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February 15,
2010
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IN
THIS ISSUE
Editor's Column:
Physicians And The Law Of Intended Consequences
Sen. George Examines Key Issues With
WCMSSM Delegate Body
WSU, DMC Agree On Long-term Deal
Henry Ford Study Tests Using Progesterone
To Treat Brain Injuries
Oakwood Patients Can Use Computers
In Waiting Rooms
WSU People In The News
Feds Pledge Almost $1 Billion For Health
Care IT, Michigan To Benefit
Social Security Awards Nearly $20 Million
In Contracts For EMR
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Editor's
Column: Physicians And The Law Of Intended Consequences
By
JOSEPH WEISS, MD
The New Year brings patients with new health care plans. In my practice
and likely in others as well, the most marked difference between
past health care insurance and 2010 plans is the huge deductible
in the new plans. I see a number of patients with deductible amounts
as high as $5,000 with a 10 percent co-pay on all prescriptions when
the deductible is met, and no payment for office visits.
This increase in deductibles and the concomitant loss of
office coverage is creating a change in my physician-patient
relationship. With some patients I spend more time at the
bargaining table than in the examining room. Patients with
high deductibles want to negotiate visits, laboratory work
and medication in the same manner as buying a rug from
a vender at an open-air bazaar.
The patient with the high deductible wants to spend as little
as possible on care and views me, the physician, as trying
to extract as much profit as possible from the scheduled
appointment.
This change in relationship brings the following consequences.
First, I find myself bargaining for care rather than prescribing
it. Second, because I must accommodate the patient if I
want to continue a connection with that patient, I must
respond to his view. And third, I must accommodate because
the patient makes the good point that less cost doesn’t
necessarily mean less care.
Let me illustrate: I treated a patient, M.M., who had rheumatoid
arthritis, with a combination of methyltrexate and Enbrel;
I obtained laboratory tests monthly. With his $5,000 deductible
he had to pay out of pocket both the medication, ($1300/month),
the office visit and the laboratory tests. Initially, he
argued over the laboratory testing pointing out that his
results had remained stable over the last six months. We
worked out an arrangement that I would rotate what tests
I ordered each month. Instead of 6 tests he could
have two. Then he bargained for office visits: he would
come in-person every 3 months so I could see for myself
if his joints remained free of swelling, but the other
months he would go to a draw station for the laboratory
work and save the expense of an office visit.
I have lengthened intervals between office visits, modified
laboratory testing orders and re-arranged medical
regimens with a number of patients because their increased
out-of-pocket expenses caused them to challenge my
approach to their care.
These experiences taught me that at times, I had developed
a pattern of care, that when scrutinized could be criticized
as not necessary for that patient. Also, if I wanted a
patient to listen to me, I better be prepared to listen
to him. Compromising and negotiating is not only for politicians.
A patient’s compliance depends on both his respect for
your orders, and in his belief that you are working with
his needs. I had to accept that using the large deductible
to control the cost of care is a successful way to bring
physicians into the strategy. And finally, I had to know
when and how to tell the patient that cutting his cost
of care was not in his best interest.
Each physician will need to work out an approach of when
to accommodate and when to resist a change in his role.
For guidance, do not look to the Ethics of the Fathers,
your malpractice carrier, or management consultant. The
decisions of how to cut cost and not compromise care will
be yours alone.
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Sen.
George Examines Key Issues With WCMSSM Delegate Body
By
PAUL NATINSKY
Sen. Tom George, MD, spent some time at the Feb. 10 WCMSSM Delegate
Body Meeting sharing his views on health care. George, an anesthesiologist
from West Michigan, did not put the audience to sleep. Rather, he
gave members a preview of what he would do if he is elected governor
in November.
“We
must change the behavior of our patients,” he said in outlining
his approach making health care more efficient and less
costly. “This is one of the keys to turning Michigan around,
getting a better return on our investment (in health care
dollars).
His
second priority is streamlining government at all levels.
George bemoaned the multi-layered and expensive structure
of government that he said includes dated concepts like
townships (parceled areas of land that overlay the state
like a grid and exist, archaically as precursors to modern
cities and villages). He said many costly government features
were incorporated in the most recent revision of the state
constitution, almost 50 years ago when Michigan was a “rich
state.”
On
more specific, and health-care-focused levels, George,
an ally of physicians against last year’s physician tax
proposal, said that spending more state money on health
care to draw down more federal dollars is not the answer
to that part of our state’s budget problems. He said we
have to learn to be more efficient and change behaviors
to get better results. More money is not the answer.
“The
premise is that if we put more money in, the feds will
match it. That’s a failed system for a poor state. It’s
a death spiral. We need to negotiate those social programs
that are open-ended,” he said.
Philosophically,
George doesn’t like ratcheting up spending without seeing
results. He favors a “block-grant” approach, in which innovative
programs that produce positive health outcomes get money
directly from the federal government.
The
physician tax would have added a 3 percent surcharge to
physician services. The surcharge would have been used
to obtain federal matching funds and physicians would be
granted a higher reimbursement rate from Medicaid.
The
state Senate shot down the proposal last year, but Gov.
Granholm reincarnated it in her State Of The State speech
last month. Rumor has it several major health systems are
now on board with the plan, which might sway the Senate
this time.
George
also addressed his ongoing efforts regarding individual
market insurance reform, the so-called “IMR Bills.” The
issue began last year, when Blue Cross and Blue Shield
of Michigan and friendly legislators in the Michigan House
pushed through a series of bills. The legislation would
have ended the Blues’ responsibility as an “insurer of
last resort”—which forces the company to write policies
for all comers—but retained the Blues’ favorable tax treatment.
The legislation also would have allowed BCBSM to do business
more like commercial insurers, scrapping its obligation
to ignore age and other factors when establishing premiums.
BCBSM’s rationale for the legislation was that it was losing
a dangerous amount of money in the individual market, where
people who don’t have policies through their employers
buy insurance. As the economy continues to skid and leaves
an increasing number of people without insurance and/or
work, the Blues assert that the problem is worsening.
The
bills went through the House very quickly with substantial
debate beginning in Sen. George’s Health Policy Committee.
The
legislation died last session, but the issue continues
to march forward. George and House Health Policy Chair,
Rep. Marc Corriveau, are working toward a solution that
George said likely would be unveiled toward the end of
February. Details are not yet clear, but a scheme that
would relieve the Blues of their part of their tax burden
in favor of a proportional plan tabbing all state insurers
to take a share of high-risk patients is in the mix. In
the trade-off, BCBSM would be assessed for a the portion
of the high-risk market they no longer insure, with the
money going toward a federal matching fund to bring in
more Medicaid dollars; a move George said would obviate
the need for a physician tax. The Blues might also get
some relief on the rate setting end, allowing them greater
flexibility, and other concessions, said George.
The
Delegate Body Meeting stop was another on the long chain
of statewide stops Sen. George is making in his quest for
the governor’s office. It’s a long road for a wide-open
field of candidates with no clear favorite from either
party.
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WSU,
DMC Agree On Long-term Deal
The
Wayne State University School of Medicine and the Detroit
Medical Center Feb. 10 signed new contracts that provide
stability to clinical and educational programs, according
to a statement appearing on the WSU and DMC websites. The
contracts replace an agreement signed in November 2006
that was scheduled to expire in June.
The
deal includes a long-term teaching agreement between the
two organizations for the education of medical students.
The five-year contract is automatically renewable.
An
agreement transfers sole sponsorship of 50 residency training
programs to the DMC, as opposed to the previous co-sponsorship
by Wayne State and the DMC. Sole sponsorship is the current
national model and is expected to create several educational
and administrative efficiencies. Wayne State School of
Medicine faculty members will have a teaching contract
for the residency programs.
The
DMC and Wayne State also signed a three-year clinical services
contract for the ten Wayne State University Physician Group
practices that provide patient care and administrative
services in the DMC’s eight hospitals. Those practices
include internal medicine, neurology, neurosurgery, obstetrics
and gynecology, ophthalmology, pathology, psychiatry, physical
medicine and rehabilitation, radiation/oncology and surgery.
The
contracts are the culmination of months of negotiations.
“I’m
proud of the commitment that the DMC and Wayne State are
making together,” said Valerie Parisi, MD, MPH, MBA, interim
dean of the WSU School of Medicine. “These agreements provide
great stability for Wayne State students, residents and
faculty, as well as patients of the DMC.”
“This
contract not only cements the future of what has been a
more than 100-year partnership between the DMC and Wayne
State,” said Mike Duggan, CEO and president of the DMC, “it
is a testament to the unwavering commitment of both of
our organizations to the city of Detroit, training our
nation’s future physicians and caring for people most in
need.”
“To
the residents, this agreement represents a renewal and
stabilization of a great partnership. This partnership
has served well both the training of resident physicians
and its community at large. Those of us who have personally
benefited are excited to see that future residents will
continue to have this terrific training opportunity,” said
Resident Council President Mark Hoeprich, MD, a current
fifth-year neurosurgery resident.
As
part of the agreement, Wayne State will receive a reduction
in its compensation from the DMC over the next three years.
This is due in part to the evolving DMC-Wayne State relationship
in which both entities have forged additional relationships
with other clinical and academic institutions.
“This
evolution of our partnership allows us to continue providing
educational opportunities and clinical services that are
critical to Detroit,” said WSU President Jay Noren, MD. “While
it is reduced from where it once was, it is still a very
important and constructive relationship. It is also consistent
with the strategic direction of both DMC and Wayne State
to expand their respective networks of clinical partnerships
with other institutions to ensure stability in all aspects
of medical education, research and patient care. ”
“These
are very difficult economic times, so in negotiations we
tried to put ourselves in the other organization’s shoes,” Dean
Parisi said. “In the end, the compromises we made allow
both entities to focus on our shared mission of serving
vulnerable populations and preparing the next generation
of physicians.”
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Henry
Ford Tests Using Progesterone To Treat Brain Injuries
Henry
Ford Hospital will evaluate the effectiveness of using
the hormone progesterone to treat traumatic brain injuries
without first obtaining patients' informed consent as part
of a national research study.
During
emergency conditions federal regulations allow research
to be performed without the informed consent of patients
who are unconscious at the time. As soon as family members
are available or the patients awaken their consent is sought
to continue their participation in the study.
Called
ProTECT, the study aims to determine if progesterone can
decrease the disability and death associated with TBI,
the leading cause of death and disability in children and
adults under age 44, according to the Brain Trauma Foundation.
Multiple animal studies have demonstrated that progesterone
may decrease brain damage caused by a traumatic brain injury.
Progesterone
is a naturally occurring hormone that regulates ovulation
and menstruation in females. It is also present in small
amounts in the brain and helps regulate normal brain function
in men and women.
A
traumatic brain injury, or TBI, is a blow or jolt to the
head that disrupts brain function. An estimated 1.4 million
people suffer a traumatic brain injury every year, and
50,000 die from it. Most of these injuries are caused by
motor vehicle accidents, physical assaults and falls. TBI
is also considered the signature wound of soldiers injured
during the Iraq war.
The
double-blind study will evaluate patients who suffer moderate
to severe traumatic brain injuries and are taken to Henry
Ford, DMC Detroit Receiving, DMC Sinai Grace and Beaumont,
Royal Oak hospitals within four hours of the injury to
be considered for the study. Enrolled patients will be
randomly given either progesterone intravenously or a placebo,
a fake version of the study drug.
The
study is funded by the National Institute of Neurological
Diseases and Stroke and involves 17 hospitals across the
country.
Henry
Ford's Institutional Review Board, Wayne State University's
Human Investigation Committee and Beaumont's Human Investigation
Committee will review and monitor the study.
For
more information, visit www.detroitprotect.org
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Oakwood
Patients Can Use Computers In Waiting Rooms
Oakwood
Hospital & Medical Center (OHMC) has launched a program
designed to help visitors stay connected to their lives
outside of the hospital. The “In-Touch” program allows
visitors in the public waiting rooms the ability to use
loaner laptops provided by the hospital. OHMC is the only
hospital in Michigan to institute the “In-Touch” program.
“As
loved ones undergo surgery, visitors’ lives continue,” said
Ioan Duca, Director, Service Excellence & Volunteer
Services, OHMC. “It became apparent that busy lifestyles
and demanding schedules make it necessary for our visitors
to stay connected at a moment’s notice. That is why Oakwood,
the first to offer a program such as this, is very pleased
to offer wireless internet service along with laptops to
anyone while they are waiting.”
The “In-Touch” project
originated with the Guest Relations and Employee Relations
divisions of OHMC, who then partnered with Nancy Gorski,
Community Health Volunteer Services Representative, and
her team to successfully execute the program.
The
loaner laptops, lent out for an hour at a time, enable
visitors who are waiting long hours to connect family and
friends via a built in web camera. Visitors are also able
to check email, surf the web and read the news. The laptops
also allow visitors to plug in their flash drives enabling
them to work on any projects they have set aside while
at the hospital.
“I
think this a great idea,” said visitor Cynthia Raymond. “It
helps pass the time and you can finish up any work that
you may be worried about falling behind in.”
The
program currently includes six laptops with hopes to acquire
four more. By the end of the year, the “In-Touch” program
is hoped to be included in the remaining Oakwood hospitals:
Oakwood Annapolis Hospital in Wayne, Oakwood Southshore
Medical Center in Trenton and Oakwood Heritage Hospital
in Taylor.
“These
laptops are definitely an advantage for visitors and family,” said
visitor Mark Pogorzelski. “People can connect to family
and friends that are not in the hospital and keep them
updated. It allows visitors to feel more comfortable and
waiting becomes less stressful especially since they have
so many other things on their minds.”
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WSU
People In The News
McCarty
Cancer Foundation Awards Grant To Dr. Zonder
The McCarty Cancer Foundation has presented a $25,000 grant to Jeffrey
Zonder, MD, of the Wayne State University Physician Group.
The
award supports Dr. Zonder’s multi-center clinical research
projects, coordinated by the Multiple Myeloma Research
Program at Karmanos Cancer Center. Since 2005, the program
has received approximately $232,000 from the McCarty Cancer
Foundation. McCarty Cancer Foundation funds were instrumental
in providing seed money for the program, which has become
one of the most active clinical programs of its kind in
the Midwest. That funding also has allowed the program
to secure federal grant monies and pharmaceutical contracts.
Student
Groups Bring Emmy-Nominated Native American Doc To SOM
Three student organizations have combined efforts to bring a Native
American physician to the Wayne State University School of Medicine
to present his Emmy-nominated documentary focusing on the health
problems affecting the nation’s native peoples.
Arne
Vainio, MD, will speak and present his film, “Walking Into
the Unknown,” at 6 p.m. March 15, in the Margherio Family
Conference Center. His appearance was funded and organized
by the Wayne State University School of Medicine’s chapters
of the American Medical Student Association, the Rural
Medicine Interest Group and the Family Medicine Interest
Group.
Dr.
Vainio is a Family Medicine physician who practices on
the Fond du Lac Reservation in northern Minnesota. His
film traces the personal journey of a middle-aged American
Indian physician – himself -- as he becomes a patient.
Frustrated by his patients who avoided health screenings,
Dr. Vainio filmed his own journey through the health care
system as he experienced medical screenings and procedures,
from the routine drawing of a blood sample to a prostate
exam and colonoscopy. The film addresses the major health
problems affecting Native American people and aims to show
men that they need not fear preventive health screenings.
Dr.
Vainio has received the National Indian Health Service
Director’s Award, the National Diabetes Physicians Recognition
Award and the Minnesota Medical Foundation’s Early Distinguished
Career Award. His film was nominated for an Emmy in 2009.
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Feds
Pledge Almost $1 Billion For Health Care IT, Michigan
To Benefit
Health
and Human Services Secretary Kathleen Sebelius and Labor
Secretary Hilda Solis Feb. 12 announced a total of nearly
$1 billion in Recovery Act awards to help health care providers
advance the adoption and meaningful use of health information
technology (IT) and train workers for the health care jobs
of the future. The awards will help make health IT available
to over 100,000 hospitals and primary care physicians by
2014 and train thousands of people for careers in health
care and information technology. This Recovery Act investment
will help grow the emerging health IT industry which is
expected to support tens of thousands of jobs ranging from
nurses and pharmacy techs to IT technicians and trainers.
In
Michigan, two groups will receive grants: State Designated
entity-Michigan Department of Health,$14,993,085 and Regional
Extension Center-Altarum Institute, Michigan $19,619,990.
The
over $750 million in HHS grant awards Secretary Sebelius
announced today are part of a federal initiative to build
capacity to enable widespread meaningful use of health
IT. This assistance at the state and regional level will
facilitate health care providers' efforts to adopt and
use electronic health records (EHRs) in a meaningful manner
that has the potential to improve the quality and efficiency
of health care for all Americans. Of the over $750 million
investment, $386 million will go to 40 states and qualified
State Designated Entities (SDEs) to facilitate health information
exchange (HIE) at the state level, while $375 million will
go to an initial 32 non-profit organizations to support
the development of regional extension centers (RECs) that
will aid health professionals as they work to implement
and use health information technology - with additional
HIE and REC awards to be announced in the near future.
RECs are expected to provide outreach and support services
to at least 100,000 primary care providers and hospitals
within two years.
The
more than $225 million in DOL grant awards Secretary Solis
announced will be used to train 15,000 people in job skills
needed to access careers in health care, IT and other high
growth fields. Through existing partnerships with local
employers, the recipients of these grants have already
identified roughly 10,000 job openings for skilled workers
that likely will become available in the next two years
in areas like nursing, pharmacy technology and information
technology. The grants will fund 55 separate training programs
in 30 states to help train people for secure, well-paid
health jobs and meet the growing employment demand for
health workers. Employment services will be available via
the Department of Labor's local One Stop Career Centers,
and training will be offered at community colleges and
other local education providers.
The
HHS and DOL awards are part of an overall $100 billion
investment in science, innovation and technology the Administration
is making through the Recovery Act to spur domestic job
creation in growing industries and lay a long-term foundation
for economic growth. In addition to the 10,000 jobs the
DOL grantees expect to fill with freshly trained workers,
the health IT extension centers are expected to hire over
3,000 technology workers nationwide in the months ahead.
Overall, the Administration investments in health IT and
training will help significantly expand an emerging industry
expected to support tens of thousands of secure, well-paid
jobs nationwide.
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Social
Security Awards Nearly $20 Million In Contracts For
EMR
Michael
J. Astrue, Commissioner of Social Security, today announced
that 15 healthcare providers and networks have received
$17.4 million in contract awards to provide electronic
medical records to the agency. These electronic medical
records, which will be sent through the Nationwide Health
Information Network (NHIN), will significantly shorten
the time it takes to make a disability decision and will
improve the speed, accuracy, and efficiency of the disability
program.
“Using
health information technology will improve our disability
programs and provide better service to the public,” Commissioner
Astrue said. “We’ve seen a significant increase in disability
applications. To process them, the agency sends more than
15 million requests annually for medical records to healthcare
providers. This largely paper-bound workload is generally
the most time-consuming part of the disability decision
process. The use of health IT will dramatically improve
the speed, accuracy, and efficiency of this process, reducing
the cost of making a disability decision for both the medical
community and the American taxpayer.”
The
contract awards are funded through the American Recovery
and Reinvestment Act. They will require awardees, with
a patient’s authorization, to send Social Security electronic
medical records through the NHIN. The NHIN, a safe and
secure method for receiving access to electronic medical
records over the Internet, is an initiative of the Department
of Health and Human Services supported by multiple government
agencies and private sector entities.
For
the last year, Social Security has been successfully testing
health IT to obtain electronic medical records. Disability
applications processed with electronic medical records
from the test sites in Massachusetts and Virginia have
significantly reduced processing times. Some decisions
are now made in days, instead of weeks or months. Social
Security expects to receive more than 3.3 million applications
in fiscal year (FY) 2010, a 27 percent increase over FY
2008.
Contracts
were awarded to the following organizations:
1.
Cal RHIO, San Francisco, CA - $1,625,000
2.
CareSpark, Kingsport, TN - $1,363,000
3.
Center for Healthy Communities, Wright State University,
Healthlink,
Dayton,
OH - $999,000
4.
Central Virginia Health Network/MedVirginia, Richmond,
VA - $1,139,000
5.
Community Health Information Collaborative (CHIC), Duluth,
MN - $977,000
6.
Douglas County Individual Practice Association, Roseburg,
OR - $502,000
7.
EHR Doctors Inc., Pompano Beach, FL - $1,000,000
8.
HealthBridge, Cincinnati, OH - $1,400,000
9.
Lovelace Clinic Foundation (LCF), Albuquerque, NM - $1,083,000
10.
Marshfield Clinic Research Foundation, Marshfield, WI -
$998,000
11.
Memorial Hospital Foundation & Memorial Hospital of
Gulfport Foundation, Inc.,
Gulfport,
MS - $1,100,000
12.
Oregon Community Health Information Network (OCHIN), Portland,
OR - $284,000
13.
Regenstrief Institute, Inc, Indianapolis, IN - $350,000
14.
Science Applications International Corporation (SAIC),
Reston, VA - $1,587,000
15. Southeastern
Michigan Health Association, Detroit, MI - $2,988,000
More
information on Social Security’s use of health IT is available
at www.socialsecurity.gov/hit.
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