http:// Fri, 29 Jan 2010 16:38:02 GMT Fri, 29 Jan 2010 16:38:02 GMT modmedadmin@advanstar.com (ModernMedicine) modmedadmin@advanstar.com (ModernMedicine) KickApps Feed Builder 2010-01-29T16:38:02Z 441 http://community.modernmedicine.com/service/searchEverything.kickAction?as=33379&includeBlog=on&sortType=recent 89301 http://community.modernmedicine.com/_But-Why-Do-I-Have-This-Problem-Doc/BLOG/1778199/33379.html I often find this question from my patients very difficult to answer. Other than infections and some skin cancers, many times in dermatology we don’t know the cause of the condition. Or we have difficulty explaining in layman terms the immune-mediated conditions, of which there are many. I find it best to mention the effects of smoking, stress, genetics, and “plain bad luck” as possible causes so that patients don’t blame themselves. I also explain that, unfortunately, the drug companies and government are interested in funding heart disease and cancer research. Little or no money is given to the study of morphea or bullous pemphigoid or (INSERT immunologically mediated disease here). [Editor’s Note: Have you had a similar experience? How do you handle it? Please Log in and Comment in the box below this blog.] I often find this question from my patients very difficult to answer. Other than infections and some skin cancers, many times in dermatology we don’t know the cause of the condition. Or we have difficulty explaining in layman terms the immune-mediated conditions, of which there are many. I find it best to mention the effects of smoking, stress, genetics, and “plain bad luck” as possible causes so that patients don’t blame themselves. I also explain that, unfortunately, the drug companies and government are interested in funding heart disease and cancer research. Little or no money is given to the study of morphea or bullous pemphigoid or (INSERT immunologically mediated disease here). [Editor’s Note: Have you had a similar experience? How do you handle it? Please Log in and Comment in the box below this blog.] Fri, 29 Jan 2010 16:38:02 GMT http://community.modernmedicine.com/_But-Why-Do-I-Have-This-Problem-Doc/BLOG/1778199/33379.html bbarankin 2010-01-29T16:38:02Z Dermatology Modern Medicine Community I often find this question from my patients very difficult to answer. Other than infections and some skin cancers, many times in dermatology we don’t know the cause of the condition. Or we have difficulty explaining in layman terms the immune-mediated conditions, of which there are many. I find it best to mention the effects of smoking, stress, genetics, and “plain bad luck” as possible causes so that patients don’t blame themselves. I also explain that, unfortunately, the drug companies and government are interested in funding heart disease and cancer research. Little or no money is given to the study of morphea or bullous pemphigoid or (INSERT immunologically mediated disease here). [Editor’s Note: Have you had a similar experience? How do you handle it? Please Log in and Comment in the box below this blog.] dermatology, doctor-patient relationships nonadult false “But Why Do I Have This Problem, Doc?” text blog dermatology,doctor-patient relationships 23 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771876&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388889_33379_2771876_ap_160X120.jpg false 0 0 1778199 2771876 Member 0 http://community.modernmedicine.com/_Everything-I-Never-Knew-About-Elder-Care/BLOG/1778191/33379.html Many years ago, when my children were little, I remember my pediatrician saying that he never knew how hollow and meaningless much of his advice to parents was until he had his own children. I now make a similar claim. Except in my case, it is about elder care. My mother has had extraordinary health. Until age 92—2 years ago—she volunteered at my health center. For more than 10 years, she sat at the child-sized table and chairs in the dental department’s waiting room (she is not much taller than a fifth grader herself), coloring, doing word games, and making puzzles with children from the school dental program who would otherwise run wild as they waited for their appointments. She lived in an in-law apartment on the third floor of our house until one year ago, and until recently filled her days with knitting, reading, listening to her divas Ella Fitzgerald and Billie Holiday. Just after Labor Day, 2009, my mother was hospitalized for about a month. Between the hospitalization and a stint in a highly recommended rehabilitation facility, I received an education on the state of elder care, and on the state of the health care “system” in general that my 29 years of practice had not yet provided. Questions about hospital care: Where are the nurses? What used to be nursing care has been divided up according to discrete tasks: one nurse’s aide does the vital signs; another aide changes the bed; yet another shows up for bathroom calls; the dietary aide picks up the next day’s menu. Patient care as piece work. As far as I can tell, the nurses mainly focus on medications—tracking, administering, and an enormous amount of documentation. My mother had no idea who her primary nurse was. Although the nurse’s name was dutifully written on the whiteboard across from my mother’s bed, this person was a phantom. No one knew very much about my mother. No one could really answer simple questions, like when a test that required fasting would be done so she would know when she could expect to eat. At the rehabilitation facility, there simply was no one minding the store. How do patients eat? For most of the time during her hospitalization, my mother had an IV line in her right hand. Being right handed, this presented some challenges in eating. If a family member wasn’t there at mealtime, her tray would sit too far for her to reach, and even if she could reach it, she wouldn’t have been able to open the various packages, remove the lids and actually get the food from the plate to her mouth. At rehab it was even worse. Many days we arrived at dinner time, only to find the lunch tray next to the door, cold, untouched, and completely unappealing. The degree of neglect at the rehab facility was such that my mother, who entered fully continent, left 10 days later in diapers that she has not been able to shed. She entered rehab walking unassisted from her bed to the bathroom. She left barely able to walk, fully assisted by another person, fully dependent on a walker. Re-hab? No. De-hab. Not funny. She has never regained her independence. My mother has had a lifelong fear of nursing homes. We had promised to honor her wish to be cared for at home. After considering her needs, wants, wishes, values and options, my mother chose to be cared for by a home hospice agency. We were so happy to get her home, where we could keep an eye on things and have some choice about who would care for her and how she would be cared for. We soon learned that choice was really another word for responsibility—way more responsibility than we expected. If I have so many case managers, why am I managing everything? In the week following my mother’s discharge, I met with nurse case managers, social work case managers, chaplains, nurses’ aides. There was a long list of services that I needed to get in place and an even longer list of equipment and supplies. Thankfully, hospice is great about the latter. You want a hospital bed—you get one within a few hours. I know because I needed one that quickly. I called late Sunday morning. By sundown the bed was in place, assembled and our 2 cats had adjusted to this strange new mechanical device. Arranging the actual services and personnel is a bit trickier. My husband and I both work full time plus. We knew we needed to arrange for full-time care for my mother. But in retrospect I admit that I didn’t really know what that meant. Luckily, we could fill in some of the hours with a student who took my mother’s former apartment in exchange for some hours of care. But waking hours are a lot of hours to fill. We learned quickly that hospice doesn’t provide actual care. Nursing visits, therapists, chaplains, a little bit of personal care, yes. But not care that filled in any of the unfilled long hours of the day. They provided us with a list of agencies, but we were on our own to arrange this. We then learned that Medicare doesn’t pay for home health care. The hourly wages plus the agency fees would all be out-of-pocket expenses. Although we have excellent salaries, the dollars add up fast. We tried to be practical and realistic in the schedule we drew up. We quickly covered the hours from when we left for work until we returned. But as my mother has become weaker and more needy, we quickly needed more hours. And more. And more. And then the tasks. Keeping track of medications. Keeping track of supplies. Laundry. Emails to each of the care providers. Some days require up to 15 emails to keep things on track. Is it because I am a physician that I am in the middle of all of these details? Within a few weeks I felt I was so consumed by all of these tasks that I had no time to spend enjoying my mother’s last days. I found myself looking longingly back at the weeks she spent in the hospital and at rehab. What did I expect? It seems so naïve now. I am embarrassed to even write what I expected. I thought there was a system of care. No. There isn’t. There are pieces of care that you, the consumer, you, the family must string together. You provide the glue—the coordination, the communication hub. I thought that hospice focused on the quality of life—for the patient at the end of life, for the family and friends. There are, indeed components of such a vision. Each individual person is lovely, hard working and devoted. But the components are just that—discrete pieces of a badly engineered plan. I thought that someone who was an expert and experienced in end-of-life care could help me anticipate the things we would need to put in place. While it is helpful for someone to remind me of the stages of grief, it would have been more useful for someone to point out that if a person is this weak now, it is likely that she will be this much weaker in XX amount of time, and would consequently require XXX additional care. My mother has been home for nearly 4 months. I feel like I am still chasing her needs—still barely keeping up with the moving target that end of life is. Don’t the nurses and social workers who see this all the time know this? I feel that they are generous with generic advice and insight (sitting in my living room, my resplendent Steinway with my current Mozart sonata on the stand in full view, the social worker asked if I had ever thought about bringing music into the home because it can be so helpful to the dying patient) but no one helped me think ahead to the need for a hospital bed with side rails until it threatened to became a crisis. I am not a geriatrician, but I have taken care of many elderly patients. I even care for them at home as they become unable to come into the health center. If you had asked me 5 months ago if I knew what it was like to take care of your failing elder at home, I would have said that I had some idea. But I would have been wrong. I now encourage my students and residents to consider geriatrics. And for nonphysicians who are looking for a promising career—how about a career in elder services planning. The demographics are with you. And if health care continues in its current poorly engineered state, there will be great demand for people who can plan and coordinate care for this vulnerable group. [Editor’s Note: Do you have thoughts on this topic? Please Log in and Comment in the box that will appear below this blog.] Many years ago, when my children were little, I remember my pediatrician saying that he never knew how hollow and meaningless much of his advice to parents was until he had his own children. I now make a similar claim. Except in my case, it is about elder care. My mother has had extraordinary health. Until age 92—2 years ago—she volunteered at my health center. For more than 10 years, she sat at the child-sized table and chairs in the dental department’s waiting room (she is not much taller than a fifth grader herself), coloring, doing word games, and making puzzles with children from the school dental program who would otherwise run wild as they waited for their appointments. She lived in an in-law apartment on the third floor of our house until one year ago, and until recently filled her days with knitting, reading, listening to her divas Ella Fitzgerald and Billie Holiday. Just after Labor Day, 2009, my mother was hospitalized for about a month. Between the hospitalization and a stint in a highly recommended rehabilitation facility, I received an education on the state of elder care, and on the state of the health care “system” in general that my 29 years of practice had not yet provided. Questions about hospital care: Where are the nurses? What used to be nursing care has been divided up according to discrete tasks: one nurse’s aide does the vital signs; another aide changes the bed; yet another shows up for bathroom calls; the dietary aide picks up the next day’s menu. Patient care as piece work. As far as I can tell, the nurses mainly focus on medications—tracking, administering, and an enormous amount of documentation. My mother had no idea who her primary nurse was. Although the nurse’s name was dutifully written on the whiteboard across from my mother’s bed, this person was a phantom. No one knew very much about my mother. No one could really answer simple questions, like when a test that required fasting would be done so she would know when she could expect to eat. At the rehabilitation facility, there simply was no one minding the store. How do patients eat? For most of the time during her hospitalization, my mother had an IV line in her right hand. Being right handed, this presented some challenges in eating. If a family member wasn’t there at mealtime, her tray would sit too far for her to reach, and even if she could reach it, she wouldn’t have been able to open the various packages, remove the lids and actually get the food from the plate to her mouth. At rehab it was even worse. Many days we arrived at dinner time, only to find the lunch tray next to the door, cold, untouched, and completely unappealing. The degree of neglect at the rehab facility was such that my mother, who entered fully continent, left 10 days later in diapers that she has not been able to shed. She entered rehab walking unassisted from her bed to the bathroom. She left barely able to walk, fully assisted by another person, fully dependent on a walker. Re-hab? No. De-hab. Not funny. She has never regained her independence. My mother has had a lifelong fear of nursing homes. We had promised to honor her wish to be cared for at home. After considering her needs, wants, wishes, values and options, my mother chose to be cared for by a home hospice agency. We were so happy to get her home, where we could keep an eye on things and have some choice about who would care for her and how she would be cared for. We soon learned that choice was really another word for responsibility—way more responsibility than we expected. If I have so many case managers, why am I managing everything? In the week following my mother’s discharge, I met with nurse case managers, social work case managers, chaplains, nurses’ aides. There was a long list of services that I needed to get in place and an even longer list of equipment and supplies. Thankfully, hospice is great about the latter. You want a hospital bed—you get one within a few hours. I know because I needed one that quickly. I called late Sunday morning. By sundown the bed was in place, assembled and our 2 cats had adjusted to this strange new mechanical device. Arranging the actual services and personnel is a bit trickier. My husband and I both work full time plus. We knew we needed to arrange for full-time care for my mother. But in retrospect I admit that I didn’t really know what that meant. Luckily, we could fill in some of the hours with a student who took my mother’s former apartment in exchange for some hours of care. But waking hours are a lot of hours to fill. We learned quickly that hospice doesn’t provide actual care. Nursing visits, therapists, chaplains, a little bit of personal care, yes. But not care that filled in any of the unfilled long hours of the day. They provided us with a list of agencies, but we were on our own to arrange this. We then learned that Medicare doesn’t pay for home health care. The hourly wages plus the agency fees would all be out-of-pocket expenses. Although we have excellent salaries, the dollars add up fast. We tried to be practical and realistic in the schedule we drew up. We quickly covered the hours from when we left for work until we returned. But as my mother has become weaker and more needy, we quickly needed more hours. And more. And more. And then the tasks. Keeping track of medications. Keeping track of supplies. Laundry. Emails to each of the care providers. Some days require up to 15 emails to keep things on track. Is it because I am a physician that I am in the middle of all of these details? Within a few weeks I felt I was so consumed by all of these tasks that I had no time to spend enjoying my mother’s last days. I found myself looking longingly back at the weeks she spent in the hospital and at rehab. What did I expect? It seems so naïve now. I am embarrassed to even write what I expected. I thought there was a system of care. No. There isn’t. There are pieces of care that you, the consumer, you, the family must string together. You provide the glue—the coordination, the communication hub. I thought that hospice focused on the quality of life—for the patient at the end of life, for the family and friends. There are, indeed components of such a vision. Each individual person is lovely, hard working and devoted. But the components are just that—discrete pieces of a badly engineered plan. I thought that someone who was an expert and experienced in end-of-life care could help me anticipate the things we would need to put in place. While it is helpful for someone to remind me of the stages of grief, it would have been more useful for someone to point out that if a person is this weak now, it is likely that she will be this much weaker in XX amount of time, and would consequently require XXX additional care. My mother has been home for nearly 4 months. I feel like I am still chasing her needs—still barely keeping up with the moving target that end of life is. Don’t the nurses and social workers who see this all the time know this? I feel that they are generous with generic advice and insight (sitting in my living room, my resplendent Steinway with my current Mozart sonata on the stand in full view, the social worker asked if I had ever thought about bringing music into the home because it can be so helpful to the dying patient) but no one helped me think ahead to the need for a hospital bed with side rails until it threatened to became a crisis. I am not a geriatrician, but I have taken care of many elderly patients. I even care for them at home as they become unable to come into the health center. If you had asked me 5 months ago if I knew what it was like to take care of your failing elder at home, I would have said that I had some idea. But I would have been wrong. I now encourage my students and residents to consider geriatrics. And for nonphysicians who are looking for a promising career—how about a career in elder services planning. The demographics are with you. And if health care continues in its current poorly engineered state, there will be great demand for people who can plan and coordinate care for this vulnerable group. [Editor’s Note: Do you have thoughts on this topic? Please Log in and Comment in the box that will appear below this blog.] Fri, 29 Jan 2010 16:35:38 GMT http://community.modernmedicine.com/_Everything-I-Never-Knew-About-Elder-Care/BLOG/1778191/33379.html bgottlieb 2010-01-29T16:35:38Z Primary Care Modern Medicine Community Many years ago, when my children were little, I remember my pediatrician saying that he never knew how hollow and meaningless much of his advice to parents was until he had his own children. I now make a similar claim. Except in my case, it is about elder care. My mother has had extraordinary health. Until age 92—2 years ago—she volunteered at my health center. For more than 10 years, she sat at the child-sized table and chairs in the dental department’s waiting room (she is not much taller than a fifth grader herself), coloring, doing word games, and making puzzles with children from the school dental program who would otherwise run wild as they waited for their appointments. She lived in an in-law apartment on the third floor of our house until one year ago, and until recently filled her days with knitting, reading, listening to her divas Ella Fitzgerald and Billie Holiday. Just after Labor Day, 2009, my mother was hospitalized for about a month. Between the hospitalization and a stint in a highly recommended rehabilitation facility, I received an education on the state of elder care, and on the state of the health care “system” in general that my 29 years of practice had not yet provided. Questions about hospital care: Where are the nurses? What used to be nursing care has been divided up according to discrete tasks: one nurse’s aide does the vital signs; another aide changes the bed; yet another shows up for bathroom calls; the dietary aide picks up the next day’s menu. Patient care as piece work. As far as I can tell, the nurses mainly focus on medications—tracking, administering, and an enormous amount of documentation. My mother had no idea who her primary nurse was. Although the nurse’s name was dutifully written on the whiteboard across from my mother’s bed, this person was a phantom. No one knew very much about my mother. No one could really answer simple questions, like when a test that required fasting would be done so she would know when she could expect to eat. At the rehabilitation facility, there simply was no one minding the store. How do patients eat? For most of the time during her hospitalization, my mother had an IV line in her right hand. Being right handed, this presented some challenges in eating. If a family member wasn’t there at mealtime, her tray would sit too far for her to reach, and even if she could reach it, she wouldn’t have been able to open the various packages, remove the lids and actually get the food from the plate to her mouth. At rehab it was even worse. Many days we arrived at dinner time, only to find the lunch tray next to the door, cold, untouched, and completely unappealing. The degree of neglect at the rehab facility was such that my mother, who entered fully continent, left 10 days later in diapers that she has not been able to shed. She entered rehab walking unassisted from her bed to the bathroom. She left barely able to walk, fully assisted by another person, fully dependent on a walker. Re-hab? No. De-hab. Not funny. She has never regained her independence. My mother has had a lifelong fear of nursing homes. We had promised to honor her wish to be cared for at home. After considering her needs, wants, wishes, values and options, my mother chose to be cared for by a home hospice agency. We were so happy to get her home, where we could keep an eye on things and have some choice about who would care for her and how she would be cared for. We soon learned that choice was really another word for responsibility—way more responsibility than we expected. If I have so many case managers, why am I managing everything? In the week following my mother’s discharge, I met with nurse case managers, social work case managers, chaplains, nurses’ aides. There was a long list of services that I needed to get in place and an even longer list of equipment and supplies. Thankfully, hospice is great about the latter. You want a hospital bed—you get one within a few hours. I know because I needed one that quickly. I called late Sunday morning. By sundown the bed was in place, assembled and our 2 cats had adjusted to this strange new mechanical device. Arranging the actual services and personnel is a bit trickier. My husband and I both work full time plus. We knew we needed to arrange for full-time care for my mother. But in retrospect I admit that I didn’t really know what that meant. Luckily, we could fill in some of the hours with a student who took my mother’s former apartment in exchange for some hours of care. But waking hours are a lot of hours to fill. We learned quickly that hospice doesn’t provide actual care. Nursing visits, therapists, chaplains, a little bit of personal care, yes. But not care that filled in any of the unfilled long hours of the day. They provided us with a list of agencies, but we were on our own to arrange this. We then learned that Medicare doesn’t pay for home health care. The hourly wages plus the agency fees would all be out-of-pocket expenses. Although we have excellent salaries, the dollars add up fast. We tried to be practical and realistic in the schedule we drew up. We quickly covered the hours from when we left for work until we returned. But as my mother has become weaker and more needy, we quickly needed more hours. And more. And more. And then the tasks. Keeping track of medications. Keeping track of supplies. Laundry. Emails to each of the care providers. Some days require up to 15 emails to keep things on track. Is it because I am a physician that I am in the middle of all of these details? Within a few weeks I felt I was so consumed by all of these tasks that I had no time to spend enjoying my mother’s last days. I found myself looking longingly back at the weeks she spent in the hospital and at rehab. What did I expect? It seems so naïve now. I am embarrassed to even write what I expected. I thought there was a system of care. No. There isn’t. There are pieces of care that you, the consumer, you, the family must string together. You provide the glue—the coordination, the communication hub. I thought that hospice focused on the quality of life—for the patient at the end of life, for the family and friends. There are, indeed components of such a vision. Each individual person is lovely, hard working and devoted. But the components are just that—discrete pieces of a badly engineered plan. I thought that someone who was an expert and experienced in end-of-life care could help me anticipate the things we would need to put in place. While it is helpful for someone to remind me of the stages of grief, it would have been more useful for someone to point out that if a person is this weak now, it is likely that she will be this much weaker in XX amount of time, and would consequently require XXX additional care. My mother has been home for nearly 4 months. I feel like I am still chasing her needs—still barely keeping up with the moving target that end of life is. Don’t the nurses and social workers who see this all the time know this? I feel that they are generous with generic advice and insight (sitting in my living room, my resplendent Steinway with my current Mozart sonata on the stand in full view, the social worker asked if I had ever thought about bringing music into the home because it can be so helpful to the dying patient) but no one helped me think ahead to the need for a hospital bed with side rails until it threatened to became a crisis. I am not a geriatrician, but I have taken care of many elderly patients. I even care for them at home as they become unable to come into the health center. If you had asked me 5 months ago if I knew what it was like to take care of your failing elder at home, I would have said that I had some idea. But I would have been wrong. I now encourage my students and residents to consider geriatrics. And for nonphysicians who are looking for a promising career—how about a career in elder services planning. The demographics are with you. And if health care continues in its current poorly engineered state, there will be great demand for people who can plan and coordinate care for this vulnerable group. [Editor’s Note: Do you have thoughts on this topic? Please Log in and Comment in the box that will appear below this blog.] elder care, geriatrics, primary care nonadult false Everything I Never Knew About Elder Care… text blog elder care,geriatrics,primary care 15 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 0 1778191 2771822 Member 0 http://community.modernmedicine.com/_Concierge-Medicine-Can-Doctors-Still-Care-for-Patients-After-Health-Care-Reform/BLOG/1778183/33379.html Do you long to spend more time with your patients, without pressure to generate more billing? If so, concierge medicine may offer the perfect solution. But, can it really work for you? Adding 30 million new insureds to the health care roles and cutting a half billion dollars from Medicare will almost certainly increase pressure on physicians to see even more patients in less time. For those who do not want to practice conveyor belt medicine and believe that good medicine requires time and attention to patients, concierge medicine may offer a highly satisfying alternative to managed care. Unfortunately, federal and state regulators have historically taken a dim view of these practices, arguing that the amenities offered by concierge practices discriminate against those who can’t afford the extra charges, and amount to a surcharge on care that should be covered under a patient’s health care policy. Given this background, it was somewhat surprising to see that the Federal Trade Commission on December 11, 2009, approved the acquisition of a concierge medicine network by consumer and household product giant Procter & Gamble (P&G). P&G will be acquiring complete ownership of MDVIP, Inc, of Boca Raton, Florida. According to its Web site, MDVIP serves over 111,000 patients in 28 states and the District of Columbia through a network of over 310 physicians. P&G previously held a 48% minority stake in MDVIP. According to the company, each physician’s practice case load is limited to a maximum of 600 patients. This allows physicians to provide more timely and customized service to each patient, along with a more comprehensive personal health care plan. Patients who join a concierge practice pay a premium by way of an annual retainer. The fee, a portion of which is apparently shared with MDVIP, Inc., allows patients access to same day appointments, longer patient visits, and home visits--benefits often unavailable in modern primary care practices. Concierge medicine also often provides more health and wellness services and greater assistance to patients who need to navigate the complexities of the health care system. Those who promote concierge medicine claim that physicians enjoy a lighter patient load, more time spent with individual patients, and less administrative paperwork. Often, patients supplement their concierge network with insurance coverage or pay out-of-pocket for these services. While the prospect of working less, enjoying it more, and earning more in the process is hard to ignore, FTC approval does not eliminate the regulatory concerns discussed above. Those interested in concierge medicine need to carefully review their own state laws, federal laws, their existing participating provider agreements, and the effect of concierge practice on their existing patients. In addition, while a concierge practice may be viable in Boca Raton, which is home to one of the nation’s highest net worth populations, a similar practice in an urban center or rural area may face far greater challenges. Like any other business proposition, this one requires substantial due diligence before signing on the dotted line. [Editor’s Note: Do you have any thoughts on this topic? Please Log in and Comment in the box that appears below this blog.] Do you long to spend more time with your patients, without pressure to generate more billing? If so, concierge medicine may offer the perfect solution. But, can it really work for you? Adding 30 million new insureds to the health care roles and cutting a half billion dollars from Medicare will almost certainly increase pressure on physicians to see even more patients in less time. For those who do not want to practice conveyor belt medicine and believe that good medicine requires time and attention to patients, concierge medicine may offer a highly satisfying alternative to managed care. Unfortunately, federal and state regulators have historically taken a dim view of these practices, arguing that the amenities offered by concierge practices discriminate against those who can’t afford the extra charges, and amount to a surcharge on care that should be covered under a patient’s health care policy. Given this background, it was somewhat surprising to see that the Federal Trade Commission on December 11, 2009, approved the acquisition of a concierge medicine network by consumer and household product giant Procter & Gamble (P&G). P&G will be acquiring complete ownership of MDVIP, Inc, of Boca Raton, Florida. According to its Web site, MDVIP serves over 111,000 patients in 28 states and the District of Columbia through a network of over 310 physicians. P&G previously held a 48% minority stake in MDVIP. According to the company, each physician’s practice case load is limited to a maximum of 600 patients. This allows physicians to provide more timely and customized service to each patient, along with a more comprehensive personal health care plan. Patients who join a concierge practice pay a premium by way of an annual retainer. The fee, a portion of which is apparently shared with MDVIP, Inc., allows patients access to same day appointments, longer patient visits, and home visits--benefits often unavailable in modern primary care practices. Concierge medicine also often provides more health and wellness services and greater assistance to patients who need to navigate the complexities of the health care system. Those who promote concierge medicine claim that physicians enjoy a lighter patient load, more time spent with individual patients, and less administrative paperwork. Often, patients supplement their concierge network with insurance coverage or pay out-of-pocket for these services. While the prospect of working less, enjoying it more, and earning more in the process is hard to ignore, FTC approval does not eliminate the regulatory concerns discussed above. Those interested in concierge medicine need to carefully review their own state laws, federal laws, their existing participating provider agreements, and the effect of concierge practice on their existing patients. In addition, while a concierge practice may be viable in Boca Raton, which is home to one of the nation’s highest net worth populations, a similar practice in an urban center or rural area may face far greater challenges. Like any other business proposition, this one requires substantial due diligence before signing on the dotted line. [Editor’s Note: Do you have any thoughts on this topic? Please Log in and Comment in the box that appears below this blog.] Fri, 29 Jan 2010 16:30:27 GMT http://community.modernmedicine.com/_Concierge-Medicine-Can-Doctors-Still-Care-for-Patients-After-Health-Care-Reform/BLOG/1778183/33379.html skern 2010-01-29T16:30:27Z Health Law & Policy Modern Medicine Community Do you long to spend more time with your patients, without pressure to generate more billing? If so, concierge medicine may offer the perfect solution. But, can it really work for you? Adding 30 million new insureds to the health care roles and cutting a half billion dollars from Medicare will almost certainly increase pressure on physicians to see even more patients in less time. For those who do not want to practice conveyor belt medicine and believe that good medicine requires time and attention to patients, concierge medicine may offer a highly satisfying alternative to managed care. Unfortunately, federal and state regulators have historically taken a dim view of these practices, arguing that the amenities offered by concierge practices discriminate against those who can’t afford the extra charges, and amount to a surcharge on care that should be covered under a patient’s health care policy. Given this background, it was somewhat surprising to see that the Federal Trade Commission on December 11, 2009, approved the acquisition of a concierge medicine network by consumer and household product giant Procter & Gamble (P&G). P&G will be acquiring complete ownership of MDVIP, Inc, of Boca Raton, Florida. According to its Web site, MDVIP serves over 111,000 patients in 28 states and the District of Columbia through a network of over 310 physicians. P&G previously held a 48% minority stake in MDVIP. According to the company, each physician’s practice case load is limited to a maximum of 600 patients. This allows physicians to provide more timely and customized service to each patient, along with a more comprehensive personal health care plan. Patients who join a concierge practice pay a premium by way of an annual retainer. The fee, a portion of which is apparently shared with MDVIP, Inc., allows patients access to same day appointments, longer patient visits, and home visits--benefits often unavailable in modern primary care practices. Concierge medicine also often provides more health and wellness services and greater assistance to patients who need to navigate the complexities of the health care system. Those who promote concierge medicine claim that physicians enjoy a lighter patient load, more time spent with individual patients, and less administrative paperwork. Often, patients supplement their concierge network with insurance coverage or pay out-of-pocket for these services. While the prospect of working less, enjoying it more, and earning more in the process is hard to ignore, FTC approval does not eliminate the regulatory concerns discussed above. Those interested in concierge medicine need to carefully review their own state laws, federal laws, their existing participating provider agreements, and the effect of concierge practice on their existing patients. In addition, while a concierge practice may be viable in Boca Raton, which is home to one of the nation’s highest net worth populations, a similar practice in an urban center or rural area may face far greater challenges. Like any other business proposition, this one requires substantial due diligence before signing on the dotted line. [Editor’s Note: Do you have any thoughts on this topic? Please Log in and Comment in the box that appears below this blog.] concierge practice, health law & policy, mmglobal nonadult false Concierge Medicine? Can Doctors Still Care for Patients After Health Care Reform? text blog concierge practice,health law & policy,mmglobal 58 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=3407919&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_2089258_33379_3407919_ap_160X120.jpg false 0 0 1778183 3407919 Member 0 http://community.modernmedicine.com/_The-Haitian-Disaster-and-ObGyns/BLOG/1771922/33379.html Right now, the magnitude of the tragedy in Haiti is beyond most of our understanding. The Web sites I have seen from relief organizations say that they need anesthesiologists, trauma surgeons, and orthopedic surgeons, but at this point other medical specialties are not a priority. Realistically, most of us can’t drop our practices and run to help, but a few Ob/Gyns are making a difference. Remember that even before the earthquake, Haiti had among the worst maternal and infant mortality rates in the Western Hemisphere. Alfred Abuhamad, Chair of Ob/Gyn at Eastern Virginia Medical School, fellow in ultrasound here at Yale, and President-Elect of the American Institute of Ultrasound in Medicine, happened to be in Haiti last week along with a group from Partners in Health and the International Society for Ultrasound in Obstetrics and Gynecology (ISUOG). He was in Cange, located in Haiti’s central plateau northeast of Port au Prince, to teach Ob/Gyn ultrasound. Alfred’s gripping description of his time there is posted on the ISUOG Web site. The site has pictures of their teaching program before the earthquake and in the aftermath, when they became inundated with injured refugees from Port au Prince, even as isolated as they were, 40 miles away along terrible roads. Alfred made a brief cameo appearance on CBS, shown here in a still image. Another Yale alum is on the ground as of this writing. Mike Cackovic finished a Maternal-Fetal Medicine fellowship here 18 months ago on assignment from the US Navy. He e-mailed over the weekend to let us know he is on the USS Bataan, which was due to arrive in Haiti the morning of January 19. He is a skilled Ob/Gyn and has completed naval training to work as a surgeon. In all of the pressure to deal with the acutely injured, it is good to know that someone of his level of obstetrical skill will be available, because women will continue to have babies. For those who want to donate money, there is no shortage of ways to provide support. (Just remember that there are scams out there, too.) Alfred Abuhamad was in Haiti with Partners in Health. There is also a list of legitimate charities at the SMFM Web site. Every one of us in who practices medicine in the United States lives a far more comfortable life than almost every Haitian. Click on one of these links, and make a donation. Right now, the magnitude of the tragedy in Haiti is beyond most of our understanding. The Web sites I have seen from relief organizations say that they need anesthesiologists, trauma surgeons, and orthopedic surgeons, but at this point other medical specialties are not a priority. Realistically, most of us can’t drop our practices and run to help, but a few Ob/Gyns are making a difference. Remember that even before the earthquake, Haiti had among the worst maternal and infant mortality rates in the Western Hemisphere. Alfred Abuhamad, Chair of Ob/Gyn at Eastern Virginia Medical School, fellow in ultrasound here at Yale, and President-Elect of the American Institute of Ultrasound in Medicine, happened to be in Haiti last week along with a group from Partners in Health and the International Society for Ultrasound in Obstetrics and Gynecology (ISUOG). He was in Cange, located in Haiti’s central plateau northeast of Port au Prince, to teach Ob/Gyn ultrasound. Alfred’s gripping description of his time there is posted on the ISUOG Web site. The site has pictures of their teaching program before the earthquake and in the aftermath, when they became inundated with injured refugees from Port au Prince, even as isolated as they were, 40 miles away along terrible roads. Alfred made a brief cameo appearance on CBS, shown here in a still image. Another Yale alum is on the ground as of this writing. Mike Cackovic finished a Maternal-Fetal Medicine fellowship here 18 months ago on assignment from the US Navy. He e-mailed over the weekend to let us know he is on the USS Bataan, which was due to arrive in Haiti the morning of January 19. He is a skilled Ob/Gyn and has completed naval training to work as a surgeon. In all of the pressure to deal with the acutely injured, it is good to know that someone of his level of obstetrical skill will be available, because women will continue to have babies. For those who want to donate money, there is no shortage of ways to provide support. (Just remember that there are scams out there, too.) Alfred Abuhamad was in Haiti with Partners in Health. There is also a list of legitimate charities at the SMFM Web site. Every one of us in who practices medicine in the United States lives a far more comfortable life than almost every Haitian. Click on one of these links, and make a donation. Tue, 26 Jan 2010 20:08:48 GMT http://community.modernmedicine.com/_The-Haitian-Disaster-and-ObGyns/BLOG/1771922/33379.html jcopel 2010-01-26T20:08:48Z OB GYN & Women’s Health Modern Medicine Community Right now, the magnitude of the tragedy in Haiti is beyond most of our understanding. The Web sites I have seen from relief organizations say that they need anesthesiologists, trauma surgeons, and orthopedic surgeons, but at this point other medical specialties are not a priority. Realistically, most of us can’t drop our practices and run to help, but a few Ob/Gyns are making a difference. Remember that even before the earthquake, Haiti had among the worst maternal and infant mortality rates in the Western Hemisphere. Alfred Abuhamad, Chair of Ob/Gyn at Eastern Virginia Medical School, fellow in ultrasound here at Yale, and President-Elect of the American Institute of Ultrasound in Medicine, happened to be in Haiti last week along with a group from Partners in Health and the International Society for Ultrasound in Obstetrics and Gynecology (ISUOG). He was in Cange, located in Haiti’s central plateau northeast of Port au Prince, to teach Ob/Gyn ultrasound. Alfred’s gripping description of his time there is posted on the ISUOG Web site. The site has pictures of their teaching program before the earthquake and in the aftermath, when they became inundated with injured refugees from Port au Prince, even as isolated as they were, 40 miles away along terrible roads. Alfred made a brief cameo appearance on CBS, shown here in a still image. Another Yale alum is on the ground as of this writing. Mike Cackovic finished a Maternal-Fetal Medicine fellowship here 18 months ago on assignment from the US Navy. He e-mailed over the weekend to let us know he is on the USS Bataan, which was due to arrive in Haiti the morning of January 19. He is a skilled Ob/Gyn and has completed naval training to work as a surgeon. In all of the pressure to deal with the acutely injured, it is good to know that someone of his level of obstetrical skill will be available, because women will continue to have babies. For those who want to donate money, there is no shortage of ways to provide support. (Just remember that there are scams out there, too.) Alfred Abuhamad was in Haiti with Partners in Health. There is also a list of legitimate charities at the SMFM Web site. Every one of us in who practices medicine in the United States lives a far more comfortable life than almost every Haitian. Click on one of these links, and make a donation. gyn & women’s health, haiti earthquake, mmglobal, ob, ob/gyns in disaster area nonadult false The Haitian Disaster and Ob/Gyns text blog gyn & women’s health,haiti earthquake,mmglobal,ob,ob/gyns in disaster area 33 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771774&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388009_33379_2771774_ap_160X120.jpg false 0 0 1771922 2771774 Member 0 http://community.modernmedicine.com/_Being-Optimistic-When-Nature-Strikes/BLOG/1763602/33379.html I was struck by a recent press release from Doctors Without Borders/Médecins Sans Frontières (MSF) reporting that a plane carrying 12 tons of medical equipment, including drugs, surgical supplies, and 2 dialysis machines, was turned away 3 times from Port-au-Prince airport recently despite repeated assurances of its ability to land.1 Since this natural disaster in the form of a massive 7.0 earthquake struck the nation of Haiti on Tuesday, January 12, the hungry and injured grow more impatient by the day in the face of the slow aid response. It seems the US military is doing all it can with the resources available to them. However, at times, it also appears that a clear leadership and command structure are lacking. What bothers me are the continuous media reports that aid groups, including medical response teams, are having difficulties in commencing their work even after they arrive in Haiti.2,3 This is resulting in increasing number of lives lost by the day. It is estimated that up to 200,000 people may have died, and about 3 million have been affected by this tragedy In Haiti. Many thousands are still awaiting life saving surgeries such as amputations. The demand for health care is second only to food and shelter. Safety is another factor as rioting and looting are being reported. For most Americans, it feels as if their neighborhood has trembled. As humanity once again gathers to respond to this colossal tragedy, it is reminder how we as humans are more similar than different. Nevertheless, we must not forget that this is only the beginning of the public health needs in Haiti. Although emergency work is being done to save many lives, many more are at risk due to out-of-control chronic illnesses like diabetes, hypertension, and heart disease or acquiring infectious diseases. It is going to be a challenge to maintain a safe water supply, prevent or treat malnutrition, and dispose of the corpses to prevent further spread of diseases. Being optimistic, I also look at this as an invaluable opportunity for the international community to help Haitians in ways they have never been able to before. Weeks to months from now, when all the media has left and the world begins to forget about this tragedy, there will be an opportunity to build a public health infrastructure in Haiti. Let’s hope and wish that the Haitian government and the international community, including the United States, can come together to accomplish this as a memorial to all those who have lost their lives and those who continue to suffer. I was struck by a recent press release from Doctors Without Borders/Médecins Sans Frontières (MSF) reporting that a plane carrying 12 tons of medical equipment, including drugs, surgical supplies, and 2 dialysis machines, was turned away 3 times from Port-au-Prince airport recently despite repeated assurances of its ability to land.1 Since this natural disaster in the form of a massive 7.0 earthquake struck the nation of Haiti on Tuesday, January 12, the hungry and injured grow more impatient by the day in the face of the slow aid response. It seems the US military is doing all it can with the resources available to them. However, at times, it also appears that a clear leadership and command structure are lacking. What bothers me are the continuous media reports that aid groups, including medical response teams, are having difficulties in commencing their work even after they arrive in Haiti.2,3 This is resulting in increasing number of lives lost by the day. It is estimated that up to 200,000 people may have died, and about 3 million have been affected by this tragedy In Haiti. Many thousands are still awaiting life saving surgeries such as amputations. The demand for health care is second only to food and shelter. Safety is another factor as rioting and looting are being reported. For most Americans, it feels as if their neighborhood has trembled. As humanity once again gathers to respond to this colossal tragedy, it is reminder how we as humans are more similar than different. Nevertheless, we must not forget that this is only the beginning of the public health needs in Haiti. Although emergency work is being done to save many lives, many more are at risk due to out-of-control chronic illnesses like diabetes, hypertension, and heart disease or acquiring infectious diseases. It is going to be a challenge to maintain a safe water supply, prevent or treat malnutrition, and dispose of the corpses to prevent further spread of diseases. Being optimistic, I also look at this as an invaluable opportunity for the international community to help Haitians in ways they have never been able to before. Weeks to months from now, when all the media has left and the world begins to forget about this tragedy, there will be an opportunity to build a public health infrastructure in Haiti. Let’s hope and wish that the Haitian government and the international community, including the United States, can come together to accomplish this as a memorial to all those who have lost their lives and those who continue to suffer. Fri, 22 Jan 2010 18:47:24 GMT http://community.modernmedicine.com/_Being-Optimistic-When-Nature-Strikes/BLOG/1763602/33379.html rgupta 2010-01-22T18:47:24Z Primary Care Modern Medicine Community I was struck by a recent press release from Doctors Without Borders/Médecins Sans Frontières (MSF) reporting that a plane carrying 12 tons of medical equipment, including drugs, surgical supplies, and 2 dialysis machines, was turned away 3 times from Port-au-Prince airport recently despite repeated assurances of its ability to land.1 Since this natural disaster in the form of a massive 7.0 earthquake struck the nation of Haiti on Tuesday, January 12, the hungry and injured grow more impatient by the day in the face of the slow aid response. It seems the US military is doing all it can with the resources available to them. However, at times, it also appears that a clear leadership and command structure are lacking. What bothers me are the continuous media reports that aid groups, including medical response teams, are having difficulties in commencing their work even after they arrive in Haiti.2,3 This is resulting in increasing number of lives lost by the day. It is estimated that up to 200,000 people may have died, and about 3 million have been affected by this tragedy In Haiti. Many thousands are still awaiting life saving surgeries such as amputations. The demand for health care is second only to food and shelter. Safety is another factor as rioting and looting are being reported. For most Americans, it feels as if their neighborhood has trembled. As humanity once again gathers to respond to this colossal tragedy, it is reminder how we as humans are more similar than different. Nevertheless, we must not forget that this is only the beginning of the public health needs in Haiti. Although emergency work is being done to save many lives, many more are at risk due to out-of-control chronic illnesses like diabetes, hypertension, and heart disease or acquiring infectious diseases. It is going to be a challenge to maintain a safe water supply, prevent or treat malnutrition, and dispose of the corpses to prevent further spread of diseases. Being optimistic, I also look at this as an invaluable opportunity for the international community to help Haitians in ways they have never been able to before. Weeks to months from now, when all the media has left and the world begins to forget about this tragedy, there will be an opportunity to build a public health infrastructure in Haiti. Let’s hope and wish that the Haitian government and the international community, including the United States, can come together to accomplish this as a memorial to all those who have lost their lives and those who continue to suffer. haiti earthquake, mmglobal, primary care, public health needs nonadult false Being Optimistic When Nature Strikes text blog haiti earthquake,mmglobal,primary care,public health needs 49 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771864&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388883_33379_2771864_ap_160X120.jpg false 0 0 1763602 2771864 Member 0 http://community.modernmedicine.com/_The-End-of-Out-of-Network-Care/BLOG/1742898/33379.html Many physicians, unwilling to accept the dramatically reduced payment schedules of managed care companies, practice “out-of-network.”  Out-of-network reimbursement rates are usually based upon the physician’s “usual, customary, and reasonable” fees.  These “UCR” fees are often many times greater than the fees paid to in-network physicians for the same services. Recently, Oxford UnitedHealthcare has announced that, effective January 2010, certain of its insurance products would limit out-of-network benefits to no more than 140% of Medicare rates.   Oxford UnitedHealthcare will effectuate this change by amending language in its insurance policies to no longer pay based upon usual, customary, and reasonable fees.  Rather, those insureds who continue to contract (directly or through their employers) for a policy with out-of-network benefits will receive 140% or less of the Medicare rates when they go out-of-network, less co-payments and deductibles.  Any amounts charged by out-of-network physicians, beyond the 140%, will be the responsibility of the patient. With these changes, individual patients who have health insurance policies with out-of-network benefits will now have to bear a financial burden which will force many of them to in-network physicians.  As a result, the increased premium costs associated with the availability of out-of-network benefits will have far less value.  Given the reduced value, these policies may no longer be perceived as worth the added cost and policies which provide only in-network coverage will become even more attractive. There can be little doubt that this is only the beginning of a trend.  Health insurance companies continue to pressure physicians to go “in-network” and accept the vastly reduced payments associated with being “in-network”.  If Oxford UnitedHealthcare is successful in this effort, it will likely expand its efforts to its other product lines.  Other health insurers will also follow suit.  This change will not only have a substantial effect on out-of-network physicians but will ultimately affect in-network physicians as well.  As more and more physicians decide that they must join managed care networks, the supply of in-network physicians will increase and managed care companies will be able to further reduce reimbursement rates.  Of course, with Congress set to pass a new health reform bill that could provide insurers with an additional 30 million covered lives, insurance companies will have even more influence over the practice of medicine.  With this increased influence, reimbursement rates will, almost certainly, continue to deteriorate. Given the fact that the AMA has already sold out the nation’s physicians, it is highly unlikely that the Federal Government will do anything to alter this trend.  However, insurance companies are regulated by the states.  This provides perhaps one last chance for physicians.  It’s time to work closely with state legislators and insurance regulators to prevent changes in insurance coverage that will diminish patients’ ability to obtain services from physicians of their choice.  Out-of-network plans that protect patients’ choice must be encouraged and protected.  Efforts by insurers to reduce out-of-network benefits to a level that will assure that they are rarely if ever used must be prohibited.  Changes that only benefit insurance companies and their profits, and diminish the right of patients to choose their physicians, must be stopped. Many physicians, unwilling to accept the dramatically reduced payment schedules of managed care companies, practice “out-of-network.”  Out-of-network reimbursement rates are usually based upon the physician’s “usual, customary, and reasonable” fees.  These “UCR” fees are often many times greater than the fees paid to in-network physicians for the same services. Recently, Oxford UnitedHealthcare has announced that, effective January 2010, certain of its insurance products would limit out-of-network benefits to no more than 140% of Medicare rates.   Oxford UnitedHealthcare will effectuate this change by amending language in its insurance policies to no longer pay based upon usual, customary, and reasonable fees.  Rather, those insureds who continue to contract (directly or through their employers) for a policy with out-of-network benefits will receive 140% or less of the Medicare rates when they go out-of-network, less co-payments and deductibles.  Any amounts charged by out-of-network physicians, beyond the 140%, will be the responsibility of the patient. With these changes, individual patients who have health insurance policies with out-of-network benefits will now have to bear a financial burden which will force many of them to in-network physicians.  As a result, the increased premium costs associated with the availability of out-of-network benefits will have far less value.  Given the reduced value, these policies may no longer be perceived as worth the added cost and policies which provide only in-network coverage will become even more attractive. There can be little doubt that this is only the beginning of a trend.  Health insurance companies continue to pressure physicians to go “in-network” and accept the vastly reduced payments associated with being “in-network”.  If Oxford UnitedHealthcare is successful in this effort, it will likely expand its efforts to its other product lines.  Other health insurers will also follow suit.  This change will not only have a substantial effect on out-of-network physicians but will ultimately affect in-network physicians as well.  As more and more physicians decide that they must join managed care networks, the supply of in-network physicians will increase and managed care companies will be able to further reduce reimbursement rates.  Of course, with Congress set to pass a new health reform bill that could provide insurers with an additional 30 million covered lives, insurance companies will have even more influence over the practice of medicine.  With this increased influence, reimbursement rates will, almost certainly, continue to deteriorate. Given the fact that the AMA has already sold out the nation’s physicians, it is highly unlikely that the Federal Government will do anything to alter this trend.  However, insurance companies are regulated by the states.  This provides perhaps one last chance for physicians.  It’s time to work closely with state legislators and insurance regulators to prevent changes in insurance coverage that will diminish patients’ ability to obtain services from physicians of their choice.  Out-of-network plans that protect patients’ choice must be encouraged and protected.  Efforts by insurers to reduce out-of-network benefits to a level that will assure that they are rarely if ever used must be prohibited.  Changes that only benefit insurance companies and their profits, and diminish the right of patients to choose their physicians, must be stopped. Mon, 18 Jan 2010 21:15:42 GMT http://community.modernmedicine.com/_The-End-of-Out-of-Network-Care/BLOG/1742898/33379.html skern 2010-01-18T21:15:42Z Health Law & Policy Modern Medicine Community Many physicians, unwilling to accept the dramatically reduced payment schedules of managed care companies, practice “out-of-network.”  Out-of-network reimbursement rates are usually based upon the physician’s “usual, customary, and reasonable” fees.  These “UCR” fees are often many times greater than the fees paid to in-network physicians for the same services. Recently, Oxford UnitedHealthcare has announced that, effective January 2010, certain of its insurance products would limit out-of-network benefits to no more than 140% of Medicare rates.   Oxford UnitedHealthcare will effectuate this change by amending language in its insurance policies to no longer pay based upon usual, customary, and reasonable fees.  Rather, those insureds who continue to contract (directly or through their employers) for a policy with out-of-network benefits will receive 140% or less of the Medicare rates when they go out-of-network, less co-payments and deductibles.  Any amounts charged by out-of-network physicians, beyond the 140%, will be the responsibility of the patient. With these changes, individual patients who have health insurance policies with out-of-network benefits will now have to bear a financial burden which will force many of them to in-network physicians.  As a result, the increased premium costs associated with the availability of out-of-network benefits will have far less value.  Given the reduced value, these policies may no longer be perceived as worth the added cost and policies which provide only in-network coverage will become even more attractive. There can be little doubt that this is only the beginning of a trend.  Health insurance companies continue to pressure physicians to go “in-network” and accept the vastly reduced payments associated with being “in-network”.  If Oxford UnitedHealthcare is successful in this effort, it will likely expand its efforts to its other product lines.  Other health insurers will also follow suit.  This change will not only have a substantial effect on out-of-network physicians but will ultimately affect in-network physicians as well.  As more and more physicians decide that they must join managed care networks, the supply of in-network physicians will increase and managed care companies will be able to further reduce reimbursement rates.  Of course, with Congress set to pass a new health reform bill that could provide insurers with an additional 30 million covered lives, insurance companies will have even more influence over the practice of medicine.  With this increased influence, reimbursement rates will, almost certainly, continue to deteriorate. Given the fact that the AMA has already sold out the nation’s physicians, it is highly unlikely that the Federal Government will do anything to alter this trend.  However, insurance companies are regulated by the states.  This provides perhaps one last chance for physicians.  It’s time to work closely with state legislators and insurance regulators to prevent changes in insurance coverage that will diminish patients’ ability to obtain services from physicians of their choice.  Out-of-network plans that protect patients’ choice must be encouraged and protected.  Efforts by insurers to reduce out-of-network benefits to a level that will assure that they are rarely if ever used must be prohibited.  Changes that only benefit insurance companies and their profits, and diminish the right of patients to choose their physicians, must be stopped. health law & policy, in-network, insurancement reimbursement, managed care, out-of-network nonadult false The End of Out-of-Network Care? text blog health law & policy,in-network,insurancement reimbursement,managed care,out-of-network 193 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=3407919&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_2089258_33379_3407919_ap_160X120.jpg false 1 0 1742898 3407919 Member 0 http://community.modernmedicine.com/_Which-Personalized-Care-Is-the-Most-Important/BLOG/1740565/33379.html We are all reading about the genetic revolution and the coming of "personalized medicine."  In this context, personalized medicine is about using a person's genetic information to help guide drug choices, lab tests, preventive medicine, diagnosis, and treatment.  The director of NIH, Francis Collins, has a new book about the promises of personalized medicine through genetic information.  As a primary care physician, this all sounds exciting, but I wonder whether it will be affordable and just how much difference this will make.  I am a futurist and an optimist, so I am sure there will be some good coming out of this new genetic era. There is another emerging personlized medicine that I am more excited about and that I think in the long run will make even more of an impact.  That is the personalized medicine that comes from the patient-centered medical home model of practice (see my last Blog on practicing ideal primary care).  In the past, patients were often passive recipients of care through a frustrating system of needing to make appointments.  The new personalized care model connects patients with their primary physician and care team anytime through secure online communication.  The communication and care access becomes continuous and highly personalized.  This enhanced connection for care should promote healing and result in much better patient outcomes. At most, genetics plays about a 25% role in health and disease.  How we live is much more important.  We will make improvements through genetics, but we will gain much more by an improved care model that better connects people and their health to their physicians and other caregivers.  That is the most important personalized medicine for primary care. We are all reading about the genetic revolution and the coming of "personalized medicine."  In this context, personalized medicine is about using a person's genetic information to help guide drug choices, lab tests, preventive medicine, diagnosis, and treatment.  The director of NIH, Francis Collins, has a new book about the promises of personalized medicine through genetic information.  As a primary care physician, this all sounds exciting, but I wonder whether it will be affordable and just how much difference this will make.  I am a futurist and an optimist, so I am sure there will be some good coming out of this new genetic era. There is another emerging personlized medicine that I am more excited about and that I think in the long run will make even more of an impact.  That is the personalized medicine that comes from the patient-centered medical home model of practice (see my last Blog on practicing ideal primary care).  In the past, patients were often passive recipients of care through a frustrating system of needing to make appointments.  The new personalized care model connects patients with their primary physician and care team anytime through secure online communication.  The communication and care access becomes continuous and highly personalized.  This enhanced connection for care should promote healing and result in much better patient outcomes. At most, genetics plays about a 25% role in health and disease.  How we live is much more important.  We will make improvements through genetics, but we will gain much more by an improved care model that better connects people and their health to their physicians and other caregivers.  That is the most important personalized medicine for primary care. Sun, 17 Jan 2010 15:39:51 GMT http://community.modernmedicine.com/_Which-Personalized-Care-Is-the-Most-Important/BLOG/1740565/33379.html jscherger 2010-01-17T15:39:51Z Primary Care Modern Medicine Community We are all reading about the genetic revolution and the coming of "personalized medicine."  In this context, personalized medicine is about using a person's genetic information to help guide drug choices, lab tests, preventive medicine, diagnosis, and treatment.  The director of NIH, Francis Collins, has a new book about the promises of personalized medicine through genetic information.  As a primary care physician, this all sounds exciting, but I wonder whether it will be affordable and just how much difference this will make.  I am a futurist and an optimist, so I am sure there will be some good coming out of this new genetic era. There is another emerging personlized medicine that I am more excited about and that I think in the long run will make even more of an impact.  That is the personalized medicine that comes from the patient-centered medical home model of practice (see my last Blog on practicing ideal primary care).  In the past, patients were often passive recipients of care through a frustrating system of needing to make appointments.  The new personalized care model connects patients with their primary physician and care team anytime through secure online communication.  The communication and care access becomes continuous and highly personalized.  This enhanced connection for care should promote healing and result in much better patient outcomes. At most, genetics plays about a 25% role in health and disease.  How we live is much more important.  We will make improvements through genetics, but we will gain much more by an improved care model that better connects people and their health to their physicians and other caregivers.  That is the most important personalized medicine for primary care. medical home model, personalized medicine, primary care nonadult false Which Personalized Care Is the Most Important? text blog medical home model,personalized medicine,primary care 52 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2830352&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1413986_33379_2830352_ap_160X120.jpg false 0 0 1740565 2830352 Member 0 http://community.modernmedicine.com/_A-Look-into-the-Future-of-Monitoring-Neurological-Disability-with-the-Proposed-new-Healthcare-System/BLOG/1716418/33379.html In a recent article (abstract) on health-related quality of life in MS (MS), the authors evaluate the utilities which are identified as a "key summary index measure" of increasing neurologic disability reflective of different stages of MS.1 Their specific focus was on the relapsing-remitting and secondary progressive forms of MS, with disability measured by the Expanded Disability Status Scale (EDSS). It is important to point out that, clinically, MS can have a very benign course with or without immunomodulating therapy in a significant number of patients. However, a not insignificant proportion experience a progressive disabling course. This has a primary economic effect on the patient and family in terms of work status and support system costs. The health care system is affected by the relatively expensive medications along with physical and occupational therapy as well as functional aides, and so on. MS would appear, from my perspective, to be an ideal neurologic disorder to use as a model for a cost-benefit analysis. The type of information gathered in studies such as that by Naci et al can provide an objective determination of how effectively medical and economic goals are being met with presently available treatment regimens for chronic neurologic disability secondary to disorders such as MS. Although such data collection is not necessarily as exciting as an article about a new treatment for MS, in the grand scheme of the proposed new health care system in the United States, reining in healthcare costs will be pivotal. Thus, specific attention to outcome measures, including quality of life issues, would appear to become increasingly important to justify what specific treatment regimens will be covered by this proposed health care plan. Hopefully, there will be greater efficiencies that will not only help to control healthcare costs but also allow greater support to improve outcomes. Reference Naci H, Fleurence R, Birt J, et al. The impact of increasing neurological disability of MS on health studies: a systematic review of the literature. J Med Econ. Posted online on Jan 4, 2010. In a recent article (abstract) on health-related quality of life in MS (MS), the authors evaluate the utilities which are identified as a "key summary index measure" of increasing neurologic disability reflective of different stages of MS.1 Their specific focus was on the relapsing-remitting and secondary progressive forms of MS, with disability measured by the Expanded Disability Status Scale (EDSS). It is important to point out that, clinically, MS can have a very benign course with or without immunomodulating therapy in a significant number of patients. However, a not insignificant proportion experience a progressive disabling course. This has a primary economic effect on the patient and family in terms of work status and support system costs. The health care system is affected by the relatively expensive medications along with physical and occupational therapy as well as functional aides, and so on. MS would appear, from my perspective, to be an ideal neurologic disorder to use as a model for a cost-benefit analysis. The type of information gathered in studies such as that by Naci et al can provide an objective determination of how effectively medical and economic goals are being met with presently available treatment regimens for chronic neurologic disability secondary to disorders such as MS. Although such data collection is not necessarily as exciting as an article about a new treatment for MS, in the grand scheme of the proposed new health care system in the United States, reining in healthcare costs will be pivotal. Thus, specific attention to outcome measures, including quality of life issues, would appear to become increasingly important to justify what specific treatment regimens will be covered by this proposed health care plan. Hopefully, there will be greater efficiencies that will not only help to control healthcare costs but also allow greater support to improve outcomes. Reference Naci H, Fleurence R, Birt J, et al. The impact of increasing neurological disability of MS on health studies: a systematic review of the literature. J Med Econ. Posted online on Jan 4, 2010. Thu, 14 Jan 2010 20:33:38 GMT http://community.modernmedicine.com/_A-Look-into-the-Future-of-Monitoring-Neurological-Disability-with-the-Proposed-new-Healthcare-System/BLOG/1716418/33379.html rkelley 2010-01-14T20:33:38Z Neurology Modern Medicine Community In a recent article (abstract) on health-related quality of life in MS (MS), the authors evaluate the utilities which are identified as a "key summary index measure" of increasing neurologic disability reflective of different stages of MS.1 Their specific focus was on the relapsing-remitting and secondary progressive forms of MS, with disability measured by the Expanded Disability Status Scale (EDSS). It is important to point out that, clinically, MS can have a very benign course with or without immunomodulating therapy in a significant number of patients. However, a not insignificant proportion experience a progressive disabling course. This has a primary economic effect on the patient and family in terms of work status and support system costs. The health care system is affected by the relatively expensive medications along with physical and occupational therapy as well as functional aides, and so on. MS would appear, from my perspective, to be an ideal neurologic disorder to use as a model for a cost-benefit analysis. The type of information gathered in studies such as that by Naci et al can provide an objective determination of how effectively medical and economic goals are being met with presently available treatment regimens for chronic neurologic disability secondary to disorders such as MS. Although such data collection is not necessarily as exciting as an article about a new treatment for MS, in the grand scheme of the proposed new health care system in the United States, reining in healthcare costs will be pivotal. Thus, specific attention to outcome measures, including quality of life issues, would appear to become increasingly important to justify what specific treatment regimens will be covered by this proposed health care plan. Hopefully, there will be greater efficiencies that will not only help to control healthcare costs but also allow greater support to improve outcomes. Reference Naci H, Fleurence R, Birt J, et al. The impact of increasing neurological disability of MS on health studies: a systematic review of the literature. J Med Econ. Posted online on Jan 4, 2010. cost-benefit analysis, health care reform, multiple sclerosis, neurology nonadult false A Look into the Future of Monitoring Neurological Disability with the Proposed new Healthcare System text blog cost-benefit analysis,health care reform,multiple sclerosis,neurology 10 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771761&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1413325_33379_2771761_ap_160X120.jpg false 0 0 1716418 2771761 Member 0 http://community.modernmedicine.com/_Embezzling-Economic-Indicators/BLOG/1694855/33379.html I have had my second call in a month about discovered embezzlement. As far as we know, the employees had not done this before. One was known to be in big financial trouble, living out of her car. The other had some vague hint of family trouble and perhaps some big psychotherapy bills to pay. In any event, the option of dipping into the practice income was too tempting. The first case concerned a manager who took collections made at the time of the service from 3 offices and deposited them separately from mailed-in checks. When trying to reconcile the income for end-of-year bonus distributions, the accountant discovered that income posted to the accounts did not match that deposited in the bank. If the accountant had received monthly payment summaries along with the bank reconciliations, this scam would not have worked. This lack of information is not unusual. Most profit and loss statements begin with what was deposited with no tie-in to what was collected. It is even worse when practices use Quick Books to create reports, and the CPA only sees them once a year at tax time. The second case was a bit different. The bookkeeper was overwhelmed, and she could not get all the work done. She refused help. Instead, she posted what she could and made the deposit equal the posting. What was missing was the number and amount of checks she didn’t post. Payment posters also make adjustments. It is too early to tell if she had a phantom bank account where she deposited the “extra” checks, making adjustments on patient accounts instead of posting the payment. How did the manager discover this problem? She was concerned about the “rat’s nest” in the billing office; so, while the bookkeeper was away, the manager started opening cabinets and drawers. She found many unposted checks, unposted EOBs, and overpayment refund requests from insurance companies hidden months’ prior. This bookkeeper also paid the bills! Big surprise, she “advanced” herself $1,500 when the manager was away. That was discovered at the end-of-the-year reconciliation with the payroll service account showing $1500 less than the expense summary for payroll. Moral: Get several people involved in opening the mail, totaling the checks, posting, and making the deposit. Make sure the CPA gets a summary by day of the collection posted to the computer as well as the bank rec. Recognize people in trouble and take the opportunity for creative solution. I have had my second call in a month about discovered embezzlement. As far as we know, the employees had not done this before. One was known to be in big financial trouble, living out of her car. The other had some vague hint of family trouble and perhaps some big psychotherapy bills to pay. In any event, the option of dipping into the practice income was too tempting. The first case concerned a manager who took collections made at the time of the service from 3 offices and deposited them separately from mailed-in checks. When trying to reconcile the income for end-of-year bonus distributions, the accountant discovered that income posted to the accounts did not match that deposited in the bank. If the accountant had received monthly payment summaries along with the bank reconciliations, this scam would not have worked. This lack of information is not unusual. Most profit and loss statements begin with what was deposited with no tie-in to what was collected. It is even worse when practices use Quick Books to create reports, and the CPA only sees them once a year at tax time. The second case was a bit different. The bookkeeper was overwhelmed, and she could not get all the work done. She refused help. Instead, she posted what she could and made the deposit equal the posting. What was missing was the number and amount of checks she didn’t post. Payment posters also make adjustments. It is too early to tell if she had a phantom bank account where she deposited the “extra” checks, making adjustments on patient accounts instead of posting the payment. How did the manager discover this problem? She was concerned about the “rat’s nest” in the billing office; so, while the bookkeeper was away, the manager started opening cabinets and drawers. She found many unposted checks, unposted EOBs, and overpayment refund requests from insurance companies hidden months’ prior. This bookkeeper also paid the bills! Big surprise, she “advanced” herself $1,500 when the manager was away. That was discovered at the end-of-the-year reconciliation with the payroll service account showing $1500 less than the expense summary for payroll. Moral: Get several people involved in opening the mail, totaling the checks, posting, and making the deposit. Make sure the CPA gets a summary by day of the collection posted to the computer as well as the bank rec. Recognize people in trouble and take the opportunity for creative solution. Wed, 06 Jan 2010 16:42:02 GMT http://community.modernmedicine.com/_Embezzling-Economic-Indicators/BLOG/1694855/33379.html jbee 2010-01-06T16:42:02Z Managing Your Practice Modern Medicine Community I have had my second call in a month about discovered embezzlement. As far as we know, the employees had not done this before. One was known to be in big financial trouble, living out of her car. The other had some vague hint of family trouble and perhaps some big psychotherapy bills to pay. In any event, the option of dipping into the practice income was too tempting. The first case concerned a manager who took collections made at the time of the service from 3 offices and deposited them separately from mailed-in checks. When trying to reconcile the income for end-of-year bonus distributions, the accountant discovered that income posted to the accounts did not match that deposited in the bank. If the accountant had received monthly payment summaries along with the bank reconciliations, this scam would not have worked. This lack of information is not unusual. Most profit and loss statements begin with what was deposited with no tie-in to what was collected. It is even worse when practices use Quick Books to create reports, and the CPA only sees them once a year at tax time. The second case was a bit different. The bookkeeper was overwhelmed, and she could not get all the work done. She refused help. Instead, she posted what she could and made the deposit equal the posting. What was missing was the number and amount of checks she didn’t post. Payment posters also make adjustments. It is too early to tell if she had a phantom bank account where she deposited the “extra” checks, making adjustments on patient accounts instead of posting the payment. How did the manager discover this problem? She was concerned about the “rat’s nest” in the billing office; so, while the bookkeeper was away, the manager started opening cabinets and drawers. She found many unposted checks, unposted EOBs, and overpayment refund requests from insurance companies hidden months’ prior. This bookkeeper also paid the bills! Big surprise, she “advanced” herself $1,500 when the manager was away. That was discovered at the end-of-the-year reconciliation with the payroll service account showing $1500 less than the expense summary for payroll. Moral: Get several people involved in opening the mail, totaling the checks, posting, and making the deposit. Make sure the CPA gets a summary by day of the collection posted to the computer as well as the bank rec. Recognize people in trouble and take the opportunity for creative solution. embezzlement, income reconciliation problems, managing your practice nonadult false Embezzling: Economic Indicators? text blog embezzlement,income reconciliation problems,managing your practice 312 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771849&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1733228_33379_2771849_ap_160X120.jpg false 1 0 1694855 2771849 Member 0 http://community.modernmedicine.com/_The-Crisis-in-Primary-Care/BLOG/1694851/33379.html I spend most of my time working in the outpatient setting. However, each year for 2 weeks I dust off my inpatient skills and attend on the general medical service of my busy academic teaching hospital. I’m never sure how much I have to teach, but I know that I learn a lot each year—about acute/inpatient medicine and about the state of health care. As it turned out, these were 2 interesting weeks to be on-service. As the Senate debated the language of the health care bill and health reform was the on the minds of all Americans, I witnessed a critical dimension of our nation’s challenge in health care each time I rounded in the hospital—the crisis in primary care. At least one third of the patients were admitted with problems that could have been (should have been) prevented by reasonably well-coordinated primary care: CHF, hypertension, diabetes, asthma out of control due to misunderstanding of medications; several cases of herpes zoster in patients who had never been vaccinated—adding to the cost and complexity of hospital care; patients who had not been treated and/or retested for their MRSA or VERS following previous hospitalizations, also adding to the cost and complexity of their subsequent admissions. One patient with cardiomyopathy was admitted because she could not afford the copayments on her medications. The residents and I were struck by the irony that it would be easier to get her a heart transplant than to ensure that she received her Lasix every year. Patients were sick because they had not received influenza vaccines, pneumococcal vaccines, and on and on. Many of our patients actually had primary care providers but all reported difficulty getting an appointment. “She is so busy; I can never get an appointment.” “He never has a chance to call me back when I have a question.” None of this is new, although it seemed a little worse this year. What was new was the plea I began to hear on a daily basis. “Would you be my doctor?” Many patients have no primary care provider. Others hadn’t seen theirs in a very long time. On several occasions, while rounding in a double room, my patient asked if I would be her doctor, and her roommate chimed in, “Can I come and see you, too?” One morning the woman cleaning the floors asked if I would mind seeing her. She has qualified for insurance for the first time and needs a doctor. Another day it was the phlebotomist--insured for several years, but still unable to find a doctor with an open practice. "Please let me come to your practice." The most remarkable request came while I was Christmas shopping. I had run out of the hospital for an hour to do some frenetic gift-hunting. As I was checking out, the clerk asked what kind of doctor I was. For a moment I wondered how she had guessed. Then I realized that I had forgotten to remove my stethoscope. I told her that I was a primary care internist. When she asked where I practiced. I assumed she was just making conversation until she, too, joined the chorus. “Could I become your patient?” It turned out that she had been treated for breast cancer, was up-to-date with all of her cancer follow-up and doing well, but has no primary care doctor. “So I’m behind on ‘the regular things that people get.’ ” Complicated and incomplete as the bills before Congress may be, it is exciting that the country is beginning to see health care as a basic right. However, there is a lot more to resolve than who will have insurance and how that insurance will be paid for. We need well-run systems that link inpatient to outpatient care; that constantly seek to improve outpatient care for people with complex chronic conditions such as CHF, hypertension, diabetes and asthma. We need to provide preventive care and surveillance and to maintain optimum health and well-being for all people. We need to avoid unnecessary suffering and the use of scarce resources for complications that are preventable. In my view, primary care would, of course, be at the center of such a well-designed system. However, primary care will not be able to deliver on its potential to provide high quality care, insure rational use of resources, and foster the best and most equitable outcomes possible if it is overwhelmed by the onslaught of increased demand. Health care reform efforts must be tied to plausible short- and long-term strategies to address the shortage in primary care providers. I spend most of my time working in the outpatient setting. However, each year for 2 weeks I dust off my inpatient skills and attend on the general medical service of my busy academic teaching hospital. I’m never sure how much I have to teach, but I know that I learn a lot each year—about acute/inpatient medicine and about the state of health care. As it turned out, these were 2 interesting weeks to be on-service. As the Senate debated the language of the health care bill and health reform was the on the minds of all Americans, I witnessed a critical dimension of our nation’s challenge in health care each time I rounded in the hospital—the crisis in primary care. At least one third of the patients were admitted with problems that could have been (should have been) prevented by reasonably well-coordinated primary care: CHF, hypertension, diabetes, asthma out of control due to misunderstanding of medications; several cases of herpes zoster in patients who had never been vaccinated—adding to the cost and complexity of hospital care; patients who had not been treated and/or retested for their MRSA or VERS following previous hospitalizations, also adding to the cost and complexity of their subsequent admissions. One patient with cardiomyopathy was admitted because she could not afford the copayments on her medications. The residents and I were struck by the irony that it would be easier to get her a heart transplant than to ensure that she received her Lasix every year. Patients were sick because they had not received influenza vaccines, pneumococcal vaccines, and on and on. Many of our patients actually had primary care providers but all reported difficulty getting an appointment. “She is so busy; I can never get an appointment.” “He never has a chance to call me back when I have a question.” None of this is new, although it seemed a little worse this year. What was new was the plea I began to hear on a daily basis. “Would you be my doctor?” Many patients have no primary care provider. Others hadn’t seen theirs in a very long time. On several occasions, while rounding in a double room, my patient asked if I would be her doctor, and her roommate chimed in, “Can I come and see you, too?” One morning the woman cleaning the floors asked if I would mind seeing her. She has qualified for insurance for the first time and needs a doctor. Another day it was the phlebotomist--insured for several years, but still unable to find a doctor with an open practice. "Please let me come to your practice." The most remarkable request came while I was Christmas shopping. I had run out of the hospital for an hour to do some frenetic gift-hunting. As I was checking out, the clerk asked what kind of doctor I was. For a moment I wondered how she had guessed. Then I realized that I had forgotten to remove my stethoscope. I told her that I was a primary care internist. When she asked where I practiced. I assumed she was just making conversation until she, too, joined the chorus. “Could I become your patient?” It turned out that she had been treated for breast cancer, was up-to-date with all of her cancer follow-up and doing well, but has no primary care doctor. “So I’m behind on ‘the regular things that people get.’ ” Complicated and incomplete as the bills before Congress may be, it is exciting that the country is beginning to see health care as a basic right. However, there is a lot more to resolve than who will have insurance and how that insurance will be paid for. We need well-run systems that link inpatient to outpatient care; that constantly seek to improve outpatient care for people with complex chronic conditions such as CHF, hypertension, diabetes and asthma. We need to provide preventive care and surveillance and to maintain optimum health and well-being for all people. We need to avoid unnecessary suffering and the use of scarce resources for complications that are preventable. In my view, primary care would, of course, be at the center of such a well-designed system. However, primary care will not be able to deliver on its potential to provide high quality care, insure rational use of resources, and foster the best and most equitable outcomes possible if it is overwhelmed by the onslaught of increased demand. Health care reform efforts must be tied to plausible short- and long-term strategies to address the shortage in primary care providers. Wed, 06 Jan 2010 16:32:47 GMT http://community.modernmedicine.com/_The-Crisis-in-Primary-Care/BLOG/1694851/33379.html bgottlieb 2010-01-06T16:32:47Z Primary Care Modern Medicine Community I spend most of my time working in the outpatient setting. However, each year for 2 weeks I dust off my inpatient skills and attend on the general medical service of my busy academic teaching hospital. I’m never sure how much I have to teach, but I know that I learn a lot each year—about acute/inpatient medicine and about the state of health care. As it turned out, these were 2 interesting weeks to be on-service. As the Senate debated the language of the health care bill and health reform was the on the minds of all Americans, I witnessed a critical dimension of our nation’s challenge in health care each time I rounded in the hospital—the crisis in primary care. At least one third of the patients were admitted with problems that could have been (should have been) prevented by reasonably well-coordinated primary care: CHF, hypertension, diabetes, asthma out of control due to misunderstanding of medications; several cases of herpes zoster in patients who had never been vaccinated—adding to the cost and complexity of hospital care; patients who had not been treated and/or retested for their MRSA or VERS following previous hospitalizations, also adding to the cost and complexity of their subsequent admissions. One patient with cardiomyopathy was admitted because she could not afford the copayments on her medications. The residents and I were struck by the irony that it would be easier to get her a heart transplant than to ensure that she received her Lasix every year. Patients were sick because they had not received influenza vaccines, pneumococcal vaccines, and on and on. Many of our patients actually had primary care providers but all reported difficulty getting an appointment. “She is so busy; I can never get an appointment.” “He never has a chance to call me back when I have a question.” None of this is new, although it seemed a little worse this year. What was new was the plea I began to hear on a daily basis. “Would you be my doctor?” Many patients have no primary care provider. Others hadn’t seen theirs in a very long time. On several occasions, while rounding in a double room, my patient asked if I would be her doctor, and her roommate chimed in, “Can I come and see you, too?” One morning the woman cleaning the floors asked if I would mind seeing her. She has qualified for insurance for the first time and needs a doctor. Another day it was the phlebotomist--insured for several years, but still unable to find a doctor with an open practice. "Please let me come to your practice." The most remarkable request came while I was Christmas shopping. I had run out of the hospital for an hour to do some frenetic gift-hunting. As I was checking out, the clerk asked what kind of doctor I was. For a moment I wondered how she had guessed. Then I realized that I had forgotten to remove my stethoscope. I told her that I was a primary care internist. When she asked where I practiced. I assumed she was just making conversation until she, too, joined the chorus. “Could I become your patient?” It turned out that she had been treated for breast cancer, was up-to-date with all of her cancer follow-up and doing well, but has no primary care doctor. “So I’m behind on ‘the regular things that people get.’ ” Complicated and incomplete as the bills before Congress may be, it is exciting that the country is beginning to see health care as a basic right. However, there is a lot more to resolve than who will have insurance and how that insurance will be paid for. We need well-run systems that link inpatient to outpatient care; that constantly seek to improve outpatient care for people with complex chronic conditions such as CHF, hypertension, diabetes and asthma. We need to provide preventive care and surveillance and to maintain optimum health and well-being for all people. We need to avoid unnecessary suffering and the use of scarce resources for complications that are preventable. In my view, primary care would, of course, be at the center of such a well-designed system. However, primary care will not be able to deliver on its potential to provide high quality care, insure rational use of resources, and foster the best and most equitable outcomes possible if it is overwhelmed by the onslaught of increased demand. Health care reform efforts must be tied to plausible short- and long-term strategies to address the shortage in primary care providers. health care resources, primary care, quality medical care nonadult false The Crisis in Primary Care— text blog health care resources,primary care,quality medical care 707 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 8 0 1694851 2771822 Member 0