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D4PC responds to Aetna CEO Declaring Obamacare is in a Death Spiral

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“Aetna CEO Mark Bertolini made headlines by declaring that Obamacare is in a death spiral. It is difficult to understand how this is a news worthy comment. The Obamacare death spiral began 2 years ago when state-operated healthcare exchanges began shutting down. It got worse last year when insurers began pulling out of many states, leaving some with a single insurer under Obamacare. Instead of reporting the obvious, the media should ask how Mr. Bertolini earned $27.9 million in 2015 in total compensation if Aetna was doing so badly as a result of Obamacare, or how his company posted $2.3 billion in earnings on $63 billion in revenues.” Hal Scherz MD, Founder- Docs 4 Patient Care.

This was posted in response to Aetna CEO Mark Bertolini recent comments in the Washington Post.

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A Virtual Debate

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 From CNN to Contentious Nominee Hearings

Michael Koriwchak, MD

The past weeks have seen a contentious health care debate on CNN and an interrogation style HHS nomination process.

Dr. Michael Koriwchak is hosting a special virtual debate and virtual nomination process this week by engaging the tough questions from a doctor’s perspective on the front lines of medicine.

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Reflections on the CNN Healthcare Debate

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The CNN healthcare debate between Senators Ted Cruz & Bernie Sanders on February 7 was dubbed a success by the network, ranking first in its cable time slot. With healthcare once again thrust into the headlines, and with two big personalities squaring off, this was certainly the marquee event, as was advertised. It turned out to be what one would have expected; a clash of ideologies, but a deeper look into what was said, and specifically what wasn’t, turned out to be most revealing.

Senator Sanders’ positions contained very little substance as he clung to his talking points which reflected his belief that healthcare was a right and that the government needed to provide it for everyone. Senator Cruz countered with several lines of attack, first giving an explanation regarding his interpretation of the definition of rights, maintaining that government giving something to individuals, in this case healthcare, did not constitute a right. He asked “why would we want to give the government MORE control over Americans’ healthcare, when they have done such a miserable job managing things up to this point?” Cruz concluded with the point that individuals are better at making healthcare decisions for themselves than the government. When the government does so, as in socialized countries, it leads to rationing- the government deciding what kind of care a patient may receive.

It was interesting that both men agreed that a big part of the problem stemmed from greed and excessive influence of special interests. Insurance and pharmaceutical companies were specifically singled out. Where they differed was their approach to solving this problem, retreating to their respective corners of the ring, with government control on one side versus a free market solution on the other.

The Senators missed the biggest problem in healthcare however, which is not surprising because everyone else has as well – the high cost of care. The healthcare reform debate has focused exclusively on insurance coverage and access. What plan will the GOP create to replace Obamacare? Although a market-based approach to healthcare insurance as is being offered by the GOP will result in substantial savings, the current cost of healthcare is unnecessarily high and will continue to be a strain on the American economy. There is a way out of this, but it does not appear to be on anyone’s radar.

The third major special interest, which went unmentioned in this debate is the hospital industry. Obamacare accelerated a trend which was to drive healthcare into the hospitals- the costliest place of delivery. It is folly to believe that taking an approach which focuses only on making insurance more affordable without doing something about the high costs of the healthcare itself, will have a significant impact on overall costs. Why should services be 5-10 times as expensive in the hospital as they would in free standing facilities? It defies logic.

There are many other factors that contribute to the high cost of healthcare that also need to be addressed. The third party payer system hides the true cost of healthcare, which really is not expensive when all of the overhead created by government and insurance bureaucracy is removed. Medical malpractice and frivolous lawsuits has created an adversarial relationship between doctors and patients giving rise to the practice of defensive medicine- performing an extra test or procedure, “just in case something rare could have been missed.” This practice results in annual costs between $200- $600 billion of mostly unnecessary spending that could be returned to patients.

The other major disappointment with this debate were the questions from the audience. CNN undoubtedly had an agenda in the selection of the questions and those chosen to ask them. It appeared that they wished to showcase typical “victims” – the ones who would lose their coverage if Obamacare is repealed. While this is understandably a concern for millions, and people are nervous, it might have been more illuminating to hear questions about other problems that are damaging our healthcare system and how Washington plans to deal with these issues. CNN squandered an opportunity to bring a doctor into the debate; one who was sitting in the first row and happens to be an expert in healthcare information technology and its problems. He was prepared with an important and insightful question but CNN thought otherwise.

In this latest round of the healthcare fight in America, a prudent person would realize that the so-called “experts” on healthcare- the policy wonks, the politicians, the healthcare economists, didn’t do so well the last time. To go back to what Senator Cruz said in this debate- why would we want to give them another chance at it? It is time to hear from the real experts in healthcare; those who have had to deal with the misery created by these “faux experts.” It is astounding how once again, the medical community has been excluded from this debate. CNN had a chance to begin to change the conversation by bringing a doctor into the discussion, but chose not to. They simply blew it.

This was originally posted on Townhall.com.

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Doctors Disappointed at Debate

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A fitting metaphor from a Doc who was there

m-koriwchakThanks to some undeserved serendipity I had the good fortune of being invited to last week’s live broadcast town hall debate on CNN between Senator Bernie Sanders and Senator Ted Cruz regarding the future of Obamacare. I was offered the opportunity to appear in person to ask a question to the congressmen and spent many hours in communication with CNN producers to formulate a question acceptable to them.  Sadly the event ended in disappointment.  As the congressmen got long-winded and Senator Cruz had already spontaneously addressed the topic of my question, time ran out with my question unasked.  I have no ill feelings towards CNN over this.  Such is the nature of live events. 

Yet such an outcome is a fitting metaphor regarding the main problem with the narrative on health care reform.  My wife Amy said it first:  “This debate was no different from the ones we heard almost 10 years ago when Obamacare was first offered.”  She is absolutely right.  For decades we have heard – from both sides of the aisle – the same tired arguments from people who have never touched a patient and have no understanding of how health care should work.  There was nothing new offered Tuesday night.  On the Democratic side we heard that because health care is a right the government should provide “Medicare for all.”  On the Republican side we heard there is no way to finance such a big plan and that the government needs to get out of health care.  Familiar scapegoats – pharmaceutical companies and insurers – were dragged out with torches and pitchforks.  Both sides fight the war from the same trenches that were dug ages ago.  On Tuesday night no new hearts and minds were won for either side.

It is also fitting that the one opportunity to bring new life to the discussion – to bring physicians into the conversation – was turned away.  The one group who lives and breathes health care every day was ignored – as it has been for decades.  To be fair, some of the blame lies with us physicians – in the past we have as a general rule been averse to carrying our Hippocratic Oath beyond the clinic and the operating room.  But over the last several years that has changed.

Tuesday night’s debate may not have been the right time to engage.  We did not have as much time to prepare as we would have liked, and the exact rules of engagement were not clear.  But even with such apparent misfires we gain knowledge and wisdom.

The right moment to engage will come.  And we will be ready.

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A Plan to Repeal and Replace Obamacare

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Obamacare is a proven policy failure. Congress and the Trump Administration must completely repeal the law, beginning by seizing the opportunity to accomplish as much of repeal as possible through the reconciliation process. Congress must focus on the fundamentals: equalizing the tax treatment of health insurance; restoring commonsense regulation of health insurance; and addressing the serious need for reform in Medicare and Medicaid by adopting policies that give individuals control over their health care. High quality health care means all Americans should be free to choose a health care plan that meets their needs and reflects their values. Congress must act now to repeal Obamacare and replace it with a new set of options that empower Americans, not government.

Read the full report at Heritage.org.

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The Doctor’s Computer Will See You Now

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By Sally C. Pipes and Michael Koriwchak

If you have visited the doctor recently, you probably noticed a new instrument in the examination room. It is a computer running an electronic medical records system, or EMR, that has been lauded by federal agencies as bringing a revolution to health care. But to patients, the computer has proven to be a nuisance rather than a blessing. It is hard to get quality health care when a patient must compete with the computer for his or her doctor’s attention.

Rest assured, most doctors do not like the computer coming between them and their patient either. Multiple studies demonstrate that roughly two-thirds of physicians are dissatisfied with their EMRs and do not think that they improve quality of care.1, 2, 3, 4

For physicians, the computer has become the instrument of obedience to a senseless body of regulations that directs not only the technology itself but also its use as a vehicle to “improve quality of care.” If your doctor pays attention to you instead of entering data, he or she will be penalized by Medicare regulations that reduce physicians to data-entry clerks.

The use of information technology as a Trojan horse for government-driven health care began with a part of the 2009 federal Stimulus Bill called Meaningful Use, or MU. Through a system of incentives and penalties, the architects of MU masterminded a major digital revolution of our health care infrastructure within five short years.

The developers of this system also force-fed physicians the unproven practice of using information technology to improve quality. Despite the mandated implementation of EMRs under MU, they have failed to deliver on any of the promises made in 2009, including a higher quality of care.5 By the end of the five-year program, doctors’ support for MU was waning.

MU would have disappeared quietly had it not been for a unique set of circumstances and timing related to Medicare, the federal healthcare program for seniors. The formula used to calculate Medicare payments to physicians — called SGR, or the Sustainable Growth Rate — had for several years dictated payment cuts of 20-30 percent.

Every year from 2003 to 2014, Congress had to act under duress to override SGR and pass a temporary “fix.” When Members of Congress became desperate for a permanent solution, the architects of MU seized an opportunity to re-brand their unpopular program by offering the repeal of SGR as part of a bill called MACRA — the Medicare Access and CHIP Reauthorization Act of 2015.

The MU program found a safe haven within MACRA. Its proponents even changed its name to camouflage it. Congress passed MACRA in April 2015, mere hours before another SGR-mandated payment cut was to go into effect.

The implications were not clear until the Centers for Medicare and Medicaid Services issued the MACRA regulations the following year. The centerpiece of the rule is a draconian compliance scoring system that pits small medical practices against large healthcare institutions to compete for a place on the upper half of the MACRA compliance bell curve. Physicians on the lower half of the bell curve who do not meet the requirements must pay penalties to cover the incentives paid to physicians in the upper half who meet more of the requirements.

CMS’s own data predicts that 87 percent of solo practices and 70 percent of practices with 2-10 physicians will receive penalties under MACRA.6

Physicians in independent practices cannot compete, so they are being driven to become employees of large hospitals. It is inevitable that costs will increase as these large institutions gain market share. Quality will suffer as care is depersonalized and unproven “value based reporting” consumes resources formerly directed towards patients.

Physician burnout will continue to increase as doctors must spend more evenings and weekend time on data entry.7,8 And the information technology itself, designed first and foremost to comply with MU certification requirements, will remain useless relative to the needs of individual patients and the doctors who care for them.

The irony is that quality of care was not the original problem. The healthcare reform narrative that began in 2008 was based on legitimate issues regarding cost and access. But the architects soon realized that their agenda would be better served by pivoting the discussion to quality and value.

Cost and access are easy to measure; the latter two are not because they lack well-established definitions. It is impossible within a quality/value paradigm to measure the performance of any program and judge its merits.

The cost of quality reporting alone has been estimated at $15.4 billion per year, according to a March 2016 study published in Health Affairs.9 The total cost of MACRA will significantly exceed that figure.

Reporting quality data to CMS has never been shown to improve outcomes. At a time when cost and access are the real problems facing our healthcare system, our limited resources would be more wisely directed to cost and access problems.

Is there a politician or a bureaucrat that has the chutzpah to face several million Americans and tell them we can’t afford their health care because of our devotion to a program whose benefits are completely unproven?

It is time to make participation in MACRA voluntary. Dropping the penalties and preserving the incentives will allow MACRA devotees to continue their work while unshackling other doctors from unproven quality measures and EMR mandates. Every physician, MACRA supporter or not, will be free to pursue his or her own vision of health information technology — the one that is best for patients.

Understanding exactly how MACRA was passed makes clear that it did not and does not enjoy “bipartisan” support and protection. A new administration should have the incentive to promote and introduce legislation that would make effective changes.

Sally C. Pipes is President, CEO, and Thomas W. Smith Fellow in Health Care Policy at the Pacific Research Institute. Dr. Michael Koriwchak is an ENT physician in Atlanta, co-host of “The Doctors Lounge” radio show, and Vice President of the Docs4PatientCare Foundation.

 

1Medical Economics and MPI Group. EHR Survey 2013.  

2Medical Economics. 2016 EHR Report.

3Deloitte Center for Health Solutions. 2016 Survey of U.S. Physicians.

4American EHR Partners and the American Medical Association. Physician Use of EHR Systems 2014.

5Kellermann, AL and Jones, SS. What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology. Health Affairs 32(1) 2013: pp 63-68

6Proposed Rule, The Medicare Access and CHIPS Reauthorization Act of 2015, Table 64, April 2016

7Shanafelt, TD; Dyrbre, LN et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment with Physician Burnout and Professional Satisfaction. Mayo Clinic Proceedings 2016; 91(7) 836-848.

8Shanafelt, TD; Hasan, O et al. Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General U.S. Working Population Between 2011 and 2014. Mayo Clinic Proceedings 2015; 90(12): 1600-1613.

9Casalino, LP; Gans, D et al. U.S. Physician Practices Spend more than $15.4 Billion Annually to Report Quality Measures. Health Affairs 35(3), March 2016.

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Doctors Disappointed After CNN Cruz / Sander Debate

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The Health Care Debate is Over and the One Group Ignored – Doctors #Disappointed

Dr. Mike Koriwchak was ready in the front row to engage with a question he was never able to ask:

“I’m Dr. Mike Koriwchak, an ear, nose and throat surgeon from Atlanta.

One of the biggest frustrations physicians face is the paperwork and regulatory burden associated with patient care.  The situation has become so dire that for every hour we spend face-to-face with patients, we must spend 2 hours on paperwork and compliance with regulations  In a world where cost and access are the biggest shortcomings we face in health care, this creates unacceptable levels of inefficiency.

So, Senator Sanders, my question is:  How do we reduce the regulatory and paperwork burden so my colleagues and I can be doctors again?”

The people serving on the front lines of American medicine had no voice in tonight’s debate as answers went long and time drew short.  A doctor’s perspective is key because health care truly begins when the physician begins the exam – not when politicians pick a policy.

 

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ELECTRONIC MEDICAL RECORDS RECONSIDERED

At Docs 4 Patient Care Foundation we believe in the potential of electronic medical records (EMR) and other forms of health information technology (HIT) to improve quality of health care and reduce costs by improving efficiency and reducing errors. But if these powerful tools are designed poorly or used incorrectly, they have equal potential to do harm to patients. We are very concerned that the HITECH incentive program, passed as part of the American Recovery and Reinvestment Act, is forcing the adoption of HIT too quickly, before these products are ready for widespread use and before health care providers understand them adequately.

To most practicing physicians the benefits of EMR remain elusive. Why do so many doctors question the wisdom of EMR when its benefits seem so clear to the government and to the health information technology (HIT) industry?

1. There is little evidence to support the safety and efficacy of EMR. Although it seems intuitive that “computerizing” health care will improve quality and efficiency, this has not yet been proven. There is in fact some evidence to suggest that EMR, as it is currently designed and used, may reduce quality of care and raise costs. A 2009 report by the National Research Council, written by two HIT pioneers who visited several centers of HIT excellence, concluded that current implementations of HIT, “will not be sufficient to achieve medical

Docs4PatientCare Foundation · A 501(C)3 Non-Profit Organization www.d4pcfoundation.org · 888-788-5515
1210 North Maple Road · Ann Arbor, MI 48103

leaders’ vision of health care in the 21st century and may even set back the cause.” A more recent study published in 2012 showed an increase in imaging test utilization by providers who had electronic access to imaging test results. The same study showed that the use of an EMR did not improve (lower) the rate of test utilization.

  1. There is no business model that makes EMR profitable, or even revenue- neutral. Like any business a medical practice must survive financially. EMR is a huge expense. The total cost of an EMR over the first 5 years far exceeds the $44,000 per provider incentive offered by HITECH. A practice cannot purchase and maintain an EMR without a strategy to recover the investment. This is one of the reasons so many practices have abandoned EMRs.
  2. There are no established EMR implementation strategies for medical practices.A mature EMR has many components that must work together. A practice cannot implement every component at once. The right parts must be implemented in the right order. New components must be added without reducing patient volume and without any errors in patient care. It is akin to replacing an aircraft’s engines while it is still flying. How does a practice decide what to purchase first and what to upgrade next? Right now it is by trial and error.
  3. Data capture technology is badly lacking. The most detrimental effect of EMR is the burden of data entry. This burden has changed the culture of medicine where EMR is used. Clinicians have been reduced to data entry clerks. The emphasis has changed from face time with patients to face time with computers. That is terrible for patient care. No currently available technology allows efficient, timely data capture.Docs4PatientCare Foundation · A 501(C)3 Non-Profit Organization www.d4pcfoundation.org · 888-788-5515
    1210 North Maple Road · Ann Arbor, MI 48103

5. Usability of today’s health IT products is poor. The Department of Commerce’s National Institute of Standards and Technology reported in 2011 that shortcomings in the usability of current EHR systems impair the adoption and meaningful use of these systems, and opined that the poor usability of current EHR applications has a substantial negative effect on clinical efficiency and data quality.

Health information technology will change the landscape of medicine more than any drug, imaging modality, operation or minimally invasive endoscope. It will profoundly affect the care of every patient. No other past or current medical advancement can make that claim. HIT has the potential to make medicine safer, more efficient and less costly – but only if designed, implemented and maintained with care. It is equally capable of doing the opposite of all these things if done poorly.

We do not yet understand how to use EMR well. We therefore also do not understand what expertise is required of those who design and implement this technology. The recent abandonment of UK’s National Health Service EMR system demonstrates that no EMR is “too big to fail.” We must learn from this example. To avoid a similar fate in the U.S. we must develop an adequate fund of HIT knowledge before pushing its widespread use.

Any new technology, including health information technology, produces unexpected adverse consequences. For such events the HITECH incentives create a frightening multiplier in HIT. What if the government had required all overweight patients to use Fen-Phen before its cardiac side effects were discovered? What if all patients with arthritic hips had been required to receive cobalt-containing implants? In an environment where every innovation is rightfully scrutinized before it is placed into

Docs4PatientCare Foundation · A 501(C)3 Non-Profit Organization www.d4pcfoundation.org · 888-788-5515
1210 North Maple Road · Ann Arbor, MI 48103

widespread use, why do so many accept the unproven claims of HIT as unchallenged fact? The HITECH alliance between government and the HIT industry has replaced critical analysis with blind enthusiasm and has replaced innovation with mindless regulatory compliance. The HITECH incentives have sucked all the oxygen out of the room where original thought once took place.

It is time to get our priorities straight. Quality patient care comes before information technology, and until the latter is proven safe, effective and practical, the former must prevail.

For more information on EMR and other HIT issues call:

Michael Koriwchak, MD
Vice President
Docs 4 Patient Care Foundation 404-276-2461 mkoriwchak@entofga.com

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CNN Cruz and Sanders Debate will have a Doctor in the House

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Michael Koriwchak, M.D. (Vice President of the Docs 4 Patient Care Foundation) is one of six audience questioners participating in tonight’s CNN health care debate.

Dr. Koriwchak has been asked to participate and he will be posing a question that will address the real world experiences of a practicing physician directly delivering care to patients.

Republicans have recently been floating trial balloons testing “repairing ObamaCare” versus “repeal and replace” in the face of the daunting task of dismantling a law with over 1,000 pages of text, over 10,000 pages of additional regulations, and 7 years of implementation.

Dr. Koriwchak’s participation promises to focus the debate on the real world impact of large regulatory systems on the front lines of American medicine.

Tune in to CNN tonight Feb 7, 2017 at 9PM EST

Dr. Koriwchak’s Biography

Dr. Mike

Michael J. Koriwchak, M.D. received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice.

He is board certified by the American Board of Otolaryngology-Head and Neck Surgery.

After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients depend on their voice for their careers. Some are well-known entertainers.

Dr. Koriwchak has performed thousands of thyroid, parathyroid and head and neck cancer operations. He was also one of the first to offer balloon sinuplasty for the treatment of chronic sinusitis.

Dr. Koriwchak has also been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using Visual BASIC script.

In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. He has been writing about health information technology since 2010.

Follow him on Twitter

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National Women Physicians Day

From Rolling My Eyes to Being Moved 

EdisonSpecial Commentary – Meg Edison, M.D. – It’s now 10pm and like many working moms, dinner is finished but dishes need to be done, the kids are in bed but I still hear cackles of laughter from my older girls’ room as they are talking before sleep, I’m finally sitting down but I have a lot yet to do. Tomorrow is the 2nd annual “National Women Physicians Day” and I’m thinking about what that means.

I’ll admit it, last year when the 1st National Women Physicians Day was announced, I may have rolled my eyes just a little and wondered why we needed a day to celebrate women only.  Either by luck, sheer optimism, or choice of specialty, I’m fortunate enough to say I’ve never once felt held back by my gender. To the contrary, as a pediatrician, being a woman and a mom is actually an asset rather than a liability.

But when February 3rd arrived, and I watched social media light up with new profile pictures of my fellow women physicians celebrating the day, along with photos at work in scrubs, performing surgery, giving lectures, in rescue helicopters, in military uniforms,  I was moved.  The face of medicine has changed and it is beautiful.  In that moment, I was truly proud to be part of the sisterhood and was thankful for a day to remind each other of all we have in common and all we have accomplished.

Celebrating Women Physicians Day on the birthday of Elizabeth Blackwell, the first woman to receive a medical degree in the United States, puts our careers and successes in context.  We stand on the shoulders of giants. From Elizabeth Blackwell, to Rebecca Lee Crumpler, Mildred Jefferson to Linda Brodsky—countless women physicians not only broke through barriers, they paved the way and mentored others.  They left medicine better than they found it.  This commitment to the future of our profession has never been more pressing.

As it stands, nine out of ten physicians do not recommend medical careers to their children. Those that do, do not recommend primary care.  This is a tragedy.  Our world needs good doctors, and who better than the children of healers to carry on this calling?  There are many things we do for our children to prepare their future, from teaching them to read to saving for college.  We need to take a hard look at the problems in medicine with them in mind. What can we do to make medicine a better career for them, how can we ease their way?

Before my girls went to bed tonight, I asked if they’d ever consider being doctors. My oldest, who is genetically wired to be an engineer, gamely said she’d think about it only after making a complete list of the pros and cons. I think the engineer mind is strong with that one!  My younger daughter said she’d be interested, but wasn’t sure about “that blue cross stuff”. My heart sank as I realized my frustrations with bureaucracy, MOC, and third party payers were far more transparent than I’d realized. “But if I can fix those things, what would you think about being a doctor, like mom?” Her eyes brightened and she responded, “Spending the day around babies? Sign me up!”

On this 195th anniversary of Elizabeth Blackwell’s birth, it is interesting to note that despite all her hardships and challenges as the only female medical student among 150 men and subsequently the only female doctor in the country, she loved medicine and recommended the career to other women. Just five years after Elizabeth graduated from medical school, her sister Emily became the third woman in the United States to receive a medical degree, one sister paving the way for the other.

This is what being a woman physician means to me now. It’s no longer about passing the next test, proving myself, and advancing in my career. I am happy and fulfilled where I am. Having reached my goals, I can look beyond myself to the next generation of physicians. Within the next 6-8 years, my girls will be making their career choices.  If I do my job and “fix those things”, medicine will be better than I found it.  I truly hope one, or both, of my daughters will look at this wonderful profession with bright eyes and say, “Sign me up”.

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