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Physicians warm to value-based pay models, but skepticism runs deep 

Physicians warm to value-based pay models, but skepticism runs deep  | Healthcare and Technology news |

Though significant barriers still stand in the way of the transition to value-based reimbursement, a new study offers encouraging signs that physicians are getting more comfortable with new payment models.


The study, a joint effort between the American Academy of Family Physicians and Humana, follows up on a similar study they conducted in 2015. Representatives from both organizations—plus Health Care Transformation Task Force Executive Director Jeff Micklos—participated in a briefing Wednesday on to discuss the findings.


Amy Mullins, M.D., medical director of quality improvement for AAFP, said one of the data points that stood out the most was that 37% of those surveyed said payments based on quality measures were distributed to physicians at their practice—a “huge jump” from 2015, when it was just 18%.


Micklos also highlighted that finding, noting it’s a good sign that shared savings are trickling down to frontline doctors.

“Without that financial incentive, it’s really hard to convince a medical professional that there’s a sustainable business model there,” he said.


Mullins said it’s also promising that significantly fewer physicians said they were “not at all familiar” with the concept of value-based payments—7% in 2017 versus 12% in 2015. In addition, the study found that more practices are also hiring care management, care coordinators and behavioral health support to prepare for value-based care.


A variety of barriers

It is not all positive news, however. In 2017, only 8% of family physicians agreed with the statement that “quality expectations are easy to meet in value-based payment models,” compared to 13% in 2015. Plus, 62% cited “lack of evidence that using performance measures results in better patient care” as a barrier to adoption.


Even the finding that little more than half of physicians said their practice participates in value-based care models shows there is still work to be done.


“If you didn’t already know, physicians are a skeptical bunch,” Mullins said, later adding, “we are slow adopters for lots of things.”

And while the share of family physicians who have contracts with 10 or more payers remained about the same, Mullins said it’s still noteworthy that it’s as high as 37%. That illustrates how “frustrating and exhausting” it can be for physicians to deal with the myriad quality measures and systems associated with each payer, she added.


One potential barrier not covered in the survey is the uncertainty over what will happen with the Center for Medicare and Medicaid Innovation, Micklos said, noting that Medicare has long been the driver of what happens with the rest of the industry. The Trump administration has asked industry stakeholders for input on an effort to take the innovation center in a “new direction.”


The panelists were less concerned, though, with the administration’s move to end mandatory bundled payment models. Regardless of what specific policy levers are pulled, the move to value is smart for the private sector, as fee-for-services has a “tremendous amount of demonstrable inefficiencies,” said Roy Beveridge, M.D., Humana’s chief medical officer and senior vice president.


Micklos agreed, adding that bringing people “screaming” into certain payment models isn’t the most sustainable concept anyway.


The IT factor

A little more than half of the physicians surveyed said their practices were updating or adding IT infrastructure to prepare to participate in value-based care models. The same share—54%—said as much in 2015.


As important as that is, though, physicians still must have better, easier-to-understand and more timely data to truly move forward on connecting payment to health outcomes, Mullins pointed out.

In that effort, insurers can be a crucial partner, Beveridge said. They have a tremendous amount of analytics and other supports to offer physicians, he said, and thus have the responsibility to share that with physicians so that they can act upon it.


One of the biggest issues that both payers and providers continue to face, however, is the lack of interoperability between electronic health records systems.


From Humana’s point of view, “some of the barriers for interoperability really should not exist,” Beveridge said. But Mullins added that “I don’t know if there is a light at tend end of the tunnel or not,” on fixing the issue.

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How New Jersey Public Policy Fails Primary-Care Physicians

How New Jersey Public Policy Fails Primary-Care Physicians | Healthcare and Technology news |

We live in a very exciting time in the healthcare industry. Regardless of how you feel or think about decisions that are made on the government level, healthcare is in a period of controlled chaos right now.

With the potential merger of Anthem and Cigna and Aetna and Humana, or Assurant closing its doors on its health insurance business, things are about to get really interesting for medical practices. Arming yourself with as much information as possible is key to not just surviving financially, but thriving in this new environment.

Let's take Assurant, for example. They've decided that doing business in the healthcare arena and competing against the dominant healthcare insurance companies was far more expensive than expected. What does this mean for your practice? If you have patients that use Assurant as their medical insurance, it's a great idea to step in and take control of those accounts, now. Create a waiver for Assurant patients that explains what is going on, what to expect from their plan, and how they can still see you with a new insurance plan. The waiver should also state that in the event Assurant does not pay the medical claim, patients will be responsible for the allowed amount, and they will have to pay out of pocket if it is a PPO Plan. If the plan is an HMO, and Assurant does not pay, the practice is not allowed to place a PR (patient responsibility) to the patient and will lose that money.

Aetna and Assurant have similar fee schedules, so suggest to your patients to look into individual Aetna plans, to ensure that you will retain those patients and not lose revenue if you are contracted with Aetna. You will also need to really follow up with those claims and make sure that Assurant is paying you. I have seen them use a delaying tactic of denying a claim with the code CO95 (plan procedures not followed), which basically means they are sending your claim to a different claim address than what was provided to you at the time of benefit verification.  

As far as the pending mergers, I really love it when this happens. I'm particularly fond of the companies that have been courting each other lately. With the possible Aetna/Humana merger, Aetna will be able to add a lot more patients to their network. It will position them as a real player and earn them much needed respect within the market. I still have some overall issues with both Aetna and Humana, but merging them together should ease some of those issues.

The Anthem/Cigna cat-and-mouse game going on is particularly interesting. Cigna claims they're worth more than $184/share, and said no to Anthem's last purchase attempt. But Anthem is not giving up. Cigna used to be a premium plan until they teamed up with American Specialty Health. They have basically cut reimbursements to providers in half (if you signed up under their new network, otherwise you are seeing Cigna patients out of network), and implemented a time-consuming authorization process that eats away at whatever profit your practice may have left over from the reimbursement cuts. They implemented this over the course of the last year, or so. Working with Anthem is pretty cut and dried: What you see is what you get, with no hidden agendas. Anthem requires few to no pre-authorizations, allowing you to see your patient and maybe make a few bucks.

Just taking a few moments and reading up on what is going on in the healthcare industry today is really key to insuring your practice is not caught off guard. Always be learning, always be aware. There are multiple newsletters you can sign up for that will drop a daily or weekly e-mail into your inbox that will help you keep up.

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Medicine: A profession of sacred trust

Medicine: A profession of sacred trust | Healthcare and Technology news |

I remember one day a few years ago when I was talking with one of my friends about the challenges of being a doctor after a tough day at work. I had seen a large number of patients within the span of a few hours, and in addition to many of them being sick, I dealt with family members who had so many questions and who wanted to provide me more historic background about why their family member was in the hospital. I would try to patiently listen, but at times, I found it overwhelming since having so much interaction with other people was contrary to my introverted personality, the kind that preferred to be by myself in the midst of so much perceived chaos. I asked my friend, in a lamenting tone, why did so many people want to talk to me? Didn’t they realize that I was pressed for time and that I had so much to do? After I finished complaining, my friend told me, in a non-judgmental way, that I entered into a profession that by default brought forth a “sacred trust.”

“That’s why people want to talk to you; the white coat you wear, the demeanor you bring with you, and the reputation of the profession you entered allow people to trust you quickly. It is a sacred trust that comes with great responsibility.”

Sacred trust. Those two words stayed with me throughout the rest of the day, mainly because I was trying to figure out what my friend meant. What was ironic was that this was a member of the clergy telling me this; if any profession deserved to have those two words describe it, it was my friend’s profession, not mine. What was sacred about the interaction between a patient and a doctor? I could understand the trust aspect of the relationship, but a sacred aspect to it? My understanding of sacred had to do with encountering the divine, a sort of holy engagement of the senses. I ascribed it to things such as prayer, communion and liturgy, events within a religious context that I encounter on a frequent basis at church. So how could these two words be applied to medicine?

The more I’ve thought about it over the years, the more I realize that medicine is inherently a profession of vulnerability. We meet patients at their most vulnerable times, and inevitably there is a realization that only a privileged few have the knowledge to help improve their health, a most personal aspect of an individual. In the patients’ vulnerability, there is a realization that hiding certain aspects of their lives could potentially hinder their care. So conversation begins to take place as they gauge how much to tell us. As the conversation progresses, more aspects of a patient’s life are shared and these aspects become more personal. After a certain point, if enough trust is established, a conversation occurs as if two friends are talking, since the initial wall between doctor and patient is broken down, and as such, more intimate things are shared. It is in that intimacy that the sacred trust manifests, and unfiltered conversation happens, even if it is just for a little while. If we pay attention, we may find out that we are in the presence of a world-renowned author or a person who is one of the few people remaining from a generation that fought in World War II. These details do not come up initially and in most conversations would only be reserved for a select few, but somehow, doctors can become part of that select few in a few minutes when it usually takes a longer time for others. Without expecting it, I met both of those people all because of revelations from them in the setting of a sacred trust.

When I think about all this, it makes more sense for the word “sacred” to come into play. In a sense, we are coming in contact with patients and their real souls. We learn about what makes them tick in those moments of vulnerability. It is in that vulnerability where true intimacy takes place, and we learn more about one another in a few minutes than some people learn about others in a lifetime. When I think about those prior religious events that I mentioned earlier, I am bringing my whole soul to those moments, and that is what makes those events sacred to me. Perhaps in realizing that a patient may bring his own soul to me as a physician, in a moment of vulnerability, I can begin to see how medicine can foster a “sacred trust.”

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68% of New Doctors Prefer to be Employed Physicians

68% of New Doctors Prefer to be Employed Physicians | Healthcare and Technology news |

Newly-minted physicians have between fifty and one hundred job offers to sift through before the starch even wears out of their lab coats, according to a new survey by Merritt Hawkins, and the majority will choose employment with a larger practice, hospital, or health system over entering a solo private practice.  As an ongoing shortage of physicians, driven in part by the burden of mandates such as meaningful use and the expense of EHR adoption, begins to put the squeeze on care availability, new trends in physician employment are changing the way healthcare is delivered in the United States.

“Unlike virtually any other type of professional in today’s economy, newly trained doctors are being recruited like blue chip athletes,” said Mark Smith, president of Merritt Hawkins. “There are simply not enough physicians coming out of training to fill all the available openings.”

The organization asked more than 1200 medical residents about to graduate into the job market, about recruitment opportunities and their future plans.  More than 60 percent of the residents had received more than fifty solicitations from recruiters in the last year of residency, while 46 percent were flooded with more than one hundred job offers.

The overwhelming number of offers may have something to do with the extraordinarily low percentages of new recruits choosing what have become challenging career paths: solo practice or employment in a rural area.  Just two percent of respondents were interested in opening up their own practice, while a mere three percent would consider seeking a position in a community with less than 25,000 people.  More than two-thirds of new physicians headed straight for larger medical practices in more urban areas.

These decisions are contributing to the growing shortage of care in rural areas, which is compounded by an increasing number of elderly patients, more patients becoming eligible for care under the Affordable Care Act and Medicaid expansions, and the prevalence of chronic diseases.  In Colorado, for example, some rural counties would need to increase their physician population by more than 100% to meet basic state benchmarks for the ratio of providers to patients.

But that might not happen if the urban employment trend continues.  “The days of new doctors hanging out a shingle in an independent solo practice are over,” Smith said. “Most new doctors prefer to be employed and let a hospital or medical group handle the business end of medical practice.”

Yet even physicians who secure a place in a hospital or group setting are not entirely happy with their choice.  A quarter of residents indicated that if they had the option to start over again, they wouldn’t even choose the medical field at all.  Physician dissatisfaction is at an all-time high, driven by everything from an overwhelming number of EHR alerts that interrupt patient care and frustrate technology users to the coming of ICD-10, which is placing a considerable strain on hearts and wallets alike.

Employed physicians might not have to worry about cooking their own books, but they complain instead about being treated as cogs in a machine, losing autonomy, and being mismanaged by executive staff.  A March survey by the former American College of Physician Executives, now the American Association for Physician Leadership, found that many employed physicians gripe at corporate culture clashes, a lack of financial incentives, and disinterest in their opinions from organizational leaders.

“With declining reimbursement, increasing paperwork, and the uncertainty of health reform, many physicians are under duress today,” added Smith. “It is not surprising that many newly trained doctors are concerned about what awaits them.”

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Physician Asset-Protection Basics to Understand in 2015 | Physicians Practice

Physician Asset-Protection Basics to Understand in 2015 | Physicians Practice | Healthcare and Technology news |

To begin a discussion on asset protection basics, here are some key conceptual issues that doctors should understand:

1. The best medicine, just as in your profession, is prevention, not treatment.

Timing is always a key concept from a legal perspective; you may be legally unable to act (fraudulent conveyance, voidable transaction, etc.) or put in a position where the results are much less predictable and often more expensive if you try to implement even the best asset protection strategies against a known and existing exposure.

2. Asset protection is not just one thing; it's a system and lifestyle, just like wellness.

I warn the doctors I work with all over the country that there is no "magic pill" in asset protection and that when done right it involves four key areas:

• Clean living. A good first step is avoiding or eliminating legally risky behavior and not getting in trouble in the first place. This means having good, professionally drafted, legally compliant policies and procedures in place, and actually following and enforcing them uniformly.

• Managing risk factors. This means using experienced help in properly identifying all (or as many as possible) of your risks and addressing them proactively. A common mistake by doctors is failing to think beyond just medical malpractice risk. While that risk is very real and can be financially fatal, there are many others I've covered ranging from employee-related liabilities, to debt, Medicare audits, and even director's and officer's legal liability for practice owners and executives; this is just a small sample of the other issues that can negatively affect physicians who often overlook their personal liability in variety of areas as well. For instance, losing sleep over the possibility of a med-mal claim, but not having adequate personal liability insurance to cover an exposure at home, with family cars or for the actions of children.

• Insurance — and lots of it. Clients often ask me how much insurance they should have in place, and I say the same thing every time, "Every dollar you can afford, then have a back-up plan." This goes far beyond your professional liability or malpractice insurance and includes half a dozen or more varieties of specialty insurance that I've discussed before, and that can be well covered with the help of a top-notch property and casualty (P&C) insurance agent.

• Defensive legal structures. There will be gaps in the number of things that can be covered or the dollar limit to which you can insure yourself. This is where all the trusts, partnerships, corporate structures, estate-planning techniques, etc., that lawyers are so fond of talking about come into play. As an attorney who uses these structures every day I'll be the first to remind you that this is only one piece of the puzzle required. If your lawyer can't talk about anything but his own tools and can't speak knowledgably about your real exposures as outlined above, get better help.

3. Finally, asset protection is fact specific.

Every doctor seeking asset protection must have a thorough "exam" of her own assets, then have personal and professional risks "diagnosed," and have tools and solutions "prescribed" by a qualified and experienced professional. Just as in medicine, there may very well be a proven course of treatment for a particular problem, but your lawyer should know what the problems are before they (or worse, a non-lawyer or you yourself) start proposing solutions.

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Doctor Who? When Men Skimp on Physicals

Doctor Who? When Men Skimp on Physicals | Healthcare and Technology news |

If you're like a lot of guys, you probably haven't had a physical in a while. Men are 24% less likely than women to have seen a doctor in the past year. Yet men are more likely to check into the hospital for congestive heart failure, diabetes -- related problems -- and pneumonia. These are all issues that you might prevent with checkups.

Now, you don't have to go every year, but if it's been more than 2 years since you've seen your primary care doc, it's probably time to make that appointment.

What happens at a physical and how often you need one depend on your health and your age. The physical itself is a head-to-toe exam, and men over 50 can expect a rectal exam to check for prostate problems, intestinal bleeding, and early signs of prostate and colorectal cancers.

A typical visit also includes a blood pressure check, which you should have at least every 2 years, and giving blood samples. Doctors use blood tests to check for diabetes and cholesterol level. Adults older than 20 who don't have risk factors for heart disease should have their cholesterol checked every 4 to 6 years. Adults who are overweight or have high blood pressure should get a diabetes screening test.

Chronic diseases and cancers may not show any symptoms at first, but you stand the best chance of curing or managing them when your doctor catches them early.

"Somebody may have severe diabetes and not have any symptoms, so certainly there's opportunity to turn some of those things around if they're detected early," says Clark T. Eddy, DO, of ProPartnersMD. That's a medical group in the Kansas City area that specializes in men's health.

During your checkup, you'll answer questions that can help your doctor see signs of depression or habits that might be a risk to your health. Depending on your lifestyle and personal and family history, your doctor might suggest more tests. The doctor will also recommend vaccines based on your age and lifestyle.

"Even if you haven't been to a doctor in 20 years," Eddy says, "coming in for a physical is the first step to being a more active participant in your health."

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How Community Hospital Used Health IT to Conquer MERS

How Community Hospital Used Health IT to Conquer MERS | Healthcare and Technology news |

A little more than a month ago, Community Hospital was not in the most enviable of positions for a hospital.

The 450-bed, regional tertiary care facility in Munster, Ind. became home to the first patient in the U.S. with a confirmed case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in late April. The potentially deadly viral respiratory illness, which has no known recommended vaccine or treatment, can spread like wildfire to anyone in close contact with the patient. In Saudi Arabia, where it likely originated, the Centers for Disease Control (CDC) say there have been 450 lab-confirmed cases and 112 deaths (as of May 2014).

It’s fair to surmise that things could have gone very badly for Community Hospital. Look no farther than Abu Dhabi, where experts from the World Health Organization (WHO) say that failure to control the virus by hospitals and healthcare settings in the city have exacerbated the problem. If MERS had spread in the U.S., Community Hospital, which is located very close to one of the busiest interstate highways in the nation, very well could have been targeted for blame.

Instead, MERS cases in the U.S. have been few and far between, and not one person has contracted the virus from the patient who stepped into the Community Hospital’s ER the night of April 28th. Much of this has to do with Community Hospital’s fast acting approach in treating the patient from the minute he arrived.

“We have protocols and procedures in place that we like to use. When someone has respiratory symptoms, we like to isolate them every time because there are some diseases that we’re not aware of that could be contagious,” says Alan Kumar, M.D., Chief Medical Information Officer at Community Hospital. “You don’t want to take chances. We had a room that was negative airflow [when the air from the room doesn’t mix the rest of the hospital]. We put him in that room in the possibility that it was something bad.”

It ended up being something bad.

Thanks to the infectious disease specialist finding out the patient had recently visited Saudi Arabia, she and other members of Community’s medical staff were able to deduce that he likely had MERS. The isolation was amped up with Community using gloves, masks, gowns, and all kinds of protection. Two days later, a test confirmed that the patient was positive for MERS. The hospital began working with the CDC and Indiana Department of Health to ensure the disease didn’t spread and that the Community Hospital workers and public were being educated.

One important task was to determine who had come into contact with the patient and was possibly at risk for MERS. To do this, Community relied on video footage, patient interaction notes in the electronic medical record (EMR), and radio-frequency identification (RFID)-based technology.

The RFID system (from the Traverse City, Mich.-based Versus Technology) was installed by Community in 2009 to decrease overhead noise in hospital units. It automatically logs when healthcare providers have entered the room, how long they’ve been in a room, and how long it takes from them to go from one room to the next. Thus, when nurses and doctors are needed, the hospital knows where they are located. In this case, it allowed them to track who was in the room with the MERS patient and for how long.

“The CDC found this data absolutely amazing because it’s something they never had access to in any prior investigation, to know down to the minute and down to the second, how long a healthcare worker was in contact with the patient,” says Kumar. He adds that for those healthcare workers who don’t wear the RFID tags, such as ambulatory workers, imaging specialists, and social workers, the EMR was a useful tool in tracking interactions.

A few weeks after he first stepped into the hospital, the patient was cleared of the virus and deemed not a risk to the public. Every single person who came in contact with him was tested. Even though none of them came back positive, they were taken offline until the longest window of incubation (14 days) had passed. They were repeat tested after that window and again, none tested positive.

From beginning to end, Community Hospital was able to escape this incident unscathed. Everything went smoothly when it absolutely had to go smoothly. When it comes to the role RFID and other health IT played in this success, Kumar says there is a lesson to be learned for other hospital executives.

“It’s not meant to watch employees. It’s meant for something more admirable. If you approach IT spending with the goal of ‘Does this improve quality of care to patients?’ and the answer is yes, that’s why you invest. Everything else is secondary to that goal,” Kumar concludes. 

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Is reactive scheduling for hospitalists a good idea?

Is reactive scheduling for hospitalists a good idea? | Healthcare and Technology news |

My earliest memories of medicine take me back to dinner table conversations with my mother, who is a physician. She would share with us her daily stories, telling us about patients she took care of in her clinics and in the hospital. As an internist, she often found herself traveling between many locations. I grew up knowing this to be medicine. As I have progressed in my career as a hospitalist, I have seen how physicians’ practice has evolved and changed in many ways. Some of us stick to the inpatient world, some of us the outpatient, and many still partake in the ‘traditional’ model my mother practiced in. Throughout all of these scenarios, I see one commonality. Most of us see our patients day after day in a continuous fashion for the length of time that we work; we have a degree of continuity.

Recently I have been hearing more and more discussions in the c-suite  about ”reactive scheduling” models for hospitalists. And it should come as no surprise to you then that I find this concerning.

Reactive scheduling suggests a system akin to that used by many nursing practices throughout the country. The model functions by way of supply and demand. Practitioners are scheduled, canceled or asked to work overtime based on the hospital-wide census and a need for manpower on a day-to-day basis. My nursing colleagues tell me stories of waiting for “the call” to hear if they will be working or not, and sometimes coming in to work only to be sent home early later in the day. To me, it seems a bit chaotic.

I can easily see the allure of applying this model to hospital medicine. Census can shift dramatically; one day the patient volume is exceptionally high with many admissions, but several days and many discharges later, it’s very low. Wouldn’t it be great if you could cancel shifts for docs you didn’t need? Or call more in when things are busy? While it might make financial sense on the surface, this type of model creates a slippery slope that could harm physician morale, patient care,  and the overall function of any given hospital system.

Let’s start with physician morale. Most physicians enter the medical profession knowing they will make sacrifices to succeed as a doctor. This creates a mindset that makes it the right thing to do to put in extra hours to ensure a patient is well taken care of. Our days by their very nature are fluid and dependent on the needs of our patients. We also like to (when possible) provide complete care for our patients, seeing them through the entirety of their hospital stay, helping them get better.  Reactive scheduling undermines this mindset and dampens our level of commitment.

For example, if a doc’s shift could be canceled, he or she may be less inclined to put in that extra effort to tee things up for the next day. Additionally, continuity of care suffers. It becomes difficult to make thoughtful medical decisions, especially if you are covering shifts in a spotty fashion. Where do you get a chance to see the big picture? And with a constantly shifting census, will you even be seeing the same patients?

I re-emphasize here continuity of care. Besides just affecting our medical thought process, it more importantly impacts patient care. This is why most hospitalist practices are a 7-on/7-off model. A full week of work allows for the majority of one’s patients to be managed by a single practitioner. That person is aware of everything that happens to the patient, makes consistent medical decisions, and is better equipped to see the big picture. Furthermore, hand-offs decrease, and with that, so do medical errors. All of these things are positive for patients. From an institutional perspective, continuity is a wonderful thing. HCAHPS scores go up, length of stay goes down, and patients move through the system more efficiently and are better cared for. Reactive scheduling would kill continuity, eliminating all of the efficiency we’ve provided for our hospitals over the many years.

While a great financial argument can be made to staff physicians based on census, the benefits do not outweigh the true cost to the health system. It would create an environment where hospitalists are dissatisfied and disassociated from their job. It does not engage practitioners to commit to providing high-quality, efficient, big-picture medicine. It would likely reflect poorly on patient outcomes and the metrics we currently look at to ensure that we are practicing well. It will definitely increase hand-offs, worsen medical errors, and negatively affect care.

Patients like familiarity and to see the same doctor day after day. While they certainly need work, our current hospital medicine models do provide for this. Let’s continue to provide our patients with the best possible care, and stop trying to beat the supply/demand curve.

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Physicians must expand the vision of their role

Physicians must expand the vision of their role | Healthcare and Technology news |
Once upon a time, in a medical school far far away, I was taught that my sacred oath was to the patient. The one patient; not the patient down the hall, in the next town, or in a country halfway around the world. I would commit my heart, soul, sweat and blood to the suffering and healing of the person directly, immediately in my care. This was a noble calling taught by wise and noble teachers. It was wrong.

This model of medicine demanded that I be an absolute biased advocate and was to ignore all other considerations and consequence. Each patient was to know that when we sat together I was not thinking about dollars, resources, limitations of a mythical “health care system,” the effect on other patients, nor any ethical caveat. In their worse hours, in the middle of fear, pain and the threat of infinite loss, I would be there for them. I was their unconditional champion.

In a limitless attempt to heal, I swore to fight not only disease and fear, but society itself. No beds in the hospital? Sneak through the clinic. No data? Make it up … extrapolate from other disease. Side effects be damned. And cost? Expense? Limitations of insurance or personal fortune? Scream from the mountaintops and demand that someone else, anyone else, find the resources to pay for the care of my patient and ignore those patients who were somewhere else, maybe even in the exam room next door.

Like every doctor in my generation, I denied that there was more than one patient; as if the health of my patient could be seen completely in isolation. The result was a disaster of health care dysregulation and malcoordination. Not only did the choices for my patient become scarce, many more patients suffered as I consumed precious resources in an imbalanced crusade to treat the one.

Health research has progressed slowly because it is poorly coordinated. One-third of families go bankrupt paying medical bills. Tens of millions die from inadequate or non-existent care. 600 billion dollars a year are wasted in the U.S. alone. The chaos produces quality variation, which makes a mockery of the word “system.” If it were written as a play, it would be panned as horrendous farce.

Slowly, doctors have come to understand that in order to take care of the one patient, they must take care of the many. Resources are precious and are best used in a coordinated fashion. Quality medicine cannot be practiced for the one as an island surrounded in a hostile sea; we must understand that the one touches many.

We cure cancer by coordinating discovery and treatment. Fight obesity, diabetes and heart disease by improving the nutrition of all. Save thousands by national anti-tobacco campaigns. Limit traumatic injury by focusing on auto, home and work place safety. Stop Ebola from infesting my hometown, not by waiting for Africa to collapse, but by aggressively attacking the virus at its source.

When I was a medical student, my gestalt of the patient extended no further then the sheets of a single bed. Now I understand that the patient is connected to the entire world, and I cannot help them, cannot save them, unless I appreciate that my role, the role of the doctor, must be international. Therefore, I now wonder if physicians are called to address the greatest health threat in the history of man.

Far beyond any cancer, war or plague, the coming health disaster promises disease and death at a scale never seen. Perhaps, given failing world leadership, it is the role of physicians, as caregivers, as scientists, as those ultimately responsible for the treatment of human suffering, to address global warming.

Every scientific model shows that the fire which mankind has lit and pours carbon into the atmosphere at a rate unmatched in the history of the earth, will result in continued rapid rise of global temperatures. Even the most optimistic prediction shows sea levels rising by inches within decades and some predict a meter or two elevation by 2100. The surface of the planet is going to rapidly change.

Global warming will cause massive human illness and disease. The World Health Organization already estimates a minimum of 150,000 deaths each year from climate change and this number is expected to rise rapidly, perhaps logarithmically. In Moscow this year, 10,000 people died from heat exposure, while New Delhi, where is air conditioning scarce, frequently reached 120 degrees. 2014 will be the hottest year ever recorded. Infectious illness will spread, malnutrition will increase, chronic lung disease skyrocket and lethal skin cancers will reach epidemic proportions.

While these basic results of global warming represent a catastrophe, this may be only the beginning. As governments have wasted time pounding their chests and making believe that planetary transformation is a nationalistic concern, we have lost precious decades, which might have been used to prevent devastation. If not arrested soon, the transformation of the habitable parts of the planet will wipe out through flood, storm, starvation and disease most human life. What part of mankind is not exterminated will be obliterated by war as the remnants of man and womankind claw to find safety on isolated habitable soil.

In the decades to come will the doctors at each bedside wonder how we allowed such horrendous, preventative, health care neglect to happen? Without support and direction, we cannot depend on the autocrats, plutocrats, technocrats and even democratically elected leadership to seize the day.

Physicians must again expand the vision of their role. While we work to fight conventional disease, we must understand that if we cure cancer, heart disease, dementia and all infections tomorrow, we will fail to save a single soul. Even if we stop aging and extend the life span to 200 years, there will be nothing left. The species itself is threatened; most, if not all, persons may perish. As healers, we are called upon to prevent suffering at a scale never before dreamed.

Once upon a time, in a medical school far far away, I was taught that my sacred oath and calling was to the patient. The one patient. That has not changed. What I see now, what all doctors must understand, is that the individual patient, that one patient, that precious, irreplaceable patient, is mankind.
David Greene's curator insight, December 9, 2014 3:20 PM

I think the challenge with this line of thinking is it puts everything on the shoulders of the physician.  There are many other players in the delivery of care.  I would agree physicians must be flexible in their thinking, but systems need to expand the solution of improving quality to include other factors as well as the patient and physician relationship.!

Diffusing Angry Patients: It's as Simple as ABCD | Physicians Practice

Diffusing Angry Patients: It's as Simple as ABCD | Physicians Practice | Healthcare and Technology news |
Unsurprisingly, people are more stressed than ever before. According to a recent poll by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health, nearly half of 2,500 adults surveyed admitted to a major stressful event within the last year. More than a quarter tied their specific stressor to a health-related problem.

And when that outside stress becomes too much for patients (see sidebar below), physicians may witness more angry or violent behavior in the exam room.

Acknowledge the anger

Emergency rooms are notorious for running high on emotional energy, simply due to the nature of the operation. So it can be difficult to pinpoint what is triggering a patient's outbursts.

Aaron Braun, medical director of PhysiciansER Mission Bend, a freestanding emergency room located in the Houston area, tries to find the path of least resistance. "If the patient is angry, is there some quick fix? If the answer is simple," said Braun, "I would capitulate and get them what they would like within reasonable bounds."

That may mean providing a snack or meal to a hungry patient, or if the anger is stemming from a personality conflict with staff, reassigning nurses or caretakers as needed. Regardless, the focus should be on listening and acknowledging the patient's anger, even if you can't solve the immediate problem at hand.

"Frequently, there are no simple solutions, especially if the patient is psychotic," said Braun. "And the best way to [approach] them is to talk to them in a calm and gentle manner."

As odd as it may sound, Braun relies on food to help these situations. "I always try to get the angry patient to eat something, because it gets their mind off of what is bothering them and a full stomach tends to make for a sleepy (more docile) patient."

Be benevolent

Marc Leavey, board-certified in internal medicine and a primary-care specialist at Maryland-based Lutherville Personal Physicians, says he's seen finances become a catalyst for this type of erratic behavior too.

Is Your Patient Prone to Greater Stress?

NPR's recent study shed light on specific groups who were more likely to experience periods of great stress. Note that personal health concerns ranked among the top three groups.

• Poor health condition: 60 percent
• Disabled: 45 percent
• Chronic illness: 36 percent
• Income less than $20,000: 36 percent
• Experiences dangerous work situations: 36 percent
• Single parent: 35 percent
• Parent of a teen: 35 percent

Given the drastic changes to healthcare recently, and the misinformation that has inevitably followed, patients are rightfully concerned about being able to afford ongoing treatments. "It doesn't seem to matter if you say to the patient, 'Don't worry about [the cost] or we will deal with it [later],' they begin getting a little bit testy," said Leavey.

Remembering that these patients are most likely scared to lose their coverage or medical access can help lead physicians to a solution. "Being creative and trying to come up with a solution that meets the patient's needs while still maintaining good medical care [is ideal]," said Leavey.

And ensuring patients know about options like alternative treatments and medications can go a long way in negating their anger, especially when their concerns are based on personal finances. If a patient is most upset because they can't afford the medicine as prescribed, simply offering a generic medication — at a fraction of the cost — can resolve the entire dilemma.

Curtail confrontation

Confrontation may seem inevitable in these instances, but ideally, it should be avoided at all costs.

"If you do confront [the patient], all you are going to do is make them [more] angry," said Leavey. He recalls a patient who jumped over the front check-in desk during a fit of rage. Knowing he wasn't angry at the front-desk employee, but was instead, angry in general, helped staff understand how to approach the patient.

"It sounds trite, but you have to understand where they're coming from," said Leavey. "You have to be aware of your voice and body language and avoid doing things that are obviously antagonistic."

Although it goes against human instinct, physicians will have greater success at diffusing a scenario if they remain calm and monitor their language, while avoiding raised voices or body language like crossed arms.

Don't forget to document

As in every other patient-physician exchange, documentation is key. Physicians will want to include the details of angry and violent outbursts in the patient's chart. This not only serves to forewarn other healthcare professionals who encounter the patient, but also may identify an ongoing decrease in mental health status that warrants further intervention.

Ideally, physicians would be able to diffuse every angry patient, while also determining the core of their angst. But Braun reminds us that's just not feasible. "Negotiation is an art that is learned simply by experience. Some are better at it than others," he said. "The bottom line is that the safety of the staff, other patients, and the patient must be of first priority and not every situation will allow a physician the luxury of being able to tease out the root of the patient's abnormal behavior."
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Get help: Most physicians are not good at business

Get help: Most physicians are not good at business | Healthcare and Technology news |

We’ve all heard or used the phrase, “Leave it to the professionals.” It certainly applies to me as the only tools that I can use with competence are the scopes that I pass through either end of the digestive tunnel. Yeah, I have a toolbox at home, but it is stocked similarly to the first aid kit that your new car is equipped with. It contains a few Band-Aids, adhesive tape and, hopefully, the phone number of a local doctor. My home tool box has an item that can practically fix anything — the phone number of a handyman.

It is essential to know one’s limitations, regardless of one’s profession.

Politicians shouldn’t speak authoritatively as if they are climatologists.

Gastroenterologists should not prescribe chemotherapy, even though we are permitted to do so.

Bloviating blowhards on cable news shows are likely not military experts.

The guy who fixed your toilet might not be a top flight kitchen remodeler even though his business card includes home remodeler, along with railroad engineer, IT professional, seamstress and stand up comic.

Some of us are good at a lot of stuff. Some of us have a narrower, but deeper range of competence. Yes, we’re all good at something, as our moms and teachers taught us during our early years. Without doubt, most of us are not good at lots of stuff, and it’s important to know where our comfort zone approaches the chaos zone. In my own profession, it is absolutely critical that physicians readily solicit assistance from a colleague when additional knowledge, experience or judgment is needed. Asking for help to help a patient is evidence that the physician is focused on his patient’s welfare. Every doctor has witnessed circumstances when a physician is reaching too far beyond his toolbox, and it’s not pretty.

Should a surgeon perform a complex operation that he only seldom performs?

Should a local oncologist treat a patient’s rare cancer or refer the patient to the expert downtown?

How long should an internist struggle with a patient’s hypertension before recruiting an expert?

If an allergist’s patient keeps losing weight, is it time to consider a cause beyond the scourge of gluten?

Last year, our practice needed some restructuring. We met with our accountants for advice on streamlining and managing our practice. I was impressed how quickly these pros looked over our financial statements and readily understood the state of our practice. Of course, these guys see the world through Excel spread sheets, just like we GI physicians do through our colonoscopes. To us physician clods, these reams of number filled pages containing every permutation of various financial reports were encrypted codes that would require NSA cryptographers to decipher. Most physicians are not good businessmen, although many feel otherwise.

Luckily, my partner and I know the truth about ourselves. We didn’t ask the accountants for a second opinion. We came to them first, and we’re glad we did. I presume that when they need a colonoscopy, they won’t try it themselves.

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Reporting’s Rising Role in Healthcare Success 

Reporting’s Rising Role in Healthcare Success  | Healthcare and Technology news |

Today’s healthcare market is saturated with hospitals, health systems, and physician practices tackling EHR optimization, cost analytics, and other data-related projects. The industry has made great strides to establish a digital, real-time record of patient care. As that clinical, operational, and financial data piles up, one of the industry’s latest challenges is identifying ways to make that valuable information actionable.

When viewed collectively, data tells a story of what has happened over time. In the healthcare setting, effective data capture helps providers easily assess a myriad of pertinent business metrics, including (but by no means limited to):

How many patients were seen today?

Which patients presented with co-morbidities?

On average, how long was the reimbursement process by payer?

What is the Accounts Receivable impact?

By monitoring business performance, healthcare stakeholders can understand where they stand today relative to past periods and peer organizations. Analysis of that data illuminates areas for improvement and the progress the healthcare organization is making in pursuit of long-term goals. As value-based care initiatives continue to take root, performance reporting also fuels reimbursement under quality payment programs like the Merit-based Incentive Payment System and Meaningful Use.

Hospitals working towards the triple aim of improving population health and patient experience while reducing the cost of care will have to leverage analytics to trend patient outcomes and identify improvement opportunities. With patient health, regulatory compliance, and reimbursement on the line, reporting stakes have never been higher. Amid the proliferation of data-oriented business processes and payment models, reporting expertise and analysts will be among healthcare’s greatest assets.

As your healthcare organization undertakes the complex process of broader clinical and financial reporting, build a successful data management strategy by keeping the following reporting considerations in mind.

Start with your current process.

How are you capturing relevant data now? Analysts should shadow staff members to see what information they are trying to get and how they are presently documenting those details. This can help you identify points in the data capture process that can be improved upon, or are perhaps being overlooked. Help employees understand the “why” behind data capture requirements. Demonstrate how current practices impact the data staff members see in reporting results.

Avoid knowledge gaps by involving reporting stakeholders early on.

In almost every healthcare setting there are gaps in the data being captured. Involve reporting in all implementation initiatives to make sure your organization is consistently capturing the right variables. This is particularly true among clinicians preparing to report on new metrics under MACRA’s inaugural Quality Payment Program period. Set field requirements in your EHR or other healthcare IT platform to ensure the necessary data makes it into the system.

Format reporting data in a manner that highlights actionable insights.

How do you want to see reporting data portrayed? Data may need to be sourced as a dashboard, manipulated in Excel, or sent to a third party, depending on the project at hand. In most use cases, a visual representation of data can help administrators more easily:

  • Compare performance data to other hospitals.
  • Track metric performance over time.
  • Visualize outliers, high-performance areas, and low-performance areas.

Armed with that insight, stakeholders can quickly identify downward trending financial KPIs, clinical quality measures that best support the organizations value-based reporting endeavors, and more.

Develop a data governance strategy.

Avoid common data quality “gotchas” by developing a data governance plan that cultivates consistency in how data is documented. Implement EHR rules that bar duplicate data entry and support field normalization. Establish a data source hierarchy to defer to the highest quality data source in cases where fields may come from multiple sources.

End-users often have not considered the impact that data documentation has on the reporting perspective. Data quality issues revealed during reporting often drive process or policy changes and can shed light on training opportunities. Reporting is a data mining process that supports more effective decision making on behalf of the organization. With reporting and analytics poised to play an expanding role in healthcare initiatives like population health management and improved utilization management, now is an ideal time for healthcare organizations to engage reporting expertise to establish a strong foundation for data-driven success.

Technical Dr. Inc.s insight:
Contact Details : or 877-910-0004

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Many docs come to work sick

Many docs come to work sick | Healthcare and Technology news |

Many doctors, nurses, midwives and physicians assistants come to work sick even through they know it puts patients at risk, a new survey suggests.

Many said they don’t call in sick because they don’t want to let colleagues or patients down by taking a sick day, and they were concerned about finding staff to cover their absence.

At the Children’s Hospital of Philadelphia, Julia E. Szymczak and colleagues analyzed survey responses collected last year from 536 doctors and advanced practice clinicians at their institution.

More than 95 percent believed that working while sick puts patients at risk, but 83 percent still said they had come to work with symptoms like diarrhea, fever and respiratory complaints during the previous year.

About 9 percent had worked while sick at least five times over the previous year. Doctors were more likely than nurses or physicians assistants to work while sick.

Analyzing their comments, the researchers found that many report extreme difficulty finding coverage when they’re sick, and there is a strong cultural norm to come in to work unless extraordinarily ill.

The findings are reported in JAMA Pediatrics. The researchers were not able to respond to a request for comment by press time.

Sick health care workers present a real risk for patients, especially ones who are immunocompromised, like cancer patients or transplant patients, said Dr. Jeffrey R. Starke of the Baylor College of Medicine in Houston, who coauthored a commentary on the new study.

“Most of us have policies restricting visitation by visitors who are ill, we screen them for signs or symptoms,” Starke told Reuters Health by phone. “Yet we don’t do the same thing for ourselves.”

Most hospitals do not have a specific policy restricting ill healthcare workers, and developing and enforcing these policies may help address the issue, he said.

These policies should put the decision about who is well enough to come into work into someone else’s hands, not the doctor’s, Starke said.

Aside from spreading illness in the hospital, sick doctors likely perform worse on the job than healthy ones, he said.

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What physicians need to know about Medicare's new telemedicine reimbursement rules

What physicians need to know about Medicare's new telemedicine reimbursement rules | Healthcare and Technology news |

On October 31, 2014, the Centers for Medicare and Medicaid Services (CMS) released the final rule for the physician fee schedule, an annual list of what the federal government pays physicians for seeing patients who have Medicare in different regions of the country. This year, according to CMS, the schedule “adds procedures to the telehealth list“. Let’s take a closer look at the changes and what they may mean for clinicians interested in using telehealth and digital health technology in their day-to-day practice.

To understand what the changes mean, we’ll start with some basics about reimbursement for telehealth services. A number of conditions remain for practitioners seeking reimbursement for telehealth services. The highlights are that:

  • The service must be furnished via an interactive telecommunications system.
  • The practitioner furnishing the service must meet the telehealth requirements, as well as the usual Medicare requirements.
  • The service must be furnished to an eligible telehealth individual.
  • The individual receiving the services must be in an eligible originating site.

The “eligible originating site” condition refers to certain rural areas lacking in health services, aptly called rural health professional shortage areas (HSPAs). The definition of these regions was expanded by CMS in 2014 to include more rural areas but still covers a minority of Americans.

Key changes made were the expansion of telehealth services being covered by Medicare and an increase in the amount of coverage for the “originating site” — this is the location of the patient receiving telehealth services from a distant site (location of the remote physician). Every year, Medicare accepts requests from the public for adding or deleting telehealth services. This year, seven new services were added. They are:

  • Psychotherapy services CPT codes 90845, 90846 and 90847.
  • Prolonged service office CPT codes 99354 and 99355.
  • Annual wellness visit HCPCS codes G0438 and G0439.

Reimbursement didn’t change much; the payment amount for the originating site (where the patient is located) was increased by 0.8 percent in 2015, from $24.63 to $24.83. The amount that the distant site receives does not change because the service is being offered remotely. According to CMS, “a practitioner who furnishes a telehealth service to an eligible telehealth individual will be paid an amount equal to the amount that the practitioner would have been paid if the service had been furnished without the use of a telecommunications system.”

Another important point is that the conditions to be eligible to deliver or receive telehealth services didn’t change much. Some proponents would like to expand this area more to include other service shortage areas or patients’ homes regardless of where they are located. For example, some patients in urban areas that are not located near a specialist or unable to travel for some reason might be able to benefit from telehealth services. And if there’s equipoise between receiving a particular service via telehealth or in person, many patients and clinicians may prefer the telehealth approach for sparing patients the burden of a trip and physicians the additional expenses associated with an in-person visit. Expansion of the area where people can receive telehealth services would be in line with other CMS and private insurer efforts to increase interaction with patients electronically via email and patient portals in EHR’s.

Some media outlets and organizations that support telemedicine are also reporting that CMS is paying for remote monitoring of chronic care management patients because of a new rule that offers providers reimbursement for non-visit based services for chronic care management patients. However, this change is not focused on telehealth or digital health services as it can include many other activities. It does, however, present opportunities to offer telehealth services since one of the ways that providers can interact with patients to manage their chronic diseases is through telehealth and digital health systems.

A number of opportunities exist for medical apps in this area that are primarily focused on tools that enhance the interaction between physicians and patients in some way, such as providing the distant site with additional information (e.g., imaging, vital signs) while talking with a patient or offering the patient additional information while talking with a remote provider. There are a number of novel tools for providing an ever increasing range of services remotely. And the newly added eligible services seem particularly ripe for innovation.

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Do You Know Why Patients Don’t Pay Their Doctors?

Do You Know Why Patients Don’t Pay Their Doctors? | Healthcare and Technology news |

Like most people after the holidays, I am swamped by the number of bills and charges that have accumulated over the past month! It certainly has been an expensive time of year. And like most I bite the bullet and remit payments and pay my bills on time. However there is a large segment of bills that aren’t getting paid, and it’s those that are owed to physicians and hospitals.

According to a report just released by the Consumer Financial Protection Bureau, almost 43 million Americans have unpaid medical bills. The main cause for this is that many Americans are confused by the statements that they receive from their medical providers and insurance companies about the cost of treatment. Lack of transparency in their statements and understanding what they owe has put a lot of people in a tough situation.

Practices too are feeling the pain. Because of this issue they are writing off a significant amount of bad debt that through some easy fixes could translate into quicker payments and better cash flow. The average overdue debt that a patient owes is over $1,700 and the most baffling thing is that most of these patients show no signs of other financial stress. So what does this mean to for practices? Most patients who owe money have the means to pay but don’t, because of their lack of understanding about what they really owe.

Here are three easy fixes practices and hospitals can make to help patients pay their bills, and pay them faster.

1. Integrate bill payment into your Practice Management software. Practices today should have one place where they can go to get a full picture of a patient’s payment history and not have to switch between applications.

2. Simplify your statements. Make it easy for patients to understand what your charges are, what insurance has paid by providing a statement that matches up to the patient’s Explanation of Benefits (EOB), and most importantly what they still owe. With this information they are much more likely to remit payment quickly or start a conversation with you so that you can resolve any outstanding issues.

3. Ditch paper billing. It’s 2015 and according to the USPS more than 60% of Americans across all demographics are paying their bills online. Online bills get paid faster and you can create your online statements to match the EOBs. If the majority of patients want to pay their bills online…let them!

With deductibles now resetting, practices will be collecting a significant amount of their revenue directly from patients…on average for the first five months of the year. It’s time to help patients pay their bills and practices collect what they’re owed.

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Does Restricting Physician Duty Hours Improve Patient Care? | The Health Care Blog

Does Restricting Physician Duty Hours Improve Patient Care? | The Health Care Blog | Healthcare and Technology news |

Do physicians in training take better care of patients or perform better on their exams when their work hours are restricted?  Two recent studies in the Journal of the American Medical Association suggest that the answer is no.  In one, patients of surgery residents showed no difference in morality or postoperative outcomes after duty hour restrictions were implemented.  Their test scores did not improve either.  In the other, hospitalized Medicare patients being cared for by physicians working shorter hours experienced no improvement in mortality or readmission rates.

US resident duty hour restrictions were born in 2003, when the ACGME, the organization that accredits medical residency programs, capped the work week at 80 hours.  It also mandated that residents have 10 hours off between duty periods and a 24 hour limit on continuous duty, with 1 day in 7 free from patient care.  In 2011, the organization revised its policy, further restricting the total number of continuous duty hours for physicians in the first year of training to 16.

How could well-intentioned attempts to ensure that hardworking young physicians get sufficient rest fail to benefit patients?  To begin with, simply restricting duty hours does not guarantee that residents will use their extra off-duty time to sleep.  They might, for example, use it to study, exercise, or socialize.  It is also possible that the outcomes being assessed by these studies are influenced by so many factors that merely changing duty hours is insufficient to cause a change.  Yet if such changes do not benefit patients, how strong is the case for their implementation?

Some educators worry that duty hours restrictions are undermining the quality of medical education.  For example, a survey of surgery program directors published last year showed that 21% believe that residency graduates are unprepared for the operating room, 30% believe they cannot independently remove a gallbladder, and 68% believe they cannot perform a major procedure unsupervised for more than 30 minutes.  Another survey showed that 38% of residents themselves lack confidence in their preparation even after 5 years of training.

Part of the problem may lie in the fact that the duty hours restrictions have reduced the number of cases such residents are able to learn from.  For example, one study of the caseloads of surgery residents found that the implementation of duty hour restrictions was associated with a 26% reduction in cases per resident.  Moreover, the complexity of operating room cases in which residents participated declined even more, 32%.  To compensate for such reductions, some critics have argued that if duty hours restrictions remain in place, the length of surgery residency will need to be increased from the current  5 to 6 or even 7 years.

But the problems with attempts to reduce duty hours go deeper still.  When residents spend less time in the hospital, the number of patient “handoffs” that need to occur between residents increases.   A resident who might once have cared for a patient for 24 consecutive hours now needs to hand the patient off to a colleague at 16 hours.  It is well documented that every time a patient’s care is transferred from one health professional to another, errors in communication tend to occur.  Studies suggest that such error rates can be reduced, but not eliminated.

An associated problem is the fact that residents operating under duty hours restrictions have less time to get to know their patients.  In addition to creating opportunities for error, this also has negative implications for the quality of relationships that young physicians develop with their patients.  Confidence and trust are built in part on familiarity, which the duty hours restrictions tend to reduce.  As a result, many young physicians may expect less from relationships with patients, and these diminished expectations may remain with them throughout their careers.

The intent behind duty hours restrictions is a noble one.  As sleeplessness increases, it takes a toll on mental performance, including reaction time and the ability to memorize new information.  But sleeplessness is but one factor in the performance equation, and it may be counterbalanced by other equally or even more important factors, such as the importance of the task at hand.  When a patient’s health or even life is on the line, it is possible that many young physicians are able to compensate for lack of rest.

Another drawback of the duty hours restrictions is psychological, perhaps even cultural.  A whole generation of physicians in training is being told, directly or indirectly, that their education is not as rigorous as their teachers’.  They do work as hard and are not being tested to the same degree as those who trained before them.  As a result, many complete their training questioning whether they have given less of themselves than they needed to.

Without doubt, the culture of hard work and sacrifice can be taken too far.  A colleague recently shared with me this story.  When he was an intern, he was taking call every third night, admitting at least 8 patients each call shift, and getting too little sleep.  One morning while on rounds with his chief resident he stopped and said, “I don’t think I can keep doing this.  It is dangerous for the patients.”  The chief showed absolutely no sympathy, instead responded dismissively, “Just suck it up and carry on.”

Duty hours restrictions represent an attempt to deal with a genuine problem, a dominant culture in medicine that says, “If you can’t do this, you are weak.”  Yet they are problematic because they represent a one-size-fits-all solution.  In many cases, a more tailor-made approach is called for.  It makes no more sense to treat all residents in all medical fields identically than it would to treat all patients as if they were cut from the same mold.

Before we impose blanket restrictions on duty hours for every training program and resident in the country, we should turn our attention to more pressing matters.  First, we should try to foster a culture in which young physicians can admit they need help without fear of reprisal.  Second, we should ensure that the work residents are being asked to do is truly educational and important.  And third, we should put more trust in the ability of program directors and their residents to discern for themselves the amount of work they are able to handle.

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Healthcare and Health IT in 2015. What the world needs now is…….. simplicity - HealthBlog - Site Home - MSDN Blogs

Healthcare and Health IT in 2015. What the world needs now is…….. simplicity - HealthBlog - Site Home - MSDN Blogs | Healthcare and Technology news |

Happy New Year to my HealthBlog readers around the world. I’m back in the saddle after a 3 week hiatus for the holidays. I must say I’m feeling fully rested and looking forward to all that 2015 will deliver.

Like you, I’m getting tired of reading prognostications about what’s hot and not for tech in the year ahead. However, I did enjoy a piece I came across today by my blogosphere colleague and Forbes contributor, Dr. John Nosta. Actually, I believe Dr. Nosta published the post not this week, but rather a full year ago. The post, Digital Heath In 2014: The Imperative of Connectivity, might as well have been written this week as it is just as true today as it was in January of 2014. In it, tech pundits from John Sculley to Steve Wozniak are quoted in musings about the tech revolution in health and healthcare and how everything you know is about to change. As has been true for the past several years, people are predicting massive disruption and transformation of health and healthcare delivery fueled by technology. And, as has been the case during the vast majority of my 14-year career at Microsoft and many years before that as a physician, tech and healthcare industry executive, I feel like I’m still waiting for the big bang.

Now don’t get me wrong, we have certainly seen transformation (albeit slow) of healthcare, and technology is definitely driving a lot of that change. Policy is also driving change, perhaps more so than technology. And, at least in America, no policy is causing more disruption right now than that of the Affordable Care Act. However, all of this begs the question--are things getting better or worse? People are paying more than ever before for the services they receive. Many of us are seeing our health insurance premiums rise while being asked to fork over more and more of our money toward copays and high deductibles (often $5000 to $12,000 per year per family). And even though I love technology, thus far I think it is failing to deliver on its promises or potential. Let me ask you, is it getting easier or harder to pay for and manage healthcare for your family? And if you are a healthcare provider, is it getting easier or harder to take care of your patients the way you’d like to care for them?

Technology should be making all of his easier and less expensive, but is it? Healthcare policy should be doing the same. Instead, we seem to be getting ever more complicated rules, regulations and business practices that confound both consumers and providers alike. Health insurance is more complicated than ever before, and don’t even get me started on Medicare.

If there is a theme I’d like policy makers, tech industry leaders, insurance chiefs, healthcare executives, and clinicians to focus on more on in 2015 it would quite simply be……. simplicity. We are making everything way too complicated. Without greater focus on technology that actually makes things more simple through seamless integration of services and information exchange, improved modalities for synchronous and asynchronous communication and collaboration in clinical workflow, and business models that truly support innovation and lower costs in healthcare, all the fancy new wearable smart devices, labs on a chip and augmented reality headsets won’t do much to save us from our misery.

I believe there are but a few global companies with the breadth, depth, and scale to really deliver on the kinds of information technology advances our health industry needs. Even then, it will take a carefully choreographed dance of enlightened public policy and innovation to deliver the goods. Otherwise, a year from now, and for many years yet to come, we’ll simply be singing more of Auld Lang Syne.

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BREAKING: Cerner to Buy Siemens Health IT Division for $1.3 Billion; EXCLUSIVE: Cerner President Speaks First to HCI

BREAKING: Cerner to Buy Siemens Health IT Division for $1.3 Billion; EXCLUSIVE: Cerner President Speaks First to HCI | Healthcare and Technology news |
In one of the biggest deals in healthcare IT history, the Kansas City, Mo.-based Cerner Corporation is acquiring Siemens healthcare information technology business for $1.3 billion.

The deal will make Cerner the top revenue-earning company among U.S. electronic health record (EHR) vendors. Cerner and Siemens AG agreed upon the deal that will combine R&D, knowledgeable resources, and complementary client bases. Specifically, Cerner says the combined company will have 20,000 associates in more than 30 countries, 18,000 client facilities, including some of the largest health care organizations in their respective countries, $650 million of annual R&D investment, and a projected $4.5 billion of annual revenue.

According to an industry source, the deal is a defensive play against the Verona, Wisc.-based Epic, which has won a significant share of new hospital and health systems’ EHR contracts over the past few years. The deal with Siemens would add to Cerner’s market share and customer base.

However, in an exclusive interview with Healthcare Informatics, Cerner president Zane Burke said that was not the case at all. “There are lots of ways to actually figure out who [the top revenue producer is] in this marketplace, and actually, Epic is not the largest as of today—another competitor of ours probably is,” Burke said. “Cerner is doing incredibly well today. We didn’t need to make an acquisition, nor were we even looking for one,” he added.

Burke said that the fit with Siemens was “great,” and that Cerner is looking forward to adding some of Siemens’ additional skill-sets such as revenue cycle and connectivity through the clinical workflow process. Also noteworthy, Burke added that the RIS/PACS pieces of Siemens would not be part of the merger and would remain with Siemens separately.

Cerner says that the acquisition will have no effect on support for Siemens Health Services core platforms and current implementations will continue. The company says it plans to support and advance the Soarian platform for at least the next decade.“This means interoperability will start at home, and while we have been at that for quite a while, this is one more way to do that,” said Burke.

Burke said the main significance of the merger, in regards to the health IT industry, is getting its client base the tools they need to succeed in the ever-changing healthcare environment. “I have never seen the need for better or more efficient tools than our clients need today. We want to be able to drive innovation in a better way, advance that medical practice, and then for us, it does create some complementary global elements. There are countries we are strong in as well as countries they are strong in, and that’s a very positive thing for healthcare,” Burke said.

The deal had been reported as rumor on Twitter, by Healthcare Informatics and others, a few weeks ago for $1.2 billion. According to the industry insider, the two sides argued over the amount for a few weeks, with Cerner wanting to buy the division at the $1.2 billion price and Siemens wanting to sell it at $1.4 billion. They met in the middle and a deal was struck.

According to Burke, the two sides have been talking for about seven months and “a deal really come together in the last 30 days. As far as we knew, there were no other bidders involved. This was just about us and them,” Burke said.

Earlier this summer, Siemens was rumored to want out of the health IT business to focus on their energy and industrial businesses. In a statement, Hermann Requardt, CEO Siemens Healthcare said: “An increasing number of country-specific reruirements, many resulting from US healthcare reform, make it increasingly challenging to achieve sufficient scale effects. Going forward we will focus on the development of information systems that support our businesses in laboratory diagnostics as well as imaging and therapy.”

The transaction is expected to be more than $0.15 accretive to Cerner’s non-GAAP diluted EPS in 2015, and more than $0.25 accretive in 2016.
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Physician Employment Landscape Set to Change in 2015 |

Physician Employment Landscape Set to Change in 2015 | | Healthcare and Technology news |
The healthcare landscape will continue to consolidate through physician employment and new practice choices from medical students in 2015 and beyond.

Physician employment at larger healthcare organizations will increase rapidly in 2015 as consolidation of providers and financial pressures squeeze private practices into closing their doors.  Between the anticipated costs of ICD-10, changes to reimbursement structures that promote value-based payments, and a desire for more care coordination by working in extended teams, new medical students and established practitioners alike are leaning towards banding together in larger, more stable groups.

“The coming year will again be one of major transition for the U.S. healthcare system,” said Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer of the Texas Medical Association.  “Regulatory and marketplace forces are having a number of unintended effects, including challenging the viability of smaller medical practices, reducing patient choice and putting tremendous strain on the physician-patient relationship.”

The Physicians Foundation envisions several key challenges for providers in the next year, including external pressures on the patient-provider relationship that make practicing medicine less satisfying.  Even though one recent study states that physicians are actually spending more time with each patient now than they did a decade ago, continued dissatisfaction with the intrusion of EHR documentation on the workflow and other regulatory pressures are driving unhappy physicians to retire, seek employment with fewer administrative burdens, or reduce their availability.

Physicians who seek employment at bigger health systems tend to report higher levels of job satisfaction and more time to focus on the patient relationship, the ACPE found earlier this year, but must also contend with the downsides of being a smaller piece of a more complicated system.  Employed physicians are more likely to report feeling unheard and unrecognized for their achievements.  Physicians at private practices that have been acquired by larger health systems feel poorly integrated and complain about a lack of cultural alignment that would incentive them to perform at their best.

Medical students and new physicians are pinning their hopes on the benefits of employment, however, says a separate report from EHR developer athenahealth.  The Epocrates Future Physicians of America survey found that ninety percent of medical students will not go into private practice, which is a fifty percent increase from 2008.  Students desire the financial security and work-life balance of employment in larger facilities, and want to avoid the difficulties of being a small business owner in addition to a full-time physician.  Part of this pattern is due to inadequate instruction during medical school on how to operate and manage an individualized practice, according to nearly 60% of respondents.

In addition to feeling poorly prepared for being self-employed, medical students recognize the importance of working in larger teams with better communication and more non-physician support.  Care coordination is top of mind for 96% of these newly minted MDs, and 75% believe that better coordination is dependent on EHR data sharing, interoperability, and health information exchange.

As physicians adjust the way they practice to take advantage of more modern expectations of being valued, balanced, and engaged in the workplace, their needs must be addressed in order to maintain high levels of patient care and sufficient access to healthcare for the millions of newly insured citizens under the Affordable Care Act, Goodman says.  “It is paramount that policy makers bring physicians into the fold to ensure the policies they implement are designed to advance the quality of care for America’s patients in 2015 and beyond.”

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Why Doctors, Managers Should Rethink Their To-Do Lists | Physicians Practice

Why Doctors, Managers Should Rethink Their To-Do Lists | Physicians Practice | Healthcare and Technology news |
Ambitious physicians often face the problem of taking on too much. They’ve been so effective at accomplishing things in the course of their medical career that they seek to accomplish even more. Their inherent productivity causes them to create longer and more involved to-do lists than others.

The problem is that these individuals are setting themselves up for failure. They unconsciously ensure that they won’t reach the end of their list, by continually adding more tasks after accomplishing just a few.

This approach to managing one’s to-do list is fraught with problems. It is both rewarding and appropriate when you cross off everything on your list and feel complete about your achievements. When you’re able to finish your lists, say two to four times a week, you often return to the office the next morning with more energy, focus, and direction than you might presume.

Conversely, when you perpetually leave the office with unfinished tasks for that day’s to-do list, you unconsciously engender a situation in which you never quite feel complete or satisfied, and you find yourself in a perpetual “striving” mode.

In the short run, it’s OK to leave unfinished tasks, especially when you’re on a specific campaign or project. In the long run, however, continually overextending your daily to-do list can have a harmful, de-motivating effect on your life.

It’s understandable that as a highly ambitious person you want to achieve as much as you can and build a strong practice. If you’re not careful, however, and you attempt to accomplish one major task after another instead of alternating large and small tasks, your productivity could suffer. Attempting to tackle one major task after another can become mind-numbing, stressful, and frustrating.

Hereafter, choose to tackle a handful of key tasks in a given day, alternating them with some minor tasks so that you can maintain a fairly high level of energy and allow yourself to leave the office with a sense of completion.

You’ll be more effective with patients and staff the next day, as well as throughout the course of your week, month, year, and career. You’ll engender a distinct sense of accomplishment while experiencing, at the least, recurring feelings of work-life balance.
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Draft Medicare ACO rules would allow more time with less risk - Modern Healthcare

Draft Medicare ACO rules would allow more time with less risk - Modern Healthcare | Healthcare and Technology news |

The CMS is planning major changes to the financial incentives for Medicare accountable care organizations in a revamp aimed at preventing hospitals and medical groups from dropping out of the initiative.

A proposed rule issued late Monday (PDF)would alter the structure of the Medicare Shared Savings Program, an attempt launched in 2012 under the Patient Protection and Affordable Care Act to reduce U.S. health spending with new incentives that seek to improve the quality and efficiency of healthcare.

Those incentives have been a battleground between policymakers and the healthcare industry since the program's start. Policymakers have sought more substantial incentives—penalties as well as rewards—as a means to hasten changes to the way healthcare is delivered. Hospital officials and physicians have called for less financial risk so they can build the infrastructure and expertise they need to succeed.

The rules adopted in 2011 require accountable care organizations to face penalties after the first three years unless they volunteer to assume downside financial risk earlier in exchange for bigger bonuses if they do well.

The industry appears to have scored a victory in the proposed rules, which acknowledge widespread concern among the participants and experts that some organizations may need more time before penalties take effect. The switch after three years “may be too steep” for organizations that lack experience and infrastructure to achieve quality and cost-saving targets and organizations may exit as a result. Even those that perform well but “not yet ready” to accept the risk of penalties may depart without another option, the agency said.

Medicare, under the revised structure, would no longer require organizations to face penalties after the third year, but they could forgo penalties only if they meet certain criteria. ACOs that fail to slow spending in their first two years would be excluded. All ACOs must assume the risk of penalties after six years if they want to remain in the program.

In order to make it more appealing for ACOs to jump into the riskier track, the CMS would reduce the potential bonuses after the third year in the safer track to 40% from 50%.

In another bid to make riskier contracts more attractive, the agency wants to add a new option, or a third track, that would include potential penalties and bonuses and would use new methods to identify which patients are included in the ACO. Organizations in this new track could keep up to 75% of what they save. They also would be responsible for up to 75% of their losses, but the amount could be reduced based on quality performance. The agency capped the bonuses at 20% of ACOs' benchmarks and losses at 15%.

Participants in the third track would also have a list of patients at the start of the year whose care and costs they must manage. Under the current rules, Medicare identifies beneficiaries as included in the ACO at the end of the year based on how much care they received from the providers in the network. ACOs have called on the CMS to identify the patients at the beginning of the year to allow more focused improvement efforts.

The CMS has rapidly expanded the Medicare Shared Savings Program over the past three years, and it is perhaps one of the most visible efforts under the law to tame the nation's healthcare bill. But many experts feared the widespread enthusiasm for the program would wane significantly if the CMS declined to modify the program to keep less experienced providers on board.

All but five of more than 300 ACOs in the program chose to forgo the penalty. That may have been wise, because their financial performance has been uneven. Only a quarter of ACOs launched in 2012 and 2013 have saved enough to earn bonuses.

Clif Gaus, chief executive officer of the National Association of ACOs, said he was “pleased and disappointed” by the proposed rule. He praised the proposal to give ACOs more time before they face penalties for financial performance, but he also said the decision to couple that with a smaller potential bonus was “counterproductive.”

Many ACOs need the additional time to prepare for the risk of potential penalties, he said. “Three years is not enough.”

Efforts to revamp the delivery of care will require more time as ACOs build new relationships, new infrastructure and learn and adapt early redesign efforts, he said. “It's probably a decade-long process to redesign all of the care processes that lead to both better care and more appropriate care,” based on experience of organizations such as Geisinger Health System or Intermountain Healthcare, he said. “There's a big learning curve for many ACOs,” he said. “They are almost new businesses starting from scratch.”

The association surveyed Medicare Shared Savings Program ACOs in October and found two-thirds were somewhat or highly unlikely to continue if they were required to accept penalties. About 20% of the MSSP ACOs responded. “There's too much risk for the amount of reward” under contracts with penalties and bonuses, he said.

Coastal Carolina Quality Care in New Bern, N.C., entered Medicare's accountable care program in 2012 and saw its expenditures increase a marginal 0.6% against projections during the first year.

“It's very unlikely that we would continue” without the continued option to forgo penalties, said Stephen Nuckolls, Coastal Carolina's CEO.

Dr. Farzad Mostashari, founder and chief executive of accountable care contractor Aledade, said the option to continue without penalties may benefit some smaller organizations in the program. “There are a lot of home grown ACOs,” said Mostashari, a former national coordinator for health information technology at HHS. “It takes them a long time to get going.”

Policymakers, however, likely also want to discourage organizations from abusing Medicare's shared savings program as a way to consolidate market clout with little interest in achieving the program's savings goals, he said. The proposed rule, however, may do little to discourage them from remaining in the program. The proposed criteria for ACOs to continue without penalties, Mostashari said, is “a pretty low bar."

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Physicians are treating the well, and nurses are treating the sick

Physicians are treating the well, and nurses are treating the sick | Healthcare and Technology news |

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the well

In my early career in Sweden, well-child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

The same thing happens in primary care for adults; between checkups and chronic disease management, meaningful use and other documentation requirements, many primary care doctors are unable to see all the sick patients, who call for an appointment.

A simple calculation illustrates this phenomenon. If the ideal caseload for a primary care physician is 1,500 patients but commonly exceeds 2,000, only providing a 30-minute physical or wellness visit (not the same thing) visit once a year for every patient chews up 750 to 1,000 hours. Total contact hours for each doctor according to recruitment ads these days number 32 per week times 46 weeks, or 1,472 hours. That doesn’t leave very much time for treating the sick — less than 500 to at most 750 hours, to be exact. That’s a maximum of 16 hours per work week, most of which is spent on managing chronic conditions like diabetes and cardiovascular disease. Most of the time, this amounts to tracking and treating numbers in fairly asymptomatic people — blood sugars, glycohemoglobins, microalbumins, blood pressures, lipid levels and so on.

Treating chronic diseases leaves little room for diagnosing and treating acute illnesses

With primary care physicians’ time increasingly spent on the routinized housekeeping details of modern chronic disease management, their diagnostic and therapeutic skills are less often used on the front lines of sick-care. Their new role of managing populations is not making full use of physicians’ traditional diagnostic and therapeutic skills. Instead we are performing more nurse-like duties such as carrying out standing orders (read “following guidelines” and “practicing evidence-based medicine”), and keeping track of our patients’ scheduled specialist visits as well as their sick visits, not just at the local emergency room, but also at competing walk-in clinics. Ironically, the doctor who was too busy to see that child with an earache must now sign off on the chart notes from the local Walmart. We also end up, unreimbursed, keeping track of and even rubber-stamping orders for immunizations given at pharmacies like Rite Aid.

The elimination of the truly quick and easy visits from doctors’ schedules (the rashes that the experienced clinician quickly determines are not leukemia or ITP) makes the daily load of chronic care management greater, and often decreases total revenue in a fee-for-service system. The truth is that a skilled and experienced physician can often handle “simple” medical complaints faster and with greater accuracy than providers with less training and experience.

Equally true, nurse practitioners can be just as good at following clinical guidelines and counseling patients about blood sugar, exercise, smoking cessation and the benefits of aspirin as physicians are. The broader and deeper training of physicians comes to its best use in diagnosing and managing atypical or rarely seen symptoms and conditions, many of which present acutely with nonspecific symptoms.

Yet, because of the so-called doctor shortage, this is what sometimes happens:

In many states, nurse practitioners, even newly graduated ones, are asked to fill the role of primary care provider or urgent care clinician, while seasoned physicians with mature practices are increasingly spending their time on the routinized treatment of asymptomatic conditions that arise from the modern lifestyles of the western world.

So, who should do what in primary care?

I have worked with many NPs who shoulder the responsibilities of frontline, independent, clinical practice very well because of their postgraduate experience and their personal qualities. But out of the box, a new NP is not as well prepared for that role as today’s residency trained physician. The days of practicing general medicine straight out of school ended for American physicians in the 1950s.

My point is that in today’s health care system, we are often asking the providers with the least training to see the unsorted clientele in sick-call while doctors with decades of experience may be limiting their practice to following insurance-mandated guidelines and care plans in treating non-urgent chronic medical problems and providing equally scripted wellness visits that may actually be better suited for nurses-turned nurse practitioners. I think the wisdom of this needs to be discussed openly. I think the perceived doctor shortage may just be an allocation issue.

Or, in one sentence:

If provider care teams are the way of the future, perhaps doctors should be handling more of the sick-call, and nurse practitioners more of the maintenance of modern health care.

Let’s really talk openly about who should do what in primary care today.

Dr Martin Wale's curator insight, December 14, 2014 9:10 PM

"A Country Doctor" takes aim at the paradox of the least experienced clinicians taking on those situations where maximum diagnostic acumen is required, because the most experienced are fully occupied with care of chronic diseases.