Medicare’s New Direction

Stephen Kamelgarn, MD, discusses “Medicare Pay for Performance” in the January issue of The Bulletin of the Humboldt-Del Norte County Medical Society

“Medicare, the 800 lb. gorilla, is about to strike out in new directions. As recently reported in the New York Times, the 109th Congress, in a last minute flurry of legislation, approved a change in Medicare reimbursement, that not only willnot cut physicians’ reimbursements 5.3% as originally intended, but will actually increase their pay by 1.5% — if they provide quality care as defined by the government.

“Physicians will qualify for the 1.5% increase if they report data on the quality of care: for example, how often they use a particular drug after a heart attack, or control blood pressure in patients with diabetes. On the surface this is a good idea.

“We’ve been talking about employing evidence-based guidelines for medical practice for years, and in those areas where there have been a lot of studies (blood pressure and diabetes, for instance) it is easy to draw up guidelines that all practitioners should follow to practice good medicine. And it is true, that in many areas of medical practice, there is a consensus of what the proper practice is.

“However, most of what we do is not backed up by a hundred double blind studies that unequivocally point us in the right direction. And since there is so much controversy in how we deal with a variety of conditions, who’ll be the arbiters of what good medical practice is — a government bureaucrat that wouldn’t know a CT from a 4-legged cat?; a committee? How will the data be collected and assessed — a series of electronic check boxes where the questions are so poorly worded that they’re impossible to figure out? Do the physicians have to hit a benchmark of 100% for all of their patients with the particular condition to qualify for the extra money? How much extra time and effort, i.e., money will the individual physician have to spend in order to obtain his or her ’bonus?’”…

The entire article appears atwww.humboldt1.com/~medsoc/images/bulletins/JANUARY%202007%20BULLETIN_for%20web.pdf

A Different Kind of Error

Emily Dalton, MD, discusses Electronic Prescribing: A Help or a Hindrance? in the December 2006 issue of The Bulletin of the Humboldt-Del Norte County Medical Society

“The CMA alert’s top story from 8/17/06, reported that the Institute of Medicine urged all prescriptions be written electronically by 2010. I agree, but I don’t think the reduction in errors will be as dramatic as they hope. They cited facts: such as medication errors are among the most common medical errors; that they harm 1.5 million people, and cost more than $3.5 billion annually. They stated that the problem is so serious that the average hospital patient is subject to one medication error per day. Causes for these errors included unexpected drug interactions, confusion over similarly named drugs, bad handwriting, drugs given to the wrong patient, and patients not understanding how to take the medication. Electronic records may help with some of these — such as handwriting, but not with others, such as patient comprehension or drugs dispensed to the wrong person…

“I decided to try electronic prescribing. By and large it has been fun and effective when it works (which it does most of the time) and patients like it. The set-up I use involves a small device called a pocket computer. You can use other devices like advanced cell phones, Treos, Blackberries or personal digital assistants, but I chose a pocket computer because it has the most memory and processing capability…

“I have yet to be convinced that electronic prescribing will result in error reduction. I still get calls about mistakes from the pharmacists, but they are mistakes of a different nature. They are never due to poor handwriting, but at times my unsteady hand has selected the wrong name from my patient list and I’ve accidentally sent over the right prescription but for the wrong patient. (The laxative prescription error was probably the most embarrassing such incident). Pharmacists have called to ask if I really meant to prescribe a gallon of Dimetapp, or if I really meant the dosing to be every hour instead of every day. These are not mistakes one would ever make on a traditional written prescription, but are very easy to do when you are pointing and selecting from various options listed in close proximity on a computer menu on a very small screen…”

The complete article can be found atwww.humboldt1.com/~medsoc/images/bulletins/DECEMBER%202006%20BULLETIN%20for%20web.pdf

Transparency In Medicine

Moris Senegor, MD, editor of the San Joaquin Journal of the San Joaquin County Medical Society, wrote in the Winter 2006 issue on “Whether You Like It or Not…transparency is here!”

“In the last decade hospitals have developed elaborate Quality Departments, measuring various parameters of their care both locally, and against national databases. The trend first hit the field of cardiac surgery, which lends itself easily to objective, mathematical analysis of outcomes such as mortality, complications, hours spent in ICU, numerous physiological parameters and more. The Society of Thoracic Surgeons (STS), created a national database reflecting averages, against which any hospital could measure their results. It has functioned well and allowed for adjustments in perceived weak areas, as well as cross-communication between different hospitals. For instance an obscure hospital in Pennsylvania has outshined its brethren in rapid extuba­tion after open-heart surgery, and found itself transformed into a mecca for those interested in improving their early extubation statistics. Our Stockton St. Joseph’s Hospital sent a high level delegation of surgeons, anesthesiologists and nursing staff to Lankenau Hospital in Wynnewood, PA for a fact finding visit, and has since made efforts to adopt their practices…

“Why such an intense effort for one detail of a multitude in services offered? Because CMS, the government branch overseeing Medicare and other health policy has issued an edict that this be done. Soon they plan to change the way they pay hospitals by rewarding the top 20% in such statistics with higher reimbursement. With a multimillion dollar per year carrot dangling in front of their faces, hospitals are enthusias­tically creating the infrastructure to make Herculean efforts in improving care for the parameters dictated.

“What does this all mean to us, and where is it headed?

“To begin with, it is obvious that the parameters currently measured are not comprehensive in covering all areas of care provided by full service hospitals. Therefore those that do well in pneumonia, cardiac services, and diabetes will be identified as “the best”, and rewarded; never mind that their record in obstetrics, neurosurgery, or orthopedics might be dismal. The government promises to correct this defect in due course by measuring a more comprehensive set of parameters…

“Another burgeoning problem that this new high stakes game ushers in, is the issue of honesty in reporting. The gargantuan financial incentives will induce some to lie and fudge their numbers…”

The complete article can be found at www.sjcms.org/magazine/Winter%20Quarter,%202006.pdf