Stanley Feld M.D.,FACP,MACE

President Obama’s has created an incentive program to encourage physicians to adopt functional Electronic Medical Records.  The program’s $27 billion dollars (funded by President Obama’s Economic Stimulus package) will turn out to be a colossal failure and a waste of money.

Twenty seven billion dollars would provide $44,000 for 640,000 physicians. After the bureaucratic infrastructure is built the federal government will be lucky if one third of the money remains for bonuses to physicians.

Only 21,000 of 650,000 (3%) of physicians have applied to date.

 Complex bureaucracies and complicated regulations never save money. These bureaucracies create bigger government, inconsistent policies, more complicated regulations and inefficiencies.

The best and cheapest way to create a universally accepted and functional EMR is for the federal government to put the software in the cloud and charge physicians by the click for the use of the Ideal Medical Record.

Upgrades in software to the Ideal Medical Record will be swift , inexpensive and instantly adopted.

The federal government has done it before with an electronic billing system in the 1980’s. The incentive to physicians was to be paid in one week as opposed to the one to two months wait for payment using a paper claim.

Last week the proposed rules for defining “meaningful use” of EMRs starting in 2013 were published.

As soon as Stage 2 of President Obama’s EMR bonus program were published organized medicine complained that the rules were unrealistic and onerous.

Organized medicine is correct.  This usually happens when the bureaucracy piles one set of rules on top of another. The Stage 2 rules will discourage physicians from participating even at the threat of an undisclosed penalty.

 "Meaningful Use Workgroup Rules Regarding Meaningful Use Stage 2," from the Office of the National Coordinator for Health Information Technology requires the following in order to be eligible for the federal bonus;

Higher thresholds (in % of eligible patients, visits or orders)

• Use computerized physician order entry (CPOE) (from 30% to 60%:
• CPOE will expand from drug orders to lab and radiology orders)
• Use e prescribing (from 40% to 50%)
• Record demographics (from 50% to 80%)
• Record vital signs (from 50% to 80%)
• Record smoking status (from 50%to 80%)
• Use medication reconciliation (from 50% to 80%)

Elective to mandatory requirements

• Implement drug formulary checks
• Record existence of advance directives
• Incorporate lab results as structured data
• Generate patient lists for specific conditions
• Send patient reminders
• Provide summaries of care record
• Submit immunization data
• Submit syndromic surveillance data

New measures

• Use electronic physician notes
• Offer clinical encounter information for download
• Offer health record information for download
• Ensure patient use of online portal
• Ensure patient use of secure messaging
• Record patient preferences for communication medium
• Provide lists of care team members
• Record longitudinal care plans

Physicians can receive bonuses from Medicare of $44,000 and Medicaid of up to 63,750 for installing and using an eligible EMR system.  These payments (bonus) if you qualify are taxable as ordinary income.

There are several practical problems;

1. Most physicians and physician practices cannot afford the time it takes to find an eligible EMR they can trust.

2. An EMR that might be eligible for federal bonus could cost $70,000 per physician.

3. Physicians cannot visualize the potential payback.

4. Physicians cannot visualize the added value toward improving quality care when quality care has not been adequately defined.

5.Physicians cannot get loans from banks to finance the costs.

6.Most physicians are uncertain about the future of their practices.

Thousands of physicians (3%) are trying to meet stage 1 requirements, which went into effect January 2011.

Eligible EMRs in Stage 1 must be able to meet 15 core measures of functionality and the physician's choice of five out of 10 elective measures.

In order to meet Stage 2 requirements physicians have to spend more money to upgrade their information system to be eligible.

"Unrealistic stage 2 requirements will overly burden physicians and hamper adoption — especially for those physicians in small or solo practice."

Karen Bell, MD, chair of Certification Commission for Health Information Technology said she “does not believe any vendor's system can meet stage 2 requirements yet.”

Developing EMR technology is expensive, and vendors don't want to build complete systems when the standards probably will change in the future.

A Family Practice Group of 4 physicians in Georgia recently spent $75,000 per physician upgrading the practice's EMR in order to meet meaningful use stage 1 requirements. Five years ago they spent $200,000 to launch their original EMR.

Fulfilling stage 2 requirements will probably cost at least another $75,000 per physician to continue qualifying for federal bonuses.

This Family Practice is chasing its own tail. It is working at the whim of a bureaucracy whose job it is to write regulations and not think of the consequences to practicing physicians.

Wouldn’t it be easier for the federal government to install its approved software in the cloud, upgrade it as necessary and charge physicians by the click?

Wasting $27 on bureaucratic regulations is a complicated mistake that is destined to fail.

$27 billion dollars could be better spent on direct patient care and the implementation of my ideal Electronic Medical Record   

Stanley Feld M.D.,FACP,MACE

What is the Coordinating Council for Comparative Effectiveness?

The mission of the Council for Comparative Effectiveness will be to decide on best practices and most cost effective practices. The council will recommend cost effective treatments for diseases to The National Coordinator for Health Information Technology (NCFHIT). The NCFHIT will determine treatment at the time and place of care. It is charged with deciding the course of treatment for the diagnosis given by the doctor.

The U.S. Department of Health and Human Services announced the formation and membership of the Federal Coordinating Council for Comparative Effectiveness Research that will be funded by President Obama’s stimulus program the American Recovery and Reinvestment Act (ARRA). The council was allocated 1.1 billion dollars to set up comparative effectiveness of medical practice.

Why was this 1.1 billion dollars funded from the economic stimulus package?

Unknown

The missions are based on the premise that practicing physicians do not have the ability to recommend the most cost effective medical treatment for their patients. (see executive summary)

Who are the members of the Federal Coordinating Council for Comparative Effectiveness?

The members of the committee were picked without congressional approval immediately after the economic stimulus bill was passed. They are all bureaucrats working for the government in one capacity or another. There are no practicing physicians on the panel.

Dr. George Thomas wrote in response to my last article on electronic medical records;

“The problem remains that it still takes me 25 minutes to admit a patient using the EHR, and only 5 minutes using pen and paper. If I admit 3 patients, it adds one hour to my day. Where do I get the extra hour, and who pays me for it? So far the main beneficiaries seem to be the HMO’s who can use the computer info to hassle you.”

I think Dr. Thomas stumb
led on to something. The government wants to be able track in real time treatment decisions of physicians with the use of the EMR. The government can automatically decide on whether physicians are practicing best practices as defined by the council for comparative effectiveness. If physicians are not practicing best practices that are cost effective, the government will force physicians to comply using penalties.

The sentiment about this issue is express by a physician in the following You Tube. It is a worthwhile watching.

The losers are patients and physicians. The healthcare insurance industry’s profits are unharmed and government power over the healthcare system is enhanced.

There are many defects in President Obama’s point of view on how to measure quality and appropriate care. It is a monetary viewpoint. It is not from a medical care viewpoint. President Obama’s approach will lead to many unintended consequences.

Another reader wrote in response to the electronic medical record article;

Hi Dr. Feld,

Refresh my memory please, what is your perspective on how am I going to determine how good a Dr. is in the future?  I want competition based on value and I know there is a wide difference between physicians in terms of skills, adopting technology and innovation etc. and results or outcomes.  How do you propose I determine the best value for my money?

How do you pick a restaurant, a dry cleaner, a plumber, an electrician or a builder? Each vendor competes for your business. If the vendor does not provide satisfactory service it will lose patrons and go out of business.

Websites such as Open Table and Trip Advisor help us with making wise choices. Angie’s list has been a transformational website. It has changed the way consumers choose contractors. Consumers are very interested in expressing opinions both good and bad. Contractors read every entry and improve to become more competitive.

Physicians have to be made to compete for patients. Only he consumers of healthcare can force physicians to compete. Consumers need to be given control of their health care dollars, not the government, or a third party.

Patients should make choices based on quality of care and reputation of the physicians. Patients should be incentivized to get the most value for their healthcare dollar. Value of medical care should not be determined by a government bureaucracy using inaccurate criteria.

Websites are available for consumers to make intelligent evidence based choices. Other websites can be developed to teach consumers how to evaluate physicians and their care. These websites must be interactive. Patients can share their experiences with others. The costs of services have already been negotiated by the healthcare insurance industry and the government. These fees should be made available to patients.

I believe consumers are smart. They can drive prices down in a consumer driven healthcare system.

Physicians are not the problem with the healthcare system. It is the healthcare insurance industry and its control of the healthcare dollars.

It is a mistake for the government to make decisions for consumers of healthcare.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Stanley Feld M.D.,FACP,MACE

President Obama has to understand the differences between Taylorism and Disintermediation. He would then understand the difficulties Americans are having with his healthcare reform law.

President Obama must combine the advantages of Taylorism with the advantages of Disintermediation in order to Repair the Healthcare System. The system must be for the benefit of consumers.

The disadvantages of Taylorism combined with central government bureaucracy will destroy healthcare in America.

President Obama’s only concern is to increase centralized government even if America cannot afford it.

Dr. Berwick is the right technocrat for President Obama. Dr. Berwick’s only concern is to convert the practice of medicine and the delivery of medical care to Frederick Taylor’s Principles of Scientific Management.

Taylorism

Frederick Taylor published his monograph The Principles of Scientific Management in 1911. Henry Ford utilized Taylor’s concepts in mass producing the automobile.

Taylor believed that decisions based upon tradition and rules of thumb should be replaced by precise procedures developed after careful study of an individual work process. Its application is contingent on a high level of managerial control of the worker.

He stated that central authority must provide detailed instruction and rules to each worker. Managers have to supervise and grade workers in the performance of their tasks. The managers plan the work. The workers actually perform the tasks.

Taylor was convinced that productivity efficiency lies in scientific management, rather than in searching for extraordinary creative workers to perform the work. .

Scientific management commoditizes products and lower cost of production. Medical care should not be a set of algorithms and rules that are centrally dictated. Algorithms should be a guide to help physicians’ with clinical decisions.

The problem with President Obama and Dr. Berwick’s plan is it disregards the role the healthcare industry plays in the inefficiency and cost for healthcare. It disregards the cost and inefficiency created by 160 new bureaucratic agencies to create new rules and regulations. It disregards the waste created by defensive medicine.

Disintermediation

Disintermediation is a term used in the “science of economics.” It is the elimination of the intermediaries in a supply chain. Simply put it cuts out the middlemen.

President Obama and Dr. Berwick are not eliminating the biggest middleman with their plan, the healthcare insurance industry.

Michael Dell of Dell Computing and Jeff Bezo of Amazon.com are the masters of disintermediation. They have eliminated the middlemen and revolutionized the computer industry and the publishing industry. Steve Jobs did the same to the music industry with the IPOD and ITUNES.

Consumers are empowered by market transparency. The middlemen were bypassed. Disintermediation has liberated consumers and reduced costs.

Wal-Mart uses the same disintermediation principle with its effective use of information technology. Wal-Mart passes the saving produced by eliminating the middlemen on to consumers. Wall-Mart has revolutionized retailing.

Healthcare reform should include systems of care. It should also include a disintermediation system to bypass the healthcare care insurance industry. Disintermediation in the healthcare system can empower patients to control of their health and healthcare dollars.

President Obama wants to increase quality and decrease the cost of healthcare by increasing the efficiency of healthcare delivery.

Everyone has the same goal. President Obama’s route is wrong.

Our healthcare systems problems can be solved by combining Taylorism with Disintermediation.

This can be achieved with consumer driven healthcare and ideal medical saving accounts.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Stanley Feld M.D.,FACP,MACE

http://www.ama-assn.org/ama/pub/news/news/medicare-consultation-codes.shtml  Somehow, President Obama must attack raising cost of medical care. Physicians are the easiest stakeholders to attack. They are the least organized.

A sneaky reduction in specialist reimbursement occurred on April 1^st. Medicare eliminated consultation codes. Most specialty organizations fought hard for Medicare to recognize their physicians’ additional training and experience. Specialists are well deserving of their consultation codes and its increase in reimbursement.

Elimination of the consultation codes is a back door way of reducing specialists’ Medicare reimbursement. This sneaky reimbursement reduction is going to result in many unintended consequences. President Obama will to be very upset by the result of this action.

The AMA constructed and published a survey, along with many subspecialty organizations, about the potential effects on medical care by the elimination of the consultation codes.

The survey proves to me that physicians can get upset when they are taken advantage of once too often. I have been saying all along that the AMA has been cooperating with President Obama and his healthcare reform bill as if the AMA was President Obama’s indentured servant. I think President Obama has finally gotten under the skin of the “house of medicine” (AMA). It took a long time.

“The elimination of Medicare’s consultation codes has had a negative impact on physician efforts to improve care coordination and reduced the treatment options available to Medicare patients, according to a new survey released today by medical specialty societies and the American Medical Association (AMA).”

Physicians who see Medicare patients have taken a number of cost cutting steps to offset the losses in revenues caused by the elimination of consultation codes. The cost cutting steps have resulted in seniors experiencing limited access to medical care. They have also experienced rationing of care. Unfortunately, these unintended consequences were predictable.

Highlights from the survey include:

• Three out of every ten (30%) have already reduced their services to Medicare patients or are contemplating cost-cutting steps that will impact care.
• One-fifth (20%) have already eliminated or reduced appointments for new Medicare patients.
• Nearly two-fifths (39%) will defer the purchase of new equipment and/or information technology.
• More than one-third (34%) are eliminating staff, including physicians in some cases.
• Following CMS’s suggestions that they no longer need to provide primary care physicians with a written report, about 6% have stopped providing these reports, while nearly another one-fifth (19%) plan to stop providing them.

On December 1^st when there will be a further 23% reduction in reimbursement. Seniors’ access to care will get worse. All this even before any of the major changes in President Obama’s healthcare reform act starts having its greatest effect on seniors’ care.

The Centers for Medicare and Medicaid Services (CMS) predicted, in its final physician payment rule for 2010, that no specialty would see Medicare revenues decline by more than 3%.

It turns out the minimum decline in revenue is 5%. Thirty percent of practicing specialists have experienced losses of more than 15%. This level of decrease was predictable. Most specialty practices cannot sustain cuts of this size. Specialists are reducing their services to Medicare patients.

CMS has also asserted that there is no longer any significant difference between a consultation and a routine office visit. CMS has to be kidding. Whoever believes this has no idea of the role of a consultant.

CMS has stated that consultants can send referring physicians the medical record rather than a written report. CMS recognized this dictum might discourage care coordination. Coordination of care is supposedly a priority for President Obama. CMS promised to make adjustments if there was evidence of deterioration in “effective coordination of care.”

Following CMS’s suggestion that specialists no longer need to provide primary care physicians with a written report about 6% have stopped providing these reports. Nineteen percent of specialists (19%) plan to stop providing reports and a number of others in the survey commented that they will continue providing reports but only very brief ones.

This regulation is destructive to coordinating care with the patients’ primary care physicians. The government is going in the wrong direction. There are other unintended consequences resulting from the elimination of the consultation codes. They are technical. The regulation limits payment for many services provided by the specialist.

President Obama promised the American people that he was going to reward cognitive services. Elimination of the consultation codes has the opposite effect.

One example is prolonged services for hospitalized patients. At issue is whether physicians can count time spent on any duties other than their face to face visit with the patient. Other duties include studying the patients past and present records for clues to diagnosis and treatment or discussing the case with the patient’s primary care physician or their family.

“CMS only recognizes face to face time and not other services such as establishing and reviewing charts and communicating with families and other health care professionals. In effect, Medicare is denying payment for these services and further discouraging coordination of care between professionals.”

There are other issues such as payment for a patient being seen by two specialists in one day and payment for new Medicare patients.

It is clear to me that whoever wrote these regulations has no idea of the mechanics of the practice of medicine. I doubt that anyone asked for physician inputs.

CMS is focused on changing the payment system for medical care. They are not focused on the retention of their workforce or improving the care of the American people.

President Obama believes that he will ultimately be able to force all physicians to become salaried workers of the government. I believe he will be unsuccessful.

There are many areas in the healthcare system that can be fixed to reduce the cost of medical care to affordable levels without losing the workforce.

Three important areas to improve to reduce medical costs would be effective malpractice reform, effective rules regulating the healthcare insurance industry and effective team management of chronic disease with the patient
being in the center of the healthcare team under the leadership of physicians.

All this can be accomplished by consumer driven healthcare in combination with the ideal medical savings account.

I hope President Obama is listening. Somehow, I doubt it.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.