Tuesday, December 02, 2008


As we wait, if and when health care reform is a reality (or what it would look like), I can't help but notice the external forces that are affecting the landscape for solo practitioners like me, currently, and in the future as the wheels keep turning and time is ticking. Below are some examples that highlight some of what I'm worried about.

1. CCHIT, also known as Certification Commission for Healthcare Information Technology (who comes up with these acronyms, I don't know...but as you'll see later, it's quite fitting for what kind of mess this is). It was a great idea on paper...to have an agency that sets standards for electronic medical records with the aim for interoperability and allow secure exchange of medical information. However, as it quickly evolved, it has become a sore spot for me as the $COST$ of being certified as a CCHIT product no longer becomes reasonable, especially for us smaller doctors that don't that have much overhead to negotiate without affecting our day to day operations. What bothers me is...why do they (CCHIT) have to be some agency that requires that an EMR company to pay them a substantial amount (I believe it's around $30,000 for the initial 3-year cert and then $5000 every year in the 2nd and 3rd years to cover licensing fees). That's a HUGE burden and that cost gets passed down to the physicians/hospitals/etc who are purchasing these products! As someone who also dabbles with computer software/programming (I'm actually a supporter of open-source projects), I see "standards" as a set of guidelines that in order for other systems to work or connect or to meet a minimum level of acceptability for user-friendliness...a good example is the W3C (World Wide Web Consortium) that determines the standards for HTML code for website that get translated by Web browsers like Mozilla Firefox...there's NO huge cost layout to make these standards established and for other computer software companies to comply if they want to be competitive. This is yet another example of how the cost of *anything* that is related to health care is so absurdidly high for no real, substantiative reason other than the profit motive. I mean, to get a "medical" stool costs 5 times as much from a medical vendor than it is to get from Costco (just a different color). What's the reason for that?! (and I hope it's not that the dyes for vinyl covering for the medical stools comes from some special factory that uses gold screws).

Anyways, pretty soon, Medicare has plans to make sure that doctors are using these certified EMRs and electronic prescribing. That too, on paper, sounds like a good idea...it would be great if health care finally uses electronic methods to input, store, and analyze data...like the banking system has been doing for, what, 40 something-odd years? But who's gonna pay for this? Why pay for some "standards" that have no benefit for me when I pay the EMR company who has to shell out this money to this agency to create the standards? Does it help me in any way?

I'd rather pay an EMR company to create a excellent product on its own merits and not have to up their price just to be certified. Oh, by the way, I do have that right now. I use Amazing Charts...but the bad news is that they held out for so long not having to be pressured to be certified. However, with the inevitablity of Medicare mandates, they have now made the decision to become certified, and (guess what?), the cost of their EMR is now 10 times more than when I purchased it including the annual fees for updates. YIKES! So I'm actually trying to shore up a way to create some HTML/PHP templates for OpenEMR...that's what I do in my spare time these days...at least the EMR is free.

I don't really know what I would offer as a solution; I think there's definitely a developed culture of "If it's medically-related, it's gotta be expensive. Let's offer a product to doctors and because they have lots of money, we can up our charge for the same product that we sell to others, but let's don't tell them that." Yeah, well I'm rowing up CCHIT creek because I'm not one of those well-paid doctors.

2. Vaccinations - a nightmare of epic proportions for me. Let's say you're a clothing store and you order your merchandise from the manufacturer for $10 an item. As a store, you need to increase the charge cover the cost of your operations, so you bring the total to $20 and that's the asking price to the customer.

OK, so now let's say that instead of the customer paying for $20 item, he/she uses their grandmother to pay for the item and the grandmother says, "I'm not going to pay for this item for $20, I'll pay you $5". What would the store do at this point? The store would say, "I'm sorry, that's how much we charge".

OK, so now let's say the vaccine manufacturer is our manufactuer in this example. The store is the doctor's office, the customer is the patient, and the grandmother is the insurance company (I mean no insult to grandmothers). Right now, the store would say, "OK...I'll give you the item, you pay me $5 dollars, and that's that."

I don't know how medical doctors and offices got into this (I think I know, we're probably too nice or maybe back in the day, we didn't read the fine print) but no self-respecting business person would even consider this a fair deal. It's a raw deal.

So you've got these mandates (again). I'm generally a believer in vaccines (but there are some caviats to some of the more recent ones, but I'll discuss that later) and there's a huge public health benefit for vaccinations. It sounds good on paper but the devil is in the details. The system is rigged so that in the end, doctors are losing money to give them. This is highly magnified in a smaller practice, hence the argument that to absorb the loss, you have to be in a bigger group. But why does it have to come to this? All that I ask is that the cost burden be fair, starting from whether the cost of the vaccine is justified, to making sure the insurance companies are actually paying the cost of the vaccine if the manufacturer is asking for that cost so that us doctors aren't left with the bill.

There are victims I see amongst some of my colleagues, too numerous to count, that have been so frustrated with this system and dealing with programs (Vaccine for Children's programs for the uninsured or on Medicaid) that try to aid because it's so unfair. We're literally at the mercy of money-hungry entities that believe you're well off and can be bought off and sold off; but there are no alternatives; no regulations.

3. A very well-written blog about the concept of "overtreatment." I second all the statements!

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