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Are More Doctors Leaving Medicare?

Today’s blog is a bit of a departure from my usual EMR and EHR focus, but I think that Medicare is pretty intricately intertwined with the EMR incentives via Meaningful Use, and so I thought I would share some perspective on a recent article that set my mind’s hamster wheel spinning.

Bob Keaveney’s article at Physicians Practice, With Friends Like These… paints a powerful summary to the reason doctors are running from Medicare and Medicaid — left and right — these days and how the New World Order coming in the form a ACOs may put a strain on the relationships between physicians and patients.

Last Tuesday evening, my practice manager was visiting with a freindly neighborhood PCP and her practice manager from down the road.  They are literally a block up as a matter of fact.  My manager was helping them understand how we use our EMR system, Practice Fusion, and how they could do the same.

The conversation at one point turned to why we were seeing a lot of Medicare patient referrals for diabetes care from the PCP’s father earlier this year.  Her father is also a PCP in the same practice here in DC.  She had an interesting answer.  “Oh, he left Medicare and had to find a home for them.  I’m also planning to leave Medicare in January 2012,” she said.  And to think that we just dumped Medicare ourselves on July 1!

Another interesting part in considering this PCP’s story of leaving Medicare in January is that she is probably not planning on going after Meaningful Use incentive money, an idea that I’ve nearly given up on as well given the complexities involved, in particular, to my current situation.  But that’s a completely different story for a different day.  At any rate, read Bob’s article above.  It’s food for a hungry mind as the year in Meaningful Use progresses.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine and opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.  Some of his blogs also appear at EHROutlook.com.

October 3, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Do EMR and EHR Registries Equal Better Care?

Meaningful Use includes the creation and transmission of patient registries for reporting various medical data such as vaccinations, medications, lab results and vital signs including weight, body mass index (BMI) and blood pressure.  To be honest, I don’t know any real practicing doctors out there who worry about their EHR’s ability to perform registry generation, but non-doctors with more time on their hands seem to think it’s the Holy Grail.  As it turns out, a recent post by Ken Terry EHRs Give Docs Analytics Tools They May Ignore sparked my interest.  

It was pretty intriguing that an insurance company like Blue Cross Blue Shield would be sponsoring a pilot experiment to correlate doctors’ access to EMR and EHR technology with doctors’ ability to generate patient registries.  Clearly, this is the first step in making searchable databases that will enable users to ask more detailed questions.  Since the pilot study was not clear on what or how much information was shared with the insurance company by the administrating body for the study, the Massachusetts eHealth Collaborative, there’s an interesting closed door there that the public can’t see behind right now.  Why does an insurance company want such information?  Let’s be honest:  it’s got to be money, plain and simple.  Insurance companies are for-profit entities after all.  Assigning report cards and pay-grades to doctors based on performance?  Stratifying out “good” and “bad” doctors?  Door #3?  If they just want to study problem areas for public health improvement, then it would be preferable to define their end goals publicly ahead of time — which has been one of my big beefs with Meaningful Use.

I loved the comment by Jane Metzger, a CSC consultant who is an expert in registries.  Most of today’s EHRs can do a registry-like function, but it takes work to do that… Not every practice that adopts an EHR is committed to care management–having guidelines for care, knowing who your diabetic patients are, and deciding you should see them at least once a year and so forth.”  Wow — what a negative connotation of docs who might have other ways to benefit their patients.  However, Metzger did mention something I agree with in the end:  ” it’s extra work to do it.”

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

August 9, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

First iPad EMR app eligible for meaningful use

I read an interesting story on Sunday night regarding DrChrono, the first EMR to make use of iPad app technology to carry it. How powerful to have an EMR in tablet based form, indeed.  But is this the first tablet to be able to run an EMR in portable/mobile form?  I wouldn’t think so. But how many people out there crave the ability to carry around a tablet — with the style of an iPad — that they can integrate with the rest of their lives when they leave the office?  I’d wager it’s a lot.

The only problem I have with the announcement post about the DrChrono EMR app is that it claims that Drchrono is “the only app of its kind to receive such [meaningful use] certification so far.”  Interestingly, there is a much older announcement allowing Practice Fusion users — of which I am a member — to use their web-based EMR on an iPad via a Logmein app.  I haven’t done this yet, although I use PF on my MacBook Air at home all the time.  One key difference between Practice Fusion and DrChrono is the cost.  With PF, there is no data limit to this free EMR.  However, for DrChrono, the free version will only support up to 10 GB of stored patient data, beyond which there is a charge per provider which can be up to $799/month, depending on the amount of data to be stored.  Nevertheless, it’s certainly a welcome sign of the times that an app, in and of itself, is now meaningful use-certified.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com. 

August 1, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

The $44K incentive for EHRs is TAXABLE!

The topic today folks is a short but poignant one.  Yesterday, I noticed on a blog somewhere out there in cyberspace that apparently the $44K incentive money isn’t exactly all that  it’s counted on to be.  Most people probably do not recognize that even though it’s originating from a federal program, the federal government is going to be taking about a third of it right back in taxes based on how it’s paid out.  Unlike tax write-offs that we can all qualify for if we are using money for business expenses, apparently this isn’t the case for the $44K, which is slated to be paid to individual doctors.

How does $29K sound?  If you’re the federal government, let me say it sounds like a really good deal for saving money.  Will $12K in the first year recoup all that is needed to be put into computer hardware, complex software, office rewiring/networking, and IT consulting and maintenance costs?

I’ve said it before and I’ll say it again.  Go for an EHR system if you want it for your practice to be more modern and electronic, not for incentive carrots.  You know those baby carrots that are left after all the outsides are shaved away?  Yeah, the two-inch stubbies you can find in the produce aisle in plastic bags.  Well, I wonder if this is an apt comparison with what you can really expect from the incentive money in the end.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 19, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

CMS to cut healthcare payments by 30% in January 2012

You knew it was coming folks.   I did, too, as a matter of fact.  And so, as of July 1st, I famously exited Medicare, stage right.  Earlier in the spring, I enjoyed a lunch here in DC at Lauriol Plaza — my favorite Mexican resuarant in the District — with a personal friend of mine fairly high up in HHS who works on MU rules.  At one point, when we were discussing the highly cliche will-they-or-won’t-they cut Medicare/Medicaid payments, he rhetorically stated with eyebrows raised, “Think about it, the money’s got to come from somewhere.”  The clear implication being that it will logically come from cutting from doctors’ payments.

Now, the New York Times reports this post, discussing the compromises that the Obama administration is proposing to make by cutting CMS payments for services to seniors in exchange for the Republicans allowing them to raise taxes to solve the budget crisis.

Suddenly the $44k incentive money for using EHRs is looking quite pale.  E-prescribing for 2%?  Pee-shaw!

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 7, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Idealism and Motashari’s politics

I just waded through a description of Dr. Farzad Motashari’s speech to providers recently at a session of the National Health IT and Delivery System Transformation Summit in Washington.  Dr. Mostashari, MD, ScM, is the national coordinator for health IT.  Although he appears to have a lot of degrees and certificates behind his name — most, it seems, in public health and epidemiology — it’s not clear how much actual time in a private practice office Dr. Motashari has spent, beyond his internal medicine residency.

Residencies are great at teaching you the ideal, textbook way medical practice is supposed to take place.  But, unfortunately, the real world of private practice doesn’t start educating you until you are out in the real world, with pressures and requirements that are not discussed or taught in medical school or residency.

More than a career in data crunching and writing research papers would give me confidence that Dr. Motashari really understands how many hoops –which he insists that meaningful use is not about — are actually entailed by MU and how much it has the potential to side track doctors’ abilities to self-direct patient care as they see fit.  It’s one thing to make eloquent public health speeches and have public health research as your personal goal in life .  It’s another to get practicing doctors to buy in up to the point that they are willing to change their own goals and work flows in providing excellent patient care in order to support someone else’s plans of collecting a ton of data for research use.

I wish someone could help me understand why I should be helping support an already way-overpriced program for researching what doctors already do all the time.  Do we have not trust in our nation’s doctors to do such basic healthcare as addressing blood pressure, obesity, and smoking cessation?  Somehow, I don’t buy that we need such a program at such a high price.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 6, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Lack of motivation of private payers to incentivize EHRs

In his June 30, 2011 post “Private Payers Need to Join Humana, CMS With EHR Subsidies”, Neil Versel wonders where all the private payers are when it comes to providing incentives to doctors for implementing meaningful use of EHRs.  Apparently, Humana is now one company slated to start following CMS’ lead.

This reminded me of an interesting story involving an insider I knew who previously worked for insurance companies.  He once told me an interesting story about the conversations that happen behind closed doors of private health insurance corporate boardrooms.  Alas, it was so long ago, that I honestly don’t remember who it was, or who they previosuly worked for, but it put such an indelible mark on my memory that I couldn’t resist the chance to share it here.  This may be a bit graphic to some, so turn back now if you have a faint heart.

I told my contact that I just couldn’t understand why preventive office visits such as counseling by registered dieticians dealing with weight loss for patients with obesity weren’t ever covered.   Did these patients really need to develop diabetes first before any coverage for such services would be provided by the insurance companies? It just didn’t make any sense to me or others that I had discussed it with.

My contact told me about an example of how insurance companies employ actuaries to mathematically predict odds of a bad outcome.  [For those of you who worship the movie Fight Club, you might find some similarity here to a particular dialog in that film.]  Because the odds are very good that a particular patient will change insurance companies within a few years –happens all the time — there is much less of a chance that insurance company A will have to end up paying for their leg amputation by the time it happens.   Therefore, insurance company A doesn’t provide much in the way of preventive care and counseling visits today.   The odds are with the insurance company that they’ll never have to pay for that operation in the future because the patient’s out the door by then and on to insurance company B.  I know, what a callous and disgustingly money-grubbing view!  Gee, you don’t say.

Now, getting back to this private insurance company incentive plan idea …

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 5, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Two faces of Eve: CMS payment cuts and MU

Let’s get real for a moment, shall we?  I just read a post about the AHA blasting CMS for supporting payment cuts to help balance the budget.  At the same time, CMS is offering all of this “free” money in the form of incentive payments for incentivizing doctors to buy expensive electronic medical records systems to get an extra $2 per $100 billed.  So is CMS interested in giving doctors more or less?  I’m a bit curious here, as I’m sure many others are as well.

Let’s see.  In January 2012, the SGR formula for payment reductions to doctors will cut off 29%, or $29 per $100 billed.  If you add back $2 per $100 billed, you get a net loss of $27 per $100 billed by doctors.  Even if you get $44K back from CMS over 4-5 years, this would really only cover the cost of setting up the EMR equipment, if that.

Although most of my patients are pretty tuned-in and tell me how much they understand “completely” why I am opting out of Medicare as of tomorrow, July 1, I still periodically get a few questions from other patients, asking, “What’s so bad about Medicare?”  Maybe I’m nuts, but in my mind this really makes a statement about the different levels of enlightenment out there among the general public regarding why some doctors are opting out of Medicare these days.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

June 30, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Quantity vs quality: keeping America’s doctors back with MU regulations

I read the following post on Saturday over at TheHill.com.  I have to quote from the article here because it’s such a perfect setup for what so many doctors feel about meaningful use/MU.  Warning:  possible ravings of a complete lunatic coming at the end.

“Small medical practices warned Congress on Thursday that health information technology risks being less than useless if it’s designed to meet bureaucrats’ arbitrary standards rather than the needs of doctors and patients.

Testifying at a House Small Business healthcare subcommittee hearing, the CEO of HIT Services company Ingenix said cost isn’t the main reason physician’s offices are struggling to make the switch to paperless. Rather, Andy Slavitt testified, the “purchase and design of technology (…) have taken a back burner to all of the compliance reporting requirements” needed to qualify for federal incentive payments.

“Today,” Slavitt said in written testimony, “the end-users, doctors and patients, are further away than ever from system design, because new product development is focused on satisfying those regulatory hurdles, rather than on simple innovations that improve productivity.”

I could not agree more.  The U.S. federal government, in the form of HHS and CMS, is basically hijacking the doctor-patient relationship by giving doctors extra steps to do during office visits.  The way I see it, if CMS and HHS are so hellbent on puppetmastering the show and making doctors into mere data-reporting automatons — which, I have to tell you, PQRI reporting felt an aweful lot like — then I suggest that they take an even fuller responsibility for providing the healthcare to the patient themselves.  After all, what do they need doctors for if they can practically write the script for the visit?  With the increasing number of MU requirements that have to be incorporated into each visit — to basically “help” doctors “do a better job” — it begs the question “Where will it end?”.  Is it much different from an organized crime boss telling me, “Do this… or we’ll hurt you?”    As MU progresses into stages 2 and 3 — I’ve said it before and I’ll say it again — I can’t wait to find out what my CMS-participating peers will end up dealing with.

It all reminds me that I didn’t go to medical school because I wanted to become a data collector for Uncle Sam.  Call me old fashioned, but I actually like having enough time to to listen to why the patient really came to see me today.  However, for the government, apparently, the numbers are more important.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

June 7, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Frustrating government incentive programs for health IT

Have you ever noticed that just about everything the government touches gets turned into a steaming pile of jelly beans?  Maybe I am exagerrating, but my friend and health IT guru John Lynn over at EMRandHIPAA.com had a comment conversation back and forth with me about Accountable Care Organizations (ACOs) recently.  After a post by Neil Versel, I mentioned that my beef with ACOs derives partially from their unformed nature and lack of concrete details.  How is anyone supposed to be convinced this isn’t just a government-run HMO?  How many patients do you know who love HMOs?

I told John “I suppose that that is a blessing, since without details, there can’t be any implementation.”  But then he correctly asserted, “Until you learn that they’re holding you to all the details for which they didn’t define or make known.”  Which is true!

And that’s exactly what happened to me when I tried to participate in PQRI for 2010.  What did I get for it after investing a lot of time and sweat as it required an extra form to be filled out at the end of already long and complex visits with my Medicare patients?  I get no one who will tell me or my practice manager any useful information other than the “program” is still “crunching the numbers” and will not be done doing so until late in 2011.  Although they are supposed to be able to provide an advance report on how much data I correctly fed into their system, the report is not accessible due to a lot of red tape and hoops to jump through (which in the end you find out are insurmountable).  As my last example and point for this post, it took my manager about a week on the phone to figure out that the advance report would be virtually impossible to get at this point.  It would be so much better if government incentive programs were properly formed before they went live.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

May 19, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.