JOSMA Editorials

January 2012 - My New Year Wish List

2012-01-15T21:14:00.000-06:00

My New Year Wish List....

It is a New Year. I am thinking that maybe it is time to put down the list of things, mostly in the management of my practice, which I would like to fix over the next year.

You might call it my wish list.

As I start the process though, I find things on this list that have resided there for the last decade or two. And try as I might, there is never any in-road into a solution. You have read of my rants in these editorials about the nameless/faceless rule makers that are turning a deaf ear to my concerns or my ideas....this editorial continues down that path.

I suppose the other reality is that the my world view on these improvement and my needs do not align with the needs of the insurance company, the Medicare or Medicaid system and therefore are not seen as worthy of intervention or change.

My ego will not allow me to accept this answer as reality...therefore I will proceed with my list and my suggestions.

I despise doing work over...I work from a premise of “do it correctly the first time”. So when confronted with doing the work again...I lose my cool demeanor and become the Edward Hyde portion of Dr. Jekyll...example...I receive a form from those diabetic testing companies on one of my patients. I dutifully fill it out in a timely manner, I send it in...I have learned to keep a copy for my EMR, because these companies tend to have a penchant for losing my paperwork (surely they do not ever lose yours...)...then the patient does not like the service or decides that they like the advertising for another company and I get another form to fill out from the second company...remember I do not like to do work “over”...so I fax a copy of the original fax to the second company...only to find out that they can't accept the first fax because it has another company's name on it...I explain it is a prescription for diabetic supplies and I have written it once and am not going to write it again...

They decide to send me a fax a day for a full year, just to punish me...please.

When is someone going to design an electronic medical record that learns...seems to me that I am a creature of habit. I tend to do the same thing when confronted with a clinical problem. Most of us do as we practice medicine. The EMR asks that I spell out each and every time how I am going to manage this or that...and this is somehow supposed to save me time.

And then there are the formularies...designed to make it difficult for the prescribing clinician to ever be able to master the content, much less the steps that have to be attempted before a medication can be utilized. Not sure about you, but once I understand that the correct “verbage” for erectile dysfunction medications includes putting into the medical record the fact that they don't have diabetes on Thursday evening as their primary diagnosis...they then change the rules, making it a never ending game trying to figure out what the insurance company wants...when you ask them to write down their criteria, they will tell you that they are not able to accommodate that request....

And so all of those sad folks are denied their erectile dysfunction medications...thinking all the while that Dr. Pontious has something against September sex...

Standard forms are a wonderful thing...I can teach my EMR to populate them and produce a document that is readable, that documents my plan, that fulfills the requirements of the reporting. Then the insurance company or Medicare sends it back to me as unacceptable...it was not on form XYZ and will not be accepted until it is generated on form XYZ....please, please, please release me from the hell in which I find myself...

And what about those “tattle” emails from the pharmaceutical management companies. Seems that Mrs. Jones has not filled her prescription with the mail order drug house for two of the last six months. They just want me to know that this might just be a sign of non-compliance and consideration should be given to an intervention on my part. I wonder if they want me to “tattle” that her weight has gone up thirty pounds over the last three months, even though she tells me that she is following my diet to the letter...

And finally, there are those linked diagnosis for lab tests. Again the reference lab is precluded by law from telling me which diagnosis code will cover which lab. They are more than happy to bill my patient for uncovered services when I put “high blood pressure” rather than “Hypertension, essential”...I have a sneaking suspicion the price they charge the patient for uncovered services is much higher than the negotiated price for the same service for the insurance company. But we best not talk of that in a public forum.

I guess I am a bit old fashioned on some of this stuff...but really, what happened to common sense...

November 2011 - The Silo

2011-11-15T21:18:00.000-06:00

The Silo...

One of the unwritten issues in Oklahoma Medicine is what I call the silo effect.

Seems that the convergence of clinicians in the larger metropolitan areas of Oklahoma would cause most of you to think of medicine as a cosmopolitan effort. In reality, it is a silo effort and it seems to me that therein lies the potential problem with physician clinical care and physician distribution for that matter.

For many of my sub-specialty colleagues, this conversation is going to be puzzling. For urban clinicians, you will have had some experience in the silo effect and at least an understanding of the dilemma, but for the rural clinician, this conversation is about how you see life...well if you were honest with yourself.

The simple realty is that many of us, no matter where we practice our profession, end up practicing in a silo. My own silo is surrounded by medicine that I was taught in the late 1970's. This silo also has surrounded me with a primary care perspective. The silo has limited me to a set of two to three thousand patients that I know fairly well and who are satisfied with the medical care that I provide them...and yet these restricted silo's become in a way "my reality".

There are ideas that percolate up through the system that challenge my comfort in my silo. I am sure that many of you were frustrated and a bit miffed with the utilization of performance improvement tools as they are applied to clinical care. Seems that we physicians are resistant to anything that would tear down our silo or push us away from the approach that we have traditionally take with a clinical problem over the years.

Our mantra centers around a logic of “we are not interested in cookbook or template medicine”.

But then there is the irritating issue of the markers of clinical quality in medical care. If you don't see them as problematic for our state then I am not sure where you have been over the last decade. We can rationalize this away as an academic exercise or by claiming that each of us, as an individual, are excellent clinicians...it is just those "other folks" who don't practice very good medicine.

Right...

Then there is the whole "Continuing Medical Education" industrial complex to contend with. Each of us need fifty hours a year to maintain our medical license in the State of Oklahoma. So we sign up in droves for CME courses that teach us the things we already know and this viscous cycle of the medical silo raises its ugly head once more.

Simple fact...you can't know what you don't know...

Disseminating appropriate clinical evidence is problematic and our current approach is not working to obtain the impact that is needed to improve the healthcare of Oklahoma's population. Moving us beyond the status quo is going to take looking at the problem from a new perspective.

In this edition of the Journal of the Oklahoma State Medical Association, Jim Mold has published a paper "A Cooperative Extension Service for Primary Care in Oklahoma". ^ⁱ I strongly encourage each of you to take the time to read this paper. Dr. Mold has done a skillful job of looking at the dissemination of the scientific basis in the agricultural profession and has worked to develop a process by which this same type of dissemination plan is utilized in primary care practices across our state. He has taken the new perspective from the past, modified it and has then applied it to our profession. It has been successful beyond imagination in it's previous use, maybe the same is true for primary care.

I find the concept fascinating. It is a way to bring "evidence-based practice" to the front line in Oklahoma's primary care practices. It renews this concept of bringing the "University to the practitioner" and it offers new and innovative ways of disseminating and sharing best practice by looking at practices that have stepped up and provided the healthcare that our patient's deserve. And it provides for this without the town-gown politics...

You see, this is the other problem with living in a silo...you never know how to provide the care any better than what you are providing. Maybe by sharing the experience of how another clinicians have done it in a different way the process and content of clinical care will improve.

I am sensing that the walls of my silo are slowly being destroyed...I am thinking it is about time...

iMold, J.,”A Cooperative Extension Service for Primary Care in Oklahoma”, JOSMA November 2011

October 2011 - SGR...Something's Gotta Reduce

2011-10-26T09:12:00.004-05:00

SGR...Something's Gotta Reduce

I am sure you saw the news, the MedPAC has proposed that the dreaded SGR be abandoned. It is one of those moments where we might have been reminded to be careful about what we wish for.

To remind you the MedPAC - The Medicare Advisory Panel (http://www.medpac.gov/) is the 17 membered "independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program". And the SGR is the Sustainable Growth Rate for Medicare, a formula that has been used to determine Medicare payments to physicians since 1986. If you research the history of the SGR, you will find:

"The SGR mechanism aims to control spending for physicians’ services provided under Part B of Medicare. It does so by setting an overall target amount of spending (measured
on both an annual and a cumulative basis) for certain types of goods and services provided under Part B; included are payments for physicians’ services as well as payments that
Medicare makes for items—such as laboratory tests, imaging services, and physician-administered drugs—that are furnished “incident to” (in connection with) physicians’ services.
Payment rates are adjusted annually to reflect differences between actual spending and the spending target—upward if spending is below the target, downward if spending is
above the target." (http://www.cbo.gov/ftpdocs/75xx/doc7542/09-07-SGR-brief.pdf page 2)

As we have been told, the formula utilized is flawed,...so- every 12 to 18 months the threatened reduction in Medicare payments requires a huge lobbying effort to convince Congress that it is going to create disaster if the formula is followed and physician compensation for Medicare is instituted. You will remember that the cuts were delayed, once again by Congress, until January 2012...but when the SGR kick in there will be a 29.5 % decrease, across the board, in Medicare reimbursement.

The MedPAC has made the recommendation that the SGR funding scheme be scrapped and that a two tiered fee schedule be instituted...one for primary care and one for all other services. The Medicare rates for primary care would remain flat over the next ten years. Non-primary care services would decline 5.9% a year for three years and then remain flat for the next 7 years. (http://www.ama-assn.org/amednews/2011/09/26/gvsa0926.htm) Even with this reduction formula, Medicare spending for physician services will rise from $60 Billion to $120 billion over the ten year mark.

I imagine with an election around the corner, the politicians have not wanted to deal with the SGR and would like to fall back to their normal "Modus Operendi"....and kick it further down the road...so it is someone else's problem. Why make a decision today, when you can put it off. But then you have to remember that the MedPAC is advisory only and how often Congress listens to their recommendations can be debated deep into the night.

But they have made a recommendation. In this time of budget shortfalls, depressed economy and a gridlock in government that is especially tea-stained, I am thinking that the business as usual mindset is not going to work. I am thinking the traditional lobbying is going to fall on deaf ears...and you can say that you read it here first...the political will of physicians (and patients for that matter) is going to fall short...significantly short.

I will make some further predictions...there will be a wedge driven between the generalist and the specialist. You will hear each side articulate why they deserve a bigger portion of the pie, while the other will remind the system that one of the reasons that we find ourselves in this mess is that we have undervalued primary care for decades and subsequently there is a great divide in the compensation for each type of service.

I also predict, lots more of you will see yourselves as primary care histo-nephrologists or the like. But then that is the way it has always been...he who controls the gold controls the outcome and it seems that the economic difficulties of the system are now going to come to bear. And you and I need to be seeing the new world order, as it is coming from us on all sides.

There are a couple of recommendations that I might make as you look at the issue as scientifically and logically as you can muster...(1) go to http://www.medpac.gov/ and download the document entitled "Moving Forward on the SGR" and (2) try to pull deep into your soul to find that last genetic remnant of altruism....seems to me that in this day and time that is the only way you are going to survive.

September 2011 - Women in Medicine

2011-09-26T08:54:00.000-05:00

Women in Medicine

Ok, you will have to bear with me one more time. I am going to request personal privilege with this editorial. It is the easiest way for me to make my points about that special nature of women who chose this profession.

Many of you know the woman to whom I am married. You see her as a quiet medical school classmate, or a fellow Family Medicine resident, or a long standing emergency physician or the wife of your editor....but few of you know the story behind the path that this woman has taken in medicine. And, I dare say, is her path and approach all that uncommon when one looks at physicians who happen to be female in their gender?

In freshman chemistry there was always a social security number that showed up consistently above mine and my study partners on the posted grade sheet. We were always trying to figure out who this was. Over the Thanksgiving break I needed a ride home...found this girl who was going to Pond Creek who would drop me off in Enid. I tried to give her money for gas and she would not accept it. On the way back to Shawnee to finish up the semester, she asked if I would tutor her in freshman chemistry...what self respecting pre-med student would say “no” to this...so I abandoned my study partners and tutored for the rest of semester.

There was one “A” given that semester. She evidently was the social security number that I could not figure out. It was at that point that I realized what a gift I had as a teacher...and refused to tutor her the next semester. You see women in medicine have a lifetime of dealing with male colleagues who just don’t get the competition thing...and yet somehow they deal with it and go about their life work.

Along this same path, she took pity and married me. But decided that both of us going to medical school at the same time would be too much of a financial burden. In retrospect, I believe this was code for “the relationship will not stand the competition”...so she waited until I finished medical school to apply. She was accepted...life is good.

So, in an effort to live in the same town as she finished medical school, I took a teaching position at the medical school while she was finishing her training. I am minding my own business when I received a phone call from her on a Thursday afternoon. She is in Watonga Oklahoma doing her rural preceptorship. She tells me that she is ovulating and I need to drive to Watonga for the evening. I remember mumbling something about the fact that she had ovulated before and why was this one all that special...she then discussed with me that she had calculated back from the graduation date from medical school and this was the cycle that needed to be utilized in order to have the child, that would be delivered after her clinical rotations had ended and before she was to walk across the stage in her cap, gown and hood, to receive her medical diploma.

Again, what self respecting physician/husband is going to say “No” to this logic...child born, graduated from medical school without being pregnant, and started her internship with a 6 week old infant...and for the rest of my career when someone tells me that they can’t plan their pregnancies I just roll my eyes and smile,

So for all these years, she has worked to raise this child and the two that followed. She participated in the PTA, she made all of the birthday parties, she travelled to all of the band concerts, softball games and basketball games. She even made the sporting events when the daughter played college basketball in four different states...and she continued to work full time. Sure there would be times that she asked me to help out by picking one of the children up from practice or show up for an appearance, but for the bulk of these, it was that chemistry student from years ago that got all this accomplished....

Then annually she always made more money than I did...not that I am bitter mind you...I have gotten over the competition thing...at least a bit...

For us male brained physicians, we don’t always see the big picture...but this month, and for all months for that matter, we need to take a moment, open our eyes and look at the masterful way that our female colleagues manage their careers and lives.

I am convinced there are lessons to be learned here...or at least that is my experience....

August 2011 - Struggling with the Pain of it all

2011-08-26T08:40:00.002-05:00

Struggling with the Pain of it all

In my community it has been a difficult summer. The Oklahoma heat has been oppressive but it is the reality that way too many patients are flocking to physicians as a source of narcotic medications. I dawns on me that the emotional strength to get through my day is centering on my approach to pain control, an approach that is not always patient friendly.

It has not escaped my attention over the years that opiate dependance is a very real problem. I am convinced that it is becoming a greater problem on a daily basis. This land of conservative patients, is not without it's drug seeking patients and the development of a cadre of clinicians that are willing to fulfill the increased demand. I am not alone in my concern over this issue, it appears that the Oklahoma Board of Medical Examiners, the Oklahoma State Board of Medical Licensure and Supervision and the Medicaid program have all expressed concerns about the bulging using of narcotics in this state.

There has recently been an influx of narcotic seeking patients into my practice, often with minimal evaluations and with significant drug use.

What is a clinician to do? Go with the flow and not upset the current dosing? Or take the time that is required to work on tapering patients, who have often been on years worth of these medications and tend to see them as a way of life. For the clinician to intervene in this situation is to create anxiety and friction, often to the point of reputation damaging confrontation of problem patients.

I recently sat through a Joint Commission site visit meeting at one of the hospitals in which I practice. The site surveyor is focusing on the fact that the patient survey for our hospital in the area of pain control is less than stellar. Of course these surveys are anonymous and I often have confrontations with my patients and patients that I care for off the call wheel about the amount of pain medication that they are using. There are passive ways that they confront me about this, often asking the patient to contact me about their pain at 3 A.M. or by "reporting me" on the surveys that are performed after their hospitalization.

It seems this phenomena is becoming more prevalent in our society.

As clinicians, we are concerned about the perception of the public about our medical care. With patient reporting or internet ranking services, there is an industry springing up who's sole duty is to scour the internet and report negative comments about my reputation or the clinical care that I provided. We have always walked that narrow line of too much or too little. I was always taught that I only have one reputation and that I must protect it, because once damaged it will not ever be repaired entirely.

I know that those of you in pain management see this issue as a clinical issue only, but I sense it is much more than that. We live in a culture that tends to believe that pain is evil and anyone that allows you to feel pain is somehow evil as well. This then morphs into the idea that somehow I am entitled to be pain free. But what then do we do when it interferes with life to achieve total pain control. When I tell someone that they are going to have to learn to live with their pain, they look at me like I have just landed from Mars....and then the negotiations start.

I have started to require random drug testing in my practice, I have also started to utilize narcotic contracts that require that I manage all opiates or addictive medications and that they be obtained from a single pharmacy. I am utilizing the Prescription Monitoring Program online from the Oklahoma Bureau of Narcotics and Dangerous Drugs on a regular basis to make sure that patient's do not obtain controlled medication from multiple providers. All of this takes time that keeps me from the next patient, but I suppose it is warranted.

Certain days though I am in a mind to develop an office policy that states no controlled substances will be utilized in our clinic for more that a two week period.

Pretty sure that would just initiate a new set of negotiations with the drug seeking patients, but at some level gives me the protection and permission to say to a patient, I just don't have the skill to adequately take care of you.

Now that I have put the thought down on paper, it is beginning to sound better and better....

July 2011 - On the issue of potential...

2011-07-26T08:37:00.000-05:00

On the issue of potential...

You will note that this edition of the Journal is focused on issues involved in the care of Oklahoma’s children. I am indebted to the Physician’s Campaign for a Healthier Oklahoma and Melissa Johnson for gathering this set of articles and discussing these issues in this forum.

The next step is for you to take the time to read, review and think about the issues that are discussed. And your first excuse will be that you do not include pediatric care in your practice. And in this excuse you would be wrong, because we all are, by necessity, involved in the care and nurturing of children.

It is our investment in the future.

These pages have been filled in the past with concern about the future of our state from a medical perspective. We are all confronted daily with the ravages of poor health choices on the population. At some level this can be overwhelming. On another level there is no start, nor no end in sight.

And then the cynicism sets in...they have done this to themselves...I cannot change human nature...I am not responsible for the consequence of someone else’s decisions. We turn our back on the need to educate and encourage... and then at some level make our economic advantage from the medical misfortunes of the population.

Bear with me, it gets worse...

It has never really dawned on me how intricately woven is the fabric of public health with the provision of health care for children. Look at each of the articles submitted...each has a strong public health component. If we chose to ignore this as clinicians, we destine our future and the future of Oklahoma’s children to the lowest health rung of all states.

Tobacco addiction, obesity, dental health...one after another are tied to our unwillingness or resistance to address the issues in childhood. And the statistics reassure me that we are making no headway in this fight, we have not stepped up to the need and we are whistling our happy tunes and looking through rose coloured glasses...as we descend further down the health status ladder.

I suppose at some level we have become comfortable with this stigma...

The implications of this descent are huge. Our economies are tied up in the issue, our state’s focus and ability to plot a path for the future is dependant on all of us being the voice and the vision for those who do not have the ability to articulate the need. In the practice of medicine we see the future in the results of each and every one of these problems. They sit in my office waiting room and deal with the years of neglect and poor decisions. Somehow they expect me to reverse the trend and then become frustrated with me when I explain that there is little to be done.

Maybe it is time to join forces and reset the path from the beginning of life, rather than trying to address it after disease and addiction has set in. Seems to me our authors have shown the pathway, work in encouraging and mentoring proper nutrition, exercise, dental care, avoidance of nicotine and a diet dripping with fat.

But now wait a minute...that would just be un-Oklahoman to even mention those things.

Right...

June 2011 - Thinking about the End

2011-06-26T08:36:00.000-05:00

Thinking about the end...

I did not miss the fact that Jack Kavorkian M.D. passed away recently...he evidently died of natural causes...I find it odd that the path he developed for so many was not followed by him in his final exit.

At some level this is a bit odd.

Consistency is one of those things that I have come to see as the mantra of my work. You can expect Dr. Pontious to do this, because he always does this...consistency is what I try to teach and mentor. There is something comforting and efficient about this way of life...my children would tell you that it is boring, but I take great joy in being bored in this manner.

When it comes to end of life discussions with patients, I find that my consistency falls into chaos. I suppose that it is not appropriate for me to judge Dr. Kavorkian and his seeming inconsistent path.

Yet we all struggle with our decisions.

I have been faced with this several times over the last few weeks. The stories of their pilgrimage or the final disease process that caused their death are all varied and personal...but their final path was that which we physicians find with our patients over and over.

And yet we have such discomfort in discussing it or trying to help patients make a decision while they have their cognition. It seems that you turn your back and the opportunity for discussion is gone and then it becomes a legal morass, that rarely leads to an acceptable final exit.

I have written it out for my wife and children. I have had open discussions about my end of life wishes. I don't dwell on it, but none-the-less I have articulated it as best I know how. I have also taken the steps of creating the documents that outline my wishes...all to make sure that even in my exit I have the opportunity to make the decisions, not leaving this as a passive decision.

Problem is, many in our society have not taken this step. Lots of legitimate reasons... time, hassle, never seemed all that important, passive assumption that my love ones know what I want....all articulated to me day in and day out when it comes to defining end of life issues.

Then there is the subset of our society that somehow sees this as playing God, when we define how we would prefer to be cared for in our end days. I find this judgment a bit disingenuous...wiring me up to a ventilator, peg tub and dialysis machine worships a mechanical god to a much higher degree than my personal theology will allow.

You can't have it both ways in this argument.

I am thinking that our Native American ancestors had a much more theologically sound approach by wandering out into the shadows when death was near, rather than using an ICU waiting room as a location for a family reunion...

And then there is the conversation about cost. Some will say that the healthcare dollars that we spend in end-of-life care is money well spend...because in so doing we honor our elderly. Others would say that they have paid for it and therefore are entitled to never ending technological support of the human body. And then others would say to do anything less that the ultimate medical care is just morally wrong...

I am going to say it, because it is what I believe...there is a limit to the life that I will enjoy on this earth, for me to take more than I need is morally wrong. There is a finite amount of healthcare dollars and resource, as one human being I am not somehow entitled to all I can obtain or manipulate or even afford.

Keep me comfortable and give me my dignity. Let me pass from this place with honor and without fanfare. Let it be known that I understand that in finality it is not all about me...I am sure there are huge numbers of immunizations that can be afforded by society to protect against disease, please spend the resource that you would have spent keeping my heart beating on these things...and never once look back.

I am hoping Dr. Kavorkian saw it the same way...

May 2011 - Getting the Straight Story...

2011-05-26T08:29:00.000-05:00

Getting the straight story...

You’re more than likely thinking that I have been on a tirade lately. Seems that I am having further difficulties in understanding the wisdom of certain approaches taken in this era of computerization.

Published in the Journal of the Oklahoma Sate Medical Association last month was a scathing commentary about the “evils” inherent in the current system of federal incentives to augment physician’s ability to computerize electronic medical records and to incentivize meaningful use of the process. The article was written by a software developer who was extremely critical of the process that has been taken by the federal government to improve he computerization of medical care.

Seems to me that he has all the correct credentials...but the wrong message...

If you read the article closely you will have noted the agenda of cautioning the reader to not take the incentive money, as it would be a slippery slope. The article went on to further comment that computerization was such an economic burden to the practice, that there was a possibility that it could cause irreparable damage.

On the surface the facts are presumably accurate, while the agenda was hidden poorly. And then there is the complete disregard of the real issue, improving the delivery of medical care by computerization in our country.

Any of you that know me will recognize that this is a approach that makes absolutely no sense to me. I believe the dangerous portion of the article is that it supposes that this process can be delayed or modified.

Friends, this train has left the station...

I find this mindset extremely difficult to accept. It does remind me of living one’s life with their head buried in the sand. And yet this is the strident and often mainstream approach that is taken by physicians in Oklahoma.

Computerization of health records is not going to go away.

Computerization of health records promises to improve the health care of the patient’s that are included in practices that have embraced this approach. Anyone telling you different is attempting to sell you a bill of goods and anyone who listens will surely live to regret that decision.

Sure, there are bad products out there. And there is always the mindset of “I have never done it that way before...” And yet once the change has been made there are huge advantages in the process.

Painful it may be to get there, once arrived it is worth the journey.

Once again the strident nature of discussion of an extremely small minority of physicians within our state and to some degree the organization that represents them, serves only to confuse and create unwarranted delay. And all of this for what reason...resistance to change, or maybe civil disobedience...

We will beat our chests and will take great pride in the fact that we as Oklahoma physicians will become further and further behind the rest of the country in terms of our quality markers and now in terms of our computerization of practice... all because we were foolish enough to believe that somehow this is a government conspiracy and because we have never done it this way before...and we end up believing that computerization of the medical record is somehow wrong and evil.

At what point will we wake up.

I am sure there are snake charmer’s and charlatans who sell computer equipment and software programs. The standardization of the content of the Electronic Health Record attempts to protect us against this kind of unscrupulous business activity. Resources are extremely constricted and it is important that a workable model be obtained. The requirements and regulation are not overwhelming, but may be different than the normal state of practice.

It is time that Oklahoma physicians understand the larger issue. Accepting new technology and new approaches does not have to be inherently evil. There is not a conspiracy...and this change will come.

The “carrot” of incentives will be replaced by the “stick” of financial discounts for our work if we delay to utilize these new technologies. Physicians seem to accept the progression and improvements of diagnostic equipment, where old technology is compensated at a lower rate than newer technology. For some reason we have difficulty in accepting the newer technology for documenting and managing the massive amount of health information that is required in the practice of medicine these days.

It is time that to put on a game face and accept the change of the Electronic Health Record...

April 2011 - And Yet Another Modest Proposal...

2011-04-26T09:15:00.000-05:00

And Yet Another Modest Proposal...

It is always my habit to think in the absurd.

Seems it is a technique I use to deal with my frustration or my concern. The pain of reality sometimes is more than I care to deal with and since I don’t have multiple personalities, I have to put together the escape... in my thoughts. Sometimes it works, other times it is bizarre and mostly it is just junk that needs not be repeated.

But it keeps me sane, or at least my version of sane...

One of the burdens of medical practice is the huge amount of regulation and rules that have to be considered. Compliance with regulation has become an entire industry unto its own. With additional rules and masters and costs. I am not sure about you, but for each and every decision that I make, compliance raises its ugly head as I consider what the appropriate path will be.

It is my nature to dissect my frustration on this type of issue. I often ask myself what would my world be like if ... I were allowed to practice my profession without fear of breaking a regulation or being non-compliant with a rule. It is a thought that recurs frequently, usually at that moment when I am confronted with yet another educational intervention which will bring me into compliance, or the attestation that I sign which certifies that I am compliant. I suppose there are also the reminders as I write the checks to the multitude of agencies and organizations that have as their sole purpose my compliance with the sea of rules...and the list is growing exponentially.

I read in the newspaper about fraud and deceit within our profession. I am serving on a task force that looks at the approach that can be taken to decrease the opportunities for fraud. It seems that it is all around us....and yet the message that I try to disseminate is one that states there will always be those who push the limits of reason or try to game the insurance system or take clinical short-cuts or cheat the organization paying the bill.

Since that is a reality, deal with them and leave the 98% of us alone. Am I missing something, what is the problem with using a strong intervention to address the physician who persistently has problems with following the rules or regulation. Three strikes and you are out, and if strike two was identical to strike one, then maybe a two strike rule..

But that does not seem to make sense to the regulating authority or to the accrediting authority or to the insurance payor...for them it is so much more comfortable to write sweeping regulation and rules....knowing full well that the pain and frustration will be amplified in the vast majority who are already practicing by the rules. What always amazes me is that the “authority” organization is totally surprised when another non-compensated mandate is tacked on and there is such anger and frustration articulated by those who have to live up to proving that they were doing it correctly in the first place. .

But this seems to make no difference and our current path is to have another rule enacted, another layer of checks and balances are applied and a significant amount of cost and frustration are borne by all...this is our way.

There is an ancient approach to caring for agricultural land that may have some usefulness in this process of regulation and compliance. Shmita is the mandate that every 7 years the land needs to lay “fallow” (i.e. not planted) so that there is a refurbishing of its resources. In recent times a similar concept has been introduced by having term limits for politicians or sundown laws for certain regulations that are time limited and have to see the light of day before they can be re-enacted.

I am thinking that maybe this is the answer to my frustration with rules and regulatory compliance. What would happen if every seven years the rules and regulations for medical practice were erased or at least reviewed following a time of public comment? I am certain that this would keep the regulation and rule writers busy, with trying to make sure that they were compliant with their own rule and get re-introduced the regulations that were actually useful...all of a sudden there would be an incentive to cull the process down to a manageable set, regulations that actually make sense and a compliance plan that did not require a full time employee to implement and monitor.

Every seven years you and I would be given a reprieve or at least an opportunity to shine a light into the abyss of regulation.

Now that I have written this out, I am pretty sure this is not going to happen...it makes too much sense...oh well...it is just another of my absurd thoughts.

March 2011 - If Nothing gets Looked at...Nothing Changes

2011-03-26T08:21:00.001-05:00

If Nothing gets Looked at...Nothing Changes...

Seems there is a lot of concern recently about the the Oklahoma Health Care Authority’s Cesarean Section Quality Initiative. It has created quite a stir with the portion of physicians that deliver infants in our state.