Posted by Metamorphoses Healthcare 12/23/11
“The Senate…met… to give its unanimous thumbs up to both the Medicare "doc fix" and other deal provisions… "With this brief reprieve from the massive 27 percent cut to Medicare payments, Congress now has to enact a real and fiscally responsible solution to this sorry cycle of scheduled cuts and short-term patches that compromises access to care for patients and drives up costs for tax payers," said the American Medical Association in a statement after last evening's eleventh-hour deal, worked out among House Republicans. The association continued: "Members of Congress need to use this time to work out in a bipartisan manner to provide stability for seniors, military families, and the physicians who care for them." Whether such "a real and fiscally sound solution" can be worked out by Congress …remains doubtful…revamping the much-reviled sustainable growth rate formula, which is the basis for the draconian Medicare pay cuts, remains among the thorniest. (Guglielmo 2011)
The following are interview excerpts from DAVID WINTER, PROFESSOR UNIVERSITY OF TEXAS at DALLAS (UTD). The excerpts from the interview with DAVID WINTER, MD can be viewed on the documentary website, http://www.emrdocumentary.net/transcripts.htm
IN: A medical economist we interviewed about health reform believes we can’t move forward effectively until we decide whether healthcare is an individual right or responsibility.
Given the strengths and weaknesses of private insurance as well as federal insurance programs such as Medicare and Medicaid, what are your recommendations to policymakers about best ways to manage runaway healthcare costs?
DW: Universal healthcare would solve a lot of problems.
Doctors struggle with Medicare and Medicaid criteria (reduced reimbursements, restricted use of treatments and tests, etc.). Overall, Medicare has been great for Americans. It’s brought healthcare to many who otherwise would have none.
Nonetheless, physicians find it easier to work with commercial payers than with the government, which lacks flexibility and makes changes slowly. Some have proposed merging private and federal coverage, but all the proposed solutions have problems.
END of excerpt
The case for private medicine in USA: healthcare as a personal responsibility
A private physician’s view of Medicare and Medicaid
The state of Kansas and 34 other states are submitting amendments to their states’ constitution, often called “the Healthcare Freedom Amendment”. The proponents of these amendments believe that “Medicaid [is] for the truly desperate situations” and “that private contracting was the way to bring down medical costs.” They also believe that “rationing, like charity, is best decided at the local level.”
This private medical model proposes the following tenets.
Patients should own their own health insurance not their employers. This is the economic model used for auto and life insurance. Patients, therefore, would not lose their insurance if they lost their job. Health insurance premiums should be tax deductible for both individuals and employers. Physicians who render charity care should be allowed tax deductions for the cost of that care. The author states that his groups “mission clinic” has done very well with this economic model. If the physicians contracts directly with each patient, tort reform is a less pressing issue.
The author gives an example of how he negotiated a refund of part of an unsatisfied patient’s bill.
The author goes on to say that physicians can move to independence by opting out of Medicare and Medicaid contracts.
This doctor’s patient said: "Medicare only paid the doctor 17 percent of his bill. How long will he be able to stay in business?" The physician went on to say that even if the percentage of your practice of Medicare (or BCBS) is 50% of his patients and you cancel your contract and lose 50 percent of those patients… If you are getting 17 percent of what you bill (as in the Medicare example above), you could set your new cash fees at 25 to 50 percent of your previous fees and be much better off. Years ago, 10 percent of my monthly revenue came from Medicaid. When I cancelled my contract with Medicaid, the very next month, I received twice as much revenue in the time slots that Medicaid had previously taken…What will another 21 percent cut in Medicare payments do to your bottom line? Or, How much will you get paid when the global payment goes to the hospital to be divided among the 'providers'?" (Watson 2010)
George R. Watson, D.O., practices family medicine in Park City, KS. Contact: drgeorge@watsonmedicalgroup.com. He serves as president of AAPS.
The case for government funded medicine in USA: healthcare as an individual right
In a 2002 survey of physicians, 49% supported government legislation to establish national health insurance (Ackermann and Carroll 2003). In a six year follow up survey, the same authors randomly sampled 5000 physicians from the American Medical Association Masterfile. They asked the physicians if they supported government legislation to establish national health insurance and if they supported introducing universal coverage through an incremental reform.
The response rate was 51%. The majority of physicians who responded to the survey (59%) supported legislation to establish national health insurance, 9% were neutral on the topic, and 32% opposed it.
Similarly, the majority of physicians (55%) supported incremental reform in order to achieve universal coverage, 21% were neutral on the topic, and 25% opposed it.
A minority of physicians (14%) opposed national health insurance but supported more incremental reforms.
Most (>50%) medical specialties supported national health insurance legislation. A minority of respondents opposed to this were from the procedural specialties: the surgical subspecialties, anesthesiologists, and radiologists.
There was a 10% increase in support for a national health insurance from 2002 to 2008 (49% to 59%) amongst physician respondents. Pediatric subspecialists were highly supported of such a program in both surveys. Support increased in every subspecialty between the two surveys time periods. (Carroll and Ackerman 2008)
In summary, we present two different models of healthcare from physicians’ viewpoints: The first model is based on the value that healthcare is an individual responsibility. Patients own their own health insurance policies, not employers, which would make job loss less onerous in regards to its impact on a patient’s access to continued healthcare. The premiums would be tax deductible. This model contains a pathway for those patients that do not have health insurance with tax deductible "charity" clinics. The second model is based on the value that healthcare is an individual right. This model reflects the opinions of physicians who participated in a survey. This model contains a national health insurance plan.
Ackermann, R. T. and A. E. Carroll (2003). "Support for national health insurance among U.S. physicians: a national survey." Ann Intern Med 139(10): 795-801.
Carroll, A. E. and R. T. Ackerman (2008). Support for National Health Insurance among U.S. Physicians: 5 Years Later, American College of Physicians. 148: 566-567.
Guglielmo, W. J. (2011) "House and Senate Give Nod to Medicare Pay Cut Postponement." Medscape Medical News 12/23/2011
Watson, G. R. (2010). "We can win the battle to maintain the practice of private medicine. Journal of American Physicians and Surgeons 15(1): 4.
1.161 words
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Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry as an adjunct to the federally mandated purchase and installations of EMRs in all hospitals and physician practices by 2014.
The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from a different background in regards to race, ethnic ancestry, religion, regions of the country, medical specialties, and political views (from conservative to liberal viewpoints).
The goal of this organization is to identify reforms that benefit the quality of patient care outcomes. We do not advocate a particular political point of view. That is we are a non-partisan organization.
A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM. http://www.emr-ndr.net/index.html
Links to Facebook, twitter and our blog can be found on the website.
.
Friday, December 23, 2011
Monday, December 5, 2011
EMR-NDR-Health Reform. Topic.4. Can small physician practices afford to purchase and install EMRs by 2014? Why is there a shortage of general practioners? What can be done about it?
Posted by Metamorphoses Healthcare 12/05/11
The federal mandate to purchase and install EMRs by 2014 has many small physician practices concerned about their ability to afford such systems. Why is this? In the USA, small physician practices are decreasing in number partly due to the increasing difficulty in maintaining a profit due to decreasing reimbursement from insurance companies and increasing overhead costs.
In the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM, Dr. James Frame explains why it will be difficult for small physician practices to install EMRs by 2014 and why there is an ever increasing shortage of general practioners (GPs). IN: Can small physician practices absorb the relatively high costs of implementing EMRs?
JF: Most small practices cannot. The ever increasing financial drain caused by malpractice insurance, regulatory requirements, restricted Medicare reimbursements, etc., already has resulted in reduced numbers of general practitioners and internists, while hospital-based practices are increasing.
Many private physicians can’t afford to care for UN- and under insured patients. Like hospitals, they’re fortunate to have financial margins (net income /operation costs & expenses) at 2, 3 or 5 percent. (ERs have absorbed the costs of caring for the un- and under-insured, partly because small practices can’t afford this.)
End of documentary excerpt
This overall shortage of GPs in the USA will aggravate the long standing shortage of GPs in traditionally medically under-served areas; this is a problem in countries throughout the world.
The shortage of GPs is not related to whether a countries medical care economic model is public or private.
Barnighausen et. al., state that many countries are faced with shortages of general practioners, especially in underserved areas. A review of studies that assessed the efficacy of financial incentive programs to increase the supply of GPs was done. Studies between 1930 and 1998 were reviewed. The authors investigated financial-incentive programs in the US, Japan, Canada, New Zealand and South Africa. Five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives) were identified. Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470.
Financial-incentive programs for physicians to serve in areas that are medically underserved have been studied mainly in the USA. This limits generalizability of these studies. “Program participants are more likely than non-participants to work in underserved areas in the long run”. But, this difference may possibly be due to “selection effects”. Therefore, it is unclear whether these programs have “caused increases in the supply of health workers to underserved areas”.(Barnighausen and Bloom 2009)
In the United Kingdom, a country with a public healthcare system called the National Health Service (NHS), Ding et. al., state that the NHS national policy changes has recently offered “salaried employment, which offers reduced hours and freedom from out-of-hours and administrative responsibilities, aimed at improving recruitment and retention in a labour market facing regional shortages.” Ding assessed the “salaried GPs and their mobility within the labour market” by profiling all GPs in England in late 1990s through 2005.
Salaried GPs tended to be either younger (35 years) or older (65 years), female, or overseas-qualified; they favoured part-time working and personal medical services contracts. They were more mobile than GP principals, scored more Quality and Outcomes Framework points and were located in slightly more affluent areas.
Salaried status appears to have reduced limitations in the labour market, leading to better workforce deployment from a GP's perspective. However, there is no evidence to suggest it has relieved inequalities in GP distribution.(Ding, Hann et al. 2008)
In the Republic of Ireland (ROI) and Northern Ireland (NI), Galway et. al., evaluated the access to GP services in both countries. Both populations are very homogeneous with similar levels of health and number of patients per GP. But the healthcare systems are very different with free universal access for all citizens to healthcare in NI and a mixed private/public systems ROI.
In the study, 22,796 patients were surveyed. The response rate was 52% (n=11,870). The outcome measures were overall satisfaction and the access to GP services. Overall satisfaction with GP practices was high in both countries but slightly higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than NI (69.2% and 57.0% respectively. Only 8% of patients waited more than 2 days for an appointment in ROI compared to 45% in NI.
In both systems satisfaction decreased as size of practice increased. ROI imposes a consultation charge for faster access to GPs. This is believed to have a deterrent effect and may explain the difference in waiting time for appointments between the two countries. This improved accessibility in ROI may be realized at the cost in equity, i.e., since the poorest and sickest are deterred more by this charge. Policy makers value the provision of equitable services, so this inequity raises a concern for them. Access is reduced in both systems in large practices as compared to smaller ones
.
Medical care economic models in ROI and NI
As in all the UK, NI’s health services are free at the point of delivery. The majority of a physician’s income in the UK is based on a “capitation” fee. That is, they are reimbursed a negotiated fee from the government based on the number of patients that they provide medical care. The new GP contract has introduced economic incentives to physicians by increasing the portion of their income that is based on physicians meeting “quality/process targets”.
Like the USA, ROI has a mixed medical economic model: part public and part private medical care. The majority of patients are private patients (70%) and they pay a consultation charge when they visit the GP (40-50 Euros at the time of publication of the paper). Means testing and age (greater than 70 years) determine those patients (called GMS patients) that are given care in the public medical model (30%).[In the USA, public/private distribution is 48% and 52%]. They receive free care at the point of delivery.
So the income of physicians in ROI is based on capitation for GMS patients and fee-for-service for private patients. The cultural and historical homogeneity of this population suggest the overall high satisfaction with both economic medical models is not based on bias. The authors concluded that despite the inequities of the public/private medical model in ROI,” enhanced accessibility [to GPs] may occur where supply and demand financial incentives are present."
But, the price that is paid for this increased accessibility is that 1 in 4 patients who had a medical problem in ROI in the previous year did not seek medical care due to financial concerns in ROI. Since low income and elderly receive free care, the deterrent effect is felt largely in the middle income group of patients. They are four times as likely to be deterred from seeking medical care as are the affluent. The poorest and most medically sick of the private patients are most affected by this “charging structure”.
The authors conclude that more comparative studies like this one need to be done in other countries in order to identify “the best balance between enhanced accessibility and optimal equity.” (Galway, Murphy et al. 2007)
This is a complex problem to study. Within both public and private medical models throughout the world, the source and magnitude of physician income and the amount of out of pocket expenses incurred by patients is highly variable. Therefore the actual impact those public and private medical models have on physicians’income and patients' out of pocket expenses are also quite variable. Comparative studies will have to take these factors into account.
So, in summary, the downward spiral of patient care reimbursement from both public and private insurance companies and increasing costs to run a medical practice in the USA will result in an increasing shortage of GPs in the USA.
There is a shortage of GPs throughout the world in both public and private medical care systems. What appears to be clear from the data summarized in the papers reviewed in this article is that a salaried physician model without economic incentives does not appear to attract the number of GPs needed by society with the proper distribution, especially in underserved areas, nor achieve the best quality medical outcomes. More studies are needed to identify the ideal economic medical model to solve this worldwide problem.
Barnighausen, T. and D. E. Bloom (2009). "Financial incentives for return of service in underserved areas: a systematic review." BMC Health Serv Res 9: 86.
Ding, A., M. Hann, et al. (2008). "Profile of English salaried GPs: labour mobility and practice performance." British Journal of General Practice 58(546): 20-25.
Galway, K. J., A. W. Murphy, et al. (2007). "Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems." Ir Med J 100(6): 494-497.
**************************************************************************************
Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry as an adjunct to the federally mandated purchase and installations of EMRs in all hospitals and physician practices by 2014.
The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from different background in regards to race, ethnic ancestry, religion, regions of the country, medical specialties, and political views (from conservative to liberal viewpoints).
The goal of this organization is to identify reforms that benefit the quality of patient care outcomes. We do not advocate a particular political point of view.
The excerpts from the interview with JAMES FRAME, MD can be viewed on the documentary website, http://www.emr-ndr.net/index.html
A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM.
Links to Facebook, twitter and our blog can be found on the website.
Words: actual article 1679; total words that include article, references and notes about organization: 1589
The federal mandate to purchase and install EMRs by 2014 has many small physician practices concerned about their ability to afford such systems. Why is this? In the USA, small physician practices are decreasing in number partly due to the increasing difficulty in maintaining a profit due to decreasing reimbursement from insurance companies and increasing overhead costs.
In the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM, Dr. James Frame explains why it will be difficult for small physician practices to install EMRs by 2014 and why there is an ever increasing shortage of general practioners (GPs). IN: Can small physician practices absorb the relatively high costs of implementing EMRs?
JF: Most small practices cannot. The ever increasing financial drain caused by malpractice insurance, regulatory requirements, restricted Medicare reimbursements, etc., already has resulted in reduced numbers of general practitioners and internists, while hospital-based practices are increasing.
Many private physicians can’t afford to care for UN- and under insured patients. Like hospitals, they’re fortunate to have financial margins (net income /operation costs & expenses) at 2, 3 or 5 percent. (ERs have absorbed the costs of caring for the un- and under-insured, partly because small practices can’t afford this.)
End of documentary excerpt
This overall shortage of GPs in the USA will aggravate the long standing shortage of GPs in traditionally medically under-served areas; this is a problem in countries throughout the world.
The shortage of GPs is not related to whether a countries medical care economic model is public or private.
Barnighausen et. al., state that many countries are faced with shortages of general practioners, especially in underserved areas. A review of studies that assessed the efficacy of financial incentive programs to increase the supply of GPs was done. Studies between 1930 and 1998 were reviewed. The authors investigated financial-incentive programs in the US, Japan, Canada, New Zealand and South Africa. Five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives) were identified. Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470.
Financial-incentive programs for physicians to serve in areas that are medically underserved have been studied mainly in the USA. This limits generalizability of these studies. “Program participants are more likely than non-participants to work in underserved areas in the long run”. But, this difference may possibly be due to “selection effects”. Therefore, it is unclear whether these programs have “caused increases in the supply of health workers to underserved areas”.(Barnighausen and Bloom 2009)
In the United Kingdom, a country with a public healthcare system called the National Health Service (NHS), Ding et. al., state that the NHS national policy changes has recently offered “salaried employment, which offers reduced hours and freedom from out-of-hours and administrative responsibilities, aimed at improving recruitment and retention in a labour market facing regional shortages.” Ding assessed the “salaried GPs and their mobility within the labour market” by profiling all GPs in England in late 1990s through 2005.
Salaried GPs tended to be either younger (35 years) or older (65 years), female, or overseas-qualified; they favoured part-time working and personal medical services contracts. They were more mobile than GP principals, scored more Quality and Outcomes Framework points and were located in slightly more affluent areas.
Salaried status appears to have reduced limitations in the labour market, leading to better workforce deployment from a GP's perspective. However, there is no evidence to suggest it has relieved inequalities in GP distribution.(Ding, Hann et al. 2008)
In the Republic of Ireland (ROI) and Northern Ireland (NI), Galway et. al., evaluated the access to GP services in both countries. Both populations are very homogeneous with similar levels of health and number of patients per GP. But the healthcare systems are very different with free universal access for all citizens to healthcare in NI and a mixed private/public systems ROI.
In the study, 22,796 patients were surveyed. The response rate was 52% (n=11,870). The outcome measures were overall satisfaction and the access to GP services. Overall satisfaction with GP practices was high in both countries but slightly higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than NI (69.2% and 57.0% respectively. Only 8% of patients waited more than 2 days for an appointment in ROI compared to 45% in NI.
In both systems satisfaction decreased as size of practice increased. ROI imposes a consultation charge for faster access to GPs. This is believed to have a deterrent effect and may explain the difference in waiting time for appointments between the two countries. This improved accessibility in ROI may be realized at the cost in equity, i.e., since the poorest and sickest are deterred more by this charge. Policy makers value the provision of equitable services, so this inequity raises a concern for them. Access is reduced in both systems in large practices as compared to smaller ones
.
Medical care economic models in ROI and NI
As in all the UK, NI’s health services are free at the point of delivery. The majority of a physician’s income in the UK is based on a “capitation” fee. That is, they are reimbursed a negotiated fee from the government based on the number of patients that they provide medical care. The new GP contract has introduced economic incentives to physicians by increasing the portion of their income that is based on physicians meeting “quality/process targets”.
Like the USA, ROI has a mixed medical economic model: part public and part private medical care. The majority of patients are private patients (70%) and they pay a consultation charge when they visit the GP (40-50 Euros at the time of publication of the paper). Means testing and age (greater than 70 years) determine those patients (called GMS patients) that are given care in the public medical model (30%).[In the USA, public/private distribution is 48% and 52%]. They receive free care at the point of delivery.
So the income of physicians in ROI is based on capitation for GMS patients and fee-for-service for private patients. The cultural and historical homogeneity of this population suggest the overall high satisfaction with both economic medical models is not based on bias. The authors concluded that despite the inequities of the public/private medical model in ROI,” enhanced accessibility [to GPs] may occur where supply and demand financial incentives are present."
But, the price that is paid for this increased accessibility is that 1 in 4 patients who had a medical problem in ROI in the previous year did not seek medical care due to financial concerns in ROI. Since low income and elderly receive free care, the deterrent effect is felt largely in the middle income group of patients. They are four times as likely to be deterred from seeking medical care as are the affluent. The poorest and most medically sick of the private patients are most affected by this “charging structure”.
The authors conclude that more comparative studies like this one need to be done in other countries in order to identify “the best balance between enhanced accessibility and optimal equity.” (Galway, Murphy et al. 2007)
This is a complex problem to study. Within both public and private medical models throughout the world, the source and magnitude of physician income and the amount of out of pocket expenses incurred by patients is highly variable. Therefore the actual impact those public and private medical models have on physicians’income and patients' out of pocket expenses are also quite variable. Comparative studies will have to take these factors into account.
So, in summary, the downward spiral of patient care reimbursement from both public and private insurance companies and increasing costs to run a medical practice in the USA will result in an increasing shortage of GPs in the USA.
There is a shortage of GPs throughout the world in both public and private medical care systems. What appears to be clear from the data summarized in the papers reviewed in this article is that a salaried physician model without economic incentives does not appear to attract the number of GPs needed by society with the proper distribution, especially in underserved areas, nor achieve the best quality medical outcomes. More studies are needed to identify the ideal economic medical model to solve this worldwide problem.
Barnighausen, T. and D. E. Bloom (2009). "Financial incentives for return of service in underserved areas: a systematic review." BMC Health Serv Res 9: 86.
Ding, A., M. Hann, et al. (2008). "Profile of English salaried GPs: labour mobility and practice performance." British Journal of General Practice 58(546): 20-25.
Galway, K. J., A. W. Murphy, et al. (2007). "Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems." Ir Med J 100(6): 494-497.
**************************************************************************************
Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry as an adjunct to the federally mandated purchase and installations of EMRs in all hospitals and physician practices by 2014.
The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from different background in regards to race, ethnic ancestry, religion, regions of the country, medical specialties, and political views (from conservative to liberal viewpoints).
The goal of this organization is to identify reforms that benefit the quality of patient care outcomes. We do not advocate a particular political point of view.
The excerpts from the interview with JAMES FRAME, MD can be viewed on the documentary website, http://www.emr-ndr.net/index.html
A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM.
Links to Facebook, twitter and our blog can be found on the website.
Words: actual article 1679; total words that include article, references and notes about organization: 1589
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