RE: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

February 8, 2009

I ran a model like this; I called it the Virtual Hospital, for

elderly patients. Dropped Hospital / ER expenses by 70% compared to the prior

year. When I tried to market the idea to the insurance companies met a lot of

resistance, they really did not want to pay a cent for these services even if

it save them millions down the line.

In our area Affinity tried something similar, they went and

hired “case managers” to follow “high risk patients”; all

they did was to create a lot of correspondence, forms and phone calls; to the

point that I told them I would drop them if I saw another form in my office.

The system needs to realize that the easy, and cheaper, answer

is to pay the doctor for her/his work.

José

From:

[mailto: ] On Behalf Of

Malia, MD

Sent: Sunday, February 08, 2009 9:55 AM

To:

Subject: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

See below for link to article from NYTimes about

IBM in Arizona teaming up with UHC to " experiment " with medical homes

and payment methods to doctors. Like any article, it's hard to know the

whole truth and details about the plan, but, I must say, a few things mixed in

seemed promising.

Gordon, et al, know anything about this from any power-broker-schmoozing?

What do you think?

Tim

---------------------------- NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan

From: chasqui@...

Date: Sun, February 8, 2009 9:32 am

To: tmalia@...

------------------------------------------------------------------------------------

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This page was sent to you by:

chasqui@...

BUSINESS

| February 07, 2009

UnitedHealth and I.B.M. Test Health Care Plan

By REED ABELSON

The giant insurer will test a system to reward doctors for the overall

quality of care patients receive.

Error! Filename not specified.

1. Op-Ed

Contributor: The Value of ‘Other People’s Money’

2. In

Florida, Despair and Foreclosures

3. Op-Ed

Columnist: Playing With Fire

4. Op-Ed

Contributor: Till Children Do Us Part

5. The

Downside for Condos in a Downturn

»

Go

to Complete List

Error! Filename not specified.

The Wrestler Nominated

for 2 Academy Awards, including Best Actor-

Mickey Rourke, and Best Supporting Actress-

Marisa Tomei. Now playing

Click

here to view trailer

Error! Filename not specified.

Copyright

2009

The New York

Times Company | Privacy

Policy

Error! Filename not specified.

----------------------------------------

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

-- Confidentiality Notice --

This email message, including all the attachments, is for the sole use of the

intended recipient(s) and contains confidential information. Unauthorized use

or disclosure is prohibited. If you are not the intended recipient, you may not

use, disclose, copy or disseminate this information. If you are not the

intended recipient, please contact the sender immediately by reply email and

destroy all copies of the original message, including attachments.

----------------------------------------

February 8, 2009

Can you elaborate on the " Virtual Hospital " ?

I ran a model like this; I called it the Virtual Hospital, for

elderly patients. Dropped Hospital / ER expenses by 70% compared to the prior

year. When I tried to market the idea to the insurance companies met a lot of

resistance, they really did not want to pay a cent for these services even if

it save them millions down the line.-- Pedro Ballester, M.D.Warren, OH

February 8, 2009

I am suspicious of anything connected with United Health Care. Their actions over the past 5 years have indicated that they realize health care insurance may not have a viable future when looking at a 20 year projections. They are behaving just as big tobacco did when they read the writing on the wall that their US market was going to start shrinking.

UHC is acquiring everything in their path related to health care and have disbanded any form of " customer relations department, " (My understanding is that this is the first thing big corporations do when they feel they do not have a viable, sustainable market share).

Once big tobacco had consolidated power, they then started diversifying into other areas. Nabisco, our national cookie maker, is owned by now, I believe. When UHC starts diversifying into non health care related industry, I will figure they will have milked just about every dime out of the health care system that they can. Who knows, maybe they will start marketing their health insurance products in third world countries, just like Big Tobacco.

I feel like the American public and its allopathic and osteopathic physicians are addicted to health insurance, and the health insurance industry knows this. They will string us along with little programs here and there that give us all hope that one day our dreams will be realized. They want to keep us playing the game for as long as possible. I do not believe the industry will ever have the interests of the patients as its primary goal as long as reporting to shareholders is part of the equation.

I am not generally a conspiracy theory advocate, but big business is big business, whether or not it involves lives and suffering. The health insurance industry's mission and legal responsibilities are very clear, and that is to report financial gain to their shareholders. They do not keep this secret, but hope we will forget about this nasty fact while we as physicians and health care providers struggle daily with our clear mission to do no harm to our patients.

Mike (I can not seem to find your last name--I apologize) shared a recent post on leadership, where he mentioned three aspects of effective leaders: responsibility, accountability and authority. He also mentioned that all three aspects must be present. As health care providers, we have the responsibility for the proper and ethical care of our patients. Through studies like the IMP project, we are learning to implement accurate, timely measurement tools to take on more accountability for our patient population's health and outcomes. The truly tragic part of this picture is that we have basically abdicated our authority to entities who are not bound by doing what is right for our patients.

Durango, CO

I ran a model like this; I called it the Virtual Hospital, for elderly patients. Dropped Hospital / ER expenses by 70% compared to the prior year. When I tried to market the idea to the insurance companies met a lot of resistance, they really did not want to pay a cent for these services even if it save them millions down the line.

In our area Affinity tried something similar, they went and hired " case managers " to follow " high risk patients " ; all they did was to create a lot of correspondence, forms and phone calls; to the point that I told them I would drop them if I saw another form in my office.

The system needs to realize that the easy, and cheaper, answer is to pay the doctor for her/his work.

José

From: [mailto: ] On Behalf Of Malia, MD

Sent: Sunday, February 08, 2009 9:55 AMTo: Subject: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

See below for link to article from NYTimes about IBM in Arizona teaming up with UHC to " experiment " with medical homes and payment methods to doctors. Like any article, it's hard to know the whole truth and details about the plan, but, I must say, a few things mixed in seemed promising.

Gordon, et al, know anything about this from any power-broker-schmoozing? What do you think?Tim---------------------------- NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan

From: chasqui@...Date: Sun, February 8, 2009 9:32 amTo: tmalia@...------------------------------------------------------------------------------------

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This page was sent to you by: chasqui@...

BUSINESS | February 07, 2009

UnitedHealth and I.B.M. Test Health Care Plan

By REED ABELSONThe giant insurer will test a system to reward doctors for the overall quality of care patients receive.

Error! Filename not specified.

Error! Filename not specified. 1. Op-Ed Contributor: The Value of 'Other People's Money' 2. In Florida, Despair and Foreclosures 3. Op-Ed Columnist: Playing With Fire 4. Op-Ed Contributor: Till Children Do Us Part 5. The Downside for Condos in a Downturn » Go to Complete ListError! Filename not specified.

The Wrestler Nominatedfor 2 Academy Awards, including Best Actor-Mickey Rourke, and Best Supporting Actress-Marisa Tomei. Now playingClick here to view trailer

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---------------------------------------- Malia, MD (phone / fax)www.MaliaFamilyMedicine.comwww.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton Square MallFairport, NY 14450-- Confidentiality Notice --This email message, including all the attachments, is for the sole use of the intended recipient(s) and contains confidential information. Unauthorized use or disclosure is prohibited. If you are not the intended recipient, you may not use, disclose, copy or disseminate this information. If you are not the intended recipient, please contact the sender immediately by reply email and destroy all copies of the original message, including attachments.

----------------------------------------

February 8, 2009

Isn’t Andy Cuomo investigating UHC for basically “price

fixing” doctor’s appointment fees?

From:

[mailto: ] On Behalf Of

Sent: Sunday, February 08, 2009 11:36 AM

To:

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

I am suspicious of anything connected with United Health Care.

Their actions over the past 5 years have indicated that they realize health

care insurance may not have a viable future when looking at a 20 year

projections. They are behaving just as big tobacco did when they read the

writing on the wall that their US market was going to start

shrinking.

UHC is acquiring everything in their path related to health

care and have disbanded any form of " customer relations

department, " (My understanding is that this is the first thing big

corporations do when they feel they do not have a viable, sustainable

market share).

Once big tobacco had consolidated power, they then started

diversifying into other areas. Nabisco, our national cookie maker, is

owned by now, I believe. When UHC starts diversifying into

non health care related industry, I will figure they will have milked just

about every dime out of the health care system that they can. Who knows,

maybe they will start marketing their health insurance products in third world

countries, just like Big Tobacco.

I feel like the American public and its allopathic and

osteopathic physicians are addicted to health insurance, and the health

insurance industry knows this. They will string us along with little

programs here and there that give us all hope that one day our dreams will be

realized. They want to keep us playing the game for as long as

possible. I do not believe the industry will ever have the

interests of the patients as its primary goal as long as reporting to shareholders

is part of the equation.

I am not generally a conspiracy theory advocate, but big

business is big business, whether or not it involves lives and suffering.

The health insurance industry's mission and legal responsibilities are

very clear, and that is to report financial gain to their shareholders.

They do not keep this secret, but hope we will forget about this

nasty fact while we as physicians and health care providers struggle daily

with our clear mission to do no harm to our patients.

Mike (I can not seem to find your last name--I apologize)

shared a recent post on leadership, where he mentioned three

aspects of effective leaders: responsibility, accountability and

authority. He also mentioned that all three aspects must be present.

As health care providers, we have the responsibility for the proper and

ethical care of our patients. Through studies like the IMP

project, we are learning to implement accurate, timely measurement tools

to take on more accountability for our patient population's health and

outcomes. The truly tragic part of this picture is that we have

basically abdicated our authority to entities who are not bound by doing what

is right for our patients.

Durango, CO

On Sun, Feb 8, 2009 at 8:23 AM, José Batlle, MD

wrote:

I ran

a model like this; I called it the Virtual Hospital, for elderly patients.

Dropped Hospital / ER expenses by 70% compared to the prior year. When I

tried to market the idea to the insurance companies met a lot of resistance,

they really did not want to pay a cent for these services even if it save them

millions down the line.

In

our area Affinity tried something similar, they went and hired " case

managers " to follow " high risk patients " ; all they did was to

create a lot of correspondence, forms and phone calls; to the point that I told

them I would drop them if I saw another form in my office.

The

system needs to realize that the easy, and cheaper, answer is to pay the doctor

for her/his work.

José

From: [mailto: ]

On Behalf Of Malia, MD

Sent: Sunday, February 08, 2009 9:55 AM

To:

Subject: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

See below for link to article

from NYTimes about IBM in Arizona teaming up with UHC to " experiment "

with medical homes and payment methods to doctors. Like any article, it's

hard to know the whole truth and details about the plan, but, I must say, a few

things mixed in seemed promising.

Gordon, et al, know anything about this from any power-broker-schmoozing?

What do you think?

Tim

---------------------------- NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan

From: chasqui@...

Date: Sun, February 8, 2009 9:32 am

To: tmalia@...

------------------------------------------------------------------------------------

Error! Filename not specified.

This page was sent to you by:

chasqui@...

BUSINESS

| February 07, 2009

UnitedHealth and I.B.M. Test Health Care Plan

By REED ABELSON

The giant insurer will test a system to reward doctors for the overall

quality of care patients receive.

Error! Filename not specified.

1. Op-Ed

Contributor: The Value of 'Other People's Money'

2. In

Florida, Despair and Foreclosures

3. Op-Ed

Columnist: Playing With Fire

4. Op-Ed

Contributor: Till Children Do Us Part

5. The

Downside for Condos in a Downturn

»

Go

to Complete List

Error! Filename not

specified.

Error! Filename not specified.

The Wrestler Nominated

for 2 Academy Awards, including Best Actor-

Mickey Rourke, and Best Supporting Actress-

Marisa Tomei. Now playing

Click

here to view trailer

Error! Filename not specified.

Copyright

2009

The New York

Times Company | Privacy

Policy

Error! Filename not specified.

----------------------------------------

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

-- Confidentiality Notice --

This email message, including all the attachments, is for the sole use of the

intended recipient(s) and contains confidential information. Unauthorized use

or disclosure is prohibited. If you are not the intended recipient, you may not

use, disclose, copy or disseminate this information. If you are not the

intended recipient, please contact the sender immediately by reply email and

destroy all copies of the original message, including attachments.

----------------------------------------

February 8, 2009

What I called the ”Virtual Hospital” was a model I

ran in a poor neighborhood of NYC. We basically targeted senior citizen city

subsidized apartment buildings. Most patients were elderly and basically have

problems living their apartments for care. Most had a care giver (family

member or home aide). My team was made of a RN (whom I can trust blindly), a

pharmacist (that did home deliveries) and me. Patients were seen at their

home. After a first full evaluation which included throwing away tons of

bottles of medications (that were duplicated, old, from multiple doctors) we

got a personalize plan for the patient in conjunction with the care giver and

the RN. The plan included self management algorithms has FS sliding scales for

insulin, weight scales for furosemide treatment for CHF, self management

instructions for COPD and asthma exacerbations and clear goal for the patient.

We promptly identified that most Hospital / ER visits for due to medication

problems or easily managed exacerbations of chronic problems. Patient was

given open access to the RN (first line of defense) that would evaluate patient

as often as needed and was in direct communication with me. Issues like a FS

of 300 was easily managed with a phone call and an extra insulin order, UTI’s

were treated on the spot prior to complications. I would use single dose parenteral

antibiotics, if warranted, as a first dose and then continue PO Abx for example.

Patients quickly learned that they had great care at hand and ambulance calls disappeared.

Second, the pharmacist delivered at home and had direct access to my cell, the

line was that no patient would run out of meds. Any issues the pharmacist would

call directly and fix it (from patient needs a refill to insurance formularies

changes). Also they would deliver any acutely needed medication within the

hour. We also had access to next day laboratory work at home; a licensed lab

tech would go to the home and get whatever I needed and reports would be

available that evening.

At first it was involved due to barriers like patient, or family

members did not trust us and “tested” the system; after that barrier

disappeared the problem became that I could not find family members (they had

stop worrying). Second, it takes several visits to get people on the right

track and a lot of education but with time you end up seen them every 6 to 8

weeks.

One of the most valuable aspects was to get into patients homes:

you found chocolate stashes at the uncontrolled DM patients, area rugs that

were a hazard, mold at the home of the frequently exacerbated asthmatic.

Another important factor was setting goals; for me the plan was

to keep the patient as functionally as possible and minimize medications and medical

visits. I was astonished how for many of this patient medical care had become

a full time job. I strived to make sure that we were all on the same plan,

from the patient to the family member.

One story comes as an example, I had this 92 year old, almost

deaf, that had been in and out of the hospital and nursing home due to “heart

failure” after talking with her, and her son, I promptly realized that

eves so the quit 15 years prior she had smoked for 60 something years, she

never had been diagnosed as having COPD. I taught my RN the difference between

a COPD exacerbation and Heart Failure and we made a plan. I surely next “heart

failure” event was actually a COPD exacerbation and was treated as such

at home with great results. In short no more admissions, after 4 to 6 weeks

better oxygenation of her brain got her to converse and remember things (she was

diagnosed with dementia). The worse thing that happened was that I never saw

the son again; he stopped worrying about her health.

To do this you have to be willing to improvise and become a part

time social worker, doctor, home attendant, hospice worker and nurse. I

created “ink” notes in my computer and kept copies of all patients’

charts in the computer. Now with 3G I can just access the office if I start

this service again at my new office. You also need a RN, or equivalent, that

you can trust blindly.

One surprise was how cheap and relatively easy it was to get it

done. You also need to learn to compromise, I don’t get x-rays just to

prove heart failure. Third you have to become humble and respectful (not easy

for me) and learn to treat people on their own turf.

I also found out that because it was the same care team, issues

could be solved with very little talking as we all knew the patients and always

did things the same way (following our protocols).

One last big problem became that patients expected a visit, I

had to just drop by and say hello or they would get “mad” with me

when they found out I was in the building.

For billing purposes we used the home care visit codes that

reimburse at a higher rate.

Sorry for the length,

José

From:

[mailto: ] On Behalf Of Pedro

Ballester

Sent: Sunday, February 08, 2009 11:10 AM

To:

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

Can you elaborate on the " Virtual

Hospital " ?

I ran a model like this; I

called it the Virtual Hospital, for elderly patients. Dropped Hospital / ER

expenses by 70% compared to the prior year. When I tried to market the

idea to the insurance companies met a lot of resistance, they really did not

want to pay a cent for these services even if it save them millions down the

line.

--

Pedro Ballester, M.D.

Warren, OH

February 8, 2009

I agree, home visits give mnore info than any patient ever will./

I am thinkign of switrching to home calls only. Drop my overhead of rent.

I have a USB spiromter, ECG and lots of neighborhood help.

We'll see, it's only one of many options.

To: Sent: Sunday, February 8, 2009 12:24:15 PMSubject: RE: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

What I called the â€Virtual Hospitalâ€ was a model I ran in a poor neighborhood of NYC. We basically targeted senior citizen city subsidized apartment buildings. Most patients were elderly and basically have problems living their apartments for care. Most had a care giver (family member or home aide). My team was made of a RN (whom I can trust blindly), a pharmacist (that did home deliveries) and me. Patients were seen at their home. After a first full evaluation which included throwing away tons of bottles of medications (that were duplicated, old, from multiple doctors) we got a personalize plan for the patient in conjunction with the care giver and the RN. The plan included self management algorithms has FS sliding scales for insulin, weight scales for furosemide treatment for CHF, self management instructions for COPD and asthma exacerbations and clear

goal for the patient. We promptly identified that most Hospital / ER visits for due to medication problems or easily managed exacerbations of chronic problems. Patient was given open access to the RN (first line of defense) that would evaluate patient as often as needed and was in direct communication with me. Issues like a FS of 300 was easily managed with a phone call and an extra insulin order, UTIâ€™s were treated on the spot prior to complications. I would use single dose parenteral antibiotics, if warranted, as a first dose and then continue PO Abx for example. Patients quickly learned that they had great care at hand and ambulance calls disappeared. Second, the pharmacist delivered at home and had direct access to my cell, the line was that no patient would run out of meds. Any issues the pharmacist would call directly and fix it (from patient needs a refill to insurance formularies changes). Also they would

deliver any acutely needed medication within the hour. We also had access to next day laboratory work at home; a licensed lab tech would go to the home and get whatever I needed and reports would be available that evening.

At first it was involved due to barriers like patient, or family members did not trust us and â€œtestedâ€ the system; after that barrier disappeared the problem became that I could not find family members (they had stop worrying). Second, it takes several visits to get people on the right track and a lot of education but with time you end up seen them every 6 to 8 weeks.

One of the most valuable aspects was to get into patients homes: you found chocolate stashes at the uncontrolled DM patients, area rugs that were a hazard, mold at the home of the frequently exacerbated asthmatic.

Another important factor was setting goals; for me the plan was to keep the patient as functionally as possible and minimize medications and medical visits. I was astonished how for many of this patient medical care had become a full time job. I strived to make sure that we were all on the same plan, from the patient to the family member.

One story comes as an example, I had this 92 year old, almost deaf, that had been in and out of the hospital and nursing home due to â€œheart failureâ€ after talking with her, and her son, I promptly realized that eves so the quit 15 years prior she had smoked for 60 something years, she never had been diagnosed as having COPD. I taught my RN the difference between a COPD exacerbation and Heart Failure and we made a plan. I surely next â€œheart failureâ€ event was actually a COPD exacerbation and was treated as such at home with great results. In short no more admissions, after 4 to 6 weeks better oxygenation of her brain got her to converse and remember things (she was diagnosed with dementia). The worse thing that happened was that I never saw the son again; he stopped worrying about her health.

To do this you have to be willing to improvise and become a part time social worker, doctor, home attendant, hospice worker and nurse. I created â€œinkâ€ notes in my computer and kept copies of all patientsâ€™ charts in the computer. Now with 3G I can just access the office if I start this service again at my new office. You also need a RN, or equivalent, that you can trust blindly.

One surprise was how cheap and relatively easy it was to get it done. You also need to learn to compromise, I donâ€™t get x-rays just to prove heart failure. Third you have to become humble and respectful (not easy for me) and learn to treat people on their own turf.

I also found out that because it was the same care team, issues could be solved with very little talking as we all knew the patients and always did things the same way (following our protocols).

One last big problem became that patients expected a visit, I had to just drop by and say hello or they would get â€œmadâ€ with me when they found out I was in the building.

For billing purposes we used the home care visit codes that reimburse at a higher rate.

Sorry for the length,

JosÃ©

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:Practiceimp rovement1@ yahoogroups. com] On Behalf Of Pedro BallesterSent: Sunday, February 08, 2009 11:10 AMTo: Practiceimprovement 1yahoogroups (DOT) comSubject: Re: [Practiceimprovemen t1] [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

Can you elaborate on the "Virtual Hospital"?

On Sun, Feb 8, 2009 at 10:23 AM, JosÃ© Batlle, MD <jbatlle@doctorbatll e.com> wrote:

I ran a model like this; I called it the Virtual Hospital, for elderly patients. Dropped Hospital / ER expenses by 70% compared to the prior year. When I tried to market the idea to the insurance companies met a lot of resistance, they really did not want to pay a cent for these services even if it save them millions down the line.

-- Pedro Ballester, M.D.Warren, OH

February 8, 2009

I have a home visit that paid me 58 dollars for an acute problem. Still trying to it out. But I don't think I'm even breaking even on home visits with my Medicare Advantage plans.

I ran a model like this; I called it the Virtual Hospital, for elderly patients. Dropped Hospital / ER expenses by 70% compared to the prior year. When I tried to market the idea to the insurance companies met a lot of resistance, they really did not want to pay a cent for these services even if it save them millions down the line.

-- Pedro Ballester, M.D.Warren, OH

February 8, 2009

i think and 's posts a re both brilliant and hit the nail on the headIn a rural area traveling to people's homes becomes so much more lengthy and ther fore expensive and so a simple straightforward dare i say commonsensical model becomes untenable due to " reimbursement "

I have long known I am part social worker part nurse etc I have mad e budgets told people where to g et food all that stuff etcetc.Its just not that hard ott ake care of people if we could knock down the damn barriers.

I have my own stroy A week before christmas this jaundiced guy with abd pain shows up- lfts up ultrasound shows some obstrcution. a CAt scan needing PA on christmas eve my day off --was nl .Needed ercp. I call GI whose office says he is at the endoscopy unit at hospital-- i call there and get a amchine To this day he has never called me back. Next day is christmas. 2 of patietns brothers both docs call me at home. On dec 26 i go to radiology and talk to radiologist , he thinks there is a gallstone in there, and says i need a surgeoin for th e patietn. Call a surgeon- he says what I thoguht-- needs ercp So i call the next town GI docs. Theyw ill do ercp that day, dec 26 . I call the admitting place and am told patitn will be admitted by

a surgeon.And he must go to t he rI am in so deep here it is a friday what do i do? I allow him to go to er . The admitting note from the surgeon acknowledges my u/s/ ct /labs i snet and yet repeats al the labs and says " The PCP could not be located " No attempt was made I assure you

Guy get s a ercp has a strciture GI calls me 7 pm and tells me results. 11 pm dec 26 the neurosuregon brother calls and say GI told him there is amass in the head of the pancreas and likelya choleangiocarcionam He is crying.He is with his whole family in vet on ski vacation and they are hearing their brother is going to die.

theer are ten thousand more parts to this story, though at 11 pm dec 26 i call GI and he admits he got confused. i call the borther backa nd say what i already knew ther e is no mass in the pancreas!! I call patietn who has been admitted( why>???) and tellhim to leav e the hospital Get out of there I say .

He gets a second CT scan- which is the same before I tell him to leavei can go on and on there is MUCH more to this stroy, including a chicken, BUT I call the CEo of said medical center and discuss this mess. and I got slammed Sitting in t eh room was a surgeon who says HOW COULD I have snet that man for an erc?p You cannot just order a procedure ! he was minutes away from being ill ! He came by ambulalnce he asys yes? " No LArry he came form home with his three girls and his wife and I had talked ot a surgeon "

I say- this is all such a waste of time and money and they do not get it . Tehy tell me GI NEVER admits. Never So some other doc who has no relationship with the patietn has to go do busy work..Shall i go on??

this particular story goes on and onyet the thing is simple commonsnesical primary care done right is not allowed to e xist becasue we might have to charge a couple hundred dolllors for thos e nurses and pharmcists( whata cocnept!! Invovling a pharmacist ont he team How often have I said that!!) and our time in the living room with the pill bottles-- but it is ok to repeat CTs and labs and tie up ERs and surgeons with erros and miscommunications And terrify families.

oh stop the madness!!

I am suspicious of anything connected with United Health Care. Their actions over the past 5 years have indicated that they realize health care insurance may not have a viable future when looking at a 20 year projections. They are behaving just as big tobacco did when they read the writing on the wall that their US market was going to start shrinking.

UHC is acquiring everything in their path related to health care and have disbanded any form of " customer relations department, " (My understanding is that this is the first thing big corporations do when they feel they do not have a viable, sustainable market share).

Once big tobacco had consolidated power, they then started diversifying into other areas. Nabisco, our national cookie maker, is owned by now, I believe. When UHC starts diversifying into non health care related industry, I will figure they will have milked just about every dime out of the health care system that they can. Who knows, maybe they will start marketing their health insurance products in third world countries, just like Big Tobacco.

I feel like the American public and its allopathic and osteopathic physicians are addicted to health insurance, and the health insurance industry knows this. They will string us along with little programs here and there that give us all hope that one day our dreams will be realized. They want to keep us playing the game for as long as possible. I do not believe the industry will ever have the interests of the patients as its primary goal as long as reporting to shareholders is part of the equation.

I am not generally a conspiracy theory advocate, but big business is big business, whether or not it involves lives and suffering. The health insurance industry's mission and legal responsibilities are very clear, and that is to report financial gain to their shareholders. They do not keep this secret, but hope we will forget about this nasty fact while we as physicians and health care providers struggle daily with our clear mission to do no harm to our patients.

Mike (I can not seem to find your last name--I apologize) shared a recent post on leadership, where he mentioned three aspects of effective leaders: responsibility, accountability and authority. He also mentioned that all three aspects must be present. As health care providers, we have the responsibility for the proper and ethical care of our patients. Through studies like the IMP project, we are learning to implement accurate, timely measurement tools to take on more accountability for our patient population's health and outcomes. The truly tragic part of this picture is that we have basically abdicated our authority to entities who are not bound by doing what is right for our patients.

Durango, CO

I ran a model like this; I called it the Virtual Hospital, for elderly patients. Dropped Hospital / ER expenses by 70% compared to the prior year. When I tried to market the idea to the insurance companies met a lot of resistance, they really did not want to pay a cent for these services even if it save them millions down the line.

In our area Affinity tried something similar, they went and hired " case managers " to follow " high risk patients " ; all they did was to create a lot of correspondence, forms and phone calls; to the point that I told them I would drop them if I saw another form in my office.

The system needs to realize that the easy, and cheaper, answer is to pay the doctor for her/his work.

José

From: [mailto: ] On Behalf Of Malia, MD

Sent: Sunday, February 08, 2009 9:55 AMTo: Subject: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

See below for link to article from NYTimes about IBM in Arizona teaming up with UHC to " experiment " with medical homes and payment methods to doctors. Like any article, it's hard to know the whole truth and details about the plan, but, I must say, a few things mixed in seemed promising.

Gordon, et al, know anything about this from any power-broker-schmoozing? What do you think?Tim---------------------------- NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan

From: chasqui@...Date: Sun, February 8, 2009 9:32 amTo: tmalia@...------------------------------------------------------------------------------------

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This page was sent to you by: chasqui@...

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UnitedHealth and I.B.M. Test Health Care Plan

By REED ABELSONThe giant insurer will test a system to reward doctors for the overall quality of care patients receive.

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Error! Filename not specified. 1. Op-Ed Contributor: The Value of 'Other People's Money' 2. In Florida, Despair and Foreclosures 3. Op-Ed Columnist: Playing With Fire 4. Op-Ed Contributor: Till Children Do Us Part 5. The Downside for Condos in a Downturn » Go to Complete ListError! Filename not specified.

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---------------------------------------- Malia, MD (phone / fax)www.MaliaFamilyMedicine.comwww.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton Square MallFairport, NY 14450-- Confidentiality Notice --This email message, including all the attachments, is for the sole use of the intended recipient(s) and contains confidential information. Unauthorized use or disclosure is prohibited. If you are not the intended recipient, you may not use, disclose, copy or disseminate this information. If you are not the intended recipient, please contact the sender immediately by reply email and destroy all copies of the original message, including attachments.

----------------------------------------

-- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax impcenter.org

February 8, 2009

The concepts behind this test appear to be

solid and a move in the right direction. The real test is in the implementation.

Several of these implementation efforts

have failed. There are a number of reasons for the failures:

The

costs of practice level improvement far exceeded any promised financial

rewards (I once got a nice check for $635 for that year’s quality

bonus in Rochester.

Yay! Case manager here I come! (I hope you sense the dripping

sarcasm.))

The

measurement and accountability systems were too onerous and costly for the

practices – just take a look at NCQA’s PPC-PCMH™ tool

and ask “Who is going to bear the costs of jumping through all these

hoops and answering all these arcane questions?”

The

initiative addressed only a small book of work in the practice –

meaning we’d either have to develop a unique system of care for that

project (ethical failure of two-tiered care), or we absorb the cost of

improved care for all with reward for only a fraction

The

program pays practices that don’t actually do anything different

(this is a dual failure – the program should stipulate the “different”

desired and the practices need to deliver)

The

program never helped the practices learn how to behave in a new and different

way

All the cranky cynicism aside, I am

pleased to see continued efforts in many places around the US. There

really are folks trying to do the right thing. Some insurers (I know lots

of you have good reason to be suspicious) are even trying to do the right

thing.

The system is so broken and getting worse

that change is inevitable.

I want to see change that makes sense.

Change informed by front line experience

(that’s us, folks) is more likely to actually help.

To that end we’re launching http://SavingPrimaryCare.org

Gordon

From: [mailto: ] On Behalf Of Malia, MD

Sent: Sunday, February 08, 2009

6:55 AM

To:

Subject:

[Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

See below for link to article from NYTimes about IBM

in Arizona

teaming up with UHC to " experiment " with medical homes and payment

methods to doctors. Like any article, it's hard to know the whole truth

and details about the plan, but, I must say, a few things mixed in seemed

promising.

Gordon, et al, know anything about this from any power-broker-schmoozing?

What do you think?

Tim

---------------------------- NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan

From: chasquirochester (DOT) rr.com

Date: Sun, February 8, 2009 9:32 am

To: tmalia@...

------------------------------------------------------------------------------------

This page was sent to you by:

chasquirochester (DOT) rr.com

BUSINESS

| February 07, 2009

UnitedHealth and I.B.M. Test Health Care Plan

By REED ABELSON

The giant insurer will test a system to reward doctors for the overall

quality of care patients receive.

1. Op-Ed

Contributor: The Value of ‘Other People’s Money’

2. In

Florida, Despair and Foreclosures

3. Op-Ed

Columnist: Playing With Fire

4. Op-Ed

Contributor: Till Children Do Us Part

5. The

Downside for Condos in a Downturn

»

Go

to Complete List

The Wrestler

Nominated

for 2 Academy Awards, including Best Actor-

Mickey Rourke, and Best Supporting Actress-

Marisa Tomei. Now playing

Click

here to view trailer

Copyright

2009

The New York

Times Company | Privacy

Policy

----------------------------------------

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY

14450

-- Confidentiality Notice --

This email message, including all the attachments, is for the sole use of the

intended recipient(s) and contains confidential information. Unauthorized use

or disclosure is prohibited. If you are not the intended recipient, you may not

use, disclose, copy or disseminate this information. If you are not the

intended recipient, please contact the sender immediately by reply email and

destroy all copies of the original message, including attachments.

----------------------------------------

February 8, 2009

If you get PAID LESS to do the quality, then not worth the expense.

If this system is another way to "capitate" quality, will only work if you have large pt panel NOT SEEN.

If it is another way to "guide pts" to certain large practices, then it's a Kaiser-like group; I don't work for a group, and solos are out, which also WON'T WORK as most of us DON'T SEE THE efficiencies, and increased payment.

How much more "quality" do we have to PROVE to be paid.

1) If you "give it away" for free, they'll be lots of takers.

2) The "perfect" is the ENEMY of the "good enough."

Seems like another method of reducing costs and increasing performance, to the primary's detriment.

Matt in Western PA

NYTimes.com: UnitedHealth and I.B.M. Test Health Care PlanFrom: chasquirochester (DOT) rr.comDate: Sun, February 8, 2009 9:32 amTo: tmalia@...------------------------------------------------------------------------------------

This page was sent to you by: chasquirochester (DOT) rr.comBUSINESS | February 07, 2009UnitedHealth and I.B.M. Test Health Care PlanBy REED ABELSONThe giant insurer will test a system to reward doctors for the overall quality of care patients receive.

1. Op-Ed Contributor: The Value of ‘Other People’s Money’ 2. In Florida, Despair and Foreclosures 3. Op-Ed Columnist: Playing With Fire 4. Op-Ed Contributor: Till Children Do Us Part 5. The Downside for Condos in a Downturn » Go to Complete List

The Wrestler Nominatedfor 2 Academy Awards, including Best Actor-Mickey Rourke, and Best Supporting Actress-Marisa Tomei. Now playingClick here to view trailer

---------------------------------------- Malia, MD (phone / fax)www.MaliaFamilyMedicine.comwww.SkinSenseLaser.comMalia Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton Square MallFairport, NY 14450-- Confidentiality Notice --This email message, including all the attachments, is for the sole use of the intended recipient(s) and contains confidential information. Unauthorized use or disclosure is prohibited. If you are not the intended recipient, you may not use, disclose, copy or disseminate this information. If you are not the intended recipient, please contact the sender immediately by reply email and destroy all copies of the original message, including attachments.----------------------------------------

February 8, 2009

Totally agree the problem, as I see it, is that we keep adding

layers and layers instead of just starting form a clean slate.

I am going to give my program a second try, with the goal of

just diminishing Hospital cost / utilization (where most money and resources

go) while improving overall pt. wellbeing. I believe that this is the secret

for the care of our aging population in a time of dwindling resources.

In my experiment the high population density made it feasible

and I only dedicated Wednesday morning to the program, usually seeing only 2 to

4 new patients. All Hx and Med forms were filled out prior and sent to me the

week prior to the visit, which made the visits quick as I pretty much knew what

I was getting into. And I would “target” just 2, close by,

building each week. I was seeing patients in 6 buildings.

The other big problem is that while we do “the right thing”

and improve pts. health and create huge savings, the insurance industry seems

to want to keep the benefits for themselves. That was a bitter point when I

tried to get the insurance companies, or Medicare, to share the savings with

me. I even told them identify the 5% of your panel that is spending the most

money due to exacerbations of chronic conditions and assign them to me, with

the condition that we share the savings. I could not get that one thru their

heads even so I proved to them that I could save millions with just 250

patients. That is the stupidity of the system we are in.

We can all wait for the system to collapse, which in my opinion

may not take 5 years, or get something going.

Personally, I think that Primary Care Provider should band in

groups and convince, Medicare for example, that we would improve outcomes but with

the condition that we share in the savings in some type of contractual form. That

would not happen as long as the image continues to be that our services are a

social good but not the payments.

José

PS: Gordon I already signed up.

From:

[mailto: ] On Behalf Of Dr. Gordon

Sent: Sunday, February 08, 2009 1:29 PM

To:

Subject: RE: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

The

concepts behind this test appear to be solid and a move in the right

direction. The real test is in the implementation.

Several of

these implementation efforts have failed. There are a number of reasons

for the failures:

The costs of practice level improvement far exceeded

any promised financial rewards (I once got a nice check for $635 for that

year’s quality bonus in Rochester. Yay! Case manager

here I come! (I hope you sense the dripping sarcasm.))

The measurement and accountability systems were too

onerous and costly for the practices – just take a look at

NCQA’s PPC-PCMH™ tool and ask “Who is going to bear the

costs of jumping through all these hoops and answering all these arcane

questions?”

The initiative addressed only a small book of work

in the practice – meaning we’d either have to develop a unique

system of care for that project (ethical failure of two-tiered care), or

we absorb the cost of improved care for all with reward for only a fraction

The program pays practices that don’t actually

do anything different (this is a dual failure – the program should

stipulate the “different” desired and the practices need to

deliver)

The program never helped the practices learn how to

behave in a new and different way

All the

cranky cynicism aside, I am pleased to see continued efforts in many places

around the US. There really are folks trying to do the right thing.

Some insurers (I know lots of you have good reason to be suspicious) are even

trying to do the right thing.

The system

is so broken and getting worse that change is inevitable.

I want to

see change that makes sense.

Change

informed by front line experience (that’s us, folks) is more likely to

actually help.

To that

end we’re launching http://SavingPrimaryCare.org

Gordon

From:

[mailto: ] On Behalf Of

Malia, MD

Sent: Sunday, February 08, 2009 6:55 AM

To:

Subject: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

See below for link to article from NYTimes about IBM in Arizona teaming up

with UHC to " experiment " with medical homes and payment methods to

doctors. Like any article, it's hard to know the whole truth and details

about the plan, but, I must say, a few things mixed in seemed promising.

Gordon, et al, know anything about this from any power-broker-schmoozing?

What do you think?

Tim

---------------------------- NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan

From: chasqui@...

Date: Sun, February 8, 2009 9:32 am

To: tmalia@...

------------------------------------------------------------------------------------

This page was sent to you by:

chasqui@...

BUSINESS

| February 07, 2009

UnitedHealth and I.B.M. Test Health Care Plan

By REED ABELSON

The giant insurer will test a system to reward doctors for the overall

quality of care patients receive.

1. Op-Ed

Contributor: The Value of ‘Other People’s Money’

2. In

Florida, Despair and Foreclosures

3. Op-Ed

Columnist: Playing With Fire

4. Op-Ed

Contributor: Till Children Do Us Part

5. The

Downside for Condos in a Downturn

»

Go

to Complete List

The Wrestler Nominated

for 2 Academy Awards, including Best Actor-

Mickey Rourke, and Best Supporting Actress-

Marisa Tomei. Now playing

Click

here to view trailer

Copyright

2009

The New York

Times Company | Privacy

Policy

----------------------------------------

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

-- Confidentiality Notice --

This email message, including all the attachments, is for the sole use of the

intended recipient(s) and contains confidential information. Unauthorized use

or disclosure is prohibited. If you are not the intended recipient, you may not

use, disclose, copy or disseminate this information. If you are not the

intended recipient, please contact the sender immediately by reply email and

destroy all copies of the original message, including attachments.

----------------------------------------

February 8, 2009

,

You are now listed among my heroes. I really enjoyed reading what you have shared and it inspired me.

I have been doing home visits even before I stopped contracting with insurance. Medicare even paid me once, I believe, at almost thirty cents on the dollar. Now, home visits and phone consultations have become a mainstay of my membership practice.

I am toying with a new idea, but " change fatigue " is keeping me from acting on it at this time. I have started thinking about using my paid-off 27-foot motorhome as my mobile office and getting out of my landlocked office location. Durango is " the mecca " for our little four corners community here in the somewhat isolated Southwest corner of Colorado. I have enough patients in the various outlying communities that I could have certain days where I'm scheduled to be in various communities. I envision parking in the " Durango Mall " parking lot on Mondays and Thursdays, and the " Mercantile " (no relation) parking lot in Bayfield on Tuesdays, then on other days of the week, alternating with Farmington and Pagosa Springs, perhaps even throwing in Mancos one day a month . My part time receptionist would take on the role of dispatchh and run the office from her home. I think I might be able to draw in new patients to my practice with this approach. For those who can not navigate the steps into the motorhome, I would just drive over to their house (like I already do) and see them in their homes.

Now if I could just figure out a way to get better gas mileage....

Durango, CO

Totally agree the problem, as I see it, is that we keep adding layers and layers instead of just starting form a clean slate.

I am going to give my program a second try, with the goal of just diminishing Hospital cost / utilization (where most money and resources go) while improving overall pt. wellbeing. I believe that this is the secret for the care of our aging population in a time of dwindling resources.

In my experiment the high population density made it feasible and I only dedicated Wednesday morning to the program, usually seeing only 2 to 4 new patients. All Hx and Med forms were filled out prior and sent to me the week prior to the visit, which made the visits quick as I pretty much knew what I was getting into. And I would "target" just 2, close by, building each week. I was seeing patients in 6 buildings.

The other big problem is that while we do "the right thing" and improve pts. health and create huge savings, the insurance industry seems to want to keep the benefits for themselves. That was a bitter point when I tried to get the insurance companies, or Medicare, to share the savings with me. I even told them identify the 5% of your panel that is spending the most money due to exacerbations of chronic conditions and assign them to me, with the condition that we share the savings. I could not get that one thru their heads even so I proved to them that I could save millions with just 250 patients. That is the stupidity of the system we are in.

We can all wait for the system to collapse, which in my opinion may not take 5 years, or get something going.

Personally, I think that Primary Care Provider should band in groups and convince, Medicare for example, that we would improve outcomes but with the condition that we share in the savings in some type of contractual form. That would not happen as long as the image continues to be that our services are a social good but not the payments.

José

PS: Gordon I already signed up.

From: [mailto: ] On Behalf Of Dr. Gordon

Sent: Sunday, February 08, 2009 1:29 PMTo: Subject: RE: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

The concepts behind this test appear to be solid and a move in the right direction. The real test is in the implementation.

Several of these implementation efforts have failed. There are a number of reasons for the failures:

The costs of practice level improvement far exceeded any promised financial rewards (I once got a nice check for $635 for that year's quality bonus in Rochester. Yay! Case manager here I come! (I hope you sense the dripping sarcasm.))

The measurement and accountability systems were too onerous and costly for the practices – just take a look at NCQA's PPC-PCMH™ tool and ask "Who is going to bear the costs of jumping through all these hoops and answering all these arcane questions?"

The initiative addressed only a small book of work in the practice – meaning we'd either have to develop a unique system of care for that project (ethical failure of two-tiered care), or we absorb the cost of improved care for all with reward for only a fraction

The program pays practices that don't actually do anything different (this is a dual failure – the program should stipulate the "different" desired and the practices need to deliver)

The program never helped the practices learn how to behave in a new and different way

All the cranky cynicism aside, I am pleased to see continued efforts in many places around the US. There really are folks trying to do the right thing. Some insurers (I know lots of you have good reason to be suspicious) are even trying to do the right thing.

The system is so broken and getting worse that change is inevitable.

I want to see change that makes sense.

Change informed by front line experience (that's us, folks) is more likely to actually help.

To that end we're launching http://SavingPrimaryCare.org

Gordon

From: [mailto: ] On Behalf Of Malia, MD

Sent: Sunday, February 08, 2009 6:55 AMTo: Subject: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

See below for link to article from NYTimes about IBM in Arizona teaming up with UHC to " experiment " with medical homes and payment methods to doctors. Like any article, it's hard to know the whole truth and details about the plan, but, I must say, a few things mixed in seemed promising.

Gordon, et al, know anything about this from any power-broker-schmoozing? What do you think?Tim---------------------------- NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan

From: chasqui@...Date: Sun, February 8, 2009 9:32 amTo: tmalia@...------------------------------------------------------------------------------------

This page was sent to you by: chasqui@...

BUSINESS | February 07, 2009

UnitedHealth and I.B.M. Test Health Care Plan

By REED ABELSONThe giant insurer will test a system to reward doctors for the overall quality of care patients receive.

1. Op-Ed Contributor: The Value of 'Other People's Money' 2. In Florida, Despair and Foreclosures 3. Op-Ed Columnist: Playing With Fire 4. Op-Ed Contributor: Till Children Do Us Part 5. The Downside for Condos in a Downturn » Go to Complete List

The Wrestler Nominatedfor 2 Academy Awards, including Best Actor-Mickey Rourke, and Best Supporting Actress-Marisa Tomei. Now playingClick here to view trailer

---------------------------------------- Malia, MD (phone / fax)www.MaliaFamilyMedicine.comwww.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton Square MallFairport, NY 14450-- Confidentiality Notice --This email message, including all the attachments, is for the sole use of the intended recipient(s) and contains confidential information. Unauthorized use or disclosure is prohibited. If you are not the intended recipient, you may not use, disclose, copy or disseminate this information. If you are not the intended recipient, please contact the sender immediately by reply email and destroy all copies of the original message, including attachments.

----------------------------------------

February 9, 2009

Dr ,Thank you for your efforts.While I believe in " Medical Home " concept, I doubt that it will succeed if the aim is to further squeeze the primary care. The fact that UNH is behind this effort, like other docs, I too feel that there must be something ominous behind the veil. As they are saying they think that $50 is reasonable pay per visit, it stands to logic that by removing number of visits from the equation, they are freezing payments at these rates and will move them only lower with time.

Another fear is what will stop them from " case managing " sitting in their HQ looking at your computer screen running your EMR with remote access to them?I simply can not fathom that UNH is doing it for patients' or doctors' benefit.

If pt are getting AMA average 2.3 visits per year, a doc is getting $115 per year per patient and that is before overheads. I wonder why docs can not go cash-only and charge 30 cents per day per patient per year ?? This will be 109.5 $ (with no nsurance related overheads) per year per pt.

Is 30 cents too high a price for quality healthcare? Why do docs do not get the math?Pawan

February 9, 2009

Do you think $110/year per pt ONLY is enough pay for care?

I agree that $50/visit is NOT the standard; and if THIS is the number behind the UHC effort, then THIS IS their agenda.

United Healthcare (and Aetna) is such a poor payor that they've made NO INROADS in Western PA -- I take Aetna (thankfully most are discounted FFS, not HMO, although I have a few of these -- $3/month is nuts).

They can package this up ANY WAY THEY WANT but CAPITATION is NOT any way for a doc in a low volume practice to go, NO WAY NO WAY NO WAY.

Matt in Western PA

Solo FP since Dec 2004

Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

Dr ,Thank you for your efforts.While I believe in "Medical Home" concept, I doubt that it will succeed if the aim is to further squeeze the primary care. The fact that UNH is behind this effort, like other docs, I too feel that there must be something ominous behind the veil. As they are saying they think that $50 is reasonable pay per visit, it stands to logic that by removing number of visits from the equation, they are freezing payments at these rates and will move them only lower with time. Another fear is what will stop them from "case managing" sitting in their HQ looking at your computer screen running your EMR with remote access to them?I simply can not fathom that UNH is doing it for patients' or doctors' benefit.If pt are getting AMA average 2.3 visits per year, a doc is getting $115 per year per patient and that is before overheads. I wonder why docs can not go cash-only and charge 30 cents per day per patient per year ?? This will be 109.5 $ (with no nsurance related overheads) per year per pt.Is 30 cents too high a price for quality healthcare? Why do docs do not get the math?Pawan

February 9, 2009

Thanks for pointing out. I did not mean 110 is enough. It is not and I apologize if my cynic sarcasm was not evident. Usually people complaint the opposite about me :-)My point is if Docs in AZ are willing to take $50 per visit from UNH, why would they not do better without UNH contract? I do not understand why anyone is accepting such rate?

February 9, 2009

After seeing this and the Senate hearing that Alan Falkoff posted, my

thoughts for today on PCMH and payment reform:

1. The messages being sent to Washington from medical professionals

appear terribly muddled. Everyone seems to have their own axe to

grind, and each supports their view with anecdotes and data that can't

logically support their conclusions. How can any coherent fix for

primary care payment come out of this?

2. It appears that there will be no appetite for payment reform until

a model " proves " that it can improve outcomes. My question is: What

will be accepted as acceptable outcomes? Some proxies for good care

such as HEDIS disease-specific markers, adoption of certified EMRs,

meeting NCQA criteria? The whole conversation needs to be shifted to

focus on the outcomes we need -- actually healthier, happier people.

But what measures do you offer Washington as proof that a model works?

Doctors are never going to agree to base this on patient-reported

measures.

Don't you think, if the Grail of a REAL set of outcome measures that

could be applied to individual practices could be presented to the

power-brokers, then they could get out of the business of telling us

HOW to do our jobs and focus on the funding mechanism to pay those who

make it happen? Can't we leave some room for innovation, practice

differences, geographic differences? What are these measures?!

Haresch

February 9, 2009

This is what UHC is up to. I hope that the NYS Attorney General

keeps on the chase.

Check the link: http://www.nytimes.com/2009/01/13/health/policy/13care.html?_r=1 & scp=5 & sq=United%20health%20care%20cuomo & st=cse

José

From:

[mailto: ] On Behalf Of Pawan Kumar

Sent: Sunday, February 08, 2009 11:36 PM

To:

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

Thanks for pointing out.

I did not mean 110 is enough. It is not and I apologize if my cynic sarcasm was

not evident. Usually people complaint the opposite about me :-)

My point is if Docs in AZ are willing to take $50 per visit from UNH, why would

they not do better without UNH contract? I do not understand why anyone is

accepting such rate?

February 9, 2009

Another point to keep in mind, from Fortune’s website, talking

about UHG (25 on the list)

“The company is currently facing a potential $1.3

billion fine for allegedly failing to pay claims at its PacifiCare unit. In

December, ex-CEO McGuire agreed to return $618 million in executive pay

to settle claims brought by shareholders and the SEC over backdated stock

options, bringing a massive scandal to a close”

The attack has to be 2 prong, one make patients aware of

what, truly, happens to their premiums (see above) and second, the providers

need to start thinking as service providers (business people); the rest of the

industry does. Personally, I have come to believe that if patients, knowingly,

pay premiums to abusive and unfair insurers then they are part of the problem.

We have to make them aware of it if we want change.

As long as patients think that we make a lot of money or

that our work is an entitlement (our services are considered a social good) we

are doomed. Personally I don’t “help” anymore, in my mind I

provide a “service” and I expect, and I am not ashamed, to get paid

for it.

I came to this after realizing that my patients go to the

nail parlor, drink whisky, smoke, contribute to church, drink bottle water, and

pay lawyers and taxis. If they did not have the impression that health care is

an entitlement they would pay for my services too. I strive to provide a great

service, and patients know it and they have the choice to go elsewhere, you get

what you pay for.

Think about it, the same population (our patients) that want

us to basically work for free allows pharma to charge them immoral prices for

medications, supports tort laws that are breaking the system and bounces $10

dollar copay checks (I only take credit or debit cards now); just to name a

few.

Time to speak with one voice, get catastrophic insurance

(MSA account even better) and pay a retainer or cash for you service. In the

medium and long term it is cheaper; we need to show patients the math.

Just a thought!

José

From:

[mailto: ] On Behalf Of Pawan Kumar

Sent: Sunday, February 08, 2009 11:36 PM

To:

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

Thanks for pointing out.

I did not mean 110 is enough. It is not and I apologize if my cynic sarcasm was

not evident. Usually people complaint the opposite about me :-)

My point is if Docs in AZ are willing to take $50 per visit from UNH, why would

they not do better without UNH contract? I do not understand why anyone is

accepting such rate?

February 9, 2009

I believe the logic of how we are going about this in this country

is fundamentally flawed.

So if you believe this-

Most other developed countries have at least as good health care and

outcomes as the United States for substantially less money.

Why?

Because they have a strong primary care component to their health

care system (70% primary care versus 30% primary care here)

Then-

The way to fix our system is to have 70% primary care rather than

30%.

So-

Why is this not being accomplished? (For the multitude of reasons

we discussed on this listserv-insurance issues, payment issues,

morale issues the list goes on)

The first domino in the series is the establishment of a

predominant, strong primary care system and the rest of the dominoes

which include " quality " (including numbers and other criteria which

are not able to be quantified)-will fall into place.

Therefore-

Asking primary care to prove that they should exist before being

allowed to do so is fundamentally flawed.

Lou

>

> After seeing this and the Senate hearing that Alan Falkoff posted,

my

> thoughts for today on PCMH and payment reform:

>

> 1. The messages being sent to Washington from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to

> grind, and each supports their view with anecdotes and data that

can't

> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?

>

> 2. It appears that there will be no appetite for payment reform

until

> a model " proves " that it can improve outcomes. My question is: What

> will be accepted as acceptable outcomes? Some proxies for good care

> such as HEDIS disease-specific markers, adoption of certified EMRs,

> meeting NCQA criteria? The whole conversation needs to be shifted

to

> focus on the outcomes we need -- actually healthier, happier

people.

> But what measures do you offer Washington as proof that a model

works?

> Doctors are never going to agree to base this on patient-reported

> measures.

>

> Don't you think, if the Grail of a REAL set of outcome measures

that

> could be applied to individual practices could be presented to the

> power-brokers, then they could get out of the business of telling

us

> HOW to do our jobs and focus on the funding mechanism to pay those

who

> make it happen? Can't we leave some room for innovation, practice

> differences, geographic differences? What are these measures?!

>

> Haresch

>

February 9, 2009

Do other countries (with better health statistics and more primary care docs) use measures to monitor how primary care is doing?

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]To: Date: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and outcomes as the United States for substantially less money.Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-The way to fix our system is to have 70% primary care rather than 30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues, morale issues the list goes on)The first domino in the series is the establishment of a predominant, strong primary care system and the rest of the dominoes which include "quality" (including numbers and other criteria which are not able to be quantified)- will fall into

place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for> primary care payment come out of this?> > 2. It appears that there will be no appetite for payment reform until> a model "proves"

that it can improve outcomes. My question is: What> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it happen? Can't we leave some room for innovation, practice> differences,

geographic differences? What are these measures?!> > Haresch>

February 9, 2009

Thanks Lou

You state the essential message of http://SavingPrimaryCare.org

G

From: [mailto: ] On Behalf Of l_spikol

Sent: Monday, February 09, 2009

6:36 AM

To:

Subject:

Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

I believe the logic of how we are going about this in

this country

is fundamentally flawed.

So if you believe this-

Most other developed countries have at least as good health care and

outcomes as the United

States for substantially less money.

Why?

Because they have a strong primary care component to their health

care system (70% primary care versus 30% primary care here)

Then-

The way to fix our system is to have 70% primary care rather than

30%.

So-

Why is this not being accomplished? (For the multitude of reasons

we discussed on this listserv-insurance issues, payment issues,

morale issues the list goes on)

The first domino in the series is the establishment of a

predominant, strong primary care system and the rest of the dominoes

which include " quality " (including numbers and other criteria which

are not able to be quantified)-will fall into place.

Therefore-

Asking primary care to prove that they should exist before being

allowed to do so is fundamentally flawed.

Lou

>

> After seeing this and the Senate hearing that Alan Falkoff posted,

my

> thoughts for today on PCMH and payment reform:

>

> 1. The messages being sent to Washington

from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to

> grind, and each supports their view with anecdotes and data that

can't

> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?

>

> 2. It appears that there will be no appetite for payment reform

until

> a model " proves " that it can improve outcomes. My question is:

What

> will be accepted as acceptable outcomes? Some proxies for good care

> such as HEDIS disease-specific markers, adoption of certified EMRs,

> meeting NCQA criteria? The whole conversation needs to be shifted

to

> focus on the outcomes we need -- actually healthier, happier

people.

> But what measures do you offer Washington

as proof that a model

works?

> Doctors are never going to agree to base this on patient-reported

> measures.

>

> Don't you think, if the Grail of a REAL set of outcome measures

that

> could be applied to individual practices could be presented to the

> power-brokers, then they could get out of the business of telling

us

> HOW to do our jobs and focus on the funding mechanism to pay those

who

> make it happen? Can't we leave some room for innovation, practice

> differences, geographic differences? What are these measures?!

>

> Haresch

>

February 9, 2009

Yes. A number of tools have been

used to compare the US

to other developed countries. A lot of the work has been done by Barbara

Starfield of s Hopkins. She has published more than two decades of

work demonstrating the links between population access to primary care,

quality, and cost.

When using measures of population health

we don’t measure up to other developed countries – we’re

number 23 – 35 in rank order on thinks like infant mortality and a host

of other markers.

A lot of this is due to our willingness as

a society to write off the poor and disadvantaged – the outcome

disparities based on income are shameful to the extreme. Providing

universal health care based on effective primary care is what defines a high performing

health system – something we don’t have in the US.

We need to keep hammering on the point

that effective primary care is the solution to the US health care crisis. When

we are provided the resources we need and given relief from the insane burden

of work coming from “coding” and “mother-may-I” health

care denials we will be able to deliver on the promise of effective primary

care.

Gordon

http://SavingPrimaryCare.org

Don’t give in to apathy or

hopelessness, sign up and be part of the solution!

From: [mailto: ] On Behalf Of Lonna Larsh

Sent: Monday, February 09, 2009

8:39 AM

To:

Subject: Re:

Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test

Health Care Plan]

Do other countries (with better health statistics

and more primary care docs) use measures to monitor how primary care is

doing?

From: l_spikol <lspikolptd (DOT) net>

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

To:

Date: Monday, February 9, 2009, 6:36 AM

I believe the logic of

how we are going about this in this country

is fundamentally flawed.

So if you believe this-

Most other developed countries have at least as good health care and

outcomes as the United

States for substantially less money.

Why?

Because they have a strong primary care component to their health

care system (70% primary care versus 30% primary care here)

Then-

The way to fix our system is to have 70% primary care rather than

30%.

So-

Why is this not being accomplished? (For the multitude of reasons

we discussed on this listserv-insurance issues, payment issues,

morale issues the list goes on)

The first domino in the series is the establishment of a

predominant, strong primary care system and the rest of the dominoes

which include " quality " (including numbers and other criteria which

are not able to be quantified)- will fall into place.

Therefore-

Asking primary care to prove that they should exist before being

allowed to do so is fundamentally flawed.

Lou

>

> After seeing this and the Senate hearing that Alan Falkoff posted,

my

> thoughts for today on PCMH and payment reform:

>

> 1. The messages being sent to Washington

from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to

> grind, and each supports their view with anecdotes and data that

can't

> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?

>

> 2. It appears that there will be no appetite for payment reform

until

> a model " proves " that it can improve outcomes. My question is:

What

> will be accepted as acceptable outcomes? Some proxies for good care

> such as HEDIS disease-specific markers, adoption of certified EMRs,

> meeting NCQA criteria? The whole conversation needs to be shifted

to

> focus on the outcomes we need -- actually healthier, happier

people.

> But what measures do you offer Washington

as proof that a model

works?

> Doctors are never going to agree to base this on patient-reported

> measures.

>

> Don't you think, if the Grail of a REAL set of outcome measures

that

> could be applied to individual practices could be presented to the

> power-brokers, then they could get out of the business of telling

us

> HOW to do our jobs and focus on the funding mechanism to pay those

who

> make it happen? Can't we leave some room for innovation, practice

> differences, geographic differences? What are these measures?!

>

> Haresch

>

February 9, 2009

What I meant was - do other countries monitor the "performance" of their primary care docs, such as with HEDIS measures, P4P programs, or other such devices.

From: l_spikol < lspikolptd (DOT) net >Subject: [Practiceimprovemen t1] Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]To: Practiceimprovement 1yahoogroups (DOT) comDate: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and outcomes as the United States for substantially less money.Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-The way to fix our system is to have 70% primary care rather than 30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues, morale issues the list goes on)The first domino in the series is the establishment of a predominant, strong primary care system and the rest of the dominoes which include "quality" (including numbers

and other criteria which are not able to be quantified)- will fall into place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for> primary care payment come out of this?> > 2. It appears that

there will be no appetite for payment reform until> a model "proves" that it can improve outcomes. My question is: What> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it

happen? Can't we leave some room for innovation, practice> differences, geographic differences? What are these measures?!> > Haresch>

February 9, 2009

I’ve not delved very deep into the

literature of how other countries assess the quality of individual providers or

practices. There are some measures in place in many developed countries.

Your question raises another one for

me: “Is office/provider quality measurement the differentiating

feature of high performing health systems?”

An interesting question and while there

may be studies, I am unaware of them in my limited searching on similar topics.

What makes overall care so much better and

so much less expensive is the fact that the other countries organize their

health systems around primary care. Ours is organized around procedures,

gizmos, technology, and interventions.

Gordon

From: [mailto: ] On Behalf Of Lonna Larsh

Sent: Monday, February 09, 2009

9:16 AM

To:

Subject: RE:

Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test

Health Care Plan]

What I meant was - do other countries monitor the

" performance " of their primary care docs, such as with HEDIS

measures, P4P programs, or other such devices.

From:

l_spikol < lspikolptd (DOT) net >

Subject: [Practiceimprovemen t1] Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

To: Practiceimprovement 1yahoogroups (DOT) com

Date: Monday, February 9, 2009, 6:36 AM

I

believe the logic of how we are going about this in this country

is fundamentally flawed.

So if you believe this-

Most other developed countries have at least as good health care and

outcomes as the United

States for substantially less money.

Why?

Because they have a strong primary care component to their health

care system (70% primary care versus 30% primary care here)

Then-

The way to fix our system is to have 70% primary care rather than

30%.

So-

Why is this not being accomplished? (For the multitude of reasons

we discussed on this listserv-insurance issues, payment issues,

morale issues the list goes on)

The first domino in the series is the establishment of a

predominant, strong primary care system and the rest of the dominoes

which include " quality " (including numbers and other criteria

which

are not able to be quantified)- will fall into place.

Therefore-

Asking primary care to prove that they should exist before being

allowed to do so is fundamentally flawed.

Lou

>

> After seeing this and the Senate hearing that Alan Falkoff posted,

my

> thoughts for today on PCMH and payment reform:

>

> 1. The messages being sent to Washington

from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to

> grind, and each supports their view with anecdotes and data that

can't

> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?

>

> 2. It appears that there will be no appetite for payment reform

until

> a model " proves " that it can improve outcomes. My question

is: What

> will be accepted as acceptable outcomes? Some proxies for good care

> such as HEDIS disease-specific markers, adoption of certified EMRs,

> meeting NCQA criteria? The whole conversation needs to be shifted

to

> focus on the outcomes we need -- actually healthier, happier

people.

> But what measures do you offer Washington

as proof that a model

works?

> Doctors are never going to agree to base this on patient-reported

> measures.

>

> Don't you think, if the Grail of a REAL set of outcome measures

that

> could be applied to individual practices could be presented to the

> power-brokers, then they could get out of the business of telling

us

> HOW to do our jobs and focus on the funding mechanism to pay those

who

> make it happen? Can't we leave some room for innovation, practice

> differences, geographic differences? What are these measures?!

>

> Haresch

>

February 9, 2009

I agree (you have more than convinced me, over time, Gordon), and I am skeptical that quality measurements really do that much to increase quality. There is just so much emphasis on them here in the US. I understand that employers, insurance and other interested parties want proof that their money is being well spent, which I believe is the reason for all the quality measures. If our argument for increasing primary care is pointing to other countries with better outcomes, I wonder if also comparing their performance measures/lack thereof would be helpful or just a distraction.

Lonna

From: l_spikol < lspikolptd (DOT) net >Subject: [Practiceimprovemen t1] Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]To: Practiceimprovement 1yahoogroups (DOT) comDate: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and outcomes as the United States for substantially less money.Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-The way to fix our system is to have 70% primary care rather than 30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues, morale issues the list goes on)The first domino in the series is the establishment of a predominant, strong primary care system and the rest of the dominoes which include "quality" (including numbers

and other criteria which are not able to be quantified)- will fall into place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for> primary care payment come out of this?> > 2. It appears that

there will be no appetite for payment reform until> a model "proves" that it can improve outcomes. My question is: What> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it

happen? Can't we leave some room for innovation, practice> differences, geographic differences? What are these measures?!> > Haresch>

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