Is grief an illness to be treated with medications?

February 18th, 2012

Authors of DSM-V seem to think bereavement or grief over a loss of loved one should be "treated". 

Time author Maia Szalavitz wrote this article explaining the background . 

Professor David J. Kupfer, who chairs the DSM-5 Task Force making the revisions, is reported to have told The New York Times that making grief into a disease would allow psychiatrists to treat people who were suffering so that they would get the treatment they need for being depressed. And that’s the rub really. Is grief something that we can or should no longer tolerate? Is this existential source of suffering like any dental or back pain unwanted and unneeded?

Click here to read the complete article

I am not sure grief should be eliminated with medications. Just give the person time to heal. 

What are your thoughts?

 



				




				
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Retail Medical Clinics: An Objective Analysis




				January 31st, 2012 



				


					
 




Is there a consumer-driven market business trend offering a cost-effective and highly convenient means of receiving care for basic and routine conditions? Retail health clinics such as those found in CVS or Walmart might be the answer. The appeal of such clinics is increased access to care (generally open from 10-12 hours/day, on weekends). This set-up is ideal for busy working people and the care received complements that given by the patient’s primary care doctor. Furthermore, the total charges billed to the patient are shared up front. The patient demographics are pretty similar to those in those elsewhere, with 80 percent insured and 20 percent uninsured. Retail clinics will only treat minor problems and perform preventative care (immunizations, etc.) –the rest must be referred out.


A SWOT analysis provides a framework by looking at the advantages, disadvantages and opportunities for improvement regarding a particular business venture. As relates to retail health clinics, the SWOT results are below.


Strength:


• Reduces barriers to access to service (increased wait times in ER, doctor’s office)


• Cost transparency facilitates patient decision-making


Weakness:


• Not part of the local health care system and provider network, thereby, more difficult to track data for quality of care studies. Although this is the current state of affairs, it certainly leads to an opportunity of being part of an Accountable Care Organization going forward.


• Interrupts continuum of care established with primary care physician


Opportunities:


• Potential to improve low-income patients’ access to basic preventive and low-level acute services.


• Staffed primarily by nurse practitioners. This is important with the current shortage of primary care physicians, and even fewer physicians going into primary care, resulting in a shortage of as many as 44,000 physicians in the fields of general internal medicine and family medicine by the year 2025


Threats:


• In June 2007, the American Medical Association (AMA) asked state and federal officials for an official probe of retail health clinics. The AMA cited, among other objections, the potential conflicts of interest posed by joint ventures between store-based health clinics and pharmacy chains, since retail health clinic employees could write prescriptions to help pharmaceutical sales.


• May erode a patient’s “medical home” by fostering a dependence on the clinic rather than an ongoing relationship with one primary care physician.


Closing Comments


With health care reform, many of these clinics may not get patients since health coverage could become universal. However, on the other hand, many could be forced to enlist into high-deductible plans and so end up coming to these clinics which would make more sense (since costs are transparent to the patient).


In a healthcare system that is as complicated as the one here in the United States, there are always new ideas generated on how to optimize delivery of services. No one form of healthcare delivery is ideal but the important thing is to be adaptable to changes in the environment. Retail clinics, whether they are the new successful consumer-driven market trend or not, definitely have made their mark in American healthcare.


By Jitesh Chawla, MD


CMIO, Patagonia Health




 


				




				
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Accountable Care Organizations: How do I know it is right for me?




				January 31st, 2012 



				


					
 




As providers we are always bombarded with new regulations, government mandates and creative insurer plans or programs designed to help us increase our revenue. But with limited time and other resources, doctors and mid-levels need to quickly  and clearly understand if some new program is right for them. With that in mind, here is a summary of Accountable Care Organizations based on what we know about them from the latest CMS regulations and a pros/cons analysis to help you decide if it is something you want to participate in.


Definition:


An accountable care organization is a group of providers and suppliers of services that coordinate to provide high quality care (as defined by CMS) to a group of Medicare beneficiaries who are not in a Medicare Advantage program


    

  • Providers from individual practices, group practices or a network of ACO professionals can participate regardless of speciality
    • 

  • The financial benefit is that providers can get the savings from care provision in an ACO program  as extra revenue
    • 

  • The risk is that providers may share in the loss of money from care provision in an ACO program
    • 



The requirements to participate are:


    

  • File application with CMS,
    • 



    

  • Form a legal entity that is linked through bank accounts with CMS,
    • 



    

  • Have at least 5,000 Medicare beneficiaries over 3 years in panel,
    • 



    

  • From governing body with at least 75% of individuals participating in ACO.
    • 



    

  • Have a Board certified physician as medical director, CMS liason on ACO leadership
    
			committee
    • 



    

  • Have quality improvement program and abiility to identify high-risk individuals in place
    • 



Approval is a for a 3-year period at stretch


 


What quality measures are tracked:


    

  • Patient-care giver experience
    • 



    

  • Care coordination
    • 



    

  • Patient safety
    • 



    

  • Preventative health
    • 

  • At risk population/frail or elderly
    • 



These measures are tracked by comparing to benchmark data sent by CMS and scores 1-5 are assigned to each.


If the performance is better than the benchmark then savings occurs, if not then loss.


 


Example:


Practice XYZ  has teamed up with Practice A, B and C to form an ACO. Each individual practice only has 1-2 physicians. The ACO scores 2,3,3,4,5 in the quality measures listed above in year 1. CMS determines that it is above benchmark and decides to pay $500,000 of savings from quality care to the practice. In year 2, the scores change and the expected performance (shown by the benchmark) result in loss of 400,000 and also in year 3 the loss is 250,000. The data for the performance in each of the 5 areas is supplied through the electronic medical record. Each year the gain or loss is split up within the group forming the ACO.


Pros- ACOs:


 


Can result in extra revenue through cost savings




Help organizations establish valuable care processes (ie. quality improve program, tracking certain data, better of electronic medical record functions)


Results in better coordination of care for the patient


Cons-ACOs:


Time-consuming to set up an ACO and run it


Could be costly from setting up the ACO, loss from performance below benchmarks


Too many unknowns -not sure what new rules CMS will require in years to come


 


The ideal ACO participants: Practices that have several providers and staff, have a QI program, use the EMR to track outcomes and have a large Medicare population.


 


Quotes about ACOs from different experts in the field:


"But if ACOs models are to work, they’ll eventually have to embrace smaller practices, which make up the vast majority of U.S. medical groups overall. And if those groups are either EMR-less or just getting started, it’s going to be pretty tough to share value-based payments, coordinate across episodes of care and track quality jointly" -Kathryn Rourke (EMR and EHR)


 


"But here’s the  problem with ACOs: They are a tool in a big tool box of care and cost  management tools but, like all of the other tools over the years like  HMOs and IPAs, they won’t be used as they were intended because  everybody—providers and insurers—can make more money in the existing so  far limitless fee-for-service system." - ROBERT LASZEWSKI (The Healthcare Blog)


Conclusion:


Accountable care organizations represent, yet, another paridigm to deliver high-quy ality care. The summary about ACOs presented here is very cursory with specific details that are available on the CMS website . I hope the information presented here will give you, as provider, a feel for wether the ACO program is something that you qualify for and want to participate in. My opinion is that ACOs are not a good return of investment for small practices with 1-3 providers or any practice


 



What do you think? Are ACOs something you want to or would be a part of? We would love to hear your thoughts?


By Dr. Jitesh Chawla


 




 


				




				
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Who accessed your health records?




				January 31st, 2012 



				


					
 




MSNBC.com carries this provocative headline: "Is someone snooping on your health records? New Rule will tell you who".




"The update to federal health care privacy laws proposed on Tuesday by the Department of Health and Human Services would give patients the right to see the name of any person who accessed their electronic health records, and what he or she did with them. The so-called "access report" would be available from some health care providers as soon as Jan. 1, 2013.  It would function much like a free credit report — consumers would have the right to ask for one such report for free every year."




This means, tracking all the people in the system who view or edit your records. In a typical hospital setting, up to 100 people may touch a patient record. There may be unauthorized people accessing patient records. For example, a doctor who is not involved in a patient's care views that patient's record. That is illegal. In paper world, that is almost impossible to track, without some serious lock and key with lots of administrators.


In electronic world, it is simple. Databases have done that for a long time. It is simple and straightforward for database to make an entry in an access log table whenever a user reads any thing. Run this is as a report and you have this "snooping" list.


ARRA Meaningful Use stipulates this as one of the requirement for Stage 1. That means EHRs and hospitals must do this by end of 2012. I don't see how doctors or hospitals can meeting MU requirements and not have the ability to generate a report of this kind. I don't see a significant additional burden to add these safeguard measures.


I guess the only thing Government added to the requirement was ability to print this report for the patient. Otherwise this report is misleading and confusing at the best. It is probably trying to scare some patients. I think the popular media can do a better job of educating both the b


What are your thoughts?




 


				




				
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Patient Centered Medical Home: What is it and should I pursue it?




				January 31st, 2012 



				


					
 




The patient centered medical home certification allows practice to receive extra money for demonstrating patient-centric, efficient, care-processes. National Center of Quality Assurance gives this certification.

		Who can qualify: Any practice

		How do you start? : File an application under the appropriate agency you choose. (link for NCQA PCMH 2011 Application) (link for Join

		How much does it cost? : $80 application fee per site and $250 per provider per month

		As seen by the graphic below there are certain areas of care that are measured by PCMH.


Pros – PCMH:

		•Helps improve the practice’s quality improvement program or establish good quality practices

		•Improves access and coordination in the patient care provided

		•May lead to higher payment from insurers


Cons-PCMH:

		•Upfront costs to qualify for certification

		•Takes time and resources to collect and report data

		•May lead to decreased morale from assessment of current practice patterns


Cross walk with MU:

		Finally, there are certain types of information that needs to be shared and certain types of data that needs to be captured for PCMH, which is overlapping with that from meaningful use.

		1. Electronic copy of health information within 3days to more than 50%of patients who request it*

		2. Electronic access to current health information within 4days to at least 10%of patients**

		3. Clinical summaries provided for more than 50%of office visits within 3days*

		4. More than 50% of demographic data such as date of birth, gender, race, ethnicity

		Therefore, those of you who are trying to get patient-centered medical home certified might benefit for participating in the EHR incentive program for meaningful use.


Conclusion:

		PCMH certification can take a certain amount of time and expense depending on your practice size and how well care processes are set up already. The decision to pursue this depends your organization’s goals. I feel this will be a difficult endeavor for small practices. If you decide to do PCMH certification then aiming for meaningful use should be done as you can leverage the same resources for both programs. The EMR would be the common tool that would help you achieve both. The EMR will help you collect and report the data needed for PCMH certification.


By Dr. Jitesh Chawla




 


				




				
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Medication Adherence Score – Increasing premiums?




				January 31st, 2012 



				


					
 




According this NYTimes blog, FICO, the credit rating agency, will now keep track of patient medication adherence score.


The premise is great, improve patient's compliance with taking medications on time. This improves outcomes and reduces costs on the overburdened health system.


According to FICO,




While other methodologies identify lapses in patient medication adherence only after the fact, the Medication Adherence Score is a predictive model that allows you to identify and proactively address adherence problems before they occur




While well intentioned, not sure what this means to the patient.


FICO is supposedly going to use publicly available data like home ownership, marital status, employment etc. to determine adherence to prescriptions. How will the insurance companies use this data? Will this cause premiums for the patients to go up? Will Insurance companies use this data to help patients who are less likely to comply with the prescriptions?


What is the recourse if the score is incorrect? What is the impact of identity theft?


What is next? Will EHRs share data with FICO to come up more accurate scores? Scary thoughts.


What do you think?




 


				




				
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USA Monitoring Doctor Bias Towards Medicare/Medicaid?




				January 31st, 2012 



				


					
 




According to New York Times, another well intentioned plan from our Government. Mystery shoppers will call Doctor's offices to schedule appointments for supposed illnesses.




The administration says the survey will address a “critical public policy problem”: the increasing shortage of primary care doctors, including specialists in internal medicine and family practice.




Who would have a problem with this? Additional purpose of the survey




It will also try to discover whether doctors are accepting patients with private insurance while turning away those in government health programs that pay lower reimbursement rates.




…




According to government documents obtained from Obama administration officials, the mystery shoppers will call medical practices and ask if doctors are accepting new patients and, if so, how long the wait would be. The government is eager to know whether doctors give different answers to callers depending on whether they have public insurance, like Medicaid, or private insurance, like Blue Cross and Blue Shield.




This should cause alarms across all physician practices. Seriously? Aren't we in a free market economy? Don't the doctors have some degree of freedom in deciding who they serve and how?


Except for emergencies, physicians should be allowed to make certain choices.


As a patient, if I don't bring in enough revenue to the practice, as a business person, isn't the doctor correct in putting me on a lower priority? Schedule me when the slots are free, when the practice is not as busy.


As compared to a patient who will pay the full bill. That patient may be scheduled on a priority basis.


The doctors also have bills to pay, pay off the student loans.


What do you all think?


 




 


				




				
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Health insurance law changes and how could it affect your practice




				January 31st, 2012 



				


					
 




Introduction


Medical insurance coverage is directly related to the amount of billing activity done by a practice. The better the coverage the more likely patients come and the more you can bill. At Patagonia Health, we strive to provide our EMR clients with strong billing support through our partnerships with respected billing companies and practice management vendors. There have been many changes to the insurance law in the last year and several regulations are set to be in effect in the years to come. Some of these are on off-shoot of the Affordable Care Act signed into law by President Obama. In this article, I will describe some of these changes and how it may affect your practice.


Examples of insurance law changes due to healthcare reform


For those who already have health insurance:


•Insurers will not be allowed to take away your coverage if you get sick-effective 2010


•Insurers will not be allowed to limit how much they will pay for medical benefits over your lifetime – effective 2010


•Policies will now have to pay for tests to detect chronic diseases (ie. cancer) at earlier stages but not require any deductibles, co-pays or co-insurances -effective 2010


•Insurers will not be allowed to limit how much they will pay for medical benefits during a year-effective 2014

		For those who can’t afford insurance or have trouble finding coverage for 1 or more persons:


•Your children may be on your policy or be added to your family policy until they turn 26-effective Sept 2010


•Temporary coverage to those with pre-existing conditions till health insurance exchanges are set up (in 2014)- effective Sept 2010


•Insurers can no longer charge you excessively more because of past medical history age or sex. But, they can charge up to 50% more if you smoke –effective 2014


•The HIEs will be set-up for those who can’t get insurance through work or lost their job. -effective 2014. (Those who qualify for one and don’t sign up will be penalized)


What does this mean to you?


If you are a small practice, particularly in primary care, these changes may provide you increased financial viability as more people likely will seek medical care. Small practices often don’t get as much reimbursement as a larger practice for the level of work and need to make the make up the different by seeing more patients. Also, if you serve an area with a lot of uninsured patients, then you may be able to accept them soon, as nearly everyone will have health insurance by 2014. Oftentimes, patients may hesitate to seek medical care because of all the limitations on what is covered as dictated by their insurance policy. But, with changes such as no limits of benefits over a lifetime or year, coverage of illnesses excluded by pre-existing condition clauses, etc. more patients will be able to get their treatment paid for.


Conclusion


It is  that apparent that there are major changes to insurance coverage as result of healthcare reform. Also, it is likely there could be many more in the years to come. Those having insurance and not having insurance are the 2 categories used as examples. But, the insurance law changes also affect people on Medicare exclusively, in long term care and small business owners. As patient volume increases, logically it becomes more and more important to have a very efficient, structured billing process in place.


What do you think about this topic? Do you think these changes will affect you? We would love to hear from you.


By Dr. Jitesh Chawla




 


				




				
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Web-based quality dashboards and the potential impact on your practice




				January 31st, 2012 



				


					
 





		Background on Dashboards


Quality dashboards provide organizations a snapshot of how they are doing on certain performance measures. The information then can be used by the organization to make improvements in care and sustain best practices. But, many dashboards don’t result in change of provider behavior. Some reasons may be: data presented is retrospective; it provides information only about the organization but not individual providers; and providers don’t see head to head comparisons with their peers. Currently, most quality dashboards are not available in a web-based format integrated within the electronic medical record (EMR), and therefore, do not leverage the technological advantages of using such a system. EMRs can be essential tools in applying quality improvement techniques in the practice of medicine.


 


Advantages of the web-based system


A web-based format addresses all these concerns by increasing the accessibility, portability and collaborative data gathering or reporting potential of a quality dashboard. Some important points to note include:


•Once the data leaves the reporting server (a computer that serves data to other computers) , it is posted directly onto the internet and accessible through a web portal. Therefore, the dashboard is available at home on a PC, on PDAs, smart phones or any mobile device that supports a browser.


•As long as the reporting server is functional, the crashing of a particular workstation won’t hinder access to the dashboard.


•The dashboard reports will be available in real time, allowing providers to make changes in care based on the feedback.


• Reports, drilled-down from other reports within the dashboard (ie. list of patient names with A1c <9% from number of patients with A1c <9%) could be generated on web pages opening up in different windows.


Additionally, if the dashboard was able to be pulled up within the electronic medical record being used, providers can see patient chart data along with dashboard results in order understand how treatment decisions affected dashboard results.



		How is this advantageous to practicing clinicians or their office administrators?


•A web based quality dashboard offering advanced data displaying and reporting capabilities, would enable clinicians to make better decisions at the point of care.


•Also, administrators could be better equipped to work on their care processes by tracking these measures as drill-down reports from outcomes measures.


This could result in


•Better quality of care leads to higher reimbursement, easier achievement of certifications from entities such as JCAHO, NCQA and greater patient satisfaction


•Increased reimbursement from meaningful use incentive money which requires six quality measures to be reported; NCQA which has a diabetes and patient centered medical home program and PQRI (physician’s quality reporting initiative), in which providers get reimbursed for reporting clinical information about their Medicare patient care panel.


•The formulation of a strong quality improvement program/process in your practice.


•Higher quality care and better patient satisfaction which will improve your practice’s reputation in the community


•Perhaps, most importantly, decreased errors which are financially and reputation wise very costly.


A link to a good dashboard as described in this article is found at http://projectpophealth.org/index.html.


What do you think? Would you use such a dashboard? We would love to hear your thoughts.


By: Dr Jitesh Chawla


 




 


				




				
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Firing Patients Who Refuse Vaccinations




				January 31st, 2012 



				


					
 




Interesting article in Time about vaccine-concerned parents. There are number of parents who refuse to vaccinate their kids for philosophical or religious or other reasons.


As a parent of a 5-year old, I think there are obvious problems with this. Regardless of the reasoning, un-vaccinated kids in the school pose a risk. They may be carriers of somewhat scary diseases and spread it among friends.


For the physician, there are ethical and practical concerns. Without the vaccinations, physicians may determine they cannot provide the best outcomes for the child. Practically, handling such a patient may also pose risks to the physician and the staff.


What do you think? As a physician would you fire a patient whose parents refuse vaccination?


As a patient, what would you think if your physician fired you for this reason?


 




 


				




				
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