At a hospital staff meeting, a family physician asked a
pediatrician whether he could apply for a job as a nurse practitioner in the pediatrician's office. The RNPs in that office do most
of the work. The family doctor was not joking.
A prominent roadside sign at a CVS pharmacy reads, "You're
sick; we're quick." This is one of 900 retail medical clinics in
the U.S.; there will probably be 1,500 by year's end.
But as clinics staffed by nurse practitioners expand, those
staffed by physicians are closing. Medical Marts reported that
venture capitalists backing the company "decided to go another
direction with their funding" (Chicago Tribune 3/13/08).
Now, more than 200 nursing schools are starting or readying
programs to offer a degree of D.N.P., doctor of nursing practice
(Wall St J 4/2/08).
Who Needs a Doctor?
More prospective medical students, and even fully qualified
physicians are asking, "Why be a doctor?" (see AAPS News,
2004). Payment is by the code, not by the qualifications, and
top salaries for advanced practice nurses, $100,00 or more, are
approaching those of physicians. Up-front investment,
indebtedness, overhead, and liabilities are much greater for
physicians, and scope of practice is narrowing, owing to
licensure boards as well as professional liability concerns.
Although it is said that the U.S. has a serious shortage of
primary-care physicians, not everyone agrees. "There are now more
physicians per capita in the United States than there have been
for at least 50 years," write David C. Goodman, M.D., and Elliott
S. Fisher, M.D., M.P.H., of Dartmouth, without commenting on how
many are in full-time practice. Regional supply of physicians
varies by more than 50%, and "patient outcomes are not better in
regions with a very large supply of physicians." This, they say,
"contradicts the notion that health care systems have inflexible
physician requirements." In fact, "increasing the number of
physicians will make our health care system worse, not better."
Rather than expanding physician training, we should invest in
preventive care, disease management, and broader insurance
coverage, they write (N
Engl J Med 2008;358:1658-1661).
Doctor Nurse will probably fit well into the "systemness"
domain (see AAPS News, May 2008).
Candidates "are being trained to have more focus than doctors on
coordinating care among specialists and health-care settings,"
explained Mary Mundinger (Wall St J, op. cit.), Dean of
Columbia University School of Nursing and a director of Gentiva
Health Systems and of UnitedHealth Group. One commenter on the
Wall St J Health Blog called them "gatekeeper pan-
They might well satisfy the American Academy of Family
Physician's (AAFP) desired attributes for retail clinics:
"evidence [protocol]-based" and "quality-improvement-oriented"
services; a "team-based approach," and electronic health records
(American Family Physician, May 2006).
Staving Off System-wide Disaster
These attributes are like those that HHS Secretary/ Medicare
trustee Michael Leavitt says are required in re-designing a
Medicare system that will be "solvent through the 21st century."
In an April 29 talk, he recognized that the trickle of Medicare
liabilities is becoming a "class 5 rapids." We're headed for
intergenerational warfare, and the U.S. economy could experience
the same fate as Argentina's. The fix? "Value of care would
replace quantity of care as Medicare's best-rewarded virtue."
This requires an "infrastructure of quality metrics," tracking
patients with chronic conditions, "strong doses of information
transparency," better coordination among providers and
Doctor Nurse, even without a D.N.P., will help to enforce
such changes as by squelching disruptive physician behavior. In a
recent poll, "96%!" of nurse respondents said they had witnessed
or experienced disruptive behavior by a physician. Nurses, show
other surveys, are the primary victims. Offenses include
"sarcastic, cynical, or demeaning remarks"; "disregarding
policies"; "blaming others for adverse outcomes"; or "routinely
making rounds at odd hours." Nurses are urged to report all
incidents, even if they resulted from the stress of the moment
and the doctor apologized. Reporting "benefits every-one" and
"helps doctors change" (Am Nurse Today, May 2008).
The War against Medicine
Physicians are under assault from many sides. Economically,
the supposedly valuable primary-care physicians are being
squeezed out: they are not permitted to charge enough for complex
services, and can no longer subsidize them with fees from simpler
services taken over by "physician extenders." In hospitals, notes
Lawrence Huntoon, M.D., Ph.D., doctors are being beaten into
subservience and total submission by the unholy alliance of
hospital associations, hospital bar, and nursing associations,
acting through the new "disruptive physician" and "code of
conduct" requirements of the Joint Commission on Accreditation of
Health Care Organizations (JCAHO). Then there are the HHS anti-
As Prof. Ron Libby, Ph.D., points out in his book
The Criminalization of Medicine: America's War on
Doctors, "The government has made medical doctors
scapegoats for the financial crisis of health care in this
country.... Physicians' role as sacrificial lambs follows a long
history of political scapegoats in the United States." It started
with the Salem witch trials.
Physicians dare not assume they will always be needed. Even
if they are, does the government care? Or does it prefer Dr.
Nurse less skilled, less costly, and less "disruptive"?
Drifting to Disaster
HHS Secretary Michael Leavitt observes that when he was
born, medical expenditures represented 4% of the U.S. economy.
When his son was born, the fraction had grown to 8%, and when his
first grandson was born, to 16%.
In 1965, the U.S. decided that the cost of seniors' medical
care would be borne by the younger workers. The demographic
assumption that there would always be a larger fresh crop of
workers was mistaken. "Most of you have done the math yourself
and know [that]...sooner or later, this formula implodes." When
the Medicare Hospital Insurance Trust Fund becomes insolvent,
projected to occur in 2019, "there is no backup plan...to ensure
that hospitals continue to be paid."
Leavitt notes that at the beginning of the 20th century,
Argentina was even wealthier than the U.S. Over 50 years, it
expanded its social benefits, using borrowed funds. By the 1990s,
its mortgage outstripped its ability to pay. Creditors said, "No
more, unless you fix your entitlements." It was too late.
"Argentines had put off hard choices for so long they were forced
to make change too quickly, and they simply didn't have the
political strength to do it."
Read Leavitt's speech at: www.hhs.gov/news/speech/2008/sp20080429a.html.
The Evidence on Disease Management
Can Medicare be saved by EBM, EMRs, "prevention," and
chronic disease tracking? The short answer, writes Greg Scandlen,
is "no" (Consumer Power Report 4/29/08).
In a 3-year, $360 million experiment, nurses have been
calling patients with chronic diseases periodically to see
whether they are taking their medicine and seeing the right
doctors. So far, the Medicare Health Support program has failed
to save enough money even to offset its cost about $2,000 per
patient per year (NY Times 4/7/08).
IT and Dumbing Down
Commenting on the "irrational exuberance" over health
information technology (IT), bloggers on hcrenewal.blogspot.com,
posting on 4/27/08, quote Pamela Hartzband, M.D., and Jerome
Groopman, M.D. (N
Engl J Med 2008;358:1656-1658): IT facilitates "clinical
plagiarism," with clinicians cutting and pasting verbatim from
other doctors' notes. The electronic medical record (EMR) becomes
"a powerful vehicle for perpet-uating erroneous information,
leading to diagnostic errors that gain momentum when passed on
electronically." One doctor has resorted to writing key
information on index cards, which he refers to on bedside rounds.
A first-year medical student comments that using the EMR
takes much longer than a hand-written note. Yet, writes a
physician blogger, the use of an EMR further dilutes the quality
of clinical training.
Most ERs Lack On-call Specialists
Of the 1,328 emergency departments responding to a 2005
survey, 73% said they had inadequate coverage by specialists,
including neurosurgeons, orthopedists, and obstetricians.
"Something people don't understand is that even if you have
insurance, if I don't have an on-call...surgeon, I can't help
you," said ER physician Linda Lawrence, M.D. (Wash Post
The numbers aren't quite lies. It's just that the U.S.
government changes the way the measures are computed to get more
desirable outcomes. When the core inflation rate started to sound
alarm bells, food and energy were removed from the equation.
Housing prices, removed when they started to soar, may be put
back in now that they are declining. When the unemployment rate
started to rise, the number crunchers stopped counting returning
veterans and people whose unemployment benefits had run out. If
the price of a product goes up 15%, but some valuable feature has
been added, the number stretchers could decide that the product
is actually cheaper. The money supply (M3) which Federal Reserve
Chairman Ben Bernanke stopped reporting 2 years ago, is
increasing by 17.4% each year; it was 16.4% in 1971, whereupon
Richard Nixon closed the gold window.
Each month, John Williams reviews the footnotes and fine
print accompanying official numbers and publishes his results at
With food costs up 20% since January, and interest rates
running less than inflation, it makes sense to stock the pantry
rather than saving (Jim Powell's Global Changes and
Opportunities Report, May 2008).
International Health Rankings
The World Health Report 2000, frequently cited to
show that U.S. medicine ranks 37th in the world, depends on
assumptions, which may be logically incoherent, characterized by
substantial uncertainty, or rooted in ideological beliefs (for
example, that the rich should pay more for medical care). For an
analysis of the rankings, see "WHO's Fooling Whom?" by Glen
Whitman, Cato Briefing Paper No. 101, Feb 28, 2008.
For a summary of a dozen other medical systems, see "The
Grass Is Not Always Greener" by Michael Tanner, Cato Policy
Analysis No. 613, Mar 18, 2008 (www.cato.org). He notes that if one corrects for homicides and
accidents, the U.S. rises to the top in life expectancy. In
outcomes for specific diseases, such as cancer, pneumonia, or
heart disease, the U.S. outperforms the rest of the world. Costs
are rising almost everywhere, causing budget deficits, tax
increases, and benefit reductions. Promises of universal coverage
mean rationed care and long waits for treatment. The most
effective national health systems incorporate market mechanisms
such as competition, cost sharing, market prices, and consumer
choice, and eschew central government control. Almost all have a
way out of government restrictions: French patients, for example,
can contract privately to avoid the "coordinated care pathway."
May 30-31, 2008. Seminar, Board of Directors, Dayton,
Sep 9-13, 2008. 65th annual meeting, Phoenix, AZ.
Sep 30-Oct 3, 2009. 66th annual meeting, Nashville,
Antitrust Investigation Shows Guidelines Flawed
On May 1, Connecticut Attorney General Richard Blumenthal
announced that his antitrust investigation has uncovered serious
flaws in the Infectious Diseases Society of America's (IDSA)
process for writing Lyme disease guidelines.
Although IDSA called the guidelines "voluntary," they are
used by UnitedHealth Care, Health Net, Blue Cross of California,
Kaiser Foundation Health Plan, and other insurers to deny payment
for long-term antibiotic treatment. They strongly influence
physicians' treatment decisions and are frequently cited to
justify conclusions that chronic Lyme disease does not exist.
Blumenthal found that IDSA failed to conduct a conflicts-of-
interest review and that influential panelists had a conflict.
Failure to follow its own procedures enabled the chairman to
appoint a hand-picked panel, without scrutiny. The Lyme panel
refused to consider dissenting opinions, and once even removed a
member in order to achieve "consensus." IDSA tried to portray the
guidelines promulgated by the American Academy of Neurology (AAN)
as independent corroboration, when in fact the panels shared key
members, came to the same conclusions, and used the same wording.
IDSA then used the AAN's supposedly independent findings in
attempt to defeat federal legislation to establish a Lyme disease
advisory panel and state legislation to support antibiotic
therapy for chronic Lyme disease.
IDSA and AAN reject the guidelines of the International Lyme
and Associated Diseases Society (ILADS) because it cites evidence
they consider insufficiently rigorous. (Neurology Today
10/16/07). IDSA and AAN rely heavily on randomized controlled
double-blind studies; however, "when a positive result is found,
they discredit the study," notes neurologist Lawrence R. Huntoon,
M.D., Ph.D. Too many patients in the study (Neurology
2003;60:1923-1930) guessed that they were in the treatment group,
suggesting that "unblinding" had occurred.
AAN's confidence in its ability to judge the effectiveness
of treatment is apparently not dampened by its inability to make
an accurate diagnosis of neuroborreliosis (neurologic Lyme
disease). The state-of-the-art antibody test has too many false
negatives (Neurology Today, op. cit.)
Insurance coverage is not the only issue. Malpractice
attorneys can attack physicians who do not follow
guidelines which become the de facto "standard of care." And
insurers can file anonymous complaints with medical boards about
noncompliant physicians. "Too expensive" = "practicing below the
insurance standard of care," notes Dr. Huntoon.
RACs Start "Outreach" in May
CMS has announced the deployment of new permanent recovery
audit contractors (RACs) as part of the postpayment Medicare
claims audit initiative. An "outreach and education" effort was
slated for May, to precede actual audits. A report on the three-
year demonstration program should be released soon; Congress
already decided to make the program permanent and to require it
in all states by 2010.
The RACs are "not as rogue as they're made out to be," said
CMS Program Integrity Director Kimberly Brandt. CMS has made some
changes, such as requiring that RACs return contingency fees if
claims denials are later overturned. Also the number of records
that RACs could demand at any one time will be limited (BNA's
Exclusive Contracts: New Control Tactic
Hospitals have long used exclusive contracting as a method
to gain control of physicians on the medical staff. Medical staff
privileging has, however, often been independent of the
contracts although privileges may be moot if an exclusive
contract bars access to equipment and facilities needed to
practice. A Georgia court recently upheld the authority of
medical staff bylaws to govern credentialing decisions and to
afford physicians the right to appeal a termination (Madonna
v Satilla Health Systems and Lefever et al. v. Satilla
Exclusive contracts could "allow physicians to be terminated
from the medical staff without due process protections," stated
Donald Palmisano, Jr., general counsel to the Medical Association
of Georgia, which filed an amicus brief supporting the physicians
(AM News 4/28/08).
Loss of hospital privileges must be reported to the National
Practitioner Data Bank (NPDB), and could end a physician's
career, notes Lawrence R. Huntoon, M.D., Ph.D., chairman of the
AAPS committee to combat sham peer review.
"Physicians who sign these exclusive contracts, hoping for a
secure paycheck, may be risking their entire career if things go
sour with the hospital administration," warns Dr. Huntoon.
Tip of the Month: In the guise of "strengthening
medical staff self-governance," the AMA is promoting the new
JCAHO MS 1.20 standard, which says that medical staffs can decide
what authority to delegate to the Medical Executive Committee
(MEC). This could "improve efficiency" of hospital efforts to
control doctors. The hospital bar lobbied aggressively for a
provision to allow procedural details of credentialing and peer
review to be moved from the medical staff bylaws to
administrative procedure manuals, which can be approved by the
MEC without medical staff input. To help reduce control by
hospital administration, physicians should exercise the power to
not delegate authority to pass any medical staff bylaw,
regulation, rule or policy to the MEC, and to de-authorize the
MEC to act on behalf of the medical staff between meetings.
A statement on the website of the Division of Consumer
Affairs, New Jersey Office of Attorney General, states that as of
Oct 8, 2008, all NJ prescription blanks must be preprinted with
the prescriber or facility NPI and must be consecutively numbered
or serialized. The governing statute, however, 45:14-49,
provides that the NPI shall be included if the
prescriber has one. AAPS General Counsel Andrew Schlafly has
asked the Attorney General to clarify the statement on the
website and to bring it into compliance with the statute, which
expressly recognizes that not all physicians need have an NPI.
It is possible that carriers may try to force a physician to
obtain an NPI in order to opt out of Medicare. But the opt-out
provision in 4507 of the Balanced Budget Act is worded as a
safe harbor rather than a requirement. There is still no written
provision forbidding private contracting by Medicare beneficiaries. Two Medicare clerks have told AAPS members that there is
no need to opt out if they are not providers either because they
have never filed a claim or have not done so for years. Contact
AAPS with information or questions.
"Freedom in its broadest sense no longer has doctors as
participants." Ronald Reagan
Protected Lying. When ordinary citizens lie to
prosecutors, they are often prosecuted and go to prison. When
Martha Stewart lied, she went to prison. When prosecutors use
perjured testimony to obtain a conviction (as in the case of Dr.
Bernard Rottschaefer), the accused often goes to prison. When
Bill Clinton lied, it was passed off as semantics and his own
personal business. "Former Gov. Eliot L. Spitzer lied to
prosecutors about what turned out to be his major role in a
campaign to smear a political rival [Senate Majority Leader
Joseph L. Bruno], but the Albany County district attorney David
Soares said he "will not pursue any criminal charges against the
already-disgraced ex-governor" (Buffalo News 3/29/08).
His ability to prosecute is limited, he said, as the ex-governor
is no longer a public official. Release of the records of the
case could not occur because issues of executive privilege
involving Spitzer and Gov. Paterson have not been resolved.
Apparently, holding high office confers absolute immunity on
the official. Is it any wonder that some holding the highest
offices are the most corrupt?
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
EBM and Quality. Evidence-based medicine (EBM)
originated in the UK and was institutionalized in the National
Institute for Health and Clinical Excellence (NICE even George
Orwell would have a hard time performing at this level!). NHS
Blog Doctor often discusses NHS quality guidelines. The
discussion of the dumbing down of people who care for patients
especially nurse midwives is horrifying. Women with uncomplicated
pregnancies don't need an obstetrician, the guidelines say.
Reportedly, maternal deaths have been rising in the UK. It's a
road map for what will happen here if we don't get third-party
payment under control. I predict that after another century or
two of research we'll end up with rich academicians, poor
doctors, and a bunch of evidence showing that the best medical
decisions are made by properly trained people considering the
needs of the individual patient.
Linda Gorman, Independence
Institute, Golden, CO
The End of Excellence? We may have some of the best
respiratory medicine expertise in the world. Enjoy it whilst it
lasts, for it will soon be gone...because, to save a few pence
here and there, we are eating our seed corn....
[In the past we had a] busy medical "firm" with enthusiasm
passing up the chain, and experience passing down...the young
lean and hungry medical registrar who is genuinely interested in
emphysema,... who is questioning orthodoxy, who is driving his
consultant mad by saying, "why don't we do it this way, ... have
you seen that new paper in the Brazilian Journal of
Respiratory Medicine?..." It has all gone. Old fashioned
senior registrars do not exist.... The clinics are run by nurse
specialists. The nurse have neither the training, nor the
experience to do the job the registrars of old did. They do not
question, and they cannot think and analyse in the same way. They
are protocol bound.... When the current generation of experienced
consultants retires, there will be a void in medical expertise
that will never be filled (http://nhsblogdoc.blogspot.com/2007_06_01_archive.html).
Dr. John Crippen, posted 6/11/07
P4P and Quality. Current pay-for-performance measures
are not quality measures, but "standards of care" for
prevention and for standardized management of established
diagnoses. Remember, failure to meet the standard of care is
called "malpractice." P4P measures compliance with a third-party
cookbook which is the inverse of quality. At least 15% of
patients have circumstances that are inappropriate for the
cookbook. Quality means the ability to recognize those patients
and to prescribe treatments adapted to individual needs. The
peril is that P4P rewards those best at following a protocol.
Already, nonphysicians, who are superb at cookbook compliance,
are beginning to replace physicians.
Stephen R. Levinson, M.D., Easton, CT
Recertification. When Harry Kimball, then head of the
American Board of Internal Medicine, was asked nearly a decade
ago about the reason for changes to the recertification process,
he said they were partly in response to demands from managed care
plans for more specific recredentialing data. Why was ABIM
kowtowing to insurers instead of listening to the demands of its
diplomates for a simple, fair, inexpensive process? The current
process is like the written test for a driver's license, only
more time-consuming and expensive. I am concerned that internal
medicine (IM) residents are being taught to "study the book,"
rather than care for patients. I suspect IM programs are rated by
their board pass rates.
Alan G. Pocinki, M.D., Washington, D.C.
Guidelines, or Else. An article headlined "States May
Warn Doctors to Follow Smoker Treatment Guidelines or Be Sued for
Medical Malpractice" quotes a study claiming that 40,000
"victims" a year die because doctors don't follow federal
guidelines on smoking cessation. When will doctors ever stand up
and say "enough"? Every visit my doctor asks me do I smoke, how
much, do I drink water,...." From now on, he gets no information
from me! I do not want my information in some database that some
Foundation is pushing! Who do they think will even want to be a
doctor in the future?