Payment for quality performance, legislators practicing medicine, similarities of sex and medical care, the consequences of not receiving timely care January/February 2006
Pay for Performance
In the President’s Point of View column of Santa Barbara County Medical Society’s Medical Society News of July/August 2005, Dennis H. Baker, M.D., wrote:
“In 1999, when the Institute of Medicine published its reports, ‘To Err is Human’ and ‘Crossing the Quality Chasm’ pointing out the high prevalence of medical errors. Since then, policymakers at all levels have been looking for ways to repair the situation where, it is said, tens of thousands die unnecessarily and where billions of dollars are lost each year due to mistakes made in hospital and outpatient settings. While many argue the basis and methodologies used for these figures, the fact is there are wide variations in the quality of care provided in this country and, that efforts to remedy the situation can save valuable lives and resources.
“Clearly, the leadership for these efforts must come from medicine itself. Only the profession and its physician leaders can properly balance the factors that directly impact quality and cost of care. Leaving this work to payers or the government will only result in harm to patients, physicians, and the profession of medicine. It is increasingly likely that the federal government will soon mandate performance measurement and payment for quality performance. Called ‘pay for performance’ (P4P), or as it is known in proposals on Capitol Hill, ‘value based purchasing’ would tie Medicare payment to physicians to objective measures of improvement in the quality of care we provide.”
To read more of this article, go to www.sbmed.org/webpages/publications.asp.
Legislators: Quit Practicing Medicine
In his “Mert’s Musings” in the Fresno-Madera Medical Society’s Vital Signs, Executive Director Mert Scholten wroteto legislators:
“Quit trying to practice medicine! OK, So you don‘t really practice medicine, but many of the decisions you make on legislation proposed (and too often adopted) have a direct influence on the way in which medicine is practiced. And that may not be good for either patients or doctors.
“A case in point: requiring 12 hours of continuing medical education in pain management for virtually all physicians other than pathologists, anesthesiologists, and radiologists. This law grew out of a professional liability, case wherein the family of a dying, patient charged that the doctor did not properly manage the gentleman’s pain though the patient himself did not seek additional pain relief nor complain that his pain was unbearable.”
Read more at www.fmms.org/default.asp (membership required).
As physicians, we well know that simply seeing a loved one in bed and maybe even unconscious causes the family member more pain than the patient is experiencing, just as in the example that precipitated this unconscionable law. The rest of the article details the downside of legislators practicing medicine without a license and how it harms both physicians and patients. Physicians are well able to determine their Continuing Medical Education (CME) needs. Should the legislators that voted for this law be prosecuted for this offense of making medical decisions without a medical license? They are not experts in medicine; it seems difficult to find any field in which they have any expertise.
While legislators reduce us and our practice to hard facts, we would do well to remember a comment in last month’sMars Hill Audio Journal: Twenty years ago, writing in The Wilson Quarterly, the literary critic Cleanth Brooks noted that: “A world reduced to hard facts would thereby become a dehumanized world, a world in which few of us would want to live. We are intensely interested in how our fellow human beings behave — in their actions, to be sure, but also in the feelings, motives, purposes that lead them into these actions.” In this case, even the facts were not factual.
Medicine and Sex: A top 5 list
In the Humboldt-Del Norte County Medical Society Bulletin, Luther F. Cobb, MD, started The President’s Message: with a one-word headline: SEX. He continued:
“Now that I have your attention, it occurs to me that there are several similarities between the average American’s attitudes toward sex, and their attitudes toward medical care. In the spirit of David Letterman’s famous Top Ten list, I offer my modest version of a Top Five list on the subject.
“REASON #5. Although not everybody is interested at all times in getting some, at certain critical points of their lives it becomes a very prominent concern.
“REASON #4 Most Americans believe that obtaining it is a basic human right, to which they are entitled just for being here.
“REASON #3 Most Americans agree that their usual and customary provider doesn’t give frequent enough, prompt enough, or good enough quality service.
“REASON #2 Many people think to get the exotic, high-tech, cutting-edge level of service they have to leave town, but they’re often disappointed to find once it’s over that the attention received was a lot less personal.
“AND THE #1 REASON IS:
“People think it’s a sin to pay for it.
“While the above is definitely offered in the spirit of good humor, it does occur to me that it’s a lot more truth than joke. We really do have a different attitude in this country toward medical care than we do about any other economic enterprise, other than warfare. There is a serious disconnect… “
Affordable Health Care
Internist Mark K. Belknap, MD, President of the Wisconsin Medical Society, argued that society must lead the way in reforming health care. He used this example in his article:
“A 50-year-old female convenience store manager from the Upper Peninsula of Michigan was recently referred to me from the emergency department (ED) for evaluation of heart failure. She had presented to the ED with progressively severe shortness of breath and leg edema. She had no health care insurance and had not seen a physician for several years. Following an episode of rheumatic fever as a teenager, she had a history of a murmur. An echocardiogram was performed, and it showed severe mitral stenosis and severe pulmonary hypertension. I referred her for cardiac catheterization, which confirmed the findings of the echocardiogram, and she underwent mitral valve replacement. Several aspects of this patient’s case are typical in patients without health insurance. Because she had no personal physician, she initially presented to the ED, where care is much more expensive. Her costs exceeded $60,000 and she has since applied for “compassionate care.” She presented at an advanced stage of her disease because she had not had regular ongoing health care. It is likely that she developed rheumatic fever and, subsequently, mitral valve disease because of lack of access to care for her initial episode of streptococcal pharyngitis. As a consequence of her need for mitral valve replacement, she will need lifelong anticoagulation with warfarin, with its attendant cost and risks. It is uncertain at this point how much of her pulmonary hypertension is reversible, and she may continue to suffer the morbidity of this condition because she did not receive care in a timely manner.”
Measuring quality care, another society’s history, and a boost in license fees March/April 2006
Dancing Elephants and the P4P
From the President’s Message in The Bulletin of the Humboldt-Del Norte County Medical Society, by Luther F. Cobb, M.D:
“The elephants are dancing in Washington, but it’s a minuet, not the jitterbug. As I write this, only two months remain until the SGR (Sustainable Growth Rate) formula is due to operate to reduce Medicare reimbursement by about 5%. As you probably know, the SGR formula links Medicare reimbursement to the gross national product, which basically has nothing to do with the growth of the Medicare population or their medical needs. The good news, we are told, is that Congress really, truly does understand that this is a bad formula and doesn’t want to let this reimbursement rate fall at the level that is scheduled. The bad news is that Congress is demanding ‘something in return.’ This appears, will be Pay For Performance, or P4P for you lovers of hip-hop style acronyms.
“Paying For Performance. That sounds like something we should all get behind, like apple pie, motherhood, and the flag. (Come to think of it, even those are controversial these days). The basic underlying idea is that, as Medicare is currently run, every ’provider’ (I hate that word!) is reimbursed at the same rate for the same (CPT –coded level of service, Of course with fudge factors added in for geographic variations, etc. (And again those are the source of much consternation as well — see GPCI.) So, shouldn’t we reimburse the ones who do the very best work at a higher rate? Won’t that save lives, add to quality, and reduce all those preventable deaths we all know are out there being killed by less competent ’providers’?
“Well, to re-use a very trite phrase, the devil is in the details. How exactly do we measure ‘quality’? It’s not as if it is a new concept, or that physicians and lay groups haven’t been trying for a very long time to do exactly that. Now, of courts, if it’s going to be worth MONEY, it’s going to be worth a fight too. I have talked with folks at the CMA who are intimately involved with this process, including Ron Bangasser, M.D., a former CMA President and a really smart and energetic guy…
“Well, Ron confessed, the working groups couldn’t come up with a single criterion for surgery that they thought would withstand scrutiny. So, there will be NO criteria for surgery, at least as things currently stand. Well, maybe that’s a good thing…
“Because these criteria must be objective and verifiable, they almost have to be limited in impact. I also think they’re highly likely to be unfair. I could be wrong, and maybe this really is the best thing that could happen. But it reminds me of the debate at the time of he original passage of the Medicare legislation. When AMA representatives expressed concern about the control that was being given up over the practice of medicine, they were reassured that ‘“the only thing that will change will be the signature at the bottom of the check.’”. I think we all know how that turned out. What will be reimbursed under these rules will be things that will be quantifiable and clear-cut, which will practically demand electronic medical records and data retrieval. This could well be a huge unfounded mandate, because whatever the P4P reimbursements, I really doubt they’ll cover the cost of the currently available EMR systems, which still, of course, aren’t interoperable. A lot of this information will go whizzing over the Internet also. Despite HIPAA, I suspect a lot of this information will get out; after all, we hear almost weekly of equally sensitive information, like credit card numbers being stolen by hackers. This criteria may be simple and straightforward now, there’s a huge potential for creeping imperceptibly into more basic areas that may threaten our independence as physicians. In a lot of ways, this concept reminds me of the ‘“No Child Left Behind’” federal education legislation, which is wreaking havoc in public education as we watch from the sidelines…
“So, maybe I’m just a technophobic curmudgeon. Certainly my skepticism won’t be the deciding factor in whether this gets through Congress or not, because it’s pretty much a done deal. I just suggest we watch out, pay attention, and consider whether there is some level beyond which our tolerance for intrusion will be exhausted.”
The full article is on the society’s website. Go to www.humboldt1.com/~medsoc/images/bulletins and click on November 2005.
Placer-Nevada’s first 100 years
Excerpts from a Foothill Medical Bulletin, by Ted Bacharach, MD, .First Centennial Edition of the History of the Placer- Nevada County Medical Society 1889-1989:
“In the annals of medicine and surgery, 1889 was not a particularly memorable time, but it was the year Physicians in Placer County organized a local medical society comprised of Placer and El Dorado counties. Nevada County had its own organization, the Grass Valley Medical Association, founded in 1865. They merged with Placer County to form the Placer-Nevada Society in 1904.
“In the years to follow membership extended…into Sierra County, and the society was renamed the Placer, Nevada, Sierra, El Dorado Medical Society. In those days, the meetings were held at noon because the doctors had to come by horseback or by horse and buggy, and many of them stayed overnight in Auburn. Because the roads were so poor, physicians in El Dorado County joined the Sacramento Society for Medical Improvement in 1940 and in 1961 Sierra County doctors became affiliated with the PlumasModocPlurnasModoc Medical Society….
“Physicians apparently were preyed upon by insurance companies even during the l800s, as evidenced by a resolution passed in 1896 refusing to examine candidates for life insurance for any fee less than $5 per applicant.”
The full article, at www.pncms.org/mc/page.do, unfortunately can be accessed only by society members — an increasing hindrance to a wider audience for physicians’ messages.
MBC’s Growing Licensure Fees
Excerpted from New Laws 2006: Elimination of Medical Board Cost-Recovery, by Catherine I. Hanson, Esq.
“CMA was also successful in eliminating the ability of the Medical Board of California (MBC) to charge individual physicians for the costs the MBC incurs in investigating and prosecuting disciplinary actions. After monitoring the impact of this practice for over a decade, CMA determined that ’cost recovery’ improperly increased the potential for abusive prosecutions and unfair settlements, as the financial stakes were increased to the point that it was virtually impossible for physicians to challenge even baseless accusations of wrongdoing. The revenue impact on the MBC will be moderated by a modest increase in fees spreading the amount previously collected in cost recovery across all physicians.”
My comment: CMA supported the astronomical increase in licensure fees to $600 some years ago because that would cover the cost of physician investigation and prosecution. It was justified because it would distribute that cost among all physicians. Almost immediately, the MBC began extracting the cost of physician investigation and prosecution from individual physicians, in addition to these exorbitant fees. Let’s hope this increase in license renewal fees again by nearly $200, under the same pretense, isn’t a replay of past subterfuge.
A hospital crisis, an epidural that wasn’t and the curse of interesting times May/June 2006
Between Danger and Opportunity
Luther F. Cobb, MD, wrote on “Crises” in his president’s message in The Bulletin” of April 2006, published monthly by the Humboldt-Del Norte Medical Society. [This is an important message for our medical society. For background of the hospital crises in Humboldt, and how important the issues are to physicians who can only speak effectively through their medical societies, and read one of the Op-Ed articles atwww.humboldt1.com/~medsoc/images/bulletins/APRIL%202006%20BULLETIN%20for%20web.pdf.]
“I’ll admit that I don’t speak or read Chinese, and it may just be an urban legend. But I’ve been told that the Chinese character for the concept of ‘crisis’ is the conjunction of the pictographs for ‘danger’ and ‘opportunity.’ This strikes me as an appropriate metaphor for the recent events locally with St. Joseph Hospital. I’m sure we all have our own ideas about the reasons for the current difficulties, and many of us in the medical profession, as well as elsewhere, are only too happy to point out our own candidates for scapegoat. However, I don’t think that gloating over others’ misfortunes or misjudgments will get us very far, even though it may be a personally satisfying exercise in Schadenfreude.
“We often talk about being behind the ‘Redwood Curtain,’ but I think a more appropriate metaphor may be a goldfish tank. You may have noticed while feeding your (or in my case my college kid’s) fish in an aquarium that while you’re putting fish food in the top of the tank, the fish have to swim around in water containing the ultimate processed residue of the food you put in over the last days and weeks. It seems to me that we often battle over issues pertaining to our own little share of the medical universe, trying to look out for our own. Certainly, there must be a goodly amount of attention paid to our own turf and responsibilities. But I also believe that we ought to be considering the future welfare and viability of the system as a whole. We are participating in building and maintaining the system that will be around this area for a long time to come. When we need medical, hospital, and yes even nursing home care for ourselves and the rest of our family, we will have to contend with the system that we have created together…
“I have discussed the participation of the Medical Society with Joe Mark, the new CEO of St. Joseph Hospital, who is open and welcoming to our organization’s help and advice.
“This apparently dangerous situation may turn out to be a great opportunity for ourselves, our patients, and the whole community. I certainly hope so.”
To read the entire message, go to www.humboldt1.com/~medsoc/images/bulletins/
An Epidural to Remember
The Spring 2006 Sonoma Medicine, the magazine of the Sonoma County Medical Association was devoted to clinical empathy. One article, The Saline Solution by editor Steve Osborn, began this way:
“The placebo effect has been defined as ‘a physical or emotional change, occurring after a substance is administered, that is not the result of any special property of the substance.’ As part of this theme issue on clinical empathy, we decided to investigate the placebo effect, so we sent local physicians an informal survey consisting of the following question: ‘What experiences, if any, have you had with the placebo effect when caring for your patients?'”
This was one response.
“The most amazing placebo response I ever witnessed was as a scared first-year resident doing OB. A very obese woman came in with active labor. When I went to check on her, she was already completely dilated, and the head was well within the vagina.
“‘Time to push,’ I said.
“‘No way, not without my epidural!’ she exclaimed adamantly.
“‘Please!’ I begged.
“‘No!’ she replied, and laid down and groaned and screamed for her epidural.
“‘OK, OK!’ I shouted, and demanded the nurse bring me the epidural cart.
“The patient sat up obediently. With trembling hands, I cleaned the skin and proceeded to push a spinal needle through the layers of fat toward what I prayed was an interspace. No luck: bone. I withdrew the needle.
“Before I could say anything, the patient promptly laid down, said, ‘Thank you,’ and proceeded to push out a healthy 9-pound boy.
“‘Thank you, doctor, for giving me the epidural,’ she said. ‘My friends were right: it really helps.’
“Speechless, I merely stammered, ‘You’re welcome.’ —Herb Brosbe, MD”
To read the other placebo stories, go to www.scma.org/magazine/scp/sp06/osborn.html
Changing Times, Interesting Times
In the Santa Barbara County Medical Society News, president Christopher V. Lambert, MD’ wrote A Point of View.
“‘May You Live in Interesting Times…’ Ancient Chinese curse
“…We are living in interesting times for medicine, needless to say. Change and challenge approach us from many directions. My focus this month is on the ever growing influence of government on the practice of medicine, and our need to be involved.
“Lee Hamilton spent 34 years in the United States Congress. He chaired the 9/11 Commission, and now heads the Center for Congress at Indiana University. He is in his early 70’s and still actively involved in leadership. He was interviewed recently on CSPAN, where the discussion turned to the Abramoff investigation. Hamilton was asked what changes he had observed in Congress over his 34 years.
“He replied, ‘There has been a sea change in the mindset of people about government. When I was elected to Congress in 1964, the constant theme I remember was “get government off my back,” which I heard from everyone. Now, what you hear is, “what can government do for me?”‘
“…This observation certainly holds true for health care. The federal government first intervened in healthcare with Medicare and Medicaid, then with EMTALA (Emergency Medical Treatment And Labor Act) and other unfunded mandates, now with Medicare Part D. Meanwhile in California the number of legislative bills involving health care sent to the State Assembly expands ever more rapidly. Issues of reimbursement, contract dispute resolution, scope of practice, even continuing education mandates all have the potential to be passed into law. While one can wish for a simpler local solution to many healthcare issues, the size and complexity of the health care system makes government legislative solutions the ‘arena of last resort.’ We must acknowledge this reality, while insisting that decisions at the legislative level need to be made in the best interests of our patients and our physicians, and that in order for this to happen the legislators must receive accurate and timely information, guidance and opinions from us. This requires constant diligence on our part. We must accept the importance of lobbyists and political contacts to move our agendas forward.”
The entire President’s message, is at www.sbmed.org/public/components/societytools/admin/viewNewnews.asp?newsjob=ArticleID&ArticleID=6820&ArticleName=President%27s+Point+of+View++January%2FFebruary+2006
Opinions on Ads by Physicians, Patient Contact by Anesthesiologists, and Best Doctor lists July/August 2006
Lamenting Physician Ads
Dr. Emily Dalton does not like physician advertising, as she makes clear in “Physician Advertising: Compromising Ethical Standards in Surrender to the Relentless Capitalistic Model of Corporate America.” The article is in The Bulletin of May 2006, a monthly publication of the Humboldt-Del Norte County Medical Society.
“Is medicine a profession? A business? A calling? All three? What is it that distinguishes a profession from a simple trade? Most experts agree that the difference lies in a code of ethics. When professionals are required to adhere to a strict ethical code, that profession, in return, receives a special trust from the public. In medicine, everything we do depends on trust. Imagine a patient encounter fraught with mistrust: they don’t go very well. A medical professional is perceived as being bound by ethical rules that prevent exploitation of his/her special skills and knowledge, and this creates trust. Advertising undermines that safe haven of trust.
“There is a difference between the doctor-patient relationship and other types of business transactions. Physicians have a moral obligation to provide the best and most appropriate medical care possible, regardless of financial profitability. Patients need health care; their lives depend on it.
“Patients are not in a position to able to shop around — they lack the financial resources to flit from office to office to compare doctors, and they lack the medical knowledge to know good medical practices from bad ones. In fact, businesses that help physicians advertise their healthcare practices recognize this well and do not hesitate to take advantage of it. Healthcare Success Strategies is one such business that comes up easily on Google. They note that: ‘The practical reality of clinical care is that most patients cannot judge the quality of clinical care unless it’s really bad and/or painful. Patients generally assume most providers to be of roughly equal quality or you wouldn’t have a license to practice…. Truth be told, the public has a hard time distinguishing your quality of care from anyone else. Fortunately you can now borrow the best techniques from corporate America…(to better market your practice).’”
The entire article is at www. humboldt1.com/~medsoc/images/bulletins/MAY%202006%20BULLETIN%20for%20web.pdf
Brief but Crucial Contact
J. Antonio Aldrete, MD, MS, writes about “Quality vs. Quantity of Patient Contact” in the Winter 2006 bulletin of the California Society of Anesthesiologist.
“While interviewing numerous medical students contemplating anesthesiology as their future specialty, one definite concern frequently surfaces. In their abstract idealism they expressed, in one way or another, a genuine pre-occupation for the amount of patient contact afforded by anesthesiologists in their daily practice. Though the acute care and prompt problem solving of our specialty attracted them, what they have seen and/or heard in their experience at medical school regarding anesthesiologists being in contact only with sleeping patients caused them alarm. That image hangs on us, justifiably or not, but it does and must be changed.
“In reality, our contact with patients, though perhaps shorter in duration when compared to other specialties, occurs at a time crucial for our patients, at a moment when major events in their lives are about to happen. When we first see them in the preanesthetic interview, they are concerned about a number of unknowns. Do they have cancer? Are they going to be able to walk? Is their sexual activity going to change? Are they going to be left without a breast, a leg, a hand, et cetera? How much longer are they going to live? Will they survive the operation? [This is] only to mention a few of the more frequent worries that surgical patients may have the day before their operation.
“Our visit must provide assurance and confidence and not produce more worries. This is indeed a precious time when we may alleviate some of the patient’s concerns about their operative and anesthetic experiences. What better time to explain our role in watching over their vital functions, to explain the careful administration of potent medications used during anesthesia, to warn over possible complications, to emphasize how our technique may ameliorate immediate postoperative pain, et cetera?
“It may be a short contact, but if properly conducted, that interview may play not only a valuable support of the patient’s emotional status but also an informational activity of what we do and how we do it, at a moment when the patient’s attention is all ours. This can be extended during our encounter with them in the operating room; there, we have from five to 30 minutes, depending on the preparation for the operative procedure. While performing our functions we can literally ‘chat’ with them, explaining what we do and why we do it and then they will be more willing to accept the pain of a needle stick, the removal of a gown, the discomfort of lying on a hard operation table…. Finally, let’s make the post-anesthetic visit more than a ‘hi’ meeting; let’s make it a real visit…
“So, there is my answer to the inquiring potential resident candidates; the contact with our patients may be brief (as measured by units of time), but it is in crucial moments of the patient’s life, dealing with life and death matters; thus, we can make it one for them to remember and appreciate, if we just take the time.
“The preanesthetic interview, the O.R. encounter and the postanesthetic visit(s) are what we make of them, as short or as lengthy as we wish; as important or as irrelevant as we want to think they are.”
The entire article may be viewed at www.csahq.org/pdf/bulletin/issue_11/Quality054.pdfA Few Good Doctors: Don’t look for them on a magazine top-10 list.
Kent Sepkowitz, a physician in New York City who writes about medicine, has some choice words about magazine “best doctor” lists.
“About this time every year, doctors across New York City begin to cast a wary eye at local newsstands. When the bundle of New York magazine’s ‘Best Doctors’ issue drops onto the pavement, torture commences for the city’s prim and laconic physician class. (Other cities get their chance at other times of year.) It’s high school all over again, a life lived at the mercy of cruel arbiters of who is up and who is down. To their credit, I suppose, the compilers of the Best Doctors list define worthiness with more objectivity: They poll local doctors and ask whom they would refer a family member to. With this quasi-statistical information in hand, they go behind closed doors and construct the dreaded list.
“To my expert eye, every year the New York survey gets it about half right: Half of the selections are first-rate doctors, no doubt about it. Another 25 percent are people whom I don’t know well (though I have my doubts), and 25 percent are certifiable duds — doctors who (hopefully) haven’t seen a patient in years but have risen to the lofty realm of high society and semi-celebrityhood.
“Of course, the list isn’t really about accuracy or quality. It’s about sales — not only of doctors’ services but also of fancy plaques, directories, and pen-and-pencil sets fitted into paper weights…” To see the entire article, go towww.slate.com/id/2143506/
“Time’s fun when…”, the three S’s of insssurance companies, liability risks of team docs September/October 2006
Dr. Cobb’s Finale.
“Time Flies” was the title the president of the Humboldt-Del Norte County Medical Society, Luther F. Cobb gave to his farewell message in The Bulletin of May 2006
“As the saying goes, time flies while you’re having fun. Or, as I’ve been told Kermit the Frog pointed out, time’s fun when you’re having flies. In either case, it is somewhat of a surprise to realize that this is the last column I shall write as the incumbent president of HDNCMS…
“I suppose it can be said in almost any day and time that things are tough and that the good old times were better, but I really do believe that our noble and beloved profession faces a set of challenges unprecedented since the days of the Flexner Report a century ago. As you all know, great forces are arrayed against the interests of medical practitioners and their patients, mainly in the service of the various corporate greed of Big Pharma, insurance companies, and the government. None of these malfeasors appear to believe that the medical goose that laid the golden egg of modern scientific medicine can be slain. (Please pardon the tortured metaphor.) Well, there are a lot of us who refuse to go down without a fight. My successor as president, Dr. Ellen Mahoney, in addition to being the only person in the world able to put up with me as a spouse, is a terrific organizer and thinker. She and Dr. Ann Lindsay, another phenomenal talent we are fortunate to have in her many roles in our community, are hard at work on a truly audacious and innovate project that has the potential to revamp and revitalize the practice environment behind the Redwood Curtain…
Dr Cobb’s complete article, including his plan to campaign for CMA office, appear inwww.humboldt1.com/~medsoc/images/bulletins/JUNE%202006%20BULLETIN%20for%20web.pdf.
A Sadly Broken System
In the same issue of the Bulletin, Stephen Kamelgarn, MD, wrote an opinion piece:
“The May 25, 2006, issue of the New York Times had an interesting little article titled ’The Check is not in the Mail.” This article did a good job illustrating how doctors are not getting reimbursed by insurance companies for legitimate services rendered. The companies engage in all sorts of stalling, shenanigans and subterfuges (the 3 S’s) to avoid paying the bills.
“The companies will ’lose’ claims, even those submitted electronically (a tough thing to do). They will obfuscate. They will dispute. They will delay payment. If any of us tried that trick when we have to pay our own health insurance premium watch what would happen; do the words ’cancelled policy,’ strike a familiar note?…
“When we couple the poor payment practices of the insurance companies with their generally abysmal reimbursement rates, is it at all surprising that more and more of us are opting out of the insurance game altogether: we become contract workers, or we accept cash only (thereby limiting our services to those who can afford to pay), or we opt out of medicine altogether?
“In a nation where over 45 million people have no health insurance, and many of the rest of us are under insured in the form of high co-pays and deductibles and exorbitant premiums, it is no wonder that, far and away, the largest source of personal bankruptcy in the United States is from costs incurred from severe illness. We spend more money, per capita, than any other nation on Earth for health care, yet we are at the bottom of the list of industrialized nations for how well that health care is delivered — we’re getting less bang for our healthcare buck. Poll after poll shows how the American public is overwhelmingly in favor of some form of single payer health care.
“Many, if not most, physicians are in favor of single payer, and even organized Medicine is officially entertaining the notion of a single payer healthcare system. Yet we remain with this sadly broken system that solely benefits the insurance industry and their investors…
The complete article is at the website above.
[But, Doctor Kamelgarn, don’t we have a choice? We can stop taking Blue Cross, we can stop taking Medicaid, we can stop taking Medicare, we can stop taking any HMO we desire. But if only Uncle Sam were responsible for paying us, like in Medicare, many physicians may have a great deal of difficulty getting Uncle Sam to write that check on time or ever. — D.M.]
Who Pays Team Doctors?
Dr. Stephen S. Hurst, MD wrote on “Assessing Liability Risk For a Team Physician” in the June issue of the Bulletin of the San Mateo County Medical Association.
“The discussion of the sports team physician’s medical liability risks begins with a question. Who pays the team doctor?
“The answer, of course, will differ depending on the level of competition, the sport, and the sports market. At the high school level, where I have enjoyed my role as team physician for nearly 40 (seems like only 10) years, and teams junior to it, any stipend offered should be waived so that the physician may enjoy the umbrella protection provided by the Good Samaritan laws of the state of California while on the field. If the physician continues to follow the patient after having provided on-the-field emergency care, fees can be charged and the liability game is ”on”…
“Physicians who act as team doctors must also be ready to treat on-the-field emergencies that may [not] be covered by our normal job description. It is hoped that the immediate stress of the situation will allow us to recall some basic facts from our medical student and internship rotations. As an orthopaedist, I have had to provide pre-participation physicals that require some knowledge of medicine, infectious disease, cardiology, neurology, urology, dermatology, and pediatrics, just to name the most commonly used disciplines…
“At the college level, the selection of the team physician is often the result of past political networking. Fortunately, the job usually goes to that person who has shown an interest in the care of athletes and has earned a sports medicine reputation by enabling the athletes to return to competition rapidly and safely. The medical care usually is provided on a fee-for-service basis and most college athletes are insured by the university or a student athlete health plan. Occasionally, there also may be a small retainer fee. Again, these college communities rarely have a shortage of subspecialtists and often have affiliated medical schools to provide the required expertise. This greatly reduces the potential for legal action…
“Payment arrangements for the treatment of the professional athlete may be very different from those described above. I am certain that you, my medically sophisticated and informed audience, will be surprised to learn that in most major sports markets for the high profile NBA, NFL, MLB teams, the orthopaedist pays for the privilege of providing these services because it is the best advertising and practice-building tool available. These positions are very high-profile marketing “dream” deals that almost guarantee a large, lucrative practice…. On the flip side of the equation, this is a very high-risk occupation with tremendous public and media scrutiny. Professional team physicians are subject to medical practice suits at a higher rate than the general orthopaedic population…
To read the entire article, please go towww.smcma.org/Bulletin/BulletinIssues/June06issue/Assessing%20Liability.html
A Critical Response Team of Physicians?, and Re-evaluating the Role of Doctors. November/December 2006
We are Human, We Make Mistakes.
George Ingraham, MD, calls his article “A Missed Opportunity,” in the In My Opinion column of the August 2006 issue of The Bulletin, published monthly by the Humboldt-Del Norte County Medical Society.
“On April 27 of this year Cheri Lynne Moore, a 48 year old woman suffering from a bipolar disorder, ran out of medication and decompensated. She began playing her stereo at high volume, yelling insults at the people walking along G Street outside her apartment, and threatening them. At some point she displayed a weapon (“brandished” is the term used by law enforcement), which brought her to the attention of the Eureka Police, who evaluated the situation from a law enforcement perspective and brought the Critical Incident Response Team into the picture. After making attempts to end the situation by negotiation, the team forced entry into the apartment upon being told that Moore had appeared at her window and appeared at that moment to be unarmed. Unfortunately, she did, in fact, have her weapon in her hand and the CIRT opened fire.
“We can fault Moore for letting herself run out of medication; but we’ve all done that, and we’ve all forgotten to take our meds, or left them home when we went on a trip. Human beings, doing their level best, can make mistakes.
“We can fault the police. In a perfect world, the response team entering the apartment would calmly evaluate the situation, perceive that the weapon was a flare pistol, probably not dangerous, and would not touch their triggers. In a perfect world. Last April, on G Street, young men, their adrenalin and steroid levels pegging the meter, waited for the go signal while wondering what it would feel like if a bullet hit them in the next few minutes: maybe the last thing they would ever feel in this life. Suddenly they saw in front of them a wild eyed crazy person with a gun in her hand. They looked death in the eye. Their training kicked in. They killed her. Human beings, doing their level best, can make mistakes. There were… there always are… opportunities to prevent the death of Cheri Lynne Moore. She called public health asking for more meds. A friend offered to try to talk her down, but the police judged the possible risk not acceptable. Perhaps the CIRT could have waited a little longer or tried a different negotiation strategy. We are all Monday morning quarterbacks. It makes no sense to try deciding who is at fault: we can’t help Cheri Moore. But we can perhaps help someone in the future if we decide to fix the problem instead of the blame.
“Even given that these things don t happen often (the last similar incident was in 2000, when an armed man threatened an officer in a downtown parking lot and was shot to death in the confrontation) we could still give a thought to “next time.” Perhaps the Medical Society could give some thought to a Critical Incident Response Team of its own: a panel of physicians and mid level practitioners with expertise in psychiatric crisis, triage, critical injury management in the field and so on; who would volunteer to make themselves available to drop what they were doing and be available on the scene of situations like this if the first responders or authorities on site needed them. These folks would need to do some familiarizing work, maybe participating in training drills and classes with police, sheriff, and fire departments so as to be familiar with the way these folks work and communicate, and to be on greeting terms with the people they’d be working with. Of course, we could have thought of this a long time ago. But we didn’t. Perhaps we made a mistake. Human beings do that.”
This and other August issue articles are atwww.humboldt1.com/~medsoc/images/bulletins/August%202006%20Bulletin%20for%20web.pdf
Reevaluating the Physician
In the Fall issue of the Bulletin of the California Society of Anesthesiologists, Donald J. Priolo, MD, wrote on “Hippocrates Upended: A Cause for Revaluation of the American Physician.”
“What the earthquake of 1906 did to the Bay Area, World War II in 1941 and the advent of Medicare in 1965 did to the American physician. Let us look at the parallels. Before Hippocrates, physicians could be hired as assassins to do in an enemy or facilitate the premature demise of a parent for early inheritance. Now physicians are paid to perform according to the bureaucratic formulas and edicts of the federal government, business groups, insurance companies, HMOs and IPAs. Lost in this third-party deluge of financial forces is the primacy, prestige and freedom of a properly educated and licensed physician to act and advocate entirely for the patient, as well as the patient’s freedom to choose a physician and to expect that physician to honor a sacred bond of trust. American medicine has been reduced to considerations of what percent of gross domestic product can be spent on healthcare, how many forms can reasonably be completed before a third party will pay, whether an insurer will allow an assistant at surgery, and how fast a patient can be rushed through an examination or discharged from the hospital.
“The impact of these exactions on the value of both the patient and the physician is enormous. Our contemporary ethos is to devalue patients, their physicians, and their bond of trust in order to legitimize payer coercion. The patient becomes a pawn, the doctor becomes a wage slave, and both lose their freedom to aspire to and achieve their highest hopes and calling.
“If the dignity and stature of physicians are not universally idealized societal values, then patients cannot be healed. A sick, fragile human, ravaged by physical and/or emotional illness, surrenders himself or herself to the mercy and unmitigated loyalty of a physician. This experience is not analogous to standing in line awaiting service from a bank teller or a grocery clerk. This profound act of self-exposure and trust by a patient to the skills and mercy of a physician is a difference in kind from all other human interactions, not a difference in degree.
“Societies do not grant this privilege casually: Consider the rigorous and prolonged educational process, national board examinations, licensure, specialty training, specialty board certification, and maintenance of certification and recertification. Paradoxically, the federal government and its echoing chorus of commercial business and payers now expect the physicians to behave as drones, groveling annually to the Congress for their share of a diminishing handout. The fact is that it is only collectively through our professional associations that we can respond in an effective manner. It has been stated, “Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to be competent and to use their competence in the patient’s interests. Today, this covenant of trust is significantly threatened. By its traditions and very nature, medicine is a special kind of human activity—one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion and effacement of excessive self-interest. Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it.1” “Ask not what organized medicine can do for you; ask what we can do for our patients.” The strangulating grip of third-party influence destroying health care over financing issues must be broken.
“Let us insist on revaluation of the American physician as the cornerstone critical to the healing power of physicians.
“Let us pledge eternal warfare against influences and health systems that violate our calling.
“Let us renew our commitment to the 2,400-year-old Oath of Hippocrates, immortalizing the patient-physician covenant.”
To read the original along with the references, please click on Hippocrates at www.csahq.org/pageserver.cgi?tpl=internal.tpl§ion=publications&name=bulletin_view&idx=14
Dr. Priolo is a neurosurgeon practicing in San Jose, California. He is the past president of the California Association of Neurologic Surgeons and the president of the Santa Clara County Medical Association. He also serves on the Executive Committee of the Specialty Delegation to the California Medical Association.