MiamiMedBlog

Keep it Simple and Stupid: Rick Scott's Healthcare Plan and the FMA

2010-10-12T19:32:00.001-07:00

“Florida is not a physician-friendly state to practice medicine because of the high cost of medical liability insurance and excessive lawsuits,....the FMA PAC supports Rick Scott for Governor because he shares our goal of increasing access to quality health care for all of Florida’s citizens. Rick Scott is not afraid of taking on personal injury lawyers and shaking up the status quo in order to get things done for the people of Florida.”

President of the FMA PAC, Dr. Madelyn Butler

I tried to understand Rick Scott's healthcare plan and ideas, which convinced the Florida Medical Association Political Action Committee to endorse him as Gubernatorial Candidate.
First, I searched on his web site and found the following:

* On Abortion: "I believe that abortion is wrong and Roe versus Wade should be overturned."
o What shall I tell a woman who is pregnant but unmarried, unemployed, on food stamps and lives with friends or relatives?
o Teenagers who were raped or married women who were sexually attacked by their husbands?
o Should government tell women and doctors what to do and how to lives their lives?
* On Health Care:
o "As a businessman, I know I am held accountable for results, and I held the people in my company accountable for results, too. Delivering quality care at a lower cost to patients was a top priority when I ran Columbia/HCA, and when I started Solantic urgent care facilities here in Florida....In the 1990’s, we were able to transform the hospital industry and prove that free market health care can deliver high quality care at a lower cost to patients."
+ That’s it? We just have to emulate the Columbia/HCA model and open a couple of Solantic Urgent Care centers and we solve all healthcare problems? Guess, I can shred all my healthcare economics test books and magazines, join Rick Scott's model and everything will be just fine. How naive or stupid can anyone be to believe that? Obviously, the FMA PAC does!
o "Rick believes that our health care system should focus on choice, competition, accountability and personal responsibility."
+ So I will have the choice of choosing between an unaffordable health insurance policy or none?
+ Accountability and personal responsibility only applies to the consumers of healthcare but not Rick Scott who just made " some mistakes in his life."

o "Most recently, Rick led the fight to defeat President Obama’s government-run public option. As the founder of Conservatives for Patients’ Rights (CPR), an advocacy group dedicated to the free market principles of choice, competition, accountability and personal responsibility in health care, he was instrumental in defeating the public option plan that would have led to socialized medicine."
+ Fear mongering and painting the government as the boogeyman trying to enslave citizens is a silly and dangerous tactic which just reveals that Rick Scott and friends have no other arguments to offer to resolve the critical problem facing us today and in the near future: how to provide affordable healthcare for an aging population suffering from chronic diseases that consume already 75% of all health care spending.
* On healthcare management experience:
o " I’ve made mistakes in my life...I learned very hard lessons from what happened and those lessons have helped me become a better businessman and leader."
+ That’s it! Mistakes imply taking personal responsibility and not blaming others (i.e. Columbia/HCA) for it. These are the lessons he brings to the table and those character traits make him the knight in shining armor for the FMA PAC?

So what can I say about the FMA PAC decision to endorse Rick Scott? A sad day for Florida's doctors. A sad day for medicine.

Yours

Bernd

Strange Bedfellows: The FMA and Rick Scott

2010-10-11T18:55:00.000-07:00

According to a posting on the Florida Medical Association PAC web site ( see attached) the FMA PAC is endorsing endorsing Rick Scott's candidacy as Governor for our State of Florida!!???
Even though I already lowered my expectation regarding FMA's actions and politics I am still surprised that the leadership of such an organization is willing to sacrifice its principles on the altar of political correctness. Sadly, ideology trumped rational thought and consideration. Its hard to believe that the FMA political leadership has omitted considering the following facts in their deliberation process. These facts are available for anyone to read on multiple web sites and were summarized by the Miami Herald in an article published on June 11th, 2010 http://www.miamiherald.com/2010/06/11/v-print/1674327/was-candidate-involved-in-us-healthcare.html, entitled "Was candidate Rick Scott involved in US Healthcare Scam."
In the article the author states that:

"Scott started what was first Columbia in the spring of 1987, purchasing two El Paso, Texas, hospitals. He quickly grew the company by purchasing more hospitals. A hospital network created efficiencies. Efficiencies created profits.

In 1994, Scott's Columbia purchased Tennessee-headquartered HCA and its 100 hospitals, and merged the companies. When Scott resigned as CEO in 1997, Columbia/HCA had grown to more than 340 hospitals, 135 surgery centers and 550 home health locations in 37 states and two foreign countries, Scott's campaign says. The company employed more than 285,000 people.

Now about Scott's departure in 1997. That year, federal agents went public with an investigation into the company, first seizing records from four El Paso-area hospitals and then expanding across the country. In time it became apparent that the investigation focused on whether Columbia/HCA bilked Medicare and Medicaid.

Scott resigned as CEO in July 1997, less than four months after the inquiry became public and before the depth of the investigation became clear. Company executives said that had Scott remained CEO, the entire chain could have been in jeopardy.

At issue, Scott says, is that he wanted to fight the federal government's accusations. The corporate board of the publicly traded company wanted to settle. And settle Columbia/HCA did.

In December 2000, the U.S. Justice Department announced what it called the largest government fraud settlement in U.S. history when Columbia/HCA agreed to pay $840 million in criminal fines and civil damages and penalties.

Among the revelations from the 2000 settlement, all of which apply to the time Scott was CEO:

• Columbia billed Medicare, Medicaid and other federal programs for tests that were not necessary or ordered by physicians.

• The company attached false diagnosis codes to patient records to increase reimbursement to the hospitals.

• The company illegally claimed nonreimbursable marketing and advertising costs as community education.

• Columbia billed the government for home health care visits for patients who did not qualify to receive them.

The government settled a second series of claims with Columbia/HCA in 2002 for an additional $881 million. The total fine: $1.7 billion."

Furthermore the article continues:

"As part of the 2000 settlement, Columbia/HCA agreed to plead guilty to at least 14 corporate felonies. A corporate felony comes with financial penalties but not jail time, since a corporation can't be sent to prison. Among the 14 felonies, Columbia/HCA pleaded guilty to three counts of conspiracy to defraud the United States.

Also, four Florida-based Columbia/HCA executives were indicted. Two were convicted of defrauding Medicare in 1999 and were sentenced to prison, only to have those convictions overturned on appeal. A third executive was acquitted. A jury failed to reach a verdict on the fourth.

Was Scott close to going to prison for his part in the case? It appears not at all.

The former CEO was never indicted and was never questioned in the case, he says. He may have been a target of the investigation -- an ABC News report from 1997 says he was -- but that never translated into charges."

Let's boil this down.

Was Scott running Columbia/HCA when it found itself at the center of a massive federal investigation? Yes.

Did the company pay a record $1.7 billion in government penalties and fines? Yes.

And as we checked in this item, did his former company commit fraud? Yes, it pleaded guilty to fraud charges as part of a settlement.

The million-dollar question is: How much of the blame ultimately falls on Scott? That's an answer we can't provide.

Scott was in charge, so he bears some responsibility and has said so. But there has yet to come to light any detail of how much he knew, and when he knew it. Though that won't keep us from looking.

What did Rick Scott had to say about all that? Either he pleaded the Fifth Amendment, or claims that he did not know what was going on in his own company. I ask myself just one question: How on earth can anyone entrust the keys to the Governors' office to Rick Scott?
Maybe we should admire the Chutzpah (audacity) of Rick Scott and those who endorse his candidacy?
Maybe its time that in light of these facts doctors should reconsider their support for the FMA's endorsement because this time their leadership went too far.

Yours
Bernd

Attachment: FMA PAC web site http://www.fmaonline.org/Layout_1Column.aspx?pageid=2580

FMA PAC – General Election Endorsements

Statewide Races

Governor – Rick Scott
Attorney General – Pam Bondi
Chief Financial Officer - Jeff Atwater
Commissioner of Agriculture - Adam Putnam

Prescription Drug Prices

2010-10-03T20:39:00.001-07:00

In todays Miami Herald State Representative Juan C. Zapata calls for a mandated use of generic drugs for Medicaid and other state-funded programs http://www.miamiherald.com/2010/10/03/1854185/mandate-use-of-generic-drugs-for.html . He is correct saying that the use of generic drugs will slow down the predicted explosive growth of Medicaid expenditures but the mandated use of generic drugs addresses only ONE aspect of the problem.According to a New York Times article , Drug Makers Accused of Ignoring Price Law,” http://www.nytimes.com/2010/10/03/us/03drug.html , drug manufacturers consistently defy complying with a federal law that requires them to provide the government with pricing data needed to calculate discounts on medications prescribed for Medicaid recipients. More than three-fourths of drug manufacturers did not fully comply with the law requiring them to provide price data. They are supposed to file monthly and quarterly reports on what wholesalers paid them for drugs eventually sold to retail pharmacies. Without price data, the federal government cannot compute rebates, and states may be unable to collect them. As a condition of having their drugs covered by Medicaid, pharmaceutical companies must agree to provide discounts in the form of rebates. Drug companies pay the rebates to state Medicaid programs. The federal government and the states share the cost of Medicaid — roughly $400 billion in the last year — and share the savings that result from the rebates. Under the health care law, the minimum rebate on brand-name drugs dispensed to Medicaid recipients was increased to 23.1 percent of the average manufacturer price, from 15.1 percent. The minimum rebate on generic drugs was increased to 13 percent, from 11 percent. The Congressional Budget Office estimates that the changes could save the federal government more than $35 billion over 10 years. Major drug companies are already reporting adverse effects on their revenues. However, drug companies stand to gain many customers with the scheduled Medicaid expansion in 2014. What can be done to address this problem? Under federal law, the government can impose penalties of $10,000 a day on a drug manufacturer that fails to provide the information “on a timely basis. According to the Inspector General at the Department of Health and Human Services the federal government has had this authority since 1990 but has not used it! Why not? We must control and limit the rising healthcare costs and drug manufactures must understand that they can be either be part of the problem, or part of the solution. We also should lift the limitation on prescription drug re-importation and stop the unscrupulous use of antipsychotic drugs, which generate over $14 billion in revenue for drug manufacturers. Otherwise, we have no choice but to resort to rationing of healthcare services and prescription drugs.

Yours
Bernd

Medicare Fraud

2010-09-30T20:40:00.001-07:00

So, it finally happened! Jay Weaver, the Miami Herald journalist who uncovered many Medicare fraud issues in South Florida, wrote another excellent article reporting that CMS is now being forced to revamp its payment policy. In his latest article http://www.miamiherald.com/2010/09/30/v-print/1849528/medicares-new-order-first-weigh.html he emphasizes that:

"An anti-fraud provision, tucked into the Small Business Lending Act that became law Monday, would force Medicare to end its 45-year-old policy of paying claims quickly without verifying them. The Centers for Medicare and Medicaid Services, which pays out $500 billion yearly for elderly and disabled Americans, would have to adopt new billing software with ``predictive modeling'' by next year. Such analytical technology enables the credit card industry to detect questionable bills for, say, a flat-screen TV purchased outside a cardholder's immediate area so that companies can notify the customer and stop payment if fraud is a factor.The cost of rolling out the new billing technology would reach an estimated $930 million over the next decade but it may reduce or prevent paying one of every $7 to fraudulent claimants.
Furthermore, the new Affordable Care Act includes tougher penalties for offenders, expanded administrative powers for Medicare and $350 million to combat healthcare corruption over the next decade."

Sen. George LeMieux, R-Florida, who sponsored the anti-fraud bill, said he has been frustrated watching Medicare continue to pay billions to dubious healthcare providers for unnecessary or bogus services. But Senator LeMieux supports the Republican Party platform to repeal the same Affordable Care Act which funds such anti-fraud activities! Does he really believe that the voters are that stupid, or short-term memory challenged, to forget his election antics?
Its time that politicians start collaborating and cooperating to solve the real problems we are facing and to focus on stopping the Medicare fraud gravy train.
But maybe I am too naive to believe that politicians are capable to act and behave rationally.

Yours
Bernd

Healthcare Reform

2010-09-22T20:34:00.001-07:00

Several very important component of the federal healthcare reform package are going to go into effect tomorrow.
Therefore, we should review the facts (and not fiction) regarding those components which will protect our patients (i.e. our families) from insurance companies. I hope that physicians will finally embrace these reforms, too. There should be no reason to reject them!
I also recommend reading today's Miami Herald editorial supporting healthcare reform. I agree with the authors conclusion:

"But tweaking the law and trying to get rid of it altogether, as a lawsuit filed by Florida's attorney general and others aims to do, are two different things. The law is an investment in the health and future of the American people. It can be improved, but it should become a permanent feature of American society."

Read more: http://www.miamiherald.com/2010/09/22/v-print/1836040/healthcare-reform-should-be-here.html#ixzz10Jt5GrD4
Yours
Bernd

* Preventive services:
o Based on the theory that inexpensive preventive measures can reduce expensive hospital visits later, the reform act requires insurers to pay all costs for many immunization vaccines and screenings for colorectal cancer (for those over 50), depression, high blood pressure (for diabetics) and autism (for children 18 months to 24 months.)
o Also covered at 100 percent are mammograms for women over 40 and smoking cessation programs. For a full list of preventive services covered go to www.healthcare.gov/law/

* Adult children:
o All new private insurance that offers dependent coverage must allow parents to cover their children until age 26. They can live elsewhere and still be covered, and they must be charged at the policy's prevailing child rates.I
o If adult children can get insurance through their own jobs, they can't switch to their parents' existing job-based coverage if it's grandfathered. But if they don't have work coverage, they can move to parents' plans, even if the employers are planning to continue using their current plans.

* Right to appeal:
o Consumers covered under new, non-grandfathered insurance plans will have a right to appeal to an external party if, for example, their insurer denies coverage of treatments recommended by their doctors.
o Consumers will first have to file an internal appeal with the insurers. If not satisfied, they then can appeal to an impartial reviewer. Details of who will handle reviews and what regulations will apply are being worked out.

* No exclusions for children:
o In the past, insurers can -- and regularly did -- deny children with pre-existing conditions. As of Sept. 23, Thursday, they will be required to accept all kids, regardless of health status.
o This provision has led to spirited debate. Insurers' fear is that parents would wait until their kids got sick to buy coverage. `
o Insurers depend on providing coverage for a broad pool of people -- with the healthy majority paying premiums that fund the sick minority. Their fear with reform is that if only sick people sign up, insurers will lose huge amounts of money or need to raise premiums to horrendously high rates. Starting in 2014, that fear vanishes, because virtually everyone will be required then to have insurance.
o Health and Human Services recently responded to the insurers' fears about kid coverage, allowing insurers in the individual market to have an open enrollment period of, say, one month a year in which families could sign up children under 19 with pre-existing conditions. That means families will be encouraged to enroll healthy kids because they won't be able to automatically sign them up when they get sick.

* Lifetime caps removed:
o Many policies have limitations of $1 million, $2 million or even more. Most people never even have to think about them. But for those with severe chronic illness, their removal could mean a lot, possibly even preventing bankruptcy.

* High risk pools:
o For the truly desperate, the new high-risk pools can be a lifesaver -- but not a cheap one. They're intended for uninsured patients who have pre-existing conditions and can't get coverage elsewhere. They will serve as a bridge until 2014, when there are new government-regulated insurance exchanges accepting virtually everyone who can't get coverage elsewhere.
o Florida has had a high-risk pool for years, but because of the expense, it has been closed to new patients since 1991 and has only 250 members left.
o The Legislature opted not to re-open it in response to the reform act, meaning that the state's residents can sign up for a federally sponsored pool, known as the Pre-Existing Condition Insurance Plan.
o Under the plan, Florida residents will pay monthly rates ranging from $363 for those up to 34 and as much as $773 for those 55 and older, according to healthcare.gov . That's with a $2,500 deductible and maximum out-of-pocket of $5,950 a year. Those payments cover only part of their insurance costs. The feds have allocated $351 million to Florida to pick up the rest of the expenses till 2014. Critics fear that's not enough.
o The program is only for those who are legally in the United States, have been uninsured for at least six months and have been denied coverage because of a pre-existing condition. Applications are available at healthcare.gov or by calling (866) 717-5826.

* Limiting insurers' profits:
o Starting Jan. 1, insurers of large groups will be required to spend 85 percent of premiums on healthcare. For insurers of small groups and individual policies, it's 80 percent. In 2012, if insurers fail to meet these requirements, they must offer rebates to customers.
o Should money spent on converting to electronic records be counted as a medical expense or an administrative one? What about monitoring infectious disease rates in hospitals or money spent managing chronic conditions?
o The National Association of Insurance Commissioners has been working on draft guidelines. The U.S. Department of Health and Human Services says it has not yet received them.

* Other changes:

* About one million seniors have already received $250 rebate checks because of high prescription drug costs that were not covered by Medicare Part D.

* About 70 South Florida organizations -- including the Miami-Dade and Broward school systems -- will get funds to help pay for healthcare for retirees aged 55 to 64 who are not eligible for Medicare.

* Starting this year, businesses with no more than 25 workers with average annual wages under $50,000 can get tax credits of up to 35 percent of the costs of premiums.

For further information, healthcare.gov is the government site for the reform act. The Kaiser Family Foundation (kff.org), the Commonwealth Fund (commonwealthfund.org ) and Families USA (familiesusa.org) are three Washington nonprofits that provide details and analysis of the reform act.

Shifting Healthcare Costs

2010-09-06T18:48:00.001-07:00

According to a recent editorial published in the New York Times (Shifting the Health Cost Burden, September, 2nd, 2010) "the latest annual survey of employer health benefits contains good news for the employers but bad news for their workers."
What are the good news? The average total premium for employer-sponsored health insurance (typically paid partly by employers and partly by their workers) rose only a modest 3 percent this year for family plans, reaching $13,770 in 2010.
What are the bad news? The employee share of their premium soared by 14% reaching almost $4,000, while the amount employers contributed did not increase.
Whats are the results?

* Employers shifted virtually all of the increased premium costs to their employees , who were in a weak position to resist in an economy where there were few other jobs to jump to.
* Since 2005, while wages have increased just 18 percent, workers’ contributions to premiums have jumped 47 percent, almost twice as fast as the rise in the policy’s overall cost.
* Meanwhile insurances are getting stingier and less comprehensive.
* Workers face higher deductibles, forcing them to pay a larger share of their overall medical bills. The Kaiser survey found a significant increase in the number of employees who had a deductible of at least $1,000, to 27 percent this year, from 22 percent in 2009. Almost half of workers who are covered by a small employer with fewer than 200 workers have an annual deductible of that amount.
* Increasing out-of-pocket expenses will almost certainly reduce the number of medical office visits, will force staff to collect deductibles at the point-of-care, or bill the patients and write off the increasing amount of unpaid bills. This will further decrease the margins in family medicine offices and force doctors to see more patients for less money!

What can we do? Facing very tight profit margins doctors must improve the efficiency of their offices, teach their staff to work as teams and advertise their medical services to those seeking cheaper medical services.
Instead of working harder we must work smarter. Yelling and screaming will not help us to move forward. We must learn to run our offices as small businesses and adapt quickly to the rapidly changing market place.

Yours
Bernd

FMA Off Base Fighting Reform

2010-08-22T08:39:00.001-07:00

The recently published OpEd succinctly characterizes the Florida Medical Association's policy vis-a-vis healthcare reform.
The authors concluded that
"The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need. It is coming, and the FMA should get on board or out of the way."
In a NEJM (N Engl J Med 2009;360: 2495-2497) article Fisher et al clearly defines the positions we as physicians can take.
“ In the face of this uncertainty, physicians have a choice: to wait and see what happens or to lead the change our country needs. We'd prefer the latter....Physicians can become our most credible and effective leaders of progress toward a new world of coordinated, sensible, outcome-oriented care in which they and their communities will be far better off. Defending the status quo is a bankrupt plan, and physicians have an opportunity to help us all see beyond it."
I wholeheartedly agree with this conclusion.
Yours
Bernd

Guest column: Florida Medical Association is off base fighting reform

Source URL: http://jacksonville.com/opinion/letters-readers/2010-08-19/story/guest-column-florida-medical-association-base-fighting

At an Orlando meeting last week, Florida Medical Association members fumed that their parent, the American Medical Association, isn't adequately representing Florida's private practice doctors.

After talk of secession, they settled for writing a stern letter urging the AMA to straighten up.

The FMA dustup began with a resolution written by Douglas Stevens, a Fort Myers cosmetic surgeon - you can't make this stuff up - complaining that the AMA's support for recent reforms was "a severe intrusion in the patient-physician relationship and allows government control over essentially all aspects of medical care."

He wrote that it will "relegate physicians to the role of government employees ... and essentially end the profession of medicine as we know it."

A St. Petersburg neurological surgeon, David McKalip, added that without AMA support, reform would have died.

Well, no. Stevens might have had two reform provisions in mind.

One uses subsidies to encourage doctors to obtain electronic health record technologies, so patient information can be easily exchanged and unnecessary or redundant services can be reduced.

Some data would be submitted to a federal repository, so doctors can better understand how effectively they practice compared to their peers and how to improve if needed.

Of course, physicians opposed to these rules could opt to avoid patients whose care is paid for with public dollars. But we think most doctors will welcome the opportunity to modernize their care.

The second bone of contention was a well-intentioned but flawed 1997 Medicare formula, the Sustainable Growth Rate, which tied physician payments to the growth of the U.S. economy. If Medicare physician spending exceeded the target in one year, then payment the following year would be reduced.

But every year, Congress has delayed the payment reductions. Now, in 2010, the accumulated cuts would be 21.2 percent.

Congress is reluctant to spend the additional $200 billion to forgive the cuts. American specialists, who make triple the salaries of their primary care colleagues, are bound to see smaller Medicare checks.

In the past, we've had many differences with the AMA, which was often more focused on physicians and their economic prosperity than on patients and theirs, especially as health insurance costs relentlessly grew four times faster than the economy.

Through a specialist-dominated reimbursement advisory committee, the AMA urged Congress to pay specialists more at the expense of primary care physicians. So it is not far-fetched to lay much of the current health care cost crisis at the AMA's feet.

But recently, the AMA became more progressive. It mounted a three-year campaign for universal coverage. It supported government's efforts to reward the meaningful use of modern computerized tools and the best medical science in clinical practice.

They are incredibly important to us, but over the last half century, American physicians have been handsomely, even often excessively, rewarded.

But now, the system that has been hugely wasteful must find ways to reduce costs while improving quality, and make sure that care is accessible to everyone. These imperatives are emerging just as data and information tools are becoming more available. Health care will become more like a market than before.

Medical practice is changing profoundly, mostly for the better. Doctors will still be highly valued, but many may earn less.

The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need.

It is coming, and the FMA should get on board or out of the way.

Brian Klepper of Atlantic Beach and David Kibbe, a physician from Chapel Hill, N.C., write on health care policy, market dynamics and technology.

Medicare Conundrum

2010-08-16T19:59:00.001-07:00

I highly recommend reading an article http://www.ama-assn.org/amednews/2010/08/16/gvl10816.htm published in AMA NEWS entitled, "Medicare trustees' upbeat outlook relies on big pay cuts for doctors, Aug. 16, 2010."
In the 2010 Medicare trustees report the trustees said Medicare savings that are included in the overhaul will extend the insolvency date of Medicare's hospital trust fund to 2029, 12 years beyond the point that last year's report said Part A would run out of money.Medicare Part B does not face insolvency because it is funded by a combination of general tax revenues and beneficiary premiums. Expenditures on outpatient care grew at an average annual rate of 8.3% during the past five years, exceeding gross domestic product growth by 4.2 percentage points annually, on average. Projected annual spending growth for Part B is estimated to average only 5.3% during the next five years, about the same as the GDP growth rate, the report said. But this assumes deep physician pay cuts will take effect. Unless Congress steps in, physician rates are scheduled to decline 23% on Dec. 1, an additional 6.5% in January 2011 and 2.9% in 2012.
Medicare Part B spending now approximates 1.5% of the GDP, the report said. Last year's report projected that figure would increase to 4.5% by the end of the trustees' 75-year projection. With the new law, it is now projected to reach only 2.5% of GDP by the end of the long-term window.Preventing rate cuts to doctors would increase that estimate, as would a failure to realize long-term savings envisioned under reform.
What does this mean for physicians?

* We need to focus on the implementation of new care models, such as patient-centered medical homes, accountable care organizations.
* We should expect and prepare for payment bundling and pay-for-performance.
* We should deploy and apply systems that help us to measure, optimize and improve productivity.

Unfortunately, many of us will prefer to resist and protest the inevitable change. In my opinion responsible physician leaders should prepare their membership for and guide them towards meeting the new challenges of a more complex healthcare delivery system by using finite (financial) resources.

Yours
Bernd

Impaired Physicians

2010-08-15T18:26:00.001-07:00

In a recently published article " Physicians reluctant to report impaired colleagues, study says,"(amednews.com) the author summarizes the findings of a national survey of 2,000 physicians. The survey results were published in the July 14th edition of JAMA " Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues."
Unfortunately, the key findings are troubling:

* Just 64% of physicians completely agreed that they had an obligation to report all impaired or incompetent doctors. The rest of the physicians either "somewhat agreed" that they were obliged to report problem colleagues or disagreed that they had such a responsibility.
* The most common reason for not reporting incompetent or impaired colleagues was physicians "thought someone else was taking care of the problem," the study said. Some physicians said reporting would be fruitless, while 12% feared retribution.

Only 17% of respondents had direct knowledge of an impaired or incompetent physician. The question remains if this is due to ignorance or choice.
What can we do? Doctors need to be better educated on how to report problem colleagues and their ethical responsibility to do so. Those who do report should be kept in the loop on how a colleague's case is progressing, and that the reporting process should be confidential.
Looking forward to your comments.
Yours
Bernd

Barriers to Reporting:

Two-thirds of physicians with direct knowledge of an impaired or incompetent physician colleague reported them to a medical board, hospital, clinic, professional society or other body. Of doctors who didn't report:

19% thought someone else was taking care of the problem.

15% believed nothing would happen as a result of the report.

12% feared retribution.

10% believed it was not their responsibility.

9% believed the person would be excessively punished.

8% did not know how to report.

8% believed it easily could happen to them.

Note: respondents could answer "yes" to more than one reason.

Source: "Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues," Journal of the American Medical Association, July 14 (jama.ama-assn.org/cgi/content/abstract/304/2/187/)

Americans Cut Back in Visits To Doctors

2010-07-31T18:16:00.000-07:00

Attached an article of concern published in the Wall Street Journal (July 29th, 2010) highlighting the fact that insured Americans are using fewer medical services. This may be a result of the increasing co-payments and deductibles which may force patients to see a doctor ONLY if it hurts and not for preventive medicine. Some speculate that we may face now a less "aggressive consumer of healthcare." The continued weak demand for healthcare services may slow the increasing healthcare costs and cut put pressure on health insurance companies to lower their premiums. I believe it when I see it!! Already, large insurance companies are reporting record profits. The top five earning insurance companies averaged profits of $12.2 billion, an increase of 4.4. billion, or 56% and so does the CEO compensation of those companies.
For family physicians the trend for less services may have significant adverse effects on the financial viability of their practices. Doctors visits have declined each month this year, including a 7.6% drop in May compared to May 2009! What can we do? Well, we need to trim as much as we can from our practice expenses. We also should make it more convenient and affordable for our patients to visit our offices. Early morning or late evening appointment, Saturday or Sundays, online consultation and discounted service packages for the uninsured. Patients will spend money for convenience and great customer service. . In the long term we have to abandon the fee-for-service system which forces us to see more patients for less.
Bundled payments may be an option too. Change is happening rapidly and quick adaptation and response to the changes guarantees survival. Its not too late!!
Yours
Bernd

Americans Cut Back On Visits To Doctor
By AVERY JOHNSON, JONATHAN D. ROCKOFF And ANNA WILDE MATHEWS

Insured Americans are using fewer medical services, raising questions about whether patients are consuming less health care as they pick up a greater share of the costs.

The drop in usage is showing up as health-care companies report financial results. Insurers, lab-testing companies, hospitals and doctor-billing concerns say that patient visits, drug prescriptions and procedures were down in the second quarter from year-ago levels

"People just aren't using health-care like they have," said Wayne DeVeydt, WellPoint Inc.'s chief financial officer, in an interview Wednesday. "Utilization is lower than we expected, and it's unusual."

Others say that consumers are beginning to forgo elective procedures like knee replacements. "We have a very weak economy and it's just a different environment for the elective parts of health care," said Paul Ginsburg, a health economist who runs the Center for Studying Health System Change and has been analyzing health-company earnings. But "this could go beyond the recession. Being a less aggressive consumer of health care is here to stay."

Continued weak demand could eventually put downward pressure on spiraling health-care costs, a long-sought goal of policy makers. It could also force insurers to lower premiums.

The new trend comes amid a broader drop in health-care use as more Americans lose their jobs and their health insurance. Such cutbacks have happened before in recessions, but the drop seems to be more pronounced this time, industry analysts say.

More Americans also are buying high-deductible health plans that force them to bear more of the upfront costs for health services. Some 18 million Americans bought high-deductible plans this year, compared with 13 million last year, according to Paul Mango, a director at consulting firm McKinsey & Co.

At the beginning of the year, Dan and Natalie Johnson, of Gig Harbor, Wash., used the website eHealthInsurance.com to buy a new plan with a high deductible, now set at $5,500 for their family. Their previous coverage had no deductible.

Now, the couple says they are thinking twice before scheduling doctor visits. Recently, when their 16-year-old daughter's allergy prescription ran out, Ms. Johnson called the allergist's office to ask for a renewal, without coming in for an appointment, as she would have done under their previous insurance.

And this spring, their son, 14, got his athletic physical at a local urgent-care clinic that charged just $40, instead of a doctor's office, which would have cost about $90. "We don't want to go through our savings going to the doctor," says Ms. Johnson, a photographer.

All this raises the question of whether, after a year of national attention on out-of-control health costs before the federal health overhaul passed in March, the trend portends a lasting change in the way Americans use the medical system.

Just a year ago, insurers reported surging health-care usage. Back then, more consumers were signing up for Cobra, the federal program that allows people who have lost their jobs to keep their insurance. The government had extended a subsidy to cover 65% of the cost of the coverage, which can be prohibitively expensive.

However, the Cobra subsidies only covered the unemployed for 15 months, and many people have hit the limit and dropped coverage. What's more, people who have lost their jobs since the end of May don't qualify for the Cobra subsidies.

To be sure, the change in behavior could be short-lived. On an earnings call last week in which it reported a decline in hospital usage, UnitedHealth Group Inc. said it thought utilization would rise again in the second part of the year, as Americans exhaust their deductibles and insurers start paying for services. Both Aetna Inc. and WellPoint said the utilization fall-off was new as of this year, and they had not seen the trend previously even as the economy has deteriorated. Some insurers also cited an unusually mild flu season this year as a temporary factor.

What's more, the federal health overhaul could cause usage to surge again. The new law will hand insurance cards to many Americans in 2014, which could unleash pent-up demand.

Utilization has ticked down in previous recessions, and tends to take a year or two to change because of how far in advance employers and insurers design their health plans, said Carl McDonald, an analyst at Citigroup Investment Research. He said the last time he saw utilization fall off was in 2003, adding that usage also dipped in the early 1990s. But he added the drop is bigger this time than in previous recessions.

The declines in utilization has boosted profits for insurers, who set their prices to cover anticipated medical costs. Insurance industry prices and profits have been under fire by Democrats and regulators this year. Insurers have justified high premiums by pointing to out-of-control medical costs. But the recent drop in usage could make it difficult for insurers to argue that continued price increases are necessary.

On Wednesday, Aetna said usage of health-care fell in the second quarter, feeding a 42% increase in profits. WellPoint reported a 4% earnings bump, saying that hospital admissions and usage of prescription drugs had dropped compared with a year earlier.

After the earnings releases, Rep. Pete Stark (D., Calif.) called on the companies to reduce their premiums since they are paying out less in medical care. In an interview, Aetna's chief financial officer Joseph Zubretsky said companies might eventually have to do just that. "If utilization stays down, it will have a favorable impact on rates," he said.

One company reporting evidence of lower utilization is CVS Caremark Corp., the drugstore giant. In its earnings announcement Wednesday it said it is seeing a drop-off in new prescriptions for maintenance drugs tied to a decline in physician visits.

People are "visiting fewer primary care doctors and specialists," said Chief Executive Tom Ryan, in a conference call with analysts.

Last week, Quest Diagnostics Inc., a laboratory-testing company, told investors that its volume fell 2.6% in the first quarter and 1.3% in the second partly because of decreasing physician visits. In addition, AmSurg Corp., an outpatient-surgery company, reported that same-store procedures declined by 2.6% compared to a year earlier.

Another sign that people are forgoing doctor visits or getting less care came from athenahealth Inc., which provides billing services and electronic health records for more than 1,700 medical groups. It said last week that the number of claims filed per physician, as well as the average value of the billing for each visit, had dropped from a year earlier.

Physician visits and hospital admissions are dropping this year, according to Thomson Reuters's healthcare business, which surveys doctors and hospitals. Doctor visits have declined each month this year, including a 7.6% drop in May from May 2009. Likewise, hospital admissions dropped in three of the first four months of this year compared to those months last year, including being down 2.3% in April from April 2009.

Pharmacists and the Patient Centered Medical Home

2010-07-19T20:19:00.000-07:00

Attached an Op-Ed published in today's Wall Street Journal in which Pete Vanderveen, dean at the School of Pharmacy at the University of Southern California, emphasizes the role of pharmacists in chronic disease management to "alleviate the burden on physician," and to "fill the gap" in patient care. Furthermore, he calls for the change in reimbursement modalities to " allow pharmacists to play a larger role in patient care" admitting that it will initially increase medical costs.
I am not opposed to collaborate my patients care with pharmacists but we are missing the point.
By including additional providers in the health care delivery process we may inadvertently contribute to greater fragmentation and costs of care because we fail to coordinate such care. We may share the e-prescribing system with the pharmacists but not the entire medical record. We have to continue emphasizing that the patient centered medical home is not a loose collaborative of multiple provider. All health care professionals withing the PCMH will coordinate health care delivery along the horizontally and vertically structured health care delivery system to achieve, among others , the following goals: improved quality of care, decreased medical costs of care and to ascertain the outcome of care rendered.
Therefore, I do NOT agree with the position stated in the Op-Ed.
Looking forward to your comments.
Yours
Bernd

OPINION
JULY 19, 2010

How to Care for 30 Million More Patients

Pharmacists can help fill the gap and save money, too.

By R. PETE VANDERVEEN

Many worry there won't be enough physicians to care for the estimated 30 million more patients who will be insured under the health law passed earlier this year. The Association of American Medical Colleges estimates a shortage that could reach 150,000 doctors by 2025.

Pharmacists, who number almost 300,000 today, could help fill the gap. The men and women who complete a four-year graduate professional program are trained to master complex medications—including more than 10,000 prescription drugs and dozens of new, more sophisticated ones approved annually by the Food and Drug Administration.

For patients with chronic diseases such as diabetes, hypertension and asthma who typically must take multiple drugs, pharmacists' knowledge of drug interactions can be life-saving. Yet pharmacists typically do little to help these patients. If they were allowed to take on some oversight duties, they could help alleviate the burden on physicians.

Pharmacists could review test results such as the blood glucose levels of patients with diabetes. They could adjust the dosage of prescribed drugs to achieve the goals for these patients set by physicians. They could keep an eye on patient use of other medications to avoid complications. And they could teach patients how to conduct self-administered tests, order lab tests when indicated, and monitor compliance with medication, diet and exercise regimens.

Considering that 40% of Americans have at least one chronic disease during their lifetime that requires regular oversight, the time savings for physicians could be substantial. And so might the costs of care.

This is not an untested theory. Pharmacists already manage some patients with chronic diseases. In 1996, the city of Asheville, N.C., a self-insured employer, began paying pharmacists to work with its diabetic employees. Known as the Asheville Project, the goal was to improve worker health and lower treatment costs for both employee and employer.

The results exceeded expectations. From 1997 to 2001, the city of Asheville reported that annual direct medical costs per worker dropped, on average, by $1,200 to $1,872—even as 15% more enrollees came within reach of their therapeutic goal.

The project has since been expanded to cover other chronic diseases, and Asheville estimates it has saved $4 for every $1 invested. Some 80 employers nationwide have adopted the treatment model, including Mohawk Industries, the national carpet manufacturer in Dublin, Ga.

At safety-net clinics in Los Angeles, Minneapolis and Pittsburgh, pharmacists have teamed with physicians to care for patients with chronic diseases while saving hundreds of thousands of dollars in treatment costs. This is remarkable because many of these patients struggle with homelessness, low literacy and unemployment. Now the federal Health Resources and Services Administration's Patient Safety and Clinical Pharmacy Collaborative is pushing for the presence of pharmacists at every community clinic in the nation.

Still, these projects are limited in scope because pharmacists are not considered health-care providers by Medicare and Medicaid. Private foundations or grants underwrite services at some safety-net clinics, while other clinics pick up the tab.

The next, critical step is to change the reimbursement codes of the Center for Medicaid and Medicare Services to allow pharmacists to play a larger role in patient care. Doing so may initially increase overall medical costs. But in the long run, as the Asheville Project demonstrates, it will save money and improve patient health.

Pharmacists are not spoiling for a turf war with physicians. The two professions already team up under "collaborative practice" agreements as in Asheville and Los Angeles that clearly define what the pharmacist can and cannot do.

The traditional medical model—in which a single physician provides all recommended care to patients—has run its course. With an aging population and millions of expected new patients, chronic disease rates are expected to rise. What we need is a new health-care delivery model in which the primary-care physician is complemented by a team of professionals and providers. Congress should enable pharmacists to become part of that team.

Mr. Vanderveen is the dean of the School of Pharmacy at the University of Southern California.

Medicare Fraud in the News Again

2010-07-14T19:22:00.001-07:00

"In 2008, Medicare paid $520 million to Miami-Dade home healthcare agencies for treating diabetic patients
more than what the agency spent in the rest of the country combined, according to federal authorities."

Attached an article from today's Miami Herald highlighting the growing problem of Medicare fraud in South Florida and the efforts to contain its metastatic growth.
I still am puzzled WHY CMS cannot hold the contracted Medicare administrators in Florida accountable for their mistakes amounting to billions of dollars each and every year.
Its either a problem of political unwillingness to tighten the screws, or professional incompetency and absence of any oversight and control mechanisms.
Meanwhile, fraudsters getting away with hundreds of millions per incident and good physicians who are trying to serve Medicare patients are being nickled and dimed by CMS.
But our politicians do not have to worry to find a doctor who still takes new Medicare patients. They go to Walter Reed Medical Center to enjoy the benefits of a government controlled healthcare system. Go figure!!
Yours
Bernd

Posted on Wed, Jul. 14, 2010
Magnitude of Medicare fraud in South Florida grows

BY JAY WEAVER
jweaver@MiamiHerald.com

As the feds squeeze tighter, South Florida's Medicare schemers have scurried into new territory to loot hundreds of millions of dollars from taxpayers, now billing the system for bogus mental health, physical therapy and other rehabilitation services.
The magnitude of the region's fraud is astonishing: Florida mental health clinics submitted $421 million in bills to Medicare last year -- about four times more than Texas and a whopping 635 times higher than Michigan, both also hotbeds of healthcare rackets, according to government records.

Florida rehabilitation facilities billed $310 million for physical and speech therapy -- 140 times more than New York and 10 times higher than California, records show.

Not all of that activity is criminal. But Florida's numbers are so much higher than other major states' that officials say the only logical explanation is fraud -- the bulk of it in Miami-Dade, Broward and Palm Beach counties.

Law enforcement and healthcare officials say that mental health and rehabilitation providers are the latest agents of pervasive theft in South Florida, long considered the nation's epicenter of Medicare corruption. The services are not needed or provided, yet the federal program for the elderly and disabled still foots the bill.

``This is like a game of whack a mole,'' U.S. Attorney Wifredo Ferrer told The Miami Herald. ``The numbers are off the charts.''

The vexing problem of Medicare corruption will take center stage on Friday, when Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius hold the nation's first healthcare fraud summit in Miami. The issue has gained a higher profile as the Obama administration pushes ahead with the expansion of government-subsidized healthcare for more than 30 million uninsured Americans.

FBI supervisory special agent Randy Culp, who joined the nation's first Medicare strike force in South Florida in March 2007, said the majority of fraud prosecutions still involve medical equipment such as powered wheelchairs, HIV medical services and home healthcare for diabetics.

But federal agents now are investigating more physical and occupational therapy schemes and looking at potential criminal cases against mental health centers, he said.

``We're seeing a shift of people moving into these areas,'' Culp said.

He and other experts said the transition occurred over the past year when Medicare imposed unprecedented caps on claims submitted by healthcare agencies for homebound patients seeking up to four daily nursing visits for insulin injections.

In 2008, Medicare paid $520 million to Miami-Dade home healthcare agencies for treating diabetic patients -- more than what the agency spent in the rest of the country combined, according to federal authorities.

``After we put pressure on them, they started moving their activities into other areas such as mental health and rehabilitation facilities,'' said Cecilia Franco, director of Medicare in South Florida. ``We see them move year after year from one business to another. Their patients' Medicare numbers carry great value, and they're always coming up with new ways to bill for them.''

Last year, for example, Florida's comprehensive rehabilitation facilities billed $171 million for physical, occupational and related services -- about 23 times higher than California and 26 times more than New York, records show.

Overall, Medicare fraud in South Florida costs taxpayers between $3 billion and $4 billion annually, according to experts. Nationwide, Medicare and other healthcare fraud is estimated to cost $68 billion annually -- about $18 billion more than the Obama administration plans to spend on education in the next fiscal year.

``The government has to stop pretending these are legitimate businesses and cut them off,'' said Washington attorney Kirk Ogrosky, former head of the Justice Department's healthcare fraud section, who oversaw hundreds of criminal prosecutions.

Last year, the Justice and Health and Human Services departments expanded criminal ``strike forces'' from Miami, Los Angeles and Houston to Detroit, Brooklyn, Baton Rouge and Tampa. They also committed about half a billion dollars to fraud-prevention efforts, and began working on sharing suspicious billing information with Medicare -- an agency that pays claims fast without verifying them -- to help stop fraud.

The fight to stamp it out is a constant struggle, despite convictions of about 1,000 defendants in South Florida alone who submitted roughly $3 billion in false Medicare claims since 2005. The region accounts for one-third of all healthcare fraud prosecutions in the nation.

During the past five years, thousands of Medicare fraud offenders have shown that they can outsmart the system. Their weapons: cash kickbacks to Medicare patients, repeated use of their ID numbers for unnecessary costly services, manipulation of medical records to justify phony charges, and submitting different billing codes to get around Medicare's technology to block false claims.

Authorities say the rising wave of Medicare fraud over the past decade is the result of more immigrants from Cuba and elsewhere switching from violent to white-collar crime, partly because the risks of getting caught and concurrent penalties are relatively low.

In South Florida, authorities have made a handful of major criminal cases against rehabilitation clinics.

In December, Dr. Fred E. Dweck of Hollywood, director of a Miami healthcare clinic, Courtesy Medical Group, was arrested along with 14 others, including nurses, operators and a patient.

Dweck, 74, was charged with accepting bribes to write prescriptions at $100 a pop for about 1,300 homebound patients at Courtesy and other local clinics. But the patients didn't need the prescribed diabetic, physical therapy and other costly services billed to Medicare,according to a federal indictment.

The Medicare bill from Courtesy and the other clinics: almost $41 million between 2006 and 2009. The government paid out nearly $24 million.

In April, a longtime Miami-Dade healthcare operator and his son, along with a business partner, were charged with bilking more than $2.8 million from Medicare in an undercover FBI case. Ernesto Angel Montaner, 69, and his son, Ernesto Montaner, 44, were accused of operating a chain of physical rehabilitation clinics in Miami-Dade that submitted millions of dollars in phony Medicare bills between 2003 and 2008.

Kickbacks were paid to assisted living facilities and others for Medicare referrals,prosecutor Ryan Stumphauzer said.

Ernesto Angel Montaner fled to Costa Rica in February 2009, five months after the FBI executed a search warrant at his four medical clinics, prosecutors said. He was arrested last week.

The son, Ernesto Montaner, and business partner Jose Antonio Varona, have pleaded guilty to one count of conspiring to commit healthcare fraud.

CPI in Medicine: Change Management in Clinical Practice

2010-07-11T17:38:00.001-07:00

"The health care industry could be on the verge of an efficiency revolution,
because it is currently so far behind in applying operations management methodologies"

Attached a very interesting article from today's NewYork Times highlighting the advantages and benefits of applying continuous performance improvement (CPI) in hospital management.
These principles should not be restricted to inpatient care but should apply to the entire healthcare system. Therefore, physicians need to be taught how to apply CPI in their own offices to improve the quality of care, reduce costs and ascertain outcome of the treatments rendered. I hope that within organized medicine more enlightened leaders may emerge who challenge our profession to change. Unfortunately, ideological grandstanding and political cheerleading will not contribute to resolve the pressing healthcare financing and reimbursement issues we are facing. The translation of comparative effectiveness research into the clinical practice and the application of proven business management principles are of great value to maintain the practice of medicine. I hope that you can support and promote these issues.
Yours
Bernd

New York Times, Sunday, July 11th, 2010

Efficiency Comes to the Hospital

By JULIE WEED

SEATTLE

TWO years ago, the supply system at Seattle Children’s Hospital was so unreliable that Susanne Matthews, a nurse in the intensive care unit, would stockpile stuff — catheters in the closet, surgical dressings in patients’ dresser drawers and clamps in the nurse’s office. And she wasn’t the only one.

“Nurses get very anxious when we can’t get our hands on the tools we need for our patients,” Ms. Matthews says, “so we grabbed them when we saw them, and stashed them away.” This, in turn, made the shortages more acute.

On a busy day last month in the I.C.U., it took Ms. Matthews just a few seconds to find the specialized tubing she needed to deliver medicine to an infant recovering from heart surgery. The tubing was nearby, in a fully stocked rack, thanks to a new supply system instituted by the hospital early last year following practices typically used in manufacturing or retailing, not health care.

There are two bins of each item; when one bin is empty, the second is pulled forward. Empty bins go to the central supply office and the bar codes are scanned to generate a new order. The hospital storeroom is now half its original size, and fewer supplies are discarded for exceeding their expiration dates.

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

Manufacturers, particularly in the auto and aerospace industries, have been using these methods for many years. And while a sick child isn’t a Camry, Seattle Children’s Hospital has found that checklists, standardization and nonstop brainstorming with front-line staff and customers can pay off.

“It turns out the highest-quality care also is the most cost-effective because we make fewer mistakes and create better outcomes,” says Patrick Hagan, the hospital’s president.

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital, from the time they arrive in the parking lot until they are discharged, to see what could work better for them and their families.

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle. So many others have called for advice that Seattle Children’s put together a two-day workshop, presenting it to more than 200 medical workers and health care leaders from the United States and Europe.

“Some people think they have to choose between quality of care and saving money,” said Dr. David Chand, who attended the training and now uses C.P.I. methods at Akron Children’s Hospital in Ohio. “C.P.I. improves both patient outcomes and the hospital’s bottom line.”

To increase the number of surgeries the hospital could perform, Dr. Chand’s team spent about $20,000 overhauling the process to sterilize instruments, avoiding a $3.5 million expenditure to expand that department. More efficient scheduling in the M.R.I. department reduced the average waiting time for non-emergency M.R.I.’s from 25 days to 1 to 2.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward.

Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information.

“The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

On June 10, Ms. Munn helped lead a one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods. “We felt the cuts created an unsafe environment for patients,” she said. The nurses’ contract was settled on July 1, with no increase in staff levels.

Brian Lucas, a spokesman for Children’s Hospitals and Clinics of Minnesota, says the lean efforts have been used to reduce unnecessary tasks and have not resulted in lower nurse-to-patient ratios. “To the contrary,” he said, “they have allowed nurses to spend more time delivering care to patients.”

Techniques like C.P.I. may indeed be hard for many hospitals to put into effect, says Mark Graban, a senior fellow at the Lean Enterprise Institute, a nonprofit research, education and publishing company. The process takes a large amount of time and requires a culture shift that many hospitals may not be able to accommodate or sustain. “If the leadership tries to force new ways of doing things, the staff may chafe under the successive changes,” he says.

And George Lebovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Physical layouts can also interfere with changes that hospitals want to make, like reducing the distance a chemotherapy patient has to walk. And the techniques can fall short of their potential if they are used in just one area of a hospital, because a patient typically moves through many different departments.

At Seattle Children’s Hospital, Dr. John Waldhausen, the division chief of pediatric general and thoracic surgery, acknowledges that he and other doctors weren’t initially very enthusiastic about C.P.I. because they thought it would take some decisions about patient care out of their hands.

Over time, he changed his mind, and he is now a vocal advocate of C.P.I. “When you look closely, C.P.I. is the same scientific method we learned in medical school, including hypotheses, data collection and analysis,” he says. “It is not opinion and conjecture — it is data-driven.”

TEN years ago, Seattle Children’s set a goal to become the top hospital of its type in the country, and hired Joan Wellman & Associates, a process improvement consulting firm in Seattle, to help it get there. Ms. Wellman, who had worked with Boeing on its lean-manufacturing processes, suggested that the hospital apply similar principles.

Mr. Hagan says he became enthusiastic about lean manufacturing and C.P.I. after doing research and visiting local manufacturers. He directed the hospital staff to examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory.

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

The hospital staff has been rolling out the program in stages over the last decade. “We have probably made over 1,000 small changes, and frankly it never ends,” says Mr. Hagan.

In his C.P.I. training, Dr. Bryan H. King, director of the department of psychiatry and behavioral medicine, was one of the first Seattle Children’s staff members to visit Japanese manufacturers. He learned that “waste” could be viewed as any action that didn’t add value to the customer.

Turning to his psychiatric inpatient unit, he and his team worked to pinpoint the goal of each child’s stay and to communicate daily with families. They also made other changes, like starting to arrange outpatient resources as soon as children enter the unit, rather than waiting until they are ready to leave. These kinds of changes increased satisfaction ratings from families and helped cut the average time in the hospital from 20 days to 10. The unit can now accommodate 650 children a year instead of 400.

Changes like these are celebrated by the hospital administration. “Their support fosters the idea that everyone can make positive changes to their departments,” Dr. King said.

Dr. Howard E. Jeffries, the hospital’s medical director of C.P.I., is a fan of visual aids. One favorite is a white board at the entrance of the cardiac intensive care unit. A map of the rooms, labeled with patient names, provides a quick status report on how full the unit is and how ill the patients are. Stick-on stars indicate a patient who needs to be in isolation; a blue circle shows a patient on a ventilator.

“At a glance, staff coming in for their shift can get an idea of what’s going on and what to be aware of,” Dr. Jeffries says.

The same types of visual cues are used for inventory levels or inspection status in factories.

Another of his favorites is the “Days Without Infection” poster, like a construction site’s “Days Without an Accident” sign. “It keeps our new safety protocols top of mind for people,” he says.

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.

Dr. Lynn D. Martin, director of the anesthesiology and pain medicine department, says changes previously were instituted only when existing systems failed. Using C.P.I., teams can now make changes any time they think they can improve a process. When the operating room team saw that a tonsillectomy procedure involved filling out 21 separate forms, it sat down with the print vendor to remove duplications — and cut the number to 11.

The staff doesn’t have to wait for the perfect solution, Dr. Martin says, just a better one, because they can “keep making improvements year after year.”

Using C.P.I., the hospital has reduced the waiting time for many surgeries from three months to less than one. Recently, the bottleneck was not the surgeons’ time, but a lack of available inpatient beds for recovery. Examining the hospital’s census, administrators saw that there were empty beds on weekends. They realized that by scheduling more surgeries on Fridays, patients could recover over the weekend, when more beds were free. The change also benefited parents and patients who would miss fewer work and school days.

Lack of space in the recovery room was another logjam, and the hospital planned a $500,000 renovation to enlarge it. But a C.P.I. team saw that if a child’s parents went to a common waiting room during surgery, instead of an individual recovery room, more surgeries could be scheduled. Parents were given beepers to alert them when their child would arrive in the recovery room — and maps and colored lines on the walls helped point the way. Plans for the expensive renovation have been scrapped.

IN the hospital’s largest C.P.I. project yet, Lisa Brandenberg, the chief administrative officer, used the method to design a new $70 million clinic and surgical facility in Bellevue, Wash., just east of Seattle.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness.

The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building, which is to open July 20.

“We can’t wait to see it in use,” says Ms. Brandenberg.

Electronic Health Records and Privacy

2010-07-06T20:29:00.000-07:00

Attached two very interesting articles from today's Miami Herald highlighting the issue of EHR usage in South Florida and privacy issues.
I am actually more concerned about the uncontrolled mailing and faxing of medical records between doctors offices and hospitals WITHOUT adherence to privacy rules. Just today I was castigated by a front-desk clerk who took issue that I had the audacity requesting a medical record release before releasing the records of one of my patients.
Using an Electronic Health Record for > 12 years I can attest to the very basic privacy features in EHRs: 1) audit trail- I can document who has accessed a specific record and when it happened,b) prevent access through passwords, c) can encrypt and secure stored files. NONE OF THESE FEATURES are available in paper records!!!
Anybody can open and read a paper record, doors to the record room are often unlocked, and stored paper records cannot be encrypted or secured except with mechanical locks. So why are we talking about privacy issues? Because of the FEAR of the UNKNOWN!!! A fear stoked by those who often do not want to change and prefer to adhere to past and obsolete procedures. Many of my colleagues belong to this group too. I do have hope though that we can overcome this fear because nobody avoids using his/her ATM of computer to manage their financial transactions.
Looking forward to your comments.
Yours
Bernd

Posted on Tue, Jul. 06, 2010
Medical records go online, but at what cost to privacy?

BY FRED TASKER
ftasker@MiamiHerald.com

MARICE COHN BAND / MIAMI HERALD STAFF
Allison Grisham learns how to navigate her medical records with help from Dr. David Seo, a cardiologist at University of Miami Miller School of Medicine.
You're a South Florida resident on vacation in Boise or Bogotá. You suffer stomach pains and visit a local doctor. You whip out your BlackBerry, punch in your access code and show the doctor a list of your medications, allergies, past illnesses, tests, surgeries and advice from your physician back home.
Electronic medical records, or EMRs, are quickly becoming a reality for doctors and hospitals in South Florida and beyond.

If EMRs work, they'll be high-tech marvels -- letting patients access their own medical records on their home computers, helping doctors coordinate tests with each other to avoid duplication, giving medical researchers access to millions of medical records.

Nearly every major South Florida hospital and many doctors are joining a push by the Obama administration to spend $19.2 billion in federal stimulus money to help create a national EMR system by 2014.

Allison Grisham of Miami Beach just got her own EMR from her doctor at University of Miami Hospital, which is spending $100 million on a new Epic brand system. She hopes it can help end medical errors like one she barely avoided a few years ago.

``I was in a hospital once and the nurse tried to give me the wrong medication. We only stopped it because my mother and I refused to let her put it in the IV,'' she said. ``It could have been serious.''

There are drawbacks. Patient advocates worry that EMRs could pose a threat to privacy. Doctors and hospitals say they're not being given enough time to set up the complex electronic systems or enough financial help to pay for them. The systems can cost $50 million to $100 million for hospitals and $15,000 to $50,000 for private doctors.

But the potential pluses outweigh those complaints, many doctors and hospitals believe. The new systems are voluntary, but federal financial incentives for using them and penalties for failing to do so have most medical officials at least resigned to making the change.

Here's what else EMRs will do:

You're a university medical researcher and you suspect a popular diabetes drug is causing heart problems. On your PC, you study the records -- with patient permission, and without their names -- of all the millions of people taking the suspect drug and compare them to those who aren't.

``A researcher could access the records of nearly every patient in the country and solve problems quickly,'' said Dr. Pascal Goldschmidt, dean of the UM Medical School.

Or you're a hospital CEO, and EMRs help you communicate better and faster with other hospitals and doctors around the country -- something most hospitals can't do today even if they have older, simpler electronic medical records.

DUPLICATION

``That would eliminate a lot of duplication,'' said Linda Quick, president of the South Florida Hospital & Healthcare Association. She cited an example: an acquaintance had an EKG from his private doctor, was sent to the hospital next door for follow-up and was given another EKG 90 minutes later.

``Patients will take control of their own records. Exchange of information will be very fluid,'' said Tom Gomez, head of a Florida International University initiative promoting hospital information sharing.

``When we have the whole system, it will be as easy as using an ATM card,'' said Quick.

Still, experts predict years of hard work getting all the new EMR systems -- Epic, Cerner, Seimens and other brands -- to communicate with each other.

``This is going to be complicated,'' says Gomez. ``And we're in the very early stages. It's probably 10 years away.'' There are problems. Private doctors, especially in small practices, say they lack the money and technical staff to implement EMRs -- buying computers, hiring techs to run and repair them, taking time for the training to operate them.

``It's the wave of the future, fortunately or unfortunately,'' says Dr. Tony Prieto, a sole-practitioner family medicine physician in Plantation. ``I agree it's needed. I'm not saying I can afford it.''

Even some big hospitals say the program is moving too fast.

``The goal is noble, but the timeline is unrealistic,'' said Mimi Taylor, Baptist Health South Florida's vice president for IT. ``You have to give hospitals time to do it right.''

Baptist Health's six-hospital, 2,000-doctor system will spend $96 million by 2013 to install a Siemens Soarian system to meet the new federal requirements. An informal Miami Herald survey of 26 South Florida hospitals found every one is putting in a new system or upgrading an old one. In addition to UM Hospital and Baptist Health, hospitals installing new or upgraded systems include Broward's six-hospital Memorial Healthcare System, Tenet's 10-hospital chain, Miami Children's Hospital and Mount Sinai Medical Center.

At UM Hospital, six clinics already have begun offering patients a personal electronic medical record called MyUHealthChart. By July, all clinics on the Miller School campus are to have them. By December, patients will be able to schedule appointments and pay their bills electronically. Even Jackson Health System, with its financial woes, is upgrading its current Cerner EMR system as part of the federal push.

``We have to do it to remain competitive,'' said Fernando Martinez, Jackson's chief information officer.

The Obama administration is using both carrots and sticks to persuade hospitals and doctors to put in EMRs. The president set aside $19.2 billion from the American Recovery and Reinvestment Act of 2009 to subsidize the systems. Doctors who start implementing EMRs by 2011 can get up to $44,000 in extra reimbursements from Medicare or $63,000 from Medicaid.

REIMBURSEMENTS

Hospitals will get bigger reimbursements, although their financial officers can't say how much yet. Local administrators estimate federal subsidies will repay 20 percent to 50 percent of the cost of an EMR system.

The problem, said Prieto, the Plantation physician, is that the expense is up front for the EMR system, but the reimbursement is after the fact.

``I have 26,000 patient charts. I can't imagine what that will cost me.''

The reimbursement ``won't even be close'' to the expense, he said.

``If you're a solo practitioner, you have to go out and buy a new system and educate your staff to use it,'' said Cynthia Peterson, head of the Broward Medical Association. The stick: Doctors and hospitals that don't comply by 2015 will see their Medicare and Medicaid payments reduced by 1 percent in 2015, 2 percent in 2016 and 3 percent in subsequent years.

A Congressional Budget Office report predicts 90 percent of hospitals and doctors will have EMRs by 2019.

Posted on Tue, Jul. 06, 2010

In online medical records, worries about privacy breaches

BY FRED TASKER
ftasker@MiamiHerald.com

If millions of patients across America have electronic medical records they can access 24/7 by punching a code into a home computer or BlackBerry, how safe are those records from identity thieves?
Even today, even without a nationwide data-sharing electronic medical record system, attempts to steal medical records are alarming.

Actress Farrah Fawcett, who died of cancer in 2009, in her final days helped expose an employee of a Los Angeles hospital who was paid to leak her medical records to a tabloid magazine.

Won't putting the records online make them even more vulnerable?

``I would never say a system can't be hacked,'' said Sam Butler, spokesman for Epic Systems, which is creating a $100 million EMR system for University of Miami Hospital. ``But we're not aware that our medical records have ever been violated.''

A typical new EMR system has security programs similar to those for ATM cards or other bank records. Patients get 20-digit personal IDs and must answer questions such as date of birth or mother's maiden name to access their records.

Many users are resigned to some risk.

``Today if you have a paper record, you don't know who sees it,'' said Jacquelyn Liberto, executive director of strategic operations at UM Hospital. ``With Epic it's more secure,'' she said, because nurses or assistants will be able to access only the parts of a patient's records needed for their duties.

In the push for nationwide EMRs, Congress has tightened privacy rules, increasing penalties for leaking information, requiring immediate notification of patients if their records are leaked.

It's not enough, argued a 2009 editorial in The Journal of the American Medical Association that said the law still does too little to protect patients' records and is too restrictive in giving legitimate access to medical researchers.

``The result is that patients' medical records are not well protected, and researchers cannot effectively search for important discoveries,'' the editorial said.

Some patients are afraid insurance companies or potential employers might use their medical conditions to deny them coverage or jobs. Others fear that lawyers might demand to see their records.

In 2003, Florida prosecutors subpoenaed medical records of radio host Rush Limbaugh, who was charged with improper doctor-shopping after he acknowledged he was addicted to painkillers. The Florida Supreme Court gave some of the records to prosecutors but kept others private.

``Electronic records are wonderful tools for research, but there's so much concern about protecting privacy that it becomes a challenge,'' says Liberto.

Read more: http://www.miamiherald.com/2010/07/06/v-print/1716656/in-online-medical-records-worries.html#ixzz0sxiKTTmX

Medicare Payment Reform

2010-07-04T18:52:00.001-07:00

Attached a very interesting article published today on the HEALTH AFFAIRS web site.
It contains a thorough and very readable analysis of the Medicare payment and SGR quagmire.
Several important quotes stand out:

"Eliminating the SGR targets and permanently freezing Medicare physician fees at the 2009 level would cost $276 billion between 2011 and 2020."

"The SGR system was supposed to give physicians incentives to practice more efficiently and thus gain higher fee increases, or at least avoid decreases. But the incentives don't work for individual physicians."

"Medicare has a total cost problem, not just a physician cost problem."

The proposed solutions in my opinion could boost the role of primary care physicians:

"Whatever happens to the SGR targets, there is general agreement that long-range savings will require other reforms in the current payment system. Incentives for physicians are driven not just by the overall level of Medicare prices, but also by the prices for specific services. MedPAC and others have contended that certain services are "overvalued": The price is too high relative to the difficulty of providing the service or the physician's overhead costs.

Because overvalued services can be profitable, physicians have incentives to furnish more of them, while the system discourages the delivery of primary care and other undervalued services. Over time, misaligned incentives can even affect career choices, driving physicians into specialties with the most profitable services. CMS has been taking action on its own to correct some of these pricing problems, and further changes are mandated in the new health reform law.

Many observers argue that Medicare needs to move beyond the basic idea of paying physicians for each service that they provide to each patient. Paying service by service may encourage the fragmentation of care and the delivery of unnecessary services.

There are numerous proposals for payment changes that would promote integrated care delivery and encourage cost-effective medical treatment. One option is the bundled payment, a single payment to a provider for all services related to a specific disease or condition during some fixed period. Another is to encourage the development of accountable care organizations (ACOs), networks of physicians and other providers that would accept responsibility for the overall care of a population of Medicare patients, perhaps in return for a fixed per capita payment."

As family physicians we must realign and recalibrate our medical practice and learn to collaborate to meet the demands of integrated healthcare delivery.
The use of electronic health records and the development of a PCMH is one important step in this process.
Its just a matter of time until fee-for-service will be replaced by bundled payments. Escaping from the reality is not a solution and organized medicine seem to do just that.
Happy 4th of July.
Yours
Bernd

Paying Physicians For Medicare Services
06/25/2010

It is widely agreed that the existing payment system is broken. Congress has again enacted a short-term fix to a long-term problem that it will have to revisit.

What's the issue?
Congress has voted to halt and delay for six months a scheduled 21.5 percent cut for physician fees under Medicare that had gone into effect in June 2010. The change gives physicians a 2.2 percent rate increase retroactive to June 1. But unless a longer-term solution is found, this short-term "doc fix" will expire November 30, 2010, at which point the previously scheduled reduction will kick in.

This latest episode represents the fourth time this year that scheduled Medicare fee cuts to physicians have been averted at the last moment--or even later. A longer-term repair is needed, but will be costly for U.S. taxpayers.

A Broken System: There is widespread agreement that the existing system for paying for physician services under the Medicare program is broken. Under current Medicare rules, intended to restrain growth in spending, payments to physicians have been subject to supposedly "automatic" cuts for a number of years. However, Congress has consistently postponed those cuts and instead raised physician fees or held them constant.

The latest scheduled cut for physician fees was the 21.5 percent reduction that took effect in June. In May, the House passed a proposal to provide rate increases in 2011 and 2012, followed by an even sharper 35 percent rate cut in 2012. But the Senate was unable to pass similar legislation, contained within a long-stalled bill to extend unemployment benefits and provide Medicaid assistance to the states. Instead, the Senate approved the six-month, 2.2 percent rate increase in late June.

The Centers for Medicare and Medicaid Services (CMS) was for a time holding June bills, pending possible congressional action, but as of June 18 it had begun paying doctors' bills at the reduced rates required by current law. When it became clear that the Senate would not be able to approve the longer-term House bill, members in the House voted on June 24 to adopt the shorter Senate version, and President Obama signed it on June 25.

The Problem Is Money: 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. There is no agreement in Congress on how best to make the fix or on how to pay for it, whether by raising taxes, cutting other federal spending, or simply adding the amount to the federal deficit. This brief describes the likely options for congressional action in the months and years ahead.

What's the background?
Medicare pays physicians using what is called a fee schedule, or list of prices. This list sets a fixed maximum price for each type of service, such as an office visit, a particular surgical procedure, or a specific diagnostic test. Current law requires CMS to update these prices each year.

In computing the annual update, CMS starts with an estimate of inflation but then adjusts this amount upward or downward, depending on how rapidly overall spending for physician services has been growing. If spending has stayed within set targets, physicians get a bonus--a price increase greater than inflation. But if spending has exceeded the targets, the updated prices may rise more slowly than inflation or even be reduced.

The current system of spending targets was put into place by the Balanced Budget Act of 1997. The aim was to give physicians an incentive to restrain the growth in the number of services they furnished to patients, and to discourage them from providing higher-price services in place of lower-price ones.

The spending targets are set using a "sustainable growth rate" formula, often referred to as the SGR. The formula is complicated, but its basic goal is to keep spending for each beneficiary from growing faster than the per capita increase in the gross domestic product (GDP). GDP growth is included in the formula on the theory that it is not sustainable for Medicare physician spending to grow faster than the national economy.

Hope Not Realized: The expectation that this payment system would control spending was not realized. In the first few years under the 1997 rules, physician spending did stay within the targets, and physicians were rewarded with price increases greater than inflation. For 2002, however, the update formula in the law required a reduction in physician fees of almost 5 percent. Congress allowed the reduction to take effect. But when the formula dictated a further reduction for 2003, Congress overrode the Balanced Budget Act rules and approved a small fee increase.

That action set a precedent that has continued to this day. In each year since 2003, although the statutory formula would have led to a fee cut, Congress has instead granted an increase or at least frozen the rates and prevented a decrease.

Although Congress has repeatedly intervened to prevent rate cuts, it has never changed the formulas that dictate these cuts. Each time it has set the fee increase, Congress has specified that fee updates for later years should be computed as if it had not acted. What's more, Congress has never modified the SGR targets themselves.

Meanwhile, the number of services that physicians provide has been growing steadily, and the services are increasingly costly and complicated. That means that there has been a widening gap between actual spending each year and the amount allowed by the targets. Under the law, this ballooning deficit is supposed to be recouped by even steeper automatic rate cuts in the future.

Payment Cuts Kick In: In November 2009, CMS announced that under the formula, physician fees for 2010 would be 21.5 percent less than 2009 levels. The cut would have been even larger except for two factors. First, CMS on its own made some changes in the methods used for setting the targets. Second, the law limits how much fees can be reduced in any one year. However, cuts not made in 2010 would simply carry over into future years. Unless the law is changed, by 2014, rates could be about 40 percent less than 2009 levels.

Why has Congress consistently acted in this "Perils of Pauline" fashion, overriding automatic cuts on a short-term basis nine times so far? The answer is that a longer-range fix could greatly increase the federal deficit. Congress relies on the Congressional Budget Office (CBO) to measure the budgetary impact of proposed legislation. The CBO establishes a "baseline," projections of future spending and revenues that assume all current laws will be enforced. The baseline includes all of the physician cuts scheduled to take effect in future years, which will produce substantial savings for Medicare.

As a result, legislation that overrides future cuts would be "scored" by the CBO as increasing the deficit, in contrast with the current baseline. Eliminating the SGR targets and permanently freezing Medicare physician fees at the 2009 level would cost $276 billion between 2011 and 2020.

Postponing the cuts month by month or year by year, as Congress has done, has a smaller apparent budgetary impact. Yet even the six-month rate increase most recently passed by the House and Senate was scored as costing more than $6 billion, although the bill included savings provisions to offset that amount. Unless something is done before the end of this year, Congress will, once again, encounter pressure to avoid even bigger rate cuts in 2011 and later years.

Fixing The "Doc Fix": Few members of Congress wish to see physician payments slashed, and many would prefer to see some permanent "fix" so that they would not have to revisit the issue. Yet there are also mounting concerns about the overall size of the future federal deficit. In this context, many members on both sides of the aisle are reluctant to enact a costly fix without finding some way of paying for it.

What Are The Longer-Range Options?
Now that another short-term fix has been passed, Congress has several longer-range options. It could do nothing and let future cuts take effect. It could drop the SGR system and simply freeze future rates or let them rise with inflation. It could keep the current system but adopt various proposed modifications. It could adopt other fee schedule changes that might help slow spending growth. Or it could develop entirely new ways of paying for physician services.

Do Nothing: Congress could simply allow scheduled fee reductions to take effect. Without a fix, physician payments would drop as much as 40 percent from 2009 levels over the next several years. Although the government would save money, there are concerns about the potential impact that such large cuts would have on Medicare beneficiaries' access to health care. If Medicare rates fall too far behind those paid by private insurers, physicians might turn away current Medicare patients or stop accepting new ones. That would be more likely to happen if physicians have enough non-Medicare patients to make up for the income losses. The best guess is that physicians' ability to replace Medicare patients with those who have private insurance is likely to vary by geographic area and physician specialty.

Another possibility is that physicians would make up for lower Medicare fees by increasing the volume or intensity of services furnished to Medicare beneficiaries. However, it is unlikely that such "behavioral" changes could offset a 40 percent fee cut.

Whatever the potential effects of rate cuts might be, some people contend that the entire SGR approach has proved unworkable. The SGR system was supposed to give physicians incentives to practice more efficiently and thus gain higher fee increases, or at least avoid decreases. But the incentives don't work for individual physicians.

The problem is that if some doctors provide extra services, they will make more money in the short term than those who don't--yet the resulting penalties fall on everyone. Because of these perverse incentives, critics contend, aggregate spending targets may never be workable and should be replaced by more-focused cost containment methods.

Abandon The Sustainable Growth Rate System: Congress could decide to eliminate the formula that ties fee updates to trends in spending growth. Those who favor this step argue that since Congress is unlikely ever to allow the full scheduled rate cuts, it would be better and arguably more honest to take the full budgetary hit at once, instead of year by year. With no system in place for updating the fee schedule, Congress might at some point come up with a better approach.

A contrary view is that repeated short-term fixes to the SGR system are actually preferable. If the threat of rate cuts were permanently removed, Congress would never get around to fixing the system.

Others have suggested shelving the problem for some years, rather than a few months at a time, in the hope that additional breathing room would make it possible to develop a consensus around more comprehensive reforms in the system. But even that kind of half-measure would cost a great deal. For example, the CBO estimates that freezing the rates through 2014 would raise the deficit by $89 billion.

Make Long-Term Modifications To The SGR System: There are numerous proposals on the table to continue the current system of SGR targets, but with various modifications. CMS could simply wipe the slate clean and base future targets on actual current spending levels. In effect, past overspending would be forgiven, offering physicians a new chance to restrain spending but threatening them with penalties in the future if they failed to do so.

This approach, known as "rebasing," would be almost as costly as getting rid of the targets altogether. And rebasing would not correct the distorted incentives in the current system. Over time, physicians might once again ramp up service delivery until the formula dictated rate reductions.

Other options include setting separate spending targets for different services, different geographic areas, or even specific providers or groups of providers. For example, Congress could allow more spending growth in services such as primary and preventive care, while clamping down on such fast-growing areas as x-rays and other imaging services.

Another approach might be to establish separate targets for areas with lower and higher average per capita spending. Physicians in some areas deliver or order far more services for Medicare beneficiaries than do physicians in other areas, and there is little evidence that patients in high-volume areas have better health outcomes. Geographically based targets would arguably focus on constraining spending in high-cost areas.

Although these options are more focused than the current system, there is still a risk that they would penalize some efficient providers or reward some inefficient ones. To prevent this, updates or targets could be set for specific providers.

Under one proposal, CMS could identify physicians who provide or order an unusually high number of services and could reduce fee updates for those who fail to change their behavior. Any such option would be controversial. It would require extensive data collection and some consensus on how to distinguish inefficient providers from those who are treating difficult cases.

Finally, payment targets could be broadened to include a wider scope of services. The Medicare Payment Advisory Commission (MedPAC) has suggested that if payment targets are retained, they should apply to all health care sectors. MedPAC notes: "Medicare has a total cost problem, not just a physician cost problem." In this view, systemwide targets could pressure physicians, hospitals, and other actors to collaborate in order to reduce unnecessary or duplicative services.

Make Other Payment Reforms: Whatever happens to the SGR targets, there is general agreement that long-range savings will require other reforms in the current payment system. Incentives for physicians are driven not just by the overall level of Medicare prices, but also by the prices for specific services. MedPAC and others have contended that certain services are "overvalued": The price is too high relative to the difficulty of providing the service or the physician's overhead costs.

Because overvalued services can be profitable, physicians have incentives to furnish more of them, while the system discourages the delivery of primary care and other undervalued services. Over time, misaligned incentives can even affect career choices, driving physicians into specialties with the most profitable services. CMS has been taking action on its own to correct some of these pricing problems, and further changes are mandated in the new health reform law.

Many observers argue that Medicare needs to move beyond the basic idea of paying physicians for each service that they provide to each patient. Paying service by service may encourage the fragmentation of care and the delivery of unnecessary services.

There are numerous proposals for payment changes that would promote integrated care delivery and encourage cost-effective medical treatment. One option is the bundled payment, a single payment to a provider for all services related to a specific disease or condition during some fixed period. Another is to encourage the development of accountable care organizations (ACOs), networks of physicians and other providers that would accept responsibility for the overall care of a population of Medicare patients, perhaps in return for a fixed per capita payment.

Many people think these approaches could eventually yield real savings. Still, it could take many years for CMS to develop new payment systems and for providers to form the organizations that can receive the payments. In the interim, most Medicare physician services will still be paid on a fee-for-service basis. And Congress will still face the task of balancing budgetary concerns with the goal of maintaining access to quality care for Medicare beneficiaries.

What's next?
Because the six-month fix has now been signed into law, Congress will have to revisit the issue before December 1, 2010. Senate leaders are still hoping to negotiate a longer-term fix that would be part of a larger jobs and Medicaid assistance package for the states. The coming days and weeks will determine whether Congress is likely to consider more-permanent payment reforms, or take other steps to thwart a looming, major doctors' fee cut in an election year.

Resources
Centers for Medicare and Medicaid Services, "Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2010: Final Rule," Federal Register 74, no. 226 (Nov. 25, 2009): pp. 61738--62188.

Congressional Budget Office, "Budgetary Effects for an Act to Provide a Physician Payment Update, to Provide Pension Funding Relief, and for Other Purposes (as provided by staff on June 18, 2010)."

Congressional Budget Office, "CBO Estimate of Changes in Net Federal Outlays from Alternative Proposals for Changing Physician Payment Rates in Medicare," April 30, 2010.

Congressional Budget Office, Letter to Rep. John Spratt, Chairman, House Budget Committee, on potential effects of reductions in physician payment rates, March 27, 2009.

Crosson, Francis J., et al., How Can Medicare Lead Delivery System Reform? (New York: Commonwealth Fund, November 2009).

Government Accountability Office, "Medicare Physician Payments: Trends in Service Utilization, Spending, and Fees Prompt Consideration of Alternative Payment Approaches." Statement before Health Subcommittee, House Energy and Commerce Committee, July 25, 2006.

Medicare Payment Advisory Commission, Report to the Congress: Assessing Alternatives to the Sustainable Growth Rate System (Washington: MedPAC, March 2007).

Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2010).

Urgent Care Centers

2010-07-02T19:13:00.001-07:00

Attached an excellent and very interesting article written by John Dorschner highlighting the proliferation of Urgent Care centers within the Baptist Health system in South Florida.
The proponents of urgent care centers emphasize the improved access and reduced costs of care versus ER care.
One UM Family Medicine faculty teacher is being quoted too:

``The residents now going out on their own -- two or three are going to work for urgent care companies and five or so are going to larger, already established practices,'' Roberts said. ``That's just the way things are.''

I beg to differ and passionately disagree with the opinions stated.
Why? Because Urgent Care may be " cheaper" compared to emergency room visits BUT it does contribute to the fragmentation of care, the absence of care coordination and will further reduce urgently needed cash flow in primary care clinics.
Unfortunately, insurance companies seem to like the concept too. Therefore, urgent care and walk-in clinics are popping up all over Miami even in my neighborhood.
Do they provide better care ? Absolutely not!! For care coordination and continuity of care they "refer" the tough cases to family doctors because they Urgent care docs want to deliver quick fixes and have no time for history taking gibberish.
I am afraid that in search for the easy and quick buck family medicine residents will prefer those urgent care clinics.
So what can we do? Join the urgent care bandwagon? No!! We must focus on the development of collaborate practice models, develop medical homes and contract with employer groups demonstrating better and more cost-effective care.
Otherwise, we will contribute to the steady increase in healthcare costs and the fragmentation of healthcare deliver.
That's NOT just the way things are!
Looking forward to your comments.
Yours
Bernd

Posted on Fri, Jul. 02, 2010

Baptist Health makes urgent care push

BY JOHN DORSCHNER
jdorschner@MiamiHerald.com

With primary care increasingly hard to access, Baptist Health South Florida keeps expanding its urgent care centers in Miami-Dade and Broward -- and offending the chief executive of the huge Memorial Healthcare System in the process.

Urgent care -- providing faster, simpler treatment than hospital emergency rooms -- has proven to be a successful model for the prosperous Baptist system, even while smaller urgent care shops in South Florida have slid into bankruptcy.

``They're doing very well,'' said Patricia Rosello, chief executive of Baptist Out-Patient Services.

Indeed they are. Baptist Out-Patient, which includes diagnostic and imaging services, earned $52.3 million on $142.7 million in patient revenue in fiscal 2009, according to audited statements. That's a 36 percent rate of return -- and 40 percent of the $131.3 million in net income earned by the entire system, which has five hospitals.

Baptist is not alone in seeing a huge need for primary care. Many chain pharmacies stores in South Florida -- including Walgreens and CVS -- now have walk-in clinics, usually staffed by nurse practitioners who can dispense simple prescriptions for such things as antibiotics.

Aventura Medical Center, an HCA facility, is taking a slightly different tack, opening a primary care clinic in Miami Lakes operated by physicians it employs. It keeps regular doctor's hours -- daytime, Monday through Friday.

The hospital is looking cautiously at widening the service. ``We will expand geographically only as it makes strategic sense and will continue to build physician practices in communities where there is a need for primary care,'' said Aventura spokeswoman Robyn Kane.

LONGER HOURS

Baptist Medical Plazas offer broader services and longer hours -- generally 11 a.m. to 11 p.m. daily, with board-certified physicians always on duty, generally with X-rays and other tests available because the centers include outpatient diagnostic and imaging services.

Baptist now has 13 centers, with more on the way. It entered Broward last year, in Coral Springs. Its latest, opened in May, is in Davie, at Griffin Road and University Drive -- an area dominated by Memorial, the prosperous government healthcare system that dominates South Broward.

Memorial has focused on its hospitals, having only one urgent care center, in Pembroke Pines. Still, Memorial Chief Executive Frank Sacco was not happy to see Baptist's advertising in Davie: ``You'll find compassionate Baptist Health doctors and nurses. . . Broward, it's time to get treated better!''

Sacco sent a letter last month to Memorial staff: ``Such statements are offensive to thousands of dedicated and accomplished healthcare professionals. . . . It disappoints me to see Baptist Health South Florida disparage all of us.''

Baptist's Rosello says no attack was intended against Memorial.

The centers have been using the same line in their Miami-Dade advertising for the past three years: ``It's time to get treated better.''

Baptist surveys show that 90 percent of its urgent care patients walk out the door within two hours of entering, Rosello said. That's much better than lengthy waits that occur in most emergency rooms.

``We started the centers to decompress the emergency room,'' Rosello said. Baptist Hospital's, in particular, was often crammed with patients waiting for treatment. ``But then it became its own business,'' he said.

One reason: Most insurers discovered that pushing people toward urgent care is cheaper than ER visits. Baptist's own health plan for employees, for example, requires a $50 co-pay for urgent care versus $100 for an ER visit.

In the fall, another Baptist center will open in western Broward, at Dykes Road and Pines Boulevard, Rosello said. Next year, a Brickell facility is expected to open near the intersection of U.S. 1 and the Rickenbacker Causeway. Another six may open in the next three years, Rosello said.

TOUGH MARKET

Baptist's pineapple logo has become a recognizable symbol, even in Broward, where many South Dade residents moved after Hurricane Andrew in 1992. But many lesser-known centers have struggled in the market.

ER Urgent Care Centers had three facilities in South Florida. In 2004, when a reporter visited one of them, in Hallandale Beach, there were no patients. ``Our biggest problem is getting the public educated,'' said an executive of the firm. It filed for bankruptcy in 2008.

In Broward, Alan Roberts, a physician, operated three Sunshine Medical Centers, including one in downtown Fort Lauderdale, but ended up selling them to Concentra, a Dallas-based nationwide system that has the financial heft to market to patients and get good deals from insurers.

Another chain, Jacksonville-based Solantic, has 30 locations in the state, including four in Broward.

Roberts, who now teaches part time in the University of Miami family medicine program, said urgent care is only going to get bigger, because low reimbursement rates aren't enough for primary care doctors to open solo practices.

``The residents now going out on their own -- two or three are going to work for urgent care companies and five or so are going to larger, already established practices,'' Roberts said. ``That's just the way things are.''

© 2010 Miami Herald Media Company. All Rights Reserved.
http://www.miamiherald.com

Read more: http://www.miamiherald.com/2010/07/02/v-print/1711396/baptist-makes-urgent-care-push.html#ixzz0sZzFUpSe

Shorter Work Days For Doctors

2010-06-26T19:17:00.001-07:00

Attached a link to an important NEJM article http://content.nejm.org/cgi/content/full/NEJMsb1005800 entitled "The New Recommendations on Duty Hours from the ACGME Task Force."The goal of the ACGME's new approach to duty hours is to foster a humanistic environment for graduate medical education that supports learning and the provision of excellent and safe patient care.
At the heart of the ACGME's proposed changes is the recognition that the least-experienced residents need to be treated differently than more experienced ones. The plan recommends that first-year residents be limited to 16-hour shifts, and those in the second year and above work continuously for no more than 24 hours. They can stay an additional four hours to facilitate patient handoffs to another doctor. Currently residents are allowed to work up to 30-hour shifts.
The guidelines also include detailed expectations about direct supervision of younger residents by more experienced ones, in the hopes that a supervising doctor would catch any error before it affects a patient, according to Dr. Nasca.In addition, the ACGME will step up its monitoring and enforcement of the requirements, conducting on-site visits of each institution annually beginning in July 2011. The site visits are likely to cost each institution about $12,000 to $15,000, according to Dr. Nasca.
Those programs that don't comply with the rules could ultimately lose accreditation and be forced to disband.
I strongly support the proposed changes and call upon my colleagues to do the same.
Our patients deserve the same assurance about the quality of service as millions of airline passenger do already: strictly enforced duty hours for pilots, checklists before take-off and landing, elimination of human errors and the relentless pursuit of excellence.
We must change the way we do business! Our patients deserve it!!
Yours
Bernd

University of Miami and Professional Ethics

2010-06-12T17:12:00.001-07:00

John Dorschner's very well written article reveals the disturbing facts surrounding the hiring of Charles Nemeroff,MD.

I am deeply troubled by UMs response emphasizing its " unflinching commitment to scientific integrity."

Whom are they kidding? It sets a bad example for medical students, researchers and residents at the University of Miami who are supposed to learn medical ethics and professional conduct from their teachers. Does the UM administration really believe that Nemeroff's transfer to Miami constitutes a clean slate to continue his work for the NIH? I hope not.

I am grateful that someone is calling it what it is: hypocrisy on steroids.

Yours

Bernd

==============================================================================

Senator tells University of Miami he's `troubled' over hiring

BY JOHN DORSCHNER

jdorschner@MiamiHerald.com

Sen. Charles Grassley has written a strongly worded letter to University of Miami President Donna Shalala saying he is ``disturbed'' and ``troubled'' by actions surrounding UM's hiring of a psychiatrist-researcher under investigation by a federal agency.

The letter from the Iowa Republican, dated Monday, was sparked by a Sunday story in The Chronicle of Higher Education about the relationship between psychiatrist Charles Nemeroff, now head of UM's department of psychiatry, and Thomas R. Insel, director of the National Institute of Mental Health, who led a yearlong project to toughen policies against conflict of interest.

On Wednesday, UM issued a brief statement: ``The University of Miami is responding to the inquiry from Senator Grassley and will continue demonstrating its unflinching commitment to scientific integrity. UM works tirelessly to advance the quality of its teaching, research, and clinical care programs while maintaining the highest ethical standards in all that we do.''

The National Institute of Health said Insel was unavailable for comment.

Grassley and his staff have been investigating Nemeroff, once head of psychiatry at Emory University in Atlanta, because he received millions of dollars from drug companies while doing what was supposed to be impartial research for the National Institutes of Health on drugs made by the companies paying him.

Grassley reported Nemeroff received $2.8 million from GlaxoSmithKline and other drug makers over seven years for promoting drugs like GSK's Paxil. Emory eventually asked him to step down as head of psychiatry and suspended his work on major NIH grants.

E-MAILS

The Chronicle story said Insel ``quietly helped'' Nemeroff get hired at UM.

In summer 2009, when UM was thinking of hiring Nemeroff, Medical School Dean Pascal Goldschmidt e-mailed Insel saying that Nemeroff had said Insel would be able to provide a ``confidential opinion'' on him, according to documents released by the Senate Finance Committee.

Insel responded that he could not provide a formal, written recommendation because of NIH rules, but ``I can discuss informally by phone. Happy to do this,'' he wrote in an e-mail.

Goldschmidt told The Herald last fall that he thought Nemeroff was a talented researcher but didn't want to hire him if he couldn't get NIH funding.

The Chronicle article quotes Goldschmidt as saying Insel assured him that the Emory ban on Nemeroff's NIH grant activity for two years didn't carry over to Miami, and that Nemeroff would be able to apply for NIH funding as soon as he took his new job.

Goldschmidt was quoted in the Chronicle as saying that the Emory ban on Nemeroff's grant activities was due to ``political pressure that the university was under.''

SEEKS DOCUMENTS

In Monday's letter, Grassley wrote that he was ``troubled'' by that comment.

``President Shalala, I hope that you would agree -- contrary to Dr. Goldschmidt's views that disciplining researchers for failing to disclose conflicts of interest is merely a political issue -- that enforcing federal conflict of interest policy involves ethical and legal issues that ensure taxpayer trust.''

Grassley demanded Shalala produce five types of documents concerning Nemeroff, UM and NIH grants.

In last fall's Herald story, Goldschmidt called Nemeroff ``an exceptional psychiatrist and an exceptional scientist who has one issue in which he recognizes he made a mistake,'' by not informing Emory how much he received from pharmaceutical companies.

In March, UM started a transparent process, in which outside companies' pay to UM doctors is now listed on a website. Nemeroff is not listed there because the information concerns the period before he started last fall, the university has said.

Nemeroff told The Herald last fall that he decided in retrospect he should have declared drug makers' payments to him, but he thought Emory's regulations didn't require it.

The Chronicle article includes e-mails, also obtained by The Herald, indicating that Nemeroff and Insel were trying to get together at conventions and had each other's cell phone numbers.

When Nemeroff e-mailed Insel that he was taking the UM job, Insel wrote back: ``Congrats on a new position! Should be a new beginning.''

Insel told The Washington Post on Tuesday that he didn't have ``any great relationship'' with Nemeroff, and believed the psychiatrist's actions were ``so outrageous, he became the poster boy for conflict of interest.''

On Wednesday, Bernard Carroll, former head of psychiatry at Duke University and once Nemeroff's boss, told The Herald that he found Insel's comments to the Post ``disingenuous'' because the two have known each other since the early 1990s and Nemeroff helped Insel find a job at Emory.

Read more: http://www.miamiherald.com/2010/06/10/v-print/1672327/senator-tells-um-hes-troubled.html#ixzz0qgeVJdj6

Conservative Cheerleaders

2010-06-12T16:40:00.001-07:00

06/12/10

Letter To The Editor

RE: Conservatism's cool, Miami Herald 06/12/2010

Nicholas Rohrhoff, Chairman of the Medical Student Section of the FloridaMedical Association claims that young people should evaluate conservative principles, including limited government.

Well,he may be unaware that many of his peers, including medial students like him at the University of Miami, significantly benefit from government intervention into medical education.

For example, many students rely on government subsidized loans to finance their education. He also seems to forget that most physician training is subsidized by the federal government.Today less than 5 percent of medical school revenues comes from tuition and fees. Instead, medical schools rely heavily on federal and state support. Once medical students receive their degree they continue with their Graduate Medical Education, i.e. residency or specialty training. The largest source of funding for graduate medical education is the federal Medicare program, which reimburses teaching hospitals for both the direct cost of operating these programs. Florida’s Medicaid program also provides funding to graduate medical education.

I hope that he appreciates that having received government funding and subsidies for his medical education and training he is also guaranteed a much higher earning potential than many other Americans. But may be not, because now he wants lower taxes too!

I really have a hard time to understand this conservative hypocrisy.For me its nothing else but an expression of egocentric individualism. So, please try your best and be a good doctor but stay away from political cheerleading.

Bernd Wollschlaeger,MD,FAAFP,FASAM

16899 NE 15thAvenue ,North Miami Beach, FL 33162

Phone: 305-940-8717

===============================================================================

Conservatism's cool

BY NICHOLAS J. ROHRHOFF

NJROHRHOFF@MED.MIAMI.EDU

In mid-term elections, voter turnout defines success. To win, it is imperative to target likely voters and mobilize sympathetic yet diffident constituencies to the polls. Barack Obama's successful courtship of young voters in 2008 cast John McCain's GOP as the party of yesterday -- a group of old, white men out of touch with an increasingly diverse and engaged youth -- never to regain electoral clout.

This was not a triumph in the battle of ideas.

Because the adolescent prerequisite of peer affirmation to consider anything persists in this age group, conservative policies were not even entertained by many young voters as potential solutions to America's problems.

The Obama campaign manipulated this phenomenon brilliantly by wooing young voters not with policy prescriptions but retail politics. Before the Iowa caucuses, he skipped an AARP event to attend a hip-hop concert. And he was far ahead of other candidates in high-tech outreach through e-mail, YouTube and social networking media. The results were a 135-percent increase in the Democratic youth vote from 2004 and an electoral prize that set him on a trajectory to the White House.

In the general election Obama was the candidate with whom young voters would rather have a beer. Reporters who covered both campaigns marveled at how many more young volunteers the Obama campaign had at the ready. Supporting him became the cool thing to do.

His personal appeal to the demographic drew them to his party. Gallup Poll data indicate that in 2000, 36 percent of young voters identified themselves as Democrats and 35 percent as Republicans. In 2008, 45 percent in that age group indicated affiliation with the Democratic Party -- only 26 percent with Republicans.

This support extended from politics to policy. The same poll reported 69 percent of young voters said the government should do more to solve problems whereas only 27 percent said government does too much. In both style and substance, conservatives had lost touch with the next generation of Americans.

How then to make conservatism cool again? Enter former Florida House Speaker and current Republican candidate for U.S. Senate Marco Rubio. It is reasonable to suggest that Rubio would not want to collect votes based on the perception that he is the coolest candidate. He is, by all accounts, a serious policy person. His book, 100 Innovative Ideas for Florida's Future, was accompanied by ``idea-raisers'' held across the state where citizens could contribute their views.

Appearing a decade younger than his 38 years as he effortlessly transitions from English to Spanish and back, he plays flag football and is married to a former Miami Dolphins cheerleader.

When asked recently about the notion that he was the Republican Obama, referring to the president's recent slide in the polls, he quipped, ``I'm not sure people even want to be the Democrat Obama these days.''

Still, he would win any poll -- in a landslide -- on which candidate young voters would most like to join for a beer.

Yet his distaste for identity politics is clear: He defines himself simply as a conduit to advance a set of ideas that has made this country the greatest in the history of the world. In a less Herculean task but one of no less consequence, he could serve as the catalyst to broaden the appeal of conservatism to incipient voters.

Rubio seeks election to the U.S. Senate to stand up to the Obama agenda and offer a clear alternative. A Harvard Institute of Politics poll released in March suggests there is an opportunity to persuade young voters with that platform. Only 38 percent of young people approve of President Obama's handling of the deficit and a majority disapprove of his management of the economy (51 percent) and healthcare (53 percent).

Most telling, just 14 percent of those polled attending a four-year college believe that it will be easy to find a job after graduation.

In 2008, voters under 30 made up 14 percent of Florida's electorate. Gov. Charlie Crist's decision to run as an independent amplifies the importance of each of those votes. Though young people are unlikely to vote in mid-term elections, in this three-way race they could be decisive. Rubio trails Crist in a recent St. Petersburg Times/Miami Herald/Bay News 9 poll by just 3 points.

Rubio has been presented as a plausible counterweight to the president for many reasons -- the most significant comparison may manifest in the electoral etiology of his meteoric rise. An aggressive approach will lead young people to evaluate conservative principles -- limited government, low taxes, and boundless opportunity -- on the merits.

If his overtures succeed, a statewide electoral victory propelled by young voters could begin a movement that energizes, modernizes and unifies the Republican Party before returning them to power in Washington.

Nicholas J. Rohrhoff is chairman of the Medical Student Section of the Florida Medical Association and a student at the University of Miami School of Medicine.

AMA Advocacy

2010-05-28T19:01:00.001-07:00

Attached two examples how the American Medical Association advocates on behalf of physicians. I encourage you to renew your AMA membership to support those efforts which are helping us to practice medicine.
Have a great Memorial Day Weekend.
Bernd Wollschlaeger,MD,FAAFP,FASAM
AMA Outreach Recruiter

FTC Delays Red Flags Rule

The Federal Trade Commission on May 28 announced it would delay enforcement of the Red Flags Rule from June 1 to Dec. 31, 2010.

The commission cited congressional consideration of legislation that would affect the scope of entities covered by the rule to require businesses to take specific steps to minimize identity theft. For instance, S. 3416, introduced on May 25 in the Senate, would exempt health care practices with 20 or fewer employees, as well as accounting and legal practices of similar size.

Covered health care professionals under the bill include physicians, dentists, podiatrists, chiropractors, physical therapists, occupational therapists, marriage or family therapists, optometrists, speech therapists, language therapists, hearing therapists and veterinarians.

The commission in its announcement urged Congress to quickly act "to pass legislation that will resolve any questions as to which entities are covered by the rule and obviate the need for further enforcement delays. If Congress passes legislation limiting the scope of the Red Flags Rule with an effective date earlier than December 31, 2010, the Commission will begin enforcement as of that effective date."

The American Medical Association, which on May 21 filed a lawsuit to prevent the FTC from applying the rule to physicians, applauded the delay. "We call on the FTC to exempt physicians from the rule completely."

The extension is a promising sign that the AMA lawsuit caught the attention of the FTC, the association says. "Last November, a federal court blocked the rule from being applied to attorneys after the FTC was found to be extending its regulatory power beyond that authorized by Congress. We hope this latest extension will be long enough for the FTC to take a good, hard look at the rule and finally exclude physicians from this unjustified and burdensome regulation of medicine."

eVoice^®Alert

May 28, 2010

Tell Congress enough is enough!

Congress failed to address this year’s Medicare physician payment cut before the June 1 deadline next week. Although the U.S. House of Representatives passed legislation at the last minute to suspend cuts for another 19 months, the U.S. Senate left for a week-long Memorial Day recess without taking action. When Congress returns from their vacation on June 7, the Senate is expected to take up the House-passed bill.

The Centers for Medicare & Medicaid Services already issued instructions to its contractors to postpone processing claims for Medicare physician services provided on or after June 1 for 10 days to provide time for Congress to complete its action and overturn the scheduled cut retroactive to June 1.

The new proposal being considered by Congress would provide payment updates of 2.2 percent for the remainder of 2010 and an additional 1 percent increase in 2011. However, in 2012 the SGR formula will once again go into effect and payments will be cut by an estimated 33 percent!

Congress needs to hear from you! Call your representative and senators today using the AMA’s toll-free grassroots hotline at (800) 833-6354 or send them an e-mail. Urge them to end their mismanagement of these important health care programs, and honor their commitment to military families and older Americans.

It is long past time for Congress to find a long-term solution to the SGR that does not create an even bigger problem in the future. Enough is enough!

FMA and AMA

2010-02-28T18:35:00.000-08:00

OPEN LETTER TO THE DCMA LEADERSHIP:

According to the published summary of a recent Board of Governors meeting, the Florida Medical Association is actively pursuing a reevaluation of its relationship with the American Medical Association. "We also began the process of a very serious and methodical reassessment of the FMA’s relationship with the AMA. Specific time will be set aside at the spring Board meeting to continue the discussion. Please feel at liberty to share your thoughts on the FMA-AMA relationship with me."

In this context the Board also tried to pass a bylaws change making the FMA President Chair of the AMA Delegation. This attempt to undermine the AMA delegations role did not pass. Furthermore, the Florida AMA Delegation did not support Dr. David McKalip run for office in the AMA , but the FMA Board of Governors overturned their decision. This is the same Dr.McKalip who was forced to step down as President-elect of the Pinellas County Medical Association, apologizing profusely for forwarding an e-mail image that portrayed President Barack Obama as a witch doctor in a loin cloth and headdress with bones in his nose. In a statement, the Florida Medical Association said it found "the actions by Dr. Mc Kalip to be hurtful and in poor judgment" but he still remains on its board ( District C, David M. McKalip, M.D., St. Petersburg). At that time he said that he is taking a year's leave of absence from a leadership role at the American Medical Association. He also planned to take a lower public profile in the health care reform debate. Instead, he was celebrated by the Tea party activities and spoke at several meetings. Now the FMA is using him as the ideological bulldozer to destabilize the AMA and Dr. Miguel Machado, a neurosurgeon and former DCMA President, runs for FMA leadership office spearheading the separation from the AMA.

Whats the goal? The FMA want to take the lead to form a new and "pure" national medical organization based on their ideological principles.

Its just astounding that physicians never miss an opportunity to divide the House of Medicine. That's the reason why I left the FMA .

There are many other important issues we should focus on to help physicians to survive and succeed in the rapidly changing healthcare environment. We need leaders who base their decisions on rational thought but not partisanship and ideologies.

I call upon each you to challenge the FMA and Dr. Machado to clearly and publicly state their support for the AMA and their policies. Furthermore, they should assure each and every AMA member that they refrain from dividing the House of Medicine and that they stop collaborating with other state medical organizations(s) to create a separate national medical organization. Dividing us just plays in the hands of our political opponents. As a loyal DCMA and AMA member I expect that my county medical society supports my right to be represented by the AMA and to stop supporting candidates who undermine the important function and role of the AMA. Otherwise, I have no other choice but to relinquish my DCMA membership effective immediately!

Its your choice to unite or to divide the House of Medicine.

Yours

Bernd

Immediate Past DCMA President

Why We Need Health Care & Health Insurance Reform?

2010-02-18T20:08:00.001-08:00

The attached ABC news report highlights the fact that the largest health insurers in America have declared more than $12 billion worth of profits in 2009 but are requesting premium increases of anywhere from 20 percent to over 50 percent! It was a banner year for health insurers. While those profits were coming in, 2.7 million of the companies' customers lost their insurance. Health insurance companies are dropping "unprofitable" patients and demand higher premiums from their remaining customers who cannot afford dropping their insurance. Meanwhile, CEOs and shareholders are collecting big paychecks, bonuses and profits. What can be done? We must pass comprehensive health care reform now even without bipartisan support. Any reform proposal must contain provisions curbing the insurance companies profit margins, strip health insurance companies of their antitrust exemption, creating an health insurance exchange for those self-employed seeking insurance coverage, eliminating preexisting condition exclusions, full transparency of health insurance companies cost and expense structure and mandatory comprehensive insurance coverage. We also should support a strong public option! We have to stop the bleeding now! Yours Bernd Administration Says Insurance Companies Pull in Profits While Raising Premiums By KATE SNOW, DAN HARRIS, HANNA SIEGEL and BRADLEY BLACKBURN Feb. 18, 2010— Health and Human Services Secretary Kathleen Sebelius railed against the insurance companies today for raising premiums at a time when companies still post profits. "The five largest insurers in America have declared more than $12 billion worth of profits in 2009," Sebelius said at a news conference. One of those companies, WellPoint, is a for-profit company that owns Anthem Blue Cross of California. They are about to increase rates on coffee shop owner Jesse Fink. Come May, he'll pay $325 more per month to insure his family. "I felt like it was extortion. I felt like it was a crime. They had you by the throat and if you don't like it leave. That's not right," said Fink. 2009 a Record Year for Insurance Company Profits it was a banner year for health insurers. While those profits were coming in, 2.7 million of the companies' customers lost their insurance and the average premium for health insurance went up -- 5.5 percent for family coverage and 2.6 percent for individual coverage, according to the Kaiser Employer Health Benefits Survey. Today, the government pointed to examples in six states where insurers request premium increases of anywhere from 20 percent to over 50 percent. Companies Say Higher Medical Costs Mean Higher Premiums The insurance companies see it differently. Though in most states, the companies don't dispute the numbers in the government report, but they say the requests for higher premiums were not driven by profit. Insurance Companies Say They're Losing Money Brad Fluegel of Wellpoint told ABC News, "What we're experiencing in California is very rapid increases in medical costs." And as more healthy people lose their jobs and drop their insurance coverage, more sick people -- the most expensive patients -- remain in the insurance pool. Other insurers say they are actually losing money right now. Blue Cross Blue Shield of Michigan estimates they lost $280 million last year and by law have to ask for an increase in premiums to cover their losses. "We're not prospering here. Our reserves have declined for 5 straight years. We're paying out $1.20 for every dollar we collect in premiums. We're losing hundreds of millions a year on only 7% of our total membership," said Andrew Hetzel, spokesman for Michigan Blue Cross Blue Shield. Critics Say Insurers Are Dropping Unprofitable Patients Critics of the companies don't buy it. "While everyone else seems to be in a recession, the private health insurance companies are making a tremendous amount of money," said Jackie Schechner, the National Communications Director for Health Care For America Now. How could that happen? Schechner says the companies essentially get rid of customers who aren't going to make them any money -- old, sick, or high-risk patients. That way, healthy customers are still paying high premiums but the insurance companies have to make fewer big payouts. If that accusation were true, the companies could be in violation of the law. "They raise rates and companies can't afford to cover their employees anymore" says Schechner. "People try to go out and get insurance in the private market and it's just entirely unaffordable for them because the prices of premiums are so high. And if you can get something you can afford and the premiums are low, chances are it's going to be lousy coverage and it's not going to actually give you the health care benefits you need." Schechner says the answer is health care reform. That's one point that the critics and insurance companies can agree on. Brad Fluegel of Wellpoint said, "We're eager to have a fact-based, rational debate about the drivers of these issues and what we can do to fix them." The trouble is that the insurance industry and the Obama administration have very different ideas about what that reform should look like. Copyright © 2010 ABC News Internet Ventures

Doctors versus Medicare

2010-01-31T19:47:00.001-08:00

Attached a very interesting article from Saturday's Miami Herald emphasizing the issue of cost-control in healthcare and the resistance by physician groups to accept the inevitable truth: we must bend the cost curve, otherwise someone will bend it for us!We definitely need to shift our paradigm of thinking: from quantity to quality, from volume to value, from physicians- centered to patient-centered care. Now is the time to discuss and resolve the issue. Politicians from both parties must understand that concessions may only provide short-term gains but represent long-term loss. Lets not miss this opportunity.

Yours

Bernd

==============================================================================

Cardiologists battle Medicare over payment cuts

BY JOHN DORSCHNER

jdorschner@MiamiHerald.com

RICK NEASE / MCT

In a striking example of the conflict between controlling healthcare costs and providing quality service, a group of South Miami cardiologists has written a letter to patients complaining that huge cuts in Medicare rates may force many heart specialists out of business or mean reduced services for their patients.

The doctors of South Miami Cardiology said that on Jan. 1 Medicare reduced ``reimbursement for cardiac services on average by 40 percent. This is unrelated to the current healthcare reform, which is planning an additional 21 percent reduction, effective March 1.''

In fact, none of the cuts are related to the healthcare reforms before Congress. They're Medicare actions required by existing laws in an attempt to moderate doctor pay while not going broke -- a painful issue that reveals how difficult any kind of reform can be when strongly entrenched interests disagree on what should be done.

In this case, the nation's outraged cardiologists filed a federal lawsuit in Miami and have persuaded 50 members of Congress to co-sponsor a bill to rescind the cuts.

Some healthcare experts like the cuts.

``I'm not at all sympathetic with the cardiologists,'' said Robert Berenson, a doctor who was once in charge of Medicare payment policy and now is a fellow with the Urban Institute. ``Studies show they make well over $400,000 a year'' -- more than twice what a family practice physician earns.

In fact, Medicare is reducing pay to cardiologists as part of a rebalancing plan in which primary care doctors will get a 7 percent increase. ``This system is much more fair,'' said Lori Heim, president of the American Academy of Family Physicians. ``It's not the savior for primary care, but it's a start.''

Heim finds it ``disingenuous'' that the cardiologists' letter blames reform proposals for their rate cuts.

Most of the cuts involve expensive imaging diagnostics, like $800 nuclear stress tests. Studies show that when physicians have expensive imaging machines in their office, they tend to prescribe far more tests.

That's particularly true in Florida, where a study by the Government Accountability Office, the investigative arm of Congress, found that in-office imaging per senior cost $472 in 2006 -- eight times more than in Vermont.

Still, cardiologists say the changes have been devastating. Manuel Abella, a cardiologist in a large group practice in West Kendall, said he and his colleagues have been forced to lay off 15 people, cut salaries 10 percent and eliminate health insurance.

`BASIC TOOLS'

``When a patient comes in and says he has chest pains, you have to have state-of-the-art technology,'' said Romeo Majano, one of the three South Miami cardiologists who sent the letter. ``These are basic tools of our trade, and it's imperative patients have access to them.''

``This technology has greatly improved care,'' said Jack Lowen, president of the American College of Cardiology. ``We've seen a 30 percent reduction in morbidity and mortality in heart disease over the past 10 years.''

``The most affected, of course, will be the patients,'' the South Miami cardiologists warned in their letter, ``as cardiologists will be either forced out of business or forced to drastically increase the number of patients seen, most likely with physician assistants or nurse practitioners to help manage the increased volume.''

The cardiologists say that if Medicare won't pay for, say, a nuclear stress test in a cardiologist's office, the patient will have the test performed at a hospital where it might cost three to five times as much.

Medicare spokeswoman Ellen Griffith said, ``It is difficult to compare payments head-to-head because services may not always be directly comparable.'' Hospitals often get paid more for a service because they must be open around-the-clock and by law must provide coverage for the uninsured in their emergency rooms.

Berenson at the Urban Institute looks at it this way: ``If the hospitals are getting paid too much, the answer is to reduce their payments.'' He doubted the cardiologists' threat of giving up Medicare patients, noting that oncologists made a similar threat several years ago when they saw certain payments taken away and it didn't bear out.

For years, Republicans were leaders in the movement to curtail soaring Medicare costs. Tommy Thompson, secretary of health and human services under President George W. Bush, has frequently given speeches that Medicare costs must be brought under control or aging baby boomers would bankrupt the plan.

But in recent months, as the reform debate intensified, Republican leaders warned that the proposed bills would cut seniors' benefits. A poll this month by the Kaiser Family Foundation found that 48 percent of those over 65 are opposed to the reform bills while 37 percent support them.

In fact, for the past 12 years, under the Clinton, Bush II and Obama administrations, Medicare has been ordered to find ways of curtail costs without reducing quality of care. The Balanced Budget Act of 1997 required physician payments by Medicare to be adjusted annually so that the program didn't go broke.

Every year since 2003, Congress has listened to doctors' complaints and halted pay cuts. Each postponed cut gets added to the next year's calculation and this year all doctors are facing a 21 percent reduction. Congress postponed the cuts until March 1, when they take effect unless lawmakers take action.

Meanwhile, Medicare made a second set of calculations -- about how to split up the budgetary pie among doctors. Both Republicans and Democrats have agreed for some time that primary care is a key to improved healthcare -- because these doctors can coordinate treatment and reduce unnecessary tests and repetitive care.

A 2009 study by Medpac, a federal group that studies Medicare costs, found that, even adjusted for severity of illness, cardiology patients going to a doctor with imaging equipment in his office were twice as likely to get a test as those seeing doctors with no equipment.

Going further, Medicare surveyed physicians about their costs. Based on those findings, Medicare decided to reduce overall payments to cardiologists by 13 percent over four years -- while payments for their imaging services were cut by 30 or 40 percent.

`ERRONEOUS'

The ACC complained that the survey data for cardiologists was based on 55 interviews -- out of 20,000 in private practice. It called the resulting data ``patently erroneous and unreliable.'' When Medicare refused to budge, the ACC filed a lawsuit on Dec. 28.

The government argued that the courts did not have jurisdiction over a Medicare fee dispute. The judge agreed. The cardiologists have now gone to Congress, where lawmakers have a history of reversing Medicare pay cuts to pacify providers.

Griffith, the Medicare spokeswoman, said the agency is ``confident that the policies we have adopted are the most appropriate and will enhance overall access to physician services for beneficiaries. . . . If we find that there are unintended adverse consequences . . . we will have the opportunity to revisit them as part of the annual rule-making.''

Should We Stop Healthcare Reform Now?

2010-01-23T20:55:00.001-08:00

hould We Stop Healthcare Reform Now? After the election in Massachusetts many predict the collapse of the health care reform efforts. President Obama seems to seek a scaled back version, which is acceptable for Republicans who are blocking ANY reform efforts. But why do we need health care reform NOW? Lets look at the facts: If nothing will happen healthcare spending will continue to outpace the growth in the rest of the domestic product by at least 2.5% annually. Despite the overall slowdown in national health spending growth in 2008, increases in this spending continue to outpace the growth in the resources needed to pay for it! At that rate health spending will absorb 40% of GDP by 2050! The suggested reform proposal will provide 30 Million uninsured Americans adequate coverage requiring about $800 Billion to $1 Trillion in federal subsidies over the next decade. This represents only 3% of the $35 Trillion projected by actuaries to be spent on U.S. health care in the coming decade in the ABSENCE of reform. The relatively small $ 1 Trillion investment in preventing the surge of neglected chronic disease will save Trillions of healthcare dollars normally spent for the emergency room care needed to serve the growing numbers of uninsured! We need to invest money in order to save money!!! Furthermore, health care insurance companies know very well that the initial rise in health care stocks, on expectations that the Massachusetts’s vote might derail health care reform, may symbolize a pyrrhic victory only! Even though, the reform package included mandated coverage for everyone, regardless of health status, it also offered to heavily subsidize the health care for 30 million Americans who are currently uninsured. This potential financial windfall may not materialize. Insurance companies are very well aware that selling insurance package to employers has slowed because of rising premiums, which reflect rising health care expenditures. The insurance companies must have an interest to bend the cost curve and to expand insurance coverage to offer competitive products. Insurers may gamble with their financial future by supporting the Naysayer because without an overhaul of the insurance industry and the health care market they may face an even bleaker future, which will force draconian government intervention to cut costs. Therefore, we must support rational reform efforts and President Obama should stop pandering to the opponents of any meaningful reform efforts. We have to act now to avoid a future financial crisis! Bernd Wollschlaeger,MD,FAAFP,FASAM

What can we learn from Israel's efforts in Haiti?

2010-01-18T19:40:00.001-08:00

Attached a video link to a CNN report contrasting Israels disaster response in Haiti with the US response. In the words of Dr.DiGennaro, a Broward county physician, "it makes you almost embarrassed being an American." Currently, the Israelis run the only fully functioning hospital in Haiti! Its another example that we fail to understand that disaster and emergency preparedness is not measured by the amount of $$ we throw at the problem AFTER the fact but to continuously prepare and train teams of professionals in emergency and disaster response measures.This does not require a lot of money but dedicated leadership and commitment! In 2006 I have witnessed the training of the Israeli team on a military base and participated in multiple training sessions myself. I can attest to the fact that they have mastered the art of perfection; each step is documented in a manual and everyone knows how to work in a team and per checklist. Why we can't do it here? Because we are talking the talk instead of walking the walk. In October 2001 I was appointed by then Governor Bush to the Emergency and Disaster Preparedness Taskforce and urged on multiple occasions to follow the Israeli model. Nothing happened. Yes, we have special teams but too few and far apart. We need local teams that train on a quarterly basis and manage their own equipment and supplies. Do we need to learn another painful lesson from the next natural disaster or do we have to memorize the phone # of the Israeli team instead? Kudos to their bravery and tireless efforts. http://www.cnn.com/video/?/video/world/2010/01/18/dnt.cohen.haiti.patients.dying.cnn Bernd

Florida Doctors Lead The Fight Against Change

2009-12-29T21:46:00.000-08:00

Dear Friends and Colleagues:
An article in today's (12/29/2009) New York Times, "Health Lobby Takes Fight to the States," reports that Florida is debating a proposed amendment to its state constitution that would try to block, at least symbolically, much of the proposed federal health care overhaul on the grounds that it tramples individual liberty. Its 42 co-sponsors, all Republicans, were almost all recipients of outsized campaign contributions from major health care interests, a total of about $765,000 in 2008. Last year, for example, the drug industry poured more than $20 million into political contributions in states around the country. In California alone, the industry spent an additional $80 million on advertising to beat back a California ballot measure intended to push down drug prices. The idea of amending state constitutions to block the core of the federal health care legislation, including the requirement that individuals and businesses buy insurance, began at the conservative Goldwater Institute in Arizona, the state where the first such measure will appear on the ballot next year. The states where the amendment has been introduced are also places where the health care industry has spent heavily on political contributions in recent years, according to figures from the National Institute on Money in State Politics. Over the last six years, health care interests have spent $394 million on contributions in states around the country; about $73 million of that went to those 14 states. Of that, health insurance companies spent $18.2 million, according to the institute. In Florida, where health interests have given a total of about $32 million over the last six years, the state medical association has become an especially important backer of the proposed amendment. In contrast to the American Medical Association, the Florida Medical Association has come out firmly against the current Congressional proposals, and a spokeswoman said the Florida group had embraced the proposed state amendment “to protect Florida from being forced into a federal government mandate that would hurt patients.” Dr. Madelyn E. Butler, president elect of the Florida Medical Association, said, “We are trying to ameliorate the effects of national health care reform on the State of Florida.” James Greer, chairman of the Florida Republican Party, said he too supported the proposal, which could be on the ballot in 2010 or more likely in 2012. Whatever its legal weight, Mr. Greer said, its mere presence on the ballot would give it political force. Its time that doctors stand up against those powerful interest groups. In some areas in Miami (Hialeah) the Uninsured rate has surpassed 50%. Many of my patients will be forced to drop health insurance coverage in 2010 because they cannot afford the high premiums. One of my family members was told that her back pain constitutes a pre-existing condition and her employer informed her that his small group insurance premiums will increase if he decides to continue providing coverage for her. As physicians we have the moral obligation to protect our patients interests and to stand up against the powerful and mighty insurance industry. Enough is enough!

Have a Happy New Year.

Yours Bernd

Doctors in the News

2009-12-24T19:09:00.001-08:00

Well, I guess we can add another "present" under the Christmas tree.
Attached more information about the Zachariah saga which keeps getting juicier and more embarrassing.
Why does greed and lust for power seem to affect doctors more than others?
Because we do not speak up and thereby nurture those behaviors.
Its time to change our approaches and question the format and structure of our organizations.
Merry Christmas
Bernd

Posted on Thu, Dec. 24, 2009

2 Broward doctors settle insider trading case

BY DAN CHRISTENSEN
browardbulldog.org

The former chairman of the Florida Board of Medicine and another Fort Lauderdale physician have agreed to pay substantial sums to settle federal civil charges of insider stock trading.

Dr. Mammen P. Zachariah, appointed to the board of medicine by Gov. Jeb Bush in 2004, and Dr. Sheldon Nassberg allegedly reaped illegal windfalls by acting on stock tips supplied by Mammen Zachariah's brother, prominent Broward heart specialist and major Republican fundraiser Dr. Zachariah P. Zachariah.

Zach Zachariah, who has raised millions of dollars for Republican causes and candidates, including both presidents Bush, faces similar charges, but has declined to settle his case. A federal magistrate has set trial for Aug. 23, 2010.

That trial promises to offer a unique look at Republican fundraising and how political access is bought and sold. Among the expected highlights is witness testimony from two of South Florida's better-known corporate chieftains -- The Geo Group's George Zoley and Phil Frost, formerly of IVAX.

The Zachariah brothers and Nassberg, all of whom practice at Fort Lauderdale's Holy Cross Hospital, were named in a May 2008 civil complaint brought by the U.S. Securities and Exchange Commission. The complaint accuses them of collecting more than a half-million dollars in illegal profits during a fraudulent stock-trading scheme in 2005.

Without admitting or denying the government's allegations, Mammen Zachariah, 61, agreed to pay nearly $136,000 in what a judge labeled ``ill-gotten gains,'' plus an equal amount as a civil penalty. Nassberg, an endocrinologist, agreed to similar payments totaling $52,668. He admitted no wrongdoing. Both men are required to pay up by the end of the month.

The final judgments signed by U.S. Magistrate Linnea Johnson on Wednesday also include permanent injunctions that restrain both doctors from future securities law violations.

Zach Zachariah, another past chairman of the Florida Board of Medicine, is alleged to have used nonpublic information to buy and sell shares of two unrelated Florida companies, Miami-based generic drug maker IVAX and Sarasota's Correctional Services Corp. (CSC).

Zachariah was on IVAX's board of directors in July 2005 when company chairman Phil Frost informed him that IVAX had agreed to be acquired by Teva Pharmaceuticals for $26 a share. Within minutes, Zachariah bought 35,000 IVAX shares for about $21 a share, the SEC said. At the time of the alleged purchase, company insiders were forbidden from trading in IVAX stock.

Zachariah also allegedly tipped off his brother, who bought 2,000 IVAX shares for about $23 a share on the last trading day before the deal was announced in July 25. Zachariah allegedly used inside information to make even more money trading shares of CSC, which was acquired by The GEO Group of Boca Raton in 2005. According to the SEC, the Zachariah brothers and Nassberg turned $380,000 in quick profits.

The government says Zachariah acquired that inside knowledge in a couple of ways. One was through his son Zachariah ``Reggie'' Zachariah, who worked in GEO's mergers and acquisitions department. Reggie Zachariah has denied under oath tipping off his father to the deal. Another was through Zachariah's own moonlighting work for GEO. The SEC says Zachariah made ``millions of dollars'' as a corporate consultant, service provider and lobbyist for GEO, a giant prison contractor once known as Wackenhut Corrections.

Zachariah, who owns a $2.3 million home on the Intracoastal Waterway in secluded Sea Ranch Lakes, said under oath last winter that he was paid to provide access for GEO chief executive George Zoley to top federal and state Republican politicians.

Those politicians include former President George W. Bush, former Senate Majority Leader Bill Frist, former Florida Senate President Tom Lee and House Speaker Alan Bense and former attorney general Charlie Crist, now Florida's governor.

Dan Christensen, a former Miami Herald reporter and columnist for The Daily Business Review, is founding editor of BrowardBulldog.org, a nonprofit online-only newspaper.

House Reverses Medicare Payment Cuts

2009-11-21T22:15:00.001-08:00

The Medicare Physician Payment Reform Act Of 2009 passed the House on 11.19.2009 with 243 Ayes and 183 Noes. The measure would reverse a 21.2% payment cut planned for Jan. 1, 2010, wipe out the accumulated physician spending debt and implement a new formula. 242 Democrtes and ONE(1) Republican (Michael Burgess,MD, Texas) voted in favor and 172 Republicans and 11 Democrates ( including Suzanne Kozmas, FL) voted against. Lets be clear who our FRIENDS are: Democrats and NOT Republicans! But the FMA leaders are still supporting those politicians who voted AGAINST the passage of this reform act: Tom Price, Ros Lehtinen, Diaz Balart, Mack, etc.) Go figure out there logic!!! Bernd For more information see AMA News. House votes to scrap Medicare doctor pay formula The bill, which would base pay more closely on costs, now moves to the Senate. That chamber has already rejected a similar measure this year. By CHRIS SILVA, amednews staff. Posted Nov. 19. Washington -- The U.S. House of Representatives passed a major bill Nov. 19 that would abandon the current Medicare physician payment formula and allow future rates to increase based more closely on doctors' costs, a revision that is expected to cost roughly $210 billion over 10 years. By a vote of 243-183, the House approved the Medicare Physician Payment Reform Act of 2009. The measure would reverse a 21.2% payment cut planned for Jan. 1, 2010, wipe out the accumulated physician spending debt and implement a new formula. The new spending growth rate target for physician services would be equal to the gross domestic product plus 1%. Preventive care and evaluation and management services would have a separate target of gross domestic product plus 2%, allowing primary care pay to increase at a higher rate over time. "Without action by both houses of Congress, Medicare will cut payments to physicians by 21% in 2010, with more in years to come. Today's House vote is the first step toward preventing this cut and eliminating the formula that creates a roller coaster of uncertainty for seniors and physicians who care for them," said American Medical Association President J. James Rohack, MD, who called on the Senate to act on the legislation. "Promises have been made to seniors and military families -- and the House recognizes that those promises must be kept." The White House in advance of the vote issued a statement strongly supporting the legislation. "The administration believes Medicare and the country need to move toward a system in which doctors receive better incentives to provide their patients with higher quality and more efficient care," said the Nov. 18 statement from the Office of Management and Budget. "A cut of this magnitude could reduce access to physicians for Medicare beneficiaries throughout the country." The Senate must still approve the legislation before it can head to President Obama's desk. The upper chamber has already rejected a bill once this year that would have eliminated the Medicare physician payment formula. That legislation ran into opposition from Republicans and fiscally conservative Democrats who said they did not want to raise the federal deficit by hundreds of billions of dollars. The House measure was originally part of the chamber's health system reform bill but was stripped out for separate floor consideration. The primary reason for this was to decrease the total cost of the main reform package and to keep the final dollar figure under a White House-imposed limit.

Appointment

2009-11-12T21:18:00.001-08:00

Governor Crist appoints Past DCMA President to the Prescription Drug Monitoring Program Implementation and Oversight Taskforce. http://www.flgov.com/release/11150 GOVERNOR CRIST APPOINTS NINE TO THE PRESCRIPTION DRUG MONITORING PROGRAM IMPLEMENTATION AND OVERSIGHT TASK FORCE November 12, 2009 Contact: GOVERNOR'S PRESS OFFICE (850) 488-5394 TALLAHASSEE – Governor Charlie Crist today announced the following appointments: Prescription Drug Monitoring Program Implementation and Oversight Task Force · Andre Benson, 62, of Tampa, physician, Operation PAR Inc., appointed for a term beginning November 12, 2009, and ending July 1, 2012. · Lora “Lorrie” Brown, 44, of St. Petersburg, pain physician, Coastal Orthopedics, appointed for a term beginning November 12, 2009, and ending July 1, 2012. · Kristen Cortes, 45, of Panama City, Florida Department of Law Enforcement agent, appointed for a term beginning November 12, 2009, and ending July 1, 2012. · David Craig, 41, of Tampa, clinical pharmacist specialist, H. Lee Moffitt Cancer Center and Research Institute, appointed for a term beginning November 12, 2009, and ending July 1, 2012. · Joel Kaufman, 57, of Ft. Lauderdale, vice president, United Way of Broward County, appointed for a term beginning November 12, 2009, and ending July 1, 2012. · Nilesh Patel, 45, of Bradenton, interventional pain management physician, appointed for a term beginning November 12, 2009, and ending July 1, 2012. · Donnie Reynolds, 41, of Weston, chief operating officer, Automated Healthcare Solutions, appointed for a term beginning November 12, 2009, and ending July 1, 2012. · Paula “Pepper” Wakeland-Hewitt, 60, of Sarasota, pharmacy manager, Davidson Drugs, appointed for a term beginning November 12, 2009, and ending July 1, 2012. · Bernd Wollschlaeger, 51, of Miramar, self-employed primary care physician, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

Cover Florida

2009-10-25T19:44:00.001-07:00

Attached an article in todays Miami Herald pointing out the problematic issues of the so-called " Cover Florida" insurance program touted by Governor Christ as the solution for the Uninsured.

Heer are some facts:

* in many cases it offers a barebone service package.

* participating insurance companies still do not offer comprehensive services for competitive prices DESPITE the claims made by the Governor that" each provider was chosen by the state through a competitive bidding process."

* To date, about 4,500 people have enrolled -- about 0.1 percent of the state's uninsured population. More than 3800 Floridians loose their health insurance every week!!!

The question remains: is this program the result of an honest effort to find a solution to cover the Uninsured, or just another political campaign trick meant to boost the chances of Governor Christ to enter the US Senate?

Needless to say that he still refuses to accept a public option, but has yet to declare if Florida will opt out such an option if offered on federal level.

My gut feeling? He will do anything to get elected even if it means to scarify more Floridians on the altar of political vanity.

Yours

Bernd

Posted on Sat, Oct. 24, 2009

Crist exaggerates benefits of Cover Florida Health Care program

BY CATHARINE RICHERT

PolitiFact Staff Writer

In a recent Fox News interview, Florida Gov. Charlie Crist boasted about Cover Florida Health Care, an effort to provide low-cost healthcare coverage to the nearly four million uninsured in the state.

``There are no government mandates to it, no tax dollars utilized for it,'' Crist said on Wednesday. ``Just good, aggressive negotiating by our administration with health insurance companies. . . . And, really, the problem with healthcare is that it's expensive. And so what we've attempted to do is reduce the cost by reducing the expense and the premium of health insurance, and we've had success doing so. Usually it's about $900 a month to get health coverage. We've reduced that, on average, to about $150 a month.''

Given all the debate over the high cost of healthcare, we wondered if the plan could be as inexpensive as Crist claims. We found he was distorting the savings by mixing apples and oranges.

The program, which was started in 2008, allows individuals who have been without coverage for at least six months to pick from plans offered by six insurance companies. Each provider was chosen by the state through a competitive bidding process, and each offers at least two options -- one with catastrophic and hospital coverage, and another plan that can provide less coverage.

The program's website says that individual plans can be purchased for as little as $23 or as much as $800 a month, depending on age, gender and level of coverage. Patients pick and choose between various options offered through the six insurers. So, for example, a woman who is between 19 and 29 years of age can pay $130 a month for a plan that includes no deductible, $10 copays for doctor visits, but no hospital inpatient coverage.

NOT DOING ENOUGH

Since Cover Florida Health Care was enacted, critics have said the program hasn't done enough to cover the uninsured. To date, about 4,500 people have enrolled -- about 0.1 percent of the state's uninsured population.

The low-cost options so often touted by state officials don't offer patients much of a safety net, said Florida state Sen. Nan Rich.

``People are beginning to see that it doesn't cover anything,'' said Rich, a Democrat from Weston. ``It may be inexpensive, but it's inexpensive for a reason. It's a very low level of coverage.''

When we asked Crist's office about his claim -- that healthcare costs are on average $900 a month compared to $150 under Florida's plan -- we were told that the $900 figure cited by the governor came from the nonpartisan Kaiser Family Foundation and that it refers to the amount of money a family pays, on average, per month. Crist's office also noted that the figure is outdated (for instance, in 2006, the average monthly cost per family was about $950) and pointed us to a new Kaiser report released Sept. 15, 2009, that estimates families now pay about $1,114 a month.

So Crist is off by about $200 for family coverage.

AVERAGE COSTS

As for the average cost under the Cover Florida program, Crist's office pointed us to a document that lists the different providers and their rates for individuals. The average for the higher-end coverage, which would include hospitalization and catastrophic insurance, is about $227, while the average for the less-expensive ``preventive'' plan was $89. So Crist's $150 number is the approximate average of the two.

But wait. The first number Crist cited is the Kaiser estimate for a family. The second number is for an individual.

We went back to the Kaiser report and found that the average cost for an individual plan is actually around $400 a month, which would mean the gap was not as dramatically different as Crist claimed.

Crist spokesman Sterling Ivey acknowledged the apples and oranges comparison but said the underlying point is still valid that the Florida average is lower.

But we find Crist is using sleight-of-hand, comparing numbers that aren't comparable. He's used a higher family number with a lower number for individuals. We rate his claim False.

Herald/Times staff writer Steve Bousquet contributed to this report.

Leaving the FMA

2009-09-26T18:36:00.001-07:00

LETTER TO THE PRESIDENT OF THE FMA,DR.JAMES DOLAN:

Dear James:

I hope that you are doing well.

For several months now I witness the relentless anti-AMA rhetoric applied by the FMA leadership and the continuous attacks on any meaningful healthcare reform efforts which are sorely needed. I am also outraged that you continue to ignore the reality of the growing number of uninsured in Florida calling it a "myth."

In Miami we reached a 36% Uninsured rate and in Hialeah alone 56%!!! This is not a myth but REALTY! Not only does this trend challenges our public health but also adversely affects the financial viability of medical practices and hospitals and we must find a solution to this problem!!

After long deliberations I finally reached the conclusion that I have no place in the FMA. I fundamentally disagree with the FMA policies and am especially appalled by the vitriolic criticism of the AMA. It already triggered an increase in the AMA member non-renewal rate and will further diminish our representation within the AMA House of Delegates. This criticism is especially difficult to understand because Cecil Wilson is the AMA's President Elect! Why are we stabbing him in the back? Therefore, I relinquish my membership privileges effective immediately. I am saddened that I was forced making this decision but I see no other option.

Stay well.

Yours truly,

Bernd

Senator Nelson and the Public Option

2009-09-06T17:46:00.001-07:00

U.S. Sen. Nelson says “public option is dead,” believes Co-Ops will be possible alternative for nation’s 47 million medically uninsured

U.S. Sen. Bill Nelson, D-FL at the Greater Miami Chamber of Commerce monthly luncheon Wednesday said when it came to a comprehensive change in health care delivery and medical insurance being debated around the country, the Senate; a smaller body will likely craft much of the final product and believes it will involve the use of medical insurance “co-ops that are owned by the policy owners.”

Senator Nelsons support for a co-op sounds more like a cop out.What does he really support? Few politicians can clearly define either of both entities. The only thing they know that it’s politically less risky to use the term co-op than the perceived evil word “public option.”So what would it be? Insurance co-ops or health insurance purchasing co-ops?

An insurance co-op requires sustained funding, must develop a large network of providers offering discounted health care services, develop brand identity, figure out how to handle claims, develop actuarial expertise, establish reserves, meet state licensing requirements and solvency requirements. Once a co-op passes all those hurdles it needs to attract and retain customers, lots of customers, to compete with existing insurance companies. In contrast, health insurance purchasing co-ops are based on the idea that consumers bargain with insurance companies to buy insurance. They’re not insurance providers themselves. Most of such initiatives failed to provide the desired benefits for their member.

So what’s left? 1) a solid public option offering an insurance option for those who currently cannot afford to buy insurance or are underinsured; 2) a political consensus to strictly regulate insurance companies like we do with utilities; 3) a single-payer insurance plan, a public service financing the delivery of healthcare. Single-payer health insurance operates by arranging the payment of services to doctors, hospitals, and other health care providers from a single source established and managed by government. This source replaces private insurance companies with a single, public entity.

These are the options and the choice is ours.Lets have a honest and unbiased debate about those options. Time (or better money) is running out!

Bernd Wollschlaeger,MD,FAAFP,FASAM

Immediate Past President, Dade County Medical Association

White House Conference Call

2009-08-25T21:19:00.000-07:00

Miami, August 25th 2009

Dear Colleagues:

Today in the evening, I participated in a White House Office of Health Reform conference call to discuss health insurance reform. The call was intended as a briefing for physicians to discuss issues related to health reform. It started at 8:35pm and lasted for an hour. The call was moderated by Dr.Kavita Patel, who serves with Senior Adviser Valerie Jarrett and worked herself a practicing Internal medicine physician. According to her information ~ 1900 physicians participated and > 400 questions were submitted in advance.

After a briefing about the status of the current health reform efforts ( see http://www.healthreform.gov) Dr. Patel answered several questions submitted in writing and then also by people who queued for a life Q&A sessions.

Several of these questions can be grouped as follows but this does not represent a complete list:

1) Medicare Advantage plans and how they can be adjusted to provide competitive and similar-priced services to all Medicare recipients. This question focused on the preferred financing of CMS for Medicare Advantage plans.

2) Increased reimbursement for primary care services and emphasis on quality versus quantity of care. Dr.Patel clearly identified with practicing primary care docs because she herself experienced the grueling schedule and resulting deficiencies in quality of care.

3) Training of more primary care physicians by dramatically increasing funding for the National Health Service Corps program http://nhsc.hrsa.gov/. Unfortunately, she missed addressing the necessary funding increase and removing of restrictions for primary care residency positions.

4) One doctor suggested moving from a fee-for-service reimbursement system to a global fee schedule, which in my opinion is sorely needed.

5) Another doctor suggested an end-of-life conference at the White House to rationally discuss this controversial issue and to debunk the "death-panel" propaganda perpetuated by some media outlets and political pundits.

6) In a final question a doctor asked why CMS does not reimburse for preventive care services.Definitely, a golden opportunity to change the current reimbursement system to emphasize and validate our daily effortsd and hard work.

In summary, this was an excellent opportunity to connect, to listen and to ask questions in a relaxed, well organized and calm atmosphere. The focus is on primary care: to emphasize preventive services, and to provide funding for increased reimbursement.

I am pleased that rational thought can prevail and I applaud the White House of Health Reform for their efforts. They announced more phone calls in the future. I strongly urge each of you to participate and to engage in a thoughtful conversation.

Yours

Bernd

Bernd Wollschlaeger,MD,FAAFP,FASAM

Speak Up Against Propaganda

2009-08-23T19:32:00.001-07:00

Sunday, August 23, 2009

Letter To The Editor:

RE: Recess Rally

Naturally, every American has the constitutional right to free speech but healthcare protesters are going too far by likening Obama to Hitler or claiming that government will control when people die. It especially puzzles me that the many of those protesters opposing meaningful and necessary healthcare reform are Medicare recipient benefiting from a government controlled, single-payer system! Would those same people be willing to turn in their Medicare cards in protest too? Would those people consider me a “death panelist” because I follow Florida Law and need to discuss advanced directives with them? According to their “logic” hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations (HMOs), which are required to provide their patients with written information concerning health care advance directives, are part of the “death panels” too!
We have to tune down the hyperbolic and toxic rhetoric fueled by fearmongers and anti-government nut wings and return to a rational dialogue to resolve an urgent problem: how to provide healthcare for all Americans.

Bernd Wollschlaeger, MD,FAAFP,FASAM
Family Physician

Healthcare For All

2009-08-06T20:55:00.001-07:00

ear Friends and Colleagues: Attached a superb article by Dr. Dennis Mayeaux,President of the Florida Academy of Family Physicians, which was published in todays Miami Herald. Yours Bernd Posted on Thu, Aug. 06, 2009 Key to reform is doctor access for all BY DENNIS MAYEAUX dennismayeaux@yahoo.com Comprehensive healthcare reform is a political and social challenge that has escaped this country for more than 30 years. This year, divergent interests are coming together to finally fix our healthcare system. There are proposals in Congress that would provide high quality, affordable healthcare and give people the choice of keeping their current insurance plan and their family physician, internist or other primary-care doctor. As a family physician, I see the effects of our broken healthcare system every day. Let's face it. Access to coverage is never guaranteed. It is not easy to treat patients who are uninsured because they can't afford coverage or are unable to get coverage because of age or a pre-existing condition. Every day even insured patients are refused care because of coverage denials. I am tired of seeing my patients struggle paying for the healthcare they need. Healthcare reform can't come soon enough. What does it take to make this happen? • We first need legislation that covers everyone, requiring insurance companies to sell plans regardless of family history, or pre-existing conditions, and to guarantee that patients can renew their coverage after they've become sick. • Legislation also needs to ensure that once people have insurance, they also have access to a primary-care physician. Unfortunately, there is a growing shortage of primary-care doctors to meet that need. The reformed system must value primary care if we want medical students to choose careers such as Family Medicine. We need family physicians to keep people healthy, provide early treatment for the most common health problems and coordinate comprehensive and seamless care when subspecialty attention is needed. There is some good news. We have a vehicle that can begin making all these improvements happen. It's called the Affordable Health Choices Act being debated in the U.S. Senate. The House of Representatives is considering a similar bill, which also includes a focus on primary care. These proposals promise to ensure affordable health coverage for nearly everyone. It's time to stop playing politics and solve the healthcare crisis. We must find a uniquely American solution that controls skyrocketing healthcare costs and gives our patients peace of mind when it comes to their healthcare. Our Surgeon General nominee, family physician Regina Benjamin, hopes to be ``America's Family Physician.'' Having a family physician is vital to every Floridian's health. Let us support that goal by providing access to all. Meaningful and sustainable healthcare reform is possible if Congress passes legislation that gives everyone in the United States access to a patient-centered medical home, where their doctor will ensure they get the care they need, when they need it and where they need it. Dr. Dennis Mayeaux is president of the Florida Academy of Family Physicians.

Why our AMA Supports Healthcare Reform

2009-07-27T19:46:00.001-07:00

I think that we need to respond to the misperception, even deliberate propaganda, that our AMA is not informing its members regarding its position towards healthcare reform.

There are multiple resources readily available from our AMA.

* AMA Web Site: http://www.ama-assn.org/ama/pub/advocacy/health-system-reform.shtml

* AMA News: http://www.ama-assn.org/amednews/

* Health System Reform Bulletin: http://www.ama-assn.org/ama/pub/news/newsletters-journals/health-system-reform-bulletin.shtml

Also a recent article highlights the important issue why our AMA supports health system reform initiatives (http://www.ama-assn.org/amednews/2009/07/27/gvl10727.htm )

"The AMA is supporting the legislation partly on the strength of its Medicare payment reform plan, which would spend an estimated $245 billion over 10 years to align physician rates more closely with the costs of providing care. But the Association also backed the bill because it would use health insurance market reforms to cover most Americans, offer a choice of plans to consumers through a health insurance exchange, dedicate new money to boost primary care services and address physician work force problems."

Lets not forget that we also face major Medicare payment cuts and our AMA is proactively involved preventing these cuts.

For more information see http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/payment-action-kit-medicare.shtml

Lets not use our AMA as the piñata de jour! Lets stand together and focus on the task ahead. Divided we will fail!

Yours

Bernd

AMA - Outreach Recruiter

Rogue FMA Board Member Goes Too Far

2009-07-23T22:59:00.000-07:00

A truly sad day for organized medicine when passion turned into blind hatred.

The attempted "apology" is pathetic and I hope that our leadership is taking the appropriate corrective action.

Our FMA deserves better and now is the time to come together to reconsider our position.

Yours

Bernd

Posted on Fri, Jul. 24, 2009

Doctor criticized over Obama e-mail

BY ADAM C. SMITH

St. Petersburg Times

A prominent St. Petersburg doctor and conservative activist has drawn a flood of criticism for e-mailing an image depicting President Obama as a witch doctor with a loin cloth, exotic head dress and bones in his nose.

``ObamaCare, coming soon to a clinic near you,'' reads the caption on the e-mail forwarded earlier this week by St. Petersburg neurosurgeon David McKalip.

Several popular liberal blogs, including Talking Points Memo, Huffington Post and Daily Kos, highlighted McKalip's e-mail Thursday and castigated him for racism. McKalip said he was flooded with calls from people attacking him over the e-mail, which he said he had forwarded to ``a limited group'' of about 150 people.

``I am not a racist. I am simply a person speaking up to make sure patients don't get hurt by the government and by insurance companies,'' said McKalip, who earlier this month organized ``tea party'' rallies across Florida denouncing Obama's healthcare overhaul proposals.

``Because I've been so effective in pointing out how the government plans are going to hurt patients in very serious ways the only way they can neutralize my message is to discredit me personally.''

McKalip, who has written guest columns for the St. Petersburg Times on tax and healthcare issues, teaches at the University of South Florida and is president-elect of the Pinellas County Medical Association and a board member of the Florida Medical Association -- which denounced McKalip's e-mail and urged him to apologize to President Obama.

He has become an increasingly visible political activist, founding advocacy groups including Cut Taxes Now, the Florida Taxpayers Alliance and Doctors for Patient Freedom.

McKalip noted that he helped organize a career counseling day several years ago for African-American Boy Scouts and blamed liberal activists for promoting the witch doctor image more than he ever did. He called the e-mail ``satire,'' but later Thursday night released a statement apologizing directly to Obama.

``I recognize that this image is offensive and hope that the nation refocuses on assuring all Americans have access to high-quality, affordable healthcare with no party interfering in the patient-physician relationship,'' McKalip said.

He is expecting protesters outside his office soon. The Daily Kos site is encouraging people to lodge complaints against him with his affiliated hospitals, USF, and the state Department of Health.

Adam C. Smith can be reached at asmith@sptimes.com

AMA Supports Reform

2009-07-23T21:10:00.000-07:00

Kudos to Dr.Cecil Wilson, President Elect of the AMA, whose letter to the editor was published in todays Miami Herald. He should be applauded for standing up for what we know is right: comprehensive healthcare reform benefiting all Americans. Thank you Dr. Wilson for your commitment to our profession and the public health. Bernd Wollschlaeger,MD,FAAFP,FASAM AMA Member & Outreach Recruiter ============================================================================ AMA to Miami Herald: AMA Supports Reform July 23, 2009 (published) Miami Herald Letter to the Editor Floridians without health-insurance coverage are in dire straits (Report: 3,560 Floridians will lose health insurance every week, July 16). For their sake, we must achieve meaningful healthcare reform that provides all Americans with access to affordable, high-quality coverage. The American Medical Association is committed to health reform this year that covers the uninsured, improves quality and ensures patients get the best value from healthcare spending. Important progress has been made with the House and Senate vigorously working on legislation. The AMA will stay actively engaged to make certain health reform that will improve the health of America's patients is accomplished. The uninsured crisis playing out in Florida is one that can be seen all across America. We must seize the opportunity this year to pass comprehensive health reform. Cecil B. Wilson, MD President-elect, American Medical Association

Is Our AMA in Trouble?

2009-07-01T19:29:00.000-07:00

s our American Medical Association in trouble? Well, an article by Nicholas Kristoff published in the New York Times on June 25^th provided some food for thought.

Yes, we know now that our AMA's position regarding a public insurance option is a maybe but not an outright no. Nevertheless, the heated debate within our organization and the ideological rigidity displayed by some has created the impression that the AMA is AGAIN opposed to any meaningful reform of our healthcare system. Right or wrong, the impression counts and its out there.

Furthermore, our membership is indeed dwindling and as an outreach recruiter I can attest to the fact that its getting harder and harder to convince doctors to join or rejoin. For some we are too soft and for others not tough enough. For some we are too much on the right, for others too much on the left. The media reports regarding our recent Annual meeting does not help in that effort either.

In Florida alone our membership decreased by 14%! Having listened and spoken to hundreds of doctors in South Florida I can list a few reasons that our leadership must consider:

Doctors in private practice want to have their problems addressed and resolved today, rather than tomorrow. They are afraid that they are being forced to close shop and merge with larger groups , or to end up as hospital employees. I visit private offices every week and many are on the verge of financial insolvency!
Far too much time is being wasted on ideologically-motivated debate, and too little on the development and deployment of practical practice solutions. Talk the Talk, or Walk the Walk?
Our AMA delegation is comprised of individuals representing their own political interest and are detached from the constituents they supposedly should represent.

Therefore, I have resigned from the AMA delegation and return to where I came from: union style grass-root organizing, listening to our members and to find alternative modalities of membership representation. The Web 2.0 technology demonstrates what a few can do using these tools, and they can successfully bypass the encrusted and inflexible structures of organized medicine.

The time for change has come even for our AMA. The questions remains: will our AMA embrace or resist change? Thats an existential question for our organization and circling the wagons will only hasten our demise.

Looking forward to your comments.

Bern Wollschlaeger,MD,FAAFP,FASAM

AMA Member

June 25, 2009

OP-ED COLUMNIST

The Prescription From Obama’s Own Doctor

By NICHOLAS D. KRISTOF

As a society, we trust doctors to be more concerned with the pulse of their patients than the pulse of commerce. Yet the American Medical Association is using that trust to try to block a robust public insurance option as part of health reform.

In fact the A.M.A. now represents only 19 percent of practicing physicians (that’s my calculation, which the A.M.A. neither confirms nor contests). Its membership has declined in part because of its embarrassing historical record: the A.M.A. supported segregation, opposed President Harry Truman’s plans for national health insurance, backed tobacco, denounced Medicare and opposed President Bill Clinton’s health reform plan.

So I hope President Obama tunes out the A.M.A. and reaches out instead to somebody to whom he’s turned often for medical advice. That’s Dr. David Scheiner, a Chicago internist who was Mr. Obama’s doctor for more than two decades, until he moved into the White House this year.

“They’ve always been on the wrong side of things,” Dr. Scheiner told me, speaking of the A.M.A. “They may be protecting their interests, but they’re not protecting the interests of the American public.

“In the past, physicians have risked their lives to take care of patients. The patient’s health was the bottom line, not the checkbook. Today, it’s just immoral what’s going on. It’s abominable, all these people without health care.”

Dr. Scheiner, 70, favors the public insurance option and would love to go further and see Medicare for all. He greatly admires Mr. Obama but worries that his health reforms won’t go far enough.

Dr. J. James Rohack, the president of the A.M.A., insisted to me that his group is committed to making health insurance accessible for all Americans, and that its paramount concern is patient health.

“When you don’t have health insurance, you live sicker and you die younger,” he said. “And that’s not something we’re proud of as Americans.”

He added that the A.M.A. is not necessarily opposed to a public option, and I have the impression that it might accept a pallid one built on co-ops. Dr. Rohack wouldn’t repudiate his association’s letter to the Senate Finance Committee warning against a new public plan. That letter declared: “The introduction of a new public plan threatens to restrict patient choice by driving out private insurers.”

I don’t mind the A.M.A. lobbying on behalf of doctors in the many areas where physicians and patients have common interests. The association is dead right, for example, in calling for curbs on lawsuits, which raise medical costs for everyone.

An excellent study published in 2006 in The New England Journal of Medicine found that for every dollar paid in compensation as a result of lawsuits against doctors, 54 cents goes to legal and administrative costs.

That’s an absurd waste of money. Moreover, aggressive law leads to defensive medicine, in the form of extra medical tests that waste everybody’s money. Tort reform should be a part of health reform.

Yet when the A.M.A. uses its lobbying muscle to oppose major health reform — yet again! — that feels like a betrayal. Doctors work hard to keep us healthy when we’re in their offices, and that’s why they win our trust and admiration — yet the A.M.A.’s lobbying has sometimes undermined the health of the very patients whom the doctors have sworn to uphold.

I might expect the American Association of Used Car Dealers to focus exclusively on wallet-fattening, but we expect better of physicians.

In fairness, most physicians expect better as well, which is why the A.M.A. is on the decline.

“It’s what has led to the decline of the A.M.A. over the last half century,” said Dr. David Himmelstein, a Massachusetts physician who also teaches at Harvard Medical School. “At this point only one in five practicing doctors are in the A.M.A., and even among its members about half disagree with its policies.” To back that last point, Dr. Himmelstein pointed to surveys showing a surprising number of A.M.A. members who support a single-payer system.

For his part, Dr. Himmelstein co-founded Physicians for a National Health Program, which now has more than 16,000 members. The far larger American College of Physicians, which is composed of internists and is the second-largest organization of doctors, is also open to a single-payer system and a public insurance option. It also quite rightly calls for emphasizing primary care.

The American Medical Student Association has issued a sharp statement disagreeing with the A.M.A.

The student association declared that it "not only supports but insists upon a public health insurance option."

Look, a public option is no panacea, and it won’t automatically set right the many shortcomings in our health system. But if that option is killed in gestation, then we’re back to Square 1 and there’s little hope of progress in solving the vast challenges confronting us.

So, President Obama, don’t listen to the A.M.A. on this issue. Instead, for starters, call your doctor!

Prescription Drug Overdose

2009-07-01T18:55:00.001-07:00

On June 23, 2009 Florida Gov. Charlie Crist has signed legislation aimed at curbing the growing black market of illegal prescription drugs flowing from South Florida pain clinics across the eastern United States. The new law, passed nearly unanimously in the Legislature, will require doctors and pharmacists to record patient prescriptions for most drugs in a state-controlled database.

Its about pain to reign in on the explosive growth of "pain clinics" in South Florida operated by unscrupulous owners, some associated with the criminal underworld and organized crime.

The number of overdose deaths are soaring, too!

Unfortunately, the prescription drug monitoring program cannot be implemented until the end of 2011 and so far funding is pending.

As physicians we must continue to push for the comprehensive implementation of such program because our patients and fellow citizens are being harmed by drug dealers in a white coat.

Lets not be complacent but proactive. We just won ONE battle but not the war against drugs.

Yours

Bernd

Posted on Tue, Jun. 30, 2009

Prescription drug overdose deaths soar in Florida

BY SCOTT HIAASEN

shiaasen@MiamiHerald.com

Florida continues to see a rapid rise in fatal overdoses caused by prescription-drug abuse -- a trend fueled by a cottage industry of cash-only pain clinics -- while deaths from illegal drugs wane, according to a report from the state's medical examiners released Tuesday.

Nearly 1,000 deaths were caused in 2008 by the potent painkiller oxycodone -- a 33 percent increase from 2007, the report says. Four years ago, only 340 deaths statewide were attributed to oxycodone, the most popular drug in the black-market pill trade supplied by pain clinics.

Conversely, deaths from cocaine overdoses declined by 23 percent, to 648 in 2008.

Overall, prescription drugs accounted for 75 percent of the drugs found in overdose victims last year, the report says.

''The magnitude and severity of prescription drug abuse calls for strong, coordinated action,'' said Bill Janes, the director of the state's Office of Drug Control, in a written statement.

Florida took a step in that direction when the Legislature passed a law creating a statewide database to monitor prescription sales and increasing oversight of pain clinics, which operate with little scrutiny.

The prescription database is designed to detect addicts and drug dealers buying pills from multiple doctors -- often by faking ailments or medical records -- a practice known as ``doctor shopping.''

''It's almost impossible to monitor different people shopping doctors,'' said Dr. Joshua Perper, Broward County's medical examiner. ``A person can get hundreds or thousands of pills.''

This can also lead to dangerous drug combinations. Perper said the most common overdoses involve mixing several drugs, with oxycodone and anti-anxiety drugs such as Xanax and Valium among the most common combinations.

Though the new prescription monitoring law takes effect Wednesday, the database is not expected to begin operating until late next year.

Broward has become the nation's capital of illegal prescription drug trafficking, police say, with nearly 100 storefront pain clinics feeding a black market in pain pills stretching through Kentucky, Ohio, Tennessee, West Virginia and Massachusetts. Florida leads the nation in oxycodone sales -- largely because of these clinics -- according to U.S. Drug Enforcement Administration data.

In 2008, Perper's office detected oxycodone in 171 Broward County overdose deaths -- more than twice the number found in 2005.

The highest number of oxycodone overdoses were reported in Pinellas and Pasco counties, where the drug was detected in 308 deaths last year.

The medical examiner in that district, Dr. Jon Thogmartin, attributes the unusually high number to advanced detection techniques employed by his lab.

''Prescription drugs have really begun, to a significant degree, to replace illicit drugs,'' Thogmartin said.

Thogmartin said many victims overdose on pills prescribed to them by licensed doctors.

To health advocates, this shows that doctors practicing as pain-management specialists need more training and more oversight from the state medical board.

''It's unacceptable to open up a practice and call yourself a pain management physician and start writing prescriptions,'' said Dr. Laura Brown, a Bradenton physician on the board of the American Society of Interventional Pain Physicians. ``That's not pain management.''

Medicare Fraud Continues!

2009-06-29T19:11:00.001-07:00

Crackdown on Medicare fraud

On several occasions I reported on this blog http://floridadocs.blogspot.com/ about the audacious and callous Medicare fraud and abuse activity here in South Florida. During my tenure as DCMA President I met twice with representatives and senior executives of First Coast Service Options (FCSO) , the regional Medicare administrator, to discuss and understand why on one hand doctors in South Florida are being nickeled and dimed for legitimate services rendered but on the other hand billions of dollars are being paid out for obvious fraudulent claims. The most egregious example is the ongoing payment for HIV infusion “treatments” which, according to the court testimony of a leading HIV treatment expert, are obsolete, replaced for years by more effective oral antiretroviral drugs and not being utilized in clinical practice anymore. In most cases unscrupulous clinic owners, aided and abetted by medical doctors, set up such HIV Infusion clinics, recruited Medicare recipients suffering from HIV/AIDS and billed Medicare for services never rendered, In a series of award winning articles published in the Miami Herald Jay Weaver pointed out the continuous payment for those “services “ despite assurance made by First Coast Service Options that the payment were ceased. In a meeting with FCSO I personally received assurances that “ no such checks are being issued anymore.” Obviously, thats not the truth. I a recent article published on Saturday, June 27th 2009 http://www.miamiherald.com/news/front-page/v-print/story/1116390.html Experts estimate Medicare loses at least $60 billion to fraud every year, with Miami-Dade County at the center of the national crisis. I a recent crackdown agents broke up a Miami-based ring that allegedly schemed to defraud Medicare of $100 million by filing false claims for obsolete HIV therapy across five states. Two of the eight suspects have fled to Cuba.The organization, which was paid $30 million by the federal health insurance program, exported a fraudulent local business enterprise to Georgia, Louisiana, North Carolina and South Carolina by using empty storefronts and post office boxes, authorities said. What is being done to stop the bleeding of precious Medicare dollars? Well, I personally have written letters to the editors of local newspapers pointing out the obvious mismanagement of funds by FCSO. I have written to each and every member of the congressional delegation from Florida and only ONE responded advising me to contact the Officer of Inspector General to file a complaint! Thats it! Meanwhile, Medicare still considers such treatment "reasonable and necessary" and continues to pay hundreds of millions of dollars for fraudulent claims every year. FCSO refuses to consider the one and ONLY option: stop payment of ALL HIV infusion therapy claims in Florida/South Florida. The response: We can't because patients who actually need the treatment would be denied services -- a policy no-no at Medicare. But experts have testified that no one needs this treatments anymore!! If any patient would require such treatment it would be an exception and Medicare could consider payment on a case by case basis! Lets be clear: Medicare officials know the claims are fraudulent. Medicare says it has adopted technology to block false claims for HIV infusion treatment, yet the government program still misses hundreds of millions of dollars annually. To add insult to injury on September 12th, 2008 the Centers for Medicare & Medicaid Services (CMS) announced that First Coast Service Options, Inc. (FCSO) has been awarded a contract of up to five years for the combined administration of Part A and Part B Medicare claims payment in Florida, Puerto Rico, and U.S. Virgin Islands. This represents not only a contract renewal but EXPANSION! In a press release CMS emphasized that “ with this award, CMS continues its progress in reengineering the way in which the government contracts for claims administration for the largest part of the Medicare program. CMS is seeking the best value, from a cost and technical perspective for this critical function.” The “best value” they probably get from FCSO is the waste of Medicare dollars! But they do not stop here! FCSO will be financially awarded too! In the same press release CMS officials emphasized that “ the contract for FCSO includes a base period and four one-year options and will provide FCSO with an opportunity to earn award fees based on its ability to meet or exceed the performance requirements set by CMS.” So they can earn extra dollars on the fraudulent claims amount?

So what can be done:

1)Call, e-mail or write your representative and/or Senator to hold FCSO responsible for every dollar wasted.

2)Petition the Office of Inspector General of the US Department of Health & Human Services at HHSTips@oig.hhs.gov to investigate FCSO business activities.

3)Force FCSO to repay each and every dollar of fraudulent claims paid and hold company executives legally accountable for their actions (or inactions)

In times of financial crisis we all have to act in a cautious manner exercising our duties , obligations and responsibilities as citizens. The blatant abuse of the Medicare system has to stop!

Yours

Bernd

"Medical Fascism:' Fact or Fiction?

2009-06-06T20:20:00.001-07:00

I was initially surprised but then dismayed reading in an e-mail message and later on a web site posting by the same author that the

" the greatest threat to American patients in the history of our country.. is the rise of Medical Fascism. Some may wonder - what happened to socialized medicine, isn't that the great threat? While it is true that there are attempts to socialize medical care, the fact is that the power players in Washington are ready to set the rules and then hand the keys of health care spending over to large health insurance companies. This is the definition of fascism: the state decides what corporations will do and the corporations do their bidding while making a profit. As it turns out the very corporations making the profit also control the government."

In a different e-mail the author also calls upon the Florida Medical Association to support a series of public events to " Join up with your local tea party group for marches across the nation on Medical freedom planned by July 4th. Let Congress know you want medical freedom, not medical fascism."

I am concerned not only because I witnessed the devastating effect of REAL Fascism in Europe but because I feel very strongly that the inappropriate use of such a term applied to current politics is an insult to the sacrifice of American patriots who fought in WWII to liberate Europe from Fascism and an affront to the millions of victims of Fascist genocide and mass murder.

What is Fascism? Well, according to Merriam-Webster's Online Dictionary Fascism is " a political philosophy, movement, or regime (as that of the Fascisti) that exalts nation and often race above the individual and that stands for a centralized autocratic government headed by a dictatorial leader, severe economic and social regimentation, and forcible suppression of opposition."

According to Robert O. Paxton, a professor emeritus at Columbia University, he defines fascism in his book "The Anatomy of Fascism" as:

"A form of political behavior marked by obsessive preoccupation with community decline, humiliation or victimhood and by compensatory cults of unity, energy and purity, in which a mass-based party of committed nationalist militants, working in uneasy but effective collaboration with traditional elites, abandons democratic liberties and pursues with redemptive violence and without ethical or legal restraints goals of internal cleansing and external expansion."

NONE of these descriptions define our current political system, in which we have democratically elected a President, democratically elected our representatives on state and national level and maintain the separation of power to PREVENT the emergence of authoritarian and dictatorial rule.

I therefore URGE the leadership of the Florida Medical Association NOT to endorse or support any activities intended to promote the dissemination of such falsehoods which are intended to incite anger and fear and which will separate but not unite us.

I wholeheartedly support the freedom of expression. Nevertheless, such freedom implies responsibility to abstain from any incitement, too.

Our leadership has to decide if we want to represent all doctors in our State, even if we may have different political, social and religious views, or if we want to amplify the radical view of a minority!!

Thats the choice and so far I have not heard ONE of our leaders distancing him- or herself from the opinion expressed by the author who introduce the term "Medical Fascism."

I definitely do so here in public and I will continue reminding others to do the same.

Yours truly,

Bernd Wollschlaeger,MD,FAAFP, FASAM

Prescription Drug Legislation Faces Opposition

2009-05-08T20:54:00.001-07:00

Attached an article from the Palm Beach Post regarding the prescription drug legislation. I hope that our organization speaks up in FAVOR of the legislation and AGAINST the request to torpedo this bill. This legislation is the first step towards curbing the narcotic abuse. The argument that " the sensitive personal and medical information contained in such a database would be susceptible to cyber terrorists and criminals who would use information against the citizens of Florida," is ludicrous! Does that mean we will also stop using ATMs and Internet banking because our data could be misused by cyber terrorists or criminals? When do politicians learn that fear-based politics is leading us nowhere? We need to save lives and stop those drug-dealers in a white coat who claim to be doctors! They are not! They are drug dealers and they know it! Please visit South Florida to understand the enormity of the problems. The number of pain clinics skyrocketed almost 100 % since last year! The nations TOP 30 narcotic drug prescriber's practice in Dade and Broward county! Hard to believe but its true. Doctors can be drug dealers, too!! Yours Bernd ============================================================================ Drug database access worries some in Florida House By MICHAEL C. BENDER Palm Beach Post Capital Bureau Thursday, May 07, 2009 TALLAHASSEE — Thirteen state House Republicans sent a letter to Gov. Charlie Crist on Thursday, asking him to veto a bill one of their fellow GOP leaders sponsored. Ten of the 13 lawmakers voted against the bill to create a prescription drug database in Florida. Three of the Republicans - Adam Hasner of Boca Raton, Anitere Flores of Miami and Dean Cannon of Winter Park - did not vote on the original bill. The bill, sponsored by House budget co-chairman Marcelo Llorente, R-Miami, is aimed at curbing drug abuse. It was approved unanimously in the Senate and on a 113-10 vote in the House. But a similar database was recently hacked in Virginia, according to TheWashington Post. House Republicans cited that story in their letter to Crist. "This request is based on a well founded fear that the sensitive personal and medical information contained in such a database would be susceptible to cyber terrorists and criminals who would use information against the citizens of Florida," according to the letter. Crist's press office did not comment. Llorente said the bill (SB 462) creates a task force that will "ensure the protection of personal information." "The tragic deaths of almost 10 Floridians a day must stop," Llorente said. "I urge the governor to sign this bill expeditiously in an effort to end the practice of doctor shopping." In addition to Hasner, other local Republican lawmakers signing the letter were Reps. Ellyn Bogdanoff of Fort Lauderdale and Carl Domino of Jupiter.

Tamiflu and Public Health

2009-05-02T22:25:00.000-07:00

I am gravely concerned about the generous use (or abuse) of Tamiflu. Lately, I have been pressured by patients to prescribe Tamiflu " just in case to have it at home." I often deny the request to avoid the prophylactic use of Tamiflu and argue as follows:

The " regular flu" kills approximately 36,000 Americans annually and I still have a hard time convincing people to get their flu shot. In comparison,17 countries have reported 653 cases of H1N1 and 17 Mexicans have died.In the US 160 cases have been confirmed and only one patient has died in the US so far!
Outside Mexico the virus does not appear to be severe, and this virus might not be any more virulent than normal seasonal flu infections.
Scientists are encouraged by initial analyses of the DNA sequence of the virus, which has found it lacks the traits that led to the death of nearly 50m people in the 1918 Spanish flu outbreak.
A WHO medical health officer, said the biggest concern was that the virus could mutate and become resistant to Tamiflu, the anti-viral drug. This could be accelerated by the indiscriminate use of Tamiflu fueled by doctors who mean well but may cause greater harm to the public health by prescribing the drug to any one requesting it.
The Centers for Disease Control in Atlanta, Georgia, says 98% of existing H1 flu strains were resistant to Tamiflu in the last flu season. Scientists are struggling to understand why this is.Dr Nikki Shindo, a WHO medical health officer, said that he worst-case scenario is the virus will mutate and become Tamiflu-resistant. The best-case scenario is that it causes only mild illness and continues to respond to Tamiflu.

What Can We Do?

Please DO NOT prescribe Tamiflu unless their is a reasonable concern that the patient suffers from the flu and diagnostic testing was initiated (nasal swab). For more information about proper testing procedures see http://www.cdc.gov/h1n1flu/.

Tamiflu overuse can lead to resistance and the drug itself can cause significant side affects and even serious reactions (see http://www.drugs.com/sfx/tamiflu-side-effects.html)

I hope someone will listen and please forward this e-mail to anyone interested.

Yours

Bernd

Swine Flu, 04/26/2009

2009-04-26T11:50:00.001-07:00

Investigation and Interim Recommendations:

Swine Influenza (H1N1)

CDC, in collaboration with public health officials in California and Texas, is investigating cases of febrile respiratory illness caused by swine influenza (H1N1) viruses. As of 11 AM (EDT) April 25, 2009, 8 laboratory confirmed cases of Swine Influenza infection have been confirmed in the United States. Four cases have been reported in San Diego County, California. Two cases have been reported in Imperial County California. Two cases have been reported in Guadalupe County, Texas. Of the 8 persons with available data, illness onsets occurred March 28-April 14, 2009. Age range was 7-54 y.o. Cases are 63% male.

The viruses contain a unique combination of gene segments that have not been reported previously among swine or human influenza viruses in the U.S. or elsewhere. At this time, CDC recommends the use of oseltamivir or zanamivir for the treatment of infection with swine influenza viruses. The H1N1 viruses are resistant to amantadine and rimantadine but not to oseltamivir or zanamivir. It is not anticipated that the seasonal influenza vaccine will provide protection against the swine flu H1N1 viruses.

CDC has also been working closely with public health officials in Mexico, Canada and the World Health Organization (WHO). Mexican public health authorities have reported increased levels of respiratory disease, including reports of severe pneumonia cases and deaths, in recent weeks. CDC is assisting public health authorities in Mexico by testing specimens and providing epidemiological support. As of 11:00 AM (EDT) April 25, 2009, 7 specimens from Mexico at CDC have tested positive for the same strain of swine influenza A (H1N1) as identified in U.S. cases. However, no clear data are available to assess the link between the increased disease reports in Mexico and the confirmation of swine influenza in a small number of specimens. WHO is monitoring international cases. Further information on international cases may be found at: http://www.who.int/csr/don/2009_04_24/en/index.html

Clinicians should consider swine influenza infection in the differential diagnosis of patients with febrile respiratory illness and who 1) live in San Diego or Imperial counties, California, or Guadalupe County, Texas, or traveled to these counties or 2) who traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in one of the three U.S. counties or Mexico during the 7 days preceding their illness onset.

Patients who meet these criteria should be tested for influenza, and specimens positive for influenza should be sent to public health laboratories for further characterization. Clinicians who suspect swine influenza virus infections in humans should obtain a nasopharyngeal swab from the patient, place the swab in a viral transport medium, refrigerate the specimen, and then contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory. CDC requests that state public health laboratories promptly send all influenza A specimens that cannot be subtyped to the CDC, Influenza Division, Virus Surveillance and Diagnostics Branch Laboratory.

Persons with febrile respiratory illness should stay home from work or school to avoid spreading infections (including influenza and other respiratory illnesses) to others in their communities. In addition, frequent hand washing can lessen the spread of respiratory illness.

CDC has not recommended that people avoid travel to affected areas at this time. Recommendations found at http://wwwn.cdc.gov/travel/contentSwineFluUS.aspx will help travelers reduce risk of infection and stay healthy.

Clinical guidance on laboratory safety, case definitions, infection control and information for the public are available at:http://www.cdc.gov/swineflu/investigation.htm.

Swine Influenza A (H1N1) Virus Biosafety Guidelines for Laboratory Workers: http://www.cdc.gov/swineflu/guidelines_labworkers.htm
Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting: http://www.cdc.gov/swineflu/guidelines_infection_control.htm
Interim Guidance on Case Definitions for Swine Influenza A (H1N1) Human Case Investigations: http://www.cdc.gov/swineflu/casedef_swineflu.htm

Morbidity and Mortality Weekly Reports Dispatch (April 24) provide detailed information about the initial cases at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0424a1.htm

For more information about swine flu: http://www.cdc.gov/swineflu

Drug Dealers in a White Coat

2009-04-13T22:04:00.001-07:00

Posted on Mon, Apr. 13, 2009

Public health should be legislative priority

Re the April 8 editorial Belatedly, Florida takes on prescription-drug dealers: The unprecedented concentration of ''pain clinics'' in our community contributes to out-of-control opioid abuse, narcotic-drug dealing and endangers public health. It requires the concerted efforts of law enforcement, political leadership and the medical community to root out this problem. Several steps can be taken right now:

• Impose a moratorium on dispensing narcotics in physician's offices unless the prescribing physician is board certified in anesthesiology and pain medicine and operates within a licensed and certified facility to be approved by a designated agency.

• Make mandatory monthly inspections of all pain clinics in South Florida. Skilled inspectors can be trained to randomly audit charts and on-site pharmacies and monitor patient flow.

• Conduct criminal background checks of all operators and their financial backers, which will be reviewed and updated quarterly.

• Implement a prescription-drug monitoring system to identify drug-seekers and doctor-shoppers.

• Require the Board of Medicine to suspend the license of any physician who violates the standards of care as it pertains to inappropriate prescription of narcotics.

Let's act together to rid our community of these narco-cowboys. Let's protect our families, friends and patients from such predators. We can't be afraid to call them by their name: drug dealers in white coats.

BERND WOLLSCHLAEGER, MD, president, Dade County Medical Association, North Miami Beach

Every American is entitled to affordable healthcare!

2009-04-03T22:03:00.001-07:00

Saturday, April 4, 2009

Letter To The Editor

“Every American is entitled to affordable healthcare!”

The Miami Herald Editorial Board is correct: every American should have access to affordable healthcare delivered by a physician of their choice. But expanding coverage only increases the volume of healthcare services and costs! This shortsighted focus misses the bigger picture.
We have to realign our payment system and reward quality and not the quantity of medical services rendered. The current reimbursement system is centered on a volume-based model and must shift towards a value-based system instead. We have to rebuild our primary care system and reward family physicians who spent valuable time with patients teaching healthy lifestyle and nutrition to prevent the incidence of chronic diseases. We should motivate and reward physicians to integrate their practices within collaborative practice models or groups. Utilizing shared Electronic Health Records based on Web 2.0 technologies physicians can communicate easily and securely. Such systems can measure and compare their performance, create a framework for quality and not quantity based reimbursement. Furthermore, physicians will learn to work within a team of medical professionals to optimize the treatment outcome for their patients.
As a result of the above outlined steps we can finally provide a Patient Centered Medical Home with a high degree of personalized care coordination, access beyond the acute care episode, and identification of key medical and community resources to meet the patients’ needs.
We as physicians have the choice to proactively change the delivery of healthcare today! We have the tools available to make this happen. Lets not miss this opportunity!

Bernd Wollschlaeger,MD,FAAFP,FASAM - President, Dade County Medical Association
16899 NE 15th Avenue, North Miami Beach, FL 33162
Phone: (305) 940-8717
E-mail: info@miamihealth.com

=======================================================================================

MIAMI HERALD

Posted on Fri, Apr. 03, 2009
Health insurance out of balance

Among the many issues on America's healthcare-reform agenda, one deserving a high priority should be to level the playing field for people looking to buy health insurance. As it now stands, insurers have most of the advantages. Example: rejecting potential customers because of ''preexisting conditions.'' Congress and President Barack Obama should put a stop to this practice. Meanwhile, Florida Insurance Commissioner Kevin McCarty should ask the Legislature for reforms.
Patients blacklisted

In a Page One story last Sunday, Miami Herald reporter John Dorschner described how some insurers use secretive underwriting guidelines to blacklist people with certain ailments or who take certain drugs. For example, one insurer's guideline recommends rejecting people who have diabetes, multiple sclerosis, schizophrenia, Parkinson's Disease, Hepatitis C or AIDS/HIV. Other guidelines suggest automatic denial of people who take the anti-clotting drug Plavix or Seroquel, of those who use prescribed anti-psychotic medications, and anyone who uses certain medications for sleep apnea.

Insurers should not be expected to automatically enroll anyone who applies for a policy. They must be able to determine the amount of risk they are taking on in order to price policies appropriately and to earn a profit. Insurers also need to be able to protect themselves from people who lie about ailments in order to get coverage. At the same time, though, honest consumers should get a fair shake, which means not having to demonstrate a level of pristine health that virtually no one can attain. Without the right rules in place, insurers would cover only healthy people and have no risk at all.

Insurers say that their underwriting rules are based on standards set by the industry and by the state and federal governments. This is where change should begin. President Obama has said he wants to make insurance much more affordable and that having nearly 50 million Americans without health coverage is unacceptable. He stops short, however, of embracing universal healthcare.

A bit of progress

In December, some of the country's top insurers said they were willing to stop using preexisting conditions as a basis for pricing policies in return for laws requiring universal coverage. This, at least, is a start. Universal healthcare may, or may not, be the best solution, but it is clear that too many Americans have been squeezed out of the insurance market -- and that must change.

Commissioner McCarty can get the ball rolling by asking the Legislature to adopt underwriting guidelines that protect consumers. Congress should help President Obama make health insurance available to every American.

Ultrasound and Scope of Practice

2009-03-24T22:22:00.001-07:00

A measure that would require women seeking an abortion to get an ultrasound exam and have the option to view the scan was revived Wednesday. State law already requires sonograms for any abortion done more than three months into a pregnancy. The proposed bill would extend that provision to the first trimester, when most abortions take place. Under the proposed law, doctors must allow the woman a chance to see the scan, unless she signs a waiver declining that option. Doctors also would be required to provide information on fetal development. The bill provides exceptions to the ultrasound requirement in cases of medical emergencies or when the woman can provide documentation that she's a victim of rape, incest, domestic violence or human trafficking. Proponents of the measure argue that the ultrasound provision helps women make informed medical decisions and helps doctors prevent complications. Opponents argue the provision is a veiled effort to create an added hurdle for women. They say doctors -- not the Legislature -- should make the decision to perform an ultrasound. Personally, I am surprised that organized medicine would support such a measure which clearly provides the legislator the authority to dictate how a doctor should practice medicine. We struggle every year to prevent the expansion of the scope of practice. Now,legislators WITHOUT medical training or license to practice medicine is telling us HOW to practice medicine? I urge all of my colleagues to STOP this measure! Contact your legislator and ask them NOT to support this legislation. Posted on Thu, Mar. 19, 2009 Ultrasound abortion provision revived in Florida House BY BREANNE GILPATRICK A measure that would require women seeking an abortion to get an ultrasound exam and have the option to view the scan was revived Wednesday, after the state Senate rejected a similar proposal last year in a dramatic 20-20 tie vote. Following more than an hour of debate, the House Health Care Regulation Policy Committee cast a party-line vote in favor of the bill, with Republican supporters saying the ultrasound provision helps women make informed medical decisions and helps doctors prevent complications. ''I think that any time that anybody has more information when they're going in for a medical procedure I think that's a good thing,'' said Rep. Anitere Flores, a Miami Republican who is sponsoring the bill along with Rep. Rachel Burgin, R-Brandon. Opponents argue the provision is a veiled effort to create an added hurdle for women. They say doctors -- not the Legislature -- should make the decision to perform an ultrasound. ''I think that this is a very difficult decision that women make and we should not continue to put hurdles up and chip away at current law,'' said Rep. Kelly Skidmore, D-Boca Raton, who voted against the bill along with Rep. Ari Porth, a Coral Springs Democrat. State law already requires ultrasound scans -- also referred to as sonograms -- for any abortion done more than three months into a pregnancy. The proposed bill would extend that provision to the first trimester, when most abortions take place. Under the proposed law, doctors must allow the woman a chance to see the scan, unless she signs a waiver declining that option. Doctors also would be required to provide information on fetal development. The bill provides exceptions to the ultrasound requirement in cases of medical emergencies or when the woman can provide documentation that she's a victim of rape, incest, domestic violence or human trafficking. Lawmakers in several other states also have proposed bills imposing various ultrasound requirements. Ultrasounds are currently required before all abortions in Alabama, Mississippi, Louisiana and South Dakota. This is the third year in a row that the Florida Legislature has debated similar ultrasound bills. The proposal cleared the GOP-dominated House in previous attempts but failed once because the Senate would not take up the issue, and most recently when seven Republican senators joined 13 Democrats to defeat the bill. This year, Sen. Andy Gardiner, R-Orlando, is sponsoring the Senate version of the proposal. Some of the bill's supporters believe the measure has a better chance of passing this session because at least one of the senators who previously voted against the bill has been replaced by a more conservative member. However, the bill is set to pass through the Senate Health Regulation Committee, where five of the committee's eight members say they are opposed to the bill or have voted against it in the past. Breanne Gilpatrick can be reached at bgilpatrick@MiamiHerald.com

South Florida Doctor Cares for the Uninsured

2009-03-19T18:47:00.000-07:00

Attached some bad and good news regarding the situation of the Uninsured in Florida.

Whats the BAD news?

The Miami Herald today reported that according to recent Census Bureau report more than five million Floridians were uninsured for at least a month during 2007 and 2008.

That works out to 38.1 percent of residents under 65. Almost four out of five of those were uninsured for six months or more, the report said.

Those figures reveal that Florida is slightly worse than the national average of 33.1 percent uninsured at some point during 2007 and 2008.

Other information from the study about Florida:

• More than four out of five uninsured Floridians, or 80.8 percent, were in working families.''

• More than three-fifths, or 60.7 percent, were individuals or families with incomes below twice the poverty line -- $42,400 of annual income for a family of four.''

Hispanics and African Americans were much more likely to be uninsured than non-Hispanic whites: 54.4 percent of Hispanics, 42.5 percent of African Americans, compared to 30.2 percent of non-Hispanic whites.

The study was based on the most recent Census Bureau reports and the Agency for Health Care Research and Quality.

Whats the GOOD news?

Some doctors are doing something about it and one of them, a South Miami radiologist, was featured in the Miami Herald.
Congratulation Dr. Kallos and we shoukld honor her as an outstanding doctor and humanist.

============================================================================
Posted on Thu, Mar. 19, 2009
South Florida doctors offer options for uninsured

BY JOHN DORSCHNER
With the number of uninsured rising daily, a prominent South Miami radiologist is offering free mammogram screenings for women who have lost their jobs and health insurance.
''In the spirit of Barack Obama, we need to volunteer to help our country,'' said Nilza Kallos, who operates the Breast Health Center and Diagnostic Ultrasound.

She challenged other physicians to make similar offers. ''This could be like an invitation to other doctors to step up,'' she said.

``I've heard surgeons say they don't have enough work. Well, how about helping those who need help?''

Kallos' offer comes as many financially pressed patients are curtailing care because they can't afford it. Some are insured and can't even afford the co-payments. Few doctors in South Florida are matching Kallos' free offer, but many in Broward and Miami-Dade are offering discounts to those who need them.

''The situation has reached the crisis stage,'' says Bernd Wollschlaeger, a North Miami Beach physician and president of the Dade County Medical Association.

``I think we need to do something.''

He says he and others are lowering their prices for their uninsured patients or giving them other help if they can't afford to pay. ''If you donate some of your time, it comes back to help you,'' because patients will remember helpful doctors when the economy improves.

Tony Prieto, president of the Broward County Medical Association, said in a statement: ``Patients need to understand that doctors have bills to pay, staff salaries, and office expenses, but we are compassionate, reasonable people who want to help our patients.

``Patients who have lost their insurance should know that most doctors are willing to work with their patients, set up payment plans and give cash discounts so that the patients can still have access to care.''

Those doctors include Barbara Martin, a Tamarac internist. ''In my office we are not charging for any visits to patients who are in bad situations,'' Martin wrote in an e-mail. ``Also we are trying to get them medications that they can afford at Wal-Mart, and samples at the office.''

''I would be happy to offer services discounted to anyone who has lost a job,'' wrote Richard Rubenstein, a Tamarac dermatologist, in an e-mail.

Some doctors note they have always offered help to the uninsured.

Alan Routman, a Fort Lauderdale orthopedic surgeon, said: ``I've been giving patients without insurance 30 percent discounts for cash or credit-card payments forever.''

The burden of more people seeking cheaper healthcare often falls on publicly-funded health centers, who take all patients regardless of whether they have insurance. Jennifer Capezzuti, a primary care doctor at Broward Health, notes that she has been spending ``excessive amounts of time evaluating patient's prescriptions and switching to generic alternatives.''

At the Breast Center in South Miami, Kallos has long been known as a doctor who reached out to help the community.

In 2008, she was honored as a ''Woman of Vision'' by the American Committee for the Weizmann Institute of Science.

''The worst thing,'' Kallos said, 'is when I hear a woman say, `Oh, I lost my job and my insurance. I'll skip my mammogram this year.' Well, this could cost her a life,'' if a cancer went untreated for a year.

Kallos said she might have to spread out the appointments over time if she is inundated by request for free services.

''If it's a regular mammogram, it can wait a little bit. But if she says she has a lump, we'll do that right away,'' she said.

Edited and Published by

Berdn Wollschlaeger,MD,FAAFP,FASAM
President,Dade County Medical Association

Primary Care Funding

2009-03-14T13:36:00.000-07:00

Dear Friends and Colleagues:
Attached a great article from todays Miami Herald focusing on efforts to boost primary care funding.
I wholeheartedly support such efforts but am concerned to direct the funding for community health center only!
Lets not forget that the overwhelming majority of primary care visits are being rendered in private doctors offices!
In order to adapt to the rapidly changing healthcare market place those offices need the following:

Logistical support to form collaborative practice networks to leverage their purchasing power, reduce administrative overhead, optimize practice management, access to skilled and trained human resources etc.
Educate physicians and staff on how to integrate their practices into the medical home delivery system
Optimize practice workflow to reduce patient error, increase quality and ascertain outcome
Install and implement state-of-the art medical information technology tools
Continuous assistance and support in the transformation process

This requires financial incentives, loans and grants and the active participation of specialty societies and other physician groups.
We must double our efforts to increase the workforce of primary care physicians. The clock is ticking.
Bernd

Posted on Sat, Mar. 14, 2009

Study: Florida would save money by boosting primary care

BY JOHN DORSCHNER

Legislators are expected to receive next week a research paper that concludes the state could save $700 million a year in healthcare costs by making sure Floridians had a place to go for primary care.

More basic screenings and preventive care would keep many people out of expensive trips to the emergency room, wrote four researchers from The George Washington University. At present, 3.8 million Floridians don't have insurance, the study reports, and eight million ``lack access to a regular source of primary healthcare.''

The report comes at a time when the Obama administration is pouring $10 million into Florida's community health centers as part of the stimulus package, and more money may be on the way.

The Florida Association of Community Health Centers plans to use the George Washington University study to make a case that the Legislature should double funding for public clinics next year -- from $15.3 million to $31 million. The group also favors a $1 per pack increase in cigarette taxes.

''We're not asking for a lot,'' said Andrew Behrman, president of the association. ``And it could do a lot to help Florida.''

Both Democratic and Republican policymakers say more emphasis on primary care is the best way to reduce overall healthcare costs, but finding the dollars to finance it has been a challenge.

Behrman's group advocates getting the $31 million from the billion-dollar Lower Income Pool, made up of federal and local tax dollars intended for institutions that do the most for the poor and uninsured, such as the large public hospitals.

Anthony Carvalho, president of the Safety Net Hospital Alliance of Florida, which includes the Broward and Miami-Dade public hospitals, said, ''We think primary care initiatives are good,'' but he wasn't certain whether LIP is the best way to fund.

At present an LIP council, led by large public hospitals, recommends to the Legislature how the pool money should be spent. The Safety Net group, whose members form the bulk of the council, favors its retention. The Health Centers group supports a bill to abolish the council.

Meanwhile, money is rolling in from Washington. The Broward Community and Family Health Centers in Hollywood is getting $1.3 million in stimulus money to expand operations.

Community Health of South Florida (was just informed by a federal agency that it could receive $995,000 to help its seven clinics assist the poor and uninsured.

CHI Chief Executive Brodes Hartley said the group's clinics treated 58,000 patients in 2007, 65,000 in 2008 and are expecting increased growth this year. Hartley said he hopes to use the new funds to hire another obstetrician-gynecologist to deliver babies in South Dade and for other matters.

Walmart and EHR

2009-03-12T21:59:00.001-07:00

Great idea? Successful EHR integration boils down to three components:
Installation-Implementation-Transformation
Most companies do a good job to install and implement a system but hardly provide any service on how to use an EHR to reduce costs, maximize outcome and improve quality. Basic question: how do they help me to transform my practice to achieve ROI (Return on Investment) and utilize the collected data to improve my financial performance.
Walmart may sell the product but what's happening afterwards if you need individualized support?
Bernd

March 11, 2009
Wal-Mart Plans to Market Digital Health Records System

By STEVE LOHR
Wal-Mart Stores is striding into the market for electronic health records, seeking to bring the technology into the mainstream for physicians in small offices, where most of America’s doctors practice medicine.

Wal-Mart’s move comes as the Obama administration is trying to jump-start the adoption of digital medical records with $19 billion of incentives in the economic stimulus package.

The company plans to team its Sam’s Club division with Dell for computers and eClinicalWorks, a fast-growing private company, for software. Wal-Mart says its package deal of hardware, software, installation, maintenance and training will make the technology more accessible and affordable, undercutting rival health information technology suppliers by as much as half.

“We’re a high-volume, low-cost company,” said Marcus Osborne, senior director for health care business development at Wal-Mart. “And I would argue that mentality is sorely lacking in the health care industry.”

The Sam’s Club offering, to be made available this spring, will be under $25,000 for the first physician in a practice, and about $10,000 for each additional doctor. After the installation and training, continuing annual costs for maintenance and support will be $4,000 to $6,500 a year, the company estimates.

Wal-Mart says it had explored the opportunity in health information technology long before the presidential election. About 200,000 health care providers, mostly doctors, are among Sam Club’s 47 million members. And the company’s research showed the technology was becoming less costly and interest was rising among small physician practices, according to Todd Matherly, vice president for health and wellness at Sam’s Club.

The financial incentives in the administration plan — more than $40,000 per physician over a few years, to install and use electronic health records — could accelerate adoption. When used properly, most health experts agree, digital records can curb costs and improve care.

But many, especially physicians in small offices, doubt the wisdom of switching to electronic health records, given their cost and complexity.

Only about 17 percent of the nation’s physicians are using computerized patient records, according to a government-sponsored survey published last year in The New England Journal of Medicine. The use of electronic health records is widespread in large physician groups, but three-fourths of the nation’s doctors work in small practices of 10 physicians or fewer.

Wal-Mart, however, has the potential to bring not only lower costs but also an efficient distribution channel to cater to small physician groups. Traditional health technology suppliers, experts say, have tended to shun the small physician offices because it has been costly to sell to them. Taken together, they make up a large market, but they are scattered.

“If Wal-Mart is successful, this could be a game-changer,” observed Dr. David J. Brailer, former national coordinator for health information technology in the Bush administration.

In the package, Dell is offering either a desktop or a tablet personal computer. Many physicians prefer tablet PCs because they more closely resemble their familiar paper notepads and make for easier communication with the patient, since the doctor is not behind a desktop screen.

EClinicalWorks, which is used by 25,000 physicians, mostly in small practices, will provide the electronic record and practice management software, for billing and patient registration, as a service over the Internet. This “software as a service” model can trim costs considerably and make technical support and maintenance less complicated, because less software resides on the personal computer in a doctor’s office.

Dell will be responsible for installation of the computers, while eClinicalWorks will handle software installation, training and maintenance. Wal-Mart is using its buying power for discounts on both the hardware and software.

Wal-Mart’s role, according to Mr. Osborne, is to put the bundle of technology into an affordable and accessible offering. “We’re the systems integrator, an aggregator,” he said.

The company’s test bed for the technology it will soon offer physicians has been its own health care clinics, staffed by third-party physicians and nurses. Started in September 2006, 30 such clinics are now in stores in eight states. The clinics use the technology Wal-Mart will offer to physicians.

“That’s where the learning came from, and they were the kernel of this idea,” Mr. Osborne said.

Health IT and Medical Economics

2009-03-09T18:59:00.001-07:00

"It is very easy to scare people with lies. It is much, much harder to educate them with facts.
But effective persuasion does not depend entirely on facts. It also depends on credibility, honesty, simplicity, repetition, and organization. "

Attached two very interesting articles from "Health Affairs" dedicating an entire issue on Electronic Health Records http://content.healthaffairs.org/current.shtml
I highly recommend those articles to assist you in parsing out the myth and the facts.
Most industrialized nations USE EHRs but docs in the US still debating the issue based on perceived "facts" which resemble secular religious propositions that are not proved or demonstrated but considered to be self-evident.
Cooler heads must prevail. Rational thinking versus emotional knee-jerk-reflex reactions are required.
Its absolutely silly (and dangerous) to call those of us who support a coordinated health care delivery systems as "socialists" and "enemies" of the free-market system.
Any smart business man wants to control costs, ascertain quality and maximize outcome of the services rendered. Most docs don't seem to get this basic economic ABC and roll their eyes when I ask them about PL & cash flow& other financial performance statements.
We must adapt to a rapidly changing market place. If not we do not need a meteor impact to go extinct!

One great article is a must read:

* The Attack On Health IT And Comparative Effectiveness Research: A Warning For What Lies Ahead
* http://healthaffairs.org/blog/2009/03/04/the-attack-on-health-it-and-comparative-effectiveness-research-a-warning-for-what-lies-ahead

Attached the abstracts of some other articles in the same issue:

Health Information Technology: On The Fast Track At Last?

A MAJOR ANOMALY OF THE Information Age is that a huge sector of the U.S. economy has been so lacking—and for so long—in its use of information technology (IT). As dozens of major industries retooled themselves in the 1980s around new means of conveying, processing, and analyzing information, health care largely sat on the sidelines. We all suffered. How many deaths or injuries have occurred because clinicians lacked the right information about the right patient at the right time—when much or all of it could have been acted upon through the use of health IT?
Just why health care lagged so badly in adopting IT is a complex story, deeply interwoven with much of the sector’s lingering cottage-industry nature. More than half of doctors still practice in groups of four or fewer physicians; not surprisingly, a survey published in the New England Journal of Medicine (3 July 2008) suggests that only about one in eight physicians have even a basic electronic record system. Despite the substantial growth of e-prescribing, as Maria Friedman and colleagues note in this volume, the vast majority of doctors still write out their prescriptions by hand.

In the classic terms of a vicious cycle, the fact that health IT hasn’t been broadly adopted has almost certainly reinforced these cottage-industry tendencies—not to mention the many other failings of our health care enterprise. If you can’t or won’t share information across health care settings, the system inevitably remains much as the Institute of Medicine’s Crossing the Quality Chasm report summed up in 2001: insufficiently centered on patients, error-prone, needlessly inefficient, uncoordinated, and delivering vastly inadequate value for the dollars expended.

Now the overall health IT environment is changing, if not fast enough, as this issue of Health Affairs makes clear. One measure of progress is that plans are afoot in Washington to incorporate substantial health IT investments into an economic stimulus package, in hopes of boosting the economy while building the backbone of a twenty-first-century health care system. There’s already ample evidence that these technologies can and will be enablers of massive restructuring of health care delivery. In this issue’s Report from the Field, our journalism partnership with Kaiser Health News, Carleen Hawn reports on how a small but growing corps of clinicians are tapping into social-media tools such as Facebook to communicate with patients and reorganize their practices. And as Caroline Chen and colleagues record, when Kaiser Permanente introduced comprehensive electronic health records, complete with secure e-mail messaging between clinicians and patients, primary care office visits dropped by 25 percent. Can we seriously contemplate redressing the supposed primary care shortage by adding thousands more physicians before we get similar IT systems in place nationwide?

As the papers in this volume make clear, we shouldn’t embrace the likely benefits of health IT without ignoring the risks or the considerable implementation challenges ahead. Jos Aarts and Ross Koppel remind us that adoption of computerized physician order entry (CPOE) systems has been associated in some instances with unintended consequences—including, counterintuitively, more adverse drug events, not fewer. Deven McGraw and Linda Dimitropoulos and their colleagues argue that it will be critical to build public trust in health IT by addressing privacy concerns. That will be no small matter, since the combination of an unwieldy federal regulation and myriad contradictory state laws makes overall national policy on the privacy of health information a complete mess.

As of this writing, even assembling a health IT piece of a stimulus package is having its problems. Years of talk about standard-setting still hasn’t produced a sure-fire path to interoperability among competing proprietary health IT systems. If the goal is to share information broadly for the public’s benefit, why should taxpayers be asked to invest more in systems that won’t talk to each other? Talk about Bridges to Nowhere, IT-style! Surely a nation that once agreed on a common standard for the width of railroad tracks ought to be able to agree on interoperability of electronic health information. But we’re not there yet.

As momentum for health reform builds in Washington, addressing such concerns should be deemed every bit as important as broadening health insurance coverage or focusing on prevention. We thank the funders who made this well-timed thematic issue possible: the Markle Foundation, the California HealthCare Foundation, and the federal Agency for Healthcare Research and Quality.

Susan Dentzer, Editor-In-Chief

The Promises And Pitfalls Of Health Information Technology

Successful innovators leave no doubt that health information technology (IT) can have a dramatic impact on care, despite the challenges of implementation and adoption. The papers in the sections that follow describe efforts all along the continuum from large health care organizations to small independent physician practices.
Catherine Chen and colleagues document how adoption in Hawaii of Kaiser Permanente’s new comprehensive electronic health record (EHR) system—complete with secure e-mail messaging and "e-visits" between physicians and patients—has reduced enrollees’ old-fashioned office visits for primary care by more than 25 percent in four years. Next, Anna-Lisa Silvestre and colleagues report survey results describing how Kaiser’s patients value the convenience of online appointment scheduling, e-mail contact with their doctors, and instant access to lab test results. Stephen Parente and colleagues report on EHRs’ impact on patient safety and find some evidence of positive effects. Farzad Mostashari and associates then describe state-backed efforts to implement health IT among independent physician practices in Massachusetts and New York City.

Carleen Hawn’s Report from the Field on social media in health care focuses on how various organizations, physician practices, and patients are making growing use of these tools. Personal health records (PHRs)—either stand-alone or as patient-oriented complements to EHRs—have important potential in such areas as promoting better self-management for patients with chronic conditions. However, as James Kahn and colleagues report, PHRs are unlikely to fulfill their promise without improved health literacy and computer competency for many patients. Joy Grossman and colleagues describe how health insurers are developing and promoting PHRs but are also encountering lack of trust and privacy concerns among patients, providers, and payers.

Medicare’s apparently sure-fire strategy of promoting electronic prescribing with payment incentives has hit snags as well, Maria Friedman and colleagues report. A comparison by Jos Aarts and Ross Koppel of efforts under way in the United States and six other industrialized countries to implement computerized physician order entry (CPOE) systems shows advantages—even though adoption is slow, systems are often poorly integrated, they’re producing new and different types of errors, and users are frequently frustrated.

The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care

Catherine Chen, Terhilda Garrido, Don Chock, Grant Okawa and Louise Liang

Abstract

We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.

Health Information Technology And Patient Safety: Evidence From Panel Data

Stephen T. Parente and Jeffrey S. McCullough
The potential of health information technology (IT) to transform health care delivery has spurred health IT adoption and will likely contribute to increased investments in coming years. Although an extensive literature shows the value of health IT at leading academic institutions, its broader value remains unknown. We sought to estimate IT’s effect on key patient safety measures in a national sample. Using four years of Medicare inpatient data, we found that electronic medical records have a small, positive effect on patient safety. Although these results are encouraging, we suggest that investment in health IT should be accompanied by investment in the evidence base needed to evaluate it.

Healthcare Reform Summit And DCMA

2009-01-27T23:05:00.000-08:00

Tuesday, January 27, 2009

TO: The Honorable Donna Shalala, President of the University of Miami

RE: Healthcare Reform Summit Conversation: Missed Chances And Political
Opportunities

Dear Mrs. Shalala:

On Monday, January 26th 2009 the Dade County Medical Association received a fax informing us about the upcoming ‘Summit Conversations' to highlight the emerging national consensus on key components of a reformed 21st century health care system.
We welcome the focus on healthcare access and quality but we are concerned that the participation in this dialogue is being reduced to a limited number of healthcare stakeholders.
Unfortunately, no attempt was made to invite representatives of the Dade County Medical Association, the largest association representing over 1500 physicians in Miami-Dade County
For over 100 years, the DCMA has stood out as an indispensable resource for physicians dedicated to the same goals and objectives: to protect the integrity of the medical profession and to ensure access to high quality health care for all citizens of Miami-Dade County. The business of health care is constantly changing, but the focus of the DCMA remains on our physicians and our patients.
Today, many of our physicians are struggling to maintain the economic viability of their medical practice. We are facing a rapidly aging physicians workforce, a decreasing number of primary care physicians and a steady decline of physicians in certain specialties.
Therefore, we ask you to include a representative of our organization in future scheduled meetings of this healthcare forum.
Our contribution and perspective is important to reform our healthcare system to benefit physicians and patients alike.
Please feel free contacting me for any questions and I am looking forward to your answer

Respectfully,

Bernd Wollschlaeger,MD,FAAFP,FASAM
President,, Dade County Medical Association

Medicare Reimbursement and First Coast Service Option

2009-01-27T23:01:00.000-08:00

Thursday, January 15, 2009

MESSAGE FROM YOUR PRESIDENT:

Medicare Reimbursement and First Coast Service Option

In my last column I provided you with my midterm assessment. I indicated that we initiated a dialogue with representatives of First Coast Service Options (FCSO), the regional Medicare administrator and have met twice with their Chief Medical Director and their Executive Committee. I also reported that we discussed on how to clarify the claims payment process and that we agreed to limit and reduce the onerous prepayment review requirements. Unfortunately, these discussions led nowhere and I now question the competence of and integrity of their entire operation.
Who is FCSO?
FCSO and its parent, Blue Cross and Blue Shield (BCBS) of Florida, have been involved in Medicare program administration since the inception of the Medicare program. FCSO incorporated as a wholly owned subsidiary of BCBSF in May 1998, licensed in Florida as a Third Party Administrator and began operations in January 1999. BCBS Medicare contracts were formally transferred to FCSO effective October 2003. FCSO is one of the largest CMS Medicare contractors processing $ 17 Billion in claims annually.
What is the problem?
FCSO claims that “ as one of Florida’s largest payers of health care benefits. We are committed to making the most of this unique opportunity.” Well, they do indeed!
According to a 2007 report of the Office of the Inspector General at the Department of Health and Human Services South Florida health care clinics submitted $2.2 Billion in claims for HIV drug-infusion claims in 2005 – 22 times more than the rest of the country combined!
The reports states that “ CMS has had limited success in controlling the aberrant billing practices of South Florida infusion therapy providers. CMS and its contractors have used multiple approaches, but none has proven effective over time. The most common tools include payment suspensions, revocations, and claims-processing edits. CMS has taken limited action to strengthen the enrollment process for new providers “
A series for recommendation were made and the report summarizes its findings as follows:
“CMS’s positive response to our recommendations, including its initiation of the new demonstration project, indicates that the agency is now moving toward strategies that should more effectively protect the integrity of Medicare payments in South Florida.”
How do they define success:
“Although billing increased from $1.5 to $3.3 Billion (CY 2004-2006) ,Medicare payments in Florida dropped from $1 Billion to $890 Million ... as a direct result of CMS' containment efforts.”
Hardly a success story to me! Recent CMS data suggest that the "successful" containment efforts succeeded to contain as much (or little) as before.
Guess what; the party continues and First Coast Service Options continues to pay!
How do I call it? Incompetence and negligence.
The Miami Herald published a superb article series exposing these fraudulent activities but FCSO is still in denial that this problem exists!
So, they nickle and dime good doctors and impose arbitrary 100% prepayment review requirements BUT allow crooks to sail a cruise ship sized fraud operation through their loopholes.
FCSO promised to cooperate with us to reduce this onerous financial burden, which jeopardizes the viability of medical practices and will eventually limit access for Medicare recipients.
Despite multiple e-mails and communications they still continue this tactics. I suspect that they create a smoke screen on our expense to impress regulators and to conceal their true deficiencies.
What can we do? Well, now is time to play hardball! We need to notify members of Congress and the Senate and demand an audit and review of all FCSO activities. I consider a congressional hearing as necessary to address the intolerable waste of billions of taxpayer’s money!
The waste of money and abuse of physicians has to stop! The system can work if administered by smart and responsible managers. I have lost all confidence that FCSO can fulfill its charge and mandate to administer the Medicare program in Florida. I know that I will be attacked. I am aware that they are stronger. I am just a simple family doctor but I am not afraid to state the obvious failures and mistakes.
Now, its time to act! Enough is enough!

Medicare Fraud and Government Inaction

2009-01-15T20:04:00.000-08:00

Medicare Home Health Services

2008-11-23T07:17:00.001-08:00

Dear Friends and Colleagues:
Attached you find an article from todays Miami Herald reporting that Medicare will suspend millions of dollars in payments to dozens of additional home healthcare providers in Miami-Dade after a federal judge ruled it has the power to stop reimbursements to companies suspected of overcharging for diabetic and other services.
The callous abuse of the Medicare system, a vital lifeline of needed healthcare service for millions of senior patients, has reached new heights in South Florida. here are the facts for Dade county ALONE:

Miami-Dade is home to 334 Medicare-certified home healthcare providers.
All together, the top 10 home health providers were paid $139 million by Medicare in 2007.
Medicare issued the suspensions after finding that it spends one of every 15 dollars on home healthcare nationwide in one county -- Miami-Dade.
The agency's spending in Miami-Dade totals $1.3 billion out of a nationwide budget of $16.5 billion.
Since 2001, Medicare's Miami-Dade payments for home healthcare has grown at a pace 13 times the national rate.

There are only two conclusions: either the demand for home health care service has increased by 13 x times the national rate OR (more likely) unscrupulous provides are defrauding the system.

As physicians we MUST work collaboratively with law enforcement and CMS to STOP this abbuse. Every dollar diverted for for fraud will further jeopardize our struggle for reimbursement of physicians services.
We should also NOT stop from reporting those physicians who receive hefty and lucrative referral fees from home health companies. Protecting those "colleagues" means acquiescing to fraud and abuse of the system.

Yours

Bernd

Posted on Sun, Nov. 23, 2008

Ruling halts Medicare payments to more Miami-Dade home healthcare providers

BY JAY WEAVER

Medicare will suspend millions of dollars in payments to dozens of additional home healthcare providers in Miami-Dade after a federal judge ruled it has the power to stop reimbursements to companies suspected of overcharging for diabetic and other services.

The government agency began the crackdown on the top 10 Miami-Dade home healthcare operators in October, citing potential fraud, but one of the providers sued in federal court claiming Medicare exceeded its authority.

This week, U.S. District Judge Paul Huck sided with Medicare, saying the taxpayer-funded program's suspension policy is ``reasonable and appropriate.''

His decision allows Medicare to continue halting payments to local companies suspected of submitting excessive claims for nurses treating homebound patients who either aren't diabetic or don't need help injecting insulin.

Miami-Dade is home to 334 Medicare-certified home healthcare providers. Many could be affected by the giant entitlement program's unprecedented suspensions.

''Because of the judge's decision, we will be able to expand our efforts to look at other home healthcare companies for payment suspensions and audits,'' Medicare spokesman Peter Ashkenaz said Friday. ``We just want to make sure the people getting home healthcare services are receiving them under the law.''

The judge's decision followed a Miami Herald story that detailed how the home healthcare company that sued Medicare over the suspension policy had billed the agency about $75,000 last year for a nurse to inject the insulin of a homebound diabetic patient.

But the patient, 92-year-old Maria C. Perez, who was living in a Westchester group home, told the Miami Herald that she has never been diabetic and didn't receive twice-a-day insulin injections from a visiting nurse in the latter half of 2007.

Her family doctor and medical records backed up her statement.

Home Care Services Provider, based in Kendall, said it did send a nurse twice daily to treat Perez for diabetes from June to November last year based on a prescribed referral by a Hialeah physician. It denied any wrongdoing.

MULLING AN APPEAL

As for the dispute over Medicare's suspension policy, the company's lawyer said it is considering an appeal of the judge's decision, filed Wednesday.

''We respectfully disagree with the court's ruling,'' attorney Anthony Vitale said in a statement. ``We believed then and we believe now that the Medicare payment suspension regulation is illegal.''

But that dispute with Medicare could be the least of Home Care Services Provider's problems.

The company's Miami-Dade owner, Maria Del Carmen Escarpio, 48, was charged in July with defrauding the Florida Medicaid program, which covers healthcare services for low-income people.

She's accused of using her Kendall home healthcare business to bill the state program $447,000 in wound care supplies and oxygen equipment that were never delivered to Medicaid patients in 2003-04. Moreover, the patients didn't have any wounds or need the oxygen, state authorities said.

''We're vigorously defending her in that case,'' said Escarpio's criminal attorney, Louis Martinez. ``It has nothing to do whatsoever with the current Medicare case [in federal court] nor does it have anything do with the suspension.''

In early October, Medicare suspended millions of dollars in payments to the top 10 home healthcare agencies in Miami-Dade County, citing a spike in questionable billing for diabetic and other services.

All together, the 10 providers were paid $139 million by Medicare in 2007.

The suspensions, which entail audits of claims and payments dating back to 2004, are in effect for at least six months.

FIRST TARGETS

Among the first targets: Home Care Services Provider, which received $12 million in Medicare payments last year.

About 72 percent of its income came from treating mostly homebound diabetic patients, records show.

Medicare issued the suspensions after finding that it spends one of every 15 dollars on home healthcare nationwide in one county -- Miami-Dade.

The agency's spending in Miami-Dade totals $1.3 billion. Its nationwide budget is $16.5 billion.

Since 2001, Medicare's Miami-Dade payments for home healthcare has grown at a pace 13 times the national rate.

What Medicare officials have found is that the massive health insurance program for the elderly and disabled is losing potentially hundreds of millions of dollars a year in Miami-Dade to fraud, abuse and waste in home healthcare.

The first round of Medicare suspensions in Miami-Dade were based on ''reliable information'' that home care claims submitted last year ''may have involved an overpayment, fraud or misrepresentation,'' according to an Oct. 3 Medicare letter sent to the targeted companies.

DIFFERENT SIGNATURES

The letter noted that certain physicians had told Medicare that their signatures didn't match those on prescribed patient care plans submitted to home care providers.

But one Miami-Dade operator, Patient Care, Inc., fired back a letter, saying it was ``being unfairly herded into the slaughterhouse as a result of its success and not a single shred of evidence.''

Home Health Care Fraud

2008-11-17T21:02:00.001-08:00

DADE COUNTY: THE HOME HEALTH CARE FRAUD CAPITOL OF THE NATION

The Miami Herald ran another excellent investigative report about the rampant fraud and abuse committed by Home Health Care Service agencies. http://www.miamiherald.com/living/health/v-fullstory/story/773538.html

Some facts.

Medicare spends one of every 15 dollars on home healthcare nationwide in one county -- Miami-Dade. Medicare's total budget: $16.5 billion.
Since 2001, Medicare's payments for home healthcare in Miami-Dade have grown by a whopping 1,750 percent -- to $1.3 billion -- while the pool of people over 65 diagnosed with diabetes grew by just 30 percent.
Medicare was billed roughly $75,000 by a Home Health Care Service provider for twice-daily nursing visits to inject her with insulin to control diabetes during the latter half of 2007.
According to federal records, Medicare paid one company about $12.6 million last year. A little more than 70 percent of its income was for treating homebound diabetic patients, records show.

What can we do:

Report any attempt by home health company representatives offering financial “incentives” for patient referrals.
Report any physicians that you know have accepted such arrangements
Carefully scrutinize orders to be signed by the physician for inconsistencies and blatantly false medical services allegedly ordered by you.
Periodically review “routine” home health service requests.
Deny services that include for example “ twice daily insulin injections administered by a nurse. Ask why the patient is unable to learn the self-administration of insulin injections.
Do not hesitate calling the local US attorneys office and/or your local medical society to report any suspicious activities.

Remember, that EVERY DOLLAR embezzled by this crooks is one dollar less paying for legitimate medical services rendered by had-working honest doctors!

Therefore, we need to be on alert pointing out fraud and abuse whenever it occurs in our community. No, we are not snitches but responsible members of our community who care for the viability of the Medicare program.

We need to work together on that and other issues. Together we are stronger. Together we can address this challenge.

Fight Medicare Fraud

2008-11-17T20:42:00.000-08:00

WE HAVE TO FIGHT AGAINST MEDICARE FRAUD!

The Miami Herald reported again several troubling cases of Medicare fraud

The stories are very familiar:

A family-run enterprise of medical equipment and billing companies submitted more than $17 million in false claims to Medicare, they admitted in court. Their haul: $5 million. The family's scheme was launched in 1999, when David and Laura Hernandez opened their first medical equipment company, said Assistant U.S. Attorney Ryan Stumphauzer.In a statement filed in court, the three admitted opening a string of equipment suppliers in Miami-Dade and starting a billing company to file false claims with Medicare. The billing company was owned by Laura Hernandez. David Hernandez, in the lead role, recruited four people to register as the official owners of four equipment-supply companies to conceal his participation in the scam, according to the court statement. Those ''nominee'' owners, members of another family, were charged in a separate Medicare fraud indictment. Husband and wife Jose Echevarria and Magaly Martinez, along with their son, Yuniel Echevarria, and his wife, Suyima Torres, pleaded guilty earlier this year. To fuel the racket, David Hernandez and his brother, Jose, paid kickbacks to patients for the use of their Medicare numbers. In turn, the brothers billed the federal insurance program for products, such as beds, catheters and pumps, that were never delivered to anyone. Proceeds of the fraud were deposited in the corporate bank accounts of the family's medical equipment companies. Hernandez also laundered some of the Medicare reimbursements through shell companies with ''medical-sounding'' names that were set up to cash checks at banks so his family could pocket the proceeds, according to the statement filed in court. Some of that taxpayer money enabled the Hernandezes to pay $331,000 to buy the Pembroke Pines home in 2002.
A Miami doctor and nurse have been convicted of billing Medicare for millions of dollars in false claims for obsolete HIV therapy at a local clinic owned by three brothers who fled to Cuba to avoid prosecution. Dr. Ana Alvarez-Jacinto and Sandra Mateos, found guilty by a Miami federal jury Friday, played key roles in an $11 million scam involving HIV-positive patients who received kickbacks in exchange for letting the clinic use their Medicare numbers to bill the federal program. The two women who opened St. Jude Rehab Center as partners with Carlos, Jose and Luis Benitez -- fugitives charged in a separate indictment -- had already pleaded guilty to fraud this year. Mariela Rodriguez and Aisa Perera, who ran St. Jude from June to November 2003, collected $8 million from the false Medicare claims.
A local physician convicted of Medicare fraud for his role in a massive HIV therapy racket run by three Miami-Dade brothers was sentenced to seven years in prison on Tuesday. Ronald Harris, 58, wrote prescriptions to bill Medicare for an obsolete treatment that was not provided to patients with the virus that causes AIDS, according to court records. The patients received cash kickbacks in exchange for letting the Miami physician bill the federal health insurance program with their Medicare numbers.In August, Harris pleaded guilty to a conspiracy charge as the medical director for Physicians Med-Care in Miami and Physicians Health Med-Care in Hallandale Beach. The two HIV clinics submitted $26.2 million in false claims to Medicare between 2002 and 2004.

Lets be reminded that EVERY DOLLAR embezzled by this crooks is one dollar less paying for legitimate medical services rendered by had-working honest doctors!

We need to work together on that and other issues. Together we are stronger. Together we can address this challenge.

The Election Is Over. What Shall We Do Now?

2008-11-17T20:27:00.000-08:00

MESSAGE FROM YOUR PRESIDENT:

The Election Is Over. What Shall We Do Now?

The two year long presidential election session is over. Before our President - Elect can get down to business the political pundits are already preparing for the 2012 presidential elections. Furthermore, those who are unhappy with the outcome of the election are vowing to “resist” any changes to be promised by the new administration. During the recent Interim Meeting of the American Medical Association in Orlando some attendees even went a step further. A current member of the United States House of Representatives called upon doctors to carry - hopefully in a figurative manner - a loaded shotgun to fight for their freedom. A former AMA President even dared to compare the status of doctors in the US to that of Jews in Nazi Germany!

This kind of hyperbolic rhetoric is not only unacceptable but also misses the mark!

I am confident that the majority of AMA delegates do not support these positions.

What we need are pragmatic solutions to the problems we are facing: stagnating reimbursement, increasing practice costs, third-party control of our practices and unnecessary regulatory burden.

This requires the ability to reach out to all parties involved in the healthcare delivery process, listen to arguments, tolerate other opinions and reach a compromise. Collaboration and not confrontation will help us to achieve our goals. As I said many times before: we need to sit at the table, otherwise we are going to be the menu item on the table.

Therefore, I will remain focused on assisting our members to continue practicing medicine. But I will also remind each of you that there is no way back to the “good old days of medicine.” The only constant in life is change! We have to adapt to the rapidly changing economic environment and find the best solutions that suit us.

Verbal radicalism and defiance will only lead us into a political dead end street.

Many of you are helping me to identify the problems and we try our best to resolve them. One of the issues pertains to the sluggish Medicare reimbursement for services rendered and the onerous prepayment chart review requirements.

Therefore, on 10/22/08 I traveled to Jacksonville and met with the CEO and President Mrs. Sandy Coston and the Vice Chairman Mr. Curtis Lord of FIRST COAST, the regional Medicare administrator. I also had the opportunity to meet and speak with all department heads including claims processing support, claims processing center, provider customers service, provider enrollment, program integrity and Medicare Education and Performance Solution. We discussed ONE single topic: how to improve the claims processing and reimbursement process. We agreed to ease the prepayment review process thereby reducing the chart review requirements. I will depend on your feedback to monitor the promised improvements. On the evening preceding my trip I received a call from a physician reporting that he has not received ANY Medicare reimbursement in the last 6 months and that ALL of his claims were rejected. I was able to resolve the problem within 24-hours and he will receive all payments due.

You need you to join our DCMA to support these and other projects, which help you to practice medicine and to provide quality care to your patients.

What are you waiting for? Join today!

Yours

Bernd Wollschlaeger,MD,FAAFP,FASAM

President, Dade County Medical Association

Women and Health Insurance

2008-11-03T21:09:00.000-08:00

A recent study revealed a scandalous phenomenon: that women pay more than do men of the same age for identical healthcare coverage provided by individual insurance policies! This "gender rating" is discriminatory and MUST stop! We have to regulate the insurance market to guarantee that all insurance companies follow the same rules. No, this is not socialism, but smart government policy to stop discrimination and to introduce fairness into the health insurance system.

Yours

Bernd

Miami Herald, Posted on Mon, Nov. 03, 2008

Women pay more for insurance -- why?

It is an unpleasant fact that life sometimes can be an uneven experience, delivering different results for the same effort, or producing failure when success is warranted. In a well-organized society such as ours, insurance is designed to even out the rough spots somewhat by spreading risk broadly.

Which is why it should come as a surprise that women pay more than do men of the same age for identical healthcare coverage provided by individual-insurance policies. What is worse, men and women are finding it exceedingly expensive, if not impossible, to find coverage for some illnesses through the individual-insurance market.

Revealing study

This is something Congress should look into, not with a mind-set of heavy-handed mandates, mind you, but with the idea of listening to healthcare consumers and insurance companies and finding common ground for new approaches. A recent study by the National Women's Law Center shed some light on the matter. See the study at www.nwlc.org/; click on the report, Nowhere to Turn . . .

The study found that the individual-insurance market -- unlike group insurance purchased through an employer -- uses ''gender rating.'' This allows an insurer to charge women higher premiums than men for the same coverage. More and more people are discovering these discrepancies thanks to the failing U.S. economy, which has resulted in job losses for hundreds of thousands of Americans, who find themselves looking for new insurance coverage.

Some recently laid-off people who had full healthcare coverage in their previous jobs are finding that they can't get coverage at any price with individual insurers for some ailments because of ''preexisting conditions.'' Moreover, many women are finding that they are paying 30 percent more for insurance than men because of their gender. Insurers say their claim experiences show that women use healthcare services more and, therefore, are charged more. In other words, women are more likely to get checkups and visit the doctor more because, well . . . they just do.

Illogical comparison

Some insurers say this is similar to auto-insurance rates that are higher for men than women because men have more accidents and file more claims. The comparison seems logical but, in fact, it really is not. Women who proactively monitor their health may identify problems earlier, get treatment sooner and ultimately cost an insurer less. A man who crashes his car isn't involved in proactive, preventive behavior.

Society's long-term interest should be to promote more of the former behavior than the latter. This should be the goal of insurers, too. Finding a nexus between affordable healthcare and a financially viable insurance market won't be easy. Congress can get closer to a solution by hearing from, and listening to, all parties.

News and Updates From Your President

2008-11-02T19:09:00.000-08:00

As your President I have set myself two simple but, nevertheless, challenging goals:

to improve the communication with our members.
to assist and support physicians to practice medicine.

COMMUNICATION:

I am attending and speaking at each and every medical staff meeting at all local area hospitals.
I can be reached 24/7 via cell phone (305) 940-8717, or via e-mail at info@miamihealth.com, or via http://twitter.com/dadedoc.
I am offering a monthly “Meet The President” get-together to update you about our activities and to listen to your suggestions and critique.

PRACTICE SUPPORT:

· I will initiate the formation of a “Healthcare Transformation Committee” to discuss topics ranging from medical economics, health care quality and medical information technology. These meetings will be take place either via face-to-face encounters and/or via go-to-meeting technology.GOAL: to maintain the professional autonomy and financial viability of your practice.

· On 10/22/08 I traveled to Jacksonville and met with the CEO and President Mrs. Sandy Coston and the Vice Chairman Mr. Curtis Lord of FIRST COAST, the regional Medicare administrator. I also had the opportunity to meet with all department heads including claims processing support, claims processing center, provider customers service, provider enrollment, program integrity and Medicare Education and Performance Solution. We discussed ONE single topic: how to improve the claims processing and reimbursement process. We agreed to ease the prepayment review process thereby reducing the chart review requirements. I will depend on your feedback to monitor the promised improvements. On the evening preceding my trip received a call from a physician reporting that he has not received ANY Medicare reimbursement in the last 6 months and that ALL of his claims were rejected. I was able to resolve the problem within 24-hours and he will receive all payments due.

I hope that I can count on your support. Please join our organization or renew your membership.

Looking forward speaking with you soon.

Yours truly,

Bernd Wollschlaeger,MD,FAAFP,FASAM

President, Dade County Medical Association

$9.7 Million Verdict Against Bare Doctor

2008-10-09T12:55:00.000-07:00

In mid-June a Lee County jury awarded nearly $10 million to a Ft. Meyers woman in a failure to diagnose allegation case in which the trial lasted two weeks. Dr. Kenneth Berdick, an internal medicine doctor in Ft. Meyers, had no professional liability insurance coverage and has had to incur the expense of his defense, and will bear the costs of the long appeal process.

The case revolves around Dr. Berdick failing to diagnose rectal cancer for five years after her first symptoms. He subsequently referred his long time patient to a specialist who did make the correct diagnosis. The cancer now has spread to the patient’s lungs and liver and is considered to be fatal. The patient is a 43 year old mother of three young children.

The plaintiff attorneys, Craig Stevens and Joe Linnehan of Morgan and Morgan, have said that they intend to pursue the doctor’s personal assets which they believe are ample and collectable.

Dr. Berdick was represented at this two week trial by defense counsel and put forth a defense that included expert testimony on causation and the standard of care. According to industry expert sources the cost of defending this case through a two week trial probably cost the physician a minimum of $100,000.

The appeal process expenses are estimated to conservatively be around $300,000. In order for Dr. Berdick to appeal the plaintiff’s verdict, he will have to purchase the transcript of the trial. For a two week trial, estimated costs of a transcript are $10,000. The attorney fees for post trial motions and prosecuting the appeal could be anywhere from $10,000 if he uses the lawyer that defended him in the trial or $25,000 if he uses an appellate attorney. In order to protect himself from execution of the judgment during the appeal, he will have to bond off the judgment. That assumes that the doctor can find a bonding company willing to help him. According to experts, the problem is that the bonding company is going to want Dr. Berdick to have liquid assets sufficient to satisfy the judgment of $9.7 million plus two years of interest at 12% per annum or another $2.3 million for a total of $12 million. Those assets must be completely unencumbered and pledged for a minimum of two years to secure the bond. If he doesn’t have $12 million in liquid assets that are completely unencumbered and that can be pledged for a minimum of two years, no one will sell him a bond at any price. If the asset requirements are met, the bonding company could charge up to 2% of $12 million or $240,000 for the bond alone. The estimated total cost of the initial trial of $100,000 plus $300,000 roughly for the appeal means Dr. Berdick will be out an estimated $400,000 even before paying anything towards the $9.7 million judgment or the $250,000 that state law requires the doctor pay within thirty days of a judgment to keep his medical license.

This case will be watched closely by the five thousand uninsured doctors in Florida. For a internist in Ft. Meyers coverage costs between $14,000 to $17,000 per year. Even if he had chosen limits of $250,000 / $750,000 most coverage would have picked up all of the legal expenses, including the appeal costs. Excess limits verdicts like this one often then result in a bad faith claim against the doctor’s insurer, in which the insurer often is forced to pay much if not all of the doctor’s liability over and above the doctor’s chosen limits. Florida has the toughest bad faith laws against insurers, which is one reason insurance rates in Florida are so much higher than those in other states.