“The AMA is supportive of the widespread adoption and meaningful use of EHRs by physicians, but the Stage 1 criteria proposed by CMS are too aggressive,” said AMA Board Member Steven J. Stack, M.D. “It could unreasonably punish physicians who undertake great efforts to achieve meaningful use of EHRs – only to be denied incentive payments due to overly complex and unattainable criteria.”

To help ease adoption and facilitate meaningful use of EHRs, the AMA suggested a number of revisions to the proposed rule. Among them are:

·        Remove the “all or nothing” approach and require physicians to meet five of the 25 proposed objectives and measures instead of all 25.

·        Eliminate the objectives and measures that don’t directly apply to EHR adoption, such as checking insurance eligibility electronically.

·        Revise the definition of meaningful use for certain hospital-based physicians to broaden eligibility for the federal incentive programs.

·        Reduce the number of quality measure reporting requirements and allow physicians to identify only three clinically relevant measures.

“Overall, the proposed reporting criteria require more flexibility,” said Dr. Stack. “We’d like to see more help for physicians in identifying the data necessary for accurate reporting.”

“We are committed to EHR adoption that streamlines physician practices and helps them continue providing high-quality care to patients, but successful integration of EHRs into patient care takes time,” said Dr. Stack. “We support the staged approach to health IT adoption, and we’re hopeful that we can work with the administration to finalize regulations that truly encourage EHR adoption and successful physician participation in the EHR incentive programs.”

Click here to read the full letter.

Oftentimes, physicians will admit that they have difficulty in negotiating for themselves.  For that reason, some prefer to have another individual do their negotiating for them.

Nevertheless, it is important for physicians to have some background on negotiating skills since, in reality, we all negotiate every day (be it with one’s employees, insurance companies, patients, family members, etc.).  This article will set forth some tried and true practical tips.

GATHERING INFORMATION

It is important to gather as much information as one is able to before getting involved in negotiations.  Learn all you can about those with whom you are negotiating.  What is the history?  What is the other side looking for?  Why are they looking for it?  What is their reputation?  Why are you interested?  Why would you not be interested?  What are their constraints?  The more you know, the better off you will be.

PLANNING

Be prepared.

I am amazed how many people go into an important meeting in an unprepared fashion.  As a general rule, he who is best prepared wins.  You need to know what is important to you.  You also should attempt to determine what is important and why it is important to those with whom you are negotiating.  That may assist you in the negotiation process and may be used to your advantage.  Be sure that you set forth on paper what your important questions are and be sure to raise them.  Think critically about your best case scenario, what you must have (the bottom line), and what you are willing to concede/trade off for something else.

FACE-TO-FACE NEGOTIATION SKILLS

People like to hear good things about themselves.  Sincere compliments are fine.  If you do not ask, the answer is “NO!”  Be enthusiastic.  Create and emphasize the common ground.  Listen carefully.  Do not do all the talking.  Hear everything that is being said to you.  For example, someone may respond to a query “not yet.”  To some that is a “no.”  To others it may be heard as a “maybe yes, if and when.”  Pay close attention to the words being expressed, how they are said and the facial expressions and body language while they are said.  Be confident (not cocky) and visualize success.  Communicate clearly.  Remember that both sides benefit from a “win-win” result.  Aim high, without being ridiculous.  Leverage is an important thing.  Honestly evaluate who has the most to gain/lose in the matter being negotiated.  You might have more leverage and be in a better bargaining position than you think.

Never take things personally.  Remember, the other side is probably also aiming high.  That is part of the negotiation process.  Do not view the initial proposal as an “insult.”

By aiming high, you allow room for negotiation.  The more issues there are out there, the more there is to trade.  That is why it is important to throw everything out on the table and negotiate things on a “global basis.”  Do not negotiate on a piecemeal basis.

Be prompt and professional.  Do what you say you will do.  Look the other person in the eye.  As much as you can, “have fun.”

Use your planning to your advantage.  Keep short-term and long-term issues in perspective.  Never lose sight of what your most important “must have” points are and what it is you would be willing to “give up.”

THEN WHAT?

At the end of a face-to-face meeting, be sure to summarize the areas of agreement and the “win-win” elements.

I always find it useful to capsulize things in writing, promptly.  That should clearly set forth the agreed to items as well as the open issues.  Hopefully, all parties’ recollection will be the same.  If it is not, it is best to find that out earlier rather than later.  It is not uncommon for the process to take more than one session.  Even when the deal appears to be lost, it may not be.  Nevertheless, at some point, one needs to “fish or cut bait.”  Just continuing to go around in circles does not make a lot of sense and ultimately will result in failure.

SOME OTHER “BIG PICTURE” TIPS

Ask for more.  There is nothing wrong with overstating one’s demands, so long as one is not ridiculous about it or insulting about it.  I often tell my clients that we are not really “demanding” things.  We are really merely asking for certain things.

Generally, it is best to respond to the “other side’s” proposal as opposed to being the first to lay one’s cards on the table.

As a general rule, never say yes to the first offer.

If you do, the other side may believe they have “done something wrong” and could have done better.

Some of the best negotiators I know are very good at “flinching.”  When people make a proposal, they are looking for your reaction.  Flinching may involve reacting with “surprise” or “shock.”  If you don’t flinch, the other side will begin to believe that their opening position is not that outrageous and may be acceptable.  An example of verbal flinching includes: “$300,000! I could not possibly afford to pay you that amount of salary.”  Another is “I have been offered more money by other practices.”  So often, what the other side sees visually may be more important than what is actually said.

Some of us have trouble curbing our emotions in showing openly how we feel.  Being a reluctant buyer or reluctant seller can go a long way towards helping you get a better deal.  The classic example is the individual who goes into a car dealership, sees a car that “he or she loves,” and cannot “keep a poker face” about it.  The salesperson knows right away that he has a real edge before any real negotiation begins.  An example of a reluctant seller is one who says “I really am not interested in selling this right now.”  If the buyer is really wanting this to happen, they realize they have to “step up.”  An example of a reluctant buyer is one who says, “I like what you are selling, but your price is too high.”

In some instances, at the end of the day, it really is best to have someone else do the negotiating for you.  Some doctors do not do well negotiating for themselves.  They fear “hurting the relationship” with the other side.  Therefore, they “give in” too easily or do not bring up all of the points.  That is not a condemnation.  But, it is a truism for many.

Some people are subject to “nibbling.”  One of the things that I do not like when I have gone through a negotiation is when the other side comes back after we believe that everything has been agreed to and seeks “a little more.”  Some people are most vulnerable when they think the negotiations are over.  The natural tendency after the initial agreement is to let down one’s guard and relax.  A good example is a car salesperson with a “by the way, there are additional charges for the extended service arrangement.

When all is done, congratulate the other side.  “Reluctantly” accept the last offer and make the other party feel satisfied.  Never gloat.  Let the other side believe that they have won the negotiations.

One of the most important and powerful tools in negotiating is the ability to “walk away.”  This can be a tough one.  If one becomes emotionally involved and “really has to have it,” it is tough for that not to come through.  It hurts you and you will usually end up with a deal that is not as good as it could have been.

Lastly, winning in negotiations does not entail “killing the other side.”  If it is not a “win-win,” at some point that fact will come back to bite you.

The details of the plan had been previously discussed and published in great detail.  That wasn’t the purpose of this visit.  This town-hall/rock concert atmosphere was intended to get Obama back to his strength of generating support by getting on stage and playing to his base of voters.  For this speech, the president simplified his proposal to three main areas:

1) Reform the insurance industry.  ”We can’t have a system that works better for the insurance companies than for the American people,” said Obama.  The president reiterated previously discussed ideas including no bans on preexisting conditions, free preventative care, and no restrictive annual limits on care.

2) Offer choices to the consumer.  Obama wants to give everyone the same opportunity to have coverage as strong as those in Congress.  ”If it’s good enough for Congress,” he said, “it should be good enough for the people paying Congress its salary.”

3) Reduce costs, including subsidies for the insurance and pharmaceutical industries.

As for any discussion of how his plan may benefit health care workers and providers, there were few details.  The only mention of the subject was in this exchange: “So the bottom line is this:  Our proposal is paid for.  All the new money generated in this plan goes back to small business owners and individuals in the middle class who right now are having trouble getting insurance.  It would lower prescription drug prices for seniors. It would help train new doctors and nurses to provide care for American families and physicians assistants and therapists.”

Obama called for an immediate up or down vote by Congress and ended the speech to huge applause by saying “Let’s seize reform — it’s within our grasp.”

Following is the full text of today’s speech:

REMARKS BY THE PRESIDENT

ON HEALTH INSURANCE REFORM

Arcadia University

Glenside, Pennsylvania

11:23 A.M. EST

THE PRESIDENT:  Hello, Pennsylvania!  (Applause.)  Thank you.
Thank you very much.  Thank you.  This is a nice crowd.  (Applause.)
Thank you very much.  Thank you.  Well, what a wonderful crowd.

AUDIENCE MEMBER:  I love you!

THE PRESIDENT:  Love you back.  (Applause.)  I am — I’m kind of
fired up.  (Applause.)  I’m kind of fired up.  (Applause.)  So, listen,
we — this is just an extraordinary crowd and I –

AUDIENCE MEMBER:  We love you!

THE PRESIDENT:  I love you back.  (Applause.)  I want — there’s
some people I want to point out who are here who’ve just been doing
great work.  First of all, give Leslie a great round of applause for her
wonderful introduction.  (Applause.)

Somebody who’s been working tirelessly on your behalf, doing a great job
– the Secretary of Health and Human Services, Kathleen Sebelius is in
the house.  (Applause.)  One of the finest governors in the country, Ed
Rendell is in the house.  (Applause.)  Everybody notice how good Ed is
looking, by the way? He’s been on that training program, eating egg
whites and keeping his cholesterol down.  (Laughter.)

Your senior senator who has just been doing outstanding work in the
Senate, Arlen Specter is in the house.  (Applause.)  One of my great
friends, somebody who supported me when nobody could pronounce my name,
Bob Casey is in the house.  (Applause.)  Your congressman, the person
who gave me confidence that I could win even though nobody could
pronounce my name — Chaka Fattah is in the house.  (Applause.)  I
figured if they could elect a “Chaka” — (laughter) — then they could
elect a “Barack.”  (Laughter.)

A couple other outstanding members of Congress — first of all, from
Pennsylvania, Allyson Schwartz is in the house.  (Applause.)  Somebody
who rendered outstanding service to our nation before he was in
Congress, Joe Sestak is in the house.  (Applause.)  One of the sharpest
members of Congress — technically not his state but he’s just from
right next door, New Jersey, so he’s practically — (applause.)  See,
we’ve got some Jersey folks here.  (Applause.)  Rob Andrews is in the
house.  (Applause.)  And the great mayor of Philadelphia, Mike Nutter.
(Applause.)

It’s a little hot, I think.  (Applause.)  And to Arcadia University –
(applause) — thank you, thank you guys for hosting us.  (Applause.)

I was asking about that castle on the way in, by the way.  (Applause.)
That’s a — I thought the White House was pretty nice, but that castle,
that’s — (laughter.)

Well, it is great to be back here in the Keystone State.  It’s even
better to be out of Washington, D.C.  (Laughter.)  First of all, the
people of D.C. are wonderful.  They’re nice people, they’re good people;
love the city, the monuments, everything.  But when you’re in
Washington, folks respond to every issue, every decision, every debate,
no matter how important it is, with the same question:  What does this
mean for the next election?  (Laughter.)  What does it mean for your
poll numbers?  Is this good for the Democrats or good for the
Republicans?  Who won the news cycle?

That’s just how Washington is.  They can’t help it.  They’re obsessed
with the sport of politics.  And so that’s the environment in which
elected officials are operating.  And you’ve seen all the pundits
pontificating and talking over each other on the cable shows, and
they’re yelling and shouting.  They can’t help themselves.  That’s what
they do.

But out here, and all across America, folks are worried about bigger
things.  They’re worried about how to make payroll. They’re worried
about how to make ends meet.  They’re worried about what the future will
hold for their families and for our country.  They’re not worrying about
the next election.  We just had an election.  (Applause.)  They’re
worried about the next paycheck, or the next tuition payment that’s due.
(Applause.) They’re thinking about retirement.

You want people in Washington to spend a little less time worrying about
our jobs, a little more time worrying about your jobs.  (Applause.)

Despite all the challenges we face — two wars, the aftermath of a
terrible recession — I want to tell everybody here today I am
absolutely confident that America will prevail; that we will shape our
destiny as past generations have done.  (Applause.)  That’s who we are.
We don’t give up.  We don’t quit.  Sometimes we take our lumps, but we
just keep on going.  That’s who we are.  But that only happens when
we’re meeting our challenges squarely and honestly.  And I have to tell
you, that’s why we are fighting so hard to deal with the health care
crisis in this country; health care costs that are growing every single
day.

I want to spend some time talking about this.  The price of health care
is one of the most punishing costs for families and for businesses and
for our government.  (Applause.)  It’s forcing people to cut back or go
without health insurance.  It forces small businesses to choose between
hiring or health care.  It’s plunging the federal government deeper and
deeper and deeper into debt.

The young people who are here, you’ve heard stories — some of you guys
still have health care while you’re in school, some of you may still be
on your parents’ plans, but some of the highest uninsurance rates are
among young people.  And it’s getting harder and harder to find a job
that’s going to provide you with health care.  And a lot of you right
now feel like you’re invincible so you don’t worry about it.
(Laughter.)  But let me tell you, when you hit 48 — (laughter) — you
start realizing, things start breaking down a little bit.  (Laughter.)

And the insurance companies continue to ration health care based on
who’s sick and who’s healthy; on who can pay and who can’t pay.  That’s
the status quo in America, and it is a status quo that is unsustainable
for this country.  We can’t have a system that works better for the
insurance companies than it does for the American people.  (Applause.)
We need to give families and businesses more control over their own
health insurance. And that’s why we need to pass health care reform –
not next year, not five years from now, not 10 years from now, but now.
(Applause.)

Now, since we took this issue on a year ago, there have been plenty
of folks in Washington who’ve said that the politics is just too hard.
They’ve warned us we may not win.  They’ve argued now is not the time
for reform.  It’s going to hurt your poll numbers.  How is it going to
affect Democrats in November?  Don’t do it now.

My question to them is:  When is the right time?  (Applause.)  If not
now, when?  If not us, who?

Think about it.  We’ve been talking about health care for nearly a
century.  I’m reading a biography of Teddy Roosevelt right now.  He was
talking about it.  Teddy Roosevelt.  We have failed to meet this
challenge during periods of prosperity and also during periods of
decline.  Some people say, well, don’t do it right now because the
economy is weak.  When the economy was strong, we didn’t do it.  We’ve
talked about it during Democratic administrations and Republican
administrations.  I got all my Republican colleagues out there saying,
well, no, no, no, we want to focus on things like cost.  You had 10
years.  What happened? What were you doing?  (Applause.)

Every year, the problem gets worse.  Every year, insurance companies
deny more people coverage because they’ve got preexisting conditions.
Every year, they drop more people’s coverage when they get sick right
when they need it most.  Every year, they raise premiums higher and
higher and higher.

Just last month, Anthem Blue Cross in California tried to jack up rates
by nearly 40 percent — 40 percent.  Anybody’s paycheck gone up 40
percent?

AUDIENCE:  Nooo –

THE PRESIDENT:  I mean, why is it that we think this is normal?  In my
home state of Illinois, rates are going up by as much as 60 percent.
You just heard Leslie, who was hit with more than a hundred percent
increase — 100 percent.  One letter from her insurance company and her
premiums doubled.  Just like that. And because so many of these markets
are so concentrated, it’s not like you can go shopping.  You’re stuck.
So you’ve got a choice:  Either no health insurance, in which case
you’re taking a chance if somebody in your family gets sick that you
will go bankrupt and lose your home and lose everything you’ve had — or
you keep on ponying up money that you can’t afford.

See, these insurance companies have made a calculation.  Listen to this.
The other day, there was a conference call that was organized by Goldman
Sachs.  You know Goldman Sachs.  You’ve been hearing about them, right?
(Laughter.)  So they organized a conference call in which an insurance
broker was telling Wall Street investors how he expected things to be
playing out over the next several years, and this broker said that
insurance companies know they will lose customers if they keep on
raising premiums, but because there’s so little competition in the
insurance industry, they’re okay with people being priced out of the
insurance market because, first of all, a lot of folks are going to be
stuck, and even if some people drop out, they’ll still make more money
by raising premiums on customers that they keep.

And they will keep on doing this for as long as they can get away with
it.  This is no secret.  They’re telling their investors this:  We are
in the money; we are going to keep on making big profits even though a
lot of folks are going to be put under hardship.

So how much higher do premiums have to rise until we do something about
it?  How many more Americans have to lose their health insurance?  How
many more businesses have to drop coverage?  All those young people out
here, after you graduate you’re going to be looking for a job.  Think
about the environment that’s going to be out there when a whole bunch of
potential employers just tell you, you know what, we just can’t afford
it.  Or, you know what, we’re going to have to take thousands of dollars
out of your paycheck because the insurance company just jacked up our
rates.

How many years — how many more years can the federal budget handle the
crushing costs of Medicare and Medicaid?  That’s the debt you’re going
to have to pay, young people.  When is the right time for health
insurance reform?

AUDIENCE:  Now!

THE PRESIDENT:  Is it a year from now or two years from now or five
years from now or 10 years from now?

AUDIENCE:  No!

THE PRESIDENT:  I think it’s right now.  And that’s why you’re here
today.  (Applause.)

Leslie is a single mom — just like my mom was a single mom — trying to
put her daughter through college.  She knows that the time for reform is
now.

Natoma Canfield — self-employed cancer survivor from Ohio  – she wrote
us a letter.  Last year her insurance company charged her over $6,000 in
premiums; paid about $900 worth of care.  Now they’ve decided to jack up
her rates 40 percent next year.  So she’s had to drop her insurance,
even though it may cost her the house that her parents built.  Natoma
knows it’s time for reform.

Laura Klitzka — this is a friend of mine, somebody I met when I
was campaigning in Wisconsin — Green Bay, Wisconsin.  She’s a young
mother; she’s got two kids.  She thought she had beaten her breast
cancer but later discovered it had spread to her bones.  She and her
husband had insurance, but their medical bills still landed them with
tens of thousands of dollars worth of debt.  And now she spends her time
worrying about that debt when all she wants to do is spend time with her
children.  I just talked to Laura this past weekend, and let me tell
you, she knows that the time for reform is right now.

So what should I tell these Americans?  That Washington is not sure how
it will play in November?  That we should walk away from this fight, or
do something — do something like some on the other side of the aisle
have suggested, well, we’ll do it incrementally; we’ll take baby steps;
we’ll do –

AUDIENCE:  No!

THE PRESIDENT:  So they want me to pretend to do something that doesn’t
really help these folks.

We have debated health care in Washington for more than a year.  Every
proposal has been put on the table.  Every argument has been made.  I
know a lot of people view this as a partisan issue, but both parties
have found areas where we agree.  What we’ve ended up with is a proposal
that’s somewhere in the middle — one that incorporates the best from
Democrats and Republicans, best ideas.

Think about it along the spectrum of how we could approach health care.
On one side of the spectrum there were those at the beginning of this
process who wanted to scrap our system of private insurance and replace
it with a government-run health care system, like they have in some
other countries.  (Applause.) Look, it works in places like Canada, but
I didn’t think it was going to be practical or realistic to do it here.

On the other side of the spectrum, there are those who believe that the
answer is just to loosen regulations on insurance companies.  This is
what we heard at the health care summit.  They said, well, you know
what, if we had fewer regulations on the insurance companies –

AUDIENCE:  Boo!

THE PRESIDENT:  – whether it’s consumer protections or basic standards
on what kind of insurance they sell, somehow market forces will make
things better.  Well, we’ve tried that.  I’m concerned that would only
give insurance companies more leeway to raise premiums and deny care.
(Applause.)

So the bottom line is I don’t believe we should give government or
insurance companies more control over health care in America.  I believe
it’s time to give you, the American people, more control over your own
health insurance.  (Applause.)

And that’s why my proposal builds on the current system where most
Americans get their health insurance from their employer.  If you like
your plan, you can keep your plan.  If you like your doctor, you can
keep your doctor.  But I can tell you, as the father of two young girls,
I don’t want a plan that interferes with the relationship between a
family and their doctor.  So we’re going to preserve that.

Essentially, my proposal would change three things about the current
health care system.  Listen up.  First, it would end the worst practices
of insurance companies.  Within the first year of signing health care
reform, thousands of uninsured Americans with preexisting conditions
would suddenly be able to purchase health insurance for the very first
time in their lives, or the first time in a long time.  (Applause.)

This year, insurance companies will be banned forever from denying
coverage to children with preexisting conditions.  (Applause.)  This
year, they will be banned from dropping your coverage when you get sick.
(Applause.)  And they will no longer be able to arbitrarily and
massively hike your premiums — just like they did to Leslie or Natoma
or millions of others Americans.  Those practices will end.  (Applause.)

If this reform becomes law, all new insurance plans will be required to
offer free preventive care to their customers starting this year — free
check-ups so that we can catch preventable illnesses on the front end.
(Applause.)  Starting this year, there will be no more lifetime or
restrictive annual limits on the amount of care that you can receive
from your insurance companies.  There’s a lot of fine print in there
that can end up costing people hundreds of thousands of dollars because
they hit a limit.

If you’re a young adult, which many of you are, you’ll be able to
stay on your parents’ insurance policy until you’re 26 years old.
(Applause.)  And there will be a new, independent appeals process for
anybody who feels they were unfairly denied a claim by their insurance
company.  So you’ll have recourse if you’re being taken advantage of.
(Applause.)  So that’s the first thing that would change and it would
change fast — insurance companies would finally be held accountable to
the American people.  That’s number one.

Number two, second thing that would change about the current system is
this:  For the first time in their lives — or oftentimes, in a very
long time — uninsured individuals and small business owners will have
the same kind of choice of private health insurance that members of
Congress get for themselves.  (Applause.)  If it’s good enough for
Congress, it should be good enough for the people paying Congress its
salary  – that’s you.  (Applause.)

Now, the idea is very simple here, and it’s one — (audience
interruption) — I’m sorry, go ahead.  (Applause.)  Let me explain how
this would work, because it’s an idea that a lot of Republicans have
embraced in the past.  What my proposal says is that if you aren’t part
of a big group, if you don’t work for a big company, you can be part of
a pool which gives you bargaining power over insurance companies.  It’s
very straightforward.  Suddenly, just like the federal employees –
there are millions of them so they can drive a harder bargain with
insurance companies — you, as an individual or a small business owner,
could be part of this pool, which would give you more negotiating power
with the insurance companies for lower rates and a better deal.
(Applause.)  Right?

Now, if you still can’t afford the insurance that’s offered — even
though it’s a better deal than you can get on your own, but you still
just can’t get it, then what we’re going to do is give you a tax credit
to do so.  And these tax credits add up to the largest middle-class tax
cut for health care in history.  (Applause.)  Because the wealthiest
among us, they can already afford to buy the best insurance there is;
the least well off are already covered through Medicaid.  It’s the
middle class that gets squeezed.  That’s who we need to help with these
tax credits.  (Applause.)  That’s what we intend to do.  (Applause.)

Now, I want to be honest.  Let’s be clear.  This will cost some money.
It’s going to cost about $100 billion per year.  Most of this comes from
the nearly $2.5 trillion a year that America already spends on health
care.  It’s just that right now a lot of that money is being wasted or
it’s being spent badly.  So with this plan, we’re going to make sure
that the dollars we spend go to making insurance more affordable and
more secure.

So I’ll give you an example.  We’re going to eliminate wasteful taxpayer
subsidies that currently go to insurance and pharmaceutical companies.
(Applause.)  They are getting billions of dollars a year from the
government, from taxpayers, when they’re making a big profit.  I’d
rather see that money going to people who need it.  (Applause.)

We’ll set a new fee on insurance companies that stand to gain as
millions of Americans are able to buy insurance.  They’re going to have
30 million new customers; there’s nothing wrong with them paying a
little bit of the freight.  And we’ll make sure that the wealthiest
Americans pay their fair share of Medicare, just like everybody else
does.  (Applause.)

So the bottom line is this:  Our proposal is paid for.  All the new
money generated in this plan goes back to small business owners and
individuals in the middle class who right now are having trouble getting
insurance.  It would lower prescription drug prices for seniors.
(Applause.)  It would help train new doctors and nurses to provide care
for American families and physicians assistants and therapists.  I know
there are — got great programs here at Arcadia.  (Applause.)  I was
hearing about the terrific programs you have at Arcadia in the health
care field.  Well, you know what, we’re going to need more health care
professionals of the sorts that are being trained here, and we want to
help you get that training.  And that’s in this bill.  (Applause.)

So I’ve mentioned two things now:  insurance reform and making sure
the people who don’t have health insurance are able to get it.

Finally, my proposal would bring down the cost of health care for
millions — families, businesses, and the federal government.
(Applause.)  As I said, you keep on hearing from critics and some of the
Republicans on these Sunday shows say, well, we want to do more about
cost.  We have now incorporated almost every single serious idea from
across the political spectrum about how to contain the rising cost of
health care — ideas that go after waste and abuse in our system,
including in programs like Medicare.  But we do this while protecting
Medicare benefits, and we extend the financial stability of the program
by nearly a decade.

Our cost-cutting measures mirror most of the proposals in the current
Senate bill, which reduces most people’s premiums and brings down our
deficit by up to $1 trillion over the next decade because we’re spending
our health care dollars more wisely.  (Applause.)  Those aren’t my
numbers.  Those aren’t my numbers –they are the savings determined by
the Congressional Budget Office, which is the nonpartisan, independent
referee of Congress for what things cost.

So that’s our proposal:  insurance reform; making sure that you can have
choices in the marketplace for health insurance, and making it
affordable for people; and reducing costs.  (Applause.)

Now, think about it.  I think — how many people would like a proposal
that holds insurance companies more accountable?  (Applause.)  How many
people would like to give Americans the same insurance choices that
members of Congress get?  (Applause.) And how many would like a proposal
that brings down costs for everyone?  (Applause.)  That’s our proposal.
And it is paid for, and it’s a proposal whose time has come.
(Applause.)

The United States Congress owes the American people a final, up or down
vote on health care.  (Applause.)  It’s time to make a decision.  The
time for talk is over.  We need to see where people stand.  And we need
all of you to help us win that vote.  So I need you to knock on doors.
Talk to your neighbors.  Pick up the phone.  When you hear an argument
by the water cooler and somebody is saying this or that about it, say,
no, no, no, no, hold on a second.  And we need you to make your voices
heard all the way in Washington, D.C.  (Applause.)

They need to hear your voices because right now the Washington echo
chamber is in full throttle.  It is as deafening as it’s ever been.  And
as we come to that final vote, that echo chamber is telling members of
Congress, wait, think about the politics — instead of thinking about
doing the right thing.

That’s what Mitch McConnell said this weekend.  His main argument was,
well, this is going to be really bad for Democrats politically.  Now,
first of all, I generally wouldn’t take advice about what’s good for
Democrats.  (Laughter.)  But setting aside that, that’s not the issue
here.  The issue here is not the politics of it.

But that’s what people — that’s what members of Congress are hearing
right now on the cable shows and in the — sort of the gossip columns in
Washington.  It’s telling Congress comprehensive reform has failed
before — remember what happened to Clinton — it may just be too
politically hard.

Yes, it’s hard.  It is hard.  That’s because health care is complicated.
Health care is a hard issue.  It’s easily misrepresented.  It’s easily
misunderstood.  So it’s hard for some members of Congress to make this
vote.  There’s no doubt about that.  But you know what else is hard?
What Leslie and her family are going through — that’s hard.
(Applause.)  The possibility that Natoma Canfield might lose her house
because she’s about to lose her health insurance — that’s hard.
(Applause.)  Laura Klitzka in Green Bay having to worry about her cancer
and her debt at the same time, trying to explain that to her kids –
that’s hard.  (Applause.)  What’s hard is what millions of families and
small businesses are going through because we allow the insurance
industry to run wild in this country.  (Applause.)

So let me remind everybody:  Those of us in public office were not sent
to Washington to do what’s easy.  We weren’t sent there because of the
big fancy title.  We weren’t sent there to  – because of a big fancy
office.  We weren’t sent there just so everybody can say how wonderful
we are.  We were sent there to do what was hard.  (Applause.)  We were
sent there to take on the tough issues.  We were sent there to solve the
big challenges.  And that’s why we’re there.  (Applause.)

And at this moment — at this moment, we are being called upon to
fulfill our duty to the citizens of this nation and to future
generations.  (Applause.)

So I’ll be honest with you.  I don’t know how passing health care will
play politically, but I do know that it’s the right thing to do.
(Applause.)  It’s right for our families.  It’s right for our
businesses.  It’s right for the United States of America.  And if you
share that belief, I want you to stand with me and fight with me.
(Applause.)  And I ask you to help us get us over the finish line these
next few weeks.  (Applause.)  The need is great.  The opportunity is
here.  Let’s seize reform.  It’s within our grasp.  (Applause.)

Thank you very much, everybody.  God bless.  (Applause.)

What is the best EHR for your practice? As usual, the answer is, “it depends.” Choosing the right Electronic Health Record (EHR) system for your practice involves answering many questions. These include:

–   Which specific EHR features and functions do we need?

–   Which EHR vendor has experience in my practice type or specialty?

–   Which vendor has the best reputation and a stable business?

–   What’s the need for access to data for reporting and research?

–   Does the EHR system have the necessary certification and functionality to qualify for “Meaningful Use” ARRA stimulus funds?

–   Should we use a Web-based or Client Server EHR technology?

While this last question may sound overly technical, how you answer it can have a profound influence on the effectiveness of, and satisfaction with, your EHR.

Web-based systems, also called Software as a Service (SaaS), are usually Internet based (think of on-line banking). You access the application through a computer in your practice or exam room, via a web browser, but the data (information about each patient) and processing power actually resides off site at the EHR vendor’s facility.  With a Client Server (C/S) system, on the other hand, the data and processing power resides on a server right in your office.

Both of these technologies have advantages and disadvantages. This article will explore the attributes of these different technologies, and why your practice might choose one over the other.  For each technology we will look at the payment model, flexibility and ease of use, data security and ownership, and connectivity and performance. In addition, we will look briefly at a hybrid model that has some of the strengths of both SaaS and C/S.

Payment Model

With SaaS, you pay a monthly subscription fee (usually per provider) for as long as you use the EHR. There are no servers to buy or on which to load software. The EHR vendor will install new software versions, new features, upgrades, fixes or patches as necessary. You are only responsible for purchasing the individual computers, printers, and scanners, for your exam rooms and offices. The start up costs for the SaaS model are lower than with C/S systems, as you will not need to purchase the software license or purchase hardware servers and backup systems.  Like a car lease, however, there is a break-even point where the monthly fee will start to cost more than outright ownership. Unlike with a car, though, you will not be trading in your EHR every three years.

With the Client Server systems, you pay for a software license (usually per provider) as soon as you install the system, and typically pay an additional 18% of the license cost as yearly maintenance to cover upgrades, patches, fixes, and customer support. You also purchase the servers that the software resides on, as well as the individual computers, printers, and scanners in the exam rooms and offices. You are responsible for maintaining the servers and individual computers, including upgrades, operating system patches (e.g., MS Windows), security patches, backups, and data security. The startup costs of C/S systems will be higher, but over time could actually be lower.

Flexibility and Ease of Use

By its nature, an EHR built on the SaaS model is less flexible because many different practices and customers are using the exact same software. There will be some individual or practice configuration choices to make, but, in general, SaaS software is not as configurable as C/S systems are. You may find that you will need to conform to the suggested workflow of the vendor, even if it’s different from the workflow of your practice. However, many practices, with straightforward needs, find the SaaS model easier to set up, train on, and adopt than with the more traditional C/S approach.

Typically, C/S systems are more flexible, allowing you to configure and customize the EHR to more precisely fit the way your practice actually works. If your practice has spent years refining specific clinical and business workflows this kind of flexibility might be important.  Of course, a high degree of configuration and customization requires additional time and effort from your clinical and administrative staff, as well as from the vendor or consultants you may have partnered with for the implementation.

Data Ownership and Security

With the SaaS model the vendor takes care of backing up and securing patient data.  Some SaaS vendors maintain redundant datacenters, meaning that they have replicated the data to multiple locations. If something happens to the hardware, software, or physical facility (i.e. natural disaster) at one location, the replicated hardware, software, and data at another location takes over so your service will not be disrupted, and you have access to all your patient data.  The down side is that you must rely on another party for the security and reliability of your data. Another concern is getting access to your patients’ data if the vendor goes out of business.  It is advisable to spell out in the vendor agreement who has ownership of your data, and how, and in what format, they must return it to you.

Many practices are reluctant to lose “control” of their patients’ data. With C/S systems, your practice has direct possession and control over that data. It is not comingled with other practices and there is less worry over the fate of the vendor.  With that peace of mind, however, comes responsibility. Because you own the server the data resides on, it is your responsibility to backup the data on a regular basis, including storing duplicate sets off site (e.g.,. on CDs or tapes). You will need to consider the physical security of the server, as well as its vulnerability to water damage (flooding, pipes bursting, etc.) and heat (proper air-conditioned environment).  You also need to schedule monthly maintenance of the server’s operating system, and often more frequent patches and updated anti-virus profiles.

Connectivity and Performance

A natural advantage of the SaaS model, for those practices that have multiple locations or where there is a need to review patient files at home, is that the EHR can be accessed anywhere there is an Internet connection and a Web browser. The drawback is that your access is only as good as your Internet connection. There are various Internet connectivity options, depending on your practice location(s), but it is essential to purchase reliable Internet connections at speeds recommended by the EHR vendor. In addition, several surveys have indicated that the performance of SaaS systems can be slower than client/server systems, often because of the lack of reliability and variability of the Internet service.

C/S systems typically have faster response times to bring up patient information and generally feel more responsive than SaaS.  You are also able to more readily make changes to fine tune performance. For those practices with multiple locations, the C/S system takes additional work. You will need to engage a telecommunications company for a dedicated high-speed data link between your locations (if you don’t already have one) or use encryption technology (to secure your patients’ data) to connect offices over your high speed Internet connection.

Hybrid Model

The hybrid model combines the flexibility, performance, and cost advantage of the C/S system and the maintenance advantage of the SaaS system. The hybrid model is essentially a C/S system, but instead of the server residing in your practice (i.e. under someone’s desk), the server is located in a secure, professionally managed datacenter. All of your server maintenance, backup, and disaster recovery needs are taken care of by the datacenter. Another advantage is that you only need to purchase the data storage and processing power you need now. As your data needs grow, the datacenter can dynamically allocate more space. Obviously, your connection to the datacenter becomes a factor, as it does with SaaS. The Hybrid model is a relatively new service for EHRs, but has been around in other industries for several years.

Conclusion

Which technology or model is right for your practice? If you need to minimize start up costs, don’t have a complex environment, don’t mind conforming to a narrow scope of workflows, and don’t have the capacity for the “care and feeding” of servers, then the SaaS model could be right for you. Like many smaller practices, you may fit into this category. Make sure you negotiate  clear ownership of the patient data, how you get access to it, and find the most reliable Internet access possible. In addition, you should add specific performance and software availability criteria in your vendor agreement, with financial penalties for violations.

If you need to configure the EHR for a more customized fit, can afford the upfront costs (to save money over the long run), and want to more closely monitor and control your patients’ data, then the C/S model could be the right choice. If you want the advantages of a C/S model but find the maintenance, back-up, security, and disaster recovery tasks daunting, than you could be a candidate for the hybrid approach. You retain the advantages of the C/S model, but outsource the IT headaches to those whose expertise is running a data center and protecting data.

As you go through the EHR selection process, the technology choice is just one of several factors you will need to consider, but understanding the trade-offs each of these systems has to offer will help ensure you make the right choice for your practice.

##

Mark Newman is a partner at EHR Associates; a consulting firm dedicated to helping physician practices adopt information technology.  He can be reached at 215.690.4133 or newmanm@ehr-associates.com

The poll taken on March 2-3 was also done last June and the results are mostly the same.  Physicians are most trusted (although seemingly least influential) to fix the health care system.  In fact, physicians were the only group to become more trusted since last June.  All other groups declined in American’s confidence.  Here’s the list according to confidence percentage:

1. Doctors, 77%
2. Hospitals, 64%
3. University professors or researchers who study health care policy, , 61%
4. Obama, 49%
5. Democratic leaders in Congress, 37%
6. Republicans leaders in Congress, 32%
7. Pharmaceutical companies, 30%
8. Health insurance companies, 26%

For more results of the survey, go to Gallup.com.

Middle-aged and older patients commonly present with neurogenic claudication, the classic nerve-related radiating leg and buttock pain caused by lumbar spinal stenosis. Imaging will typically show degenerative factors, including the narrowing of the midline sagittal spinal canal and possibly also narrowing between the facet superior articulating process, the posterior vertebral margin and nerve root canal.

The narrowing and compression of spinal stenosis is believed to cause leg, buttock and groin pain for about 1.2 million Americans. Those who experience mild or moderate symptoms typically have pain that is relieved in flexion, when they sit or walk bent forward, such as while leaning on a supermarket cart.

Some patients do well with conservative treatment of their condition. For those who do not gain relief from several months of a physical therapy regimen and/or pain medications, surgery is often the next option. Until recently, that often meant a laminectomy, or decompression, to remove the bone and soft tissue pressing on nerves and sometimes a spinal fusion procedure as well.

At Abington Memorial Hospital, we are now participating in a clinical trial of a device that offers a potential alternative to traditional spinal surgery for moderate lumbar spinal stenosis. Instead of the large incision and tissue removal of a laminectomy, we use a minimally invasive technique and one-centimeter incision to insert the Superion ™ Interspinous Spacer (ISS) from VertiFlex® Inc. The device, which is not yet approved by the FDA, is available only on study in the United States at about two dozen sites, including Abington. The Superion ISS is already in use in Europe and South America, and has been implanted in more than 950 patients worldwide.

The current clinical trial being conducted at Abington compares the safety and effectiveness of the Superion ISS to the X-STOP® Interspinous Process Distraction® Device, an FDA-approved device.  Because the study is randomized, patients do not know which device they have received until after surgery. However, regardless of which arm they are assigned to, patients participating in the trial will receive one of the two interspinous devices. They will not receive either a laminectomy or fusion.

Designed to act as a support column, the Superion ISS is implanted between the spinous processes to open the passageways through which the nerve roots travel from the lumbar spine to the legs. The small device, about the size of a quarter, gives us the potential to stabilize the affected location, relieve patients’ chronic leg pain and enable them to move without significant restriction while preserving their natural anatomy. If indicated, two devices can be implanted to support two levels.  The device is titanium-based, so it is not likely to pose limitations on post-operative studies, such as MRIs.

To be eligible for the study, patients (male or female) must be 45 years or older, with a diagnosis of moderate degenerative lumbar spinal stenosis and symptoms that have been unresponsive to conservative care for at least six months. Patients will be excluded if they have significant peripheral neuropathy, morbid obesity, osteoporosis, insulin-dependent diabetes mellitus, prior surgery of the lumbar spine, or other criteria that may be assessed upon examination. The study and devices are not appropriate for patients with severe spinal stenosis.

The study will help us determine whether patients will see a dramatic reduction in their physical limitations and greatly improve their abilities to walk or stand for long periods with a significant lessening of pain. These benefits can help restore them to more active and independent lives, which is what we hope for all of our patients.

###

Guy A. Lee, MD is Co-director, Orthopaedic Residency Program, Orthopaedic Surgery at Abington Memorial Hospital.  To refer a patient, please call Abington Memorial Hospital’s Human Motion Institute at 215-830-8700, extension 3121.

By Jeffrey C. Bauer, Ph.D.

The title of this article is intentional, as odd as it may seem.  Futures is plural on purpose, and the question about reform is not rhetorical.  The political events of the past year created a widespread and misleading impression that a (singular) new future for health care was being created in Washington.  In reality, health care in the United States is multidimensional, and it is heading in many different directions simultaneously.  Efforts to legislate a “one size fits all” solution are doomed to failure.  Consequently, physicians can look to their futures as an expanding realm of possibilities, each with its own implications for reforming a part of a complex system.

Lessons of History

Health care has changed dramatically since the modern era of American medicine began in the mid-1800s.  We have travelled an impressive distance from the days when patients had to bite the bullet (literally!) during exploratory surgery or swallow untested nostrums.  Today’s state-of-the-art health care is defined far more by research-based scientific advances than by any other factor, including political “reforms” that have done little more than shape the financial processes to pay for it.

Reimbursement has become a Rube Goldberg mechanism that must be changed because it wastes scarce resources, but it does not ultimately define the foundations of appropriate clinical practice.  If health care were suddenly redirected along the political lines most recently pursued in Washington (payment overhaul), reform would not have any impact on the exciting discoveries announced every week in medical journals.  How doctors should be treating patients is defined not by payment, but by rapid advances in knowledge about health and disease.  In particular, medical science is being revolutionized at the level of genes and molecules, creating clinical complexity that exceeds the capabilities of any single physician.

Consequently, the future is something that very few physicians can approach as sole practitioners.  The concept of a medical home is founded on the increasingly obvious fact that it takes a team to treat a patient.  In the future, physicians will need to choose which care team to join.  There will be lots of choices as reimbursement shifts from fee-for-service to bundled payment—a shift to be accelerated, ironically, by the latest failure of legislated health reform.

In addition to choosing a care delivery team in the coming years, physicians will also have the choice of being a player (direct caregiver), a coach (care coordinator), or even a general manager (chief executive) of an integrated health system (accountable care organization).  The accelerating development of new practice arrangements will also provide exciting opportunities for entrepreneurially inclined physicians.  Some of the most important advances in medical practice over the next 5 to 10 years will be developed by MDs and DOs who see the “big picture,” not patients.

Digital Transformation

The expanding realm of futures for physicians is also made possible by the medical applications of networked computers and communications technologies (generally abbreviated HIT).  Indeed, the exciting growth of medical science would not be possible without ongoing advancements in data collection, storage, and processing.  Physicians will need to embrace the digital transformation of medical practice, particularly the adoption of electronic health records, because the information required for good patient care is already exceeding the storage and processing capabilities of the human brain (and physicians are human).

Like physicians, technical experts who design electronic medical records are struggling to cope with the increasing complexities of medical science.  However, today’s problems with user-friendliness are not an excuse for staying on the paper trail tomorrow.  The real imperatives of reform, finding the least-expensive ways to deliver medical care of acceptable quality, compel development and adoption of HIT that enables state-of-the-art medicine.  Consequently, many physicians will find their futures at the interface between clinical practice and information technology—doing more good for health care by designing systems than by treating patients.

Digital transformation will provide additional proof that science and technology have more long-run influence on the future of medical practice than payment mechanisms.  Clinical care teams using integrated medical records will be able to evaluate their performance in real-time and apply the proven tools of continuous quality improvement with their own current data, correspondingly reducing the need for quality indicators and other national standards based on historical data.  Best processes will replace best practices as more health care delivery systems adopt information systems that promote consistent delivery of effective and efficient health care—doing it right all the time, as inexpensively as possible.* Ultimately, pay-for-performance will become non-payment for non-performance and create new opportunities for physicians who complement their knowledge of clinical practice with skills in information technology and decision sciences.

Diversification of Practice Locations
The transformative power of information and communications technologies is not limited to electronic medical records.  Computer scientists and mechanical engineers are developing portable devices and telemedicine tools that allow physicians to see patients in an expanding variety of locations.  Physician-patient interaction is no longer confined to the exam room in a hospital or medical office.  With telemedicine, the physician and the patient don’t even need to be in the same place, or even to be together virtually at the same time.

Physicians will have more options to practice in non-traditional settings, and patients will not always need to leave home or work to interact with caregivers who build their futures on these technologies.  In addition, more delivery organizations are providing medical services in locations that are convenient to patients, such as shopping centers and worksites (factories and office buildings).  For more than a few physicians, the future offers the option of working from home and managing the health care needs of their patients located somewhere else.

Prescription for Meaningful Reform

The latest reform efforts in Washington have been remarkably detached from these emerging foundations of medical science and clinical practice for the 21^st century.  A few elected officials and industry leaders addressed them in early stages of the political process.  However, the progressive trends in health care were forgotten as the focus of reform shifted almost exclusively to “overhauling” insurance—that is, seeking to expand the number of insured Americans without seeking to improve insurance’s impact on efficiency and effectiveness of the medical marketplace.

Because health reform is very unlikely to be legislated in the foreseeable future, physicians are still stuck with a problematic status quo.  Or are they?  Why shouldn’t physicians take full advantage of the diverse opportunities being created by science and technology?  The answer is obvious.  Physicians who can envision a more effective, efficient, and equitable health system must become actively involved in collective efforts to build it from within, not to wait for elected officials to impose it from outside.

However, physicians cannot accomplish reform alone because hospitals and health systems, private and public payers, and corporate and individual purchasers are also affected by the outcomes.  Acceptable reform can only be accomplished by multi-stakeholder partnerships—and physicians can be anything from players to “owners” on these teams.  Physicians should not be asking whether to get involved in improving American health care, but how to be involved and how to use medical science and technology to achieve desired improvements in cost, quality, and access.

An increasing number of physicians will determine that their greatest contributions to improving health care will be made as entrepreneurs and executives, not as caregivers.  (Indeed, most of the health systems identified as models for reform are led by physicians who no longer treat patients.)  Regardless of the role they choose to play, all physicians should think globally and act locally because reform, like health care itself, is ultimately local.  It will not come from Washington.  It can be led by open-minded, visionary physicians.

##

Jeff Bauer, Ph.D., a nationally recognized medical economist and health futurist, is a vice president of Affiliated Computer Services (ACS), a Xerox Company.  Visit www.jeffbauerphd.com or contact him at jeff.bauer@acs-inc.com.  His weekly blog is posted at www.thehealthydebate.blogspot.com.

According to the ACS, “men with no symptoms of prostate cancer who are in relatively good health and can expect to live at least 10 more years have the opportunity to make an informed decision with their doctor about screening after learning about the uncertainties, risks, and potential benefits associated with prostate cancer screening. These talks should start at age 50. Men with no symptoms who are not expected to live more than 10 years (because of age or poor health) should not be offered prostate cancer screening. For them, the risks likely outweigh the benefits, researchers have concluded.”

As for higher risk patients, including African-Americans and men with family history, ACS recommends beginning those “conversations” at age 40 or 45, depending on risk.  According to the ACS, “for men who choose to be screened after discussing the pros and cons with their doctor, the new guidelines make the digital rectal exam (DRE) optional and offer the option of extending the time between screening for men with low PSA levels.”  For those unable to decide, the ACS says the doctor should make the call.  Read the full report in CA: A Cancer Journal for Physicians.

In related news, The New York Times reports on a new drug designed to benefit men with advanced prostate cancer.  ”Men whose cancer has spread beyond the prostate gland are usually treated with drugs that reduce the body’s production of testosterone…. When such therapy fails, the only approved option now is the chemotherapy drug Taxotere, but that often fails as well….The new chemotherapy drug, cabazitaxel, would step in when Taxotere stops working….In the clinical trial, men who received cabazitaxel lived a median of 15.1 months, compared with 12.7 months for those who received another cancer drug, mitoxantrone, a difference that was statistically significant.”

1. “Although the proposal I released last week included a comprehensive set of initiatives to combat fraud, waste, and abuse, Senator Coburn had an interesting suggestion that we engage medical professionals to conduct random undercover investigations of health care providers that receive reimbursements from Medicare, Medicaid, and other Federal programs.
2. My proposal also included a provision from the Senate health reform bill that authorizes funding to states for demonstrations of alternatives to resolving medical malpractice disputes, including health courts. Last Thursday, we discussed the provision in the bills cosponsored by Senators Coburn and Burr and Representatives Ryan and Nunes (S. 1099) that provides a similar program of grants to states for demonstration projects. Senator Enzi offered a similar proposal in a health insurance reform bill he sponsored in the last Congress. As we discussed, my Administration is already moving forward in funding demonstration projects through the Department of Health and Human Services, and Secretary Sebelius will be awarding $23 million for these grants in the near future. However, in order to advance our shared interest in incentivizing states to explore what works in this arena, I am open to including an appropriation of $50 million in my proposal for additional grants. Currently there is only an authorization, which does not guarantee that the grants will be funded.
3. At the meeting, Senator Grassley raised a concern, shared by many Democrats, that Medicaid reimbursements to doctors are inadequate in many states, and that if Medicaid is expanded to cover more people, we should consider increasing doctor reimbursement. I’m open to exploring ways to address this issue in a fiscally responsible manner.
4. Senator Barrasso raised a suggestion that we expand Health Savings Accounts (HSAs). I know many Republicans believe that HSAs, when used in conjunction with high-deductible health plans, are a good vehicle to encourage more cost-consciousness in consumers’ use of health care services. I believe that high-deductible health plans could be offered in the exchange under my proposal, and I’m open to including language to ensure that is clear. This could help to encourage more people to take advantage of HSAs.”

The debate raging over ObamaCare has been carried on mostly by politicians, pundits, policy wonks and economists, with little input from those most intimately involved with delivery of health care—medical practitioners.  Doctors have too often been marginalized as self-interested.  If that were true, there would be far fewer practicing physicians.  Of course we are concerned with income, as are all taxpayers and businesses faced with rising costs and taxes.  Unlike other businesses, however, most doctors are unable to pass higher costs to consumers due to price controls on reimbursement.    When costs outpace income, bankruptcy ensues. This renders discussions of autonomy moot.

Autonomy, for physician and patient, is central to the medical profession and dates back to Hippocrates: “I will prescribe regimen for the good of my patients according to my ability and my judgment. I will keep them from harm and injustice.”

To be fair, physician autonomy, and the doctor-patient relationship, have been under assault for decades.   This was an inevitable result of the acceptance of third party payment by physicians, and was greatly accelerated by Medicare and Medicaid beginning in 1965, and the Health Maintenance Organization in the 1970s.

Medicare and Medicaid sought to control costs by limiting reimbursement to physicians, payment to hospitals based on diagnosis, and by limiting payment to services it deemed “medically necessary.”  Practice was and is distorted by these interventions.  For example, faced with declining payment for services, doctors increase the volume of services.   This means less time per patient, declining quality, and greater reliance on laboratory services, imaging procedures, consultants and hospitalizations.  Total costs actually rise when physician fees are cut!

Health Maintenance Organizations promised to improve quality and control costs by assigning each patient to a Primary Care Provider, or PCP.  The PCP, who could be a nurse practitioner or physician, serves as a gatekeeper, blocking access to higher level care.   They receive direct financial incentives to spend the least amount per patient.  This is the opposite of physician autonomy, with the PCP in effect working for the HMO.

Whatever its final form, ObamaCare would perpetuate these failed models.  In addition, it will include enhanced measures to control medical care.  These will be implemented under the guise of quality assurance and cost containment.  Slipped into the so called stimulus bill passed last February is a new federal health care panel that will decide which procedures and drugs are “medically necessary” and “cost effective.”  Based on the writings of Ezekiel Emmanuel, brother of Rahm and close Obama health advisor, we can assume rationing of care to the elderly (over 65!) and very young (under 2).    Also included is a mandate for adoption of electronic health records (EHR).  The clear goal here is to have access to every medical interaction; the only rationale for gathering such detailed information is to exercise control over medical decision-making.

The mechanisms are already in place.  For the past couple of decades medical specialty societies, aided and abetted by the government, the American Medical Association, and Big Pharma, have been crafting clinical practice guidelines.  These mostly opinion based recommendations will be transformed into mandates, first as “clinical performance measures,” then as “payment for performance.”   Treatment algorithms will be built into the EHR to guide decision making at the point of service.   Such a “one size fits all” approach will be an unmitigated disaster for patients.

The Senate bill states that qualified health plans may only work with doctors who “implement such mechanisms to improve health-care quality as the secretary (HHS) may by regulation require.”   In other words, doctors who refuse to turn over patient information and treat according to guidelines will be barred from participating.

The way to preserve a semblance of physician autonomy is to send this bill to the shredder.  Failing this, the medical profession must come together and refuse to sell out their patients and their profession.   We must assert our right to treat patients as individuals, to the best of our ability.