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Genetic testing initially will promote Chaos and misinformation

June 16, 2008

Analysis of:Experts see boost to genetic testing from US bill | www.reuters.com

As a clinician leader for some time, it is overtly obvious that comprehensive genetic testing will be fraught with misinterpretation and will lead to consumer confusion and potentially wrong life behavior. Genetic testing has been available for 2-3 decades on a very limited basis and for specific fetal diseases yet physicians wholly inadequately trained are referring patients to nursing geneticists with a 85% incorrect diagnosis or treatment recommendations for patients.  This wholesale look into the future will bring chaos and fright to many patients.

Behavioral change aint easy for physicians regardless of data

June 16, 2008

Analysis of:Good is Never Enough for P4P | www.hhnmag.com

Although administrative and nursing/allied medical staff can and will respond to the Quality challenges, physicians (forgive my stereotyping) must be approached more comprehensively to elicit medical behavioral change based on evidenced based medicine or process improvement.  They will slow the process if not attended to their resistance factors for change.  Hospitals and medical groups alike need to understand comprehensively physician resistance for change and accordingly design appropriate interventions for the good of the American People.

The Human Genome will promote genetic counciling chaos and misinformation

April 30, 2008

Analysis of:Experts see boost to genetic testing from US bill | www.reuters.com

There are many reasons why the commercialization of human genome "information" will be ABSOLUTE CHAOS AND COST.  The three most prominent are the following:   1. Physician education is almost devoid of practical genomic teachings except for Diabetes and lipid disorders.   2.  Fully 85% of genetic referrals now are inappropriate with "simple" genetics.  Human genomic knowledge is quantums greater   3.  The American people will embrace this new gizmology (technology) especially when forecasting the future and invest highly ripe for greed and opportunism.

Education is over rated regarding pharmaceuticals

April 8, 2008

Analysis of:Rx Watchdog Report: Trends in Manufacturer Prices of Brand Name Prescription Drugs Used by Medicare Beneficiaries—2002-2007 | www.aarp.org

If I may, Mr. Goldstein suggests that education to providers re: cost/benefit or value will drive drug selection.  I disagree in that there are may barriers to provider (most physicians) behavior and their selection of drugs.  To mention a few are as follows:  1. My anecdotal experience 2. My eductation (in past). 3. Do I believe in this? 4. Is this aligned with my best interests 5. Never the first to try something new and never the last.  And so on.  If education was the dominent driver, then propranolol and a thiazide diruretic would be the first choice of anti-hypertensives based on evidence based population studies.  Yet drugs 10-20 fold more expensive are often used as first line. Adherence would increase volume and if free market dynamics are alive would decrease costs/unit.  Total cost may rise and I agree with that. Price controls have never worked--let them die.

The DOJ and the FTC rarely join antitrust suits unless there is the likelihood of merit

April 7, 2008

Analysis of:DoJ joins whistle-blower suit against OH MDs, hospital | www.fiercehealthcare.com

From the rather strick interpretration of Peter Stark's antitrust principles complied with mostly in the 1980's we have entered an era where rampent greed and highly sophisticated antitrust relationships exists in nearly of all hospitals especially with their own "dedicated" (read as owned)  multispecialty group or with the traditional hospital based groups or high earners for the hospitals such as orthopedists, cardiologists, pathologists, anesthesiologists and imagining specialities (radiology for the most part).  Allowing (if the report is correct) the most compensated specialists in Medicine to bill for procedures performed in the hospital setting (technical component) would raise eyebrows of Mr. Stark and the DOJ and FTC (whichever appropriate).  These veiled relationships have contributed greatly to the rate of inflationary growth of medical care and is a powerful source opposed to the use of evidence based medicine to guide indications for high priced diagnostic procedures.

More oversight to foil bribes is wishful thinking

April 7, 2008

Analysis of:New Focus of Inquiry Into Bribes: Doctors | www.nytimes.com

Illegal and unethical bribes to orthopedists have gone on since time immemorial and have been visible throughout the medical and device profession and business.  Yet little (despite Peter Robert Stark's attempt) to separate this added incentive from the most highly paid specialists in medicine, it has continue unabated.  Yes, it has morphed as the law has, but it continues as long as the orthopedist influences revenue generation within the walls of the hospitla. Yes, other specialties also have the same conflict of interest, but the lack of man power and political willingness to prosecute this few in the medical profession has "sanctioned" its spread.

Can you be both right and wrong?

November 13, 2007

Analysis of:Cigna reaches deal on doctors' rankings | news.yahoo.com

Fred is both right and wrong by history.  Ranking of physician performance is akin to work (or payment) for performance.  Since I was around at the beginning of this movement and watching its development, it is clear that work efficiency particularly will high acuity patients is very difficult to measure and our metics are immature to say the least.  Misrepresentation of performance will be rejected and health care savings will return to a contracting strategy (known to work).

Cost is high but quality is low--why the paradox?

September 25, 2007

Analysis of:Medical costs up again | www.mercurynews.com

While cost per capita is the highest in the world, why is our quality substandard?--Health care status is not solely based on healthcare and rejection of accountability of American people remains prevelant. More money is NOT the answer to what ails us in health care.

Physicians will have to look in the mirror to solve America's medical cost inflation

September 4, 2007

Analysis of:Health Insurers Mull Costs, Future of Medicare | www.thestreet.com

I disagree with Dr. Horvitz's assertions regarding rising cost of health care being the government and health plans.  These costs are but a drop of water compared to the actual unit cost of services and the # of services being delivered to Americans.  Health plan + governmental costs are in the 15% of the total spend. The mirror is a good place to begin for physicians if they wish to mitigate our national trajedy--Twice the cost per capita (wage adjusted) and somewhere about 35th. on population quality by all metrics commonly used. The second place to look is at the American culture and its expectations of our "health care system"--nothing but the perceived best for me--"spare the cost" even though it may have no medical evidence basis.

Current Medicare policy rewards mediocre/poor care to Americans

August 30, 2007

Analysis of:New Medicare Regulations Adopted To Reduce Certain Hospital Infections And Medical Errors | www.medicalnewstoday.com

The current RBRVS pre-payment system to hospitals currently rewards hospitals for those patients who suffer a hospital induced infection, injury, or other illness that elevates their acuity and ultimately payment from Medicare.  Only a payment for services system that pays for excellence and a lowering of the rate of harmful nosocomial events can focus money and expert attention to these issues. The new Medicare policy is an attempt at this change but lacks the recognition that adverse events will always occur at some lower level and will never reach zero.

Retail medical clinics are a welcomed addition to our current medical delivery model

August 27, 2007

Analysis of:Drugstore Clinics Spread, and Scrutiny Grows | www.nytimes.com

Retail clinics are health care centers of limited low risk services staffed most commonly by masters in primary care level nationally certificated Nurse Practioners who have provided primary care to millions of Americans for 40 years without issues of Quality by all evidence based studies. This is serving the uninsured who have difficulty finding a "medical home" and those Americans who wish a more accessable, convenient, lower cost per per episode  ) for minor low risk issues well within the training, education, and experience of licensed health care professionals.  This is only a "turf issue" and where money may flow cloaked in the cloths of "Quality."  Dr. Nosrati should study the model before commenting on Quality.

Market forces and health care are mutually exclusive

August 15, 2007

Analysis of:Doctor Shortage Hurts A Coverage-for-All Plan | online.wsj.com

The requirements of "market forces" or better free market enterprize as defined by Adam Smith has long been obliterated from American Health care. In the absence the of the  free market and daily attack on the Golden rule. one cannot rely on increased demand ultimately dictating more supply. American health care with its stakeholder consolidation, asymmetry of information re: value, and governmental intervention will always "sit on the side lines of free enterprize" and will not achieve a fair priced, efficient, quality system for all Americans. It is likely that Specialty Societies and Hospitals will be the subverting dark forces for a healthy Primary care segment of providers to meet the growing needs of Americans.  Consumer culture unknowingly aids and abets our chaotic, self-serving, inefficient, mediocre provision of health care. 

Primary care physicians--look to your "friends" for your professional salvation

August 15, 2007

Analysis of:Doctor Shortage Hurts A Coverage-for-All Plan | online.wsj.com

Health plans have merely followed the payment (reimbursement) profile created in the 1940's by the trade unions of hospitals and physicians who were dominated by specialists and special interests. Only primary care physicians have had a real drop in real income in the last 7 years while specialists enjoy income increases equal to or above real inflation.  This discourages physicians in specializing in the primary care specialities Many physicians in the 60's and 70's gave 20% of their patient care time free to our poverty segments, a plan that pays even at Medicaid levels for care for this segment has replaced this professional commitment and does pay for some fixed costs. The arrogance in our physician system towards being a primary care physician has equally played a major role in devaluing physicians who choose to practice in Pediatrics, Family Practice, and Internal Medicine.  This represents a major barrier for residents to seek these specialities.

Consumer engagement in the financing of health care is necessary, but not medical decision making

August 10, 2007

Analysis of:When patients pay more, they use less medicine, study finds | www.tennessean.com

Consumers and physicians alike must become more cost conscious to attend to our medical inflation rate that is mostly technologically driven--both immaging diagnostics and pharmaceuticals. Physicians will always play the role as the patient's medical fiduciary to inform the patient on relevant and appropriate diagnostics and tools. Consumers must with the cooperation and engagement of their physicians eliminate non evidence based diagnostics and therapeutics in our system Health plans should seek to encourage consumer engagement through benefit design yet not eliminate appropriate care choices

Classic HMOs improved Quality while decreasing cost-their loss is societies and physicians

August 10, 2007

Analysis of:HMOs to start ad blitz against Medicare cuts | news.yahoo.com

  Dr. Parish has a rather shortsighted view of the role of third party administrators in general and appears not to appreciate their intended role in our "system." Both Cost and Quality have and are suffering from the "stepping back" and demonization of HMOs by stakeholders who do not relect on their professional fiduaciary role to Americans. Physicians need to realize that the AMA (allocation of dollars under RBRVS) and lack of responsiveness of government and the abandonment of the true HMO model has led to super inflation and subsequent frustration for providers--especially those in primary care.

Failure of Primary care has fostered the development of Retail Convenient Clinics

October 16, 2006

Analysis of:Retail Medical Clinics draw patients and Payors | www.managedcaremag.com

In response respectfully to Dr. Rieser, MD and the original article, the emergence of "Retail Convenience Clinics" was encouraged by the failure of Primary Care for a growing American Population.

If one does their homework, it is clear that no one can question the quality of ARNPs who have provided primary care for 50+ years in America with academic studies showing equivalency to family physicians

All surveys to date, show impulse has no relevancy--it is timely access to care for common disorders well within the scope of a masters level nationally certified Nurse Practitioner.

This is not another supplemental health care cost, it has been shown to be highly cost effective and decisions are evidence based and monitored unlike Family Physicians in practice today.

It is a superior method to manage minor common illnesses than those who have a more robust and deep understanding of complicated medicine--7 years to become a family physician to treat a sore throat seems practicing way beneath their training and scope.

Insurance payment for telephone calls is very unlikely to occur

October 11, 2006

Analysis of:Statement On Pediatric Telephone Care By The American Academy Of Pediatrics | www.medicalnewstoday.com

Dr. Grella and the AAP document the reality of uncompensated time but do not offer answers to cost of health care inflation if this were a "covered benefit" by insurers.

There are many specialities suffering also from high telephone use for patient care and that includes Family Practice, Internal Medicine, Oncology, HIV specialists, and others--

The devil is in the details, but no new technology seems to be offered with this recommendation to document time and service and thus is a target for fraud.

Deja Vu all over again

September 21, 2006

Analysis of:Reimbursements to drop 5.1% in 2007, not 4.6% | www.hemonctoday.com

1.  Some technologically based physicians may defer purchasing new technology, but if there is a margin at all, it will likely lead to increased inappropriate utilization as Medicare has seen before.

2.  Office based technologically based specialists are a major driver of America's expensive health system on a cost/capita/year--this may in fact assist in mitigating our explosive use (much inappropriate) of technology to all age segments.

3.  This could but is unlikely to slow the diffusion rate of technology in America (#1 driver of cost. American expectations demand our technologically based health system.

4.  The growing segments of Americans over the age of 65 will "force" specialists to remain within Medicare for income payment.

A solution to primary care-no silver bullet

August 23, 2006

Analysis of:Retail Medical Clinics Draw Patients & Payers | www.managedcaremag.com

ARNPs (NPs) are more than trained and experienced in managing common illnesses that are the majority of episodic care

Family Practitioners are leaving practice and have less graduating leaving a void for Americans for perceived health issues

NPs are scientifically educated (allopaths) and in this consumer world we need Americans to turn to them for minor illnesses when their primary physician is not available

Integration of NP care with their identified Primary doctor is required so as not to fractionate care beyond today's "system."

Professionals (NPs) like others always practice within their education and experience and refer when appropriate.

Generics--fool me once, but......

August 23, 2006

Analysis of:Consumer-Directed Health Plans Boost Demand for Drug Price Comparisons | www.aishealth.com

Generics are losing their financial luster

Pharma has successfully limited effect of generic industry by many measures

Physician's behavior in prescribing is a major factor in lack of use of generics today   

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