Technology assistance

BusinessWeek‘s Gene Marks feels sorry for doctors because of the way they are being forced to purchase technology.  The issues facing independent physicians:

For example, right now there are dozens and dozens of companies offering technologies that claim to provide electronic health records. And guess what? None of their systems talk to each other. Surprise! And none of them have the same architecture. And they don’t exchange data with all the same hospitals. That’s because most hospitals’ systems are all over the place too. What, you think those big hospitals actually have their act together?

Has such a high tech industry ever had so much trouble implementing personal technology?  Feel bad for physicians, yes.  That financial benefits of an EMR accrue to payers, hospitals, and to the larger system is but one reason.  But sooner or later, a minimum level of technology in the exam room is the price of entry, right?  So the U.S. federal government is on board with the stimulus bill—should assistance to physicians in purchasing technology end there?  Does the mandate preclude participation by commercial payers and hospitals?

Don’t write about your physician interaction online, ok? Dumb.

Some physicians are upset because anonymous patients are leaving (reckless? sniping?) comments on review sites like Angie’s List and Zagat’s.  Welcome to the internet.

The response?  They’re asking patient’s to sign what amounts to a gag order (waiver form) according to this Associated Press article.  Welcome to medicine.

Dumb. Really dumb.  Dumb, dumb, dumb.

Why?  One of the sites that allows anonymous comments is going to create a “Wall of Shame” for physicians who use waivers.  A lawyer says the waivers likely will not produce successful results in a lawsuit anyway.  And if a patient really wants to share negative anonymous comments online, they will (despite a signed waiver).  It’s a snowball effect with bad outcomes.

What should a physician do?  Two possibilities:

1. Change behavior so patients don’t have bad things to say.  Yes, there will be the occasional patient who is unhappy about everything.  They may even post a negative review online.  But when there are multiple patients saying the same things, it may be time to look inward.
2. Embrace the long tail.  Ask all patients to review physician services.  Give them a business card (or an Angies’s form, pdf) or a list of reviewing sites to enable them to brag about how great the service is.  Get on the ratings sites and professionally respond to criticisms.  Build a page on Squidoo.  Write a blog.  Build a website. 

   Here’s the best advice, it’s from Seth and is especially pertinent:

   Google never forgets.

   Of course, you don’t have to be a drunk, a thief or a bitter failure for this to backfire. Everything you do now ends up in your permanent record. The best plan is to overload Google with a long tail of good stuff and to always act as if you’re on Candid Camera, because you are.

Are physicians risking their seat at the Medicare table?

Last week the United States Congress chose physicians over insurance companies in overriding a presidential veto of a bill that repealed Medicare fee cuts by 10.6 percent.  The measure, in large part, was a move to save health care accessibility for seniors.

From The New York Times:

The vote “renews the light of hope for those who need our help the most, senior citizens who depend on Medicare,” said Senator Harry Reid of Nevada, the majority leader.

It seems a light of hope was all it was for some seniors.  This from Anne Zieger at Fierce Healthcare:

With Medicare cuts looming, many physicians vowed that they’d stop accepting Medicare patients entirely if and when the cuts went through. The thing is, even though Medicare cuts have been held off, large numbers of physicians are dropping out anyway. One example of this comes in Tennessee, where doctors are increasingly dropping out of the program. Not only are many refusing new Medicare patients, some are thinking about dropping current Medicare patients too. That’s because in some cases, doctors aren’t even getting paid enough to cover their expenses, they say.

While the bill that prevented fee cuts does nudge reimbursements up just a bit, the problem of low reimbursements has been well documented, especially for primary care physicians.  In fact, we’re less than 18 months away from another fee cut, this one topping 20 percent.  Some think a completely new approach to Medicare is needed—such a measure is likely necessary to save the Medicare program.

Amidst promises by physicians to stop accepting Medicare patients should the cuts have remained, politicians prevented such a catastrophe from happening.  But some physicians have reversed course.

Are physicians risking their place at the table when new Medicare payment policy is formulated?

Too soon to tell.  Granted, physicians need to support themselves and adding minuscule incremental fee increases doesn’t fix already notoriously low reimbursement schedules.  But are doctors risking their credibility with politicians, who supported them by preventing this year’s version of the traditional Medicare fee cuts, by not accepting or dropping Medicare patients?

Unlikely since Medicare needs physicians in order to make the program work, but it’s worth a discussion.

In politics, leverage is everything.

The Answer: More Doctors?

USA Today had an article recently on the shortage of surgeons across the country, writing the shortage is particularly hurtful to the 54 million rural Americans.

The article goes on to say what many already know: more medical students are choosing specialty care and “‘fewer and fewer are going into family medicine and primary care,’ says James King, president of the American Academy of Family Physicians. And ‘many are not willing to go’ to rural areas.”

The problem, they say, was rooted in 1980s and 1990s when medical schools capped enrollment.

The solution?

To address the problem U.S. medical schools admitted nearly 18,000 students last year and the ultimate aim is to increase enrollment by 30% over 2002 numbers by the year 2015.

Whether or not we need more doctors is a matter of debate, but that’s not my argument here. There’s a reason medical students aren’t choosing career paths like primary care and general surgery and it’s easy to understand.

I was talking with a medical student who will shortly begin his intern status. We were talking about primary care; he indicated his $200,000 debt (!) and the fact that he will be in his early 30s before he makes his first real paycheck prevent him from even thinking about about general medicine as a career. So I asked, if a primary care physicians made $100,000 more than they currently make, would you at least consider it?

“Yes.”

That’s wrong. Primary care physicians are an important element of our current system, future reform may hinge on their abilities. It’s one thing to say that we will have a shortage of physicians with the solution being to train more and an entirely different matter to convince/persuade them to train for needed primary care roles.

Paying them more is a start.

Addressing the lack of physicians in rural areas will take more creativity. Training more physicians and “hoping” they will choose underserved areas to serve is a bit naive. Maybe we could start with tuition forgiveness programs for serving in rural/underserved areas?

The Need for More…Primary Care Physicians

Yesterday, the post was about medical homes. An integral part of that strategy is the primary care physician–a role many experts see a shortage of in the near future.

From Newsday, “The General Accountability Office said Tuesday that as of 2006 there were 22,146 American doctors in residency programs in the United States specializing in primary care. That was down from 23,801 in 1995.”

In that same article Senator Bernie Sanders said, “There are simply not enough primary-care providers now and the situation will become far worse in the future unless we do something.”

There may be a multitude of reasons that fewer medical students are choosing primary care as a career path. But I am going to go out on a really fragile limb here: the problem is money, specifically the lack of it.

The role of a primary care physician is extensive, we expect them to be knowledgeable about, well, everything. But we’ve seen specialist reimbursements rise inordinately compared to primary care physicians.

Robert Berenson at Health Affairs Blog writes of the problems being created by Medicare reimbursements for PCPs:

When physicians receive less than 1 percent fee increases year after year, we can expect physicians increasingly to stop seeing Medicare patients, at least those whose clinical expertise does not depend inordinately on the disabled and seniors. Already many PCPs have stopped accepting new Medicare patients, whether or not national surveys have detected the phenomenon. Many physicians who continue to serve Medicare patients are themselves approaching Medicare age and will soon retire, leaving patients without a personal physician and little likelihood that younger physicians will fill the void.

Mr. Berenson continues, “Payment for generalist physicians needs to increase. Payment for niche specialists can safely be reduced, perhaps with a redesigned expenditure target approach. Additional funding sources will need to be found to get out of the SGR budget hole. And there needs to be a process for shifting funds across provider silos.” Mr. Berenson provides good detail on a multitude of topics, I suggest you read it, and not just take my brief summation as the catch-all for the entire post.

The day previous Paul Ginsburg wrote of Medicare reform on the Health Affairs Blog (it’s a series that has a few more posts so stay updated by visiting the Health Affairs Blog), “Primary care physicians are most impacted by the lack of increase in Medicare (and private insurer) payment rates. Physicians in many other specialties can more readily accept declining payment rates because of productivity increases for newer procedures and the ability to increase the number of profitable procedures.” I suggest you read Mr. Ginsburg’s post as well, he lists some potential solutions to the Medicare reimbursement issue(s).

Anyway, we know there is a problem with reimbursement for primary care physicians. Research indicates better medical care if a patient sees a primary care physician when he or she enters the health care system, not to mention cost savings. As always, however, there are varying opinions, and with varying opinions come endless ideas for solutions.