July 21, 2008

IN THIS ISSUE

Editor's Column: The Myth Of The Marvelous
Medicare Physician Rate Cut Averted, SGR Remains Unsolved
WSUSOM Student's Struggle Guides Career
WSU Continues Push For Translational Medicine
DMC Facilities Ranked Among Nation's Best In Magazine Report
CMS Provides Options On Tamper-Proof Paper
New York Times Peeks At McCain's Health Care Record
CBO Boss Views Health Care As Most Inefficient

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Editor's Column: The Myth Of The Marvelous

 By JOSEPH WEISS, MD
In an editorial by John Engler in the Detroit Free Press Wednesday June 11 edition, and repeated in the Sunday June 15 edition in a column by Ron Dzwonkowski, the American public hears again the myth of the marvels it should expect if only more physicians would implement the electronic medical record. According to both accounts, if physicians adopted the electronic medical record, America would end its yearly 98,000 hospital-related deaths and the country would save $81 billion in medical bills.

Both Engler and Dzwonkowski urge Washington to immediately pass legislation to mandate that all physicians start using electronic medical records now.

Neither writer has bothered to see what physicians are doing and facing. If either writer had looked, he would have found that electronic medical records are creating a greater problem of communication between physicians than already exists. Computers are building a new Tower of Babel. One computer system cannot communicate with another computer system. Worse yet as every regional conference on computer communication illustrates, no hospital or large organization is willing to give up its system in favor of any other system. It is not possible to transfer records from Beaumont Hospital to St. Mary Mercy Hospital, or to Oakwood or Ford as each hospital has an electronic medical records system in place that seems deliberately incompatible with any other organization’s electronic medical record system. No institution seems willing to cooperate with any rival hospital system.

A recent experience of the Michigan State Medical Society further illustrates the problem of incompatibility. In the Medical Society's study of 14 practices that had installed an electronic medical record system, 16 venders were involved as two practices were so disgusted with their initial choice that they began again. No office in the 14 practices could communicate electronically with any other computerized practice because each vendor used his own private (proprietary) system of programming. 

The Michigan State Medical Society evaluation also brought out the difficulties physicians face evaluating electronic medical record software, and the distance that persists between programmers who design the software, and physicians and medical offices that use the programs in real life. The gap between theory and practice remains enormous.

In addition, no study to date has shown that introduction of the computerized records to a hospital has changed a hospital’s mortality rate. Statistics eventually may show the mortality worsens since tending computers takes nursing and physician time away from caring for patients.

It is naïve to expect that Congress should or would act immediately to set a standard and supply funds to develop a single network of electronic medical records across the country. John Engler, with his experience in politics, should know better than to tell Congress to legislate expanded use of information technology. Congress cannot develop a standard for electronic transmission because of the intense efforts of competing Silicon Valley groups to become the winner in the giant payoff that will result. Furthermore, with the government budget already strained beyond revenue capacity, no chance exists that Congress will provide any more than a token amount for information technology, which is what Congress has done the last five years.

The problem for physicians is that articles such as published by Engler and Dzwonkowski, poison physician-patient relations. The articles make physicians look more concerned with holding on to income then in furthering patient care. The newspapers also give readers the impression that physicians are backward in their understanding and acceptance of technology. 

The paradox is that the public clamor for this supposed life-saving technology now yields an advance in information that goes no further than a doctor’s office or a hospital’s front door. The present electronic medical record makes patient care more sophisticated but how much improved is debatable.

To obtain more information, physicians continue to rely on the fax and the phone. Eventually, freely mobile and readily accessible medical information will gird this country, but not for the foreseeable future.

Dr. Adelman’s Response
The problems outlined are certainly real, and they are major obstacles. The technology is over-hyped, and the Tower of Babel is upon us, but nevertheless younger physicians will demand the electronic medical record, because that is how they work. As a result, the systems gradually will begin to work with each other. The trick is to push insurers, clinics, hospitals and government to foot as much of the costs as possible.

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Medicare Physician Rate Cut Averted, SGR Remains Unsolved

By PAUL NATINSKY
In a widely anticipated veto override vote July 15 Congress overturned a 10.6 percent cut to physicians under the Medicare Sustainable Growth Rate formula and installed a 0.5 percent “update,” read increase.

The vote wasn’t close in either chamber, passing 383-41 in the House with 153 Republicans voting against President Bush’s proposal. In the Senate the count was 70-26 with 21 Republicans supporting the override.

The big story regarding this year’s SGR crisis wasn’t cuts to physicians, but a Democratic power play that cut back Medicare Advantage plans’ role in acting increasingly as a middleman in government payment for Medicare services. The MA plans are private plans that administer and distribute Medicare dollars under legislation expanding their role passed in 2003. The vetoed Bush legislation would have expanded further the role of MA plans.

The endgame was a study in drama, with cancer-stricken Sen. Edward Kennedy making a rare Senate floor appearance to help guarantee the necessary votes for a veto. Prior to the vote, news outlets were abuzz with talk of private plans reaping profits from Medicare and cherry-picking the lowest risk seniors for inclusion in their programs while leaving the rest out in the cold. The AMA and the insurance industry engaged in advertising warfare to argue their sides.

In the end the AMA touted the 0.5 percent raise as a substantial victory and urged that the fight continue to replace the SGR.

“HR 6331 replaces the 10.6 percent payment cut that went into effect on July 1 with a 0.5 percent update extension through Dec. 31, and it provides an additional 1.1 percent update for 2009,” stated AMA President Nancy Nielsen, MD, PhD. “The 18-month reprieve this bill provides allows Congress time to work with physicians on developing a long-term solution to a payment system that is fatally flawed.”

However, similar solutions in recent years have not germinated serious attempts to overhaul the flawed formula.

Brian Lang, a visiting scholar at the American Academy of Family Physicians opined that Congress is unlikely to address the issue for as long as two more years. He stated that the yearly patches cost about $4 billion, while a fix of the formula would cost about $300 billion over 10 years.

Louisiana Congressman Jim McCrery, a Republican, told the New York Times that the fix bill “just kicks the can down the road.” He said in 18 months doctors will face a 20 percent cut in Medicare payments.

The SGR sets spending targets which are routinely exceeded by the demand for care and cuts physician reimbursement based on the overage. Any reform acceptable to physicians would have to include recognition of the rising cost of health care and realistic assessments of practice costs.

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WSUSOM Student's Struggle Guides Career

Justin Belsky is turning his own experience with vision problems and a corneal transplant into a career of helping others with similar problems.

Mr. Belsky, 22, completed his undergraduate work at Michigan State University. The West Bloomfield native, who now resides in Royal Oak, is a second-year medical student at the Wayne State University School of Medicine.

He became interested in ophthalmology when he began to lose his vision near the end of high school. He said a corneal transplant two years ago taught him "to value vision.”

“It seemed like overnight I lost my vision, and the impact it has had on my life has driven me to help people see again. If it wasn't for the corneal specialists who worked with me, I would be legally blind,” he said. “I want to spread my message that vision is a gift and should be valued. It can be taken away at any time for no apparent reason. I was lucky enough to have it restored, but for many, this is not an option. Hopefully my future research will narrow the gap between those who have no cure and those who do.”

Mr. Belsky is spending the summer performing research at the Wilmer Eye Institute at Johns Hopkins, examining the effectiveness of intraocular pressure measures in abnormal corneas. Mr. Belsky, who selected WSU for his medical education because of the diversity of the clinical setting, secured the Wilmer position through persistence. He sent e-mails to doctors across the country who perform cornea research, and the institute took him on for the summer.

The “gold standard” in measuring intraocular pressure is only accurate for normal corneas, he explained. In unusual corneas, the measuring standard is inaccurate, a factor in incorrect diagnosis and treatment for glaucoma. His research involves looking at various parameters of the cornea and seeing how inaccurate the standard is in measuring abnormal corneas. The work will include inserting a device into the eye during surgery, determining the true value and comparing it with the standard.

“In short, I am looking to see how inaccurate the gold standard in measuring intraocular pressure is with the true intraocular pressure in abnormal corneas,” he explained. “This will give physicians a better indication of when to start treatment for glaucoma and other various diseases.”

Involved in the Humanistic Medicine program and Vision Detroit – a program that seeks to screen the Detroit population for serious eye conditions that need immediate attention – he wants to wants to join an academic institution to pursue his passion for research, specializing in the cornea.

The friendly setting at the School of Medicine has been a welcome surprise for Mr. Belsky. “I thought medical school would be cutthroat. Although competition between the class exists, everyone for the most part is willing to help you get through this.”

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WSU Continues Push For Translational Medicine

Wayne State University submitted its application for a Clinical and Translational Science Award (CTSA) from the National Institutes of Health (NIH) on June 16. This application is to fund integrated research to transform clinical and translational research, with the goal of developing bedside treatment more rapidly and efficiently.

“I’m very excited about this application,” said Michael Diamond, MD, principal investigator for the CTSA project, assistant dean of Clinical & Translational Research and Associate Chair of the Department of Obstetrics and Gynecology for the Wayne State University School of Medicine. “I think there are definite strengths and assets that Wayne State brings to a comprehensive national infrastructure that will help us in the assessment of our application by the NIH.”

School of Medicine Dean Robert M. Mentzer Jr., MD, noted that the application meets one of the strategic goals set by the School of Medicine, which align with the university’s strategic plan of improving Wayne State’s stature as a nationally ranked research university.

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DMC Facilities Ranked Among Nation's Best In Magazine Report

The Detroit Medical Center has two hospitals ranked in the 2008 US News and World Report list of America’s Best Hospitals. DMC Harper University Hospital ranked #27 in Neurology & Neurosurgery, jumping up from #31 last year, and DMC Sinai-Grace Hospital moved up from #48 in 2007 to #40 in Neurology & Neurosurgery. Sinai-Grace also ranked in the Top 50 for gastrointestinal disorders. The DMC is proud to be the only health care system with two nationally ranked neurology hospitals ranked in the Top 40 list of Best Hospitals.

The announcement follows the June announcement that US News selected and ranked DMC’s Children’s Hospital of Michigan as one of the top hospitals for pediatric care, including clinical neurology and neurosurgery, in its America’s Best Hospitals for Children.

The 2008 America’s Best Hospitals guide ranks 170 medical centers nationwide in 16 specialties.

“Talent and money alone don’t put hospitals in the rankings,” said Best Hospitals editor Avery Comarow. “The truly best hospitals are never satisfied,” he said. “Of course they have high medical standards. But the emphasis is not only on doing well, but always doing better--squeezing another few percentage points out of the infection rate, improving the quality of life of elderly patients besides helping more of them survive.”

US News and World Report Methodology
The rankings in 12 of the 16 specialties weigh three elements equally: reputation, death rate, and a set of care-related factors such as nursing and patient services. In these 12 specialties, hospitals have to pass through several gates to be ranked and considered a Best Hospital:

1. The first gate determines whether a hospital is eligible to be ranked at all by requiring that any of three conditions be met--to be a teaching hospital, to be affiliated with a teaching hospital, or to have at least six important medical technologies from a defined list of 13.

2. The second gate determines whether a hospital is eligible to be ranked in a particular specialty. To be eligible, the hospital had to either have at least a specified volume in certain procedures and conditions over three years, or had to have been nominated in our yearly specialist survey.

3. The third gate is whether a hospital does well enough to be ranked, based on its reputation, death rate, and factors like nurse staffing and technology.

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CMS Provides Options On Tamper-Proof Paper

A pending fiasco seems to have been averted involving a Medicaid edict requiring the use of tamper-proof paper in printing prescriptions with electronic prescribing systems.

Physician information expert Peter Basch, medical director of ambulatory clinical systems at MedStar Health, Columbia, Md., told attendees at the 17th annual Physician-Computer Connection Symposium in Ojai, Calif., about the breakthrough late last week, according to Modern Healthcare. Basch worked to overturn the CMS regulation interpreting a federal 2007 law that required tighter security on Medicaid prescriptions.

The CMS has accepted recommendations that soon should be released by the National Council for Prescription Drug Programs to create anti-fraud measures using computerized printing technology deployable in electronic health-record systems and standalone e-prescribing tools as a substitute for expensive tamper-proof paper, which the CMS originally required.

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New York Times Peeks At McCain's Health Care Record

The New York Times July 21 examined how presumptive Republican presidential nominee Sen. John McCain (Ariz.) since his failed 2000 presidential campaign has "mastered the art of political triangulation -- variously teaming up with ... the new Republican leaders, with Democrats against Republicans and with the president against the Democrats" on health care and other issues -- to "become perhaps the chamber's most influential member." According to the Times, "McCain's supporters argue that he demonstrated the kind of bipartisan bridge-building" that presumptive Democratic presidential nominee Sen. Barack Obama (Ill.) has "often pledged but seldom displayed," but critics maintain that McCain "was a fickle gadfly who ultimately traded his independence to pander to the right."

McCain "was a reliable Reaganite until around 1998 -- his first big break from his party -- when the Republican leaders chose him to negotiate a bill that would address tobacco lawsuits and finance public health programs," the Times reports. "As conservatives outmaneuvered him on the floor, Mr. McCain lashed out at his fellow Republicans, accusing them of turning a cold shoulder to children's health," a move that resulted in a standing ovation from Democrats, according to the Times.

In his 2000 presidential campaign, McCain experienced his "first face-to-face confrontation with domestic issues like global warming and health insurance costs," according to his advisers, the Times reports. After the 2000 election, McCain -- who previously had "kept his distance" from Sen. Edward Kennedy (D-Mass.) because of his "record of pulling Republicans into grand compromises" -- "pulled up a chair at Mr. Kennedy's desk near the back of the Senate floor" and expressed interest in cooperation on a patients' rights bill, which he previously had opposed, according to the Times. "Soon he was cooperating with Democrats on ... many issues," the Times reports (Kirkpatrick, New York Times, 7/21).

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CBO Boss Views Health Care As Most Inefficient

Congressional Budget Office Director Peter Orszag told lawmakers that the healthcare sector is far and away the most inefficient economic driver in the United States, according to Modern Healthcare, with more than $700 million each year being spent on medical procedures that seemingly have no effect on patient outcomes at all.

“There is no other inefficiency that I can identify that even comes close to it,” he added. Orszag, who has earned the respect of Democrats and Republicans alike for his data-backed assessments on the current and future healthcare economy, said that a multipronged approach that includes comparative-effectiveness research and a redirection of financial incentives should serve as the bedrock for broader reforms.

Part of the discussion on Capitol Hill focused on the idea of a Federal Reserve-like board for healthcare, which would operate independently of Congress to help shape policy and payment rules. Orszag told lawmakers that the CBO is studying the idea and would release a report on the topic later this year.

Jeanne Lambrew, a senior fellow at the Center for American Progress, said that another key underpinning for reform is for Congress to accelerate the use of health information technology, such as electronic health records. She said that reductions in Medicare reimbursement could be used as a way to prod providers into using the widely available technology, but added that loans and grants would likely also be needed.

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