Malpractice Reform; A Fresh Start

Attached an interesting article published in the New York Times on October 20th, 2010.
In this article Peter Orszag, the former director of the White House Office of Management and Budget, emphasizes that Congress (Democrats AND Republicans alike) " missed an important opportunity to shield from malpractice liability any doctors who followed evidence based guidelines in treating their patients." He argues that malpractice reform, i.e.liability insurance reform, could encourage doctors to adopt new evidence more quickly.
He continues stating that instead of imposing caps on liability a far better strategy would be to provide safe harbor for doctors who follow evidence based guidelines. In such circumstances ANYONE who could demonstrate that he/she has followed the recommended course for treating a specific illness or condition could NOT be held liable! To successfully transform our broken malpractice system he suggests taking the following steps:

1. Organizations like the American Medical Association and the Institute of Medicine could also be called upon to issue the needed evidence-based standards for malpractice immunity.
2. Approach to reform will require larger investments in research into what works and what doesn’t. Fortunately, both the health care reform act and the 2009 economic stimulus act provided additional financing for such comparative effectiveness medical research, and the health care act provides for a Patient-Centered Outcomes Research Institute to coordinate the work.
3. Develop and fund information technology solutions that quickly suggest best-practice methods of treatment.
4. Align financial incentives for delivering higher-quality care and and to shift Medicare’s payments toward “fee for quality” rather than “fee for service.”

In my opinion we should discuss these ideas, ask for federal funding to start pilot projects and to actively support any such initiatives.
Unfortunately, organized medicine is focusing on liability caps as the ONLY solution for malpractice reform ignoring and discarding ANY other approaches to address and resolve this important issue. At this point in time progressive physicians and other healthcare professionals should form partnerships and alliance to counter this dogmatic position. Healthcare professionals should consider seeking representation in partnership with ALL participants in the healthcare delivery process including PAs,ARNPs,Nurses and hospital administrators and to engage in strategic planning sessions to develop rational responses to increasing complex problems.
This requires new leadership with the ability to listen, to tolerate other opinions and to seek a compromise based on the most common denominator.
Discussing malpractice reform also requires the inclusion of legal professionals and to engage the trial bar in the deliberations.
We must move from confrontation to collaboration and to stop dividing the world into "friends" and "enemies" of medicine.
Maybe just a dream but the opportunity to change is still present.
Yours
Bernd


October 20, 2010
Malpractice Methodology
By PETER ORSZAG

The health care legislation that Congress enacted earlier this year, contrary to much of today’s overheated rhetoric, does many things right. But it does almost nothing to reform medical malpractice laws. Lawmakers missed an important opportunity to shield from malpractice liability any doctors who followed evidence-based guidelines in treating their patients.

As President Obama noted in his speech to the American Medical Association in June 2009, too many doctors order unnecessary tests and treatments only because they believe it will protect them from a lawsuit. Instead, he said, “We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines.”

Why does this matter? Right now, health care is more evidence-free than you might think. And even where evidence-based clinical guidelines exist, research suggests that doctors follow them only about half of the time. One estimate suggests that it takes 17 years on average to incorporate new research findings into widespread practice. As a result, any clinical guidelines that exist often have limited impact.

How might we encourage doctors to adopt new evidence more quickly? Malpractice reform could help — possibly a lot.

The academic literature tends to play down the role of medical liability laws in driving up health care costs. Doctors themselves, however, almost universally state that malpractice statutes lead to extraneous testing and treatment.

It is also conceivable that because such laws usually focus on “customary practice” — that is, a doctor who has treated a patient the way most other doctors in the area would is considered safe from accusations of malpractice — they create a strong contagion effect among doctors. The laws, no matter how weak or stringent, may therefore explain why doctors in some parts of the country generally adopt much more intensive approaches than those in other areas do.

The traditional way to reform medical malpractice law has been to impose caps on liability — for example, by limiting punitive damages to something like $500,000. A far better strategy would be to provide safe harbor for doctors who follow evidence-based guidelines. Anyone who could demonstrate that he has followed the recommended course for treating a specific illness or condition could not be held liable.

The health care reform act that Congress passed earlier this year included a modest set of state pilot projects, including one in Oregon that is intended to experiment with this approach. But these pilots are small; the project in Oregon, for example, has only $300,000 in financing.

What’s needed is a much more aggressive national effort to protect doctors who follow evidence-based guidelines. That’s the only way that malpractice reform could broadly promote the adoption of best practices.

Congress has taken a step in this direction before. As Prof. James Blumstein of Vanderbilt University Law School has pointed out, a little-known provision in the Social Security Act amendments of 1972 provides immunity from malpractice liability to doctors who treat patients in conformity with the standards set forth by so-called quality improvement organizations — nonprofits under contract with Medicare that work to improve care. The provision remains in force, though those organizations have yet to set such standards.

Organizations like the American Medical Association and the Institute of Medicine could also be called upon to issue the needed evidence-based standards for malpractice immunity. But no matter which body is put in charge of certification, this approach to reform will require larger investments in research into what works and what doesn’t. Fortunately, both the health care reform act and the 2009 economic stimulus act provided additional financing for such comparative effectiveness medical research, and the health care act provides for a Patient-Centered Outcomes Research Institute to coordinate the work. It’s a good start.

Better technology would help, too. Your doctor’s computer should be able to not only pull up your health records (after you have approved such access) but also quickly suggest best-practice methods of treatment. The doctor should then be able to click through to read the supporting research. Subsidies in the stimulus act help doctors pay for this kind of technology.

A final step toward improving standard medical practice will be to better align financial incentives for delivering higher-quality care. Hospitals now lose Medicare dollars, for example, if they succeed in reducing readmissions. Medical professionals should be given incentives for better care rather than more care.

The health care reform act already includes measures that enable policymakers to shift Medicare’s payments toward “fee for quality” rather than “fee for service.” My next column will discuss these measures, which get far less credit than they should, in more detail.

Opponents of the act are generally off base in criticizing investments in improved care. In complaining about the missed opportunity to reform medical malpractice laws to promote evidence-based medical practice, on the other hand, the critics are entirely on target.

Peter Orszag, the director of the White House Office of Management and Budget from 2009 to 2010 and a distinguished visiting fellow at the Council on Foreign Relations, is a contributing columnist for The Times.

Keep it Simple and Stupid: Rick Scott's Healthcare Plan and the FMA

“Florida is not a physician-friendly state to practice medicine because of the high cost of medical liability insurance and excessive lawsuits,....the FMA PAC supports Rick Scott for Governor because he shares our goal of increasing access to quality health care for all of Florida’s citizens. Rick Scott is not afraid of taking on personal injury lawyers and shaking up the status quo in order to get things done for the people of Florida.”


President of the FMA PAC, Dr. Madelyn Butler



I tried to understand Rick Scott's healthcare plan and ideas, which convinced the Florida Medical Association Political Action Committee to endorse him as Gubernatorial Candidate.
First, I searched on his web site and found the following:

* On Abortion: "I believe that abortion is wrong and Roe versus Wade should be overturned."
o What shall I tell a woman who is pregnant but unmarried, unemployed, on food stamps and lives with friends or relatives?
o Teenagers who were raped or married women who were sexually attacked by their husbands?
o Should government tell women and doctors what to do and how to lives their lives?
* On Health Care:
o "As a businessman, I know I am held accountable for results, and I held the people in my company accountable for results, too. Delivering quality care at a lower cost to patients was a top priority when I ran Columbia/HCA, and when I started Solantic urgent care facilities here in Florida....In the 1990’s, we were able to transform the hospital industry and prove that free market health care can deliver high quality care at a lower cost to patients."
+ That’s it? We just have to emulate the Columbia/HCA model and open a couple of Solantic Urgent Care centers and we solve all healthcare problems? Guess, I can shred all my healthcare economics test books and magazines, join Rick Scott's model and everything will be just fine. How naive or stupid can anyone be to believe that? Obviously, the FMA PAC does!
o "Rick believes that our health care system should focus on choice, competition, accountability and personal responsibility."
+ So I will have the choice of choosing between an unaffordable health insurance policy or none?
+ Accountability and personal responsibility only applies to the consumers of healthcare but not Rick Scott who just made " some mistakes in his life."

o "Most recently, Rick led the fight to defeat President Obama’s government-run public option. As the founder of Conservatives for Patients’ Rights (CPR), an advocacy group dedicated to the free market principles of choice, competition, accountability and personal responsibility in health care, he was instrumental in defeating the public option plan that would have led to socialized medicine."
+ Fear mongering and painting the government as the boogeyman trying to enslave citizens is a silly and dangerous tactic which just reveals that Rick Scott and friends have no other arguments to offer to resolve the critical problem facing us today and in the near future: how to provide affordable healthcare for an aging population suffering from chronic diseases that consume already 75% of all health care spending.
* On healthcare management experience:
o " I’ve made mistakes in my life...I learned very hard lessons from what happened and those lessons have helped me become a better businessman and leader."
+ That’s it! Mistakes imply taking personal responsibility and not blaming others (i.e. Columbia/HCA) for it. These are the lessons he brings to the table and those character traits make him the knight in shining armor for the FMA PAC?


So what can I say about the FMA PAC decision to endorse Rick Scott? A sad day for Florida's doctors. A sad day for medicine.

Yours

Bernd

Strange Bedfellows: The FMA and Rick Scott

According to a posting on the Florida Medical Association PAC web site ( see attached) the FMA PAC is endorsing endorsing Rick Scott's candidacy as Governor for our State of Florida!!???
Even though I already lowered my expectation regarding FMA's actions and politics I am still surprised that the leadership of such an organization is willing to sacrifice its principles on the altar of political correctness. Sadly, ideology trumped rational thought and consideration. Its hard to believe that the FMA political leadership has omitted considering the following facts in their deliberation process. These facts are available for anyone to read on multiple web sites and were summarized by the Miami Herald in an article published on June 11th, 2010 http://www.miamiherald.com/2010/06/11/v-print/1674327/was-candidate-involved-in-us-healthcare.html, entitled "Was candidate Rick Scott Involved in US Healthcare Scam."
In the article the author states that:

"Scott started what was first Columbia in the spring of 1987, purchasing two El Paso, Texas, hospitals. He quickly grew the company by purchasing more hospitals. A hospital network created efficiencies. Efficiencies created profits.

In 1994, Scott's Columbia purchased Tennessee-headquartered HCA and its 100 hospitals, and merged the companies. When Scott resigned as CEO in 1997, Columbia/HCA had grown to more than 340 hospitals, 135 surgery centers and 550 home health locations in 37 states and two foreign countries, Scott's campaign says. The company employed more than 285,000 people.

Now about Scott's departure in 1997. That year, federal agents went public with an investigation into the company, first seizing records from four El Paso-area hospitals and then expanding across the country. In time it became apparent that the investigation focused on whether Columbia/HCA bilked Medicare and Medicaid.

Scott resigned as CEO in July 1997, less than four months after the inquiry became public and before the depth of the investigation became clear. Company executives said that had Scott remained CEO, the entire chain could have been in jeopardy.

At issue, Scott says, is that he wanted to fight the federal government's accusations. The corporate board of the publicly traded company wanted to settle. And settle Columbia/HCA did.

In December 2000, the U.S. Justice Department announced what it called the largest government fraud settlement in U.S. history when Columbia/HCA agreed to pay $840 million in criminal fines and civil damages and penalties.

Among the revelations from the 2000 settlement, all of which apply to the time Scott was CEO:

• Columbia billed Medicare, Medicaid and other federal programs for tests that were not necessary or ordered by physicians.

• The company attached false diagnosis codes to patient records to increase reimbursement to the hospitals.

• The company illegally claimed nonreimbursable marketing and advertising costs as community education.

• Columbia billed the government for home health care visits for patients who did not qualify to receive them.

The government settled a second series of claims with Columbia/HCA in 2002 for an additional $881 million. The total fine: $1.7 billion."

Furthermore the article continues:

"As part of the 2000 settlement, Columbia/HCA agreed to plead guilty to at least 14 corporate felonies. A corporate felony comes with financial penalties but not jail time, since a corporation can't be sent to prison. Among the 14 felonies, Columbia/HCA pleaded guilty to three counts of conspiracy to defraud the United States.

Also, four Florida-based Columbia/HCA executives were indicted. Two were convicted of defrauding Medicare in 1999 and were sentenced to prison, only to have those convictions overturned on appeal. A third executive was acquitted. A jury failed to reach a verdict on the fourth.

Was Scott close to going to prison for his part in the case? It appears not at all.

The former CEO was never indicted and was never questioned in the case, he says. He may have been a target of the investigation -- an ABC News report from 1997 says he was -- but that never translated into charges."

Let's boil this down.

Was Scott running Columbia/HCA when it found itself at the center of a massive federal investigation? Yes.

Did the company pay a record $1.7 billion in government penalties and fines? Yes.

And as we checked in this item, did his former company commit fraud? Yes, it pleaded guilty to fraud charges as part of a settlement.

The million-dollar question is: How much of the blame ultimately falls on Scott? That's an answer we can't provide.

Scott was in charge, so he bears some responsibility and has said so. But there has yet to come to light any detail of how much he knew, and when he knew it. Though that won't keep us from looking.


What did Rick Scott had to say about all that? Either he pleaded the Fifth Amendment, or claims that he did not know what was going on in his own company. I ask myself just one question: How on earth can anyone entrust the keys to the Governors' office to Rick Scott?
Maybe we should admire the Chutzpah (audacity) of Rick Scott and those who endorse his candidacy?
Maybe its time that in light of these facts doctors should reconsider their support for the FMA's endorsement because this time their leadership went too far.

Yours
Bernd



Attachment: FMA PAC web site http://www.fmaonline.org/Layout_1Column.aspx?pageid=2580

FMA PAC – General Election Endorsements


Statewide Races

Governor – Rick Scott
Attorney General – Pam Bondi
Chief Financial Officer - Jeff Atwater
Commissioner of Agriculture - Adam Putnam

Prescription Drug Prices

In todays Miami Herald State Representative Juan C. Zapata calls for a mandated use of generic drugs for Medicaid and other state-funded programs http://www.miamiherald.com/2010/10/03/1854185/mandate-use-of-generic-drugs-for.html . He is correct saying that the use of generic drugs will slow down the predicted explosive growth of Medicaid expenditures but the mandated use of generic drugs addresses only ONE aspect of the problem. According to a New York Times article , Drug Makers Accused of Ignoring Price Law,” http://www.nytimes.com/2010/10/03/us/03drug.html , drug manufacturers consistently defy complying with a federal law that requires them to provide the government with pricing data needed to calculate discounts on medications prescribed for Medicaid recipients. More than three-fourths of drug manufacturers did not fully comply with the law requiring them to provide price data. They are supposed to file monthly and quarterly reports on what wholesalers paid them for drugs eventually sold to retail pharmacies. Without price data, the federal government cannot compute rebates, and states may be unable to collect them. As a condition of having their drugs covered by Medicaid, pharmaceutical companies must agree to provide discounts in the form of rebates. Drug companies pay the rebates to state Medicaid programs. The federal government and the states share the cost of Medicaid — roughly $400 billion in the last year — and share the savings that result from the rebates. Under the health care law, the minimum rebate on brand-name drugs dispensed to Medicaid recipients was increased to 23.1 percent of the average manufacturer price, from 15.1 percent. The minimum rebate on generic drugs was increased to 13 percent, from 11 percent. The Congressional Budget Office estimates that the changes could save the federal government more than $35 billion over 10 years. Major drug companies are already reporting adverse effects on their revenues. However, drug companies stand to gain many customers with the scheduled Medicaid expansion in 2014. What can be done to address this problem? Under federal law, the government can impose penalties of $10,000 a day on a drug manufacturer that fails to provide the information “on a timely basis. According to the Inspector General at the Department of Health and Human Services the federal government has had this authority since 1990 but has not used it! Why not? We must control and limit the rising healthcare costs and drug manufactures must understand that they can be either be part of the problem, or part of the solution. We also should lift the limitation on prescription drug re-importation and stop the unscrupulous use of antipsychotic drugs, which generate over $14 billion in revenue for drug manufacturers. Otherwise, we have no choice but to resort to rationing of healthcare services and prescription drugs.

Yours
Bernd

Medicare Fraud

So, it finally happened! Jay Weaver, the Miami Herald journalist who uncovered many Medicare fraud issues in South Florida, wrote another excellent article reporting that CMS is now being forced to revamp its payment policy. In his latest article http://www.miamiherald.com/2010/09/30/v-print/1849528/medicares-new-order-first-weigh.html he emphasizes that:

"An anti-fraud provision, tucked into the Small Business Lending Act that became law Monday, would force Medicare to end its 45-year-old policy of paying claims quickly without verifying them. The Centers for Medicare and Medicaid Services, which pays out $500 billion yearly for elderly and disabled Americans, would have to adopt new billing software with ``predictive modeling'' by next year. Such analytical technology enables the credit card industry to detect questionable bills for, say, a flat-screen TV purchased outside a cardholder's immediate area so that companies can notify the customer and stop payment if fraud is a factor.The cost of rolling out the new billing technology would reach an estimated $930 million over the next decade but it may reduce or prevent paying one of every $7 to fraudulent claimants.
Furthermore, the new Affordable Care Act includes tougher penalties for offenders, expanded administrative powers for Medicare and $350 million to combat healthcare corruption over the next decade."

Sen. George LeMieux, R-Florida, who sponsored the anti-fraud bill, said he has been frustrated watching Medicare continue to pay billions to dubious healthcare providers for unnecessary or bogus services. But Senator LeMieux supports the Republican Party platform to repeal the same Affordable Care Act which funds such anti-fraud activities! Does he really believe that the voters are that stupid, or short-term memory challenged, to forget his election antics?
Its time that politicians start collaborating and cooperating to solve the real problems we are facing and to focus on stopping the Medicare fraud gravy train.
But maybe I am too naive to believe that politicians are capable to act and behave rationally.

Yours
Bernd

Healthcare Reform

Several very important component of the federal healthcare reform package are going to go into effect tomorrow.
Therefore, we should review the facts (and not fiction) regarding those components which will protect our patients (i.e. our families) from insurance companies. I hope that physicians will finally embrace these reforms, too. There should be no reason to reject them!
I also recommend reading today's Miami Herald editorial supporting healthcare reform. I agree with the authors conclusion:

"But tweaking the law and trying to get rid of it altogether, as a lawsuit filed by Florida's attorney general and others aims to do, are two different things. The law is an investment in the health and future of the American people. It can be improved, but it should become a permanent feature of American society."


Read more: http://www.miamiherald.com/2010/09/22/v-print/1836040/healthcare-reform-should-be-here.html#ixzz10Jt5GrD4
Yours
Bernd

* Preventive services:
o Based on the theory that inexpensive preventive measures can reduce expensive hospital visits later, the reform act requires insurers to pay all costs for many immunization vaccines and screenings for colorectal cancer (for those over 50), depression, high blood pressure (for diabetics) and autism (for children 18 months to 24 months.)
o Also covered at 100 percent are mammograms for women over 40 and smoking cessation programs. For a full list of preventive services covered go to www.healthcare.gov/law/

* Adult children:
o All new private insurance that offers dependent coverage must allow parents to cover their children until age 26. They can live elsewhere and still be covered, and they must be charged at the policy's prevailing child rates.I
o If adult children can get insurance through their own jobs, they can't switch to their parents' existing job-based coverage if it's grandfathered. But if they don't have work coverage, they can move to parents' plans, even if the employers are planning to continue using their current plans.

* Right to appeal:
o Consumers covered under new, non-grandfathered insurance plans will have a right to appeal to an external party if, for example, their insurer denies coverage of treatments recommended by their doctors.
o Consumers will first have to file an internal appeal with the insurers. If not satisfied, they then can appeal to an impartial reviewer. Details of who will handle reviews and what regulations will apply are being worked out.

* No exclusions for children:
o In the past, insurers can -- and regularly did -- deny children with pre-existing conditions. As of Sept. 23, Thursday, they will be required to accept all kids, regardless of health status.
o This provision has led to spirited debate. Insurers' fear is that parents would wait until their kids got sick to buy coverage. `
o Insurers depend on providing coverage for a broad pool of people -- with the healthy majority paying premiums that fund the sick minority. Their fear with reform is that if only sick people sign up, insurers will lose huge amounts of money or need to raise premiums to horrendously high rates. Starting in 2014, that fear vanishes, because virtually everyone will be required then to have insurance.
o Health and Human Services recently responded to the insurers' fears about kid coverage, allowing insurers in the individual market to have an open enrollment period of, say, one month a year in which families could sign up children under 19 with pre-existing conditions. That means families will be encouraged to enroll healthy kids because they won't be able to automatically sign them up when they get sick.

* Lifetime caps removed:
o Many policies have limitations of $1 million, $2 million or even more. Most people never even have to think about them. But for those with severe chronic illness, their removal could mean a lot, possibly even preventing bankruptcy.

* High risk pools:
o For the truly desperate, the new high-risk pools can be a lifesaver -- but not a cheap one. They're intended for uninsured patients who have pre-existing conditions and can't get coverage elsewhere. They will serve as a bridge until 2014, when there are new government-regulated insurance exchanges accepting virtually everyone who can't get coverage elsewhere.
o Florida has had a high-risk pool for years, but because of the expense, it has been closed to new patients since 1991 and has only 250 members left.
o The Legislature opted not to re-open it in response to the reform act, meaning that the state's residents can sign up for a federally sponsored pool, known as the Pre-Existing Condition Insurance Plan.
o Under the plan, Florida residents will pay monthly rates ranging from $363 for those up to 34 and as much as $773 for those 55 and older, according to healthcare.gov . That's with a $2,500 deductible and maximum out-of-pocket of $5,950 a year. Those payments cover only part of their insurance costs. The feds have allocated $351 million to Florida to pick up the rest of the expenses till 2014. Critics fear that's not enough.
o The program is only for those who are legally in the United States, have been uninsured for at least six months and have been denied coverage because of a pre-existing condition. Applications are available at healthcare.gov or by calling (866) 717-5826.

* Limiting insurers' profits:
o Starting Jan. 1, insurers of large groups will be required to spend 85 percent of premiums on healthcare. For insurers of small groups and individual policies, it's 80 percent. In 2012, if insurers fail to meet these requirements, they must offer rebates to customers.
o Should money spent on converting to electronic records be counted as a medical expense or an administrative one? What about monitoring infectious disease rates in hospitals or money spent managing chronic conditions?
o The National Association of Insurance Commissioners has been working on draft guidelines. The U.S. Department of Health and Human Services says it has not yet received them.

* Other changes:

* About one million seniors have already received $250 rebate checks because of high prescription drug costs that were not covered by Medicare Part D.

* About 70 South Florida organizations -- including the Miami-Dade and Broward school systems -- will get funds to help pay for healthcare for retirees aged 55 to 64 who are not eligible for Medicare.

* Starting this year, businesses with no more than 25 workers with average annual wages under $50,000 can get tax credits of up to 35 percent of the costs of premiums.

For further information, healthcare.gov is the government site for the reform act. The Kaiser Family Foundation (kff.org), the Commonwealth Fund (commonwealthfund.org ) and Families USA (familiesusa.org) are three Washington nonprofits that provide details and analysis of the reform act.

Shifting Healthcare Costs

According to a recent editorial published in the New York Times (Shifting the Health Cost Burden, September, 2nd, 2010) "the latest annual survey of employer health benefits contains good news for the employers but bad news for their workers."
What are the good news? The average total premium for employer-sponsored health insurance (typically paid partly by employers and partly by their workers) rose only a modest 3 percent this year for family plans, reaching $13,770 in 2010.
What are the bad news? The employee share of their premium soared by 14% reaching almost $4,000, while the amount employers contributed did not increase.
Whats are the results?

* Employers shifted virtually all of the increased premium costs to their employees , who were in a weak position to resist in an economy where there were few other jobs to jump to.
* Since 2005, while wages have increased just 18 percent, workers’ contributions to premiums have jumped 47 percent, almost twice as fast as the rise in the policy’s overall cost.
* Meanwhile insurances are getting stingier and less comprehensive.
* Workers face higher deductibles, forcing them to pay a larger share of their overall medical bills. The Kaiser survey found a significant increase in the number of employees who had a deductible of at least $1,000, to 27 percent this year, from 22 percent in 2009. Almost half of workers who are covered by a small employer with fewer than 200 workers have an annual deductible of that amount.
* Increasing out-of-pocket expenses will almost certainly reduce the number of medical office visits, will force staff to collect deductibles at the point-of-care, or bill the patients and write off the increasing amount of unpaid bills. This will further decrease the margins in family medicine offices and force doctors to see more patients for less money!

What can we do? Facing very tight profit margins doctors must improve the efficiency of their offices, teach their staff to work as teams and advertise their medical services to those seeking cheaper medical services.
Instead of working harder we must work smarter. Yelling and screaming will not help us to move forward. We must learn to run our offices as small businesses and adapt quickly to the rapidly changing market place.

Yours
Bernd

FMA Off Base Fighting Reform

The recently published OpEd succinctly characterizes the Florida Medical Association's policy vis-a-vis healthcare reform.
The authors concluded that
"The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need. It is coming, and the FMA should get on board or out of the way."
In a NEJM (N Engl J Med 2009;360: 2495-2497) article Fisher et al clearly defines the positions we as physicians can take.
“ In the face of this uncertainty, physicians have a choice: to wait and see what happens or to lead the change our country needs. We'd prefer the latter....Physicians can become our most credible and effective leaders of progress toward a new world of coordinated, sensible, outcome-oriented care in which they and their communities will be far better off. Defending the status quo is a bankrupt plan, and physicians have an opportunity to help us all see beyond it."
I wholeheartedly agree with this conclusion.
Yours
Bernd


Guest column: Florida Medical Association is off base fighting reform

Source URL: http://jacksonville.com/opinion/letters-readers/2010-08-19/story/guest-column-florida-medical-association-base-fighting

At an Orlando meeting last week, Florida Medical Association members fumed that their parent, the American Medical Association, isn't adequately representing Florida's private practice doctors.

After talk of secession, they settled for writing a stern letter urging the AMA to straighten up.

The FMA dustup began with a resolution written by Douglas Stevens, a Fort Myers cosmetic surgeon - you can't make this stuff up - complaining that the AMA's support for recent reforms was "a severe intrusion in the patient-physician relationship and allows government control over essentially all aspects of medical care."

He wrote that it will "relegate physicians to the role of government employees ... and essentially end the profession of medicine as we know it."

A St. Petersburg neurological surgeon, David McKalip, added that without AMA support, reform would have died.

Well, no. Stevens might have had two reform provisions in mind.

One uses subsidies to encourage doctors to obtain electronic health record technologies, so patient information can be easily exchanged and unnecessary or redundant services can be reduced.

Some data would be submitted to a federal repository, so doctors can better understand how effectively they practice compared to their peers and how to improve if needed.

Of course, physicians opposed to these rules could opt to avoid patients whose care is paid for with public dollars. But we think most doctors will welcome the opportunity to modernize their care.

The second bone of contention was a well-intentioned but flawed 1997 Medicare formula, the Sustainable Growth Rate, which tied physician payments to the growth of the U.S. economy. If Medicare physician spending exceeded the target in one year, then payment the following year would be reduced.

But every year, Congress has delayed the payment reductions. Now, in 2010, the accumulated cuts would be 21.2 percent.

Congress is reluctant to spend the additional $200 billion to forgive the cuts. American specialists, who make triple the salaries of their primary care colleagues, are bound to see smaller Medicare checks.

In the past, we've had many differences with the AMA, which was often more focused on physicians and their economic prosperity than on patients and theirs, especially as health insurance costs relentlessly grew four times faster than the economy.

Through a specialist-dominated reimbursement advisory committee, the AMA urged Congress to pay specialists more at the expense of primary care physicians. So it is not far-fetched to lay much of the current health care cost crisis at the AMA's feet.

But recently, the AMA became more progressive. It mounted a three-year campaign for universal coverage. It supported government's efforts to reward the meaningful use of modern computerized tools and the best medical science in clinical practice.

They are incredibly important to us, but over the last half century, American physicians have been handsomely, even often excessively, rewarded.

But now, the system that has been hugely wasteful must find ways to reduce costs while improving quality, and make sure that care is accessible to everyone. These imperatives are emerging just as data and information tools are becoming more available. Health care will become more like a market than before.

Medical practice is changing profoundly, mostly for the better. Doctors will still be highly valued, but many may earn less.

The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need.

It is coming, and the FMA should get on board or out of the way.

Brian Klepper of Atlantic Beach and David Kibbe, a physician from Chapel Hill, N.C., write on health care policy, market dynamics and technology.

Medicare Conundrum

I highly recommend reading an article http://www.ama-assn.org/amednews/2010/08/16/gvl10816.htm published in AMA NEWS entitled, "Medicare trustees' upbeat outlook relies on big pay cuts for doctors, Aug. 16, 2010."
In the 2010 Medicare trustees report the trustees said Medicare savings that are included in the overhaul will extend the insolvency date of Medicare's hospital trust fund to 2029, 12 years beyond the point that last year's report said Part A would run out of money.Medicare Part B does not face insolvency because it is funded by a combination of general tax revenues and beneficiary premiums. Expenditures on outpatient care grew at an average annual rate of 8.3% during the past five years, exceeding gross domestic product growth by 4.2 percentage points annually, on average. Projected annual spending growth for Part B is estimated to average only 5.3% during the next five years, about the same as the GDP growth rate, the report said. But this assumes deep physician pay cuts will take effect. Unless Congress steps in, physician rates are scheduled to decline 23% on Dec. 1, an additional 6.5% in January 2011 and 2.9% in 2012.
Medicare Part B spending now approximates 1.5% of the GDP, the report said. Last year's report projected that figure would increase to 4.5% by the end of the trustees' 75-year projection. With the new law, it is now projected to reach only 2.5% of GDP by the end of the long-term window.Preventing rate cuts to doctors would increase that estimate, as would a failure to realize long-term savings envisioned under reform.
What does this mean for physicians?

* We need to focus on the implementation of new care models, such as patient-centered medical homes, accountable care organizations.
* We should expect and prepare for payment bundling and pay-for-performance.
* We should deploy and apply systems that help us to measure, optimize and improve productivity.

Unfortunately, many of us will prefer to resist and protest the inevitable change. In my opinion responsible physician leaders should prepare their membership for and guide them towards meeting the new challenges of a more complex healthcare delivery system by using finite (financial) resources.


Yours
Bernd

Impaired Physicians

In a recently published article " Physicians reluctant to report impaired colleagues, study says,"(amednews.com) the author summarizes the findings of a national survey of 2,000 physicians. The survey results were published in the July 14th edition of JAMA " Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues."
Unfortunately, the key findings are troubling:

* Just 64% of physicians completely agreed that they had an obligation to report all impaired or incompetent doctors. The rest of the physicians either "somewhat agreed" that they were obliged to report problem colleagues or disagreed that they had such a responsibility.
* The most common reason for not reporting incompetent or impaired colleagues was physicians "thought someone else was taking care of the problem," the study said. Some physicians said reporting would be fruitless, while 12% feared retribution.

Only 17% of respondents had direct knowledge of an impaired or incompetent physician. The question remains if this is due to ignorance or choice.
What can we do? Doctors need to be better educated on how to report problem colleagues and their ethical responsibility to do so. Those who do report should be kept in the loop on how a colleague's case is progressing, and that the reporting process should be confidential.
Looking forward to your comments.
Yours
Bernd

Barriers to Reporting:

Two-thirds of physicians with direct knowledge of an impaired or incompetent physician colleague reported them to a medical board, hospital, clinic, professional society or other body. Of doctors who didn't report:

19% thought someone else was taking care of the problem.

15% believed nothing would happen as a result of the report.

12% feared retribution.

10% believed it was not their responsibility.

9% believed the person would be excessively punished.

8% did not know how to report.

8% believed it easily could happen to them.

Note: respondents could answer "yes" to more than one reason.

Source: "Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues," Journal of the American Medical Association, July 14 (jama.ama-assn.org/cgi/content/abstract/304/2/187/)

Americans Cut Back in Visits To Doctors

Attached an article of concern published in the Wall Street Journal (July 29th, 2010) highlighting the fact that insured Americans are using fewer medical services. This may be a result of the increasing co-payments and deductibles which may force patients to see a doctor ONLY if it hurts and not for preventive medicine. Some speculate that we may face now a less "aggressive consumer of healthcare." The continued weak demand for healthcare services may slow the increasing healthcare costs and cut put pressure on health insurance companies to lower their premiums. I believe it when I see it!! Already, large insurance companies are reporting record profits. The top five earning insurance companies averaged profits of $12.2 billion, an increase of 4.4. billion, or 56% and so does the CEO compensation of those companies.

For family physicians the trend for less services may have significant adverse effects on the financial viability of their practices. Doctors visits have declined each month this year, including a 7.6% drop in May compared to May 2009! What can we do? Well, we need to trim as much as we can from our practice expenses. We also should make it more convenient and affordable for our patients to visit our offices. Early morning or late evening appointment, Saturday or Sundays, online consultation and discounted service packages for the uninsured. Patients will spend money for convenience and great customer service. . In the long term we have to abandon the fee-for-service system which forces us to see more patients for less.
Bundled payments may be an option too. Change is happening rapidly and quick adaptation and response to the changes guarantees survival. Its not too late!!
Yours
Bernd

Americans Cut Back On Visits To Doctor

By AVERY JOHNSON, JONATHAN D. ROCKOFF And ANNA WILDE MATHEWS

Insured Americans are using fewer medical services, raising questions about whether patients are consuming less health care as they pick up a greater share of the costs.

The drop in usage is showing up as health-care companies report financial results. Insurers, lab-testing companies, hospitals and doctor-billing concerns say that patient visits, drug prescriptions and procedures were down in the second quarter from year-ago levels

"People just aren't using health-care like they have," said Wayne DeVeydt, WellPoint Inc.'s chief financial officer, in an interview Wednesday. "Utilization is lower than we expected, and it's unusual."

Others say that consumers are beginning to forgo elective procedures like knee replacements. "We have a very weak economy and it's just a different environment for the elective parts of health care," said Paul Ginsburg, a health economist who runs the Center for Studying Health System Change and has been analyzing health-company earnings. But "this could go beyond the recession. Being a less aggressive consumer of health care is here to stay."

Continued weak demand could eventually put downward pressure on spiraling health-care costs, a long-sought goal of policy makers. It could also force insurers to lower premiums.

The new trend comes amid a broader drop in health-care use as more Americans lose their jobs and their health insurance. Such cutbacks have happened before in recessions, but the drop seems to be more pronounced this time, industry analysts say.

More Americans also are buying high-deductible health plans that force them to bear more of the upfront costs for health services. Some 18 million Americans bought high-deductible plans this year, compared with 13 million last year, according to Paul Mango, a director at consulting firm McKinsey & Co.

At the beginning of the year, Dan and Natalie Johnson, of Gig Harbor, Wash., used the website eHealthInsurance.com to buy a new plan with a high deductible, now set at $5,500 for their family. Their previous coverage had no deductible.

Now, the couple says they are thinking twice before scheduling doctor visits. Recently, when their 16-year-old daughter's allergy prescription ran out, Ms. Johnson called the allergist's office to ask for a renewal, without coming in for an appointment, as she would have done under their previous insurance.

And this spring, their son, 14, got his athletic physical at a local urgent-care clinic that charged just $40, instead of a doctor's office, which would have cost about $90. "We don't want to go through our savings going to the doctor," says Ms. Johnson, a photographer.

All this raises the question of whether, after a year of national attention on out-of-control health costs before the federal health overhaul passed in March, the trend portends a lasting change in the way Americans use the medical system.

Just a year ago, insurers reported surging health-care usage. Back then, more consumers were signing up for Cobra, the federal program that allows people who have lost their jobs to keep their insurance. The government had extended a subsidy to cover 65% of the cost of the coverage, which can be prohibitively expensive.

However, the Cobra subsidies only covered the unemployed for 15 months, and many people have hit the limit and dropped coverage. What's more, people who have lost their jobs since the end of May don't qualify for the Cobra subsidies.

To be sure, the change in behavior could be short-lived. On an earnings call last week in which it reported a decline in hospital usage, UnitedHealth Group Inc. said it thought utilization would rise again in the second part of the year, as Americans exhaust their deductibles and insurers start paying for services. Both Aetna Inc. and WellPoint said the utilization fall-off was new as of this year, and they had not seen the trend previously even as the economy has deteriorated. Some insurers also cited an unusually mild flu season this year as a temporary factor.

What's more, the federal health overhaul could cause usage to surge again. The new law will hand insurance cards to many Americans in 2014, which could unleash pent-up demand.

Utilization has ticked down in previous recessions, and tends to take a year or two to change because of how far in advance employers and insurers design their health plans, said Carl McDonald, an analyst at Citigroup Investment Research. He said the last time he saw utilization fall off was in 2003, adding that usage also dipped in the early 1990s. But he added the drop is bigger this time than in previous recessions.

The declines in utilization has boosted profits for insurers, who set their prices to cover anticipated medical costs. Insurance industry prices and profits have been under fire by Democrats and regulators this year. Insurers have justified high premiums by pointing to out-of-control medical costs. But the recent drop in usage could make it difficult for insurers to argue that continued price increases are necessary.

On Wednesday, Aetna said usage of health-care fell in the second quarter, feeding a 42% increase in profits. WellPoint reported a 4% earnings bump, saying that hospital admissions and usage of prescription drugs had dropped compared with a year earlier.

After the earnings releases, Rep. Pete Stark (D., Calif.) called on the companies to reduce their premiums since they are paying out less in medical care. In an interview, Aetna's chief financial officer Joseph Zubretsky said companies might eventually have to do just that. "If utilization stays down, it will have a favorable impact on rates," he said.

One company reporting evidence of lower utilization is CVS Caremark Corp., the drugstore giant. In its earnings announcement Wednesday it said it is seeing a drop-off in new prescriptions for maintenance drugs tied to a decline in physician visits.

People are "visiting fewer primary care doctors and specialists," said Chief Executive Tom Ryan, in a conference call with analysts.

Last week, Quest Diagnostics Inc., a laboratory-testing company, told investors that its volume fell 2.6% in the first quarter and 1.3% in the second partly because of decreasing physician visits. In addition, AmSurg Corp., an outpatient-surgery company, reported that same-store procedures declined by 2.6% compared to a year earlier.

Another sign that people are forgoing doctor visits or getting less care came from athenahealth Inc., which provides billing services and electronic health records for more than 1,700 medical groups. It said last week that the number of claims filed per physician, as well as the average value of the billing for each visit, had dropped from a year earlier.

Physician visits and hospital admissions are dropping this year, according to Thomson Reuters's healthcare business, which surveys doctors and hospitals. Doctor visits have declined each month this year, including a 7.6% drop in May from May 2009. Likewise, hospital admissions dropped in three of the first four months of this year compared to those months last year, including being down 2.3% in April from April 2009.

Pharmacists and the Patient Centered Medical Home

Attached an Op-Ed published in today's Wall Street Journal in which Pete Vanderveen, dean at the School of Pharmacy at the University of Southern California, emphasizes the role of pharmacists in chronic disease management to "alleviate the burden on physician," and to "fill the gap" in patient care. Furthermore, he calls for the change in reimbursement modalities to " allow pharmacists to play a larger role in patient care" admitting that it will initially increase medical costs.
I am not opposed to collaborate my patients care with pharmacists but we are missing the point.
By including additional providers in the health care delivery process we may inadvertently contribute to greater fragmentation and costs of care because we fail to coordinate such care. We may share the e-prescribing system with the pharmacists but not the entire medical record. We have to continue emphasizing that the patient centered medical home is not a loose collaborative of multiple provider. All health care professionals withing the PCMH will coordinate health care delivery along the horizontally and vertically structured health care delivery system to achieve, among others , the following goals: improved quality of care, decreased medical costs of care and to ascertain the outcome of care rendered.
Therefore, I do NOT agree with the position stated in the Op-Ed.
Looking forward to your comments.
Yours
Bernd

• OPINION
• JULY 19, 2010

How to Care for 30 Million More Patients

Pharmacists can help fill the gap and save money, too.

By R. PETE VANDERVEEN

Many worry there won't be enough physicians to care for the estimated 30 million more patients who will be insured under the health law passed earlier this year. The Association of American Medical Colleges estimates a shortage that could reach 150,000 doctors by 2025.

Pharmacists, who number almost 300,000 today, could help fill the gap. The men and women who complete a four-year graduate professional program are trained to master complex medications—including more than 10,000 prescription drugs and dozens of new, more sophisticated ones approved annually by the Food and Drug Administration.

For patients with chronic diseases such as diabetes, hypertension and asthma who typically must take multiple drugs, pharmacists' knowledge of drug interactions can be life-saving. Yet pharmacists typically do little to help these patients. If they were allowed to take on some oversight duties, they could help alleviate the burden on physicians.

Pharmacists could review test results such as the blood glucose levels of patients with diabetes. They could adjust the dosage of prescribed drugs to achieve the goals for these patients set by physicians. They could keep an eye on patient use of other medications to avoid complications. And they could teach patients how to conduct self-administered tests, order lab tests when indicated, and monitor compliance with medication, diet and exercise regimens.

Considering that 40% of Americans have at least one chronic disease during their lifetime that requires regular oversight, the time savings for physicians could be substantial. And so might the costs of care.

This is not an untested theory. Pharmacists already manage some patients with chronic diseases. In 1996, the city of Asheville, N.C., a self-insured employer, began paying pharmacists to work with its diabetic employees. Known as the Asheville Project, the goal was to improve worker health and lower treatment costs for both employee and employer.

The results exceeded expectations. From 1997 to 2001, the city of Asheville reported that annual direct medical costs per worker dropped, on average, by $1,200 to $1,872—even as 15% more enrollees came within reach of their therapeutic goal.

The project has since been expanded to cover other chronic diseases, and Asheville estimates it has saved $4 for every $1 invested. Some 80 employers nationwide have adopted the treatment model, including Mohawk Industries, the national carpet manufacturer in Dublin, Ga.

At safety-net clinics in Los Angeles, Minneapolis and Pittsburgh, pharmacists have teamed with physicians to care for patients with chronic diseases while saving hundreds of thousands of dollars in treatment costs. This is remarkable because many of these patients struggle with homelessness, low literacy and unemployment. Now the federal Health Resources and Services Administration's Patient Safety and Clinical Pharmacy Collaborative is pushing for the presence of pharmacists at every community clinic in the nation.

Still, these projects are limited in scope because pharmacists are not considered health-care providers by Medicare and Medicaid. Private foundations or grants underwrite services at some safety-net clinics, while other clinics pick up the tab.

The next, critical step is to change the reimbursement codes of the Center for Medicaid and Medicare Services to allow pharmacists to play a larger role in patient care. Doing so may initially increase overall medical costs. But in the long run, as the Asheville Project demonstrates, it will save money and improve patient health.

Pharmacists are not spoiling for a turf war with physicians. The two professions already team up under "collaborative practice" agreements as in Asheville and Los Angeles that clearly define what the pharmacist can and cannot do.

The traditional medical model—in which a single physician provides all recommended care to patients—has run its course. With an aging population and millions of expected new patients, chronic disease rates are expected to rise. What we need is a new health-care delivery model in which the primary-care physician is complemented by a team of professionals and providers. Congress should enable pharmacists to become part of that team.

Mr. Vanderveen is the dean of the School of Pharmacy at the University of Southern California.

Medicare Fraud in the News Again

"In 2008, Medicare paid $520 million to Miami-Dade home healthcare agencies for treating diabetic patients
more than what the agency spent in the rest of the country combined, according to federal authorities."

Attached an article from today's Miami Herald highlighting the growing problem of Medicare fraud in South Florida and the efforts to contain its metastatic growth.
I still am puzzled WHY CMS cannot hold the contracted Medicare administrators in Florida accountable for their mistakes amounting to billions of dollars each and every year.
Its either a problem of political unwillingness to tighten the screws, or professional incompetency and absence of any oversight and control mechanisms.
Meanwhile, fraudsters getting away with hundreds of millions per incident and good physicians who are trying to serve Medicare patients are being nickled and dimed by CMS.
But our politicians do not have to worry to find a doctor who still takes new Medicare patients. They go to Walter Reed Medical Center to enjoy the benefits of a government controlled healthcare system. Go figure!!
Yours
Bernd





Posted on Wed, Jul. 14, 2010
Magnitude of Medicare fraud in South Florida grows

BY JAY WEAVER
jweaver@MiamiHerald.com

As the feds squeeze tighter, South Florida's Medicare schemers have scurried into new territory to loot hundreds of millions of dollars from taxpayers, now billing the system for bogus mental health, physical therapy and other rehabilitation services.
The magnitude of the region's fraud is astonishing: Florida mental health clinics submitted $421 million in bills to Medicare last year -- about four times more than Texas and a whopping 635 times higher than Michigan, both also hotbeds of healthcare rackets, according to government records.

Florida rehabilitation facilities billed $310 million for physical and speech therapy -- 140 times more than New York and 10 times higher than California, records show.

Not all of that activity is criminal. But Florida's numbers are so much higher than other major states' that officials say the only logical explanation is fraud -- the bulk of it in Miami-Dade, Broward and Palm Beach counties.

Law enforcement and healthcare officials say that mental health and rehabilitation providers are the latest agents of pervasive theft in South Florida, long considered the nation's epicenter of Medicare corruption. The services are not needed or provided, yet the federal program for the elderly and disabled still foots the bill.

``This is like a game of whack a mole,'' U.S. Attorney Wifredo Ferrer told The Miami Herald. ``The numbers are off the charts.''

The vexing problem of Medicare corruption will take center stage on Friday, when Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius hold the nation's first healthcare fraud summit in Miami. The issue has gained a higher profile as the Obama administration pushes ahead with the expansion of government-subsidized healthcare for more than 30 million uninsured Americans.

FBI supervisory special agent Randy Culp, who joined the nation's first Medicare strike force in South Florida in March 2007, said the majority of fraud prosecutions still involve medical equipment such as powered wheelchairs, HIV medical services and home healthcare for diabetics.

But federal agents now are investigating more physical and occupational therapy schemes and looking at potential criminal cases against mental health centers, he said.

``We're seeing a shift of people moving into these areas,'' Culp said.

He and other experts said the transition occurred over the past year when Medicare imposed unprecedented caps on claims submitted by healthcare agencies for homebound patients seeking up to four daily nursing visits for insulin injections.

In 2008, Medicare paid $520 million to Miami-Dade home healthcare agencies for treating diabetic patients -- more than what the agency spent in the rest of the country combined, according to federal authorities.

``After we put pressure on them, they started moving their activities into other areas such as mental health and rehabilitation facilities,'' said Cecilia Franco, director of Medicare in South Florida. ``We see them move year after year from one business to another. Their patients' Medicare numbers carry great value, and they're always coming up with new ways to bill for them.''

Last year, for example, Florida's comprehensive rehabilitation facilities billed $171 million for physical, occupational and related services -- about 23 times higher than California and 26 times more than New York, records show.

Overall, Medicare fraud in South Florida costs taxpayers between $3 billion and $4 billion annually, according to experts. Nationwide, Medicare and other healthcare fraud is estimated to cost $68 billion annually -- about $18 billion more than the Obama administration plans to spend on education in the next fiscal year.

``The government has to stop pretending these are legitimate businesses and cut them off,'' said Washington attorney Kirk Ogrosky, former head of the Justice Department's healthcare fraud section, who oversaw hundreds of criminal prosecutions.

Last year, the Justice and Health and Human Services departments expanded criminal ``strike forces'' from Miami, Los Angeles and Houston to Detroit, Brooklyn, Baton Rouge and Tampa. They also committed about half a billion dollars to fraud-prevention efforts, and began working on sharing suspicious billing information with Medicare -- an agency that pays claims fast without verifying them -- to help stop fraud.

The fight to stamp it out is a constant struggle, despite convictions of about 1,000 defendants in South Florida alone who submitted roughly $3 billion in false Medicare claims since 2005. The region accounts for one-third of all healthcare fraud prosecutions in the nation.

During the past five years, thousands of Medicare fraud offenders have shown that they can outsmart the system. Their weapons: cash kickbacks to Medicare patients, repeated use of their ID numbers for unnecessary costly services, manipulation of medical records to justify phony charges, and submitting different billing codes to get around Medicare's technology to block false claims.

Authorities say the rising wave of Medicare fraud over the past decade is the result of more immigrants from Cuba and elsewhere switching from violent to white-collar crime, partly because the risks of getting caught and concurrent penalties are relatively low.

In South Florida, authorities have made a handful of major criminal cases against rehabilitation clinics.

In December, Dr. Fred E. Dweck of Hollywood, director of a Miami healthcare clinic, Courtesy Medical Group, was arrested along with 14 others, including nurses, operators and a patient.

Dweck, 74, was charged with accepting bribes to write prescriptions at $100 a pop for about 1,300 homebound patients at Courtesy and other local clinics. But the patients didn't need the prescribed diabetic, physical therapy and other costly services billed to Medicare,according to a federal indictment.

The Medicare bill from Courtesy and the other clinics: almost $41 million between 2006 and 2009. The government paid out nearly $24 million.

In April, a longtime Miami-Dade healthcare operator and his son, along with a business partner, were charged with bilking more than $2.8 million from Medicare in an undercover FBI case. Ernesto Angel Montaner, 69, and his son, Ernesto Montaner, 44, were accused of operating a chain of physical rehabilitation clinics in Miami-Dade that submitted millions of dollars in phony Medicare bills between 2003 and 2008.

Kickbacks were paid to assisted living facilities and others for Medicare referrals,prosecutor Ryan Stumphauzer said.

Ernesto Angel Montaner fled to Costa Rica in February 2009, five months after the FBI executed a search warrant at his four medical clinics, prosecutors said. He was arrested last week.

The son, Ernesto Montaner, and business partner Jose Antonio Varona, have pleaded guilty to one count of conspiring to commit healthcare fraud.

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.