American College of Physicians: Internal Medicine — Doctors for Adults ®

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Wednesday, June 30, 2010

QD: News Every Day--More costs, less pay are group practices' biggest headaches

Rising operating costs amid declining Medicare reimbursement presented the biggest challenges to group practices, taking the top two spots in a survey of group practice managers.

Implementing electronic health records is the third biggest challenge, according to results from the Medical Group Management Association. Implementing the patient-centered medical home rose from the 22nd spot to the 12th in one year.

MGMA also tracked the impact of the recession, finding it raises issues surrounding billing collections and/or denial management processes, decreased revenue, and increases in the number of uninsured patients. Practices responded by postponing capital expenditures, cutting operating budgets and freezing salaries.

Hospitals face more diverse challenges, including setting pay models for staff physicians, recruiting them and implementing a patient-centered medical home. An spreadsheet of the top 30 challenges is available.

One item that might make up for the challenging financial environment is Medicare's expected expansion for some primary care services. Medicare wants to reimburse physicians for annual well checkups and cut co-pays for preventive services such as cancer screenings and smoking cessation under a proposed rule that could take effect next year. Annual reimbursement expands upon the one-time "Welcome to Medicare" visit. But the ROAD just got a bit more bumpy for radiologists, who will be paid less for their services now. (Medical Group Management Association, MedPage Today)

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Tuesday, June 29, 2010

QD: News Every Day--Rosiglitazone to face scrutiny

Rosiglitazone (Avandia) will face extra scrutiny soon, following two reports that suggested it's associated with cardiovascular consequences.

The first, released in the Archives of Internal Medicine, showed that rosiglitazone increased the risk of myocardial infarction (odds ratio, 1.28; 95% confidence interval [CI], 1.02-1.63; P=.04), but did not increase cardiovascular or all-cause mortality. The second, released by the Journal of the American Medical Association, an analysis of more than 227,500 Medicare patients that found the adjusted hazard ratio for rosiglitazone compared with pioglitazone (Actos) was 1.06 (95% confidence interval [CI], 0.96-1.18) for myocardial infarction; 1.27 (95% CI, 1.12-1.45) for stroke; 1.25 (95% CI, 1.16-1.34) for heart failure; 1.14 (95% CI, 1.05-1.24) for death; and 1.18 (95% CI, 1.12-1.23) for the composite of myocardial infarction, stroke, heart failure or death.

The FDA will convene a special advisory panel July 13 and 14 to evaluate the findings. GlaxoSmithKline, which makes rosiglitazone, responded that better-designed studies found no overall risk of heart attack, stroke or death.

The RECORD study, a cardiovascular outcomes trial designed in conjunction with European regulatory agencies, saw no increase in a combined endpoint that includes death, myocardial infarction and stroke [HR=0.93, 0.74-1.15, p=0.5], the company said in a press release. And, a company meta-analysis from 52 clinical trials does not show an increase in myocardial ischemia [HR=1.1, 0.89-1.35, p=0.38]. (Washington Post, NPR)

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Monday, June 28, 2010

QD: News Every Day--Congress patches Medicare payments, now tries Medicaid

Having temporarily patched Medicare reimbursement until Nov. 30, you'd think Congress would start coming up with a permanent solution. Here's the numbers. The 21.3% cut resumes on Dec. 1. The six-month fix gave doctors a 2.2% raise, so it becomes a 23.5% cut. And Medicare will tack on a 6.1% cut on Jan. 1. That totals 29.6%. American Medical Association president Cecil B. Wilson, MACP, called to scrap the entire system. (Kaiser Health News, Modern Healthcare, American Medical News)

But instead of planning ahead, Congress is going to try the same trick again, this time breaking out Medicaid as a separate bill from stalled legislation. Democrats want to extend federal funding for state Medicaid programs through their 2011 budget year. States have suffered in the recession, leading them to cut health care services to balance their ledgers. (The Hill, The Tennessean)

In case you missed it ... Part I
Lee Biblo, FACP, proudly practices "cookbook medicine." He's got the proof to practice evidence-based medicine and to try to convince his peers to follow basic guidelines for treating pneumonia, diabetes and heart failure at the medical College of Wisconsin. In the past five years, he's managed to cut the average length of stay for non-surgical admissions by a full day. (Milwaukee Wisconsin Journal Sentinel)

In case you missed it ... Part II
Arthur Rivin, FACP, treated his share of Alzheimer's patients before he retired from internal medicine. But he never thought to diagnose himself with it, choosing to ignore his symptoms. He writes about the impact of the diagnosis on his life as he prepares for his death. (Los Angeles Times)

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Friday, June 25, 2010

QD: News Every Day--Six-month doc fix finally passes

The U.S. House relented and passed a six-month extension to full Medicare reimbursement. Citing the Senate's gridlock on a slew of other health and jobs-related item, the House took action on just the "doc fix" after saying they wanted all the issued to pass. The six-month reprieve provides a 2.2% raise and is retroactive to June 1. The $6.4 billion cost to pay physicians will be offset by changing Medicare billing and antifraud rules, as well as hospital reimbursement. (New York Times)

Lawmakers will face the task again in November, but hope the post-election environment will make it easier to arrive at a permanent solution. But the finger pointing that Democrats and Republicans have engaged in isn't going to change. And, reminds the Medical Group Management Association, "This latest patch expires in November, just one month before the start of the next fiscal year for most medical groups. It throws responsible business planning for 2011 into complete disarray and occurs exactly when physicians will make the difficult decision to participate in Medicare for the coming year." The American Medical Association added that one in four Medicare patients looking for a new primary care physician are having trouble finding one, and one in five physicians are already limiting Medicare patients. Should the deadline pass again, in December the payment cut will be 23%, rising to 30% in January. (NPR, Los Angeles Times, Medical Group Management Association, American Medical Association)

Left behind in the rest of the stalled legislation are federal funds to help states pay for Medicaid, in addition to other jobs legislation. (Wall Street Journal)

In case you missed it ...
Swag may be back in Massachusetts. The legislature is considering a repeal on the ban that prevents drugmakers from offering freebies because the measure hurt local business' profits. (Boston Globe)

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Medicine vs. religion: my brother's keeper revisited

This post by Alan Dappen, MD, appeared at Better Health.


A few weeks back, I had introduced a patient who was willing to let her religious beliefs stand in the way of receiving the proper medical treatment she needed to stay alive. I want to revisit with you this dying patient, who hadn't known me or any doctor for over 30 years.

As the rest of the family, who were not as committed to a religious path, stood by her expectantly, I said to her: "I had a brother who was a true believer in the power of God and that faith could heal all things or be called God's will. Like you, he was a competent adult in charge of his decisions. He wouldn't listen to anyone else--not his wife, father, mother, children, brother--not even me, the doctor. He died two years ago, leaving behind 10 children and a wife who depended on him. We all believe he died unnecessarily.

"I visited his widow a few months later. Honoring her husband's beliefs, she'd not gotten any medical help in over thirty years of marriage. For several years she became sicker and sicker, with an illness that reminds me exactly of yours: she had lost a lot of strength and stamina, was short of breath, and short walks wore her out. Like you, it was obvious that she had a severe anemia, but I couldn't explain the exact cause. I put together a differential diagnosis of seven possibilities and told her, like I'm telling you, that some of these possibilities are irreversible, like cancers, whereas some are easy to fix, like iron replacement or Vitamin B12 replacement."

"From my religious standpoint, we don't believe that anything is irreversible," my current patient corrected me.

"Fair enough." I conceded. "But some lab tests might help us see the difference. In my sister-in-law's case, the labs I ordered indicated a severe anemia from B12 deficiency. With simple transfusion and B12 replacement and she was completely back to normal; she'd suffered for too much time with something that was easy to fix.

"A few tests may help us better understand if something as simple as taking iron, or vitamin B12, or a natural thyroid pill, might help you."

She wavered, conceding that taking vitamins or iron wouldn't be against her faith. Her family asked where she could have the labs done.

"I have everything here in my medical bag if you'd like?" I answered.

All involved, most importantly the patient consented. When I drew the sample, I noted that the blood was very watery.

Three hours after delivering the samples to the lab, I received a call with the result: "We just want you to know that there is something wrong with the blood sample so we didn't complete the rest of the samples. The hemoglobin was 1.9, so we stopped testing."

"The sample is correct' I drew it myself. After 30 years of practice, I haven't seen a number that low before."

The lab tech answered, aghast, "You mean this person was walking and talking at your office?" That's got to be impossible!"

"Talking yes." I responded, "Walking, no. Keep running the rest of the tests and I'll call her right away."

I called her and the family. My point was straight forward: Although the cause of the anemia was still unknown, a transfusion was critical to keep her alive.

"Here is my point," I stressed, "A transfusion can buy you two months of time — time to find out what's causing this, to make a decision. Plus you'd breathe more easily and have little more strength. You'd also get more time with your family, who clearly care about you."

Without a fight she relented to the idea of an ambulance, a trip to the hospital, a transfusion. And today, she lives on. She still believes in prayer and surrender that perhaps her time has come. For this I honor and respect her. May we all be in meditative surrender when our time arrives, when the walls of science are nothing but an illusion, nothing but a sand castle facing the relentless power and surge of the rising tide. From dust we came and to dust we will return.

As for my brother, I'm betting that St. Peter is holding my brother up at "The" gate with this well known story:

There once was a flood and everyone had reached safety except for one man. He climbed to the top of his house with the water lapping at his feet. A helicopter flew over his head and hung down a rope for him to climb, but the man said, "It's alright! The Lord will save me!"

The helicopter flew away. The water continued to rise and a boat came to him and offered help. Yet, once again, the man shouted, "No! Go AWAY! The Lord will come and save me!" The boat sped off.

The water was getting dangerously deep by now so the helicopter came back to help. The man insisted, "Go away! My Lord will come. I am a man of God!"Reluctantly, the helicopter left.

The rain continued to pour, the water continued to rise and the man drowned. When the man arrived at the gates of heaven, the man met St. Peter. Confused, he asked, "Peter, I have lived the life of a faithful man - why did my Lord not rescue me?"

St. Peter replied, "For pity's sake! He sent you two helicopters and a boat!"

In a way, I hope that St. Peter is holding my brother at the gates and that his key is compromise. I lost that battle for compromise, and thus felt that it cost my brother his health and ultimately his life.

Until next week, I remain yours in primary care,
Alan Dappen, M.D.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Thursday, June 24, 2010

Cholesterol: validation of the self

This post by John H. Schumann, FACP, appeared at GlassHospital.


It's hard to think of a medical concept (let alone any concept!) from the last quarter century that has achieved as much penetration into our culture than CHOLESTEROL. Every patient I can think of, whether rich or poor, old or young, educated or not knows that "cholesterol is bad for you," and that you should strive to "keep your cholesterol under control," whatever that means.

importance of a nail by red twolips via FlickrWell, doctors are hammers, and we like to hit nails. Surgeons like to do operations. It turns out that the more they do, the better they get.

Primary care docs (such as internists, like me) run lab tests. When we see a value that falls outside of norms, we like to "do" something about it. Unfortunately, this has come to almost always mean writing a prescription.

The whole cholesterol hypothesis works very well with this paradigm, now that we have relatively safe and effective drugs with which to "treat" high cholesterol.

I put "treat" in quotes, since high cholesterol (except in rare cases where the cholesterol is sky high in genetic conditions) is not a disease, but a modifiable risk factor for vascular issues like heart attacks and strokes.

There is overwhelming evidence from the medical literature that people who control their cholesterol with statin drugs (simvastatin [Zocor], atorvastatin [Lipitor], rosuvasatin [Crestor], and others) have fewer vascular events (heart attacks, strokes).

This is because the drugs lower the liver's manufacture of cholesterol in the body and alter the ratio of "good" cholesterol to "bad." A lower level of circulating cholesterol helps reduce and stabilize the cholesterol-laden plaques that build up in our arteries, mostly due to our higher fat, highly processed American diets.

I still remember learning about this from a superb Grand Rounds lecture I attended more than a decade ago by Dr. Peter "I used to think I was incorruptible because I took money from EVERY drug company" Libby. His research demonstrates that statins not only reduce cholesterol in the blood and in arterial plaques, but even reduce the amount of overall inflammation in the blood vessel wall.

Some researchers have gone as far as suggesting we put statins in the water supply, since their benefits seem so clear and ubiquitous.

Yet as with all things that become a form of orthodoxy, there are contrarians. Start with those who've had side effects from the drugs: liver injury, muscle inflammation, and less specific aches and pains. Some question the long term effects of being on the medication; others question the incessant marketing of the drugs and the seemingly ever-expanding indications for prescribing them.

Should we prescribing statins for people without risk factors? Even when the cholesterol is not "high?"

It worries me that cholesterol has become the marker of virtue at the doctor's office. It's all due to oversimplification of the physiology and the major societal buy-in to these drugs.

For the more competitive patients, the lower the total cholesterol number, the higher the achievement. Never mind that what determines the number is largely genetics mixed with diet and exercise.

How big a role does diet play?

I admit, having prescribed statins for so long, I was skeptical that lifestyle alone could make a dramatic impact. I posted about what a dietary change did for me in the course of one month. I was quite surprised.

Of course, not everyone can make the lifestyle changes necessary to improve their health profiles. Behavioral change, like all change, is difficult to both initiate and sustain.

The statins give us an alternative to making this change. It's just that we're sliding quickly down the slippery slope to pushing them on everyone.

When you're a hammer, you like to see nails. Even if you have to go out and find more of them.

John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.

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QD: News Every Day--Primary care pay increased in 2009 despite Medicare

The Senate has further tweaked its doc fix legislation to restore the extension to six months (from June 1 through Nov. 30) and the pay raise to 2.2%, reports a Senate Finance Committee Republican advisor. (See page 295) In Northern Michigan, the doc fix can't come soon enough, as yet more physicians contemplate not accepting any more Medicare patients. The legislation continues to see revisions in the Senate, following the U.S. House refusal to consider the doc fix as a stand-alone bill. (TwitDoc, WWTV/WWUP-TV News)

But, primary care physicians saw a 2.8% median compensation increase in 2009, according to a Medical Group Management Association survey. MGMA attributed the rise to employers’ and payers’ increased commitment to primary care, but noted threats to Medicare payments still exist. The ROAD continued to be the best pay-off, career-wise. Dermatologists' pay rose 12.2% due to elective procedures and increased demand, while ophthalmologists saw a 7.7% increase in 2009 from laser refractive surgery. Subspecialists were still better paid, but careers that saw declines included OB/GYN (1.1%) and invasive cardiology (0.2%). HEM/ONC continued a slow, flat trend, due to declining reimbursement for administering drugs--a trend they partly compensated for by treating more patients with the better-paid therapeutics. (MGMA, ACP InternistWeekly)

Resident work hours capped
The Accreditation Council for Graduate Medical Education (ACGME) recommended that first year residents' work hours be further capped to 16, while others should continue to work for 24 hours. Citing differences in capabilities and the need for more supervision, the Council says first-years work longer and that fatigue among them leads to more errors. Revised standards could take effect July 2011. Peter A. Lipson, ACP Member, points out that night float will likely be unavoidable. (New England Journal of Medicine, Modern Healthcare, Whitecoat Underground)

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Sit down, stay awhile

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


Patient satisfaction, as I wrote in USA Today, is being increasingly focused upon. Doctors are often pressed for time, and appear rushed, which can potentially lead to unhappy patients.

no sitting by 416style via FlickrI saw this small study showing that the simple act of sitting down while talking to patients can have a profound effect. Many doctors I know already do this, but now there's some data to support sitting.

According to the study, performed at a University of Kansas Hospital, a physician documented 120 visits, half of which he conducted sitting, and the other half, standing. The researchers found that [the researching physician] Arnold's standing visits lasted an average of 1 minute, 28 seconds. The patients, meanwhile, thought the appointment lasted an average of 3:44.

When Arnold sat down, the average time spent seated was just over one minute, which was actually shorter than when he stood. But the patients thought he spent more than five minutes in the room. Overall, patients thought Arnold spent 40% more time in the room when he sat down.

Furthermore, when patients were asked about the interaction, "The ones who saw the seated doctor 'expressed greater satisfaction and a better sense of understanding of their condition,' than those who saw the standing doc." So, maybe, while doctors continue to lobby for more time to spend with patients, they can help themselves simply by sitting down in the exam room.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 30,000 subscribers and 22,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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Wednesday, June 23, 2010

Playing chicken with health care

This post by Rob Lamberts, ACP Member, appeared at Musings of a Distractible Mind.


Chicken-- noun - A game in which the first person to lose nerve and withdraw from a dangerous situation is the loser.

This definition is wrong. As of June 18, 2010, the definition is as follows: Chicken--noun - A game in which members of Congress put Americans in a dangerous situation, with the healthcare system being the loser.

In my lament about losing my Medicare population if the 21% cut went through, Maggie Mahar commented on my post: "Please don't worry about the 21% cut. This is something that the AMA and conservatives use to fear-monger--it will never happen. It is a very crude solution to health care costs--even our Congressmen understand this. That is why they never implement it.

"On the other hand, moderates are afraid of upsetting conservative voters by killing it. So they just keep postponing it. And then conservatives use the fear of it to advance their agenda with doctors. But it won't happen."

shannon's maquette for the Cardboard Car Crash. by chadmagiera via FlickrWell, the government is, at this moment, cutting checks for service I rendered earlier this month that are 21% smaller than in the past. Despite the fact that the Senate passed a bill not only putting off the 21% cut, but actually raising the pay of doctors, the House is not happy with it.

"WASHINGTON--The top House Democrat says her chamber won't vote on Senate legislation to reverse a cut in Medicare payments to doctors.

House Speaker Nancy Pelosi says the bill--it would reverse a 21% cut on Medicare doctor fees that was imposed on Friday--has to include elements of the Democrats' jobs agenda.

The move by the California Democrat appears aimed at pressuring the Senate to break a logjam on long-sought legislation to extend unemployment benefits and give money to states to help them avoid additional layoffs and furloughs. That bill is stuck on the Senate floor because of a GOP filibuster.

The Senate passed the doctor fee fix as a stand-alone measure on Friday after a GOP filibuster killed the bigger jobs-related measure the night before. The measure would only forestall the cuts--they are required under a 1990s budget-cutting law that Congress has routinely waived--for six months. (Associated Press)"

So as of now, I am being paid 79% of the already low Medicare reimbursement. I hope Maggie Mahar is right about this being simple political posturing, but pardon me if my trust of politicians acting rationally is a bit weak. It's a great big game of chicken. The House is playing chicken with the Senate. The Democrats are playing chicken with the Republicans. They aren't in the cars themselves, we are. Doctors and patients are careening toward destruction in the name of political gamesmanship. Surely they will flinch. Surely someone will understand the consequences of the crash. But you know what? Sometimes each side expects the others will be the ones who flinch. Sometimes nobody flinches. Sometimes the cars crash and people are killed.

The longer the 21% cut is allowed to exist, the less shocking it will seem. The checks are being cut, and the world hasn't ended yet, right? Patients are still getting care. Doctors are still earning an income. People will adjust.

Wrong.

The only thing that is preventing absolute chaos in the system is the fact that nobody thinks politicians could really be this stupid. But is that really true? Who will take the political fallout if the 21% cut stands? The Democrats in the house for not passing the Senate bill? The Senate Republicans who are filibustering the bill the House would accept? Each side can demonize the other, and each side is insulated by that fact. Maybe the politicians see the implosion of the system as an opportunity to bury their opposition in the fallout.

But we are in the cars, people. We are the "casualties" that they will posture about: doctors who lose income, patients who lose doctors. It will happen. The longer the 21% cut is in place, the more solid this insanity seems, the more physicians, especially primary care doctors, will simply close their doors to Medicare patients. We can't "get used to" losing money by seeing people. It is already happening, and it will gain momentum as this madness continues.

Medicare is fragile, and this cut is a sledgehammer. It's not evil Democrats. It's not stupid Republicans. Conservatives and Liberals are both acting irresponsible. They're all betraying the trust we gave them.

Trusting Congress is more and more feeling like being asked to trust an abusive spouse. We want to think the best of these people who claimed they meant to take care of us. We want to think that they understand what damage they are doing. But sometimes insanity grips people and they stop looking at any needs but their own. They betray their vows.

Even if this disaster is averted, staying in Medicare feels more and more like we are enabling the pathological behavior of our "representatives." If they don't pay the political price for destroying health care for their own political gain, we all lose. The gamesmanship will continue and the stakes will get higher. I am just getting tired of being a pawn in the game. Averting this disaster will only embolden congress to go further in this game of chicken.

If things don't really change, the cars will really crash. That's when we all feel the sudden shock when our car meets the other at 100 miles per hour.

Then there is just wreckage.

It's not a game.

People will die.

Stop.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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QD: News Every Day--States facing Medicaid squeeze

New reports peg Medicaid's future as dismal and unsustainable, as states struggle for ways to pay for the rising costs of caring for their poorest residents. The Deloitte Center for Health Solutions study, "Medicaid Long-Term Care: The Ticking Time Bomb," estimates Medicaid costs will nearly double as a percentage of state budgets by 2030, or perhaps nearly triple. Meanwhile, the Urban Institute for the Kaiser Commission on Medicaid and the Uninsured estimates Medicaid expansion will cost $464.7 billion by 2019. The federal government will cover $443.5 billion (95.4%) and the states will cover the remaining $21.2 billion. Minnesota won't expand its Medicaid program until 2014 because of budget fears. Connecticut will. (The Fiscal Times, MedPage Today, Reuters, U.S. House Rep. John B. Larson)

U.S. Senators, meanwhile, are looking to phase out federal subsidies Medicaid as a way of pushing through stalled legislation--the same package that had included the "doc fix." Speaking of that, Sen. Majority Leader Harry Reid said the Senate may soon turn its attention away from that toward other issues. (Wall Street Journal, The Hill, ABC News)

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Tuesday, June 22, 2010

Can the patient-centered medical home save primary care?

This post by Juliet K. Mavromatis, FACP, appeared at DrDialogue.


For years now we've been hearing about the trials and tribulations that have evolved in the practice of primary care medicine. However, the discussion has intensified in recent months with passage of national health reform. Recent publications highlight the problems. A paper in the New England Journal of Medicine by Richard Baron, FACP, entitled "What Keeps Us So Busy in Primary Care?" discusses the time spent by primary care doctors on non-visit related work, which according to his findings, interrupts us 43 times daily. Health insurance reimbursement to physicians is "fee for service," thus leaving all of this work uncompensated. Moreover, health insurance pays better for procedures than it does for talking to patients. These factors have contributed to perverse incentives: "see more patients, run more tests."

With current relative shortages of primary care physicians, and the anticipation of more patients entering the health system, attracting new physicians to pursue a career in primary care is seen as critically important. However, medical students hesitate to choose it as a career because of its difficult lifestyle, lower remuneration, and the current practice environment. Yesterday, I read that Health and Human Services Secretary Kathleen Sebelius announced the release of $250 million in new funding to strengthen the primary care workforce. Of this, $168 million is set aside for training more than 500 new primary care physicians by 2015. That's good news, but who is going to want to pursue this training if the value placed on our time remains so low, and the practice pace remains as hectic as it is today?

What is the answer? There are several current responses to the primary care crisis. On the one hand, the advent of retail clinics and retainer fee medical practices, and on the other hand, the patient-centered medical home model, which has established itself with increasing legitimacy as the best solution. The May issue of Health Affairs was dedicated to "Reinventing Primary Care." For those of you who have not heard of it, the "patient-centered medical home" (PCMH) is a model of primary care that reorganizes the care team in a way that gets non-physicians more involved, supports patient "activation" toward improved self-care, and uses electronic systems--electronic health records and patient portals--to better manage populations of patients, particularly those with chronic illness. In many ways the patient-centered medical home might really be called the computer-centered medical home.

The PCMH addresses the problem of access to primary care and is particularly appealing as a solution within certain segments of the insured population, namely, Medicaid and Medicare. Physicians have increasingly dropped Medicaid because of its very low reimbursement rates. This has made access to care, despite insurance coverage, very difficult. A similar problem may soon exist within the Medicare population, with physicians dropping or capping Medicare patients, if an acceptable solution is not reached with respect to the sustained growth rate and Medicare's payments to physicians drops further.

Intrinsic to the PCMH is the concept that primary care should be reimbursed differently. Under this model payment is both fee-for-service and additionally capitated per patient member within the practice. Results of implementation of the PCMH have been published from Group Health Cooperative in Washington and also recently from Medicare's pilots projects. The Group Health results look promising, showing overall cost savings, related to decreased inpatient and emergency room use. However, reports from the large TransforMED pilot, published in the Annals of Family Medicine, are less promising. "Working feverishly, the 36 participating family practices registered only modest improvements in quality-of-care measures but backslid in terms of how patients rated them." The authors of the summary conceded that medical home transformation "requires tremendous effort and motivation," and that most practices would need outside help, as well as adequate compensation, to make the switch.

Simulateous with the PCMH, retainer fee medicine has appeared in many areas of the United States. Similar to the PCMH, retainer fee medicine, also known as "concierge medicine," provides extra funding to a medical practice in a capitated manner with a per patient annual fee. The difference is that in the PCMH, the hope is that insurers will provide the additional capitated funding. Another key difference is that PCMH designated practices must prove that they deliver certain elements of care to their patients. In fact, to become certified a practice needs to achieve a long and complex set of criteria. The model has been criticized as being "out of reach" for many small practices, who simply cannot afford the additional layer of clinic administration needed to complete the check list.

In contrast to the PCMH standardization, among retainer fee practices there is significant variability in the type of care delivered, the annual fee charged, and the practice's adoption of electronic systems and quality reporting. This type of practice typically emphasizes a more "Marcus Welby" approach, with emphasis placed on personal communication and the traditional doctor-patient relationship. Whereas PCMH practices emphasize care teams with more participation of non-physician members, and may in fact increase the number of patients cared for by each physician, retainer fee practices typically guarantee that they will care for fewer patients per doctor.

As I see it both the PCMH and retainer fee medicine are reasonable solutions to current short-comings. What's wrong with a "patient-sponsored medical home" practice, structured as a hybrid of these two primary care models, with built in systems to ensure quality, but also structured with the promise of a smaller patient panel for those want a more traditional doctor-patient relationship ? Can the medical home have its cake and eat it too? Or, will it fail to support the personal aspects of the doctor-patient relationship, the value of which is more difficult to measure with quality metrics and clinical outcomes?

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals.

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QD: News Every Day--Intra-party politics puts doc fix in limbo

A deepening rift between the U.S. House and Senate leaves the doc fix in limbo, as millions of claims go through with a 21.3% cut in physician reimbursement. The Senate took the took fix out of a larger piece of legislation to get just that component passed, but now the House is balking at that approach--they want the rest of the package, too. Even if Congress retroactively restores all claims, it will cost millions to reprocess and physician practices are being pushed to the brink in the meantime. (Politico, The Hill)

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Monday, June 21, 2010

QD: News Every Day--It just feels like the longest day of the year

The U.S. House may play partisan politics with the "doc fix" passed last week by the Senate. The six-month extension of Medicare reimbursement grants a slight increase in reimbursement, instead of the 21.3% pay cut currently in effect. But Speaker of the House Nancy Pelosi says the House might not consider it because of frustrations over inaction on jobs bills. She wagged her finger at the Senate's Republicans for not taking up the issue. The lack of a doc fix is only one reason why primary care doctors have been slowly leaving Medicare. Between 15% and 30% of primary care doctors aren't taking Medicare patients anymore, according to figures compiled by states and national medical organizations. Nearly two-thirds have contemplated leaving Medicare. Centers for Medicare and Medicaid Services counters that 97% of doctors take Medicare patients, but a spokesman admits the agency doesn't know how many doctors don't take new patients. Internist Michael A. Newman, FACP, writes, "The bottom line is that physicians have been underpaid by Medicare for almost two decades." (ABC News, USA Today, Washington Post)

Defensive medicine
Doctors in the emergency department order batteries of tests to make sure they don't miss anything. But overuse of imaging isn't risk-free, either. Needless tests are also costly, and consume a huge proportion of health care expenses. To a certain extent, defensive medicine works; missed heart attacks in the emergency room have fallen from 5% to less than 1%, insurance statistics show. But missed diagnoses still create malpractice claims, which further drive up the costs of medicine. So a judge has created an innovative program that diverts malpractice cases from litigation into negotiation instead. "Judge-directed negotiations" has saved hospitals up to $50 million a year in exchange for programs that disclose medical errors. The effort has garnered federal funding by administrators looking for ways to reduce health care costs raised not only by lawsuits (and by the needless tests conducted to avoid them). (AP)

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A man is not equal to the sum of his medical problems

This post by Steve Simmons, MD, appeared at Better Health.


I believe that those controlling the purse strings are steering modern medicine towards the practice of seeing patients more as the sum of their medical problems than as individual people. Patients have become streams of data as opposed to real human lives.

Consider the dynamics of a family. A wife may worry about her husband while their child adores a father she instinctively knows to be irreplaceable. Modern medicine, however, may only see a diabetic with hypertension and a cholesterol level running too high. The computers programmed for those advocating the power of data to revolutionize medicine would boil this man down to his "meaningful" essence ... numbers, for the above imaginary man: 250.00, 401.0, and 272.0.

Once our patients have been decocted into their numerical essence, computers can more efficiently track a doctor's treatments and outcomes (as in England, today, where these numbers create a formula that determines part of the government-employee-physicians' salaries). In 2012, Uncle Sam will begin rewarding doctors with more Medicare money for "meaningful use" of patient's health information. These additional dollars will be available if physicians provide patient data and other numerical codes in a pre-defined data-friendly format as their offices submit claims to Medicare. Less money will be paid to those practices failing to be "meaningful" in their claims submissions.

These codes are being used by insurance companies, government agencies, and even employers to track our health and the ubiquitous use by all belies a belief that the sum of one's codes can equal a living person. This could not be further from the truth. Codes do not allow any room to treat people as individuals. A coding mistake made by a doctor's office could have far-reaching consequences.

I recently cured a man of stage III chronic kidney disease simply by using the calculator I had carried in college. He had been denied life insurance and expressed a frustration with modern medicine and his previous doctors for treating him "like I was on an assembly line." He said that he came to me because he felt fine, couldn't understand how he had a kidney disease, and our medical practice operated differently. He asked me to review his records, question everything, and stated that he wanted to pay me for my time.

When his records came in I noted that the diagnosis of his kidney disease had been erroneously based on a laboratory report that "calculated" his estimated creatinine-clearance assuming an average weight. This number had been directly transferred to his chart, without question. I looked at his weight (he was very tall, muscular, and is my age which is also young) and plugged this data into the formula for creatinine clearance. My calculator showed a normal value for creatine clearance (i.e. no kidney disease.) He warily received my good news and asked if there was a way to get proof. Three days later we had the results of a 24-hour urine collection and this also showed a normal creatinine-clearance and no kidney disease.

This patient's instinct was spot-on. He was on an assembly line greased by a dependence on data that was slowed down each time someone was considered as an individual, much like the Visa Check-card commercials when someone produces cash and all joyful motion stops. I take offense at how the term "meaningful" is being used in medicine today. In my practice, meaningful refers to the individual relationships I build with my patients to ensure that they receive the best medical care possible, not how I convert someone's life into a string of data.

Until next week, I remain yours in primary care,
Steve Simmons, M.D.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Friday, June 18, 2010

Care, primarily

This post originally appeared in Musings of a Distractible Mind.


He came in for his regular blood pressure and cholesterol check. On the review of systems sheet he circled "depression."

"I see you circled depression," I said after dealing with his routine problems. "What's up?"

"I don't think I am actually clinically depressed, but I've just been finding it harder to get going recently," he responded. "I can force myself to do things, but I've never have had to force myself."

"I noticed that you retired recently. Do you think that has something to do with your depression?" I asked.

"I'm not really sure. I don't feel like it makes me depressed. I was definitely happy to stop going to work."

I have taken care of him for many years, and know him to be a solid guy. "I have seen this in a lot in men who retire. They think it's going to be good to rest, and it is for the first few months. But after a while, the novelty wears off and they feel directionless. They don't want to spend the rest of their lives entertaining themselves or completing the 'honey do' list, but they don't want to go back to work either."

He looked up and me, "Yeah, I guess that sounds like me."

"What I have seen work in people, especially men, in your situation is to get involved in something that is focused on other people. Volunteer work at the food pantry, work for Habitat for Humanity, or anything else that lets you help other people. I think the reason people get depressed is that they turn their focus completely on themselves, which is not what they are used to when they are working." (I knew that this man had a job that helped disadvantaged people).

"That's great advice, doc." he said, with a brighter expression on his face.

"It's from experience," I responded. "I've seen a lot of retirees start to feel like they are on a hamster wheel, just entertaining themselves until they die. I know I wouldn't want to retire that way. Knowing you, I wouldn't imagine you would either."

We talked for about 15 minutes about the various groups around town that would need someone of his skills. I told him about how my parents went to Africa for a year after Dad retired. He actually taught physics over there, but that is what they needed. Of all the time I spent with him, over half of it was regarding his post-retirement "blues." He wasn't clinically depressed, so I couldn't charge for depression as a diagnosis. The code I used? 99214 for Hypertension and Hyperlipidemia.

-------

I saw her name on my schedule. She's a dear woman whose husband passed away recently. I have cared for her and her husband for many years; they would always come in together, he with his dry wit and she with her motherly hugs. I was both happy and sad that she was coming in.

When I walked into the room she looked at me with bloodshot eyes and said, "I am doing OK," with a wavering voice.

I didn't say anything; I just went over to her and hugged her. She hugged me tightly and neither of us said anything. Her visit was officially listed as a recheck of her hypertension, but we spent the vast bulk of the time talking about her husband. She laughed because her blood pressure was actually lower now than it had been before. "I guess I know who was causing my blood pressure to go up," she quipped with a hint of tears still in her eyes.

I laughed, did my documentation as we talked, and scheduled her to see me back in a month. She didn't need to be rechecked in a month for a medical problem, but I knew she would want to see me soon.

I coded it as a 99214 for hypertension and grief reaction.

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With the debate about our health care system heating up, I think we lose focus on the point of the system in the first place: care. I knew both of these patients well, which made these special interactions possible. I didn't have to do the extra stuff as a doctor, but the human side of me made it impossible not to spend the extra time. Primary care is about relationship, about doctor knowing patient and patient knowing doctor. It is an opportunity for people to get help and to get care.

I am not unique in my relationship with my patients; this is why most people go into primary care in the first place. But I do think the pressure to become an E/M coding machine, for focusing on the business over the patient, is getting progressively stronger. To the system, each of these encounters is simply codes and numbers. But they were obviously so much more than that. They were about the humanity, the contact, the care that is becoming a scarce commodity in our system.

Some people may not want a doctor who spends extra time with them, but most people do. Our system is progressively snuffing this out by belittling the importance of relationship and stressing drugs and procedures. Both of these patients are Medicare, and so the idea of my practice dropping Medicare bears their faces along with many others. Yet I can't really afford to take a 21% pay cut, so we'll have to figure out something.

Medically, these visits were routine and uninteresting. But those moments are the pearl at the center of any system we set up. We need to value that pearl. We need to encourage medical students to go into primary care, so that when I get to the age of these patients, I will have someone to care for me, to really care, not just code and document. Right now, encouraging students into primary care is like encouraging them to stand at the muzzle of a loaded gun. We are endangered. These visits are what are really at stake.

Does Washington realize this? Does Washington care?

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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QD: News Every Day--Congressional action on doc fix is music to doctors' ears

Leadings members of the Senate Finance Committee came to an agreement last night on a six-month "doc fix," paving the way for physicians to be reimbursed a little more for seeing Medicare patients instead of a lot less. (This is now separate from the rest of the legislative package it had been part of. That is still under debate.) Sen. Majority Leader Harry Reid warned that without passage, there'd be "havoc in America." But the American Medical Association continued its attack on anything less than a permanent solution. The AMA compared it to fiddling while Rome burns. What tune are members of Congress playing?

A) Stayin' Alive, by the Bee Gees
B) Doctor, Doctor! by the Thompson Twins
C) Time to Get Ill, by the Beastie Boys

(The Hill, Politico, American Medical Association)

UPDATE: Should the Senate pass the doc fix, it would return to the House for a vote. But, the House has not scheduled votes for today, and it's not likely to for Monday.

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Black & white

This post by John H. Schumann, FACP, appeared at GlassHospital.

Imagine if I told you that because of the color of your skin, you wouldn't be allowed access to certain health care services. Pretty outrageous, right? After all, discrimination based on skin color or ethnicity is beyond the pale in 21st century America.

What if the color of your skin made you four times more likely to suffer a life-threatening illness? You might think it unfair, but you'd recall that certain disease states affect different groups of people at varying rates.

Black and White Trademark: The Zebra by o b s k u r a via FlickrWhen we control for access to care, these differences in health outcomes are known to researchers and advocates as health care disparities. One of the places I encounter disparate health outcomes most starkly is in the dialysis unit. Dialysis is blood filtration for people whose kidneys have stopped working. It's been around since the early 1960s, but became mainstream therapy in 1973 when Congress expanded Medicare to include all persons with end stage renal disease. With that generous entitlement, no one with chronic kidney failure dies from it in the United States.

As you might imagine, since the government pretty much automatically covers everyone in this category, a massive economy has sprung up to cater to this market. From the Wall Street Journal's marketwatch.com (6/11/09): Dialysis treatment costs Medicare almost $72,000 per patient per year; total outlays for patients in kidney failure were $23 billion in 2006, 6.4% of Medicare's total budget. Overall chronic kidney disease and its complications account for over $49 billion, or about 25%, of all annual Medicare expenditures.

Dialysis also is big business. The vast majority of dialysis centers are for-profit, and DaVita Inc., the nation's largest provider with 1,400 centers, ranks No. 433 on the 2009 Fortune 500 list with reported 2008 revenues of $5.7 billion and profits of $374.2 million.

I live and work on the South Side of Chicago. In nearly a decade working at GlassHospital, I can count the number of white people I've met in the dialysis unit on one hand. In fact, I can count him on one finger. Pick a day and come visit our unit (you'll first have to get permission, of course): weekday, weekend, first shift or second; it doesn't matter. Every face you'll see in that unit is black.

After all this time, and in spite of the fact that our government pays for all of this care, I can understand why African-Americans might be mistrustful and even somewhat paranoid about forces conspiring against them in their quests for life, liberty, happiness, and implicitly, health. I've long thought that the unit would make extraordinary fodder for a documentary film by the likes of Fred Wiseman or D.A. Pennebaker. In that cinema verite style, I could easily imagine viewers having difficulty grasping why it is that outcomes for blacks are so much poorer, even as we've improved access to care and desegregated our facilities. I would line up to see such a film.

We're collectively so used to the fact that the vast preponderance of dialysis patients are African-American that we don't even question it. We rationalize away the stark contrast. Blacks have higher rates of diabetes, high blood pressure and chronic kidney disease. We live in an area of lower socioeconomic status, urban poverty, low educational attainment and higher crime.

One last item: Because of "national trends," GlassHospital has recently reached an agreement to sell its own outpatient dialysis units. The buyer: DaVita.

John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.

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Thursday, June 17, 2010

Why you should still see your doctor when you're not sick

This post by Andrew Schorr appeared at Better Health.


Experts say over 100,000 lives a year could be saved in the United States if patients focused more on preventive medicine. What is preventive medicine? What can you do in your everyday life that may make a long-term difference?

On this Patient Power program, you will hear from two board certified internists from the UW Medicine Neighborhood Clinics in Western Washington. They will discuss how having an ongoing relationship with a primary care physician who you check in with regularly even when you're well gives you the best chance at staying healthy.

Dr. David Camitta and Dr. Edward Dy, both internists at the UW Medicine Neighborhood Clinics, explain to listeners why it is important to know your family history and how this influences the types of screenings and vaccinations you will get. Both doctors address many concerns expressed by patients who have an aversion to regular visits to a primary care physician, including concerns about being lectured about their weight or chastised by their doctor for personal lifestyle choices like smoking. Dr. Camitta assures listeners that it is not a doctor's job to judge, and it is through maintaining an ongoing relationship with patients that these fears can often be assuaged.

When it comes to preventive medicine, Dr. Camitta comments that often patients give more attention to preventive maintenance on their cars than they do on their bodies and personal health. Most people take their car in every 3,000 miles for an oil change because they want to make sure everything remains in working order. Dr. Camitta and Dr. Dy suggest if more patients took this approach to their health, a lot of medical problems could be alleviated. Find out about small lifestyle changes you can make and what you need to keep track of at home to help your primary care physician give you the best care possible.

Guests:
Edward Dy, M.D., Internal Medicine, UW Medicine Neighborhood Clinics
David Camitta, M.D., Internal Medicine, UW Medicine Neighborhood Clinics

To listen to this "Patient Power Daily Dose" show, click here.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Too much testing and treatment? Try superb primary care

This post by Davis Liu, MD, appeared at Better Health.


The Associated Press has been running a fantastic series of must reads with the latest article highlighting the consequence of too many imaging studies, like X-rays and CT scans, which are the biggest contributor to an individual's total radiation exposure in a lifetime. Americans get more imaging radiation exposure and testing than people from other industrialized countries.

Reasons for doing too many tests include malpractice fear, patient demands for imaging, the difficulty in obtaining imaging results from other doctors or hospitals, as well as advanced technologies, like coronary angioplasty, which have increased radiation but avoid a far more invasive surgery like heart bypass.

Although these are all legitimate concerns, one of the reasons listed was: "Accuracy and ease of use. Scans have become a crutch for doctors afraid of using exams and judgment to make a diagnosis. Some think a picture tells more than it does. Imaging that shows arthritis in a knee or back problems doesn't reveal how to make it better, said Dr. Richard Baron, a primary care doctor in Philadelphia."

Dr. Baron was recently widely cited for his article in the New England Journal of Medicine on the true workload of primary care doctors, which gives valid reasons why medical students as well as those in practice are avoiding the specialty or retiring respectively.

It really isn't accuracy and ease of use as Dr. Baron suggests, but rather a matter of survival for doctors on the front line. The vast majority doctors are paid fee for service. That is the more you do the more you get paid. In the case of primary care doctors, the more patients you see the more you get paid.

It has been argued that if primary care doctors were paid a salary instead of by number of patient visits that more time could be spent on asking the right questions and doing thorough examinations to get to the root of a patient's problem. When I train first-year medical students, I tell them exactly the same thing: If there is only one thing you learn from me, then it is how to take an accurate history and a relevant physical exam. Ninety percent of getting the right diagnosis is refining these two skills.

Students often ask how long it takes to be good at this. A lifetime. Professional athletes, artists, and musicians never stop getting better and as doctors neither should we.

Why is this important? Because the latest thought in health care is to slow costs by pushing more financial responsibility to patients. A report by the consulting firm PricewaterhouseCoopers found that majority employees will face a deductible of $400 or more, which is in addition to the annual premiums. Will patients really be able to ask or even challenge their doctors on the appropriateness of an imaging study? Do you ever tell your auto mechanic to not service your car when the airbag indicator or the brake light come on? (If you have, please let me know because I certainly didn't have the courage to do so).

The other thought is to make prices for procedures more transparent as start-up Castlight tries to do. Shop around for the cheapest imaging study. Although this also is a laudable approach to slow healthcare costs, it is also not addressing the root cause. Doctors are ordering too many tests. Though price transparency will make the unit cost of the test cheaper, Americans will still be overdosed with radiation.

Doctors need to step up and lead the way. They cannot until the reimbursement system changes that values primary care for time spent thoughtfully evaluating patients by talking and examining them. As Dr. Abraham Verghese of Stanford Medical School and an outstanding clinician notes, it is the patient's story that matter not the imaging tests. As he correctly argues in an editorial in the British Medical Journal: ... clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient's chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test.

To avoid overtreatment and save money, find a superb primary care doctor will to talk to you about the pros and cons of medications, imaging tests, and procedures. Be thankful he or she did. As the Associated Press series of "overtreated" articles illustrate, sometimes it is best not to keep up with the Joneses and walk away from too many tests while still staying healthy.

Can't find a stellar primary care doctor? No worries. The truth on how to avoid the traps of overtreatment are found in my book which is available on Kindle, iPad, and iPhone, as well as hardcover. This easy to read book offers the skills I use to keep my patients healthy while thoughtfully ordering treatments they really need to stay well.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--The final day for fixing Medicare reimbursement

The Senate could vote as early as today on a six-month extension to Medicare reimbursement, one that would avert a 21.3% cut. Medicare reimbursement processing has been on hold the entire month of June waiting for the latest just-in-time extension. Amid declining support and a failed procedural vote Wednesday, the Senate continued to pare down the fix to Medicare reimbursement to garner more support from budget-conscious centrists in the Senate. Previous versions failed because the duration of extending the "doc fix" drove up costs of the legislation. (Modern Healthcare, AP, The Washington Post)

The president-elect of the American Medical Association promises to continue the pressure the organization has placed on Congress recently over issues such as Medicare reimbursement. The incoming leader, pediatric neurosurgeon Peter Carmel, MD, said he's not worried about upsetting congressional leaders on either side of the aisle, and apparently, members of Congress are no longer worried about pleasing AMA's leadership, either (subscription required). (Chicago Breaking Business, Roll Call)

Primary care shortage
The federal government released the first $250 million in funding from health care reform to relieve the primary care shortage. More than half, $168 million, will go toward increasing primary care doctor residency slots, with the rest being applied toward nurse practitioners and physician assistants, as well as other caregivers. Money will also fund minority medical school programs that produce more primary care doctors, as well as those who choose to practice in medically underserved areas. (The Hill, Los Angeles Times)

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Wednesday, June 16, 2010

QD: News Every Day--Doctors worn down, quitting from Medicare uncertainty

The Senate continues to look for consensus to avoid a catastrophic 21.3% cut in Medicare reimbursement that takes effect Friday. But the legislation has more parts to it than that, and garnering the go-ahead has required near-constant tinkering with each component. For the "doc fix," Senators have floated time periods from seven months to two years in an attempt to balance Medicare reimbursement against the overall cost of the bill. Also on the line are extensions for unemployment, state Medicaid funding, and a special provision that would redefine health care payments for services delivered in areas of California that have rapidly urbanized, yet still get reimbursed under a lesser rural health care rate. (Associated Press, Washington Post, Kaiser Health News)

The delays and uncertainty are wearing physicians down, as they contemplate either to step accepting Medicare patients, or, for those whose panels are mostly Medicare, to stop practice altogether. (Subscription required) (Kaiser Health News, Wall Street Journal)

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Tuesday, June 15, 2010

QD: News Every Day--Doc fix is running out of time

The Senate may have found the 60 votes it needs to move on the legislative package that includes the "doc fix." (Subscription required). To prevent the 21.3% pay cut that takes effect on Medicare reimbursement this Friday, the Senate must vote on it, return it to the House for approval, and then get it signed. ACP President J. Fred Ralston, FACP, tells the AARP that uncertainty over Medicare reimbursement weakens recruiting new doctors, wears away at morale and makes it harder for practices to borrow money for improvements. He would know--three-qaurters of his 2,000-patient panel are Medicare patients. (Roll Call, AARP Bulletin)

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Monday, June 14, 2010

Managing pain in primary care: moving beyond the rock and the hard place

This post by Juliet K. Mavromatis, FACP, appeared at DrDialogue.


In April 2010 the American Society of Anesthesiologists published updated guidelines for the management of chronic pain. The guidelines were based on a review of recent scientific evidence, as well as a survey of expert opinion. As I read through the guidelines, summarizing the efficacy of various therapies for chronic pain ranging from epidural injection to medication management, some of my most challenging clinical cases involving pain management came to mind.

Pain by Ingorrr via FlickrThe assessment of pain is recognized as integral to the care of every patient to the extent that pain, similar to blood pressure, is assessed at every encounter as a "vital sign" on a scale from 1 to 10. Reports of the "under-treatment" of pain by doctors are prevalent in the literature. Yet at the same time physicians are increasingly fearful to prescribe some therapeutic options, mostly chronic narcotics, because of the regulatory and legal concerns intrinsic in prescribing these medications, and because of their addictive potential. The advent of pain medicine as a specialty in the past several decades has had a beneficial impact for the management of patients with chronic pain, but the reality is that most of these patients continue to be managed largely by their primary care physicians.

(Click on the "More" link below to continue the post.)

I remember the harrowing case of a patient in her thirties. She had chronic abdominal pain, had been through unending diagnostic tests, referrals to pain centers and subspecialty consultation. In the end, I was left to manage her symptoms and had her on a multimodal regimen that included chronic narcotics. One weekend I received a call for the county coroner. This mother of five had been found by her husband dead from a presumed overdose. As it turned out, unbeknownst to me, she had recently visited a new pain clinic and was prescribed additional medications, which she had added to what I was already prescribing.

Another patient, a respected professional, after many years of caring for her and a good doctor-patient relationship, forged a prescription that I wrote and was caught at the pharmacy where arrest was threatened. On returning to me she was tearful and afraid that I would no longer care for her. I did, and she went on to come off of her chronic narcotics until she was diagnosed with metastatic cancer a year later, the diagnosis of which was possibly delayed given her long history of bone disease and chronic pain.

It is the impact of cases like these that cause physicians to question themselves, in a stare down with the Hippocratic Oath, "first do no harm," and result in their reluctance to manage chronic pain. To a primary care physician the pain clinic might seem like an ideal solution. Similar to an anticoagulation clinic (for the management of patients on warfarin) the pain clinic would take over pain management, including the prescribing of medications, and provide a systematic approach, allowing primary care doctors to obviate themselves of this risky aspect of patient care. The reality is, however, that there are currently too few pain centers to handle the numbers of patients with chronic pain. Moreover, the consultative and drug monitoring aspect of pain management is not nearly as lucrative as the procedural aspect of pain management. The result is that many pain centers act as consult services, making initial treatment recommendations, including the assessment of whether a patient is a suitable candidate for a therapeutic procedure, but send the patient back to their primary care doctor for the ongoing medication prescribing and management. It's rare that the patient is cured after the pain clinic consultation, and so begins the back and forth, trial and error process, as the primary care doctors picks up the management and tries his or her best to advocate for the patient.

In primary care we have a lot of work to do. This is highlighted by the fact that in my 12 years of clinical practice within an 18-member group of academic general internists we had no practice-wide strategy or protocol for managing patients with chronic pain issues. Though a variety of pain contracts had been proposed for implementation during the course of my employment within this group, we could never settle on one to adopt. Some of this seemed to occur as a result of insufficient time to develop a process for a systematic practice approach to pain management. However, there was also general acceptance of the view that each physician had his or her own unique style and standard, the art of medicine. Nonetheless, I think the lack of systematization led to cross-coverage issues and increased risk for both patients and physicians related to inconsistency in practice.

What is the answer? In my view chronic pain, similar to other chronic conditions, is best managed by a patient's primary care physician within the context of a "medical home." There needs to be more standardization of processes and protocols within primary care practices, with clear pathways of communication back and forth with procedural specialists, opportunities for group support for patients, and linkages to physical rehabilitation and psychological support services. However, the development and management of such programs within the context of primary care will require more support from our healthcare system. Similar to other chronic health conditions, fee-for-service based reimbursement for primary care office visits at current rates is not adequate to support the care coordination necessary to deliver the highest quality and safest care to our patients.

For more information on chronic pain management I found the following site particularly informative:
Emerging Solutions in Pain

For further guidelines and resources go to:
American Pain Society
Opioid Treatment Guidelines
Institute for Clinical Systems Improvement: Assessment and Management of Chronic Pain

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals.

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QD: News Every Day--Medicare further delays payments in case 'doc fix' passes

President Barack Obama came out swinging for the doc fix in his weekend address, saying Republicans shouldn't filibuster the doc fix if it comes up for a vote. Republicans countered with calls for offsetting the additional costs of not cutting physician's Medicare reimbursement, and that health care reform passed earlier this year is stalling economic recovery. Obama retorted that he's willing to make tough fiscal choices, but not at the expense of doctors who treat seniors. (New York Times, AP, Politics Daily)

The Senate takes up the issue this morning. With a potential vote near, Medicare has instructed its contractors to delay processing payments until Friday to leave time to fully reimburse doctors, according to a key advisor to the Senate Finance Committee Republican Staff. (The Hill)

Doctors signed lab coats at the American Medical Association's annual meeting this weekend, intending to send their smocks to Congress as a protest. (American Medical Association)

Adding to the woes of soon-to-be-Medicare-eligible patients seeking treatment is the number of soon-to-be-Medicare-eligible physicians seeking to leave practice. Surely they're out there, waiting in droves to scale back practice for administration, but exactly how many is in question. (The Washington Post)

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Friday, June 11, 2010

QD: News Every Day--No closer to a doc fix than before

Senators are visiting their districts today and Monday, so the earliest they could vote on the doc fix is Tuesday, the day the 21.3% reimbursement cut takes effect. Slowing down the process are the numerous amendments; for example, the duration of the fix is still being negotiated. And, there's amendments such as redefining what makes up a rural health district. In California, some rural areas are seeing urban levels of patient demand, but giving more money to these counties is being seen as a kick-back akin to others that were proposed during health care reform. (Part B News, The Hill)

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Thursday, June 10, 2010

Defensive medicine drives overtesting, despite dire consequences

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


Let's face it, the best way to cut health costs is to say "no." That means denying unnecessary tests that most patients in the United States are accustomed to having.

The New York Times' David Leonhardt has the best take on this issue that I've read. He acknowledges the difficulty of telling the American public "no," and cites examples ranging from the breast cancer screening controversy to the managed care backlash in the 1990's: "This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment. Consider that a recent study found that 15,000 people were projected to die eventually from the radiation they received from CT scans given in just a single year, and that there was 'significant overuse' of such scans."

The economic arguments against overtesting simply won't resonate with patients. Despite the dire forecasts of bankruptcy and Medicare insolvency, "the try-anything crowd occupies the moral high ground ... Compared with an anecdote about a cancer patient looking for hope, the economic arguments are soulless."

He proposes capitalizing on the uniquely American traits of free choice and more control instead. Give patients and doctors the necessary effectiveness data to make their own decisions on whether to undergo a test. Some studies even suggest that patients would err on the side of not testing once all the risks and benefits are known.

As for doctors, the malpractice system shouldn't punish them for a shared decision that holds back testing, yet results in a poor outcome. Instead of advocating for malpractice caps, I agree with shielding doctors who follow clinical guidelines from liability.

Leonhardt says it will be very difficult to say "no" to the American "yes "culture. But if we can empower patients by providing the information to make their own informed decisions, perhaps we may not need to.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 30,000 subscribers and 22,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD: News Every Day--Doc fix fray heats up

President Obama stepped into the "doc fix" fray, calling for a permanent solution to the year-in, year-old threats to physician reimbursement. Congress continues to try to hammer out language related to Medicare reimbursement, as well as other issues such as extending COBRA benefits and offerings states more money for their Medicaid programs. Each amendment adds to the bill's final tally, something that Senators aren't eager to do in deficit-conscious times. (American Medical Association, American Health Line, New York Times)

But the 'hassle' of Medicare reimbursement continues to drive more and more doctors out of treating Medicare patients. Angry seniors are wondering why they paid Social Security all those years, while their physicians shutter practices that have large Medicare populations on their patient panels.


Read more physicians' reactions here. (CNN, KIAH TV, New York Times)

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Overtreatment: when less is more in medicine

This post by Davis Liu, MD, appeared at Better Health.


The Associated Press recent article "Overtreated: More medical care isn't always better" reiterated a commonly known fact which is not understood by the public. This problem of doing more and yet getting little in return is a common issue which plagues the U.S. health care system and was illustrated quite convincingly by Shannon Brownlee's book. Americans get more procedures, interventions, imaging and tests, but aren't any healthier.

In fact they are often worse off. Too many unnecessary back surgeries. Too many antibiotics for viral infections, which aren't at all impacted by these anti-bacterial therapies. Too many heart stents which typically are best used when someone is actually having a heart attack. Research shows that those that are treated with medications do just as well. As all patients with cardiac stents know, they also need to be on the same medications as well.

Eliminating unnecessary treatments is a good thing, particularly when it is based on science.

Already over the past year, cancer screening guidelines have been updated based on reviews of the latest medical evidence. Prostate cancer screening with blood test PSA does not appear to be helpful in determining which men have the life threatening aggressive form requiring treatment and which men have the indolent version which will never impact their health. Some medical experts have suggested that breast cancer screening with mammograms should be moved from age 40 to age 50 based on the review of studies.

You would think the public would be happier that they would be poked and prodded less as scientific evidence shows that it is safe to do so. We should want the health care system to be in the mindset of continual learning and not mired in old traditions just because that is the way it was always done.

Yet despite this reality, some people view this as rationing of medical care or the beginning of socialized medicine.

It's not. It's the time of rational medicine. Doctors need to lead the change and get away from the hype and more to the science. That is what patients really want. What is particularly disappointing is that overtreatment is well known and already profiled in various articles two years ago. Change is occurring very slowly. It is unclear why. Despite being bombarded with pharmaceutical advertisements, body scans, and easy access to medical information, patients still trust doctors the most for advice.

If we as doctors fail to lead, then patients will be left to figure it out themselves. And they are already fearful.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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