In the soundtrack the prologue is voiced by Patrick Stewart. Much better; I have no idea why they changed it to the other guy in the movie itself.
Now if you'll excuse me, I'm going to go raid my kids' candy stash...
Interesting article (front page!) in the WSJ today about the RUC:
Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.
The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement. [...]
The RUC, as it is known, has stoked a debate over whether doctors have too much control over the flow of taxpayer dollars in the $500 billion Medicare program. Its critics fault the committee for contributing to a system that spends too much money on sophisticated procedures, while shorting the type of nuts-and-bolts primary care that could keep patients healthier from the start—and save money.
I'm glad to see the RUC getting some much-needed scrutiny, and skeptical scrutiny at that. But they miss the point with the "fox watching the henhouse" angle, or at least they paint with too broad a brush. "Doctors" are not a monolithic group, and it is those subdivisions that make the RUC such a dangerous agency. The author manages to touch on the critical dysfunction here:
"This system pitted specialty against specialty, surgeons against primary care," says Frank Opelka, a surgeon and former RUC alternate member who is vice chancellor at Louisiana State University Health Sciences Center in New Orleans.
Primary-care groups have pushed for more representation on the committee, and their leaders have argued its results are weighted against their interests.
Dr. Levy says the committee is an expert panel, not meant to be representative, adding: "The outcomes are independent of who's sitting at the table from one specialty or another."
I believe is where one would feign a coughing spell and blurt "bullshit!" into your hand. While the theory is that the members are there as RUC members, the reality is that every specialty lucky enough to have a seat on the RUC leverages that seat as an opportunity to advocate for the economic interests of their specialty. The general surgeons are famous for sending a team of lobbyists, lawyers and (really) healthcare economists to make sure the RUC does not make any changes that would undermine the income of surgeons. (And yes, ER docs also have representation, though they bring a less impressive posse, and they do advocate for EM-related services to be up-valued.) This is referenced in the (oddly unlinked) accompanying article, where primary care physicians recounted an epic battle from a few years ago:
At one point, the debate reached such an impasse that J. Leonard Lichtenfeld, who represented the American College of Physicians, and at least one other RUC member, Tom Felger, who represented family physicians, actually came close to ending their involvement in the talks, and asked for a break in the meeting, according to both men. They felt a surgical faction was blocking their push, they say.
"I was willing to leave the negotiations," Dr. Lichtenfeld says. "I felt that we were being stonewalled for economic reasons."
On the other side, surgical groups had argued there wasn't strong evidence that visits with patients had gotten more difficult. "There were some bitter feelings," says John O. Gage, who represents the American College of Surgeons on the panel.
This touches on an arcane point of procedure the RUC utilizes: a code is assumed to be correctly valued unless it can be shown the amount of work involved in that service has changed. So you are not allowed to claim that the codes are fundamentally imbalanced or misvalued or that the effects of the current valuation are undesirable as a matter of policy. You have to contort yourself to make the case that somehow what you do has gotten harder, that it is different from what it was five years ago. At least that's what you have to do to increase a code's value. They rarely go down in value, despite the (nicely documented in the article) fact that surgical procedures reliably require less work as time goes on and technology/practice make them easier to perform. So the effect is that surgical procedures are even more overvalued than they were to begin with. It's also telling that the RUC relies on self-reporting surveys of doctors to determine the work that goes into a particular code. I frequently get these surveys that tell me that how I answer this survey may impact how much I get paid for this service in the future, so how much work is this service: a little, a lot, or a super-lot? The validity of these surveys which are reported by people who have an interest in their results and *know* that their responses will translate into dollars gained or lost is pretty much nil.
But this is a less biasing factor than the non-representative make-up of the RUC itself. Check out the WSJ's awesome interactive graphic about the RUC. When you view it on their site, you can mouse over the RUC members and see their specialty affiliation:
You will note that the relative specialty vs primary care representation on the committee is striking. Not only are primary care (and other so-called "cognitive" specialties) far outnumbered by their surgical/procedural colleagues, consider that these few primary care docs represent a cohort of physicians far larger than the specialists in actual practice. One neurosurgeon has as much representation as 150 internists in this body.
Now I would agree that this does not need to be a strictly democratic process as a matter of principle. While we Americans are kind of ingrained with the idea that equal representation is the ideal, there's no reason that it has to be the case with this sort of body. However, as a matter of policy, in terms of creating economic outcomes and incentives that would tilt the balance towards higher quality, lower cost health care, a more representative or weighted composition of the RUC would be preferable.
I should also add that while I rail against the corruption of the RUC, it's not meant as an indictment of the people on the RUC, but the process and the system. I know the EM representatives of the RUC (past and current) and they are absolutely awesome people of high integrity. But it is also fair to say that they understand the game they are playing, on a very pragmatic level, and they work within the framework they are given to produce the best results for Emergency Medicine. Good people, bad system.
If I were king (I can't count all the times I have said or thought that) I would remove the fig leaf of objectivity and allow RUC members to openly advocate for their interests (which they are already doing sub rosa), coupled with a rebalancing of the RUC to provide more proportionate representation. Then I would hire a couple dozen Jonathan Grubers to crunch the numbers and make recommendations to the committee, based both on physician work as well as on the macroeconomic impact of the RVU valuations. Of course, if I were king I'd also probably disband CPT entirely and also the New York Yankees, so maybe it's just as well nobody has seen fit to entrust me with that much power.
Posted by shadowfax at 11:50 PM
As usual, the Onion nails it. What could possibly go wrong?
WASHINGTON—Conceding almost certain Republican gains in next month's crucial midterm elections, Democratic lawmakers vowed Tuesday not to give up without making one final push to ensure their party runs away from every major legislative victory of the past two years.
Party leaders told reporters that regardless of the ultimate outcome, they would do everything in their power from now until the polls closed to distance themselves from their hard-won passage of a historic health care overhaul, the toughest financial regulations since the 1930s, and a stimulus package most economists now credit with preventing a second Great Depression.
"There's a great deal on the line, and we know it isn't going to be easy for us," said Senate Majority Leader Harry Reid (D-NV), speaking from the steps of the Capitol. "But if we suffer defeat, we will do so knowing we cowered away from absolutely anything we produced that was even remotely progressive or valuable in any way."
"And we will keep cowering right up until Election Day," Reid continued. "From Maine to Hawaii, in big cities and small towns, we will collapse into a fetal position and refuse to take credit for our successes anywhere voters could conceivably be swayed by learning what we have achieved on their behalf."
[...] According to party leaders, the Democrats are putting their sweeping new health care law at the top of the list of accomplishments to back away from, mainly by allowing its most popular provisions—federal subsidies to make health care more affordable; allowing children to stay on their parents' insurance until age 26; and rules that prevent sick people from being denied coverage—to be summarily dismissed as "Obamacare."
"Thanks to our efforts, a lot of people don't even realize they may already be benefiting from these reforms," Rep. Melissa Bean (D-IL) said. "They certainly don't realize they might be one of the 30 million currently uninsured people who will be provided coverage by the time the law is fully enacted."
"You can be certain we'll keep that information a deep, dark secret until we're thrown out of power," Bean added.
Posted by shadowfax at 10:12 AM
Peter Orzag is a super smart guy. He's a wonk's wonk. Serious, articulate and innovative, he possesses some serious nerd-fu powers, and I'm a huge fan of this former OMB director. (We all have a favorite, don't we?)
But he doesn't know jack about medical malpractice, it seems.
As President Obama noted in his speech to the American Medical Association in June 2009, too many doctors order unnecessary tests and treatments only because they believe it will protect them from a lawsuit. Instead, he said, “We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines.” [...] What’s needed is a much more aggressive national effort to protect doctors who follow evidence-based guidelines. That’s the only way that malpractice reform could broadly promote the adoption of best practices.
Well, it sounds great, especially from a policy nerd's point of view: you kill two birds with one stone. Encourage adoption of evidence-based medicine, and also provide doctors with much-needed protection from baseless accusations of malpractice. What's not to love?
Nothing, except the fact that it wouldn't work.
Seriously, I have reviewed lots of med mal cases, and, sadly, "failure to follow evidence-based standards" isn't a common allegation of professional negligence. It's "failure to diagnose" and technical errors that tend to be the big money-losers in the legal arena. Evidence-based standards don't help.
Consider the biggest money-loser in Emergency Medicine: missed MI. I'm not sure there are formal evidence-based standards for the diagnosis of myocardial infarction, but if there were they would probably be pretty straightforward, along the lines of get an ECG and order serum troponin, maybe with some subrecommendations about serial troponins if the first tests were negative; most of the existing guidelines focus on the most efficacious proven treatments of MI once it has been identified. But if I may slightly fictionalize a case I recently reviewed, there was a guy who presented in the ER with a toothache. He thought he lost a filling and was triaged to fast track. He never complained of chest pain, though he did have nausea and vomiting (attributed to the tooth pain) and a triage nurse had recorded a complaint of left arm numbness. He was discharged with penicillin and pain medicine and a referral to a dentist. He came back with a V-Fib arrest about 8 hours later and subsequently died.
In retrospect, it's pretty apparent what happened here. The treating doctor simply never considered "chest pain" and cardiac issues as an avenue he should work up. An ECG was never ordered, because why would you? I think this case was not malpractice (that was my opinion) in that this was a very atypical presentation of the disease and most reasonably prudent physicians would not have been able to correctly diagnose this particular MI, based on the information that was available at the time the patient presented. Evidence-based standards really only apply when the diagnosis is already made, or when the presentation is typical enough that standardized work-ups are appropriate. Orzag's clever idea would not provide much of a line of defense for the physician who simply misses the diagnosis (whether it was his fault or not).
Similarly, if you do follow evidence-based standards, that won't shield you from allegations that you did so incorrectly. Another case I recall was a baby whose mother dropped it on its head and suffered an epidural hematoma. The ER doc did follow what would likely be the evidence-based guidelines and ordered a head CT. The bleed was diagnosed and treated appropriately. The child had a poor neurological outcome, and the plaintiffs later claimed that some trivial delays in the ordering of the CT scan were the cause of the bad outcome. While in this case, the delay did not cause the bad outcome, it's hard to imagine that the "I followed the guidelines" defense would quash the lawsuit, and in some cases a delay really could cause harm and perhaps should be considered as grounds for negligence.
Then, finally, there are the claims that rely on faulty technical performance. Consider a patient in whom the ER doc follows the guidelines in securing an endotracheal airway, but cannot do so and as a result the patient suffers an anoxic brain injury. Evidence-based treatment is not at all relevant to the question of the physician's competence in adequately intubating the patient.
So what I am saying is that Orzag's proposal, attractive as it is, would not be particularly effective in changing the overall culture of defensive medicine or the jackpot mentality that pervades the medicolegal culture. It would provide physician defendants with an attractive line of defense in some occasional cases, which is welcome. But as a panacea, or even as a driver of improvement in either of the desired policy arenas, it would be completely ineffective.
Posted by shadowfax at 5:27 PM
GruntDoc posted about the classic ER doctor's nightmare: “You know that patient you saw yesterday?” was how the conversation started.
I've been there. I know the bolt of adrenaline, the cautious, "Yeah, why do you ask?" that you always respond with. But one thing that our Brave New Technological World has brought to us is this: the email of doom.
Your institution may vary, but for us, the adrenaline-producing email comes with the subject line of "SECURE Email for Dr. Shadowfax" and it links to the hospital's (damned) HIPAA compliant encrypted webmail interface. Nobody ever uses it because it's a hideous pain in the ass, except the official hospital quality officer who is responsible for reviewing all "Unusual Occurrences," which is the euphemism for unexpected deaths, bad outcomes, 24 hour returns, patient complaints, nursing complaints, etc. Nothing good. So when you see the awful subject line, you just know that whatever is waiting in there for you is an unpleasant little Christmas present, the sort you don't really want to unwrap but you have to. Just as an extra bit of pain they make sure the login process is as slow and cumbersome as possible. Two entries of your password (which has to be changed every ninety days, natch, and you can't re-use passwords).
The awful, truly awful thing about these emails is that they are only generated by BAD things. There's no possibility that this will be a patient compliment, or a "well done." So as soon as you see the header you are bracing yourself for whatever bit of awfulness lies within. It's not necessarily anything your fault. People get worse. Subtle presentations become more clear over time. Nurses mess things up and patients complain about the dirty guy in the waiting room (these also go to the secure email, for your comment). But as soon as you see the "SECURE Email" header, you are sure that it was that dizzy guy from yesterday, and you're cursing yourself for sending him home until you finish the login process and find out that it was really some dude unhappy that you only gave him ten vicodin.
I think that sometimes our medical director sends out trivial emails on the secure email system just to screw with our heads.
Of course it goes both ways. As the "boss" for our group I have found that people dread seeing my name on the caller ID, and the meanest thing I can do is leave someone a voice mail saying that I need to meet with them. It's like when you were a kid and you got called to the principal's office, that sense of "What did I do?" (or in my case, "What did I do that you found out about and can you pin it on me?"). So I try to be really clear when I'm calling about a minor thing so people don't freak out, but the power of intimidation is amazing, even when I don't want to be intimidating, which is pretty much all of the time. Worse, sometimes I do have to call someone in for a "real meeting," and that's just hateful all around.
I also remember the old medical director, a close friend, used to call from the office just to chat, and when I saw the caller ID I also had the panicked sense of "Crap, what did I do?" until I answered and found out he just wanted to talk about the Chicago Bears.
Which in my mind ranks right up there with sending out trivial emails on the SECURE system as the hallmark of an absolute bastard.
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A cruel disparity exists in the US. Most states in the nation currently recognize two separate groups of the poor—the “deserving poor” and the “undeserving poor.” The deserving poor include pregnant women, children and their parents or caregivers, and the disabled. The undeserving poor largely consist of childless adults. The deserving poor are provided with health coverage through the Medicaid program. The undeserving poor—no matter how destitute they are—do not qualify for Medicaid benefits. As of 2006, there were about 9 million adults without dependent children living under the poverty line who were uninsured.I highly recommend you click through to read the rest, and add Progress Notes to your reader -- there aren't enough openly progressive medical blogs out there.
Posted by shadowfax at 6:03 AM
Pay on Wall Street is on pace to break a record high for a second consecutive year, according to a study conducted by The Wall Street Journal.Oh, well. Problem solved. You're welcome.
|The Colbert Report||Mon - Thurs 11:30pm / 10:30c|
|Rich Iott Wears a Nazi Uniform|
Posted by shadowfax at 10:22 AM
1. Integrated Delivery SystemsIn our locality, we have both #1 and #2, and they do contribute greatly to high-quality, low cost health care in our community. I've seen the way the stakeholders and physician leaders work together, and it has led to some great results. It's not clear to me whether this is scaleable -- whether it can be translated into other communities where there is no tradition of collaboration between docs and hospitals, where caregivers at different sites view one another as rivals and enemies rather than partners in care. I don't say this, by the way, as an indictment of other communities. Our locale is unusual in that there is one big hospital and one big multispecialty group and one big HMO. They partner by necessity, and there is little to no local competition. In other places, where there may be multiple hospitals competing with one another for business, multiple physician groups trying to play one off over another, surgicenters and free-standing ERs skimming off the cream, the economic environment may make it very difficult indeed to bring these players to the table together in an ACO.
Integrated delivery systems involve a common ownership of hospitals, physician practices, and—in some cases—an insurance plan. Some examples are Kaiser Permanente, Group Health Cooperative of Puget Sound, and Geisinger Health System. These systems typically have aligned financial incentives, electronic health records, team-based care, and resources to support cost-effective care.
2. Multispecialty Group Practices
Multispecialty group practices usually own or have a strong affiliation with a hospital. Examples of this type of arrangement include Mayo Clinic and Cleveland Clinic. They usually do not own a health plan but, rather, have contracts with multiple health plans in their areas. Most have a long history of physician leadership and highly developed mechanisms for providing coordinated clinical care.
3. Physician-Hospital Organizations
These organizations are a subset of the hospital’s medical staff. One example is Advocate Health in Chicago. Most were formed in the 1990s in response to managed care pressures to negotiate with health plans. Some function like multispecialty group practices, focusing on reorganizing the delivery of care to achieve more cost-effective coordination. Although they may be less well suited than integrated delivery systems or multispecialty practices to qualify as ACOs, many could structure themselves to meet the criteria for that type of organization.
4. Independent Practice Associations
Independent practice associations consist of individual physician practices that came together largely for purposes of contracting with health plans. Over time, however, many of these have evolved into more-organized networks of practices that are actively engaged in practice redesign, quality improvement initiatives, and implementation of electronic health records. One example is Hill Physicians Group, in Northern California. Such organizations could qualify as ACOs, and that might encourage other independent practice associations to evolve similarly, given sufficiently strong financial incentives and technical assistance.
5. Virtual Physician Organizations
Finally, a number of small, independent physician practices, many located in rural areas, can organize to become “virtual” physician organizations, such as Community Care of North Carolina. This process can be led by individual physicians in rural areas or by a local medical foundation, state Medicaid agency, or similar organization that can provide the leadership, infrastructure, and resources to help small practices develop disease registries; implement electronic health records; share information; and provide better-coordinated, cost-effective care. These virtual networks could qualify as ACOs and serve as models for other groups of small practices.
Posted by shadowfax at 12:17 PM
On Thursday, U.S. District Judge George Caram Steeh issued a ruling in Thomas More Law Center v. Barack Obama. It's one of a dozen lawsuits the opponents of health care reform have filed in federal courts, in an effort to roll back the Affordable Care Act. But it is the first case in which a judge has issued a verdict. And the verdict is pretty much a wholesale win for reform.So, good. This is what basically all legal scholars have been saying all along: the law as crafted is completely within the traditional interpretation of the powers of the Federal government. What (or who) will ultimately decide this, I suspect, is Anthony Kennedy. This will go to the Supreme Court. At some point, a Federal judge who is a member of the Federalist society will strike down the law, and the Supreme Court will be called on to resolve the lower-court conflict. Or, if the law is upheld on appeal across the board, plaintiffs will appeal to the SCOTUS, and it's hard to imagine them turning down such a major case. In fact, the Roberts bloc will be only too happy for an opportunity to radically restrict the reach of the Commerce Clause (a long-time irritation for small-government conservatives), and at the same time deliver a crushing partisan blow to liberals. The four center-left judges will support the traditional interpretation of the Commerce Clause. What will Kennedy do? He's generally been relatively small-c conservative, but has been willing to sign on to some fairly radical rewritings of constitutional law (Citizens United, most prominently).
The plaintiffs in this case are the Law Center, a conservative public interest law firm based in Ann Arbor, Michigan, along with some Michigan residents. The focus of their lawsuit is the individual mandate--the requirement, which becomes effective in 2014, that all Americans obtain a "creditable" health insurance policy. ("Creditable" is wonkspeak for a policy that includes basic benefits, as defined by the government.) According to the plaintiffs, the federal government has no right to impose that requirement, since it would compel people to spend money on health insurance instead of some other good.
In response, the Obama Administration has argued the authority to impose the mandate lies in two separate constitutional provisions--one that gives the federal government power to regulate interstate commerce and one that gives the federal government power to tax for the sake of promoting the general welfare. Steeh basically agreed with both propositions.
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