March 12th, 2007 by Dr. Val Jones in Health Policy
Tags: Family Medicine, Finance, Internal Medicine, Quality
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In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).
The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought? PROBABLY NOT. Will some important detail slip past them? SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART. I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.
All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.
Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 3rd, 2007 by Dr. Val Jones in Health Policy
Tags: Medicare, News, Quality, Technology
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Improving quality in healthcare is an important fundamental goal. New “pay for performance” measures initiated by the Center for Medicare and Medicaid services is a well meaning attempt to provide financial incentives to physicians who demonstrate improved patient outcomes. Unfortunately, this incentive program could backfire.
A recent article in Medical Economics (via Kevin MD) raised the question of “cherry picking and lemon dropping” your way to higher pay. In this frightening scenario, physicians would be tempted to select healthier, more compliant patients for regular treatment in their practices. In this manner, they can demonstrate better outcomes, since the sicker, poorer, or less compliant patients no longer factor into their performance measures. And with the upcoming physician shortage, it really is a seller’s market.
It is critically important for the government programs to allow physicians to accurately risk stratify their patients so that they are not financially penalized for taking care of sicker patients bound to have below average outcomes. The same goes for surgeons, who should not be discouraged from undertaking potentially lifesaving surgeries for patients who are critically ill.
Dr. Kellerman, the president of the American Academy of Family Physicians, reminds us that quality of care is vastly improved by having a central medical home (i.e. one physician who can coordinate care for patients, so they’re not left with a group of disconnected specialists ordering duplicate tests and prescriptions). I personally think that a centralized EMR/PHR controlled by the patient (and located at an Internet based “medical home” complete with disease management tools and the ability to email a physician as needed) would go a long way to improving quality.
What do you think?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 17th, 2007 by Dr. Val Jones in Health Policy, Opinion
Tags: Cancer, Health Policy, Medicare, Politics
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Within the past few years the Centers for Medicare and Medicaid Services (CMS) chose to enforce a rule (casually known as the “75% rule”) that resulted in denial of services to many heart, lung, and cancer patients requiring rehabilitation therapies.
CMS was looking for a way to cut costs in rehabilitation facilities, and decided to create a rule whereby these facilities would lose their approval status if they admitted too many patients with certain conditions. The CMS arbitrarily decided that 75% of all patients admitted to inpatient rehabilitation facilities had to have one of 13 diagnoses, or else the rehab facility would not qualify for Medicare reimbursement. Many important diagnoses were not included in those 13, including cancer, heart and lung disease, and many types of orthopedic injuries.
What does this mean? It means that getting admitted to a rehabilitation facility is no longer based on need, but on diagnosis code. Because of the financial pressure exerted by CMS (Medicare is the primary payer for most facilities) these rehab centers cannot afford to be delisted. So they turn away patients in need, for patients who have the “right” diagnosis.
What has this rule done?
- Limited clinical decision making by doctors – a physician is no longer able to recommend patients for acute inpatient rehabilitation purely based on their need for it.
- Decreased choice for consumers – people recovering from heart attacks, cancer or COPD (to name a few) will generally not be offered the opportunity to be rehabilitated in an acute, inpatient setting.
- Reduced quality of care – rehabilitation facilities specializing in oncology or cardiopulmonary rehab will need to divest themselves of aggregated expertise. Since these centers would no longer qualify for Medicare funding, they can’t afford to remain centers of excellence in these fields of medicine. Instead, they will need to turn their attention to the 13 diagnoses that qualify for inpatient rehabilitation.
- Puts lives in danger – patients who are not admitted to acute rehab will be forced to recover in nursing homes (also known as “sub acute facilities”) that do not have the level of expertise to take care of them safely.
The 75% rule is one example of the kinds of decisions that a government sponsored universal healthcare system will make. When one payer (government or non-government) develops a monopoly, their decisions can single-handedly limit consumer choice, prevent physicians from exercising clinical judgment, and decrease quality and safety of care. What will Americans say when the decision to fund organ transplants for people over 65, for example, is denied across the board?
When medicine is no longer applied in a personalized (case by case) manner, and population-wide rules are in effect, we will face ethical dilemmas far surpassing those we already have. A system that serves the needs of many still fails the needs of some – and when we lose the flexibility to “bend the rules” for the exceptions we will lose the best of what American medicine has to offer.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
