Physicians writing on KevinMD about the rules they practice under: prior authorization and the algorithms now deciding it, gold card laws, scope of practice and who may practice without supervision, Medicare and Medicaid, the Affordable Care Act, drug pricing, rationing that is done and not named, and the policies that decide which patients get care. Four maintained records draw on this archive: Prior authorization: what physicians say, in their own words, Scope of practice: what physicians, nurse practitioners, and PAs say, in their own words, Race and medicine: what physicians say, in their own words, and Medical ethics: what physicians say, in their own words.
The Cayman Islands are nestled in the Caribbean Sea some 430 miles south of Miami. The three-island cluster is known for its inviting coral-sand beaches, laid-back island culture and tax-free status.
While it lures many tourists and big banks, it’s not the first place you’d expect to find the future of American health care. That may change soon.
Last month, I flew to the Caymans to moderate an afternoon-long panel on delivering …
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Why the future of health care can be found in the Cayman Islands
What would you think if I told you that Medicare will require laboratories to disclose to CMS payment rates from private insurers? Or that they will identify physicians who order a high volume of CT tests and require them to pre-authorize those tests in 2020? How about that CMS will begin its own analysis of the time and cost of providing services in order to determine RVUs, a job currently …
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Sleight of hand: The SGR bill’s important policy changes
Back in 1986, the Health Care Financing Administration launched the brave new era of quality reporting in this country by releasing “report cards” that detailed hospital-specific, risk-adjusted mortality rates for coronary artery bypass graft (CABG) surgery.
Since that time, the number and type of publicly reported quality outcomes has grown exponentially with the goal of helping patients make informed decisions when selecting doctors, thereby driving quality improvement by doctors and hospitals.
Has …
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Physician report cards make no difference in referral patterns
There’s been a lot of hype about the “Ban Bossy” campaign in the news lately, and the talk is all over the map. I was thinking about it in regards to health care, especially nursing, since nurses are notoriously “bossy,” or at least referred to as such.
I can remember being a nursing student and talking with a physician about a patient during my clinicals. He told me, “You …
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Differences between banning bossy and true leadership in health care
I first heard about the ICD-10 when I was working at a small start-up, trying to develop an EMR for a string of dialysis clinics. It was always spoken of with a certain gravity, like the ominous visit from an aunt that nobody in the family likes, but feels obligated to see. Practical (read: business) people hate ICD-10. It’s giant and unwieldy. Doctors think it’ll be an excuse to bilk …
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ICD-10 and the problem of interobserver variability
Health insurance reform was long overdue. But did it need to be done the way the architects of the Affordable Care Act did it?
Obamacare was enacted, and the private health insurance market fundamentally changed, so that we could cover millions of people who previously couldn’t get coverage.
Are enough people getting coverage who didn’t have it before to justify the sacrifices the people who were already covered — in the individual, …
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Measuring Obamacare’s success: Are enough people getting coverage?
The worst news in health care is not antibiotic resistance, drug-drug interactions, hospital acquired infections, lack of communication between systems of medical records, and certainly not the alarming rate of obesity in our youth.
The worst news is the increasing number of dissatisfied physicians.
The physician, also known in the system as a “provider,” has been the direct target of assault by the government. The logic has been that if the physician …
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Dissatisfied doctors can’t provide good patient care
My home hospital is small. In a town of just over 20,000 people, this hospital has 25 beds and is designated “critical access” by Medicare because it is felt to be necessary to the health care of the community. Critical access is a designation which was introduced in 1997 when modernization of Medicare payment systems threatened to close a large proportion of hospitals in small communities which were unable to …
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The whole critical access system needs to be reconsidered
Fulfilling every stereotype, I sat at my grandparents’ house in southern Sweden, sipping elderberry juice out of an IKEA glass and eating meatballs with lingonberry jam. It was Christmas Eve, and I was enjoying a getaway from the rigors of medical school. However, it wasn’t a complete escape, as my grandparents loved talking about medicine and the differences between health care in the United States and Sweden.
In this particular conversation, …
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What Sweden can teach us about primary care
In my near-decade of practicing emergency medicine I have yet to receive a letter from a hospital congratulating me on how few CT scans I’ve ordered. Nor have I ever received a special award for diverting a potential admission to an outpatient referral instead. Rather, the push has always been the opposite. Fee-for-service models encourage the opposite behavior, and trying to do the most evidenced-based or cost-effective thing is not …
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Emergency departments should embrace clinically integrated networks
Frontline caregivers across the United States — and in many other countries, no doubt — are bombarded by multiple quality improvement (QI) projects. A clinical unit might simultaneously be engaged in efforts to reduce readmissions, eliminate hospital-acquired infections and other complications, increase hand-hygiene compliance, improve performance on core measures, and enhance the patient experience. The demands brought by participating in all of these efforts risk overwhelming health care professionals, who …
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How do we avoid initiative fatigue?
Most people, regardless of their political leaning, can agree that the market for health care in the United States isn’t really working well. Take one step further, though, and disagreement rapidly ensues.
On the left, the common understanding is that a market failure has occurred, and that the proper thing to do is have government intervene to correct that failure — usually by expanding public insurance programs, subsidizing private insurance, and …
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Can transparency in health care happen in the United States?
Malcolm Gladwell hasn’t written much about American health care. But that doesn’t mean he hasn’t been thinking about it. And it sure hasn’t stopped many of his powerful ideas like “tipping point,” “outlier” and “blink” from gaining entry into the national health care debate.
In his most recent book, “David and Goliath,” Gladwell reshaped our perspectives on the underdog and highlighted our tendency to over-value certain strengths. In the health care …
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Malcolm Gladwell on our health care system
Recently JAMA published a special theme issue on critical issues in U.S. health care. Among the contributors was Dr. Ezekiel Emanuel, the oncologist, bioethicist and former White House adviser on health policy.
In his article, “Going to the Moon in Health Care: Medicine’s Big Hairy Audacious Goal (BHAG),” Emanuel argues that contemporary medicine is in need of vision, an overarching, aspirational goal “like going to the moon that can make …
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Universal coverage remains a big deal
Physicians in Congress are on the rise. From 1960 to 2004, only 25 of the 2196 members of Congress were physicians. During an era that brought such fundamental changes to health policy as the creation of Medicare and Medicaid, physicians were disproportionately less likely to hold congressional office than their counterparts in law (979) and in business (298). In recent years, the ranks of physician-representatives have swelled — twenty physicians …
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The surge of physician membership in Congress
Safety net emergency departments are frequently blamed for being the source of rising health care costs. After all, they care for the millions of underserved and un-insured Americans forced by a variety of circumstances to visit ERs for their primary care and low-acuity concerns.
With the Affordable Care Act (ACA) reforms initiated in January, demand for emergency services will rise significantly. Medicaid already covers over 50 million individuals – most of …
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How safety net ERs can save health care reform
