President Obama discusses family medicine – and he gets it
Speaking at a town hall meeting on health care in Raleigh, N.C., yesterday, President Obama was asked by the wife of a family physician what he would do to address the hardships of family physicians and entice more students to enter the specialty. He replied by emphasizing the value of family medicine and primary care, and had this to say:
"When we pass health reform and more people have access to the system, it is going to be vital that we increase the number of primary care physicians. The best way for us to do it is two-fold. One is to change how we reimburse ... so that the incomes of primary care physicians are more comparable with specialists. The second thing is to provide scholarships and financial incentives for young medical students who are willing to go into primary care."
View a short video clip here or the entire video here. (The above quote appears at the 36:40 mark.)
Health care reform: a status report
As Congress' August recess approaches, it is becoming clear that passage of a health care reform bill that expands coverage and restrains costs is not going to happen this summer, as many had expected. In both the House and the Senate, bills are stuck in committee, but Congressional leaders vow they'll be ready for a vote this fall.
In the House, the 1,000-page America's Affordable Health Choices Act (HR 3200) has been approved by the Ways and Means Committee and the Education and Labor Committee but has stalled with the Energy and Commerce Committee. The fiscally conservative Blue Dog Democrats have refused to pass the bill until cost concerns have been resolved. An analysis by the Congressional Budget Office recently concluded that the plan would cost $1 trillion and increase the federal budget deficit by $239 billion over the next decade. Lawmakers' latest idea of establishing an independent panel to make cuts to Medicare would only save about $2 billion, according to the CBO.
Key features of the House plan as it now stands include the following:
- a new government-run health insurance plan that would compete with private insurers,
- penalties for employers who do not provide health insurance for their employees (with a small business exemption) and for individuals who do not purchase it,
- subsidies for lower- and middle-class families to pay for health insurance premiums,
- a prohibition on denying coverage because of health status or pre-existing conditions,
- a health insurance exchange that would help individuals and small businesses comparison shop among private and public options,
- caps on annual out-of-pocket expenses,
- an expanded and improved Medicaid program,
- a prohibition on cost-sharing for preventive services,
- elimination of the Medicare Part D “donut hole,”
- Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula,
- a 5-percent increase in Medicare payments for designated services provided by primary care physicians,
- a 1-percent surtax on households earning more than $350,000,
- a 5.4-percent surtax on households earning more than $1,000,000.
In the Senate, the Affordable Health Choices Act, sponsored by Sen. Edward Kennedy, has been approved by the Health, Education, Labor and Pensions Committee. Its coverage provisions are similar to those in the House bill. Meanwhile, the Finance Committee, led by Sen. Max Baucus, is working on its own bill, with debate focused primarily on the funding of health care reform. The two versions will need to be combined into a single bill before going to the full Senate for a vote.
While there's progress in Washington, the public may be having some misgivings. The latest USA Today/Gallup poll found that more Americans disapprove (50 percent) than approve (44 percent) of the way the President is handling health care policy. New York Times columnist David Brooks speculated as to why: "People have a legitimate question: How is it we're going to cut my costs by creating a new trillion-dollar entitlement? ... How are we going to control costs without anybody sacrificing anything?"
Obama's prime-time news conference last Wednesday was intended to build support for health care reform, but syndicated columnist Mark Shields observed that the speech may have fallen short: "All I could think of was, Adlai Stevenson once said when he was introducing John Kennedy -- remember in classical times, whenever Cicero spoke, the people reacted and said, 'He spoke so well.' But when Demosthenes spoke, the people said, 'Let us march.' And after the Wednesday presentation, there was nobody saying, 'Let us march.'"
Feds define ‘meaningful use' of health IT
Physicians hoping to qualify for up to $44,000 in federal funds for implementing an EHR should take note of the meaningful-use criteria approved July 16 by the Office of the National Coordinator for Health Information Technology's Health IT Policy Committee. The group's recommendations will be incorporated into a final rule from the Centers for Medicare & Medicaid Services due Jan. 1, 2010. Although not yet final, the recently released criteria give physicians a better sense of what their EHR systems will need to be able to do come 2011.
The year-one meaningful-use criteria for physicians (hospitals have separate criteria) fall under five areas and include the following:
Improving quality, safety and efficiency and reducing health disparities
- Use computerized entry for all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) although electronic interfaces to receiving entities are not required in 2011
- Implement drug-drug, drug-allergy and drug-formulary checks
- Maintain an up-to-date problem list of current and active diagnoses based on ICD-9 or SNOMED
- Generate and transmit permissible prescriptions electronically
- Maintain active medication list and medication allergy list
- Record demographics (preferred language, insurance type, gender, race and ethnicity)
- Record advance directives
- Record vital signs (height, weight, blood pressure, BMI) and smoking status
- Incorporate lab-test results into EHR as structured data
- Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach
- Report ambulatory quality measures to CMS
- Send reminders to patients per patient preference for preventive/follow-up care
- Implement on decision rule relevant to specialty or high clinical priority
- Document a progress note for each encounter
- Check insurance eligibility electronically from public and private payers, where possible
- Submit claims electronically to public and private payers
Engaging patients and families
- Provide patients with an electronic copy of or electronic access to their health information (including lab results, problem list, medication lists, allergies) upon request
- Provide access to patient-specific educational resources
- Provide clinical summaries for patients for each encounter
Improving care coordination
- Electronically exchange key clinical information (e.g., problem list, medication list, allergies, test results) among providers of care and patient-authorized entities
- Perform medication reconciliation at relevant encounters and each transition of care (i.e., moving patients from one setting or provider to another)
Population and public health reporting
- Submit electronic data to immunization registries where required and accepted
- Provide electronic syndrome surveillance data to public health agencies according to applicable law and practice
Ensuring privacy and security
- Comply with federal and state HIPAA rules
- Comply with fair data sharing practices set forth in the Nationwide Privacy and Security Framework
To prove compliance with these criteria in year one of EHR implementation in order to receive the federal incentives, physicians will have to report on roughly 30 measures, such as percentage of diabetics with A1C under control, percentage of smokers offered smoking-cessation counseling, percentage of all medications entered into EHR as generic when generic options exist and percentage of claims submitted electronically to all payers.
To view all of the measures, see the "Meaningful Use Matrix." This document also lists the criteria for 2013 and 2015 (or year three and year five of EHR implementation).
A major concern for physicians is whether the 2011 measures as a whole will be achievable. Additionally, there is concern that physicians won’t understand the details of what’s required to demonstrate meaningful use and will implement an EHR but fail to qualify for the stimulus payments.
Could your practice's waiting area become obsolete?
Could a web-based “virtual queue management system” that allows patients to use their cell phones to hold their spot in line eventually replace waiting areas in physicians’ practices? Alex Bäcker, PhD (no relation of mine), the founder and CEO of abInventio, which makes QLess, believes it could. (Bäcker’s mission is actually far more ambitious: to wipe waiting lines off the face of the Earth.)
This type of system is different than those you might have encountered in some restaurants. There’s no electronic device to distribute and no need to stay on the premises. Patients could check into a line by sending a text message or making a phone call. When their turn in line has come up, they would simply receive a text message or phone call.
It’s probably too soon to begin thinking about remodeling your waiting area into another exam room – the idea has yet to take hold in health care. But it’s worth thinking about. Imagine how a system like this one could help some practices compete with retail health clinics that enable patients to shop while they wait to be seen. Imagine being able to offer patients an alternative to rubbing elbows with sick patients in your potentially crowded waiting room – one that would allow them to use their waiting time more productively. Having recently experienced a lengthy wait at a doctor’s office (not my family physician’s), I must say that eliminating the “waiting problem,” as Bäcker describes it, would give new meaning to patient-centered care and service.
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