What patient-centeredness looks like
Depending on who you believe, Donald Berwick, MD, the Harvard professor, Institute for Healthcare Improvement president, and pediatrician appointed by President Obama to head the Centers for Medicare & Medicaid Services (CMS), is a radical bent on transforming the U.S. health care system in the image of Great Britian’s or a genius capable of reinventing health care and saving the U.S. economy in the process. (Just search for “Donald Berwick” on Google to see what I mean.) Of course the truth lies somewhere in between, and time will reveal the extent to which he can effect real change in his latest role.
Back in May, Berwick was a proud father delivering the commencement address at his daughter’s Yale Medical School graduation, the prepared text of which is making the rounds via e-mail. In describing the first history and physical he performed as a medical student and also in telling the story of a woman who was prohibited from seeing her ailing husband in the intensive care unit during most of the last hours of his life, he touches on themes that should be familiar to any family physician – the biopsychosocial model, patient-centered care and family:
“Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul.”
Download the entire speech from the Institute for Healthcare Improvement web site.
'Meaningful use' is now meaningfully defined
You’re probably already hearing the new jargon: certified EHR technology, eligible professionals, and especially meaningful use are likely to be in the air a lot over the next several years as the regulations implementing the federal government’s HITECH incentives for EHR use play out.
EHR vendors are already hard at work studying the final rule that was promulgated July 13 and trying to get their systems in shape to merit the name certified EHR technology, which is what physicians and hospitals will need to use if they are to qualify for the meaningful use incentives. And those incentives are big enough to attract a good deal of interest – a maximum of $44,000 from Medicare or $63,750 from Medicaid over five or six years.
Fortunately, the government listened to the many comments it received from the AAFP and others to the effect that the criteria that physicians (excuse me: eligible providers) had to meet to qualify for the incentive payments were far too onerous.
The requirements outlined in the final rule (an 860-page PDF; enter at your own risk) have been somewhat softened, particularly in that while several are required of all eligible providers, 10 are presented in a “Menu set” from which physicians can choose five to meet. Now the barriers to success may actually be low enough to make it reasonable for many practices to pursue the incentives.
With that in mind, FPM will shortly publish a physicians’ guide to the incentive programs and a new “meaningful use” blog; stay tuned! We’ll let readers know by e-mail when they’re available.
New rule allows e-prescribing of controlled substances
In 2009, Medicare instituted bonuses of 2 percent of allowed charges for physicians who participate in its electronic prescribing program. However, controlled medications still had to be printed or handwritten on a hand-signed paper prescription. This meant that practices had to maintain two workflows for prescriptions. But no more.
Last month, the Drug Enforcement Administration's (DEA) rule “Electronic Prescriptions for Controlled Substances” went into effect, giving physicians the option of writing electronic prescriptions for controlled substances. The regulations will also permit pharmacies to receive, dispense and archive these electronic prescriptions.
E-prescribing software companies will have to undergo a third-party audit or a review by an approved certification body to demonstrate that their products comply with the new DEA requirements.
The DEA has also published instructions to physicians for getting started. The process will require that physicians obtain a
two-factor authentication credential or digital certificate through a federally approved credential service
provider (CSP) or certification authority (CA), which will conduct identity proofing. Physicians can contact their e-prescribing software company for help in determining which CSP or CA to use.
Health care reform: Reader poll results
Half of respondents to a recent FPM online poll said the health care reform bill that Congress passed in March will make things worse for medical practices. Another 44 percent said it will make things better, and nearly 6 percent said it will not change practice.
The poll was conducted between March 31 and July 12, 2010, and had 1,415 respondents. Poll results are not scientific and reflect only the opinions of those who chose to participate.
Group practices struggle most with rising operating costs, survey says
According to a survey by the Medical Group Management Association (MGMA), the three greatest challenges in running a group practice are first, "dealing with rising operating costs," second, "managing finances with the uncertainty of Medicare reimbursement rates" and third, "selecting and implementing a new electronic health record system."
This was the second year in a row that "dealing with rising operating costs" was ranked first. "Managing finances with the uncertainty of Medicare reimbursement rates" moved up from its ranking of fifth place in both the 2009 and 2008 surveys.
“It is not surprising that 'maintaining finances with the uncertainty of Medicare reimbursement rates' jumped to the number 2 spot this year due to the continued congressional irresponsibility in not permanently addressing the flawed sustainable growth rate (SGR) formula,” said William F. Jessee, MD, FACMPE, president and CEO of MGMA.
Also notable, “implementing a patient-centered medical home model of care” jumped to No. 12 this year from No. 22 last year.
When the results were analyzed according to practice type, respondents from hospitals and health systems chose "modifying physician compensation methodology," "recruiting physicians" and "dealing with rising operating costs" as their top three challenges. For independent practices, the top challenges were “maintaining physician compensation levels” and “negotiating contracts with payers."
This was the third year the MGMA published the survey, which received 1,798 responses.
Trapped in the SGR fun house
While the Sustainable Growth Rate (SGR) mess is technically limited to Medicare, it neatly images the basic problem of the entire system: As a country, we can’t afford the health care system we have but can’t afford to do without it. Medicare brings the problem into sharp focus because the government is the only payer and because the elderly represent such a large and potent voting block, but the problem is general, and solution seems impossible.
It’s the impossibility of the situation that has produced all the carnival insanity around the SGR. Congress can’t shake the SGR because, as the recent Health Affairs policy brief puts it, “A permanent ‘doc fix’ that would override both pending and expected automatic cuts in future years could add as much as $276 billion to federal spending over the next decade.” At the same time, Congress hasn’t been able to bring itself to let the SGR do its work since 2003, so it hasn’t been saving us money and isn’t saving us any now. Instead, we've seen the apparently endless string of temporary SGR patches, with four so far this year, and all the uncertainty they carry. (Let’s see. Your Medicare payments are now 2.2 percent higher than they were before they dropped 21.3 percent last month, and this happy state of affairs will last until December, when they may drop again, this time by 23.5 percent, and/or until January, when they may drop by a further 6.1 percent. Or not.)
While Congress seems to be getting progressively more sensitive to the cost of these patches, it keeps applying them. Does an endless string of temporary patches eventually become a permanent “doc fix?” Or do we need the SGR if all it saves us is imaginary billions?
It seems to me that the solution is a re-engineered, primary-care-centric health care system that keeps people healthy while costing less. While there are hints here and there (in Grand Junction, Colo., for instance) that we might be able to build such a system, it’s years, probably decades away. Today, however, we saw the most hopeful sign in months that we may be starting down the right path: the President’s appointment of Donald Berwick, MD, to head the Centers for Medicare & Medicaid Services. If Berwick can avoid being eaten alive by the bureaucracy and get beyond the large-system focus of his organization, the Institute for Health Care Improvement, his vision of what health care could be may well begin the transformation we so desperately need.
If you knew then what you know now
Whether you're just finishing medical school, contemplating retirement, or somewhere in between, the commencement address delivered by surgeon, Harvard Medical School professor, and New Yorker writer Atul Gawande to Stanford School of Medicine graduates last month should be required reading, particularly for its provocative and paradoxical description of modern medicine:
medicine requires the innovation of entire packages of care – with medicines
and technologies and clinicians designed to fit together seamlessly, monitored
carefully, adjusted perpetually, and shown to produce ever better service and
results for people at the lowest possible cost for society. ... It is work with
a different set of values from the ones that medicine traditionally has had:
values of teamwork instead of individual autonomy, ambition for the right
process rather than the right technology, and, perhaps above all, humility – for
we need the humility to recognize that, under conditions of complexity, no
technology will be infallible.”
The speech is published on the New Yorker web site, where you can read it, channel your inner med student, and ponder whether you'd do it all over again if you knew then what you know today.
Family physicians' compensation continues to lag
The median compensation earned by family physicians whose practices don’t include obstetrics was $183,999 in 2009, an increase of 2.4 percent from the previous year, according to the Medical Group Management Association (MGMA) Physician Compensation and Production Survey: 2010 Report Based on 2009 Data. Pediatricians and internists saw slightly greater increases of 2.6 and 3.1 percent, respectively. The specialties with the greatest increases in median compensation were dermatology, with 12.3 percent, and ophthalmology, with 7.7 percent. Both may have benefited from increased demand for non-covered elective procedures, for which they can collect the full fee at the time of service, according to the MGMA. Among other specialties, two saw lower increases than family medicine (emergency medicine and hematology/oncology), and two saw decreases (obstetrics/gynecology and invasive cardiology).
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