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 federal government has been trying to control the health of citizens for nearly a century, increasingly separating patients and their physicians.
WWII wage controls firmly established health insurance as an employee “benefit” in lieu of salary. This gave the employer power to choose coverage based on its needs, not the employee’s: the first degree of separation.
Since WWII, government has imposed a multitude of programs that add degrees of separation: Medicare, …
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Eliminating the 6 degrees of patient-physician separation
Born in Canada, our mother came to the United States after World War II and blended into the Greatest Generation. Raising a family in the second half of the 20th century saw her contribute to a thriving American society then maintain retirement health on Medicare. But in her early 90s, this tranquility was threatened when her HMO hospital tried to kill her.
She went to the emergency room with symptoms of …
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Demand Congress to go on Medicare at the age of 65
As clinicians continue to debate the merits and limitations of retail clinics, it is increasingly clear that they are here to stay. These nontraditional sites have proliferated around the country, appealing directly to patients’ desires for convenience in ways that many traditional primary care practices do not. A report by the Robert Wood Johnson Foundation found that retail clinics have increased by 900 percent over the last decade, an expansion …
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What economic theory can teach physicians about retail clinics
It is no secret that mental health conditions are prevalent, and recent years have seen an increase in the dialogue on their causes and consequences. However, we do ourselves a disservice when discussing mental health outside the context of the broader system in which care is provided, and the insurance constraints that drive shortcomings in health care delivery.
SAMHSA estimated that 58 percent of adults have a medical …
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Insurance constraints drive shortcomings in health care delivery
Why must we keep repeating history?
NCLB significantly increased the federal role in education by holding schools accountable for the academic progress of all students. NCLB held teachers responsible for education of children; MACRA-proposed changes will hold physicians responsible for the medical progress of our patients. The largest problem with this approach is students and patients go home each day to whatever environment in which they live. Neither teachers nor physicians …
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MACRA will do to medicine what No Child Left Behind did to education
Recently, physicians in small private practices and rural areas breathed a collective sigh of relief. There is a possibility the implementation of changes to physician reimbursement (known as MACRA) could be delayed. Thank you, Mr. Slavitt, for listening. I am grateful to Orrin Hatch (R-UT) and Ron Wyden (D-OR) for keeping our rural needs in mind. We have a window of opportunity for rural health care to survive, but we …
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To fix rural health care, you have to understand it first
Recently, ACP offered practical solutions to physicians’ concerns about Medicare’s proposal to implement the new payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA).
The College’s detailed recommendations, summarized here in a press statement that is linked to the comment letter itself, would replace CMS’s proposed and unnecessarily complex quality scoring system with a much simpler and understandable approach as developed by the College.
We challenge CMS to completely …
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Don’t rant about MACRA. Propose solutions instead.
Small, independent private practices are closing, increasing numbers of physicians are retiring, and fewer medical school graduates are choosing primary care. The old-fashioned practice my father and I have built is a dying entity. Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter. I am fighting for the survival of primary care practices. MACRA proposed reimbursement will decimate …
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How MACRA will decimate the private practice physician
I’m feeling pretty good about myself today. My patient, recently admitted to home health care, was just not herself, low O2 sats, irregular heart rate with pain on inspiration and feeling a little clammy. While her recent surgery was a neck fusion, it still didn’t completely eliminate the possibility of a pulmonary embolism. Instead of spending 15 to 30 torturous minutes in her primary doctor’s voice mail hell, I made …
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Why nurses deserve a place in primary care
This is my 12th year as a physician in the United States. I was born in London, grew up in Berkshire, and decided to become a doctor when I was a teenager. I remember being asked what I thought about the National Health Service (or NHS, the UK’s government-run health system) during my medical school interview. That question is almost a rite of passage for anyone applying to medical school in …
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Somewhere between the extremes: The ideal health system for America
It has now been confirmed that Prince’s untimely death resulted from an overdose of the drug fentanyl.
It is unclear whether the lethal dose of fentanyl was a prescription medication or a counterfeit “analog” drug from the illicit market. Regardless, the facts are now clear enough to know that the U.S. health care system failed Prince in the same ways it is failing the 78 Americans who die every …
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The health care system that failed Prince needs an immediate intervention
In 2008, mental health advocates hailed the Mental Health Parity and Addiction Equity Act as “historic;” putting an end to what Sen. Edward Kennedy called “the senseless discrimination in health insurance coverage that plagues persons living with mental illness.” The law requires most group health plans to offer coverage for mental health and substance use disorders equal to that provided for medical problems. Two years later, the Affordable Care Act extended …
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We live in a culture of mental health haves and have nots
Three weeks ago, I changed jobs. I left a high-tech, high-volume teaching hospital in one of the largest medical centers in the U.S. for the greener pastures of a small, private community hospital. Why? I needed a less stressful position, lower acuity patients and to be rid of the madness of commuting.
I am a registered nurse with experience in emergency and trauma nursing, critical care, electrophysiology and cardiovascular surgery. I …
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For hospitals to thrive, they need to value nurses
“I need help with my colitis.”
“Really? I thought we had things pretty well controlled.”
I hadn’t seen her in the better part of a year. I remembered how hard it had been to get her ulcerative colitis into remission. How sick she had been, how miserable her life was. There was a bit of trial and error in the office, followed by a hospitalization for intravenous steroids, then a tapering dose …
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People are going broke because they can’t afford care. It needs to end.
Get a group of health policy experts together and you’ll find one area of near universal agreement: We need more transparency in health care. The notion behind transparency is straightforward; greater availability of data on provider performance helps consumers make better choices and motivates providers to improve. And there is some evidence to suggest it works. In New York State, after cardiac surgery reporting went into effect, …
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Does publicly reporting hospital mortality rates improve outcomes?
I joined physicians nationwide last year in cheering when Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Not only did it eliminate the congressional budgetary fiction known as the Sustainable Growth Rate (SGR) formula, it also promised to simplify and improve Medicare’s costly and complex programs that purport to measure the quality of care we provide to our patients.
Unfortunately, as we review the draft implementing rule, …
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The MACRA rule: Not what Congress ordered
I’ve had the chance to present the changes being brought by the Medicare Access and CHIP Reauthorization Act (MACRA) to audiences of hundreds of physicians — at ACP’s Leadership Day on Capitol Hill, ACP’s Board of Governors and Board of Regents meetings, several educational sessions and a news briefing at the College’s Internal Medicine 2016 Scientific Meeting, and to the California Medical Association’s Leadership Academy. I’ve also had chats with …
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Why doctors shouldn’t worry about MACRA
