The third national Pay for Performance (P4P) Summit held in
Los Angeles in February ushered in a new IT (information
technology) word: "systemness."
"The IT-enabled systemness domain looks and acts like a
single, integrated organism like a system working together,
rather than a bunch of separate pieces going their independent
ways," explained Dolores Yanagihara, manager of the Integrated
Healthcare Association's P4P program.
It's "interconnectivity" and more: "shifting decision-making
responsibility and authority away from the subsidiary operating
units to the corporate level and centralizing or standardizing
key management systems and processes."
P4P is the "accelerator" for IT adoption. In fact,
Yanagihara said, P4P and IT are inseparable (George Lauer,
If the Federation of State Medical Boards (FSMB) gets its
way, physicians will be forced to comply with "systems-based"
practice requirements for "maintenance of licensure." They will
also have to undergo a "peer assessment" program, which could
help to eliminate independent physicians, notes Lawrence Huntoon,
M.D., Ph.D., as socialist-minded physicians are likely to want to
punish their non-conforming "peers."
The FSMB also emphasizes "professionalism" a term that
increasingly, as in the Charter on Medical Professionalism (see
AAPS News, May 2002),
has come to mean dedication to the goals of the system
(collective), rather than individual patients.
The fourth road marker on the Journey to Quality Improvement
is "culture change," as shown in the cartoon book by Manoj Jain,
M.D., M.P.H., entitled Road Map for Quality Improvement: A
Guide for Doctors (www.mjain.net), which lists as
resources the AMA, the Institute for Healthcare Improvement
(IHI), and CMS. In the quality culture, "Variations
Uniformity," "Paper records Electronic Medical Records," and
"In the past physicians in training were taught to be
autonomous and individualistic. A good physician listened to the
patient, made a decision and dictated orders.... This model can
no longer work," Jain writes.
"Today, a good physician has to work as part of a team,"
which has three modalities within an organization: system
leadership (hospital administrator), technical leadership
(physician), and day-to-day leadership (floor nurse manager). The
goals: "Doing the right thing (evidence based care)...For every
patient (equal care)...Every time (consistent care)."
The goal of HHS Secretary Michael Leavitt is to transform
the health care sector into a system:
"coordinated" rather than "disjointed" and "fragmented";
"equitable" rather than riddled with "disparities"; "disciplined"
rather than free.
Management of medical resources, one of the responsibilities
of physicians under the Charter, requires a "return to the
commons," write Christine Cassel and Troyen Brennan of the
American Board of Internal Medicine (the latter also part of the
Interdepartmental Working Group of the Clinton Task Force on
Health Care Reform). The fee-for-service model does not allow
physicians to affect where saved resources go. They might, for
example, go toward reducing the federal deficit. We thus need an
"explicit commons that would link the moral duty to individual
patients with a responsibility to the community" a new ethical
framework with a public-health focus (JAMA
The Data Imperative
Aggregated, comprehensive data from linked electronic
records is essential for the desired outcome. Ultimately, medical
records alone will not suffice. "Health" is a much broader goal.
The British National Health Service (NHS) is building a
national data "spine"; no one will be able to opt out of the
demographic record, including a unique NHS identifier assigned at
2006;296:2255-2258). At least at present, patients can opt
out of having medical information entered, though officials try
to dissuade them (Guardian politics blog 3/10/08). Many
physicians have opted themselves out and have begun encouraging
their patients to do so because of the loss of confidentiality
A proposed compulsory ID card, connected to the National
Identity Register (NIR), would have to be swiped every time a
British subject bought alcohol or cigarettes, filled a
prescription, or withdrew more than ú99 from a bank. The Home
Secretary could revoke or suspend the ID making it impossible to
do anything requiring access to the NIR, writes former New
Statesman art editor Frances Stonor Saunders.
The Real ID in the U.S., warn opponents, is an international
biometric identifier that could become essential for getting a
job, a marriage license, a bank account, or medical care
(DeWeese Report, February 2008). It's the key to
establishing a total surveillance society, of which health
tracking especially "mental health" is an essential part. State
and federal officials are pushing for automated records of people
who have been involuntarily institutionalized, or even committed
for out-patient treatment: Screening gun buyers is the rationale.
The electronic records in one's "medical home" could be used
for many purposes other than calling patients in for needed
tests. Confidentiality would be no barrier. Privacy workgroup
cochairman Paul Feldman resigned from the American Health
Information Community (AHIC) because of its disregard for privacy
Dissent is a threat to systemness, and privacy prevents
discovery of dissent, as well as other health or safety threats.
IT News Briefs
Travel Monitoring in the UK. The EU already supplies
Washington with 19 pieces of personal data, including mobile
telephone numbers and credit card details, on passengers entering
the U.S. It's considering collecting the same data for flights
within the EU, and British officials want to extend the system to
sea and rail travel. Data stored for 13 years would be used to
"profile terror suspects." Those who ask questions are considered
"soft on terror" (Guardian 2/23/08). Electric trawling
of travel records is to help MI5 counter the threat of cyber-
attacks that could cripple infrastructure (Observer
Store DNA from Young Potential Criminals, Police Urge.
Primary schoolchildren who exhibit behavior suggesting criminal
tendencies should be in the DNA database, says Gary Pugh of
Scotland Yard. "Prevention" through cognitive behavioral therapy
and other means should start in targeted children as young as
five, states a report from the Institute for Public Policy
Research (Observer 3/16/08).
Activist Jailed. After meeting with Oklahoma
legislators and before a scheduled meeting with a Dept. of Public
Safety official, Mark Lerner was arrested on a charge related to
writing a single check. Though the charge could have been handled
in civil court, Lerner was held with career criminals in a 23-
hour lockdown for 2 weeks. The intimidation tactics served to
intensify his commitment to inform legislators about the Real ID
The AMA Is There to Help. Because "integrating an EMR
[electronic medical record] system requires significant changes
in the way a practice operates," the AMA offers resources on HIT
and redesigning your work flows (www.ama-assn.org).
British P4P. Bruce Guthrie's practice in Scotland
contracted to be a subject of the world's largest P4P experiment.
In return for a 20% pay increase, they had to record all relevant
data for the Quality and Outcomes Framework (QOF) on every
patient in an EMR. The torrent of data was a constant burden on
clinical and administrative time. The percentage of patients with
ideal BP control increased from 45% to 58%. However, no quality
improvement effort is expended on the 85% of conditions that
aren't in the QOF, and initial diagnosis is no longer checked, as
QOF ignores diagnosis. The NHS paid handsomely for incentivized
diseases, but in the future "every GP I know expects that more
work will be required for no extra money" (posted 8/2/07, http://healthaffairs.org/blog
U.S. General Internists on P4P and EHR. A national
survey showed that a majority of internists (61%) believe that
measuring quality will divert physicians' attention from
important types of care for which quality is not measured, and
82% think that measuring quality may lead physicians to avoid
high-risk patients (Health Affairs, March/April 2007).
"I've witnessed more serious errors with the EHR than in my
previous 25 years as a physician," writes Christine Sinsky, M.D.
Tidbits of data are sequestered at the ends of nonintuitive
labyrinths. Doctors are not resisting electronic health records
because they are Luddites. No coercion was necessary to get them
to use cell phones, digital cameras, or the internet. "The
problem with HIT is not the purchaser; it is the product," she
concludes (Family Practice Management, March 2008).
Murray Sabrin Running for U.S. Senate
Hoping to challenge Sen. Frank Lautenberg (D-NJ), finance
professor Murray Sabrin is running against State Senator Joe
Pennachio in the primary. Sabrin promotes "freedom and the
unleashing the independent spirit of the American people from the
shackles of its government." According to a 94-page manifesto
published under the pseudonym Dr. Joseph Penn in 1991, Pennachio
favors a nationalized medical system and government "coordination
of all aspects of society." Sabrin has been endorsed by Ron Paul,
and a previous Sabrin campaign was supported by AAPS-PAC. See
Washington Members Oppose Assisted Suicide
Washington State Initiative I-1000, sponsored by Compassion
in Choices (formerly the Hemlock Society), would allow physicians
to write lethal prescriptions. "Assisted suicide turns physicians
from healers into executioners and violates 2,500 years of
medical ethics," state opponents of the measure
(www.noassistedsuicide.com). Former AAPS president Robert J. Cihak,
M.D., and AAPS members Susan Rutherford, M.D., and Shane
Macaulay, M.D., are working with the coalition that is fighting
Full Faith and Credit
For the first time in history, writes Martin Weiss, the
Federal Reserve has accepted illiquid, opaque securities as
collateral and pledged up to 60% of its reserves of Treasuries to
back "virtually any junk securities banks want to get rid of." In
a few months, Ben Bernanke "has done more to reward risk-
takers and punish America's retirees on fixed incomes than all
previous Fed chairmen combined." The Fed has already fired its
biggest guns, and an unlimited risk of a chain reaction of
defaults remains (Safe Money Report, April 2008).
The federal government has already promised more than $100
trillion in Medicare and Social Security benefits, over and above
expected taxes and premium payments (2008 Medicare Trustees
It's not just the economy. Ron Paul (R-TX) warns us:
"Monopoly control by government of a system that creates fiat
money out of thin air guarantees the loss of liberty" ("What the Price of
Gold Is Telling Us," LewRockwell.com 3/15/08).
"Innovation drives change, the market drives change.
Government 'change' just drives things away....[C]apitalism [is]
the real 'agent of change.' Politicians, on the whole, prefer
stasis.... [T]he tide is rolling in on demographically and
economically unsustainable entitlements, but that doesn't stop
politicians from getting out their beach chairs and promising to
create even more. That's government 'change'...."
Mark Steyn, Orange County Register 1/12/08
AAPS Files Amicus Supporting Dr. Eist
Arguing against the unlimited authority of medical boards
that the Federation of State Medical Boards (FSMB) asserts is
required to protect patient safety (see AAPS News, March 2008), AAPS
filed an amicus curiae brief in the Court of Appeals of Maryland
on behalf of Harold Eist, M.D.
No matter how laudable the goal of protecting public health,
"it may never serve as a justification to use an unconstitutional
means," we argue to the Court.
"Assuming arguendo that a doctor had mistreated his
or her patient(s), the Board's failure to immediately notify the
patient of the investigation, including its subpoena of Dr.
Eist's records, would expose the patient to additional improper
care, and would certainly amount to a deprivation of the pa-
tient's right to...engage the services of a new physician."
The Due Process Clauses of the Fifth and Fourteenth
Amendments to the U.S. Constitution require that a person receive
notice and an opportunity to present objections to a deprivation
of life, liberty, or property. Dr. Eist's interests include the
protection of the confidential patient-physician relationship
from third-party interference; the protection of his medical
license from attack; the protection of his financial assets from
an unwarranted fine by the Board; and the protection of his
ability and professional duty to raise objections to disclosure
on behalf of his patients.
The U.S. Supreme Court has held that "'Where a person's good
name, reputation, honor, or integrity is at stake because of what
the government is doing to him,' the minimal requirements of the
[Due Process] Clause must be satisfied" (Goss v. Lopez
419 U.S. at 574-5).
Because deprivation of due process is unlawful, Dr. Eist
cannot be said to have failed to cooperate with a lawful
investigation, and thus is subject neither to fine nor reprimand
by the Board.
Amici conclude that the Court must declare 4-307(k)(1)
(v)(1) of Maryland's Health General Article unconstitutional
because it fails to provide a patient with notice and a hearing
when the state seeks to access that patient's records.
Lawsuit Demands $67 Million in California
Tort reform notwithstanding, a California radiologist and
cardiologist were hit with a jury verdict of $67 million after
actor John Ritter died at age 54 of an aortic dissection,
misdiagnosed as a myocardial infarction. Though non-economic
damages are capped at $250,000, economic damages were
calculated on the assumption that Ritter would have continued to
work until retirement at the same income he was receiving for his
current gig, a new sitcom entitled "8 Simple Rules for Dating My
Physicians may want to think twice about taking on the care
of a high-earning celebrity. Most high earners have purchased
life and disability insurance on their own, but few physicians
are in a position to make such people whole in the event that
negligence is proven against them (Medical Justice News
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,
Medicare Has New ABN
The new CMS Advance Beneficiary Notice of Noncoverage (ABN)
has an additional option: patients may choose to receive an item
or service and pay for it out of pocket, rather than have a claim
submitted to Medicare.
Note that if Medicare denies payment on a claim, as for lack
of medical necessity, the physician is forbidden to bill the
patient unless the patient has signed an ABN (MCA
Do an Audit, or Go to Jail
Dr. Martin McLaren faces 46 months in prison, $5 million in
restitution, and perhaps additional fines of his wife for, among
other things, overutilization of CPT code 99214. The practice had
routinely used this code for "prescription pick-ups," without
justification in the record for this level of service. To
identify unusual billing patterns, staff should routinely create
a report comparing the practice with national standards using
products such as DecisionHealth's 2008 E/M Bell Curve Book. Also
check for unusual procedures or for procedures requiring
equipment you don't have (ibid.).
Spitzer Snared by PATRIOT Act
Rep. Ron Paul, M.D., (R-TX) notes that most people think
that former NY Gov. Eliot Spitzer got exactly what he deserved
when he was forced to resign after exposure of his liaisons with
high-priced prostitutes. But does the result justify the
government spying on Americans, or engaging in sting operations
to entice Americans to break the law? "Spitzer was brought down
because he legally withdrew cash from a bank not because he
committed a crime."
"[T]hink of all the harm done by Spitzer in using the same
tools of the state against so many other innocent people. He
practiced what could be termed 'economic McCarthyism,' using
illegitimate government power to build his political career on
the ruined lives of others" (Politico 3/14/08).
Despite applying for the National Provider Identifier (NPI)
well in advance of the deadline, one physician found his claims
being rejected in October 2007. Numerous daily calls were made to
CMS and carrier representatives, including "NPI specialists,"
with lengthy times on hold, resulting in various contradictory
instructions on how to resolve the problem. The crux of the
difficulty apparently was that the legacy number had been set up
under personal rather than corporate name. Staff billed, as
directed, with legacy number only, or legacy number, personal
NPI, and corporate NPI alone or in various combinations, which
were to change on May 1 or May 23, with unpredictable, sporadic
payment. At one point, a representative said that the practice
had never been in the Medicare system a situation that would make
future and retroactive billing possibly fraudulent in the eyes of
CMS. The physician therefore stopped taking most new Medicare
patients. The hospital expressed concerns about this, although
service to hospital patients was never interrupted.
The physician concluded: "Medicare is a chaotic, gargantuan,
profoundly disorganized bureaucracy."
For instructions for opting out, see www.aapsonline.org. Please inform AAPS of any difficulties with
Manpower Problems and a Solution. At a recent 5-hour
neurology symposium, I learned about things other than stroke,
headache, and MS. There seems to be a nationwide trend for
neurologists to withdraw from hospital staffs. The headhunter
offers I receive are increasingly for employed neurology
hospitalists. Though continuity of care and having a neurologist
with a broad range of inpatient and outpatient experience are
beneficial to patients, the benefits are outweighed by the poor
pay and huge time investment in being on emergency call; chronic
sleep deprivation; high liability; general unappreciation by
entitled patients; and subjection to cost-containment protocols,
failure to follow which can result in career-ending sham peer
When a shortage of neurology hospitalists occurs, states may
try to force physicians to take hospital call as a condition of
licensure. They might also evoke the Model State Emergency Powers
Act to compel physicians to work in a state-defined "emergency."
Note that "[s]ome states, such as Maryland and South Carolina,
have enacted laws that subject HCPs [health care professionals]
who refuse to work during a pandemic to penalties in a far
broader range of circumstances...." (JAMA
Lawrence R. Huntoon, M.D.,
Comparing Costs. When people quote health care
spending as a proportion of GDP, the numbers may not permit
accurate international comparisons. Some of the differences
between national accounting systems and the System of Health
Accounts (SHA) developed in 2002 by the Organisation for Economic
Co-operation and Development (OECD) may be quite large. Denmark's
expenditures are 125% higher under SHA, and Japan's 127%. Denmark
excludes long-term nursing care; Japan, services covered by long-
term care insurance or not covered by national health insurance;
Germany, research, development, and education of medical
personnel; and Canada, part of expenditures for out-of-country
Then there's the definition of "administrative costs." The
Lewin Health Benefits Simulation Model considers all of research,
education, purchasing and stores, communications, data
processing, and medical records to be administration, along with
30% of non-patient food costs, social work, and plant operation
and maintenance. Promises of huge savings in administration with
single payer start with a gross overstatement of administrative
costs and assume magical shrinkage once one big bureaucracy takes
over. Explain to me why dealing with the government will halve a
physician's need for computers and software support. Maybe
because government systems are so far behind we'll revert to
paper and pencil?
Linda Gorman, Independence
Institute, Golden, CO
How Did It Happen? The Agency for Healthcare Research
and Quality (AHRQ) recently released a study showing a steady
decline in in-hospital mortality for many diagnoses and
procedures between 1994 and 2004 before widespread or significant
implementation of process measure compliance. Compared with 1994
mortality levels, 13,000 fewer patients died during this period
from abdominal aortic aneurysm repair, coronary artery bypass,
coronary angioplasty, carotid endarterectomy, craniotomy, or hip
replacement (HýCUP Statistical Brief #38, October 2007, www.premierinc.com).
Imagine, without government or third-party intervention,
physicians improved care and reduced deaths!
David McKalip, M.D., St. Petersburg, FL
Worker's Compensation. People around here are not
joking when they say that if they fell at work, they would drag
themselves out into the street to pretend it was not a
work-related injury. Injured workers can't get care from a
physician even if willing to pay out of pocket because physicians
are prohibited by law from taking the money. There is excess
utilization driven by nonphysicians using up huge amounts of
benefit dollars because the real problem, for which the patient
had never seen a doctor, remained undiagnosed and untreated.
Donna B. Kinney, C.P.A., Texas Medical Association
Fracture in Belgrade. I am grateful that my misfortune
[falling into a manhole] took place in Belgrade, rather than,
say, in London, with its terminally dysfunctional National Health
Service [NHS], offering services equally perilous to life and
limb of the captive millions of its "clients" regardless of the
blighters' race, creed, or sexual orientation. My surgeons had
perfected their trade on thousands of cases in the ex-Yugoslav
wars and NATO's bombing of Serbia. The Belgrade Emergency Health
Center has a building more than a hundred years old that needs
new bathrooms and a fresh coat of paint; but when some top-notch
Swiss doctors tell you that your kid's leg has to be amputated,
it may well offer your only hope.
Srdja Trifkovic, www.chroniclesmagazine.org
Covered, but Without Care. During my week's stay in
London, much of the sparse television news covered the foibles of
the NHS. One story reported that 42% of women in labor were
turned away from the hospital where they had expected to have
their baby because no one was there to deliver them!
Alieta Eck, M.D., Somerset, NJ
An Innovative Idea. Perhaps Dr. Eck would sell me 10
pre-paid office visits for $400. Otherwise, I could pay her $50
each at the time of service. Why should I pre-pay an insurer?
Kirby Nielsen, Delaware, OH