"True, the Board should move with care and caution before taking away a doctor's primary means of support. However, the Board also must consider the risk to consumers, whose health and very existence could be at stake. If there is doubt, deference should be made to safeguarding the life and limb of patients......
.....The Board's mission is to protect consumers by licensing and regulating doctors and other healthcare providers. This means putting consumers first, not doctors.
Dear Friend and Colleagues:
Attached a Miami Herald editorial regarding a Miami doctor whose legal trouble received wide exposure in the local media.
I personally know the doctor and deeply regret his professional trouble and struggle. I am also a volunteer expert witness for the Florida Department of Health, have attended Board meetings and have no doubt that each and every Board member diligently considers the merits of each and every case that is being presented for review.
The Boards mission is to " protect health care consumers by licensing qualified health providers ..[and] .. establishing and enforcing health care standards.."
Doing so the Board often has to navigate the narrow course between Scylla (the physicians right to privacy and guarantee of due process ) and Charybdis ( the consumers protection).
In this process the Board is often accused to be either too hard or too soft on doctors. I can empathize with Board members who feel that that they are damned if they do, damned if they don't.
We need to support the efforts of the Board by being proactive in regulating OURSELVES and not to ignore or tolerate the wrongdoing of a FEW doctors. We should not shy away from either talking to those doctors or utilizing the established channels of notifying the Board of any behavior that violate the high health standards in our community.
I would prefer proactive self-regulation to legal actions imposed on our profession by third parties.
The choice is ours and the reported case in question could have been addressed and resolved before hitting the headlines of a local news paper.
Lets remember that each of us or our family members are healthcare consumers too and may have been or will be harmed by actions or inactions of a fellow doctor who does not abide to the same health care standards that we do. Would we keep our mouth shut? I don't think so. Therefore we should learn from this tragic case in question and draw our own conclusions on how to act in the future.
Yours
Bernd
Posted on Fri, Mar. 21, 2008
Troubled doctor puts patients at risk
It is hard to understand why Miami doctor Alex Zakharia, after facing a string of legal and professional setbacks, still has approval from the state of Florida to practice medicine. Dr. Zakharia, 70, has admitted to suffering memory problems and possible strokes. He has pleaded guilty to lying about his credentials as a heart surgeon and was suspended by a Miami hospital after several of his patients died.
Yet the state Board of Medicine says Dr. Zakharia's license is still good and lists his status as ''clear/active'' on its website.
Dr. Zakharia's travails have been chronicled in news stories for more than a year, and the Board is expected to issue a final order on his status next month. Still, the Board's handling of the case raises the question of whose interest takes precedence, a troubled doctor's or the well-being of unsuspecting healthcare consumers.
When asked about Dr. Zakharia's well-documented troubles, Department of Health spokeswoman Eulinda Jackson told Miami Herald reporter John Dorschner that the Board must follow due process. ''That's the way it works, and for good reason,'' she said.
True, the Board should move with care and caution before taking away a doctor's primary means of support. However, the Board also must consider the risk to consumers, whose health and very existence could be at stake. If there is doubt, deference should be made to safeguarding the life and limb of patients.
In this case, the Board had every reason to be aware of Zakharia's troubles, including his legal problems, and could have issued an emergency suspension. A nurse who worked with the doctor said she complained and sent copies of Miami Herald stories about the doctor's problem to the Board.
Regulating doctors
Florida voters wanted to make sure patients' rights are protected when they passed a constitutional amendment in 2004 that allows disclosure to patients about ''adverse medical events'' in hospitals. The amendment had been tied up in court since passage, but the Florida Supreme Court recently settled matters by affirming that patients have a right to know about mistakes made by doctors and hospitals.
The Board's mission is to protect consumers by licensing and regulating doctors and other healthcare providers. This means putting consumers first, not doctors.
Monday, March 24, 2008
Thursday, March 20, 2008
Florida Plans To Restrict Access For IMGs from Cuba
Dear Friends and Colleagues;
Again, Florida is leading the field in "innovative thinking" regarding International Medical Graduates (IMGs) .
This time a lawmaker introduced a bill that wouldn't allow Americans who get their medical degree in Cuba to practice medicine in Florida The bill is aimed at students who accept scholarships from the Cuban government to attend the Latin American School of Medical Sciences in Havana. About 150 American students are currently enrolled in the school and would be affected, according to information provided to the committee by the bill sponsor, Rep. Eddy Gonzalez, R-Hialeah.
Obviously, this bill is based purely on ideological grounds and should be rejected. What's next? Physicians who study abroad at "Muslim schools" or obtained a medical degree from those countries belonging to the "axis of evil."
I call upon the AAFP and AMA to oppose such an action.
Yours
Bernd
Chair, Florida Medical Association IMG Section & Past Chair of the AMA IMG Governing Council
Posted on Tue, Mar. 18, 2008
Bill would make Cuban medical degree worthless
ASSOCIATED PRESS
Americans who get their medical degree in Cuba wouldn't be allowed to practice medicine in Florida under a bill discussed by the House Health Quality Committee.
The panel didn't vote on the bill (HB 685) but could as early as next week.
The measure is aimed at students who accept scholarships from the Cuban government to attend the Latin American School of Medical Sciences in Havana. About 150 American students are currently enrolled in the school and would be affected, according to information provided to the committee by the bill sponsor, Rep. Eddy Gonzalez, R-Hialeah.
According to the information provided by Gonzalez, eight American students have graduated from the school and are currently practicing in the United States, but none are working in Florida. Since no graduates of the program have Florida medical licenses, the bill would only affect those graduates who try to become licensed here in the future.
The scholarship program, coordinated by an organization called the Interreligious Foundation for Community Organization, takes advantage of an exception in the U.S. embargo of Cuba for educational programs. The scholarships are open to Americans who go to Cuba for a 6-year medical school program and then agree to return to the United States to practice medicine in poor or underserved communities in the United States.
If the measure were to pass, Florida would be the first U.S. state to bar graduates of the program from practicing medicine here.
Again, Florida is leading the field in "innovative thinking" regarding International Medical Graduates (IMGs) .
This time a lawmaker introduced a bill that wouldn't allow Americans who get their medical degree in Cuba to practice medicine in Florida The bill is aimed at students who accept scholarships from the Cuban government to attend the Latin American School of Medical Sciences in Havana. About 150 American students are currently enrolled in the school and would be affected, according to information provided to the committee by the bill sponsor, Rep. Eddy Gonzalez, R-Hialeah.
Obviously, this bill is based purely on ideological grounds and should be rejected. What's next? Physicians who study abroad at "Muslim schools" or obtained a medical degree from those countries belonging to the "axis of evil."
I call upon the AAFP and AMA to oppose such an action.
Yours
Bernd
Chair, Florida Medical Association IMG Section & Past Chair of the AMA IMG Governing Council
Posted on Tue, Mar. 18, 2008
Bill would make Cuban medical degree worthless
ASSOCIATED PRESS
Americans who get their medical degree in Cuba wouldn't be allowed to practice medicine in Florida under a bill discussed by the House Health Quality Committee.
The panel didn't vote on the bill (HB 685) but could as early as next week.
The measure is aimed at students who accept scholarships from the Cuban government to attend the Latin American School of Medical Sciences in Havana. About 150 American students are currently enrolled in the school and would be affected, according to information provided to the committee by the bill sponsor, Rep. Eddy Gonzalez, R-Hialeah.
According to the information provided by Gonzalez, eight American students have graduated from the school and are currently practicing in the United States, but none are working in Florida. Since no graduates of the program have Florida medical licenses, the bill would only affect those graduates who try to become licensed here in the future.
The scholarship program, coordinated by an organization called the Interreligious Foundation for Community Organization, takes advantage of an exception in the U.S. embargo of Cuba for educational programs. The scholarships are open to Americans who go to Cuba for a 6-year medical school program and then agree to return to the United States to practice medicine in poor or underserved communities in the United States.
If the measure were to pass, Florida would be the first U.S. state to bar graduates of the program from practicing medicine here.
Medical Students Vote With Their Feet
"Although there are far fewer positions in dermatology (320 residencies in 2007) than in internal medicine (5,517) and family medicine (2,603), the field is attracting some of the best and brightest future doctors. Seniors accepted in 2007 as residents in dermatology and two other appearance-related fields — plastic surgery and otolaryngology (ear, nose and throat doctors, some of whom perform facial cosmetic surgery) — had the highest median medical-board scores and the highest percentage of members in the medical honor society among 18 specialties, the report said."
Dear Friends and Colleagues:
Attached an article from todays New York Times reporting about the preference of US medical students to seek out postgraduate training positions in lucrative specialties such as dermatology, ENT and plastic surgery.
I am not opposed to medical students choosing training positions in such specialties. What concerns me that the brightest minds seem to avoid primary care residency training positions which present complex challenges ( example: chronic disease management) that require input of the best and brightest in our profession.
Can we blame them to choose otherwise?According to the NEJM the prevalence of chronic conditions — most of which are handled in primary care settings — is increasing, as are requirements for their proper management. Not only has the number of primary care tasks grown exponentially, but physician performance is being measured and physicians are even being paid according to their ability to perform these tasks reliably and consistently. It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventive care, to an average panel of 2500 patients (the mean U.S. panel size is 2300)! A seemingly unsurmountable task that requires complex information management systems and the sophisticated staff to implement them. Such primary care experts should be reimbursement properly but they are not!
Our reimbursement system is tilted towards non-primary care specialties.Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression. The median income of specialists in 2004 was almost twice that of primary care physicians, a gap that is widening. In 2004 all visits to primary care physicians (FP,IM, Peds) accounted for almost half of the overall total of 967.3 million office visits but only 30 percent of the $152 billion spent on office-based care. The remaining 70 percent was spent on specialty care. This misalignment of reimbursement causes a shortage in primary care physicians and subsequently creating a population of medically disenfranchised individuals who lack access to medical homes. Fair reimbursement is the first step towards stopping the bleeding of primary care health care services.
Bernd
PS: Happy Purim holiday.
==============================================================================================================
New York Times - March 19, 2008
The Price of Beauty
For Top Medical Students, an Attractive Field
By NATASHA SINGER
BOSTON — March Madness has a different meaning for Thomas Hocker and Meena Singh, a married couple in their final year at the Harvard Medical School, who are waiting to learn Thursday if they have been accepted into their residency programs of choice.
Already saddled with about $330,000 in education loans, they borrowed $20,000 more so they could fly around the country this winter for about two dozen residency interviews each. All told, each applied to 90 such training programs.
Ms. Singh, pregnant during interview season, gave birth to their second daughter in early January. Three days later, she flew to Miami for an interview.
The search has been difficult not because they are mediocre students; indeed, each has a brand-name education, academic honors and published research on disease. No, it has been hard because they aspire to be dermatologists.
As thousands of medical students await word this week on residency programs, two specialties concerned with physical appearance — dermatology and plastic surgery — are among the most competitive.
Only 61 percent of seniors at American medical schools whose first choice was dermatology received a residency in that field last year, compared with 98 percent for those whose first choice was internal medicine and 99 percent for those seeking family medicine, according to a report by the Association of American Medical Colleges and the National Resident Matching Program, which pairs candidates and programs. Although there are far fewer positions in dermatology (320 residencies in 2007) than in internal medicine (5,517) and family medicine (2,603), the field is attracting some of the best and brightest future doctors.
Seniors accepted in 2007 as residents in dermatology and two other appearance-related fields — plastic surgery and otolaryngology (ear, nose and throat doctors, some of whom perform facial cosmetic surgery) — had the highest median medical-board scores and the highest percentage of members in the medical honor society among 18 specialties, the report said.
The vogue for such specialties is part of a migration of a top tier of American medical students from branches of health care that manage major diseases toward specialties that improve the life of patients — and the lives of physicians, with better pay, more autonomy and more-controllable hours.
“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary.
Medical school professors and administrators say such discrepancies are dissuading some top students at American medical schools from entering fields, like family medicine, that manage the most prevalent serious illnesses. They are being replaced in part by graduates of foreign medical schools, some of whom return to their home countries to practice.
“We have a shortage in America of primary-care or family-type doctors,” said Dr. Joel M. Felner, a cardiology professor who is the associate dean for clinical education at Emory University School of Medicine in Atlanta. Last year, the school enlarged its incoming class, hoping more students would specialize in the major diseases and preventative care, he said. “We do need dermatologists, but I am more worried about the really sick people and dermatologists aren’t taking care of them,” Dr. Felner said.
Until recently, saving skin did not have the cachet of saving lives. Doctors in other fields jokingly dismissed dermatology as a province of red-spot diseases that could not really be cured, but weren’t going to kill patients. Twenty-five years ago, the fiercest competition among medical students was for internal medicine and general surgery.
But dermatology’s status is rising, not just for the pay, hours and independence, but also because of the growing variety of treatments and devices in this fast-developing field that can help people in a looks-obsessed world. At a time of increased discussion of enhancing beauty, as well as narrowing standards for skin perfection, the public has a newfound esteem for doctors who treat appearance.
“People greatly value the skin because it is what is on the outside that is the face you present to the world,” Mr. Hocker said one evening last month after coming off a hospital shift in which he dealt with afflictions like heart failure and kidney failure. “Most dermatological diseases won’t kill you, but they can greatly affect your quality of life.”
Some dermatology professors said the growing allure of their field among medical students has raised the bar for applicants over the last decade. “Dermatology has always attracted bright students,” said Dr. Harley A. Haynes, a dermatology professor at the Harvard Medical School who has been mentoring medical students there since 1970. “But now we are getting more of the brightest and the best.”
Dr. Haynes likes to joke that even faculty members might not be accepted for a residency if they applied today.
A Psychological Lifeline
For an idea of the competition facing dermatology aspirants, consider the application numbers. Last fall, 383 people applied for 6 places — an average of about 64 applicants per spot — in Harvard’s dermatology program. By comparison, Harvard College received an average of 11 applications per offer of admission in the class of 2010.
Mr. Hocker and Ms. Singh were well prepared for the Darwinian process of landing a dermatology residency when they met as classmates at the Harvard Medical School in 2003. Mr. Hocker, 27, holds a graduate degree from Cambridge University and an undergraduate degree in chemistry from Yale, where he was a champion hurdler. Ms. Singh, 26, was in several honor societies as a biomedical engineering student at the University of Southern California.
During her senior year, she competed on an MTV reality show called “Sorority Life,” but was ejected midseason for being too studious.
“In one scene, you see her all happy getting the acceptance letter from Harvard and in the next scene, you see her crying up a storm because she has been de-pledged from the sorority,” Mr. Hocker recalled fondly.
Neither student had planned to become a skin specialist.
Growing up in Kansas City, Kan., Ms. Singh loved visiting the hospital with her mother, an internist with long relationships with a diverse group of patients. Ms. Singh said she initially planned to emulate her mother, a physician who focuses on treating major adult diseases.
A lecture on skin-pigment conditions like vitiligo changed her mind.
“Nobody can see if you have hypertension or asthma, but everybody knows if you have a pigmentary disorder and these changes are a lot more obvious and devastating to patients with skin of color,” Ms. Singh said. “Having something on your skin is not life or death for people, but it can be equally important for them emotionally as a life-threatening disease.”
Indeed, dermatology can be a psychological lifeline for people with severe skin problems. At pools or the beach, some people shun those with psoriasis who have scaly skin, fearing the condition is contagious, doctors said. People with deep acne scars say it affects their personal and professional lives.
Then there is the growing popularity among otherwise healthy people of tweaking one’s appearance with cosmetic treatments, from Botox injections to lip plumping and laser hair removal. Plastic surgeons, dermatologists and facial surgeons in the United States performed about 9.6 million such nonsurgical treatments in 2007, almost nine times the number a decade earlier, according to the American Society for Aesthetic Plastic Surgery.
‘Your Input Is Valued’
Mr. Hocker was finally sold on dermatology last year, while on a clinical rotation during which neurosurgeons called him and a dermatology resident to an intensive-care ward for a consultation. A patient, in a coma after surgery, was covered with mysterious red half-moon-shaped blisters. They could not determine the cause. Then Dr. Haynes of Harvard arrived.
“Dr. Haynes comes in and he is like a walking CAT scan, who eyeballs her from head to toe and has the diagnosis in 15 seconds,” Mr. Hocker said. The verdict: a rare blistering disorder caused by an allergy to an antibiotic.
Mr. Hocker said he liked the idea of drawing independent conclusions without tests or consultations with other doctors.
“The No. 1 thing that is going to save your life is the humdrum preventative stuff like blood pressure and cholesterol,” Mr. Hocker said. “But there is not a lot of respect for doctors who do that because anyone can get into it. But if you are an expert where no one else is, like the eye or the skin, your input is valued.”
Dermatology also attracts students like Mr. Hocker because of the potential for basic research on skin diseases that can lead to new treatments. Mr. Hocker said he plans to focus his career on researching the role of genetics in problems like skin cancer and abnormal scarring; he took a year off during medical school to conduct melanoma research.
While students like Mr. Hocker choose dermatology planning on research careers, others end up focusing on cosmetic treatments like skin tightening and resurfacing. Half of the dermatology residents graduating over the last five years from the program at the Boston Medical Center have chosen postgraduate fellowships that teach a combination of skin-cancer operations and cosmetic procedures, according to Dr. Barbara A. Gilchrest, the chairwoman of dermatology at Boston University School of Medicine.
Work Less, Earn More
Dermatologists say they enjoy the variety of a specialty that encompasses serious illnesses like skin cancer and psoriasis as well as conditions like uncombable hair syndrome.
But students interested in such work also often factor in personal benefits. Internists, for example, worked an average of 50 hours a week in 2006 while dermatologists worked about 40 hours, according to an annual survey by Medical Economics magazine. Dermatology also offers more independence from the bureaucracy of managed care, because patients pay up front for cosmetic procedures not covered by health insurance.
And while an internist earns an average of $191,525, a dermatologist earns an average of $390,274, according to an annual survey conducted by the Medical Group Management Association, whose membership includes more than 21,000 managers of medical practices. Dermatologists who specialize in cosmetic treatments or in skin-cancer operations can earn much more.
For thousands of medical students nationwide, especially those trying to enter the most competitive fields, this week — when residency acceptances are announced — has been fraught with tension. The National Resident Matching Program uses an algorithm to pair applicants with the one program they have ranked highest that also preferred them, a system that leaves some applicants disappointed.
Mr. Hocker and Ms. Singh face even longer odds because they entered the match process as a couple, seeking positions at the same program, or at least in the same region.
On Monday, when applicants learned whether they had been paired with a program at all, Mr. Hocker and Ms. Singh found out they will each obtain a residency. Thursday, they find out where.
“My friends going into general medicine and general surgery pretty much have an idea that they are going to be at their No. 1 or No. 2 school,” Ms. Singh said. “But we really could be anywhere in the country, together or not together.”
She added: “We would have a better chance of winning ‘American Idol.’ ”
Dear Friends and Colleagues:
Attached an article from todays New York Times reporting about the preference of US medical students to seek out postgraduate training positions in lucrative specialties such as dermatology, ENT and plastic surgery.
I am not opposed to medical students choosing training positions in such specialties. What concerns me that the brightest minds seem to avoid primary care residency training positions which present complex challenges ( example: chronic disease management) that require input of the best and brightest in our profession.
Can we blame them to choose otherwise?According to the NEJM the prevalence of chronic conditions — most of which are handled in primary care settings — is increasing, as are requirements for their proper management. Not only has the number of primary care tasks grown exponentially, but physician performance is being measured and physicians are even being paid according to their ability to perform these tasks reliably and consistently. It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventive care, to an average panel of 2500 patients (the mean U.S. panel size is 2300)! A seemingly unsurmountable task that requires complex information management systems and the sophisticated staff to implement them. Such primary care experts should be reimbursement properly but they are not!
Our reimbursement system is tilted towards non-primary care specialties.Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression. The median income of specialists in 2004 was almost twice that of primary care physicians, a gap that is widening. In 2004 all visits to primary care physicians (FP,IM, Peds) accounted for almost half of the overall total of 967.3 million office visits but only 30 percent of the $152 billion spent on office-based care. The remaining 70 percent was spent on specialty care. This misalignment of reimbursement causes a shortage in primary care physicians and subsequently creating a population of medically disenfranchised individuals who lack access to medical homes. Fair reimbursement is the first step towards stopping the bleeding of primary care health care services.
Bernd
PS: Happy Purim holiday.
==============================================================================================================
New York Times - March 19, 2008
The Price of Beauty
For Top Medical Students, an Attractive Field
By NATASHA SINGER
BOSTON — March Madness has a different meaning for Thomas Hocker and Meena Singh, a married couple in their final year at the Harvard Medical School, who are waiting to learn Thursday if they have been accepted into their residency programs of choice.
Already saddled with about $330,000 in education loans, they borrowed $20,000 more so they could fly around the country this winter for about two dozen residency interviews each. All told, each applied to 90 such training programs.
Ms. Singh, pregnant during interview season, gave birth to their second daughter in early January. Three days later, she flew to Miami for an interview.
The search has been difficult not because they are mediocre students; indeed, each has a brand-name education, academic honors and published research on disease. No, it has been hard because they aspire to be dermatologists.
As thousands of medical students await word this week on residency programs, two specialties concerned with physical appearance — dermatology and plastic surgery — are among the most competitive.
Only 61 percent of seniors at American medical schools whose first choice was dermatology received a residency in that field last year, compared with 98 percent for those whose first choice was internal medicine and 99 percent for those seeking family medicine, according to a report by the Association of American Medical Colleges and the National Resident Matching Program, which pairs candidates and programs. Although there are far fewer positions in dermatology (320 residencies in 2007) than in internal medicine (5,517) and family medicine (2,603), the field is attracting some of the best and brightest future doctors.
Seniors accepted in 2007 as residents in dermatology and two other appearance-related fields — plastic surgery and otolaryngology (ear, nose and throat doctors, some of whom perform facial cosmetic surgery) — had the highest median medical-board scores and the highest percentage of members in the medical honor society among 18 specialties, the report said.
The vogue for such specialties is part of a migration of a top tier of American medical students from branches of health care that manage major diseases toward specialties that improve the life of patients — and the lives of physicians, with better pay, more autonomy and more-controllable hours.
“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary.
Medical school professors and administrators say such discrepancies are dissuading some top students at American medical schools from entering fields, like family medicine, that manage the most prevalent serious illnesses. They are being replaced in part by graduates of foreign medical schools, some of whom return to their home countries to practice.
“We have a shortage in America of primary-care or family-type doctors,” said Dr. Joel M. Felner, a cardiology professor who is the associate dean for clinical education at Emory University School of Medicine in Atlanta. Last year, the school enlarged its incoming class, hoping more students would specialize in the major diseases and preventative care, he said. “We do need dermatologists, but I am more worried about the really sick people and dermatologists aren’t taking care of them,” Dr. Felner said.
Until recently, saving skin did not have the cachet of saving lives. Doctors in other fields jokingly dismissed dermatology as a province of red-spot diseases that could not really be cured, but weren’t going to kill patients. Twenty-five years ago, the fiercest competition among medical students was for internal medicine and general surgery.
But dermatology’s status is rising, not just for the pay, hours and independence, but also because of the growing variety of treatments and devices in this fast-developing field that can help people in a looks-obsessed world. At a time of increased discussion of enhancing beauty, as well as narrowing standards for skin perfection, the public has a newfound esteem for doctors who treat appearance.
“People greatly value the skin because it is what is on the outside that is the face you present to the world,” Mr. Hocker said one evening last month after coming off a hospital shift in which he dealt with afflictions like heart failure and kidney failure. “Most dermatological diseases won’t kill you, but they can greatly affect your quality of life.”
Some dermatology professors said the growing allure of their field among medical students has raised the bar for applicants over the last decade. “Dermatology has always attracted bright students,” said Dr. Harley A. Haynes, a dermatology professor at the Harvard Medical School who has been mentoring medical students there since 1970. “But now we are getting more of the brightest and the best.”
Dr. Haynes likes to joke that even faculty members might not be accepted for a residency if they applied today.
A Psychological Lifeline
For an idea of the competition facing dermatology aspirants, consider the application numbers. Last fall, 383 people applied for 6 places — an average of about 64 applicants per spot — in Harvard’s dermatology program. By comparison, Harvard College received an average of 11 applications per offer of admission in the class of 2010.
Mr. Hocker and Ms. Singh were well prepared for the Darwinian process of landing a dermatology residency when they met as classmates at the Harvard Medical School in 2003. Mr. Hocker, 27, holds a graduate degree from Cambridge University and an undergraduate degree in chemistry from Yale, where he was a champion hurdler. Ms. Singh, 26, was in several honor societies as a biomedical engineering student at the University of Southern California.
During her senior year, she competed on an MTV reality show called “Sorority Life,” but was ejected midseason for being too studious.
“In one scene, you see her all happy getting the acceptance letter from Harvard and in the next scene, you see her crying up a storm because she has been de-pledged from the sorority,” Mr. Hocker recalled fondly.
Neither student had planned to become a skin specialist.
Growing up in Kansas City, Kan., Ms. Singh loved visiting the hospital with her mother, an internist with long relationships with a diverse group of patients. Ms. Singh said she initially planned to emulate her mother, a physician who focuses on treating major adult diseases.
A lecture on skin-pigment conditions like vitiligo changed her mind.
“Nobody can see if you have hypertension or asthma, but everybody knows if you have a pigmentary disorder and these changes are a lot more obvious and devastating to patients with skin of color,” Ms. Singh said. “Having something on your skin is not life or death for people, but it can be equally important for them emotionally as a life-threatening disease.”
Indeed, dermatology can be a psychological lifeline for people with severe skin problems. At pools or the beach, some people shun those with psoriasis who have scaly skin, fearing the condition is contagious, doctors said. People with deep acne scars say it affects their personal and professional lives.
Then there is the growing popularity among otherwise healthy people of tweaking one’s appearance with cosmetic treatments, from Botox injections to lip plumping and laser hair removal. Plastic surgeons, dermatologists and facial surgeons in the United States performed about 9.6 million such nonsurgical treatments in 2007, almost nine times the number a decade earlier, according to the American Society for Aesthetic Plastic Surgery.
‘Your Input Is Valued’
Mr. Hocker was finally sold on dermatology last year, while on a clinical rotation during which neurosurgeons called him and a dermatology resident to an intensive-care ward for a consultation. A patient, in a coma after surgery, was covered with mysterious red half-moon-shaped blisters. They could not determine the cause. Then Dr. Haynes of Harvard arrived.
“Dr. Haynes comes in and he is like a walking CAT scan, who eyeballs her from head to toe and has the diagnosis in 15 seconds,” Mr. Hocker said. The verdict: a rare blistering disorder caused by an allergy to an antibiotic.
Mr. Hocker said he liked the idea of drawing independent conclusions without tests or consultations with other doctors.
“The No. 1 thing that is going to save your life is the humdrum preventative stuff like blood pressure and cholesterol,” Mr. Hocker said. “But there is not a lot of respect for doctors who do that because anyone can get into it. But if you are an expert where no one else is, like the eye or the skin, your input is valued.”
Dermatology also attracts students like Mr. Hocker because of the potential for basic research on skin diseases that can lead to new treatments. Mr. Hocker said he plans to focus his career on researching the role of genetics in problems like skin cancer and abnormal scarring; he took a year off during medical school to conduct melanoma research.
While students like Mr. Hocker choose dermatology planning on research careers, others end up focusing on cosmetic treatments like skin tightening and resurfacing. Half of the dermatology residents graduating over the last five years from the program at the Boston Medical Center have chosen postgraduate fellowships that teach a combination of skin-cancer operations and cosmetic procedures, according to Dr. Barbara A. Gilchrest, the chairwoman of dermatology at Boston University School of Medicine.
Work Less, Earn More
Dermatologists say they enjoy the variety of a specialty that encompasses serious illnesses like skin cancer and psoriasis as well as conditions like uncombable hair syndrome.
But students interested in such work also often factor in personal benefits. Internists, for example, worked an average of 50 hours a week in 2006 while dermatologists worked about 40 hours, according to an annual survey by Medical Economics magazine. Dermatology also offers more independence from the bureaucracy of managed care, because patients pay up front for cosmetic procedures not covered by health insurance.
And while an internist earns an average of $191,525, a dermatologist earns an average of $390,274, according to an annual survey conducted by the Medical Group Management Association, whose membership includes more than 21,000 managers of medical practices. Dermatologists who specialize in cosmetic treatments or in skin-cancer operations can earn much more.
For thousands of medical students nationwide, especially those trying to enter the most competitive fields, this week — when residency acceptances are announced — has been fraught with tension. The National Resident Matching Program uses an algorithm to pair applicants with the one program they have ranked highest that also preferred them, a system that leaves some applicants disappointed.
Mr. Hocker and Ms. Singh face even longer odds because they entered the match process as a couple, seeking positions at the same program, or at least in the same region.
On Monday, when applicants learned whether they had been paired with a program at all, Mr. Hocker and Ms. Singh found out they will each obtain a residency. Thursday, they find out where.
“My friends going into general medicine and general surgery pretty much have an idea that they are going to be at their No. 1 or No. 2 school,” Ms. Singh said. “But we really could be anywhere in the country, together or not together.”
She added: “We would have a better chance of winning ‘American Idol.’ ”
Friday, February 15, 2008
Health Care Reform: A Different Perspective
"Despite our crisis of escalating costs, dwindling insurance coverage, and deteriorating conditions of medical practice, true national health insurance that would not rely on private insurers remains at the fringes of the national debate. This reality reflects the immense power of the insurance and pharmaceutical industries, the political fragmentation and ambivalence of the medical profession, the intimidation of politicians, and the erroneous media images of dissatisfied patients in universal systems.Sometimes, we Americans do the right thing only after having exhausted all other alternatives. It remains to be seen how much exhaustion the health care system will suffer before we turn to national health insurance."
Dear Friends and Colleagues:
An article published in the February 7th issue of the New England Journal of Medicine http://content.nejm.org/cgi/content/full/358/6/549 , the author summarizes the problems associated with our health care system as follows:
The Problem:
"U.S. health care expenditures rose 6.7% in 2006, the government recently reported. According to the Centers for Medicare and Medicaid Services, total health care expenditures exceeded $2.1 trillion, or more than $7,000 for every American man, woman, and child.1 Medicare costs jumped a record 18.7%, driven by the new privatized drug benefit. Total health care spending, now amounting to 16% of the gross domestic product, is projected to reach 20% in just 7 years."
Common reasons attributed to the relentless medical inflation
* the aging population, the proliferation of new technologies,
* poor diet and lack of exercise,
* the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments) to generate its own demand,
* excessive litigation and defensive medicine
* tax-favored insurance coverage.
The author offers a different opinion, or second opinion:
"The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system."
He asks the question why markets do not optimize efficiency and offer the following explanation:
"The private insurance system's main techniques for holding down costs are practicing risk selection, limiting the services covered, constraining payments to providers, and shifting costs to patients. But given the system's fragmentation and perverse incentives, much cost-effective care is squeezed out, resources are increasingly allocated in response to profit opportunities rather than medical need, many attainable efficiencies are not achieved, unnecessary medical care is provided for profit, administrative expenses are high, and enormous sums are squandered in efforts to game the system. The result is a blend of overtreatment and undertreatment — and escalating costs. Researchers calculate that between one fifth and one third of medical outlays do nothing to improve health."
Furthermore he claims that:
"Great health improvements can be achieved through basic public health measures and a population-based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them most are the least likely to have insurance. Innumerable studies have shown that consistent application of standard protocols for conditions such as diabetes, asthma, and elevated cholesterol levels, use of clinically proven screenings such as annual mammograms, provision of childhood immunizations, and changes to diet and exercise can improve health and prevent larger outlays later on. Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need. Although the populations of most countries that belong to the Organization for Economic Cooperation and Development are older than the U.S. population, these countries have been far more successful at containing costs without compromising care."
He points out several cost-containment tactics applied by insurance companies to maximize their profits:
" A popular strategy among cost-containment consultants relies on the psychology of income targeting. The idea is that physicians have a mental picture of expected earnings — an income target. If the insurance plan squeezes their income by reducing payments per visit, doctors compensate by increasing their caseload and spending less time with each patient.
This false economy is a telling example of the myopia of commercialized managed care. It may save the plan money in the short run, but as any practicing physician can testify, the strategy has multiple self-defeating effects. A doctor's most precious commodity is time — adequate time to review a chart, take a history, truly listen to a patient. You can't do all that in 10 minutes. Harried primary care doctors are more likely to miss cues, make mistakes, and — ironically enough — order more tests to compensate for lack of hands-on assessment. They are also more likely to make more referrals to specialists for procedures they could perform more cost-effectively themselves, given adequate time and compensation. And the gap between generalist and specialist pay is widening."
"A second cost-containment tactic is to hike deductibles and copayments, whose frank purpose is to dissuade people from going to the doctor. But sometimes seeing the doctor is medically indicated, and waiting until conditions are dire costs the system far more money than it saves. Moreover, at some point during each year, more than 80 million Americans go without coverage, which makes them even less likely to seek preventive care."
"..the system also has inflationary effects on hospitals' revenue-maximization strategies. Large hospitals, which still have substantial bargaining power with insurers, necessarily cross-subsidize services. The emergency department may lose money, but cardiology makes a bundle. So hospitals fiercely defend their profit centers, investing heavily in facilities for lucrative procedures that will attract physicians and patients. For the system as a whole, it would be far more cost-effective to shift resources from subspecialists to primary care. But in an uncoordinated, commercialized system, specialists might take their business elsewhere, so they have the leverage to maintain their incomes and privileges — and thereby distort cost-effective resource allocation."
He concludes the article calling for the creation of a universal system of comprehensive national health care because:
"A comprehensive national system is far better positioned to match resources with needs — and not through the so-called rationing of care. (It is the U.S. system that has the most de facto rationing — high rates of uninsurance, exclusions for preexisting conditions, excessive deductibles and copayments, and shorter hospital stays and physician visits.) A universal system suffers far less of the feast-or-famine misallocation of resources driven by profit maximization. It also saves huge sums that our system wastes on administration, billing, marketing, profit, executive compensation, and risk selection. When the British National Health Service faced a shortage of primary care doctors, it adjusted pay schedules and added incentives for high-quality care, and the shortage diminished. Our commercialized system seems incapable of producing that result.
Despite our crisis of escalating costs, dwindling insurance coverage, and deteriorating conditions of medical practice, true national health insurance that would not rely on private insurers remains at the fringes of the national debate. This reality reflects the immense power of the insurance and pharmaceutical industries, the political fragmentation and ambivalence of the medical profession, the intimidation of politicians, and the erroneous media images of dissatisfied patients in universal systems.
Sometimes, we Americans do the right thing only after having exhausted all other alternatives. It remains to be seen how much exhaustion the health care system will suffer before we turn to national health insurance."
Yours
Bernd Wollschlaeger,MD,FAAFP
Dear Friends and Colleagues:
An article published in the February 7th issue of the New England Journal of Medicine http://content.nejm.org/cgi/content/full/358/6/549 , the author summarizes the problems associated with our health care system as follows:
The Problem:
"U.S. health care expenditures rose 6.7% in 2006, the government recently reported. According to the Centers for Medicare and Medicaid Services, total health care expenditures exceeded $2.1 trillion, or more than $7,000 for every American man, woman, and child.1 Medicare costs jumped a record 18.7%, driven by the new privatized drug benefit. Total health care spending, now amounting to 16% of the gross domestic product, is projected to reach 20% in just 7 years."
Common reasons attributed to the relentless medical inflation
* the aging population, the proliferation of new technologies,
* poor diet and lack of exercise,
* the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments) to generate its own demand,
* excessive litigation and defensive medicine
* tax-favored insurance coverage.
The author offers a different opinion, or second opinion:
"The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system."
He asks the question why markets do not optimize efficiency and offer the following explanation:
"The private insurance system's main techniques for holding down costs are practicing risk selection, limiting the services covered, constraining payments to providers, and shifting costs to patients. But given the system's fragmentation and perverse incentives, much cost-effective care is squeezed out, resources are increasingly allocated in response to profit opportunities rather than medical need, many attainable efficiencies are not achieved, unnecessary medical care is provided for profit, administrative expenses are high, and enormous sums are squandered in efforts to game the system. The result is a blend of overtreatment and undertreatment — and escalating costs. Researchers calculate that between one fifth and one third of medical outlays do nothing to improve health."
Furthermore he claims that:
"Great health improvements can be achieved through basic public health measures and a population-based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them most are the least likely to have insurance. Innumerable studies have shown that consistent application of standard protocols for conditions such as diabetes, asthma, and elevated cholesterol levels, use of clinically proven screenings such as annual mammograms, provision of childhood immunizations, and changes to diet and exercise can improve health and prevent larger outlays later on. Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need. Although the populations of most countries that belong to the Organization for Economic Cooperation and Development are older than the U.S. population, these countries have been far more successful at containing costs without compromising care."
He points out several cost-containment tactics applied by insurance companies to maximize their profits:
" A popular strategy among cost-containment consultants relies on the psychology of income targeting. The idea is that physicians have a mental picture of expected earnings — an income target. If the insurance plan squeezes their income by reducing payments per visit, doctors compensate by increasing their caseload and spending less time with each patient.
This false economy is a telling example of the myopia of commercialized managed care. It may save the plan money in the short run, but as any practicing physician can testify, the strategy has multiple self-defeating effects. A doctor's most precious commodity is time — adequate time to review a chart, take a history, truly listen to a patient. You can't do all that in 10 minutes. Harried primary care doctors are more likely to miss cues, make mistakes, and — ironically enough — order more tests to compensate for lack of hands-on assessment. They are also more likely to make more referrals to specialists for procedures they could perform more cost-effectively themselves, given adequate time and compensation. And the gap between generalist and specialist pay is widening."
"A second cost-containment tactic is to hike deductibles and copayments, whose frank purpose is to dissuade people from going to the doctor. But sometimes seeing the doctor is medically indicated, and waiting until conditions are dire costs the system far more money than it saves. Moreover, at some point during each year, more than 80 million Americans go without coverage, which makes them even less likely to seek preventive care."
"..the system also has inflationary effects on hospitals' revenue-maximization strategies. Large hospitals, which still have substantial bargaining power with insurers, necessarily cross-subsidize services. The emergency department may lose money, but cardiology makes a bundle. So hospitals fiercely defend their profit centers, investing heavily in facilities for lucrative procedures that will attract physicians and patients. For the system as a whole, it would be far more cost-effective to shift resources from subspecialists to primary care. But in an uncoordinated, commercialized system, specialists might take their business elsewhere, so they have the leverage to maintain their incomes and privileges — and thereby distort cost-effective resource allocation."
He concludes the article calling for the creation of a universal system of comprehensive national health care because:
"A comprehensive national system is far better positioned to match resources with needs — and not through the so-called rationing of care. (It is the U.S. system that has the most de facto rationing — high rates of uninsurance, exclusions for preexisting conditions, excessive deductibles and copayments, and shorter hospital stays and physician visits.) A universal system suffers far less of the feast-or-famine misallocation of resources driven by profit maximization. It also saves huge sums that our system wastes on administration, billing, marketing, profit, executive compensation, and risk selection. When the British National Health Service faced a shortage of primary care doctors, it adjusted pay schedules and added incentives for high-quality care, and the shortage diminished. Our commercialized system seems incapable of producing that result.
Despite our crisis of escalating costs, dwindling insurance coverage, and deteriorating conditions of medical practice, true national health insurance that would not rely on private insurers remains at the fringes of the national debate. This reality reflects the immense power of the insurance and pharmaceutical industries, the political fragmentation and ambivalence of the medical profession, the intimidation of politicians, and the erroneous media images of dissatisfied patients in universal systems.
Sometimes, we Americans do the right thing only after having exhausted all other alternatives. It remains to be seen how much exhaustion the health care system will suffer before we turn to national health insurance."
Yours
Bernd Wollschlaeger,MD,FAAFP
Wednesday, January 16, 2008
Response to Lombana Article
Attached an Op_ed I have submitted to the Miami Herald in response to the Lombana article.
Med-mal crisis: Working Towards A Solution
Doctors in South Florida faces the highest professional liability insurance premiums in the nation. With rapidly increasing premiums threatening the economic viability of many physicians and restricting access to needed medical care, organized medicine four years ago launched a campaign to preserve the practice of medicine in Florida. After a contentious and costly fight the Legislature responded by limiting the amounts malpractice victims can win in lawsuits – about $500,000 per doctor in most cases. Voters changed the state constitution to cap how much victim’s lawyers can get paid in contingency fees: 30 percent of the first $250,000 won (that's a maximum of $75,000) and 10 percent above that. Subsequently, the measures helped stabilize and even reduce the malpractice premiums paid in Florida. According to the state Office of Insurance Regulation Rates dropped 3 percent on average last year, but for may this is still a drop in the bucket.
Even though, the majority of medical liability claims are closed without payment to the plaintiff the physicians who win at trial still have large fees to pay for their defenses. Average defense costs were $93,559 per claim in cases where the defendant prevailed at trial. And in cases where the claim was dropped or dismissed, costs to defendants averaged $18,774.
In the daily medical practice the threat of a lawsuit hangs like a sword of Damocles over physician’s heads. This has unintended consequences including limited access to specialists in rural areas and medical residents’ growing concerns about liability issues may cause them to avoid choosing high-risk specialties or practicing in a crisis state. Forty-eight percent of students in their third or fourth year of medical school indicated the liability situation was a factor in their specialty choice, which will adversely impact the already shrinking physicians supply in a crisis state such as Florida.
According to a U.S. Department of Health and Human Services report medical liability adds billions to the cost of health care each year – which means higher health insurance premiums and higher medical costs for all Americans.
We need to find an alternative to the current litigation system, which is threatening health care quality for all Americans as well as raising the costs of health care for all Americans.
In the search for alternatives we must adapt new paradigms of thinking and abandon trench warfare in which doctors oppose lawyers and insurance companies.
Problem solving approaches requires cooperation instead of confrontation and should include the following:
1. The trial bar and organized medicine should jointly develop an alternative to the current litigation system that may include features of a no-fault approach and specialized medical courts.
2. Insurance companies must do a better job of rate setting during good markets in order to minimize steep rate hikes during bad ones. Most did the opposite during the 1990s. They underpriced policies and relied on investment gains to offset underwriting losses. Insurance regulators must be vigilant in monitoring the premiums charged policyholders. In monitoring companies' financial health, state officials should focus on underwriting profits and losses, independent of the company's investment income.
3. Insurance companies should change the way they rate individual policyholders, from a focus on specialty, risk, and location to a focus on actual claims history rewarding doctors with high skill levels of care.
4. Create a national reinsurance plan that includes all US companies that write malpractice insurance. The insurers would cede certain premiums to the plan, and, in return, the plan would assume responsibility for all claims over a set catastrophic amount. This would prevent excessive premium fluctuations.
These are just a few suggestions that may help to reform our flawed medical liability system.
Most importantly we must create a system that effectively and fairly compensates injured patients, deters poor quality medical care, and encourages the adherence to the highest standards of care for all Floridians.
The time is running out and we have to act NOW!
Bernd Wollschlaeger,MD,FAAFP
President-Elect, Dade County Medical Association
E-mail: info@miamihealth.com
=====================================================================================================================
Posted on Mon, Jan. 14, 2008
Future of med-mal caps in doubt
BY HECTOR LOMBANA
Five years ago, following a well-documented battle between insurance companies and patient rights groups,
Florida capped statutory damages on medical malpractice insurance awards. Recent news suggests that the future of these caps may be in jeopardy.
One Florida court ruled the caps unconstitutional; another court ruled them constitutional. The issue is expected to return to the spotlight as the cases are appealed to the state's Supreme Court.
Medical malpractice lawsuits are declining nationwide, even in states without caps, while in Florida insurers earn record profits. It appears the medical malpractice ''crisis,'' propagated by the insurance and healthcare industries' campaign of fear, may have been vastly overstated.
Medical liability claims filed against healthcare providers continue to fall nationwide because of more patient-safety programs created by hospitals, according to a recent study by AON Corp. in conjunction with the American Society for Healthcare Risk Management. The annual report concludes the frequency and severity of hospital claims are at new lows, resulting in a loss-cost trend that is the lowest in the study's eight-year history.
The authors of the report said that hospitals are creating patient-safety programs for emergency rooms and obstetric departments. They predict hospitals will spend less on liability judgments, and many will realize lower liability expenses in 2008.
The news that malpractice claims are diminishing nationwide is not a surprise to medical malpractice attorneys. Lawsuits involving mishandled deliveries have helped to force hospitals to focus more on fetal heart monitoring and high-risk deliveries, and improvements in the assessment of patient symptoms in emergency departments can also be traced to successful malpractice cases.
As lawyers have argued for years, the ''free market'' of meritorious litigation has forced healthcare providers to react. The reduction of claims means lives are being saved and disabilities prevented, which results in a significant positive impact for our society and economy.
Additionally, a report from the Florida Office of Insurance Regulation indicates the number of claims has declined, and the state's seven largest medical malpractice insurers (covering two-thirds of the entire market) had net income of $2.2 billion in 2006, compared to $700 million in 2005. All but one of these insurers noted a decline in the percentage of premiums allocated to claims and expenses.
The health of the market led seven new companies to enter the state's medical malpractice insurance marketplace in 2006, and the increased competition and profitability of all of the insurers yielded a 3 percent rate reduction for the average physician in the state. In addition, four of the seven largest insurers filed to lower their rates in 2007, but some did not change their rates despite paying less in claims.
While the medical and insurance industries along with their legions of ''Big Business'' lobbyists will claim that the numbers reflect positive results of the med-mal reforms in Florida and many other states, the attorneys who represent the victims of negligent medical care understand that they truly illustrate how the caps on damages have prevented attorneys from taking on many meritorious but difficult cases.
The role of medical malpractice attorneys is to help victims of medical negligence acquire justice and recover just compensation for their pain and suffering as well as economic loss. However, the current caps on damages in Florida make it impossible for qualified lawyers to take on some of the most meritorious and severe cases.
By their very nature, these cases require expensive investigations by experts in order to determine their validity, and lawyers will refuse to take them on if they believe that the injured individual will go through the hardships and emotional toll of a trial only to receive little or nothing in return.
The caps have effectively denied many injured patients their day in court, and that has fueled the increased profits that the medical malpractice insurance companies are now enjoying.
After nearly five years of caps in Florida, the hoax of a supposed med-mal crisis based on a campaign of fear that falsely attributed the rising costs of healthcare to lawsuits has been exposed and is now starting to unravel. The caps on damages have only proven that they are able to enrich the insurance companies to the detriment of the injured, and the future of these caps in Florida and other states now appears to be very much in question.
Hector Lombana is a partner with the Coral Gables-based law firm of Gamba & Lombana P.A., which focuses on medical malpractice, commercial law and litigation.
Med-mal crisis: Working Towards A Solution
Doctors in South Florida faces the highest professional liability insurance premiums in the nation. With rapidly increasing premiums threatening the economic viability of many physicians and restricting access to needed medical care, organized medicine four years ago launched a campaign to preserve the practice of medicine in Florida. After a contentious and costly fight the Legislature responded by limiting the amounts malpractice victims can win in lawsuits – about $500,000 per doctor in most cases. Voters changed the state constitution to cap how much victim’s lawyers can get paid in contingency fees: 30 percent of the first $250,000 won (that's a maximum of $75,000) and 10 percent above that. Subsequently, the measures helped stabilize and even reduce the malpractice premiums paid in Florida. According to the state Office of Insurance Regulation Rates dropped 3 percent on average last year, but for may this is still a drop in the bucket.
Even though, the majority of medical liability claims are closed without payment to the plaintiff the physicians who win at trial still have large fees to pay for their defenses. Average defense costs were $93,559 per claim in cases where the defendant prevailed at trial. And in cases where the claim was dropped or dismissed, costs to defendants averaged $18,774.
In the daily medical practice the threat of a lawsuit hangs like a sword of Damocles over physician’s heads. This has unintended consequences including limited access to specialists in rural areas and medical residents’ growing concerns about liability issues may cause them to avoid choosing high-risk specialties or practicing in a crisis state. Forty-eight percent of students in their third or fourth year of medical school indicated the liability situation was a factor in their specialty choice, which will adversely impact the already shrinking physicians supply in a crisis state such as Florida.
According to a U.S. Department of Health and Human Services report medical liability adds billions to the cost of health care each year – which means higher health insurance premiums and higher medical costs for all Americans.
We need to find an alternative to the current litigation system, which is threatening health care quality for all Americans as well as raising the costs of health care for all Americans.
In the search for alternatives we must adapt new paradigms of thinking and abandon trench warfare in which doctors oppose lawyers and insurance companies.
Problem solving approaches requires cooperation instead of confrontation and should include the following:
1. The trial bar and organized medicine should jointly develop an alternative to the current litigation system that may include features of a no-fault approach and specialized medical courts.
2. Insurance companies must do a better job of rate setting during good markets in order to minimize steep rate hikes during bad ones. Most did the opposite during the 1990s. They underpriced policies and relied on investment gains to offset underwriting losses. Insurance regulators must be vigilant in monitoring the premiums charged policyholders. In monitoring companies' financial health, state officials should focus on underwriting profits and losses, independent of the company's investment income.
3. Insurance companies should change the way they rate individual policyholders, from a focus on specialty, risk, and location to a focus on actual claims history rewarding doctors with high skill levels of care.
4. Create a national reinsurance plan that includes all US companies that write malpractice insurance. The insurers would cede certain premiums to the plan, and, in return, the plan would assume responsibility for all claims over a set catastrophic amount. This would prevent excessive premium fluctuations.
These are just a few suggestions that may help to reform our flawed medical liability system.
Most importantly we must create a system that effectively and fairly compensates injured patients, deters poor quality medical care, and encourages the adherence to the highest standards of care for all Floridians.
The time is running out and we have to act NOW!
Bernd Wollschlaeger,MD,FAAFP
President-Elect, Dade County Medical Association
E-mail: info@miamihealth.com
=====================================================================================================================
Posted on Mon, Jan. 14, 2008
Future of med-mal caps in doubt
BY HECTOR LOMBANA
Five years ago, following a well-documented battle between insurance companies and patient rights groups,
Florida capped statutory damages on medical malpractice insurance awards. Recent news suggests that the future of these caps may be in jeopardy.
One Florida court ruled the caps unconstitutional; another court ruled them constitutional. The issue is expected to return to the spotlight as the cases are appealed to the state's Supreme Court.
Medical malpractice lawsuits are declining nationwide, even in states without caps, while in Florida insurers earn record profits. It appears the medical malpractice ''crisis,'' propagated by the insurance and healthcare industries' campaign of fear, may have been vastly overstated.
Medical liability claims filed against healthcare providers continue to fall nationwide because of more patient-safety programs created by hospitals, according to a recent study by AON Corp. in conjunction with the American Society for Healthcare Risk Management. The annual report concludes the frequency and severity of hospital claims are at new lows, resulting in a loss-cost trend that is the lowest in the study's eight-year history.
The authors of the report said that hospitals are creating patient-safety programs for emergency rooms and obstetric departments. They predict hospitals will spend less on liability judgments, and many will realize lower liability expenses in 2008.
The news that malpractice claims are diminishing nationwide is not a surprise to medical malpractice attorneys. Lawsuits involving mishandled deliveries have helped to force hospitals to focus more on fetal heart monitoring and high-risk deliveries, and improvements in the assessment of patient symptoms in emergency departments can also be traced to successful malpractice cases.
As lawyers have argued for years, the ''free market'' of meritorious litigation has forced healthcare providers to react. The reduction of claims means lives are being saved and disabilities prevented, which results in a significant positive impact for our society and economy.
Additionally, a report from the Florida Office of Insurance Regulation indicates the number of claims has declined, and the state's seven largest medical malpractice insurers (covering two-thirds of the entire market) had net income of $2.2 billion in 2006, compared to $700 million in 2005. All but one of these insurers noted a decline in the percentage of premiums allocated to claims and expenses.
The health of the market led seven new companies to enter the state's medical malpractice insurance marketplace in 2006, and the increased competition and profitability of all of the insurers yielded a 3 percent rate reduction for the average physician in the state. In addition, four of the seven largest insurers filed to lower their rates in 2007, but some did not change their rates despite paying less in claims.
While the medical and insurance industries along with their legions of ''Big Business'' lobbyists will claim that the numbers reflect positive results of the med-mal reforms in Florida and many other states, the attorneys who represent the victims of negligent medical care understand that they truly illustrate how the caps on damages have prevented attorneys from taking on many meritorious but difficult cases.
The role of medical malpractice attorneys is to help victims of medical negligence acquire justice and recover just compensation for their pain and suffering as well as economic loss. However, the current caps on damages in Florida make it impossible for qualified lawyers to take on some of the most meritorious and severe cases.
By their very nature, these cases require expensive investigations by experts in order to determine their validity, and lawyers will refuse to take them on if they believe that the injured individual will go through the hardships and emotional toll of a trial only to receive little or nothing in return.
The caps have effectively denied many injured patients their day in court, and that has fueled the increased profits that the medical malpractice insurance companies are now enjoying.
After nearly five years of caps in Florida, the hoax of a supposed med-mal crisis based on a campaign of fear that falsely attributed the rising costs of healthcare to lawsuits has been exposed and is now starting to unravel. The caps on damages have only proven that they are able to enrich the insurance companies to the detriment of the injured, and the future of these caps in Florida and other states now appears to be very much in question.
Hector Lombana is a partner with the Coral Gables-based law firm of Gamba & Lombana P.A., which focuses on medical malpractice, commercial law and litigation.
Tuesday, January 15, 2008
Med-mal Crisis A Hoax?
Dear Friends and Colleagues
Attached you find an Op-Ed published in The January 14, 2008 Business Section of the Miami Herald.
The author, Hector Lombana, intends to reopen the entire med-mal discussion. He claims that,"Medical liability claims filed against healthcare providers continue to fall nationwide because of more patient-safety programs created by hospitals, according to a recent study by AON Corp. in conjunction with the American Society for Healthcare Risk Management. The annual report concludes the frequency and severity of hospital claims are at new lows, resulting in a loss-cost trend that is the lowest in the study's eight-year history."
He subsequently states that,"Lawsuits involving mishandled deliveries have helped to force hospitals to focus more on fetal heart monitoring and high-risk deliveries, and improvements in the assessment of patient symptoms in emergency departments can also be traced to successful malpractice cases."
He points out that the health of the market led seven new companies to enter the state's medical malpractice insurance marketplace in 2006, and the increased competition and profitability of all of the insurers yielded a 3 percent rate reduction for the average physician in the state. In addition, four of the seven largest insurers filed to lower their rates in 2007, but some did not change their rates despite paying less in claims.
He concludes that "After nearly five years of caps in Florida, the hoax of a supposed med-mal crisis based on a campaign of fear that falsely attributed the rising costs of healthcare to lawsuits has been exposed and is now starting to unravel. The caps on damages have only proven that they are able to enrich the insurance companies to the detriment of the injured, and the future of these caps in Florida and other states now appears to be very much in question."
I hope that most of you agree that the opinion expressed is lopsided and does not include all aspects of the debate.
Fear of litigation and actual litigation contribute to rising healthcare costs and caps have lowered professional liability insurance premiums for doctors in the State of Florida.
It is true that insurance companies are accumulating profits and we should insist that this should lead to further premium decrease.
Nevertheless, we should resists ANY efforts by trial lawyers to remove the caps on damages which have HELPED doctors to stay in business and to serve injured patients! We should remind Mr. Lombardo that Neurosurgeons and other high-risk specialties are slowly returning to Florida BECAUSE the med-mal situation has improved!
I call upon all of you to respond to this article in the form of a letter to the editor of the Miami Herald.
Yours
Bernd
Posted on Mon, Jan. 14, 2008
Future of med-mal caps in doubt
BY HECTOR LOMBANA
Five years ago, following a well-documented battle between insurance companies and patient rights groups,
Florida capped statutory damages on medical malpractice insurance awards. Recent news suggests that the future of these caps may be in jeopardy.
One Florida court ruled the caps unconstitutional; another court ruled them constitutional. The issue is expected to return to the spotlight as the cases are appealed to the state's Supreme Court.
Medical malpractice lawsuits are declining nationwide, even in states without caps, while in Florida insurers earn record profits. It appears the medical malpractice ''crisis,'' propagated by the insurance and healthcare industries' campaign of fear, may have been vastly overstated.
Medical liability claims filed against healthcare providers continue to fall nationwide because of more patient-safety programs created by hospitals, according to a recent study by AON Corp. in conjunction with the American Society for Healthcare Risk Management. The annual report concludes the frequency and severity of hospital claims are at new lows, resulting in a loss-cost trend that is the lowest in the study's eight-year history.
The authors of the report said that hospitals are creating patient-safety programs for emergency rooms and obstetric departments. They predict hospitals will spend less on liability judgments, and many will realize lower liability expenses in 2008.
The news that malpractice claims are diminishing nationwide is not a surprise to medical malpractice attorneys. Lawsuits involving mishandled deliveries have helped to force hospitals to focus more on fetal heart monitoring and high-risk deliveries, and improvements in the assessment of patient symptoms in emergency departments can also be traced to successful malpractice cases.
As lawyers have argued for years, the ''free market'' of meritorious litigation has forced healthcare providers to react. The reduction of claims means lives are being saved and disabilities prevented, which results in a significant positive impact for our society and economy.
Additionally, a report from the Florida Office of Insurance Regulation indicates the number of claims has declined, and the state's seven largest medical malpractice insurers (covering two-thirds of the entire market) had net income of $2.2 billion in 2006, compared to $700 million in 2005. All but one of these insurers noted a decline in the percentage of premiums allocated to claims and expenses.
The health of the market led seven new companies to enter the state's medical malpractice insurance marketplace in 2006, and the increased competition and profitability of all of the insurers yielded a 3 percent rate reduction for the average physician in the state. In addition, four of the seven largest insurers filed to lower their rates in 2007, but some did not change their rates despite paying less in claims.
While the medical and insurance industries along with their legions of ''Big Business'' lobbyists will claim that the numbers reflect positive results of the med-mal reforms in Florida and many other states, the attorneys who represent the victims of negligent medical care understand that they truly illustrate how the caps on damages have prevented attorneys from taking on many meritorious but difficult cases.
The role of medical malpractice attorneys is to help victims of medical negligence acquire justice and recover just compensation for their pain and suffering as well as economic loss. However, the current caps on damages in Florida make it impossible for qualified lawyers to take on some of the most meritorious and severe cases.
By their very nature, these cases require expensive investigations by experts in order to determine their validity, and lawyers will refuse to take them on if they believe that the injured individual will go through the hardships and emotional toll of a trial only to receive little or nothing in return.
The caps have effectively denied many injured patients their day in court, and that has fueled the increased profits that the medical malpractice insurance companies are now enjoying.
After nearly five years of caps in Florida, the hoax of a supposed med-mal crisis based on a campaign of fear that falsely attributed the rising costs of healthcare to lawsuits has been exposed and is now starting to unravel. The caps on damages have only proven that they are able to enrich the insurance companies to the detriment of the injured, and the future of these caps in Florida and other states now appears to be very much in question.
Hector Lombana is a partner with the Coral Gables-based law firm of Gamba & Lombana P.A., which focuses on medical malpractice, commercial law and litigation.
Attached you find an Op-Ed published in The January 14, 2008 Business Section of the Miami Herald.
The author, Hector Lombana, intends to reopen the entire med-mal discussion. He claims that,"Medical liability claims filed against healthcare providers continue to fall nationwide because of more patient-safety programs created by hospitals, according to a recent study by AON Corp. in conjunction with the American Society for Healthcare Risk Management. The annual report concludes the frequency and severity of hospital claims are at new lows, resulting in a loss-cost trend that is the lowest in the study's eight-year history."
He subsequently states that,"Lawsuits involving mishandled deliveries have helped to force hospitals to focus more on fetal heart monitoring and high-risk deliveries, and improvements in the assessment of patient symptoms in emergency departments can also be traced to successful malpractice cases."
He points out that the health of the market led seven new companies to enter the state's medical malpractice insurance marketplace in 2006, and the increased competition and profitability of all of the insurers yielded a 3 percent rate reduction for the average physician in the state. In addition, four of the seven largest insurers filed to lower their rates in 2007, but some did not change their rates despite paying less in claims.
He concludes that "After nearly five years of caps in Florida, the hoax of a supposed med-mal crisis based on a campaign of fear that falsely attributed the rising costs of healthcare to lawsuits has been exposed and is now starting to unravel. The caps on damages have only proven that they are able to enrich the insurance companies to the detriment of the injured, and the future of these caps in Florida and other states now appears to be very much in question."
I hope that most of you agree that the opinion expressed is lopsided and does not include all aspects of the debate.
Fear of litigation and actual litigation contribute to rising healthcare costs and caps have lowered professional liability insurance premiums for doctors in the State of Florida.
It is true that insurance companies are accumulating profits and we should insist that this should lead to further premium decrease.
Nevertheless, we should resists ANY efforts by trial lawyers to remove the caps on damages which have HELPED doctors to stay in business and to serve injured patients! We should remind Mr. Lombardo that Neurosurgeons and other high-risk specialties are slowly returning to Florida BECAUSE the med-mal situation has improved!
I call upon all of you to respond to this article in the form of a letter to the editor of the Miami Herald.
Yours
Bernd
Posted on Mon, Jan. 14, 2008
Future of med-mal caps in doubt
BY HECTOR LOMBANA
Five years ago, following a well-documented battle between insurance companies and patient rights groups,
Florida capped statutory damages on medical malpractice insurance awards. Recent news suggests that the future of these caps may be in jeopardy.
One Florida court ruled the caps unconstitutional; another court ruled them constitutional. The issue is expected to return to the spotlight as the cases are appealed to the state's Supreme Court.
Medical malpractice lawsuits are declining nationwide, even in states without caps, while in Florida insurers earn record profits. It appears the medical malpractice ''crisis,'' propagated by the insurance and healthcare industries' campaign of fear, may have been vastly overstated.
Medical liability claims filed against healthcare providers continue to fall nationwide because of more patient-safety programs created by hospitals, according to a recent study by AON Corp. in conjunction with the American Society for Healthcare Risk Management. The annual report concludes the frequency and severity of hospital claims are at new lows, resulting in a loss-cost trend that is the lowest in the study's eight-year history.
The authors of the report said that hospitals are creating patient-safety programs for emergency rooms and obstetric departments. They predict hospitals will spend less on liability judgments, and many will realize lower liability expenses in 2008.
The news that malpractice claims are diminishing nationwide is not a surprise to medical malpractice attorneys. Lawsuits involving mishandled deliveries have helped to force hospitals to focus more on fetal heart monitoring and high-risk deliveries, and improvements in the assessment of patient symptoms in emergency departments can also be traced to successful malpractice cases.
As lawyers have argued for years, the ''free market'' of meritorious litigation has forced healthcare providers to react. The reduction of claims means lives are being saved and disabilities prevented, which results in a significant positive impact for our society and economy.
Additionally, a report from the Florida Office of Insurance Regulation indicates the number of claims has declined, and the state's seven largest medical malpractice insurers (covering two-thirds of the entire market) had net income of $2.2 billion in 2006, compared to $700 million in 2005. All but one of these insurers noted a decline in the percentage of premiums allocated to claims and expenses.
The health of the market led seven new companies to enter the state's medical malpractice insurance marketplace in 2006, and the increased competition and profitability of all of the insurers yielded a 3 percent rate reduction for the average physician in the state. In addition, four of the seven largest insurers filed to lower their rates in 2007, but some did not change their rates despite paying less in claims.
While the medical and insurance industries along with their legions of ''Big Business'' lobbyists will claim that the numbers reflect positive results of the med-mal reforms in Florida and many other states, the attorneys who represent the victims of negligent medical care understand that they truly illustrate how the caps on damages have prevented attorneys from taking on many meritorious but difficult cases.
The role of medical malpractice attorneys is to help victims of medical negligence acquire justice and recover just compensation for their pain and suffering as well as economic loss. However, the current caps on damages in Florida make it impossible for qualified lawyers to take on some of the most meritorious and severe cases.
By their very nature, these cases require expensive investigations by experts in order to determine their validity, and lawyers will refuse to take them on if they believe that the injured individual will go through the hardships and emotional toll of a trial only to receive little or nothing in return.
The caps have effectively denied many injured patients their day in court, and that has fueled the increased profits that the medical malpractice insurance companies are now enjoying.
After nearly five years of caps in Florida, the hoax of a supposed med-mal crisis based on a campaign of fear that falsely attributed the rising costs of healthcare to lawsuits has been exposed and is now starting to unravel. The caps on damages have only proven that they are able to enrich the insurance companies to the detriment of the injured, and the future of these caps in Florida and other states now appears to be very much in question.
Hector Lombana is a partner with the Coral Gables-based law firm of Gamba & Lombana P.A., which focuses on medical malpractice, commercial law and litigation.
Wednesday, December 19, 2007
Medicare Cuts On Hold (for now!)
The U.S. Senate this evening passed legislation by unanimous consent that
replaces a 10.1% physician payment cut with a 0.5% increase for six
months,extends expiring rural physician payment provisions and the Medicare
physician quality reporting initiative and extends the SCHIP program
through March 31, 2009.
=============================================================================
Sound like good news but its NOT.
Here is the rub: The President and the Republican Senators are NOT
willing to address MEANINGFUL Medicare reform
They rejected options to reduce or eliminate Medicare Advantage
subsidies to offset the increase physician reimbursement.
Therefore the current TEMPORARY compromise can only be characterized as
anemic. The 0.5% increase is essentially a DECREASE because it does not
even come close to cover for the increase in practice expenses and the
annual inflation rate.Furthermore, in six month we have to deal again
with the issue and the outcome maybe the same or even worse.
I suggest asking our Senators the question why they are willing to use
Medicare funds for corporate subsidies (i.e. Medicare Advantage plans)
and not for the designated Medicare beneficiaries and their doctors?
Happy Holidays.
Bernd
replaces a 10.1% physician payment cut with a 0.5% increase for six
months,extends expiring rural physician payment provisions and the Medicare
physician quality reporting initiative and extends the SCHIP program
through March 31, 2009.
=============================================================================
Sound like good news but its NOT.
Here is the rub: The President and the Republican Senators are NOT
willing to address MEANINGFUL Medicare reform
They rejected options to reduce or eliminate Medicare Advantage
subsidies to offset the increase physician reimbursement.
Therefore the current TEMPORARY compromise can only be characterized as
anemic. The 0.5% increase is essentially a DECREASE because it does not
even come close to cover for the increase in practice expenses and the
annual inflation rate.Furthermore, in six month we have to deal again
with the issue and the outcome maybe the same or even worse.
I suggest asking our Senators the question why they are willing to use
Medicare funds for corporate subsidies (i.e. Medicare Advantage plans)
and not for the designated Medicare beneficiaries and their doctors?
Happy Holidays.
Bernd
Saturday, December 08, 2007
Rating Doctors
Dear Friends and Colleagues:
Attached you find an interesting editorial from todays New York Times
The editorial highlights a disputed issue: how shall doctors performance be assessed and ranked.
An investigation by New York's attorney general has concluded that existing doctor-rating systems are based solely on the cost of care NOT on its quality.
Under a negotiated agreements with several major insurers, including Aetna, Cigna, United Healthcare and Empire Blue Cross/Blue Shield, a more user-friendly rating system should be developed that includes quality as measured by national standards and guidelines.
"Insurance companies have to make public what factors are included in their ratings and reveal how much weight they gave to cost in any composite score. An independent monitoring organization, approved by the attorney general, must oversee the process.
From a consumer’s perspective, it would be much better if the insurance companies all turned over their data to an independent organization to combine the results. It would be even better if evaluations also included such information as whether a doctor has been disciplined by state medical boards or has paid a large number of malpractice settlements."
This agreement may serve as a model for other states and organized medicine should proactively participate and contribute to the development of a rating system that empowers healthcare consumers to make informed decisions regarding their doctors choice.
Looking forward to your comments and critique.
Happy Holidays,
Yours
Bernd
December 8, 2007
Rating Your Doctor, Fairly
The drive to give consumers more information about the quality of their doctors has gotten an important shove forward by New York’s attorney general, Andrew Cuomo. That could be good for patients in dozens of states across the country that are served by some of the major health insurance companies.
An investigation by Mr. Cuomo’s office found that various doctor-rating systems currently used or planned by insurers are based primarily on the cost of care, not its quality. Doctors may be awarded a grade or stars, much like a restaurant or movie review, if they routinely treat sick patients for less than their competitors do. With that information, employers are able to steer their workers to lower-cost doctors by reducing deductibles or co-payments for those who patronize them.
Unfortunately, insurers seldom make clear just how they come up with their ratings, and there is no guarantee that the cheapest doctors are necessarily the best choice. Now the attorney general’s office has negotiated agreements with several major insurers, including Aetna, Cigna, United Healthcare and Empire Blue Cross/Blue Shield, that should make the ratings systems more useful to consumers and fairer to doctors.
Under the agreements, if insurers rate doctors, they cannot rely solely on cost but must also include quality as measured by national standards and guidelines. They have to make public what factors are included in their ratings and reveal how much weight they gave to cost in any composite score. An independent monitoring organization, approved by the attorney general, must oversee the process.
This approach has been endorsed by consumer advocacy groups, such as Consumers Union and the National Partnership for Women and Families, as well as the American Medical Association and the Medical Society of the State of New York.
Even with the improvements, ratings systems run by insurance companies may fail to provide consumers with the best possible information because they are based solely on the experience of that company’s subscribers. That may provide only limited insight into a doctor’s performance. Some doctors who participate in more than one insurance plan have received different ratings from different plans.
From a consumer’s perspective, it would be much better if the insurance companies all turned over their data to an independent organization to combine the results. It would be even better if evaluations also included such information as whether a doctor has been disciplined by state medical boards or has paid a large number of malpractice settlements.
Ideally, there should be a single Web site where consumers can get all the information they need to judge the quality of a doctor’s care and its cost-effectiveness.
Attached you find an interesting editorial from todays New York Times
The editorial highlights a disputed issue: how shall doctors performance be assessed and ranked.
An investigation by New York's attorney general has concluded that existing doctor-rating systems are based solely on the cost of care NOT on its quality.
Under a negotiated agreements with several major insurers, including Aetna, Cigna, United Healthcare and Empire Blue Cross/Blue Shield, a more user-friendly rating system should be developed that includes quality as measured by national standards and guidelines.
"Insurance companies have to make public what factors are included in their ratings and reveal how much weight they gave to cost in any composite score. An independent monitoring organization, approved by the attorney general, must oversee the process.
From a consumer’s perspective, it would be much better if the insurance companies all turned over their data to an independent organization to combine the results. It would be even better if evaluations also included such information as whether a doctor has been disciplined by state medical boards or has paid a large number of malpractice settlements."
This agreement may serve as a model for other states and organized medicine should proactively participate and contribute to the development of a rating system that empowers healthcare consumers to make informed decisions regarding their doctors choice.
Looking forward to your comments and critique.
Happy Holidays,
Yours
Bernd
December 8, 2007
Rating Your Doctor, Fairly
The drive to give consumers more information about the quality of their doctors has gotten an important shove forward by New York’s attorney general, Andrew Cuomo. That could be good for patients in dozens of states across the country that are served by some of the major health insurance companies.
An investigation by Mr. Cuomo’s office found that various doctor-rating systems currently used or planned by insurers are based primarily on the cost of care, not its quality. Doctors may be awarded a grade or stars, much like a restaurant or movie review, if they routinely treat sick patients for less than their competitors do. With that information, employers are able to steer their workers to lower-cost doctors by reducing deductibles or co-payments for those who patronize them.
Unfortunately, insurers seldom make clear just how they come up with their ratings, and there is no guarantee that the cheapest doctors are necessarily the best choice. Now the attorney general’s office has negotiated agreements with several major insurers, including Aetna, Cigna, United Healthcare and Empire Blue Cross/Blue Shield, that should make the ratings systems more useful to consumers and fairer to doctors.
Under the agreements, if insurers rate doctors, they cannot rely solely on cost but must also include quality as measured by national standards and guidelines. They have to make public what factors are included in their ratings and reveal how much weight they gave to cost in any composite score. An independent monitoring organization, approved by the attorney general, must oversee the process.
This approach has been endorsed by consumer advocacy groups, such as Consumers Union and the National Partnership for Women and Families, as well as the American Medical Association and the Medical Society of the State of New York.
Even with the improvements, ratings systems run by insurance companies may fail to provide consumers with the best possible information because they are based solely on the experience of that company’s subscribers. That may provide only limited insight into a doctor’s performance. Some doctors who participate in more than one insurance plan have received different ratings from different plans.
From a consumer’s perspective, it would be much better if the insurance companies all turned over their data to an independent organization to combine the results. It would be even better if evaluations also included such information as whether a doctor has been disciplined by state medical boards or has paid a large number of malpractice settlements.
Ideally, there should be a single Web site where consumers can get all the information they need to judge the quality of a doctor’s care and its cost-effectiveness.
Sunday, November 25, 2007
AMA Presidents Speech November 2007
hall We Dance?
61st Interim Meeting
American Medical Association House of Delegates
Hawaii Convention Center
Honolulu, Hawaii
Saturday, November 10, 2007
Ronald M. Davis, MD
President
American Medical Association
Aloha, and mahalo nui loa, thank you very much. I hope you’re all enjoying our location. I know I am. The beauty of these islands is simply unsurpassed. And the people are so warm and friendly. I think I feel healthier just breathing in the air here, or smelling the flowers. I wish we could write prescriptions for that.
Another reason why I have a deep affection for Hawaii is because my very first AMA meeting was here, back in December 1979. Also, my father was stationed here during World War II, from 1942 to 1945.
Hawaii is still a crucial strategic location in the world. Did you know that this is the only place with all five U.S. armed services on one small island? Soldiers at Schofield Barracks, sailors at Pearl Harbor, airmen at Hickam Air Force Base, Marines at Kaneohe Bay, and the Coast Guard patrolling the waters as well?
Wherever they are, and whenever they served, I want to acknowledge all those who put themselves in harm's way to protect our freedom, and this country, and a way of life that embraces peace and friendship among all people. And that includes the selfless physicians here with us from the Defense Department and the Veterans Administration.
My brother returned from Iraq two months ago, and like others returning from the front lines, he’s going through a challenging transition. As physicians, we’ll be dealing for years to come with highly visible physical injuries suffered by service members returning from Iraq and Afghanistan, and also post-traumatic stress disorders and other emotional wounds that afflict our returning troops. Let’s be ready for them. They deserve it.
Getting back to my father, who passed away in 1997 … he was in the 113th Radio Intelligence Corps, just a few miles from here. And in his free time, believe it or not, he taught ballroom dancing to his fellow GI’s.
Watching a film clip a few weeks ago of him teaching dancing in Hawaii got me thinking about the dancing we do at the AMA, and the partners with whom we dance. We engage in a very special form of dancing. It’s not the Hula. It’s not Tahitian dancing. It’s not nearly as pretty, or graceful, or enjoyable to watch. Sometimes it’s more like a limbo at a luau.
Thirty years ago, a Rhodes Scholar named Eric Redman wrote about “The Dance of Legislation.”
That was actually the title of his book, about the drafting and passage of legislation to establish the National Health Service Corps. The NHSC, through scholarship and loan repayment programs, has recruited more than 27,000 health professionals to deliver primary care in underserved communities.
Many of you have no doubt read “The Dance of Legislation.” Redman published an updated version of it a few years ago.
This dance is one of both triumph and frustration, and includes some strange moves and countermoves. But most of all, it involves one hell of a lot of work. And it’s a very slow dance. Legislative change usually occurs incrementally rather than revolutionarily.
Take a look at the State Children’s Heath Insurance Program, or SCHIP. The original legislation passes 10 years ago, but with a 10-year sunset. This year, Congress passes a bill to reauthorize the program, but it’s vetoed by President Bush, and the House fails to override his veto.
So now we have a new bill, stewing in the most partisan environment I’ve ever seen. Yet it’s over something that we, the members of the House of Delegates of the AMA, had no problem with last summer. We were virtually all on board when we adopted our position. It’s clearly in the best interests of everyone.
I’ve been disappointed in hearing a lot of uninformed criticisms of the SCHIP legislation. Let’s separate fact from fiction.
*Myth No. 1 is that the SCHIP compromise is a major step toward “government-run,” “socialized” health care. In fact, SCHIP is a public-private partnership, with 77 percent of kids in the program getting their coverage through private health plans. Let me ask you this: If the SCHIP legislation is socialized medicine, why is Senator Orrin Hatch supporting it?
* Myth No. 2 is that the SCHIP compromise vastly expands program eligibility. In fact, there is no provision in the bill to expand income eligibility for children, and the compromise will limit program eligibility more than current law.
* Myth No. 3 is that the SCHIP compromise bill will cover illegal immigrants. In fact, the SCHIP bill does not change current law prohibiting coverage for illegal immigrants. Health coverage is only available for U.S. citizens and legal immigrants who have been in the United States for at least five years.
*Myth No. 4 is that the SCHIP legislation will cover adults. In fact, the bill phases out non-pregnant adults from the program.
I don’t know about you, but I can no longer stomach rollercoaster rides. So let’s get SCHIP off Washington’s rollercoaster, so children from low-income families will have secure and reliable access to health care.
* * *
The first version of the SCHIP legislation in the House included Medicare physician payment reform. Unfortunately, the Medicare provisions were not included in legislation passed by the Senate, and did not make it into subsequent compromise bills. So now it’s likely we’ll be dancing with that one all the way to December, down to the wire, once again.
Recent Congresses seem to want to wait until a crisis occurs, or until the last possible moment before it would almost assuredly occur, before taking definitive action. And this pathetic yearly tourniquet approach to the SGR cuts is a perfect example of management by crisis.
We in medicine know a lot about crises through our work in disaster preparedness. We plan for, and respond to, terrorism, tsunamis, hurricanes, and many other mass-casualty events.
The latest are the fires in southern California, which were on everyone’s minds when I was at the California Medical Association’s annual meeting in Los Angeles a few weeks ago. Our hearts go out to our colleagues and their patients who have been affected by the fires, and we’ve offered assistance through our AMA Center for Public Health Preparedness and Disaster Response.
Speaking of fires, I share a birthday with the late Red Adair. You’ll remember that he was the world-famous oil field fire fighter, who successfully battled more than 2,000 fires in oil and natural gas wells.
Adair’s well control company, which continues its work today, divides its services into three categories: prevention, response, and restoration.
Let’s apply those approaches to the looming SGR disaster.
Let’s begin with prevention. Prevention involves safety inspections. We’ve already done safety inspections, and we already see weak points in our system of care for seniors. According to the Medicare Payment Advisory Commission, or MedPAC, about a quarter of seniors seeking a new primary care physician are already having difficulty in finding one to take care to them.
Prevention also includes conducting a risk assessment. We’ve done that too. And we see huge risks if Medicare cuts go through as projected.
According to our MemberConnect survey, if the 10 percent cut goes through in January, almost a third of physicians will reduce the number of new Medicare patients they accept, and almost 30 percent will stop accepting new Medicare patients altogether. Even more disturbing is that almost a third of physicians will reduce the number of established Medicare patients in their practice, if the 2008 cut goes through. And another eight percent will stop seeing any Medicare patients in their practice.
And ladies and gentlemen, 10 days after Halloween, this is not the type of scare I want. Before the U.S. Capitol becomes a haunted house, Congress needs to listen to MedPAC, its own advisory committee, and scrap the SGR. Listen to MedPAC, and tie physician payment to the Medicare Economic Index, the government’s own index for the costs of running a physician practice.
A few years ago, the Congressional Budget Office estimated that a permanent SGR fix would cost $90 billion. Now the CBO says that deep-sixing the SGR in favor of the MEI will cost us $262 billion. As Congress continues to kick the can down the road, effective remedies become more and more costly.
But Congress seems to ignore the benefits of preventing an SGR disaster. It seems willing to rely on disaster response and restoration.
Well, we need to tell Congress that if this imminent melt-down occurs, response and restoration will be slow in repairing the damage, will be expensive, and may ultimately fail. If physicians across the country are forced out of the Medicare program, and lose trust in the program, they may become wholly resistant to any last-ditch effort by the federal government to respond to the crisis, and to restore the program to “business as usual.”
Unless Congress has a “Medicare Red Adair” to put out brush fires in every one of the 3,066 counties in the United States, a lot of seniors are going to get burned.
I’m pleased that my own senator, Debbie Stabenow, is showing leadership on this issue. You’ll recall that she spoke at our National Advocacy Conference in February, wearing her AMA purple.
Two days ago, she spoke passionately about the SGR problem on the floor of the Senate. She called on Congress to “pass legislation this year that provides physicians with two years of positive Medicare payment updates … in a way that does not add to the cost of eliminating the SGR.”
Senator Stabenow endorsed a repeal of the SGR and the establishment of “a Medicare physician payment system that will provide stable, positive payment updates to preserve Medicare beneficiaries’ access to high-quality care for the long-term.”
She said, “It defies common sense to think that payment rates that are lower today than they were six years ago will be enough to maintain the access to care that our seniors need.”
Many physicians have told me that they doubt Congress will solve this problem unless a melt-down actually occurs. Thus, some have suggested that we acquiesce to the 10 percent cut for 2008 -- just let it go through, they say -- so Congress will see that our concerns and predictions are not a poker-style bluff.
A few have even suggested to me a physician boycott of the Medicare program. Well, boycotts raise serious legal and ethical issues. But I know where those suggestions come from. Many or most physicians are mad as hell and are in no mood to take it any longer. Lest you have any doubt, there’s as much anger on this stage as there is on the floor of this House and in physician offices across this country.
So let me highlight several courses of action that are available to physicians.
First, we can do what TV news anchor Howard Beale suggested in that 1976 movie “Network” -- get up out of your chairs, go to the window, open it, and stick your head out, and yell, “I’m as mad as hell, and I’m not going to take this anymore!”
Unfortunately we don’t have any windows in this room, so you’ll have to save your best Halloween scream for later.
For our second course of action, we must continue, and intensify, our advocacy efforts, talking to our Congressmen, and our patients, and the media, about the looming melt-down.
And third, we must remind physicians, in the face of these huge cuts, that they may wish to review their Medicare participation options.
As explained in the fact sheet that’s available on the tables at the back of this room, physicians who wish to change their current Medicare participation or non-participation status for next year, must do so between November 15th and December 31st.
They have three options:
One, they may sign a PAR agreement and accept Medicare’s allowed charge as payment in full for all of their Medicare patients.
Or, two, they may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients 9.25 percent above the PAR-approved payment rates.
Or, three, they may become private contracting physicians, agreeing to bill patients directly and to forego any payments from Medicare to their patients or themselves.
* * *
For folks who are fatigued by these endless machinations in policy, Eric Redman explains our current reality: “… the dance of legislation never really ends, and … a law may [even] intensify rather than terminate the perpetual struggle over policy.”
At the AMA, it’s our job to continue this dance until the music stops. Fortunately, we’ve had some nice recent victories in the smaller dance contests, such as getting the Department of Education to extend eligibility for deferring repayment of student loans, so that medical student and resident debt burdens don’t get worse than they already are. Yet that, too, is a short-term fix. We still need a long-term legislative solution to that problem.
Have you seen either of the current reality television shows, “So You Think You Can Dance” or “Dancing with the Stars”? To win these competitions, you need to be more than just the best dancer. There’s song selection. There’s how well you’re trained by a randomly chosen choreographer. And there’s your popularity with the viewers, who vote off the contestants. Thus, winning the dance contest involves talent, training, and a tendency to be liked.
Well, physicians have a lot of talent. Are we’re certainly well trained. And I’d like to think we’re popular among our patients. So we must show Congress that we’re in this for the long haul. We aim to win our dance marathon, and not get voted off.
Now, to accomplish this, I believe the key is to always keep patients as our main focus, and to ensure that their access to care is the basic harmonic running through everything we do.
Which is why we’ve been pushing so hard to be the Voice for the Uninsured.
I’m very proud of our campaign. We’ve joined forces with some of the most influential groups in America. And we’ve joined forces with our patients. What we’re doing, we’ve done before, but never with as much strategic and tactical focus.
So this is probably a good time to show you one of our 30-second spots. These will go national in January. And those of you in Iowa, South Carolina, and New Hampshire have most likely already seen it.
I’d really like to thank the Medical Societies of those states for their superb partnership with us on this campaign. When I was out on the road for four days last week in Iowa, I personally heard several sad stories about the devastating impact that lack of insurance can have on people who experience serious illness or injury.
I heard something else, too. Leaders of the Iowa Medical Society and I met with Gov. Chet Culver for an hour, to talk about covering the uninsured, Medicare physician payment reform, and a few other important issues. Moments after we walked into his office, the Governor mentioned that he had seen our AMA billboards about covering the uninsured all over the place.
I’m glad the Governor saw our signs. Because for two days before our meeting with him, I was out driving our mobile billboard around the state capitol in Des Moines.
So we need to do whatever it takes to get the message out in this campaign, to important decision-makers but also to our patients and to voters, to convince them to consider this issue when they decide which presidential candidate to support.
Politicians everywhere, but especially in Congress, need to be told by us that we’re going to do our damnedest to win these contests; that we’re going to lead the charge to provide the best health care for all Americans, but especially the most vulnerable: our children, the elderly, and the uninsured.
* * *
As we work toward covering all Americans, we need to remind our patients, and all citizens, that they play a critically important role in determining how healthy they are and how long they will live. More than one-third of all deaths in this country are due to four unhealthy lifestyles: tobacco use, alcohol abuse, poor diet, and physical inactivity.
That’s why I’m very pleased that earlier this week, our AMA and the American College of Sports Medicine launched a new initiative to assist physicians in helping their patients get more physical activity. The theme of the campaign is “Exercise is Medicine,” and we encourage you to prescribe exercise for all of your patients. Please check out the campaign website at www.exerciseismedicine.org.
Incidentally, one way to get exercise is through dancing. In fact, the state of West Virginia is combating the epidemic of youth obesity by placing the videogame “Dance Dance Revolution” in all 765 public schools in the Mountain State.
* * *
I sometimes wish I had inherited my father’s dancing skills. I did not.
But when we do the “Dance of Legislation,” whether for SCHIP or Medicare or another important issue, it really doesn’t matter if we occasionally step on our partner’s toes. It might even prove a point. What matters is, when the music stops, who wins the dance?
I hope you get the chance to catch the evening show at the Hilton Hawaiian Village or out at the Polynesian Cultural Center. You’ll be amazed at all the dancing. And the climax is a dancer who juggles flaming torches. It’s like combining Red Adair with Fred Astaire.
Sometimes, we have to juggle a little fire in our dance. That just comes with the territory. And when we have partners, we’re not always going to be in sync. And we may have to switch partners when we find one who has better moves. And we may need to stay on the dance floor longer than we thought we should.
So bring your Dr. Scholl’s.
Because we need to fight for physicians everywhere.
We need to prevail for patients everywhere.
And we need to win, not to get a trophy, but because it’s the right thing to do.
There is no one in this country who has more expertise in health care than we do. So in this dance, we need to take the lead.
###
61st Interim Meeting
American Medical Association House of Delegates
Hawaii Convention Center
Honolulu, Hawaii
Saturday, November 10, 2007
Ronald M. Davis, MD
President
American Medical Association
Aloha, and mahalo nui loa, thank you very much. I hope you’re all enjoying our location. I know I am. The beauty of these islands is simply unsurpassed. And the people are so warm and friendly. I think I feel healthier just breathing in the air here, or smelling the flowers. I wish we could write prescriptions for that.
Another reason why I have a deep affection for Hawaii is because my very first AMA meeting was here, back in December 1979. Also, my father was stationed here during World War II, from 1942 to 1945.
Hawaii is still a crucial strategic location in the world. Did you know that this is the only place with all five U.S. armed services on one small island? Soldiers at Schofield Barracks, sailors at Pearl Harbor, airmen at Hickam Air Force Base, Marines at Kaneohe Bay, and the Coast Guard patrolling the waters as well?
Wherever they are, and whenever they served, I want to acknowledge all those who put themselves in harm's way to protect our freedom, and this country, and a way of life that embraces peace and friendship among all people. And that includes the selfless physicians here with us from the Defense Department and the Veterans Administration.
My brother returned from Iraq two months ago, and like others returning from the front lines, he’s going through a challenging transition. As physicians, we’ll be dealing for years to come with highly visible physical injuries suffered by service members returning from Iraq and Afghanistan, and also post-traumatic stress disorders and other emotional wounds that afflict our returning troops. Let’s be ready for them. They deserve it.
Getting back to my father, who passed away in 1997 … he was in the 113th Radio Intelligence Corps, just a few miles from here. And in his free time, believe it or not, he taught ballroom dancing to his fellow GI’s.
Watching a film clip a few weeks ago of him teaching dancing in Hawaii got me thinking about the dancing we do at the AMA, and the partners with whom we dance. We engage in a very special form of dancing. It’s not the Hula. It’s not Tahitian dancing. It’s not nearly as pretty, or graceful, or enjoyable to watch. Sometimes it’s more like a limbo at a luau.
Thirty years ago, a Rhodes Scholar named Eric Redman wrote about “The Dance of Legislation.”
That was actually the title of his book, about the drafting and passage of legislation to establish the National Health Service Corps. The NHSC, through scholarship and loan repayment programs, has recruited more than 27,000 health professionals to deliver primary care in underserved communities.
Many of you have no doubt read “The Dance of Legislation.” Redman published an updated version of it a few years ago.
This dance is one of both triumph and frustration, and includes some strange moves and countermoves. But most of all, it involves one hell of a lot of work. And it’s a very slow dance. Legislative change usually occurs incrementally rather than revolutionarily.
Take a look at the State Children’s Heath Insurance Program, or SCHIP. The original legislation passes 10 years ago, but with a 10-year sunset. This year, Congress passes a bill to reauthorize the program, but it’s vetoed by President Bush, and the House fails to override his veto.
So now we have a new bill, stewing in the most partisan environment I’ve ever seen. Yet it’s over something that we, the members of the House of Delegates of the AMA, had no problem with last summer. We were virtually all on board when we adopted our position. It’s clearly in the best interests of everyone.
I’ve been disappointed in hearing a lot of uninformed criticisms of the SCHIP legislation. Let’s separate fact from fiction.
*Myth No. 1 is that the SCHIP compromise is a major step toward “government-run,” “socialized” health care. In fact, SCHIP is a public-private partnership, with 77 percent of kids in the program getting their coverage through private health plans. Let me ask you this: If the SCHIP legislation is socialized medicine, why is Senator Orrin Hatch supporting it?
* Myth No. 2 is that the SCHIP compromise vastly expands program eligibility. In fact, there is no provision in the bill to expand income eligibility for children, and the compromise will limit program eligibility more than current law.
* Myth No. 3 is that the SCHIP compromise bill will cover illegal immigrants. In fact, the SCHIP bill does not change current law prohibiting coverage for illegal immigrants. Health coverage is only available for U.S. citizens and legal immigrants who have been in the United States for at least five years.
*Myth No. 4 is that the SCHIP legislation will cover adults. In fact, the bill phases out non-pregnant adults from the program.
I don’t know about you, but I can no longer stomach rollercoaster rides. So let’s get SCHIP off Washington’s rollercoaster, so children from low-income families will have secure and reliable access to health care.
* * *
The first version of the SCHIP legislation in the House included Medicare physician payment reform. Unfortunately, the Medicare provisions were not included in legislation passed by the Senate, and did not make it into subsequent compromise bills. So now it’s likely we’ll be dancing with that one all the way to December, down to the wire, once again.
Recent Congresses seem to want to wait until a crisis occurs, or until the last possible moment before it would almost assuredly occur, before taking definitive action. And this pathetic yearly tourniquet approach to the SGR cuts is a perfect example of management by crisis.
We in medicine know a lot about crises through our work in disaster preparedness. We plan for, and respond to, terrorism, tsunamis, hurricanes, and many other mass-casualty events.
The latest are the fires in southern California, which were on everyone’s minds when I was at the California Medical Association’s annual meeting in Los Angeles a few weeks ago. Our hearts go out to our colleagues and their patients who have been affected by the fires, and we’ve offered assistance through our AMA Center for Public Health Preparedness and Disaster Response.
Speaking of fires, I share a birthday with the late Red Adair. You’ll remember that he was the world-famous oil field fire fighter, who successfully battled more than 2,000 fires in oil and natural gas wells.
Adair’s well control company, which continues its work today, divides its services into three categories: prevention, response, and restoration.
Let’s apply those approaches to the looming SGR disaster.
Let’s begin with prevention. Prevention involves safety inspections. We’ve already done safety inspections, and we already see weak points in our system of care for seniors. According to the Medicare Payment Advisory Commission, or MedPAC, about a quarter of seniors seeking a new primary care physician are already having difficulty in finding one to take care to them.
Prevention also includes conducting a risk assessment. We’ve done that too. And we see huge risks if Medicare cuts go through as projected.
According to our MemberConnect survey, if the 10 percent cut goes through in January, almost a third of physicians will reduce the number of new Medicare patients they accept, and almost 30 percent will stop accepting new Medicare patients altogether. Even more disturbing is that almost a third of physicians will reduce the number of established Medicare patients in their practice, if the 2008 cut goes through. And another eight percent will stop seeing any Medicare patients in their practice.
And ladies and gentlemen, 10 days after Halloween, this is not the type of scare I want. Before the U.S. Capitol becomes a haunted house, Congress needs to listen to MedPAC, its own advisory committee, and scrap the SGR. Listen to MedPAC, and tie physician payment to the Medicare Economic Index, the government’s own index for the costs of running a physician practice.
A few years ago, the Congressional Budget Office estimated that a permanent SGR fix would cost $90 billion. Now the CBO says that deep-sixing the SGR in favor of the MEI will cost us $262 billion. As Congress continues to kick the can down the road, effective remedies become more and more costly.
But Congress seems to ignore the benefits of preventing an SGR disaster. It seems willing to rely on disaster response and restoration.
Well, we need to tell Congress that if this imminent melt-down occurs, response and restoration will be slow in repairing the damage, will be expensive, and may ultimately fail. If physicians across the country are forced out of the Medicare program, and lose trust in the program, they may become wholly resistant to any last-ditch effort by the federal government to respond to the crisis, and to restore the program to “business as usual.”
Unless Congress has a “Medicare Red Adair” to put out brush fires in every one of the 3,066 counties in the United States, a lot of seniors are going to get burned.
I’m pleased that my own senator, Debbie Stabenow, is showing leadership on this issue. You’ll recall that she spoke at our National Advocacy Conference in February, wearing her AMA purple.
Two days ago, she spoke passionately about the SGR problem on the floor of the Senate. She called on Congress to “pass legislation this year that provides physicians with two years of positive Medicare payment updates … in a way that does not add to the cost of eliminating the SGR.”
Senator Stabenow endorsed a repeal of the SGR and the establishment of “a Medicare physician payment system that will provide stable, positive payment updates to preserve Medicare beneficiaries’ access to high-quality care for the long-term.”
She said, “It defies common sense to think that payment rates that are lower today than they were six years ago will be enough to maintain the access to care that our seniors need.”
Many physicians have told me that they doubt Congress will solve this problem unless a melt-down actually occurs. Thus, some have suggested that we acquiesce to the 10 percent cut for 2008 -- just let it go through, they say -- so Congress will see that our concerns and predictions are not a poker-style bluff.
A few have even suggested to me a physician boycott of the Medicare program. Well, boycotts raise serious legal and ethical issues. But I know where those suggestions come from. Many or most physicians are mad as hell and are in no mood to take it any longer. Lest you have any doubt, there’s as much anger on this stage as there is on the floor of this House and in physician offices across this country.
So let me highlight several courses of action that are available to physicians.
First, we can do what TV news anchor Howard Beale suggested in that 1976 movie “Network” -- get up out of your chairs, go to the window, open it, and stick your head out, and yell, “I’m as mad as hell, and I’m not going to take this anymore!”
Unfortunately we don’t have any windows in this room, so you’ll have to save your best Halloween scream for later.
For our second course of action, we must continue, and intensify, our advocacy efforts, talking to our Congressmen, and our patients, and the media, about the looming melt-down.
And third, we must remind physicians, in the face of these huge cuts, that they may wish to review their Medicare participation options.
As explained in the fact sheet that’s available on the tables at the back of this room, physicians who wish to change their current Medicare participation or non-participation status for next year, must do so between November 15th and December 31st.
They have three options:
One, they may sign a PAR agreement and accept Medicare’s allowed charge as payment in full for all of their Medicare patients.
Or, two, they may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients 9.25 percent above the PAR-approved payment rates.
Or, three, they may become private contracting physicians, agreeing to bill patients directly and to forego any payments from Medicare to their patients or themselves.
* * *
For folks who are fatigued by these endless machinations in policy, Eric Redman explains our current reality: “… the dance of legislation never really ends, and … a law may [even] intensify rather than terminate the perpetual struggle over policy.”
At the AMA, it’s our job to continue this dance until the music stops. Fortunately, we’ve had some nice recent victories in the smaller dance contests, such as getting the Department of Education to extend eligibility for deferring repayment of student loans, so that medical student and resident debt burdens don’t get worse than they already are. Yet that, too, is a short-term fix. We still need a long-term legislative solution to that problem.
Have you seen either of the current reality television shows, “So You Think You Can Dance” or “Dancing with the Stars”? To win these competitions, you need to be more than just the best dancer. There’s song selection. There’s how well you’re trained by a randomly chosen choreographer. And there’s your popularity with the viewers, who vote off the contestants. Thus, winning the dance contest involves talent, training, and a tendency to be liked.
Well, physicians have a lot of talent. Are we’re certainly well trained. And I’d like to think we’re popular among our patients. So we must show Congress that we’re in this for the long haul. We aim to win our dance marathon, and not get voted off.
Now, to accomplish this, I believe the key is to always keep patients as our main focus, and to ensure that their access to care is the basic harmonic running through everything we do.
Which is why we’ve been pushing so hard to be the Voice for the Uninsured.
I’m very proud of our campaign. We’ve joined forces with some of the most influential groups in America. And we’ve joined forces with our patients. What we’re doing, we’ve done before, but never with as much strategic and tactical focus.
So this is probably a good time to show you one of our 30-second spots. These will go national in January. And those of you in Iowa, South Carolina, and New Hampshire have most likely already seen it.
I’d really like to thank the Medical Societies of those states for their superb partnership with us on this campaign. When I was out on the road for four days last week in Iowa, I personally heard several sad stories about the devastating impact that lack of insurance can have on people who experience serious illness or injury.
I heard something else, too. Leaders of the Iowa Medical Society and I met with Gov. Chet Culver for an hour, to talk about covering the uninsured, Medicare physician payment reform, and a few other important issues. Moments after we walked into his office, the Governor mentioned that he had seen our AMA billboards about covering the uninsured all over the place.
I’m glad the Governor saw our signs. Because for two days before our meeting with him, I was out driving our mobile billboard around the state capitol in Des Moines.
So we need to do whatever it takes to get the message out in this campaign, to important decision-makers but also to our patients and to voters, to convince them to consider this issue when they decide which presidential candidate to support.
Politicians everywhere, but especially in Congress, need to be told by us that we’re going to do our damnedest to win these contests; that we’re going to lead the charge to provide the best health care for all Americans, but especially the most vulnerable: our children, the elderly, and the uninsured.
* * *
As we work toward covering all Americans, we need to remind our patients, and all citizens, that they play a critically important role in determining how healthy they are and how long they will live. More than one-third of all deaths in this country are due to four unhealthy lifestyles: tobacco use, alcohol abuse, poor diet, and physical inactivity.
That’s why I’m very pleased that earlier this week, our AMA and the American College of Sports Medicine launched a new initiative to assist physicians in helping their patients get more physical activity. The theme of the campaign is “Exercise is Medicine,” and we encourage you to prescribe exercise for all of your patients. Please check out the campaign website at www.exerciseismedicine.org.
Incidentally, one way to get exercise is through dancing. In fact, the state of West Virginia is combating the epidemic of youth obesity by placing the videogame “Dance Dance Revolution” in all 765 public schools in the Mountain State.
* * *
I sometimes wish I had inherited my father’s dancing skills. I did not.
But when we do the “Dance of Legislation,” whether for SCHIP or Medicare or another important issue, it really doesn’t matter if we occasionally step on our partner’s toes. It might even prove a point. What matters is, when the music stops, who wins the dance?
I hope you get the chance to catch the evening show at the Hilton Hawaiian Village or out at the Polynesian Cultural Center. You’ll be amazed at all the dancing. And the climax is a dancer who juggles flaming torches. It’s like combining Red Adair with Fred Astaire.
Sometimes, we have to juggle a little fire in our dance. That just comes with the territory. And when we have partners, we’re not always going to be in sync. And we may have to switch partners when we find one who has better moves. And we may need to stay on the dance floor longer than we thought we should.
So bring your Dr. Scholl’s.
Because we need to fight for physicians everywhere.
We need to prevail for patients everywhere.
And we need to win, not to get a trophy, but because it’s the right thing to do.
There is no one in this country who has more expertise in health care than we do. So in this dance, we need to take the lead.
###
Saturday, November 24, 2007
AMA Efforts Not Appreciated?
"Your Senators are telling us that they are not hearing from physicians about the looming Medicare physician payment cuts.
So let’s make sure they get the message: now is the time to include positive Medicare physician payment updates in the Medicare bill that is being put together!"
AMA Grassroots Legislative Alert
Dear Friends and Colleagues;
In the last few days I have read several e-mails blaming our AMA for the looming Medicare cuts and and in one of those e-mails the author even suggest that
" the AMA likes to have this issue every year as it allows them to say they did something."
Lets examine the facts before we engage in self-destructive behaviors that will prevent us from achieving our goals.
A recent AMA News article http://www.ama-assn.org/amednews/2007/11/19/gvl11119.htm reviews the current status of the Medicare physicians reimbursement battle. In this article American Medical Association Board of Trustees Chair Edward L. Langston, MD states that " Congress must step in to replace the cut with payment increases that keep up with medical practice costs. Next year's 10.1% physician payment cut is bad news for America's seniors as 60% of physicians say the cut will force them to limit the number of new Medicare patients they can treat."Dr. Langston suggested using $54 billion in what doctors view as excess payments to private Medicare health plans to offset the cut. These Medicare Advantage plans received 112% of the amount that traditional Medicare paid for each senior's care in 2006. The AMA News also published his opinion piece http://www.ama-assn.org/amednews/2007/11/05/edsa1105.htm regarding the Medicare Advantage Plans. Congress needs to level the playing field between traditional and private Medicare plans by eliminating excess payments to Medicare Advantage plans in the amount of $54 billion! This money would be MORE than enough to offset eliminating the the two-year cut in physicians reimbursement.Cuts to Medicare Advantage health plans' payment would also have lowered Medicare's regional benchmark payments to insurance companies, ended a stabilization fund used to share risks with insurance companies and eliminated indirect medical education payments to teaching hospitals.
But what are the political REALITIES we are faced with:
* In the House, an Energy and Commerce Committee staff member said leaders are sticking with the Medicare physician pay provisions adopted as part of its State Children's Health Insurance Program reauthorization bill in early August. The measure would have increased reimbursement 0.5% in 2008 and 2009 each.But the provisions were removed in the House-Senate compromise SCHIP bill in an attempt to maintain a veto-proof Senate majority.
* Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, would prefer to adopt a two-year payment fix by shifting some Medicare Advantage payments to fund physician reimbursement.But many Senate Republicans OPPOSE cutting private health plan payments therefore making it almost impossible to free additional funds to prevent the looming Medicare reimbursement cuts.
* Today, there are more than eight million seniors enrolled in the Medicare Advantage program that provides more services at a lower cost than traditional Medicare, but are often more limited in the health care providers available.An insurance industry sponsored survey revealed that more than 8 out of 10 survey respondents (84 percent) said they are happy with their healthcare coverage and 75 percent would recommend Medicare Advantage (MA) plans to their friends or family members.The survey also shows that beneficiaries believe sustained funding for the MA program is crucial, and nearly all survey respondents said it is important for Congress to work to maintain adequate funding for the program. Many worry that Medicare cuts could mean they could not afford to pay the bill for an unexpected illness (48 percent) or afford prescription drugs (45 percent). Our OPPOSITION to the MA program may backfire on us and we need to carefully navigate between reducing funding for the program and the popular support among seniors for the MA program. Any MA cuts will results in higher premiums for seniors who are already hit with a >20% premium increase for the Medicare part D program.
What can physicians do? TO SUPPORT OUR AMA in its effort to prevent the looming cuts by enrolling in the Grassroots network http://capwiz.com/ama/issues/alert/?alertid=10510101.
We need to flood the offices of senators to impress upon them that the Medicare cuts will limit access to health care services for seniors. They need to understand that those seniors will vote in the upcoming elections and their vote may be influenced by the Senates inactivity and intransigence.
PROMPT PAYMENT LAWS:
Our AMA is also vigorously lobbying for federal prompt-payment laws to close the loopholes of a system that resembles a swiss cheese.
See http://www.ama-assn.org/amednews/2007/11/05/gvsa1105.htm . Insurers have found loopholes to get around the state endorsed prompt-payment deadlines and are using federal law to slip out of state laws.
What is needed is a tough federal law penalizing insurance companies that delay payment.
One reason insurers can ignore prompt-payment laws is that they dominate the market in most communities, says Cecil B. Wilson, MD, immediate past chair of the AMA Board of Trustees. It gives them tremendous negotiating power and prevents physicians from addressing unfair payment practices. The situation, called an oligopsony, occurs when only a few buyers operate in a market with many sellers.
Another problem is that many health plans are not subject to state prompt-pay laws. The federal Employee Retirement Income Security Act exempts companies that self-insure from state insurance laws. About 55% of workers have such coverage, according to the 2007 Kaiser Family Foundation Employee Health Benefits Survey. The percentage rises with firm size: 77% of workers at businesses employing more than 200 people are in self-insured plans.
In addition, many health plans are not subject to state prompt-pay laws. The federal Employee Retirement Income Security Act exempts companies that self-insure from state insurance laws. About 55% of workers have such coverage, according to the 2007 Kaiser Family Foundation Employee Health Benefits Survey. The percentage rises with firm size: 77% of workers at businesses employing more than 200 people are in self-insured plans.
A federal law would fill the loopholes. Or very own Cecil Wilson,MD outlined the elements of a proposal when testifying to the House Small Business Committee's health panel in August:
* A strong federal standard. The AMA's policy is to support legislation that requires payment within 30 days for clean paper claims and 14 days for clean electronic claims.
* Stiffer fines than those in state laws to deter bad behavior. Interest should be assessed on the amount of payment outstanding and increase with the claim's delinquency. Physicians' attorney's fees and costs also should be provided when they win a claims dispute with an insurer.
* State law protections. Stronger state laws should be protected, and state requirements not covered by a federal standard should not be preempted.
* Application of state laws. Any federal law should clarify that state prompt-payment laws apply to all nongovernment health plans, denying insurers the argument that ERISA preempts state law.
* Time limits for notification. Federal law should set a statutorily defined time limit for insurers to notify physicians that additional information is needed to process a claim. The notice should specify all problems with the claim and give an opportunity to provide the information needed. Insurers also should be required to pay any portion of a claim that is complete and uncontested.
In these critical times it would be politically suicidal to divide organized medicine because some have "ideological differences" with AMA policies.
Political rigidity will hurt us. We need experienced leaders that can skillfully execute political decisions, are able and willing to reach reasonable compromises and achieve incremental change.
I hope that I am not alone stating that opinion and I call upon all of you to join our AMA in this struggle.
Yours
Bernd
FMA AMA Delegate
So let’s make sure they get the message: now is the time to include positive Medicare physician payment updates in the Medicare bill that is being put together!"
AMA Grassroots Legislative Alert
Dear Friends and Colleagues;
In the last few days I have read several e-mails blaming our AMA for the looming Medicare cuts and and in one of those e-mails the author even suggest that
" the AMA likes to have this issue every year as it allows them to say they did something."
Lets examine the facts before we engage in self-destructive behaviors that will prevent us from achieving our goals.
A recent AMA News article http://www.ama-assn.org/amednews/2007/11/19/gvl11119.htm reviews the current status of the Medicare physicians reimbursement battle. In this article American Medical Association Board of Trustees Chair Edward L. Langston, MD states that " Congress must step in to replace the cut with payment increases that keep up with medical practice costs. Next year's 10.1% physician payment cut is bad news for America's seniors as 60% of physicians say the cut will force them to limit the number of new Medicare patients they can treat."Dr. Langston suggested using $54 billion in what doctors view as excess payments to private Medicare health plans to offset the cut. These Medicare Advantage plans received 112% of the amount that traditional Medicare paid for each senior's care in 2006. The AMA News also published his opinion piece http://www.ama-assn.org/amednews/2007/11/05/edsa1105.htm regarding the Medicare Advantage Plans. Congress needs to level the playing field between traditional and private Medicare plans by eliminating excess payments to Medicare Advantage plans in the amount of $54 billion! This money would be MORE than enough to offset eliminating the the two-year cut in physicians reimbursement.Cuts to Medicare Advantage health plans' payment would also have lowered Medicare's regional benchmark payments to insurance companies, ended a stabilization fund used to share risks with insurance companies and eliminated indirect medical education payments to teaching hospitals.
But what are the political REALITIES we are faced with:
* In the House, an Energy and Commerce Committee staff member said leaders are sticking with the Medicare physician pay provisions adopted as part of its State Children's Health Insurance Program reauthorization bill in early August. The measure would have increased reimbursement 0.5% in 2008 and 2009 each.But the provisions were removed in the House-Senate compromise SCHIP bill in an attempt to maintain a veto-proof Senate majority.
* Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, would prefer to adopt a two-year payment fix by shifting some Medicare Advantage payments to fund physician reimbursement.But many Senate Republicans OPPOSE cutting private health plan payments therefore making it almost impossible to free additional funds to prevent the looming Medicare reimbursement cuts.
* Today, there are more than eight million seniors enrolled in the Medicare Advantage program that provides more services at a lower cost than traditional Medicare, but are often more limited in the health care providers available.An insurance industry sponsored survey revealed that more than 8 out of 10 survey respondents (84 percent) said they are happy with their healthcare coverage and 75 percent would recommend Medicare Advantage (MA) plans to their friends or family members.The survey also shows that beneficiaries believe sustained funding for the MA program is crucial, and nearly all survey respondents said it is important for Congress to work to maintain adequate funding for the program. Many worry that Medicare cuts could mean they could not afford to pay the bill for an unexpected illness (48 percent) or afford prescription drugs (45 percent). Our OPPOSITION to the MA program may backfire on us and we need to carefully navigate between reducing funding for the program and the popular support among seniors for the MA program. Any MA cuts will results in higher premiums for seniors who are already hit with a >20% premium increase for the Medicare part D program.
What can physicians do? TO SUPPORT OUR AMA in its effort to prevent the looming cuts by enrolling in the Grassroots network http://capwiz.com/ama/issues/alert/?alertid=10510101.
We need to flood the offices of senators to impress upon them that the Medicare cuts will limit access to health care services for seniors. They need to understand that those seniors will vote in the upcoming elections and their vote may be influenced by the Senates inactivity and intransigence.
PROMPT PAYMENT LAWS:
Our AMA is also vigorously lobbying for federal prompt-payment laws to close the loopholes of a system that resembles a swiss cheese.
See http://www.ama-assn.org/amednews/2007/11/05/gvsa1105.htm . Insurers have found loopholes to get around the state endorsed prompt-payment deadlines and are using federal law to slip out of state laws.
What is needed is a tough federal law penalizing insurance companies that delay payment.
One reason insurers can ignore prompt-payment laws is that they dominate the market in most communities, says Cecil B. Wilson, MD, immediate past chair of the AMA Board of Trustees. It gives them tremendous negotiating power and prevents physicians from addressing unfair payment practices. The situation, called an oligopsony, occurs when only a few buyers operate in a market with many sellers.
Another problem is that many health plans are not subject to state prompt-pay laws. The federal Employee Retirement Income Security Act exempts companies that self-insure from state insurance laws. About 55% of workers have such coverage, according to the 2007 Kaiser Family Foundation Employee Health Benefits Survey. The percentage rises with firm size: 77% of workers at businesses employing more than 200 people are in self-insured plans.
In addition, many health plans are not subject to state prompt-pay laws. The federal Employee Retirement Income Security Act exempts companies that self-insure from state insurance laws. About 55% of workers have such coverage, according to the 2007 Kaiser Family Foundation Employee Health Benefits Survey. The percentage rises with firm size: 77% of workers at businesses employing more than 200 people are in self-insured plans.
A federal law would fill the loopholes. Or very own Cecil Wilson,MD outlined the elements of a proposal when testifying to the House Small Business Committee's health panel in August:
* A strong federal standard. The AMA's policy is to support legislation that requires payment within 30 days for clean paper claims and 14 days for clean electronic claims.
* Stiffer fines than those in state laws to deter bad behavior. Interest should be assessed on the amount of payment outstanding and increase with the claim's delinquency. Physicians' attorney's fees and costs also should be provided when they win a claims dispute with an insurer.
* State law protections. Stronger state laws should be protected, and state requirements not covered by a federal standard should not be preempted.
* Application of state laws. Any federal law should clarify that state prompt-payment laws apply to all nongovernment health plans, denying insurers the argument that ERISA preempts state law.
* Time limits for notification. Federal law should set a statutorily defined time limit for insurers to notify physicians that additional information is needed to process a claim. The notice should specify all problems with the claim and give an opportunity to provide the information needed. Insurers also should be required to pay any portion of a claim that is complete and uncontested.
In these critical times it would be politically suicidal to divide organized medicine because some have "ideological differences" with AMA policies.
Political rigidity will hurt us. We need experienced leaders that can skillfully execute political decisions, are able and willing to reach reasonable compromises and achieve incremental change.
I hope that I am not alone stating that opinion and I call upon all of you to join our AMA in this struggle.
Yours
Bernd
FMA AMA Delegate
Thursday, November 22, 2007
Working Harder or WorkingSmarter?
"The healthcare system has put physicians in a bad place... the options they have for escaping it aren't good; in our fee-for-service system,
they mainly consist of performing more services, even though they may not be needed.
We need to move away from fee for service and reward doctors for more efficient, higher-quality care."
Paul Ginsburg, Center for Studying Health System Change
The latest edition of "Medical Economics" contains an exclusive survey about physicians compensation and work hours http://www.memag.com/memag/Physician+Surveys%3A+Compensation/Exclusive-Survey-Earnings-Group-practices-pay-bett/ArticleStandard/Article/detail/471128?contextCategoryId=8485
The key findings of the survey are not surprising:
* Most primary care physicians work harder to break even.
* Physician compensation in 2006 once again reflects economic forces that are eroding the cottage-industry model of medicine. If you want to earn more, join a group practice.
* While family physicians, internists, pediatricians, ob/gyns, and general practitioners as a whole earned a median of $165,000 last year, the soloists among them trailed the pack at $152,000, with doctors in two-partner practices second from last. Their peers in groups of 50 or more posted the highest earnings—$175,000.
* The percentage of internists, FPs, and pediatricians in solo practices and two-doctor groups slipped just a notch—from 37.5 percent in 1996-1997 to 35.6 percent in 2004-2005, according to the nonpartisan Center for Studying Health System Change (HSC). Those in groups of three to five also fell as a percentage, going from 10.3 percent to 7.3 percent during the same period.
* Medical and surgical specialists stand to earn far more by consolidating, and as a result, they're deserting solo and two-doctor practices at five to six times the rate in primary care.
* Suburban and rural doctors took home more than their urban and inner-city counterparts. The white coats of suburbia benefit from having the highest percentage of privately insured patients.
What can we learn from these facts:
1. The medical economic climate will remain cloudy in the foreseeable future and doctors need to adapt to the changing market place.
2. Declining reimbursement will force many doctors to work harder to keep their practices open, but working harder will cost MORE money (more staff hours, more overhead, more office utilization etc.)
3. Working SMARTER may include the following:
* Joining a group practice
* Rebalance the payer mix
* Renegotiate contracts and if necessary discontinue existing contractual relationships
* Hire midlevel providers (PA, NP
* Implement cutting -edge technologies (EHR, Electronic Prescribing etc.) to reduce the overhead, increase patient satisfaction, reduce waiting time, maximize billing options
o Comment: Many EHR systems provide quality reporting functions allowing you to demonstrate efficient, high-quality care to potential payers (employer groups, insurance companies). This puts the doctor in the position to negotiate higher reimbursement rates based on demonstrable quality care. I have had a meeting with an executive of a large employer group who offered to pay significantly MORE $$$ per visit if chronic disease management measures can be implemented that will reduce ER visits and hospitalizations. But doctors need to have tools in place to demonstrate that they can track patients adherence and disease management performance criteria. That is an untapped potential income source for doctors who are willing to take the leap into the 21st century medical practice.
The future for medicine is not that bleak if we learn to adapt to a changing market place.
Yours
Bernd
they mainly consist of performing more services, even though they may not be needed.
We need to move away from fee for service and reward doctors for more efficient, higher-quality care."
Paul Ginsburg, Center for Studying Health System Change
The latest edition of "Medical Economics" contains an exclusive survey about physicians compensation and work hours http://www.memag.com/memag/Physician+Surveys%3A+Compensation/Exclusive-Survey-Earnings-Group-practices-pay-bett/ArticleStandard/Article/detail/471128?contextCategoryId=8485
The key findings of the survey are not surprising:
* Most primary care physicians work harder to break even.
* Physician compensation in 2006 once again reflects economic forces that are eroding the cottage-industry model of medicine. If you want to earn more, join a group practice.
* While family physicians, internists, pediatricians, ob/gyns, and general practitioners as a whole earned a median of $165,000 last year, the soloists among them trailed the pack at $152,000, with doctors in two-partner practices second from last. Their peers in groups of 50 or more posted the highest earnings—$175,000.
* The percentage of internists, FPs, and pediatricians in solo practices and two-doctor groups slipped just a notch—from 37.5 percent in 1996-1997 to 35.6 percent in 2004-2005, according to the nonpartisan Center for Studying Health System Change (HSC). Those in groups of three to five also fell as a percentage, going from 10.3 percent to 7.3 percent during the same period.
* Medical and surgical specialists stand to earn far more by consolidating, and as a result, they're deserting solo and two-doctor practices at five to six times the rate in primary care.
* Suburban and rural doctors took home more than their urban and inner-city counterparts. The white coats of suburbia benefit from having the highest percentage of privately insured patients.
What can we learn from these facts:
1. The medical economic climate will remain cloudy in the foreseeable future and doctors need to adapt to the changing market place.
2. Declining reimbursement will force many doctors to work harder to keep their practices open, but working harder will cost MORE money (more staff hours, more overhead, more office utilization etc.)
3. Working SMARTER may include the following:
* Joining a group practice
* Rebalance the payer mix
* Renegotiate contracts and if necessary discontinue existing contractual relationships
* Hire midlevel providers (PA, NP
* Implement cutting -edge technologies (EHR, Electronic Prescribing etc.) to reduce the overhead, increase patient satisfaction, reduce waiting time, maximize billing options
o Comment: Many EHR systems provide quality reporting functions allowing you to demonstrate efficient, high-quality care to potential payers (employer groups, insurance companies). This puts the doctor in the position to negotiate higher reimbursement rates based on demonstrable quality care. I have had a meeting with an executive of a large employer group who offered to pay significantly MORE $$$ per visit if chronic disease management measures can be implemented that will reduce ER visits and hospitalizations. But doctors need to have tools in place to demonstrate that they can track patients adherence and disease management performance criteria. That is an untapped potential income source for doctors who are willing to take the leap into the 21st century medical practice.
The future for medicine is not that bleak if we learn to adapt to a changing market place.
Yours
Bernd
Tuesday, November 20, 2007
AMA Interim Meeting: Disappointing Results?
I have received an e-mail from a valued colleague and friend criticizing several decisions made at the recent AMA Interim meeting in Hawaii. I have offered my attached perspective:
"As an AMA delegate I would like to offer you a different perspective of the issues outlined in your e-mail and the conclusions you have drawn.Please be advised that my comments are NOT necessarily reflecting the consensus opinion of our delegation. I will try to present the issues as accurate as possible but those comments are subject to addendum, correction or deletion by others delegates.
1. Balanced Billing: Two resolution were submitted for discussion (906, 925). Resolution 906 was submitted by our delegation.The Reference Committee made the following recommendation to the HOD,
"RECOMMENDATION A:
Mr. Speaker, your Reference Committee recommends that the first resolve of Resolution 925 be amended by insertion and deletion on page 1, line 24 to read as follows:
RESOLVED, That our American Medical Association devote the necessary political and financial resources to introduce national legislation at the appropriate time to bring about implementation of Medicare balance billing by January 2009 and to end the budget neutral restrictions inherent in to the current Medicare physician payment structure that interferes with patient access to care. (Directive to Take Action)
RECOMMENDATION B:
Mr. Speaker, your Reference Committee recommends that the third resolve in Resolution 925 be deleted.
RECOMMENDATION C:
Mr. Speaker, your Reference Committee recommends that the fifth resolve in Resolution 925 be amended by insertion and deletion on page 2, line 1, to read as follows:
RESOLVED, That our AMA Board of Trustees report back to the our AMA House of Delegates, by e-mail or fax on a quarterly basis, electronically by March 15, 2008, and at other times as appropriate on their its progress toward the completion of all of these goals. (Directive to Take Action)
RECOMMENDATION D:
Mr. Speaker, your Reference Committee recommends that Resolution 925 be adopted as amended in lieu of Resolution 906.
Resolution 906 asks (1) that our American Medical Association devote the necessary political and financial resources to protect patient access to care by advocating for national legislation or litigation to unconditionally implement Medicare balance billing by January 2009 and to unconditionally end the budget neutral restrictions of the current Medicare Physician Payment structure; (2) that this national legislation or litigation be designed to pre-empt state laws that prohibit balance billing and prohibit inappropriate inclusion of balance billing bans in insurance-physician contracts; and (3) that our AMA develop model language for physicians to incorporate into any insurance contracts that attempt to restrict a physician’s right to balance bill any insured patient.
Resolution 925 asks (1) that our American Medical Association devote the necessary political and financial resources to introduce national legislation at the appropriate time to bring about implementation of Medicare balance billing by January 2009 and to end the budget neutral restrictions inherent to the current Medicare physician payment structure that interferes with patient access to care; (2) that this national legislation be designed to pre-empt state laws that prohibit balance billing and prohibit inappropriate inclusion of balance billing bans in insurance-physician contracts; (3) that our AMA work on federal legislation that would prohibit any law or regulation from interfering with the patient-doctor relationship including any and all fiduciary relationships that are deliberate and contractual; (4) that our AMA develop model language for physicians to incorporate into any insurance contracts that attempt to restrict a physician’s right to balance bill any insured patient; and (5) that our AMA Board of Trustees report back to the AMA House of Delegates, by e-mail or fax on a quarterly basis, their progress toward the completion of all of these goals.
Your Reference Committee heard strong testimony in support of Resolutions 906 and 925. Your Reference Committee appreciates and agrees with the sponsor of Resolution 925 that it is more prudent to advocate balance billing legislation at an appropriate time in contrast to a time certain, as this may hamper ongoing advocacy efforts with respect to other issues currently pending before Congress. Further, your Reference Committee believes that the third resolve in Resolution 925 is overly broad and confusing. Since Resolution 925 mirrors Resolution 906, your Reference Committee recommends adoption of Resolution 925, as amended, in lieu of Resolution 906. Comment: This does NOT imply that the AMA opposes balanced billing. At this point in time we MUST focus on THE ISSUE pending resolution: STOP THE MEDICARE CUTS. Even though, legislators may recognize the need to stop the cuts, they have done little to prevent them. Our AMA representatives including Dr. Cecil Wilson are working tiredlessly to convince House representatives and Senators to fix the SGR and to stop the Medicare once and forever. If we add balanced billing as an additional issue we may loose the battle. We all agree that balanced billing is our final goal but we need to prioritize our efforts and focus our advocacy on ONE and the MOST IMPORTANT issue now.
2. Opposing a single payor system: This resolution was introduced by the Georgia delegation and adopted as amended or substituted by the Reference Committee.
(1) Resolution 717 - Single Payer
RECOMMENDATION A:
Mr. Speaker, your Reference Committee recommends that the second resolve of Resolution 717 be amended by insertion and deletion on lines 24 -27 to read as follows:
RESOLVED, That our AMA distribute our policy positions in opposition to a single payer system on health system reform to all declared candidates for the presidency of the United States of America and formally request their public support of AMA policy positions on single payer system those positions (Directive to Take Action); and be it further
RECOMMENDATION B:
Mr. Speaker, your Reference Committee recommends that the third resolve of Resolution 717 be amended by insertion and deletion on lines 29 – 32 to read as follows.
RESOLVED, That our AMA immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the United States on health system reform, emphasizing pluralism. (Directive to Take Action)
RECOMMENDATION C:
Mr. Speaker, your Reference Committee recommends that Resolution 717 be adopted as amended.
Resolution 717 asks that our AMA (1) reaffirm AMA policy in support of pluralism, freedom of enterprise and its strong opposition to a single payer system; (2) distribute our policy positions in opposition to a single payer system to all declared candidates for the presidency of the United States of America and formally request their public support of AMA policy positions on single payer system; and (3) immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the US.
There was strong testimony in support of the sentiment expressed in the resolution, particularly the reaffirmation of policies referred to in the first resolve. However, compelling testimony cautioned against a negative campaign. Rather than criticizing the single payer approach, it was strongly suggested that the AMA should focus on clearly articulating AMA policies for health system reform to physicians and the public. There was some support for addressing AMA opposition to a single payer approach within the context of the Voice for the Uninsured Campaign.
Your Reference Committee concurs with testimony to keep the first resolve intact, and with testimony stating that any campaign should focus on a positive message promoting the AMA proposal for health system reform. There was testimony advocating linking the positive media campaign to the Voice for the Uninsured Campaign. Your Reference Committee believes that our AMA should have flexibility in implementing the two campaigns.
Comments: During the house debate the resolution was extracted from the consent calendar. Our delegation submitted additional language to be inserted after the following RESOLVED, That our AMA immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the United States on health system reform, emphasizing pluralism, creation of a marketdriven system, and continued opposition to a single payor system.(Directive to Take Action). This language was not adopted. I personally do not support a single payor system as THE only modality to reform the US healthcare system. A comprehensive system reform requires the participation of all participants in the healthcare delivery process - government (county, state, federal), insurance companies, employers etc.- . Our AMA is offering a plan to expand health insurance and we should support a PR campaign emphasizing this POSITIVE` message. We should clearly express what we stand FOR and not only what we are AGAINST. This resolution does not imply that the AMA favors a single payor system but in favor of market based approaches utilizing the brain power of potential innovative thinkers to reform our fragmented healthcare system.
3. Presidential Candidates:
(1) Resolution 603 - Presidential Candidates' Views on Health System Reform
RECOMMENDATION:
Mr. Speaker, your Reference Committee recommends that Resolution 603 be referred for decision.
Resolution 603 calls upon our American Medical Association (AMA) to host a US presidential candidate forum of all the candidates at the 2008 Annual Meeting.
Your Reference Committee received testimony that was uniformly positive of the resolution’s goal—making the views of presidential candidates on health reform available to physicians. There was some concern, however, about the method proposed by the resolution—using the next House meeting as the specific vehicle. Additional points raised included a potentially low fiscal note associated with this resolution, the questionable value of such a forum to presidential candidates because of a fairly small audience, the practicalities (audience questions, logistics, security concerns, etc.), and alternatives such as using our AMA web site as a way to share information with all member physicians, not just those in the House.
Your Reference Committee supports referral for decision to allow the Board to investigate the legal issues associated with an organization such as our AMA hosting a presidential candidate forum. There also would be major logistical concerns associated with using the House as a venue for a town hall meeting in June 2008. Referral will give the Board opportunity to study the feasibility of organizing the event as proposed, as well as to identify other ways to make physicians more informed voters and supporters of presidential candidates who espouse their preferred health care system. Referral for decision also will allow the Board to start planning the event, if feasible.
Comment: The recommended referral for decision was debated ad our delegation disagreed with that proposal. Nevertheless, that does NOT mean that our AMA will NOT support such a Forum but is seeking for an appropriate venue and suitable modality to maximize the desired effect of a such a forum. I trust the AMA Board to reach a decision on that matter.
I hope that the above information may help you to reach a balanced conclusion of the actions taken. Our AMA is the ONLY and MOST effective national physicians organization to represent our interest. Dissent and disagreement is inevitable but we all strive towards a compromise based on a common denominator: to represent the interests of the majority of all physicians. Your input is crucial and valuable and please continue sending me your e-mails. I am sure that other members of our delegation will provide you with their perspectives.
Please stay involved and do not drop your membership. Otherwise your voice cannot be heard!"
"As an AMA delegate I would like to offer you a different perspective of the issues outlined in your e-mail and the conclusions you have drawn.Please be advised that my comments are NOT necessarily reflecting the consensus opinion of our delegation. I will try to present the issues as accurate as possible but those comments are subject to addendum, correction or deletion by others delegates.
1. Balanced Billing: Two resolution were submitted for discussion (906, 925). Resolution 906 was submitted by our delegation.The Reference Committee made the following recommendation to the HOD,
"RECOMMENDATION A:
Mr. Speaker, your Reference Committee recommends that the first resolve of Resolution 925 be amended by insertion and deletion on page 1, line 24 to read as follows:
RESOLVED, That our American Medical Association devote the necessary political and financial resources to introduce national legislation at the appropriate time to bring about implementation of Medicare balance billing by January 2009 and to end the budget neutral restrictions inherent in to the current Medicare physician payment structure that interferes with patient access to care. (Directive to Take Action)
RECOMMENDATION B:
Mr. Speaker, your Reference Committee recommends that the third resolve in Resolution 925 be deleted.
RECOMMENDATION C:
Mr. Speaker, your Reference Committee recommends that the fifth resolve in Resolution 925 be amended by insertion and deletion on page 2, line 1, to read as follows:
RESOLVED, That our AMA Board of Trustees report back to the our AMA House of Delegates, by e-mail or fax on a quarterly basis, electronically by March 15, 2008, and at other times as appropriate on their its progress toward the completion of all of these goals. (Directive to Take Action)
RECOMMENDATION D:
Mr. Speaker, your Reference Committee recommends that Resolution 925 be adopted as amended in lieu of Resolution 906.
Resolution 906 asks (1) that our American Medical Association devote the necessary political and financial resources to protect patient access to care by advocating for national legislation or litigation to unconditionally implement Medicare balance billing by January 2009 and to unconditionally end the budget neutral restrictions of the current Medicare Physician Payment structure; (2) that this national legislation or litigation be designed to pre-empt state laws that prohibit balance billing and prohibit inappropriate inclusion of balance billing bans in insurance-physician contracts; and (3) that our AMA develop model language for physicians to incorporate into any insurance contracts that attempt to restrict a physician’s right to balance bill any insured patient.
Resolution 925 asks (1) that our American Medical Association devote the necessary political and financial resources to introduce national legislation at the appropriate time to bring about implementation of Medicare balance billing by January 2009 and to end the budget neutral restrictions inherent to the current Medicare physician payment structure that interferes with patient access to care; (2) that this national legislation be designed to pre-empt state laws that prohibit balance billing and prohibit inappropriate inclusion of balance billing bans in insurance-physician contracts; (3) that our AMA work on federal legislation that would prohibit any law or regulation from interfering with the patient-doctor relationship including any and all fiduciary relationships that are deliberate and contractual; (4) that our AMA develop model language for physicians to incorporate into any insurance contracts that attempt to restrict a physician’s right to balance bill any insured patient; and (5) that our AMA Board of Trustees report back to the AMA House of Delegates, by e-mail or fax on a quarterly basis, their progress toward the completion of all of these goals.
Your Reference Committee heard strong testimony in support of Resolutions 906 and 925. Your Reference Committee appreciates and agrees with the sponsor of Resolution 925 that it is more prudent to advocate balance billing legislation at an appropriate time in contrast to a time certain, as this may hamper ongoing advocacy efforts with respect to other issues currently pending before Congress. Further, your Reference Committee believes that the third resolve in Resolution 925 is overly broad and confusing. Since Resolution 925 mirrors Resolution 906, your Reference Committee recommends adoption of Resolution 925, as amended, in lieu of Resolution 906. Comment: This does NOT imply that the AMA opposes balanced billing. At this point in time we MUST focus on THE ISSUE pending resolution: STOP THE MEDICARE CUTS. Even though, legislators may recognize the need to stop the cuts, they have done little to prevent them. Our AMA representatives including Dr. Cecil Wilson are working tiredlessly to convince House representatives and Senators to fix the SGR and to stop the Medicare once and forever. If we add balanced billing as an additional issue we may loose the battle. We all agree that balanced billing is our final goal but we need to prioritize our efforts and focus our advocacy on ONE and the MOST IMPORTANT issue now.
2. Opposing a single payor system: This resolution was introduced by the Georgia delegation and adopted as amended or substituted by the Reference Committee.
(1) Resolution 717 - Single Payer
RECOMMENDATION A:
Mr. Speaker, your Reference Committee recommends that the second resolve of Resolution 717 be amended by insertion and deletion on lines 24 -27 to read as follows:
RESOLVED, That our AMA distribute our policy positions in opposition to a single payer system on health system reform to all declared candidates for the presidency of the United States of America and formally request their public support of AMA policy positions on single payer system those positions (Directive to Take Action); and be it further
RECOMMENDATION B:
Mr. Speaker, your Reference Committee recommends that the third resolve of Resolution 717 be amended by insertion and deletion on lines 29 – 32 to read as follows.
RESOLVED, That our AMA immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the United States on health system reform, emphasizing pluralism. (Directive to Take Action)
RECOMMENDATION C:
Mr. Speaker, your Reference Committee recommends that Resolution 717 be adopted as amended.
Resolution 717 asks that our AMA (1) reaffirm AMA policy in support of pluralism, freedom of enterprise and its strong opposition to a single payer system; (2) distribute our policy positions in opposition to a single payer system to all declared candidates for the presidency of the United States of America and formally request their public support of AMA policy positions on single payer system; and (3) immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the US.
There was strong testimony in support of the sentiment expressed in the resolution, particularly the reaffirmation of policies referred to in the first resolve. However, compelling testimony cautioned against a negative campaign. Rather than criticizing the single payer approach, it was strongly suggested that the AMA should focus on clearly articulating AMA policies for health system reform to physicians and the public. There was some support for addressing AMA opposition to a single payer approach within the context of the Voice for the Uninsured Campaign.
Your Reference Committee concurs with testimony to keep the first resolve intact, and with testimony stating that any campaign should focus on a positive message promoting the AMA proposal for health system reform. There was testimony advocating linking the positive media campaign to the Voice for the Uninsured Campaign. Your Reference Committee believes that our AMA should have flexibility in implementing the two campaigns.
Comments: During the house debate the resolution was extracted from the consent calendar. Our delegation submitted additional language to be inserted after the following RESOLVED, That our AMA immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the United States on health system reform, emphasizing pluralism, creation of a marketdriven system, and continued opposition to a single payor system.(Directive to Take Action). This language was not adopted. I personally do not support a single payor system as THE only modality to reform the US healthcare system. A comprehensive system reform requires the participation of all participants in the healthcare delivery process - government (county, state, federal), insurance companies, employers etc.- . Our AMA is offering a plan to expand health insurance and we should support a PR campaign emphasizing this POSITIVE` message. We should clearly express what we stand FOR and not only what we are AGAINST. This resolution does not imply that the AMA favors a single payor system but in favor of market based approaches utilizing the brain power of potential innovative thinkers to reform our fragmented healthcare system.
3. Presidential Candidates:
(1) Resolution 603 - Presidential Candidates' Views on Health System Reform
RECOMMENDATION:
Mr. Speaker, your Reference Committee recommends that Resolution 603 be referred for decision.
Resolution 603 calls upon our American Medical Association (AMA) to host a US presidential candidate forum of all the candidates at the 2008 Annual Meeting.
Your Reference Committee received testimony that was uniformly positive of the resolution’s goal—making the views of presidential candidates on health reform available to physicians. There was some concern, however, about the method proposed by the resolution—using the next House meeting as the specific vehicle. Additional points raised included a potentially low fiscal note associated with this resolution, the questionable value of such a forum to presidential candidates because of a fairly small audience, the practicalities (audience questions, logistics, security concerns, etc.), and alternatives such as using our AMA web site as a way to share information with all member physicians, not just those in the House.
Your Reference Committee supports referral for decision to allow the Board to investigate the legal issues associated with an organization such as our AMA hosting a presidential candidate forum. There also would be major logistical concerns associated with using the House as a venue for a town hall meeting in June 2008. Referral will give the Board opportunity to study the feasibility of organizing the event as proposed, as well as to identify other ways to make physicians more informed voters and supporters of presidential candidates who espouse their preferred health care system. Referral for decision also will allow the Board to start planning the event, if feasible.
Comment: The recommended referral for decision was debated ad our delegation disagreed with that proposal. Nevertheless, that does NOT mean that our AMA will NOT support such a Forum but is seeking for an appropriate venue and suitable modality to maximize the desired effect of a such a forum. I trust the AMA Board to reach a decision on that matter.
I hope that the above information may help you to reach a balanced conclusion of the actions taken. Our AMA is the ONLY and MOST effective national physicians organization to represent our interest. Dissent and disagreement is inevitable but we all strive towards a compromise based on a common denominator: to represent the interests of the majority of all physicians. Your input is crucial and valuable and please continue sending me your e-mails. I am sure that other members of our delegation will provide you with their perspectives.
Please stay involved and do not drop your membership. Otherwise your voice cannot be heard!"
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