ObamaCare’s Electronic-Records Debacle

The rule raises health-care costs even as it means doctors see fewer patients while providing worse care.

The debate over ObamaCare has obscured another important example of government meddling in medicine. Starting this year, physicians like myself who treat Medicare patients must adopt electronic health records, known as EHRs, which are digital versions of a patient’s paper charts. If doctors do not comply, our reimbursement rates will be cut by 1%, rising to a maximum of 5% by the end of the decade.

I am an unwilling participant in this program. In my experience, EHRs harm patients more than they help.

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Apparently our poor bedside manner is a national crisis, judging by how my fellow physicians feel about the EHR program. A 2014 survey by the industry group Medical Economics discovered that 67% of doctors are “dissatisfied with [EHR] functionality.” Three of four physicians said electronic health records “do not save them time,” according to Deloitte. Doctors reported spending—or more accurately, wasting—an average of 48 minutes each day dealing with this system.

That plays into the issue of higher costs. The Deloitte survey also found that three of four physicians think electronic health records “increase costs.” There are three reasons. 

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Not surprisingly, a recent study in Perspectives in Health Information Management found that electronic health records encourage errors that can “endanger patient safety or decrease the quality of care.” America saw a real-life example during the recent Ebola crisis, when “patient zero” in Dallas, Thomas Eric Duncan, received a delayed diagnosis due in part to problems with EHRs.

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Doccupy, EHRs and the Affordable Care Act

It’s rare for doctors to turn out en masse for a public protest. But that’s what happened at “Doccupy” in Contra Costa County California in 2012. A group of safety net physicians testified before county supervisors — in what they only half-jokingly called “Doccupy” — that the cumbersome move to electronic health records (EHRs) had taken an enormous toll on patient care. The doctors saw half their usual number of patients. As a result, they told supervisors, one in ten patients left the emergency room without being seen and wait times ballooned from one to four hours — with one person waiting 40 hours for a hospital bed.

This protest came on the heels of a letter from a group of county jail nurses asserting concerns about the same electronic records system. A subsequent NYT article pointed out additional productivity and patient safety issues raised about electronic medical records at other locations, even from health care establishments as impressive as the Mayo Clinic.

It might be tempting to think of these stories as an aberrant blip. But surveys show Doccupy may have just been the first sign of trouble with electronic health records nationwide:

- See more at: http://www.docgurley.com/2014/02/doccupy-ehrs-affordable-care-act/#sthash.s8rcDZ9K.dpuf
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8 Facts that Explain What's Wrong with American Healthcare

Excellent article- worth the time to read in full .
Uvealblues
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Some highlights:

The reason that American health care is expensive is all about the price: when we go to the doctor, it costs more than when, say, someone in Canada goes to the doctor.

Part of this is about the price per unit of health care in the United States. From prescription drugs to imaging scans, nearly everything costs more when it's prescribed in America. Take the heartburn medication Nexium: the exact same medication costs $215 here and $23 in the Netherlands.

Most other countries have some form of price controls; the government negotiates with drug companies and device makers for lower prices, and the government has the power to win those negotiations. The United States doesn't do that. It leaves the negotiations up to individual insurers. And they tend to lose.

There are more nuanced ways that our health-care prices are more expensive, too. Harvard University's David Cutler points out that we have much higher administrative costs than most other countries — and those costs get tacked onto the bill when we go to the doctor. The average American doctor spends All those extra billing specialists' salaries have to get paid somehow — and that gets worked into our prices.

The National Institute for Health Care Management estimates that, in 2009, about half of health spending ($623 billion) went towards 5 percent of the population. On average, these are people who use $40,000 of health care annually.

As to who makes the most money, it's mostly drug companies and device manufacturers — the people who make the things that insurance companies buy. They typically run profit margins around 20 percent.

One study estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice

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I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.

In the end, we were able to keep Mr. V.’s blood pressure under control. My blood pressure, however, was a different story.

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Primary Care is Not General Motors

http://acountrydoctorwrites.wordpress.com/2014/07/20/primary-care-is-not-general-motors/

India Has a New Health Care Plan That Will Make Americans Jealous

The news: Millions of Indians are about to get a lot healthier. Dr. Harsh Vardhan, the country's new health minister, is rolling out a new health care initiative that will provide Indians free access to 50 essential generic medicines.

"Fifty basic essential drugs address 75% of the health care needs of the majority, and we plan to make these available free to everyone, from birth to death," Vardhan told the Hindustan Times.

How this will work: India's public hospitals and dispensaries will offer free medicine to treat pain, infections, hypertension, diabetes and many other diseases. Vardhan explained that, "The program" which will be rolled out in phases, "will focus on efficient procurement, quality control and rational use – 50% medicines are wasted or overused, leading to complications and drug-resistance."

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Ad-Tech Entrepreneurs Build Cancer Database

Flatiron Health Is Sharing Its Information About 550,000 Cases With Doctors, Medical Facilities

Most treatments for cancer are based on protocols developed from clinical trials. Outcome reporting can lag for a while until papers are published. Flatiron gathers data that weren't previously available and shareable, the 96% of cases where the patient didn't participate in a clinical trial.

Revenue comes to two-year-old Flatiron from charging cancer centers for access to its database and by joining with life-science companies on their research. The centers contribute specific information about actual cases, with patient names taken off. This includes the course of treatment prescribed, and the outcome. Every cancer center has lots of such information: If they contribute theirs, they get access to the whole Flatiron database, and their doctors can see a much wider data set as they prescribe courses of treatment.

Today, Flatiron Health has 105 employees, and half of those are engineers. More than 200 cancer centers in the U.S. either use or are testing its database, which holds information about more than 550,000 cancer cases. This spring, it received Google Ventures' largest-ever investment in a medical-software company, $130 million. Mr. Turner, age 28, recently spoke to The Wall Street Journal about his struggles so far to build the business, which he expects to break even within a few years. Edited excerpts:

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Doccupy, EHRs and the Affordable Care Act

It’s rare for doctors to turn out en masse for a public protest. But that’s what happened at “Doccupy” in Contra Costa County California in 2012. A group of safety net physicians testified before county supervisors — in what they only half-jokingly called “Doccupy” — that the cumbersome move to electronic health records (EHRs) had taken an enormous toll on patient care. The doctors saw half their usual number of patients. As a result, they told supervisors, one in ten patients left the emergency room without being seen and wait times ballooned from one to four hours — with one person waiting 40 hours for a hospital bed.

This protest came on the heels of a letter from a group of county jail nurses asserting concerns about the same electronic records system. A subsequent NYT article pointed out additional productivity and patient safety issues raised about electronic medical records at other locations, even from health care establishments as impressive as the Mayo Clinic.

It might be tempting to think of these stories as an aberrant blip. But surveys show Doccupy may have just been the first sign of trouble with electronic health records nationwide:

- See more at: http://www.docgurley.com/2014/02/doccupy-ehrs-affordable-care-act/#sthash.fkTegEgs.dpuf

Medicine’s Top Earners Are Not the M.D.s

THOUGH the recent release of Medicare’s physician payments cast a spotlight on the millions of dollars paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.

That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.

The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.

 And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.

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Continue reading the main s

Where Does It Hurt? Log On. The Doctor Is In

Telemedicine Sector Attracts Funding, But Some Physician Groups Worry About Quality of Care

Investors are betting that more Americans will like getting medical care 24/7 without leaving home or work. The telehealth sector has attracted $272 million in venture-capital funding since 2010—including $79 million in the last quarter, according to Mercom Capital Group, a health IT research firm.

"Politicians and lobbyists can't solve health care. It's quite simple: Empower consumers with patient-in-control solutions," says John Sculley, former Apple CEO and vice chairman of MDLIVE, which netted $24 million in new funding this year.

Doctor on Demand launched in December with $3 million in seed funding from Google Ventures and other investors. Its co-founder is Jay McGraw, executive producer of the talk show "The Doctors," and son of psychologist Dr. Phil.

Many health plans think such services will provide savings, and cover most or all of the cost for their members. As of last year, 11% of large employers offered telemedicine services to their employees and 28% were considering it, according to consulting firm Mercer.

But some physician groups and state medical boards worry that such e-visits are undermining the doctor-patient relationship and lowering the quality of care.

"Most physicians would never accept a phone call from a patient they haven't met and diagnose and prescribe medication for that patient. Yet that is a common practice for many 24/7 health-care services," says Greg Billings, executive director of the Robert J. Waters Center for Telehealth and e-Health Law, a nonprofit research group, also known as CTel.

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Should Doctors Care About Cost?

Excellent perspectives here: Link
Dr. Shapiro in the third letter  down points out that Congress has allowed Drug Companies exorbitant pricing on their products. While Medicare and Ins. companies try to "nickel and dime" doctors, who are operating at very low profit margins as it is, drug companies can charge 2000$ a month for medications injected into patient's eyes, and medicare wants to totally eliminate paying ophthalmologists for exams when pt's get injections. If medicare decides to cut out doctor payments for 12 exams a year per patient, it still will not equal what medicare pays for one dose of an injected medicine per month, such as Lucentis. If a patient is getting one of these expensive drugs in both eyes monthly, it costs medicare 48, 000$/year. The payment to the physician is a small fraction of that amount.

In an excellent segment on 60 minutes (link here), which one congressman pointed out was the "ugliest night he had ever seen (in Congress),  it is pointed out that pharmaceutical companies paid 100 million dollars a year to lobbyists (and that was in 2007). Their lobby is bigger than defense and oil according to a recent meeting I attended last week. It is the biggest lobby in the world. 

The whole video is a definite must watch, but at ~5:20 into the video it clearly states that the Bill prohibited the Government, with its massive purchasing power, from negotiating the price of drugs with pharmaceutical companie!. It is thus  no surprise that this bill was written by the pharmaceutical industry. 

It is no surprise that Tom Scully, Medicare's lead negotiator on the drug bill told the chief actuary to withhold  at the congressional hearings,his revised estimates that it would cost you the tax payer, 500 billion dollars for the first ten years. At the same time he prohibited this revised estimate from being announced, he was negotiating to be a lobbyist for the pharmaceutical companies. It is no surprise that 15 of the key congressman who got the drug bill based shortly thereafter got lucrative jobs working for pharmaceutical companies, either.
Uvealblues

The focus on patient satisfaction is enough to make you sick

All patients should be treated with professionalism and respect.  We all want our patients leaving our care happy, healthy and satisfied, if at all possible.  However, sometimes patients don’t leave an emergency department very happy or satisfied.  Sometimes the doctor could have prevented it, but many if not most times, such dissatisfaction has little if anything to do with what the treating physician did, or didn’t, do.

The reasons for a patient being dissatisfied with a particular healthcare encounter can be very complex.  It’s not so simple as to just include a line in a survey such as, “Were you satisfied with your doctor?”

Who should be held responsible for the results of these surveys, is where the crux of this debate lies.

So why are hospitals obsessed with patient satisfaction?

It’s the same reason Walmart puts greeters at the front door (the ED), not the back door (inpatient floors), and the same reason the government collects taxes and not sea shells: money.  The question we really need to be asking is: Why is the obsession with patient satisfaction in the ED so soul-crushing to those that work there?

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Sometimes a patient voices frustration in a survey despite your best efforts to be nice, helpful, professional and clinically astute.  This may be due to factors out of your control regarding ER wait times, a large hospital bill, dirt on the waiting room floor, or a rude staffer that wasn’t you.  If the results are used against you, it is very difficult to smile and say, “It’ll never happen again.  I’ll do better next time.”

You didn’t make it happen, and you have little if any ability to make it better next time.  You’re already nice to your patients, do your best to help them and treat them with respect.  There’s tremendous cognitive and emotional dissonance there.  Things like this can end careers and fuel burnout in a big way.  Such things are the undercurrents that cause doctors to go work for insurance companies, as non-clinical consultants, or just plain move on.

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For Drugs That Save Lives, a Steep Cost

We approve drugs and devices without considering cost-effectiveness, or even having a clue about price. We don’t ask for estimates and then are surprised when the nation is stuck with a $2.7 trillion annual health care bill.
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In the case of the naloxone device, the question is germane because the drug itself is very old, and long off patent. A simple syringe filled with a dose of naloxone should cost about $3, said Dan Bigg, director of the Chicago Recovery Alliance, which has long deployed the drug in communities to reverse overdoses. He says giving the shot is “no more complicated than basting a turkey. It’s a no-brainer: You pull up this liquid and inject it into the muscle.”

But experts expect that Evzio could well be priced close to $500.

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For many years, drug manufacturers have justified the high price of new drugs by citing their investments in research and development. But it has become harder to claim that it takes, say, $1 billion to bring a new drug to market, since many medicines originate with government-funded research, 

TEAMWORK IS BEST WHEN MAKING SURGERY DECISIONS FOR ELDERLY

Deciding if a sick, elderly patient should have surgery should be a team effort, with input from the patient, family members, the surgeon, primary care physician, nurses, and non-clinicians, such as social workers or advocates.
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How Much Does Your Doctor Really Make?

The U.S. government released payment data for 880,000 physicians this week—to widespread misinterpretation. What the numbers can actually tell us.

These approaches to looking at the new payment records suffer three major flaws.
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Malcolm Gladwell: Tell People What It's Really Like To Be A Doctor

When I asked Gladwell what topics he thought I should cover in future Forbes blogs, he said, “Help people understand what it is really like to be a physician.”

I did not see that coming. I figured he’d request an expose on Big Pharma, an in-depth examination of various medical conditions or a portrait of preventive care. But explaining what it’s really like to be doctor is a much more personal request and, as it turned out, much more challenging.

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He also expressed concerns about the economics of medical practice and the consequences for physicians:

“I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we’ve made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.”

It’s this side of medical practice that wears down even the best physicians.

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And in 2012, a study found that 9 out of 10 physicians across the country are unwilling to recommend the profession to others.

Where Does That Leave The Future Of Medical Practice?

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Why I Prescribe the Love Drug

An important and great post by Dr. Wible
Check out her blog!

People die without love.
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Dr. Wes is a thoughtful and insightful medical blogger---two recent articles of particular interest to me are  the following:

How should patients determine the quality of their doctor?  Link

Talking Heads: Link

Uvealblues

$1,000 Pill For Hepatitis C Spurs Debate Over Drug Prices

Federal regulators this month opened a new era in the treatment of a deadly liver virus that infects three to five times more people than HIV. Now the question is: Who will get access to the new drug for hepatitis C, and when?

The drug sofosbuvir (brand name Sovaldi) will cost $1,000 per pill. A typical course of treatment will last 12 weeks and run $84,000, plus the cost of necessary companion drugs. Some patients may need treatment for twice as long.

Hepatitis researchers call the drug a landmark in the treatment of this deadly infection. More than 90 percent of patients who get the new drug can expect to be cured of their hepatitis C infection, with few side effects.

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The 10 most popular KevinMD posts of 2013

KevinMD.com shares the stories of the many who intersect with our health care system, but are rarely heard from.  Over 2500 articles were published this year from these voices, including practicing physicians, patients, policy experts, nurses, social workers, medical students, and hospital chaplains, among others.

I sincerely appreciate your continued readership and conversation.

Here are the most popular posts of 2013.

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