Physicians writing on KevinMD about policy as it reaches the exam room: prior authorization and the state and federal rules now written for it, scope of practice laws state by state, the CDC opioid guideline and what forced tapers did to patients, and public health from vaccination to the pandemic. 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, Opioids: what physicians and pain patients say, in their own words, and Vaccines: what physicians say, in their own words.
If you have been paying attention to US healthcare policy debates lately, you know that hospitals have a price problem. Walk across the street from one hospital to a competitor hospital, and you could easily find yourself facing a $30,000 increase in your medical bills. At one extreme for instance recent information shows that replacing your hip with a surgical implant might cost anywhere from $5000 to …
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How Obamacare will largely eliminate price variations
A few months ago marked the 20th anniversary of the launch of evidence based medicine (EBM). Now seems a good time for a retrospective. After twenty years what does EBM mean? Where has it taken us? What are the distortions and unintended consequences? You might be surprised.
What I intend to do is start with a little of the history of EBM, talk about the essential notion as originally conceived by …
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Where has evidence based medicine taken us in 20 years?
I always believed that, if we could harness the entrepreneurial spirit of the American physician, we could be capable of great things. Physician decisions drive much of what is good and bad about our health care system. Their pens are the biggest driver of cost and their vigilance is the most significant driver of quality. It is a shame that physician-owned hospitals are accelerating the creation of a two-tier system …
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How physician-owned hospitals are making teaching hospitals pay
Several physicians have reached out recently to discuss attractive employment offers from health systems. They are invariably conflicted. They understand the trade-offs, that they’ll give up the autonomy they’ve become accustomed to in exchange for more money and fewer practice management headaches. On the down side, they’ll be accountable for generating significant revenues, sometimes independent of care appropriateness.
Most also are aware that the same care services they provide now will …
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A brave new world as more physicians become employed
Amid massive change in our healthcare delivery systems and seismic shifts in many regional markets, physicians are increasingly being faced with a simple choice: be acquired or become employed as part of a large healthcare system, or stay independent while offering a compelling service that hospitals and health systems value.
The changes occurring in our care delivery systems have generated great interest, innovation, and yes, fear among many in healthcare, doctors …
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As health care consolidates, physicians face a choice
The highly charged political debates about reforming American health care have provided tempting opportunities to rename the people who receive health services. But because the impetus for this change has been prompted by cost and quality concerns of health care payers, researchers and policy experts rather than emanating from us out of our own needs, some odd words have been called into service. Two phrases commonly used to describe us …
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Don’t call me a health care consumer
This past November, the New England Journal of Medicine published results from the “Advancing Quality” program in the United Kingdom: hospitals in the northwest of England were paid up to 4% more based on quality scores for treating several common medical conditions. Patient outcomes were compared to other National Health Service hospitals not eligible for the bonuses, and several other conditions that were not explicitly measured in the same …
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Why pay for performance saves lives in the UK but not in the US
Much has already been written about the Oregon Medicaid study that came out in the New England Journal of Medicine. Unfortunately, the vast majority is reflex, rather than reflection. The study seems to serve as a Rorschach test of sorts, confirming people’s biases about whether Medicaid is “good” or “bad”. The proponents of Medicaid point to all the ways in which Medicaid seems to help those who were enrolled …
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Why the Oregon Medicaid study is misunderstood
Not old enough to remember any sort of “glory day” in medicine, I still enjoy hearing from older colleagues who recount days when they were respected, paid fairly, and able to practice medicine autonomously at the highest and most uncompromising level. What was that like, I wonder?
For five years, I’ve been a busy practicing anesthesiologist. And for five years, I’ve listened …
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America is at war with its doctors, and patients are the losers
I recently took part in a “civil discourse,” an unusual occurrence in this era of media pundit-orchestrated shouting matches.
Unlike a debate with winners and losers, a civil discourse begins with the premise that, when there are different points of view on a topic, it is better to understand those with whom we disagree than to turn off the sound.
By listening and asking probing questions, we come to understand how such …
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Health reform needs a healthy respect for civil discourse
One of the more contentious topics on my site is the scope of practice for non-physician providers, such as nurse practitioners. This echos the debate on the national stage where leaders of physician organizations, who want to protect their scope of practice, conflict with those of nurse practitioners’, who want to perform the tasks that physicians traditionally have.
Simply Google “nurse practitioner” on this site, for instance, and you’ll see …
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How I would end the war between nurse practitioners and doctors
I used to be a stickler for time. One of my first blog posts was about how it felt to go to work without my wristwatch.
I also used to be very particular about knowing the purpose of each visit, partly to help me manage my time, and partly to help me feel prepared and in control of the visit.
I often questioned why my colleagues’ patients would sometimes end up in …
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What is the role of the physician in today’s health care system?
Experts, most recently former CMS administrator Don Berwick, tell us that no less than 20% – 30% of medical care is waste. At the very least, waste is harmful to all those who pay for Medicare. But often it’s directly harmful to the patient as well.
I recently saw a friend at a party. Since we’d last seen each other my friend’s spouse had died. (I’m deliberately avoiding gendered pronouns and …
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How waste is directly harmful to patients
It was bound to happen.
By “it,” I mean that the small group of specialty hospitals (usually orthopedic or cardiology-focused) across that country that are owned by doctors were going to have their “See! We Told ‘ya so!” moment.
Doctor-owned hospitals. How many are there? Two hundred and thirty-eight of them in the whole country (out of more than five thousand)–somewhere between four and five percent of the total in the U.S. (numbers courtesy …
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Doctor owned hospitals: Are the rich getting richer?
Of all the different criteria people use when deciding for whom to vote in presidential elections, I’ve never heard anyone talk about the importance of a background in clinical psychology—but it’s always struck me as important for a president to have as for a clinical psychologist. Certainly, foreign policy experience, a firm grasp of the principles of economics, a bold and confident leadership style, and the ability to get people …
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Why politicians should have backgrounds in clinical psychology
I know what I want in healthcare. I want it to be efficient, effective, thoughtful and inexpensive. I want it to create healthy people who don’t need very much health care. I want it to involve elegant solutions to problems that take less time, money and effort. I want it to be so much easier and less expensive that taking care of all of our people uses even less resources …
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What does American healthcare want?
What is the path forward for physicians who want to remain in private practice, outside the constraints of health system employment? How will the environment change and what new demands will that place on practices and physicians? What follows are the observations of one industry-watcher who has worked on all sides of health care, but who now spends most his time focused on the interests of those who pay for …
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The path for physicians who want to remain in private practice
Over the past decade, patient-centered care has become a mantra for high-quality health care. Policymakers, researchers, physician-leaders, and patients have all cited the need for care to be tailored to patients’ unique needs and preferences. And there is solid evidence that patient-centered care can help improve care quality and reduce costs. However, in the rush to become more patient-centered, the health care system has misplaced its focus.
Current approaches to …
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Patient-centered care requires learning from the service industries
