full budgetary hit at once, instead of year by year. With no system in place for updating the fee schedule, Congress might at some point come up with a better approach.

A contrary view is that repeated short-term fixes to the SGR system are actually preferable. If the threat of rate cuts were permanently removed, Congress would never get around to fixing the system.

Others have suggested shelving the problem for some years, rather than a few months at a time, in the hope that additional breathing room would make it possible to develop a consensus around more comprehensive reforms in the system. But even that kind of half-measure would cost a great deal. For example, the CBO estimates that freezing the rates through 2014 would raise the deficit by $89 billion.

Make Long-Term Modifications To The SGR System: There are numerous proposals on the table to continue the current system of SGR targets, but with various modifications. CMS could simply wipe the slate clean and base future targets on actual current spending levels. In effect, past overspending would be forgiven, offering physicians a new chance to restrain spending but threatening them with penalties in the future if they failed to do so.

This approach, known as "rebasing," would be almost as costly as getting rid of the targets altogether. And rebasing would not correct the distorted incentives in the current system. Over time, physicians might once again ramp up service delivery until the formula dictated rate reductions.

Other options include setting separate spending targets for different services, different geographic areas, or even specific providers or groups of providers. For example, Congress could allow more spending growth in services such as primary and preventive care, while clamping down on such fast-growing areas as x-rays and other imaging services.

Another approach might be to establish separate targets for areas with lower and higher average per capita spending. Physicians in some areas deliver or order far more services for Medicare beneficiaries than do physicians in other areas, and there is little evidence that patients in high-volume areas have better health outcomes. Geographically based targets would arguably focus on constraining spending in high-cost areas.

Although these options are more focused than the current system, there is still a risk that they would penalize some efficient providers or reward some inefficient ones. To prevent this, updates or targets could be set for specific providers.

Under one proposal, CMS could identify physicians who provide or order an unusually high number of services and could reduce fee updates for those who fail to change their behavior. Any such option would be controversial. It would require extensive data collection and some consensus on how to distinguish inefficient providers from those who are treating difficult cases.

Finally, payment targets could be broadened to include a wider scope of services. The Medicare Payment Advisory Commission (MedPAC) has suggested that if payment targets are retained, they should apply to all health care sectors. MedPAC notes: "Medicare has a total cost problem, not just a physician cost problem." In this view, systemwide targets could pressure physicians, hospitals, and other actors to collaborate in order to reduce unnecessary or duplicative services.

Make Other Payment Reforms: Whatever happens to the SGR targets, there is general agreement that long-range savings will require other reforms in the current payment system. Incentives for physicians are driven not just by the overall level of Medicare prices, but also by the prices for specific services. MedPAC and others have contended that certain services are "overvalued": The price is too high relative to the difficulty of providing the service or the physician's overhead costs.

Because overvalued services can be profitable, physicians have incentives to furnish more of them, while the system discourages the delivery of primary care and other undervalued services. Over time, misaligned incentives can even affect career choices, driving physicians into specialties with the most profitable services. CMS has been taking action on its own to correct some of these pricing problems, and further changes are mandated in the new health reform law.

Many observers argue that Medicare needs to move beyond the basic idea of paying physicians for each service that they provide to each patient. Paying service by service may encourage the fragmentation of care and the delivery of unnecessary services.

There are numerous proposals for payment changes that would promote integrated care delivery and encourage cost-effective medical treatment. One option is the bundled payment, a single payment to a provider for all services related to a specific disease or condition during some fixed period. Another is to encourage the development of accountable care organizations (ACOs), networks of physicians and other providers that would accept responsibility for the overall care of a population of Medicare patients, perhaps in return for a fixed per capita payment.

Many people think these approaches could eventually yield real savings. Still, it could take many years for CMS to develop new payment systems and for providers to form the organizations that can receive the payments. In the interim, most Medicare physician services will still be paid on a fee-for-service basis. And Congress will still face the task of balancing budgetary concerns with the goal of maintaining access to quality care for Medicare beneficiaries.

What's next?
Because the six-month fix has now been signed into law, Congress will have to revisit the issue before December 1, 2010. Senate leaders are still hoping to negotiate a longer-term fix that would be part of a larger jobs and Medicaid assistance package for the states. The coming days and weeks will determine whether Congress is likely to consider more-permanent payment reforms, or take other steps to thwart a looming, major doctors' fee cut in an election year.

Resources
Centers for Medicare and Medicaid Services, "Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2010: Final Rule," Federal Register 74, no. 226 (Nov. 25, 2009): pp. 61738--62188.

Congressional Budget Office, "Budgetary Effects for an Act to Provide a Physician Payment Update, to Provide Pension Funding Relief, and for Other Purposes (as provided by staff on June 18, 2010)."

Congressional Budget Office, "CBO Estimate of Changes in Net Federal Outlays from Alternative Proposals for Changing Physician Payment Rates in Medicare," April 30, 2010.

Congressional Budget Office, Letter to Rep. John Spratt, Chairman, House Budget Committee, on potential effects of reductions in physician payment rates, March 27, 2009.

Crosson, Francis J., et al., How Can Medicare Lead Delivery System Reform? (New York: Commonwealth Fund, November 2009).

Government Accountability Office, "Medicare Physician Payments: Trends in Service Utilization, Spending, and Fees Prompt Consideration of Alternative Payment Approaches." Statement before Health Subcommittee, House Energy and Commerce Committee, July 25, 2006.

Medicare Payment Advisory Commission, Report to the Congress: Assessing Alternatives to the Sustainable Growth Rate System (Washington: MedPAC, March 2007).

Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2010).

Urgent Care Centers

Attached an excellent and very interesting article written by John Dorschner highlighting the proliferation of Urgent Care centers within the Baptist Health system in South Florida.
The proponents of urgent care centers emphasize the improved access and reduced costs of care versus ER care.
One UM Family Medicine faculty teacher is being quoted too:

``The residents now going out on their own -- two or three are going to work for urgent care companies and five or so are going to larger, already established practices,'' Roberts said. ``That's just the way things are.''

I beg to differ and passionately disagree with the opinions stated.
Why? Because Urgent Care may be " cheaper" compared to emergency room visits BUT it does contribute to the fragmentation of care, the absence of care coordination and will further reduce urgently needed cash flow in primary care clinics.
Unfortunately, insurance companies seem to like the concept too. Therefore, urgent care and walk-in clinics are popping up all over Miami even in my neighborhood.
Do they provide better care ? Absolutely not!! For care coordination and continuity of care they "refer" the tough cases to family doctors because they Urgent care docs want to deliver quick fixes and have no time for history taking gibberish.
I am afraid that in search for the easy and quick buck family medicine residents will prefer those urgent care clinics.
So what can we do? Join the urgent care bandwagon? No!! We must focus on the development of collaborate practice models, develop medical homes and contract with employer groups demonstrating better and more cost-effective care.
Otherwise, we will contribute to the steady increase in healthcare costs and the fragmentation of healthcare deliver.
That's NOT just the way things are!
Looking forward to your comments.
Yours
Bernd

Posted on Fri, Jul. 02, 2010

Baptist Health makes urgent care push

BY JOHN DORSCHNER
jdorschner@MiamiHerald.com

With primary care increasingly hard to access, Baptist Health South Florida keeps expanding its urgent care centers in Miami-Dade and Broward -- and offending the chief executive of the huge Memorial Healthcare System in the process.

Urgent care -- providing faster, simpler treatment than hospital emergency rooms -- has proven to be a successful model for the prosperous Baptist system, even while smaller urgent care shops in South Florida have slid into bankruptcy.

``They're doing very well,'' said Patricia Rosello, chief executive of Baptist Out-Patient Services.

Indeed they are. Baptist Out-Patient, which includes diagnostic and imaging services, earned $52.3 million on $142.7 million in patient revenue in fiscal 2009, according to audited statements. That's a 36 percent rate of return -- and 40 percent of the $131.3 million in net income earned by the entire system, which has five hospitals.

Baptist is not alone in seeing a huge need for primary care. Many chain pharmacies stores in South Florida -- including Walgreens and CVS -- now have walk-in clinics, usually staffed by nurse practitioners who can dispense simple prescriptions for such things as antibiotics.

Aventura Medical Center, an HCA facility, is taking a slightly different tack, opening a primary care clinic in Miami Lakes operated by physicians it employs. It keeps regular doctor's hours -- daytime, Monday through Friday.

The hospital is looking cautiously at widening the service. ``We will expand geographically only as it makes strategic sense and will continue to build physician practices in communities where there is a need for primary care,'' said Aventura spokeswoman Robyn Kane.

LONGER HOURS

Baptist Medical Plazas offer broader services and longer hours -- generally 11 a.m. to 11 p.m. daily, with board-certified physicians always on duty, generally with X-rays and other tests available because the centers include outpatient diagnostic and imaging services.

Baptist now has 13 centers, with more on the way. It entered Broward last year, in Coral Springs. Its latest, opened in May, is in Davie, at Griffin Road and University Drive -- an area dominated by Memorial, the prosperous government healthcare system that dominates South Broward.

Memorial has focused on its hospitals, having only one urgent care center, in Pembroke Pines. Still, Memorial Chief Executive Frank Sacco was not happy to see Baptist's advertising in Davie: ``You'll find compassionate Baptist Health doctors and nurses. . . Broward, it's time to get treated better!''

Sacco sent a letter last month to Memorial staff: ``Such statements are offensive to thousands of dedicated and accomplished healthcare professionals. . . . It disappoints me to see Baptist Health South Florida disparage all of us.''

Baptist's Rosello says no attack was intended against Memorial.

The centers have been using the same line in their Miami-Dade advertising for the past three years: ``It's time to get treated better.''

Baptist surveys show that 90 percent of its urgent care patients walk out the door within two hours of entering, Rosello said. That's much better than lengthy waits that occur in most emergency rooms.

``We started the centers to decompress the emergency room,'' Rosello said. Baptist Hospital's, in particular, was often crammed with patients waiting for treatment. ``But then it became its own business,'' he said.

One reason: Most insurers discovered that pushing people toward urgent care is cheaper than ER visits. Baptist's own health plan for employees, for example, requires a $50 co-pay for urgent care versus $100 for an ER visit.

In the fall, another Baptist center will open in western Broward, at Dykes Road and Pines Boulevard, Rosello said. Next year, a Brickell facility is expected to open near the intersection of U.S. 1 and the Rickenbacker Causeway. Another six may open in the next three years, Rosello said.

TOUGH MARKET

Baptist's pineapple logo has become a recognizable symbol, even in Broward, where many South Dade residents moved after Hurricane Andrew in 1992. But many lesser-known centers have struggled in the market.

ER Urgent Care Centers had three facilities in South Florida. In 2004, when a reporter visited one of them, in Hallandale Beach, there were no patients. ``Our biggest problem is getting the public educated,'' said an executive of the firm. It filed for bankruptcy in 2008.

In Broward, Alan Roberts, a physician, operated three Sunshine Medical Centers, including one in downtown Fort Lauderdale, but ended up selling them to Concentra, a Dallas-based nationwide system that has the financial heft to market to patients and get good deals from insurers.

Another chain, Jacksonville-based Solantic, has 30 locations in the state, including four in Broward.

Roberts, who now teaches part time in the University of Miami family medicine program, said urgent care is only going to get bigger, because low reimbursement rates aren't enough for primary care doctors to open solo practices.

``The residents now going out on their own -- two or three are going to work for urgent care companies and five or so are going to larger, already established practices,'' Roberts said. ``That's just the way things are.''



© 2010 Miami Herald Media Company. All Rights Reserved.
http://www.miamiherald.com


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Arizona Law For Florida and Medical Practice

Attached an important and troubling article from today's Miami Herald pointing out that "Florida Republican leaders have begun crafting anti-illegal-immigrant legislation modeled after an Arizona law that has incited widespread protests and fueled national and international debate over U.S. immigration policies.
Under the proposed bill, police would have broad power under state law to ask suspects for proof of legal residency."
I am strongly opposing such legislation and urge my specialty society to raise concerns regarding this bill as it pertains to the way family physicians practice medicine.
I often (even today) encounter patients, mostly uninsured, who are reluctant to go to the hospital because of their residency status fearing a backlash, or possible investigation by the immigration authorities.
Today I referred a Haitian patient to Publix to benefit from a FREE Metformin program. She asked me if she would have to provide a form of identification because she has no papers. I reassured her that she should not worry.
What will happen IF we have such a discriminatory law on the books? More undocumented immigrants will avoid doctors but will be taken by ambulance to emergency rooms for preventable illnesses instead. Who will pay? The taxpayer!
Just the debate of such a law in the legislature will trigger additional pressure on our State which already has to deal with a massive and continuous oil spill, high unemployment and a jittery tourism industry. Do we need anything else to shut down!!
Looking forward to your comments.
Yours
Bernd




Posted on Sat, Jun. 26, 2010
Florida GOP risks Hispanic anger with Arizona-like crackdown

Cristina Silva
Miami Herald/St. Pete Times

TALLAHASSEE — Florida Republican leaders have begun crafting anti-illegal-immigrant legislation modeled after an Arizona law that has incited widespread protests and fueled national and international debate over U.S. immigration policies.
Under the proposed bill, police would have broad power under state law to ask suspects for proof of legal residency, said Rep. William Snyder, a Republican from Stuart who plans to introduce the legislation in November.

"We have significant components from the Arizona bill that I plan to incorporate,'' he said. "We have the beginnings of it.''

The effort, which would be filed for consideration during the March legislative session, is already drawing broad support within the GOP.

Majority leaders in the Florida Senate and House said a new approach is needed to address the federal government's failure to temper illegal immigration.

It has the backing of both leading Republican gubernatorial candidates -- businessman Rick Scott and Attorney General Bill McCollum, whose office is helping to draft the bill.

Snyder, a former police officer, said the proposed legislation is needed to protect undocumented immigrants, who are vulnerable to abusive employers and violent criminals.

"This is a human right issue,'' he said. "They don't enjoy the same rights and privileges that you and I do. The solution is to enforce the laws that currently exist and to discourage people from coming here to `find a better life' when in fact they just come here and are victimized.''

Immigrant advocates and Hispanic lawmakers alike called the measure an unconstitutional assault on minority communities.

"The reaction is, 'What? This is ridiculous,' '' said Neelofer Syed, a Tampa immigration lawyer from Pakistan. "It is supposed to be that you are legal until you are proven guilty. This law is like, `We think you are guilty unless you establish that you are innocent.' ''

Rep. J.C. Planas, a Republican from Miami, called it an election-year stunt.

"I don't understand how anyone can think the Arizona law is good for Florida,'' said Planas, chairman of the Florida Hispanic Legislative Caucus. "It is a huge waste of police resources to start doing these things.''

Senate and House leaders said immigration reform is ripe for passage.

"What we want to do is encourage legal immigration and discourage illegal immigration,'' said incoming Senate President Mike Haridopolos, who cautioned that any changes will be shaped by how the Arizona law is put into practice after it takes effect next month.

Republican leaders in Pennsylvania, Rhode Island, Minnesota, South Carolina and Michigan have made similar vows to mirror Arizona's immigration law, amid growing criticism that the federal government has not adequately protected the nation's borders.

Civil rights groups such as the American Civil Liberties Union have filed legal challenges to the legislation, and President Barack Obama's administration is expected to follow suit.

Critics questioned why Florida lawmakers would consider replicating Arizona's untested immigration strategy while legal challenges are still pending.

"Rep. Snyder's proposal solves nothing, exploits public concern over immigration and just creates new problems,'' said Howard Simon, executive director of ACLU Florida.

The tension has become a rallying point for candidates on both sides of the political spectrum.

Democratic gubernatorial candidate Alex Sink has highlighted her Republican opponents' support of the law in stump speeches.

"She was opposed to the law in Arizona,'' said campaign spokeswoman Kyra Jennings. "She believes it unfairly discriminated against American citizens. She would veto that type of legislation.''

Championing tougher immigration laws is a risky election strategy, said George Gonzalez, a University of Miami political science professor.

"It is a way to channel people's anger and frustration about the labor market onto a group and to take advantage of it, too,'' he said.

But it could also anger Hispanic voters, an important constituency in Florida's increasingly diverse political landscape, Gonzalez said.

Florida's estimated illegal immigrant population ranks third in the nation. Arizona places seventh. But while Florida's undocumented population has dropped by 10 percent during the past decade, Arizona's climbed by 42 percent.

"None of this is foolproof,'' Gonzalez said. "It could blow up in the Republicans' faces either way.''

Snyder said he doesn't want his law to stir up the same accusations of racism that hounded Arizona's decision.

His law would be refined, he said, because it would only allow law enforcement officials to inquire about immigration status during a potential arrest or traffic violation. In Arizona, officers are required to request legal documentation during any lawful stop if ``reasonable suspicion'' exists.

Coming up with the precise language will be difficult, conceded Snyder, who recently defended his views on Fox News. ``Reasonable suspicion makes people nervous,'' he said.

But he vowed his final draft would apply equally to all illegal immigrants, regardless of skin color or ethnicity.

"I've never in my 32 years been accused of using the `N' word or being racially motivated,'' he said. "No one who knows me would say I have a racist bone in my body.''

Shorter Work Days For Doctors

Attached a link to an important NEJM article http://content.nejm.org/cgi/content/full/NEJMsb1005800 entitled "The New Recommendations on Duty Hours from the ACGME Task Force."The goal of the ACGME's new approach to duty hours is to foster a humanistic environment for graduate medical education that supports learning and the provision of excellent and safe patient care.
At the heart of the ACGME's proposed changes is the recognition that the least-experienced residents need to be treated differently than more experienced ones. The plan recommends that first-year residents be limited to 16-hour shifts, and those in the second year and above work continuously for no more than 24 hours. They can stay an additional four hours to facilitate patient handoffs to another doctor. Currently residents are allowed to work up to 30-hour shifts.
The guidelines also include detailed expectations about direct supervision of younger residents by more experienced ones, in the hopes that a supervising doctor would catch any error before it affects a patient, according to Dr. Nasca.In addition, the ACGME will step up its monitoring and enforcement of the requirements, conducting on-site visits of each institution annually beginning in July 2011. The site visits are likely to cost each institution about $12,000 to $15,000, according to Dr. Nasca.
Those programs that don't comply with the rules could ultimately lose accreditation and be forced to disband.
I strongly support the proposed changes and call upon my colleagues to do the same.
Our patients deserve the same assurance about the quality of service as millions of airline passenger do already: strictly enforced duty hours for pilots, checklists before take-off and landing, elimination of human errors and the relentless pursuit of excellence.
We must change the way we do business! Our patients deserve it!!
Yours
Bernd

University of Miami and Professional Ethics

John Dorschner's very well written article reveals the disturbing facts surrounding the hiring of Charles Nemeroff,MD.
I am deeply troubled by UMs response emphasizing its " unflinching commitment to scientific integrity."
Whom are they kidding? It sets a bad example for medical students, researchers and residents at the University of Miami who are supposed to learn medical ethics and professional conduct from their teachers. Does the UM administration really believe that Nemeroff's transfer to Miami constitutes a clean slate to continue his work for the NIH? I hope not.
I am grateful that someone is calling it what it is: hypocrisy on steroids.
Yours
Bernd


==============================================================================

Senator tells University of Miami he's `troubled' over hiring

BY JOHN DORSCHNER
jdorschner@MiamiHerald.com

Sen. Charles Grassley has written a strongly worded letter to University of Miami President Donna Shalala saying he is ``disturbed'' and ``troubled'' by actions surrounding UM's hiring of a psychiatrist-researcher under investigation by a federal agency.
The letter from the Iowa Republican, dated Monday, was sparked by a Sunday story in The Chronicle of Higher Education about the relationship between psychiatrist Charles Nemeroff, now head of UM's department of psychiatry, and Thomas R. Insel, director of the National Institute of Mental Health, who led a yearlong project to toughen policies against conflict of interest.

On Wednesday, UM issued a brief statement: ``The University of Miami is responding to the inquiry from Senator Grassley and will continue demonstrating its unflinching commitment to scientific integrity. UM works tirelessly to advance the quality of its teaching, research, and clinical care programs while maintaining the highest ethical standards in all that we do.''

The National Institute of Health said Insel was unavailable for comment.

Grassley and his staff have been investigating Nemeroff, once head of psychiatry at Emory University in Atlanta, because he received millions of dollars from drug companies while doing what was supposed to be impartial research for the National Institutes of Health on drugs made by the companies paying him.

Grassley reported Nemeroff received $2.8 million from GlaxoSmithKline and other drug makers over seven years for promoting drugs like GSK's Paxil. Emory eventually asked him to step down as head of psychiatry and suspended his work on major NIH grants.

E-MAILS

The Chronicle story said Insel ``quietly helped'' Nemeroff get hired at UM.

In summer 2009, when UM was thinking of hiring Nemeroff, Medical School Dean Pascal Goldschmidt e-mailed Insel saying that Nemeroff had said Insel would be able to provide a ``confidential opinion'' on him, according to documents released by the Senate Finance Committee.

Insel responded that he could not provide a formal, written recommendation because of NIH rules, but ``I can discuss informally by phone. Happy to do this,'' he wrote in an e-mail.

Goldschmidt told The Herald last fall that he thought Nemeroff was a talented researcher but didn't want to hire him if he couldn't get NIH funding.

The Chronicle article quotes Goldschmidt as saying Insel assured him that the Emory ban on Nemeroff's NIH grant activity for two years didn't carry over to Miami, and that Nemeroff would be able to apply for NIH funding as soon as he took his new job.

Goldschmidt was quoted in the Chronicle as saying that the Emory ban on Nemeroff's grant activities was due to ``political pressure that the university was under.''

SEEKS DOCUMENTS

In Monday's letter, Grassley wrote that he was ``troubled'' by that comment.

``President Shalala, I hope that you would agree -- contrary to Dr. Goldschmidt's views that disciplining researchers for failing to disclose conflicts of interest is merely a political issue -- that enforcing federal conflict of interest policy involves ethical and legal issues that ensure taxpayer trust.''

Grassley demanded Shalala produce five types of documents concerning Nemeroff, UM and NIH grants.

In last fall's Herald story, Goldschmidt called Nemeroff ``an exceptional psychiatrist and an exceptional scientist who has one issue in which he recognizes he made a mistake,'' by not informing Emory how much he received from pharmaceutical companies.

In March, UM started a transparent process, in which outside companies' pay to UM doctors is now listed on a website. Nemeroff is not listed there because the information concerns the period before he started last fall, the university has said.

Nemeroff told The Herald last fall that he decided in retrospect he should have declared drug makers' payments to him, but he thought Emory's regulations didn't require it.

The Chronicle article includes e-mails, also obtained by The Herald, indicating that Nemeroff and Insel were trying to get together at conventions and had each other's cell phone numbers.

When Nemeroff e-mailed Insel that he was taking the UM job, Insel wrote back: ``Congrats on a new position! Should be a new beginning.''

Insel told The Washington Post on Tuesday that he didn't have ``any great relationship'' with Nemeroff, and believed the psychiatrist's actions were ``so outrageous, he became the poster boy for conflict of interest.''

On Wednesday, Bernard Carroll, former head of psychiatry at Duke University and once Nemeroff's boss, told The Herald that he found Insel's comments to the Post ``disingenuous'' because the two have known each other since the early 1990s and Nemeroff helped Insel find a job at Emory.



Read more: http://www.miamiherald.com/2010/06/10/v-print/1672327/senator-tells-um-hes-troubled.html#ixzz0qgeVJdj6

Conservative Cheerleaders

06/12/10

Letter To The Editor

RE: Conservatism's cool, Miami Herald 06/12/2010


Nicholas Rohrhoff, Chairman of the Medical Student Section of the FloridaMedical Association claims that young people should evaluate conservative principles, including limited government.

Well,he may be unaware that many of his peers, including medial students like him at the University of Miami, significantly benefit from government intervention into medical education.

For example, many students rely on government subsidized loans to finance their education. He also seems to forget that most physician training is subsidized by the federal government.Today less than 5 percent of medical school revenues comes from tuition and fees. Instead, medical schools rely heavily on federal and state support. Once medical students receive their degree they continue with their Graduate Medical Education, i.e. residency or specialty training. The largest source of funding for graduate medical education is the federal Medicare program, which reimburses teaching hospitals for both the direct cost of operating these programs. Florida’s Medicaid program also provides funding to graduate medical education.

I hope that he appreciates that having received government funding and subsidies for his medical education and training he is also guaranteed a much higher earning potential than many other Americans. But may be not, because now he wants lower taxes too!

I really have a hard time to understand this conservative hypocrisy. For me its nothing else but an expression of egocentric individualism. So, please try your best and be a good doctor but stay away from political cheerleading.


Bernd Wollschlaeger,MD,FAAFP,FASAM


16899 NE 15thAvenue ,North Miami Beach, FL 33162

Phone: 305-940-8717
===============================================================================


Conservatism's cool
BY NICHOLAS J. ROHRHOFF
NJROHRHOFF@MED.MIAMI.EDU

In mid-term elections, voter turnout defines success. To win, it is imperative to target likely voters and mobilize sympathetic yet diffident constituencies to the polls. Barack Obama's successful courtship of young voters in 2008 cast John McCain's GOP as the party of yesterday -- a group of old, white men out of touch with an increasingly diverse and engaged youth -- never to regain electoral clout.

This was not a triumph in the battle of ideas.

Because the adolescent prerequisite of peer affirmation to consider anything persists in this age group, conservative policies were not even entertained by many young voters as potential solutions to America's problems.

The Obama campaign manipulated this phenomenon brilliantly by wooing young voters not with policy prescriptions but retail politics. Before the Iowa caucuses, he skipped an AARP event to attend a hip-hop concert. And he was far ahead of other candidates in high-tech outreach through e-mail, YouTube and social networking media. The results were a 135-percent increase in the Democratic youth vote from 2004 and an electoral prize that set him on a trajectory to the White House.

In the general election Obama was the candidate with whom young voters would rather have a beer. Reporters who covered both campaigns marveled at how many more young volunteers the Obama campaign had at the ready. Supporting him became the cool thing to do.

His personal appeal to the demographic drew them to his party. Gallup Poll data indicate that in 2000, 36 percent of young voters identified themselves as Democrats and 35 percent as Republicans. In 2008, 45 percent in that age group indicated affiliation with the Democratic Party -- only 26 percent with Republicans.

This support extended from politics to policy. The same poll reported 69 percent of young voters said the government should do more to solve problems whereas only 27 percent said government does too much. In both style and substance, conservatives had lost touch with the next generation of Americans.

How then to make conservatism cool again? Enter former Florida House Speaker and current Republican candidate for U.S. Senate Marco Rubio. It is reasonable to suggest that Rubio would not want to collect votes based on the perception that he is the coolest candidate. He is, by all accounts, a serious policy person. His book, 100 Innovative Ideas for Florida's Future, was accompanied by ``idea-raisers'' held across the state where citizens could contribute their views.

Appearing a decade younger than his 38 years as he effortlessly transitions from English to Spanish and back, he plays flag football and is married to a former Miami Dolphins cheerleader.

When asked recently about the notion that he was the Republican Obama, referring to the president's recent slide in the polls, he quipped, ``I'm not sure people even want to be the Democrat Obama these days.''

Still, he would win any poll -- in a landslide -- on which candidate young voters would most like to join for a beer.

Yet his distaste for identity politics is clear: He defines himself simply as a conduit to advance a set of ideas that has made this country the greatest in the history of the world. In a less Herculean task but one of no less consequence, he could serve as the catalyst to broaden the appeal of conservatism to incipient voters.

Rubio seeks election to the U.S. Senate to stand up to the Obama agenda and offer a clear alternative. A Harvard Institute of Politics poll released in March suggests there is an opportunity to persuade young voters with that platform. Only 38 percent of young people approve of President Obama's handling of the deficit and a majority disapprove of his management of the economy (51 percent) and healthcare (53 percent).

Most telling, just 14 percent of those polled attending a four-year college believe that it will be easy to find a job after graduation.

In 2008, voters under 30 made up 14 percent of Florida's electorate. Gov. Charlie Crist's decision to run as an independent amplifies the importance of each of those votes. Though young people are unlikely to vote in mid-term elections, in this three-way race they could be decisive. Rubio trails Crist in a recent St. Petersburg Times/Miami Herald/Bay News 9 poll by just 3 points.

Rubio has been presented as a plausible counterweight to the president for many reasons -- the most significant comparison may manifest in the electoral etiology of his meteoric rise. An aggressive approach will lead young people to evaluate conservative principles -- limited government, low taxes, and boundless opportunity -- on the merits.

If his overtures succeed, a statewide electoral victory propelled by young voters could begin a movement that energizes, modernizes and unifies the Republican Party before returning them to power in Washington.

Nicholas J. Rohrhoff is chairman of the Medical Student Section of the Florida Medical Association and a student at the University of Miami School of Medicine.

AMA Advocacy

Attached two examples how the American Medical Association advocates on behalf of physicians. I encourage you to renew your AMA membership to support those efforts which are helping us to practice medicine.
Have a great Memorial Day Weekend.
Bernd Wollschlaeger,MD,FAAFP,FASAM
AMA Outreach Recruiter

FTC Delays Red Flags Rule

The Federal Trade Commission on May 28 announced it would delay enforcement of the Red Flags Rule from June 1 to Dec. 31, 2010.

The commission cited congressional consideration of legislation that would affect the scope of entities covered by the rule to require businesses to take specific steps to minimize identity theft. For instance, S. 3416, introduced on May 25 in the Senate, would exempt health care practices with 20 or fewer employees, as well as accounting and legal practices of similar size.

Covered health care professionals under the bill include physicians, dentists, podiatrists, chiropractors, physical therapists, occupational therapists, marriage or family therapists, optometrists, speech therapists, language therapists, hearing therapists and veterinarians.

The commission in its announcement urged Congress to quickly act "to pass legislation that will resolve any questions as to which entities are covered by the rule and obviate the need for further enforcement delays. If Congress passes legislation limiting the scope of the Red Flags Rule with an effective date earlier than December 31, 2010, the Commission will begin enforcement as of that effective date."

The American Medical Association, which on May 21 filed a lawsuit to prevent the FTC from applying the rule to physicians, applauded the delay. "We call on the FTC to exempt physicians from the rule completely."

The extension is a promising sign that the AMA lawsuit caught the attention of the FTC, the association says. "Last November, a federal court blocked the rule from being applied to attorneys after the FTC was found to be extending its regulatory power beyond that authorized by Congress. We hope this latest extension will be long enough for the FTC to take a good, hard look at the rule and finally exclude physicians from this unjustified and burdensome regulation of medicine."

AMA eVoice Logo

eVoice® Alert

May 28, 2010

Tell Congress enough is enough!

Congress failed to address this year’s Medicare physician payment cut before the June 1 deadline next week. Although the U.S. House of Representatives passed legislation at the last minute to suspend cuts for another 19 months, the U.S. Senate left for a week-long Memorial Day recess without taking action. When Congress returns from their vacation on June 7, the Senate is expected to take up the House-passed bill.

The Centers for Medicare & Medicaid Services already issued instructions to its contractors to postpone processing claims for Medicare physician services provided on or after June 1 for 10 days to provide time for Congress to complete its action and overturn the scheduled cut retroactive to June 1.

The new proposal being considered by Congress would provide payment updates of 2.2 percent for the remainder of 2010 and an additional 1 percent increase in 2011. However, in 2012 the SGR formula will once again go into effect and payments will be cut by an estimated 33 percent!

Congress needs to hear from you! Call your representative and senators today using the AMA’s toll-free grassroots hotline at (800) 833-6354 or send them an e-mail. Urge them to end their mismanagement of these important health care programs, and honor their commitment to military families and older Americans.

It is long past time for Congress to find a long-term solution to the SGR that does not create an even bigger problem in the future. Enough is enough!

AMA Advocates For Fair Medicare Reimbursement

Attached an urgent appeal by our AMA to call upon legislators to finally address and resolve the flawed Medicare physicians formula.
Now its time to unite and support our AMA in its effort. I call upon the FMA leadership to stop all of its efforts to undermine our AMA and to focus on the pragmatic resolution of real and not imaginary problems. Physicians deserve our attention to their problems.
Yours
Bernd
AMA Outreach Recruiter

eVoice® Alert

May 18, 2010

AMA opposes SGR proposal

Based on conversations with policymakers, the AMA cannot support an emerging proposal to address the flawed Medicare physician payment formula. The result in five years would be steeper cuts for physician practices, making it much more difficult—if not impossible—to achieve the objective of permanently repealing the “sustainable growth rate” (SGR).

It is our understanding that a draft proposal developed by the U.S. House of Representatives and the U.S. Senate congressional leadership would provide for statutory updates of 2.2 percent for the remainder of 2010 and an additional 1 percent increase in 2011. Short-term positive updates are no doubt attractive. From 2012 through 2014, physician updates would be determined by two expenditure targets that were proposed by H.R. 3961. We believe updates during this period would likely produce modest increases for E&M services and no less than a freeze for other Medicare services. In 2015, physician payments would be scheduled to revert back to the current SGR formula with a projected cut of no more than 37 percent. While this cut would result in a 2015 conversion factor in line with that projected under current law, the update baseline will continue to fall during these five years as a result of the underlying SGR formula. By 2015, we believe that the price tag to permanently repeal the SGR, or even to extend the proposed 2012-2014 policy, could exceed $500 billion.

The AMA fully appreciates the fiscal challenges confronting Congress and our nation today. The cost of permanently eliminating the currently scheduled Medicare cuts is approximately $250 billion. For the last several years, Congress has chosen short-term remedies that have resulted in larger future physician payment cuts and made it much more expensive to scrap a formula that Democrats and Republicans have both said should be repealed. Five years ago, the price tag for repealing the SGR was $49 billion.

Twice this year, Congress has allowed 30-day extensions to expire, creating turmoil for patients and physicians because a 21 percent cut became the operative policy. On June 1, the current extension will expire again.

Failure by Congress and the Obama Administration to properly solve this issue will intensify access problems for seniors and military families enrolled in the TRICARE program, and severely undermine implementation of recently enacted health system reform legislation. An existing physician shortage will be magnified and steeper cuts will prevent practice and delivery innovations.

Everyone in the health care community and Congress would like to see this problem go away. However, the AMA believes that greater long-term insolvency is too steep a price to pay for a temporary solution. We believe that policymakers must once again go back to the drawing board and make the tough decisions necessary to provide the funding to fulfill the obligations made to Medicare patients and military families, without steep cuts for medical services.

Contact your members of Congress. Urge them to pass legislation to avert a 21 percent cut on June 1 without increasing the cost of a permanent solution, and preserve access to medical services for Medicare patients and military families. We should not mortgage the future of the private practice of medicine. Growing the problem is not the solution!

Health Insurance Companies

Dear Friends and Colleagues:
Attached you find an article from today's New York Times highlighting how health insurance companies are trying to (re) shape the rules of the new health care law thereby potentially mitigating its adverse impact on their profitable business model.
The impact of the new health care law depends on regulations needed to interpret it and more than 40 provisions of the law require or permit agencies to issue rules.
Two of these rules are at the heart of the new conflict fought by insurance lobbyists.
One bars insurers from carrying out an “unreasonable premium increase” unless they first submit justifications to federal and state officials. Congress did not say what is unreasonable, leaving that to rule writers. Another provision, effective Jan. 1, requires that a minimum percentage (85%) of premium dollars be spent on true medical costs related to patient care — not retained by insurers as profit or used to cover administrative expenses. Insurers must refund money to consumers if they do not meet the standards, known as minimum loss ratios.
Therefore, insurance companies will make every effort to reclassify ANY expenses as activities " that improve health care quality” for patients.
Thus, insurers are lobbying for a broad definition of quality improvement activities that would allow them to count spending on health information technology, nurse hot lines and efforts to prevent fraud. They also want to include the cost of reviewing care by doctors and hospitals, to determine if it was appropriate and followed clinical protocols.
As physicians we should SUPPORT narrowing these definitions of quality improvement activities, limited to those that produce measurable benefits to individual patients.
Otherwise, insurance companies will continue to pad their bottom lines, continue to find reasons to increase insurance premiums and make it more difficult for the average American to pay for health care.
Its time that physician organizations STOP criticizing the new law and point the finger at the real culprit: insurance companies!
Yours
Bernd



Health Insurance Companies Try to Shape Rules
By ROBERT PEAR
WASHINGTON — Health insurance companies are lobbying federal and state officials in an effort to ward off strict regulation of premiums and profits under the new health care law.

The effort is, in some ways, a continuation of the battle over health care that consumed Congress last year.

Insurance lobbyists are trying to shape regulations that will define “unreasonable” premium increases and require them to pay rebates to consumers if the companies do not spend enough on patient care.

For their part, consumer groups say they worry that their legislative victories could be undone or undercut by the rules being written by the federal government and the states.

The health care overhaul provides a classic example of how the impact of a law depends on regulations needed to interpret it. The rules deal with relatively technical questions but go to the heart of the law, pushed through Congress by President Obama and Democratic leaders with no Republican support.

More than 40 provisions of the law require or permit agencies to issue rules. Lobbyists are focusing on two whose stated purpose is to ensure that consumers “get value for their dollars.”

One bars insurers from carrying out an “unreasonable premium increase” unless they first submit justifications to federal and state officials. Congress did not say what is unreasonable, leaving that to rule writers.

Another provision, effective Jan. 1, requires that a minimum percentage of premium dollars be spent on true medical costs related to patient care — not retained by insurers as profit or used to cover administrative expenses. Insurers must refund money to consumers if they do not meet the standards, known as minimum loss ratios.

Michael W. Fedyna, vice president and chief actuary of Aetna, underlined the importance of this issue, saying no other aspect of the law would be so “influential in shaping the future of the health care marketplace in the United States.”

The definition of medical loss ratio will “determine the willingness of health plans to enter new markets and remain in existing markets,” he said.

Senator John D. Rockefeller IV, Democrat of West Virginia, said the definition would be just as important for consumers and small businesses.

“The health insurance industry has shifted its focus from opposing health care reform to influencing how the new law will be implemented,” he said.

The law requires insurers to spend a minimum percentage of premiums on health care services and “activities that improve health care quality” for patients.

Insurers are eager to classify as many expenses as possible in these categories, so they can meet the new test and avoid paying rebates to policyholders.

Thus, insurers are lobbying for a broad definition of quality improvement activities that would allow them to count spending on health information technology, nurse hot lines and efforts to prevent fraud. They also want to include the cost of reviewing care by doctors and hospitals, to determine if it was appropriate and followed clinical protocols.

Some consumer advocates, like Carmen L. Balber of Consumer Watchdog, favor a strict, narrow definition of quality improvement activities, limited to those that produce measurable benefits to individual patients.

Alissa Fox, a senior vice president of the Blue Cross and Blue Shield Association, said that if the definition is too narrow, “health plans will come under enormous pressure to cut back quality improvement activities, including highly effective programs to reduce hospital infection rates.”

But Charles N. Kahn III, president of the Federation of American Hospitals, a trade group, said he feared that the quality improvement category would become a “catchall for a wide variety of expenses not directly related to patient care.”

Under the new law, insurers in the large group market are generally supposed to spend 85 percent of customers’ premiums on “clinical services” and quality-enhancing activities. The minimum is 80 percent for coverage sold to individuals and small groups.

Insurers and insurance regulators say that some companies will be unable or unwilling to meet the new standards.

Politicization of Medicine

Well, Florida doctors never stop surprising me. Here comes another kicker: a Florida Urologist posted a note on his officer door that reads ""If you voted for Obama…seek urologic care elsewhere."
I have plenty of issues with the health care legislation but it passed by majority vote and its the law of the land. Even though, I favor a single-payer system I accepted the legislation. My patients often ask me about MY opinion and I let them know but I always listen carefully what THEY have to say because I favor dialogue. Is dialogue such a bad word now? What happened with the concept of political discourse?
According to David W. Johnson and Roger T. Johnson from the University of Minnesota,http://www.co-operation.org/pages/contro-pol.html ,the purposes of political discourse includes

" (a) clarifying citizens' understanding of the issue, (b) helping citizens reach their best reasoned judgment as to which course of action will solve a problem, (c) increasing citizen participation in the political process, and (d) socializing the next generation into the procedures and attitudes they need to be active citizens."

The authors emphasize that

" Thomas Jefferson, and the other founders of the American Republic, considered political discourse to be the heart of democracy. Jefferson believed that instead of the social rank within which a person was born, the basis of influence within society should be discourse in a free and open discussion characterized by conflict among ideas and opinions. He noted, "Differences of opinion lead to inquiry, and inquiry to truth."

Unfortunately, we are far removed from this process and the further we deteriorate the more we degrade what generation before us tried to build.
A sad but true state of affairs.
I hope that the next sign a doctor will post in his office will read, " I welcome your opinion and your well-being should be my primary concern."

Yours
Bernd
OrlandoSentinel.com
Dr. Jack Cassell: Sudden celebrity
Mount Dora doctor's anti-Obama stance sparks firestorm nationwide
Urologist stands firm, appears on national news as blogosphere erupts over sign telling Obama voters to go elsewhere

By Stephen Hudak, Orlando Sentinel

April 3, 2010

MOUNT DORA — Doug Bell isn't a patient of Dr. Jack Cassell's, but he almost wishes he were.

The Sorrento salesman heard about the firestorm over a sign that the Mount Dora urologist posted on his office door — it reads, "If you voted for Obama…seek urologic care elsewhere" — and wanted to see it himself.

"We need more people like him to speak out and take a stand against Obama-care," said Bell, 37, who snapped a picture of the sign Friday with his camera phone and planned to post it on his Facebook page.

Reaction was swift and passionate to news of Cassell's declaration as friends and foes weighed in online and over the phone, emailing and calling the doctor's office in Mount Dora to commend or castigate him.

Fueled by Internet sites such as the Drudge Report and the Huffington Post, which linked subscribers to theOrlando Sentinel story, Cassell received invitations to appear on several national radio and TV programs, notably Neil Cavuto's Fox News show and AC360, a CNN news and commentary program hosted by Anderson Cooper. He appeared on Fox and accepted Cooper's invite Friday night.

Not everyone was a fan.

"If I was one of his patients, I would not walk away, I'd run," said Patsy Robertson, 73, of Winter Springs, a Democrat and retired nurse. "He does not need to be taking care of people's lives if that's his mentality."

Cassell, a registered Republican, believes the sharply partisan, health-care overhaul pushed through by Democratic members of Congress and signed into law by President Barack Obama will harm his practice and thus his patients.

He was applauded for his chutzpah by many who dubbed him a hero.

"Doctor Jack's a true American patriot," said Dan Evans, 34, a Georgia truck driver who detoured from a delivery in Apopka to shake the doctor's hand only to find the medical office is closed on Friday afternoons.

Sandra Boynton, 68, a retired Florida nurse now living in Idaho, described Cassell's sign as "repugnant" behavior.

"As a nurse, I was taught you don't refuse care to anyone based on anything that's your personal views," she said. "I simply cannot imagine any nurse behaving in this self-centered manner. This man is a disgrace to his profession."

Cassell told the Orlando Sentinel that he has not refused to treat any patient for his or her political views and does not quiz patients about their politics, but he also does not plan to take the sign down.

"I have plenty of Obama supporters in my patient base and we have a lot of political discussions. I'm not cutting anybody out of their care. I'm not refusing care on the basis of their political beliefs," he reiterated in an exchange with Cavuto. "I hope that more and more Obama supporters come through to find out what all the fuss is about because I think we have to do something about this."

But Cassell's former medical partner in Eustis, urologist Dr. James Young, 57, a self-described liberal Democrat, said a patient's politics should be no more important to a doctor than his favorite baseball team.

"It'd be like me saying I'm not going to treat a Cubs fan," said Young, a lifelong fan of the St. Louis Cardinals. "There are a number of thoughtful doctors who feel like Jack and probably a like number who feel the exact opposite, but they're not going to put a sign on their door. As doctors, our chief concern should always be what's best for the patient."

Cassell's story, picked up by The New York Times and driven by broadcast reports and conservative talk-show giant Rush Limbaugh, generated hundreds of e-mails and phone calls to the Orlando Sentinel from Web readers across the nation, a firm majority of whom not only support the doctor's view but also his right to voice them on his office door.

"I think he's saying, ‘If you voted for Obama, you made a decision and that decision has consequences,' " said Dr. William Crowley, 76, a retired neurologist living in Texas, who praised the doctor for provoking a discussion.

Margaret Taormino, 72, a retired social worker living in Tavares, expressed a common sentiment about Cassel.

"My husband and I don't need a urologist," she said, "but if we ever do, he's our guy."

Stephen Hudak can be reached at shudak@orlandosentinel.com or 352-742-5930.

Medicaid and Healthcare in Florida

Currently, we focus on healthcare insurance reform expanding access to million of uninsured Amercian's but we fall short in reforming healthcare delivery. We MUST focus on cost containment, quality and outcome improvement too.
Unfortunately, many of my colleagues in organized medicine focus on the "panacea" called Tort Reform to reduce to costs resulting from "defensive medicine." I seriously doubt that this approach will provide the cost reduction needed to save our healthcare system. Meanwhile, Florida Senate members call for

" a federal Medicaid waiver to permit the state, through legislative enactment, to limit annual spending on the Medicaid program to the amount appropriated in the state budget. The waiver request shall include authorization for the legislature to make changes to optional eligibility groups and services in order to prevent spending more in any fiscal year than is appropriated. In addition the waiver shall request authority to revise the benefit structure and delivery system to allow Medicaid recipients to be integrated into the private insurance market through the use of state vouchers. The wavier shall include a provision to require Medicaid recipients with higher incomes to participate in program costs through coinsurance and deductibles and to be provided incentives for cost effective utilization of the health care system."

This serves as an example for "soft" rationing by capping Medicaid and "allowing" Medicaid recipients to seek coverage on the private "market" utilizing vouchers. . This will jeopardize Medicaid and force patients to hunt for benefits among private HMOs, which can control and limit services as they want.
Instead, the medical home model is a viable alternative moving the savings back to the physicians in the Medical Home.
A good friend of mine got it right, " Someday, when nothing is left but employed physicians attached to corporate HMOs then maybe docs will get the message that the Medical Home was a good idea."
Unfortunately, many don't get it because they are (mis)lead by ideologues who set politics before policy.
Yours
Bernd