Approximately 100,000 people per year die from medical errors caused by doctors alone. According to Dr. RJ Roberts of the University of Wisconsin Medical School there are 7 reasons why medical errors occur:
1. Failure to Obtain Informed Consent: This allegation stems from the failure of the physician to ensure the patient is fully informed of expected outcomes, potential risks and reasonable alternatives to the recommended course of action advised by the doctor resulting in damages to the patient.
2. Cancer Misdiagnosis or Failure to Diagnose or a Delay in Diagnosis: This is especially true of breast cancer patients. Doctors who rely on false negative mammogram studies rather than on patient complaints and following up appropriately may cause harm to the patient and be liable for medical malpractice. Approximately 29 percent of screening mammograms return false negative results.
3. Physician Malpractice Resulting From Negligent Procedures or Surgical Errors: Physicians do not necessarily have to be performing unfamiliar procedures for such a medical malpractice suit to ensue. Many physicians are sued because they performed procedures they are trained for when the doctor was not alert due to physical exhaustion or mental distraction. In these circumstances, sleep deprivation or mental stress may cause a deficiently performed procedure leading to patient complications.
4. Wrong Diagnosis and Negligent Misdiagnosis of Fracture or Trauma: This medical malpractice claim occurs when a doctor assumes that a fracture is merely a sprain or other minor injury without follow through investigation with x-rays or other proper diagnostic tests. Dependent on the location of the fracture, this can have severe consequences, including loss of a limb.
5. Delay in Diagnosis or Failure to Consult in a Timely Manner: A doctor who is sued for failure to consult in a timely manner has hesitated too long before making a referral and the patient has suffered adverse repercussions as a result. Within a reasonable amount of visits to the family doctor, the patient should be referred to a specialist if the family doctor is having difficulty pronouncing a diagnosis or symptoms are not improving or worsening despite treatment.
6. Medication Errors or Medication Malpractice Resulting From Negligent Drug Treatment: This is the third leading cause of death. Medical error or negligence in prescribing medications may be the cause of 225,000 deaths per year. Lack of patient education about the medications prescribed is a component of negligent drug treatment. Prescription drug malpractice claims can also result from a doctor's poor handwriting on the prescription order and misinterpretation by a pharmacist.
7. Birth Injury Malpractice or Negligent Maternity Care Practice: The two most common birth defect or birth injury medical malpractice claims arise from excessive use of oxytocin, specifically if the baby is experiencing distress, and the doctor's failure to ensure their patient is covered by another physician informed about the patient's clinical history should the primary doctor be unavailable.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for THE BEST TREATMENT FOR PATIENTS WITH HEART DISEASE AND DIABETES.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Monday, December 28, 2009
Monday, December 21, 2009
THE SIX QUESTIONS:
A GUIDE TO JUDGING FAVORABLY
As Jews approach the High Holy days it is useful to remember that the Torah teaches that, whenever we experience or hear about the negative behavior of another person, we must "judge favorably." In simple terms, that means giving the benefit of the doubt. But how can one follow that advice when it seems that the facts clearly point to someone's guilt?
Sometimes we jump to the wrong conclusion because the facts are different from what we perceive them to be. Even if our facts are accurate, we often misinterpret the intent behind them. When we drop the assumption that there was a negative intention behind someone's actions towards us, we automatically deflate much of the anger and hurt that we feel.
Here are six possible ways to analyze a situation and jump to a good conclusion:
1. Are you sure it happened at all? Sometimes our perceptions of what we see and hear are mistaken.
2. Are you sure the details are correct? One small detail can completely alter the scenario. Something may have been exaggerated or omitted that would make a big difference.
3. Do you know if the other person intended harm? Often the consequences are unforeseen.
4. Do you know the assumptions the other person was operating under? Maybe the other person was operating under a misconception that would explain their behavior.
5. Could the other person's act have been the result of an innocent, human error? Everyone has limitations. Perhaps this person lacked experience, was forgetful, distracted or simply didn't think carefully enough before acting.
6. Do you know what events preceded the negative action? The other person may be enduring a great deal of pain, frustration or stress. This might be a response to a specific situation, like an illness or financial loss. Or it could be a deeper, more pervasive problem that effects the person's entire life.
Although the Torah requires us to judge others with favor and compassion, we are not required to accept abusive behavior from others. Physical, verbal or emotional abuse must be addressed and corrected.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for THE SEVEN REASONS WHY MEDICAL ERRORS OCCUR.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
A GUIDE TO JUDGING FAVORABLY
As Jews approach the High Holy days it is useful to remember that the Torah teaches that, whenever we experience or hear about the negative behavior of another person, we must "judge favorably." In simple terms, that means giving the benefit of the doubt. But how can one follow that advice when it seems that the facts clearly point to someone's guilt?
Sometimes we jump to the wrong conclusion because the facts are different from what we perceive them to be. Even if our facts are accurate, we often misinterpret the intent behind them. When we drop the assumption that there was a negative intention behind someone's actions towards us, we automatically deflate much of the anger and hurt that we feel.
Here are six possible ways to analyze a situation and jump to a good conclusion:
1. Are you sure it happened at all? Sometimes our perceptions of what we see and hear are mistaken.
2. Are you sure the details are correct? One small detail can completely alter the scenario. Something may have been exaggerated or omitted that would make a big difference.
3. Do you know if the other person intended harm? Often the consequences are unforeseen.
4. Do you know the assumptions the other person was operating under? Maybe the other person was operating under a misconception that would explain their behavior.
5. Could the other person's act have been the result of an innocent, human error? Everyone has limitations. Perhaps this person lacked experience, was forgetful, distracted or simply didn't think carefully enough before acting.
6. Do you know what events preceded the negative action? The other person may be enduring a great deal of pain, frustration or stress. This might be a response to a specific situation, like an illness or financial loss. Or it could be a deeper, more pervasive problem that effects the person's entire life.
Although the Torah requires us to judge others with favor and compassion, we are not required to accept abusive behavior from others. Physical, verbal or emotional abuse must be addressed and corrected.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for THE SEVEN REASONS WHY MEDICAL ERRORS OCCUR.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Monday, December 14, 2009
Thin Thighs Associated with Increased Risk for Death, Cardiovascular Disease
Thin Thighs Associated with Increased Risk for Death, Cardiovascular Disease
Adults with very thin thighs may be at increased risk for cardiovascular disease and death, BMJ reports. Published 3 September 2009, doi:10.1136/bmj.b3292
Cite this as: BMJ 2009;339:b3292
Researchers measured thigh circumference in some 2800 men and women, aged 35 to 65, and then followed them for about 10 years to assess incident cardiovascular disease, coronary heart disease (CHD), and mortality.
In adjusted analyses, a thigh circumference below roughly 24 inches (60 cm) was associated with significantly elevated risk for death and cardiovascular disease (but not CHD), with risk increasing as circumference decreased. While a circumference above 24 inches appeared to be protective, the benefit did not continue to increase with increasing circumference. As a potential underlying mechanism, the authors cite research suggesting that low subcutaneous thigh fat results in poor glucose and lipid metabolism. They and an editorialist call for further research to confirm these findings.
Participants 1436 men and 1380 women participating in the Danish MONICA project, examined in 1987-8 for height, weight, and thigh, hip, and waist circumference, and body composition by impedance.
Main outcome measures 10 year incidence of cardiovascular and coronary heart disease and 12.5 years of follow-up for total death.
Results A small thigh circumference was associated with an increased risk of cardiovascular and coronary heart diseases and total mortality in both men and women. A threshold effect for thigh circumference was evident, with greatly increased risk of premature death below around 60 cm. Above the threshold there seemed to be no additional benefit of having larger thighs in either sex. These findings were independent of abdominal and general obesity, lifestyle, and cardiovascular risk factors such as blood pressure and lipid concentration.
Conclusion A low thigh circumference seems to be associated with an increased risk of developing heart disease or premature death. The adverse effects of small thighs might be related to too little muscle mass in the region. The measure of thigh circumference might be a relevant anthropometric measure to help general practitioners in early identification of individuals at an increased risk of premature morbidity and mortality. Several studies have shown a U-shaped association between body mass index (BMI) and mortality, suggesting both a high and a low BMI are associated with premature death. More recent data suggest that while the increased risk seen with a high BMI is mirrored by the risk associated with a high body fat mass, the risk observed at low BMI seems more closely linked to the risk associated with low fat free mass than low fat mass. A larger hip circumference relative to BMI and waist circumference seems a strong inverse predictor of both morbidity and mortality. In this context, a recent study suggested that lower body muscle mass is particularly related to the development of type 2 diabetes. Indeed, studies have reported that insulin resistance could be provoked in lower body muscle, such as leg muscle, but not in arm muscle,8 9 suggesting that the size of the lower body muscle might have great relevance for developing type 2 diabetes. These findings are in line with results from a study among patients with chronic obstructive pulmonary disease, a condition characterized by wasting of muscle, particularly of the lower extremities, which found that the cross sectional area of mid-thigh muscle was a far better predictor of mortality than BMI. Lower body fat, however, might also offer cardioprotection through endocrine secretion of various adipokines, such as adiponectine, a peptide with apparent anti-inflammatory properties.
DISCUSSION
The asuthors found independent inverse associations between thigh circumference and total death and morbidity from cardiovascular disease in both men and women that were particularly evident when thigh circumference was below a threshold of around 60 cm. Above this threshold there did not seem to be any further benefit of having larger thighs. The increased risk associated with smaller thigh circumferences was seen independently of percentage body fat mass and height or of waist circumference and BMI for all end points, suggesting that for any given degree of general and abdominal obesity, smaller thighs are a disadvantage to health and survival for both sexes. Further analyses with adjustment for systolic blood pressure, total cholesterol and triglyceride concentrations, and alcohol weakened the associations only slightly, and suggested that associations between thigh size and the end points were not mediated by differences in these variables. Some power was lost, however, by the inclusion of more covariates and the associations between thigh circumference and particularly coronary heart disease did not remain significant. Their analyses indicated that associations were independent of heavy smoking as measured by pack years, and associations seemed to be stronger for smokers than for never smokers, but this difference was not significant, probably because of too few end points in the two groups of the stratified analysis.
SUMMARY
Low BMI and low fat free mass are associated with early mortality
High BMI, waist circumference, waist to hip ratio, and low hip circumference are also associated with early mortality
Among both men and women, smaller thighs were associated with increased risk of cardiovascular disease and total mortality
A threshold effect for smaller thigh circumference was seen at around 60 cm; above this threshold the protective effect of having larger thighs carried no further survival advantage
A focus on thigh circumference might help medical providers identify individuals who are at increased risk of early morbidity and mortality
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for THE SIX QUESTIONS: A GUIDE TO JUDGING FAVORABLY.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Adults with very thin thighs may be at increased risk for cardiovascular disease and death, BMJ reports. Published 3 September 2009, doi:10.1136/bmj.b3292
Cite this as: BMJ 2009;339:b3292
Researchers measured thigh circumference in some 2800 men and women, aged 35 to 65, and then followed them for about 10 years to assess incident cardiovascular disease, coronary heart disease (CHD), and mortality.
In adjusted analyses, a thigh circumference below roughly 24 inches (60 cm) was associated with significantly elevated risk for death and cardiovascular disease (but not CHD), with risk increasing as circumference decreased. While a circumference above 24 inches appeared to be protective, the benefit did not continue to increase with increasing circumference. As a potential underlying mechanism, the authors cite research suggesting that low subcutaneous thigh fat results in poor glucose and lipid metabolism. They and an editorialist call for further research to confirm these findings.
Participants 1436 men and 1380 women participating in the Danish MONICA project, examined in 1987-8 for height, weight, and thigh, hip, and waist circumference, and body composition by impedance.
Main outcome measures 10 year incidence of cardiovascular and coronary heart disease and 12.5 years of follow-up for total death.
Results A small thigh circumference was associated with an increased risk of cardiovascular and coronary heart diseases and total mortality in both men and women. A threshold effect for thigh circumference was evident, with greatly increased risk of premature death below around 60 cm. Above the threshold there seemed to be no additional benefit of having larger thighs in either sex. These findings were independent of abdominal and general obesity, lifestyle, and cardiovascular risk factors such as blood pressure and lipid concentration.
Conclusion A low thigh circumference seems to be associated with an increased risk of developing heart disease or premature death. The adverse effects of small thighs might be related to too little muscle mass in the region. The measure of thigh circumference might be a relevant anthropometric measure to help general practitioners in early identification of individuals at an increased risk of premature morbidity and mortality. Several studies have shown a U-shaped association between body mass index (BMI) and mortality, suggesting both a high and a low BMI are associated with premature death. More recent data suggest that while the increased risk seen with a high BMI is mirrored by the risk associated with a high body fat mass, the risk observed at low BMI seems more closely linked to the risk associated with low fat free mass than low fat mass. A larger hip circumference relative to BMI and waist circumference seems a strong inverse predictor of both morbidity and mortality. In this context, a recent study suggested that lower body muscle mass is particularly related to the development of type 2 diabetes. Indeed, studies have reported that insulin resistance could be provoked in lower body muscle, such as leg muscle, but not in arm muscle,8 9 suggesting that the size of the lower body muscle might have great relevance for developing type 2 diabetes. These findings are in line with results from a study among patients with chronic obstructive pulmonary disease, a condition characterized by wasting of muscle, particularly of the lower extremities, which found that the cross sectional area of mid-thigh muscle was a far better predictor of mortality than BMI. Lower body fat, however, might also offer cardioprotection through endocrine secretion of various adipokines, such as adiponectine, a peptide with apparent anti-inflammatory properties.
DISCUSSION
The asuthors found independent inverse associations between thigh circumference and total death and morbidity from cardiovascular disease in both men and women that were particularly evident when thigh circumference was below a threshold of around 60 cm. Above this threshold there did not seem to be any further benefit of having larger thighs. The increased risk associated with smaller thigh circumferences was seen independently of percentage body fat mass and height or of waist circumference and BMI for all end points, suggesting that for any given degree of general and abdominal obesity, smaller thighs are a disadvantage to health and survival for both sexes. Further analyses with adjustment for systolic blood pressure, total cholesterol and triglyceride concentrations, and alcohol weakened the associations only slightly, and suggested that associations between thigh size and the end points were not mediated by differences in these variables. Some power was lost, however, by the inclusion of more covariates and the associations between thigh circumference and particularly coronary heart disease did not remain significant. Their analyses indicated that associations were independent of heavy smoking as measured by pack years, and associations seemed to be stronger for smokers than for never smokers, but this difference was not significant, probably because of too few end points in the two groups of the stratified analysis.
SUMMARY
Low BMI and low fat free mass are associated with early mortality
High BMI, waist circumference, waist to hip ratio, and low hip circumference are also associated with early mortality
Among both men and women, smaller thighs were associated with increased risk of cardiovascular disease and total mortality
A threshold effect for smaller thigh circumference was seen at around 60 cm; above this threshold the protective effect of having larger thighs carried no further survival advantage
A focus on thigh circumference might help medical providers identify individuals who are at increased risk of early morbidity and mortality
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for THE SIX QUESTIONS: A GUIDE TO JUDGING FAVORABLY.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Monday, December 7, 2009
WHAT IS GERD?
WHAT IS GERD?
Acid reflux [GASTRO-ESOPHAGEAL REFLUX DISORDER]occurs when the lower esophageal sphincter (LES) muscle allows the stomach's contents to splash back into the esophagus, resulting in painful heartburn, chest pain, coughing or choking while lying down, or increased asthma symptoms while sleeping. Eating too much at one time, too much acid in the stomach, or food remaining in the stomach for too long a time can all prevent this muscle from doing what it is supposed to. Ideally, food should move smoothly and relatively quickly through the stomach and on to the lower digestive tract.
WHAT FOODS TO AVOID?
Foods that can increase acid production include coffee (caffeinated and decaffeinated), chocolate, soft drinks and cocoa. Acidic foods that should be avoided include citrus fruits and juices (orange, lemon, grapefruit), cranberry juice, lemonade, pineapple, tomatoes and tomato products (spaghetti sauce, salsa, soup).
Other foods that can cause heartburn are those high in fat, such as french fries, ground beef (chuck), marbled steak, chicken nuggets, buffalo wings, sour cream, milkshakes, ice cream, regular cottage cheese, macaroni and cheese, doughnuts, corn chips, regular potato chips, brownies, butter cookies, mayonnaise, butter, margarine, creamy sauces, salad dressing and whole-milk dairy products.
Raw onions and spicy foods can cause heartburn and alcohol relaxes the LES muscle causing it to allow acid reflux.
Avoid when possible processed foods, white sugar, white flour and wheat, which can produce an acidic reaction. Healthcentral.com suggests that wheat, a known allergen, may be the sole cause of some acid reflux and that eliminating gluten from your diet might be all that is necessary to stop acid reflux.
LOW-RISK FOODS
Foods that carry little risk of causing heartburn include apples (juice, dried and fresh), bananas, baked potato, broccoli, cabbage, carrots, green beans, peas, extra lean ground beef, London broil, skinless chicken breast, egg whites, egg substitute, fish prepared with no additional fat, feta or goat cheese, fat-free cream cheese and sour cream, low-fat soy cheese, multi-grain or white bread, bran cereal or oatmeal, corn bread, graham crackers, pretzels, brown or white rice, rice cakes, mineral water, low-fat salad dressing, fat-free cookies, jelly beans, red licorice, angel food cake, baked potato chips.
WORTH TRYING
These foods may require some experimentation, but may be tolerated in moderate amounts by some GERD patients: low-acid orange juice, peaches, blueberries, raspberries, strawberries, grapes and dried cranberries, garlic, cooked onion, leeks, chicken salad, eggs scrambled in butter, fried eggs, tuna salad, beef or pork hot dogs, ham, yogurt, 2-percent or skim milk, frozen yogurt, cheddar or mozzarella cheese, garlic bread, granola, non-alcoholic wine or beer, root beer, small amounts of ketchup.
Complex carbohydrates, whole grains and starchy vegetables, including sweet potatoes and plantains, are not only gentle on the stomach, but also help control excess stomach acid. Among the best whole grains for long-term acid reflux reduction are millet, couscous and amaranth, all of which are considered alkaline.
MORE TIPS
Eating five or six small meals per day instead of three large ones prevents the stomach from becoming too full.
Putting your fork down between bites will prevent you from eating too much too fast.
After dinner, chewing gum stimulates saliva production which can help neutralize stomach acid and increase peristalsis, the contractions and relaxation of muscles along the digestive tract that helps move stomach contents along the digestive system.
Drinking a glass of lukewarm water or herbal tea after a meal can dilute and flush out stomach acid.
An after-dinner cigarette, cigar or pipe can cause problems by weakening the LES muscle.
WEB SITES
www.heartburn.about.com/library/bl_samplemenu_charts.html.
http://www.drgourmet.com/gerd
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Thin Thighs Associated with Increased Risk for Death.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Acid reflux [GASTRO-ESOPHAGEAL REFLUX DISORDER]occurs when the lower esophageal sphincter (LES) muscle allows the stomach's contents to splash back into the esophagus, resulting in painful heartburn, chest pain, coughing or choking while lying down, or increased asthma symptoms while sleeping. Eating too much at one time, too much acid in the stomach, or food remaining in the stomach for too long a time can all prevent this muscle from doing what it is supposed to. Ideally, food should move smoothly and relatively quickly through the stomach and on to the lower digestive tract.
WHAT FOODS TO AVOID?
Foods that can increase acid production include coffee (caffeinated and decaffeinated), chocolate, soft drinks and cocoa. Acidic foods that should be avoided include citrus fruits and juices (orange, lemon, grapefruit), cranberry juice, lemonade, pineapple, tomatoes and tomato products (spaghetti sauce, salsa, soup).
Other foods that can cause heartburn are those high in fat, such as french fries, ground beef (chuck), marbled steak, chicken nuggets, buffalo wings, sour cream, milkshakes, ice cream, regular cottage cheese, macaroni and cheese, doughnuts, corn chips, regular potato chips, brownies, butter cookies, mayonnaise, butter, margarine, creamy sauces, salad dressing and whole-milk dairy products.
Raw onions and spicy foods can cause heartburn and alcohol relaxes the LES muscle causing it to allow acid reflux.
Avoid when possible processed foods, white sugar, white flour and wheat, which can produce an acidic reaction. Healthcentral.com suggests that wheat, a known allergen, may be the sole cause of some acid reflux and that eliminating gluten from your diet might be all that is necessary to stop acid reflux.
LOW-RISK FOODS
Foods that carry little risk of causing heartburn include apples (juice, dried and fresh), bananas, baked potato, broccoli, cabbage, carrots, green beans, peas, extra lean ground beef, London broil, skinless chicken breast, egg whites, egg substitute, fish prepared with no additional fat, feta or goat cheese, fat-free cream cheese and sour cream, low-fat soy cheese, multi-grain or white bread, bran cereal or oatmeal, corn bread, graham crackers, pretzels, brown or white rice, rice cakes, mineral water, low-fat salad dressing, fat-free cookies, jelly beans, red licorice, angel food cake, baked potato chips.
WORTH TRYING
These foods may require some experimentation, but may be tolerated in moderate amounts by some GERD patients: low-acid orange juice, peaches, blueberries, raspberries, strawberries, grapes and dried cranberries, garlic, cooked onion, leeks, chicken salad, eggs scrambled in butter, fried eggs, tuna salad, beef or pork hot dogs, ham, yogurt, 2-percent or skim milk, frozen yogurt, cheddar or mozzarella cheese, garlic bread, granola, non-alcoholic wine or beer, root beer, small amounts of ketchup.
Complex carbohydrates, whole grains and starchy vegetables, including sweet potatoes and plantains, are not only gentle on the stomach, but also help control excess stomach acid. Among the best whole grains for long-term acid reflux reduction are millet, couscous and amaranth, all of which are considered alkaline.
MORE TIPS
Eating five or six small meals per day instead of three large ones prevents the stomach from becoming too full.
Putting your fork down between bites will prevent you from eating too much too fast.
After dinner, chewing gum stimulates saliva production which can help neutralize stomach acid and increase peristalsis, the contractions and relaxation of muscles along the digestive tract that helps move stomach contents along the digestive system.
Drinking a glass of lukewarm water or herbal tea after a meal can dilute and flush out stomach acid.
An after-dinner cigarette, cigar or pipe can cause problems by weakening the LES muscle.
WEB SITES
www.heartburn.about.com/library/bl_samplemenu_charts.html.
http://www.drgourmet.com/gerd
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Thin Thighs Associated with Increased Risk for Death.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Monday, November 30, 2009
Section III of III The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans
Section III of III The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans
MY OPINION:
The idea of paying physicians more for providing guideline-based care has taken the American health system by storm in the last decade. Today, more than 150 pay-for-performance programs are centered on the notion that rewarding evidence-based care is key to improving health care quality.
Does evidence based research show that P4P is efficacious and improves quality care? No. At least not yet.
Some P4P efforts have shown beneficial results, according to the Centers for Medicare & Medicaid Services. An evaluation of its Physician Group Practice Demonstration found that all 10 participating practices hit or exceeded targets on at least seven of 10 quality metrics of diabetes care. A Feb. 1, 2007, New England Journal of Medicine study found that Medicare's pay-for-performance demonstration project was associated with a modest improvement on quality metrics, compared with hospitals not in the project.
Steven D. Pearson, MD, president of Harvard Medical School's Institute for Clinical and Economic Review says that "Unless you look at a control group of some kind, you may be misled about what's really happening."
There appears to be a fundamental problem with current P4P programs. They have had little to no impact on quality. That is the conclusion of many studies, including an analysis of quality incentives, published in the July/August, 2008 of Health Affairs. It compared 81 Massachusetts physician groups eligible for quality incentives with 73 that were not. The study did find, however, that overall performance from 2001 to 2003 improved on 73% of preventive care measures such as diabetes hemoglobin A1c testing, breast cancer screening and well-child visits. But the performance of the 5,350 physicians analyzed was statistically indistinguishable. Everyone's quality improved, regardless of whether the physician group stood to earn a bonus, which ranged from $200 to $2,500 per quality measure for an individual physician, depending on the health plan.
Another study that examined the CMS hospital P4P data also wasn't positive about P4P. A June 6, 2007, Journal of the American Medical Association study of heart attack care found no significant improvement for 54 hospitals in the CMS P4P demonstration, compared with 446 nonparticipating hospitals.
And a systematic review of 17 studies, published in the Aug. 15, 2006, Annals of Internal Medicine, found positive or partially positive effects of P4P programs, but the impact was usually small.
We actually have remarkably few evaluations that have a comparison group of any kind, so the evidence on pay-for-performance is rather spotty.
Overall the P4P programs evaluated over the last five years have been largely unimpressive in their results.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Acid reflux foods.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
MY OPINION:
The idea of paying physicians more for providing guideline-based care has taken the American health system by storm in the last decade. Today, more than 150 pay-for-performance programs are centered on the notion that rewarding evidence-based care is key to improving health care quality.
Does evidence based research show that P4P is efficacious and improves quality care? No. At least not yet.
Some P4P efforts have shown beneficial results, according to the Centers for Medicare & Medicaid Services. An evaluation of its Physician Group Practice Demonstration found that all 10 participating practices hit or exceeded targets on at least seven of 10 quality metrics of diabetes care. A Feb. 1, 2007, New England Journal of Medicine study found that Medicare's pay-for-performance demonstration project was associated with a modest improvement on quality metrics, compared with hospitals not in the project.
Steven D. Pearson, MD, president of Harvard Medical School's Institute for Clinical and Economic Review says that "Unless you look at a control group of some kind, you may be misled about what's really happening."
There appears to be a fundamental problem with current P4P programs. They have had little to no impact on quality. That is the conclusion of many studies, including an analysis of quality incentives, published in the July/August, 2008 of Health Affairs. It compared 81 Massachusetts physician groups eligible for quality incentives with 73 that were not. The study did find, however, that overall performance from 2001 to 2003 improved on 73% of preventive care measures such as diabetes hemoglobin A1c testing, breast cancer screening and well-child visits. But the performance of the 5,350 physicians analyzed was statistically indistinguishable. Everyone's quality improved, regardless of whether the physician group stood to earn a bonus, which ranged from $200 to $2,500 per quality measure for an individual physician, depending on the health plan.
Another study that examined the CMS hospital P4P data also wasn't positive about P4P. A June 6, 2007, Journal of the American Medical Association study of heart attack care found no significant improvement for 54 hospitals in the CMS P4P demonstration, compared with 446 nonparticipating hospitals.
And a systematic review of 17 studies, published in the Aug. 15, 2006, Annals of Internal Medicine, found positive or partially positive effects of P4P programs, but the impact was usually small.
We actually have remarkably few evaluations that have a comparison group of any kind, so the evidence on pay-for-performance is rather spotty.
Overall the P4P programs evaluated over the last five years have been largely unimpressive in their results.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Acid reflux foods.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Monday, November 23, 2009
Section II of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans
1. From Woolf, SH, JAMA, Vol. 282, 1999 - Estimated savings for good treatment of DM, HTN, MI, Colorectal CA, Pneumonia over current treatment levels.
a. DM control could prevent 2,600 cases of blindness and 29,000 cases of kidney failure.
b. HTN control could prevent 68,000 deaths
c. Following evidence guidelines in MI could prevent 37,000 deaths
d. Administration of pneumoccal vaccine could prevent an estimated 10,000 deaths per year
e. Colorectal cancer screening could prevent an estimated 9,600 deaths per year (not to mention the cases where multiple hospitalizations and chemotherapy are needed.)
2. From Diabetes Care - Vol 20, Number 12, Dec 1997 - Cost of diabetic with A1c at 6-7% is $378/year, with A1c of 9-10% is $1205 per year. Cost of Diabetic with CAD and HTN is $1505/year at A1c of 6-7%, $4116/year at a1c of 9-10%
3. Premier Report came out last month: Simple adherence to basic medical treatment guidelines for Medicare patients hospitalized for CABG, MI, and Knee replacement would save $1.35 billion per year. 5,700 deaths, 8,100 complications and 10,000 readmission to the hospital could be averted if clinicians followed medically prescribed treatment steps.
4. Bridges to Excellence (Bridgestoexcellence.org) has found that for every $1 bonused to a primary care doctor, there was a savings of $3 to the payor (not insurance company in this case, but employer). BTE is an initiative initally by fortune 500 companies and was outside of insurance companies.
Doctors say:
The doctors respond with their argument is not that P4P is the solution to all problems. Instead, the main focus now should be on the current reimbursement system that does not simply not pay for good care, but it encourages bad care.
The recent study that showed that over half of elderly patients leave the doctor's office without proper medication advice is a good example. Why is this? It happens because doctors are pressured to see as many patients as possible to meet overhead and consequently spend less time on each patient. Medicare cuts should only add fuel to this fire.
There’s plenty of data that shows that medical care in the US is not nearly at the quality it should be. It is not the doctors that are at fault (in their opinion) but the system that does not reward good care, but instead rewards doctors who spend as little time as possible with patients.
Doctors say:
The doctor’s main point, is that the current payment system is broken, CMS is dead set on fixing it via P4P.
But say the doctors instead of being judged for whether a test was done (without EMR, this is the only way to measure performance, as it is based on claims data), but whether it was addressed by the physician.
If a patient chooses to not have a mammogram, the doctor should be able to report that they refused it and get credit for addressing the issue.
If blood pressure is up and the doctor responds appropriately, he/she should be credited for doing the right thing, regardless of the outcome.
The concept should be that measuring physician behaviors on an EMR system so as to accurately record the intent of the physician.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Section III of III. The Debate.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
a. DM control could prevent 2,600 cases of blindness and 29,000 cases of kidney failure.
b. HTN control could prevent 68,000 deaths
c. Following evidence guidelines in MI could prevent 37,000 deaths
d. Administration of pneumoccal vaccine could prevent an estimated 10,000 deaths per year
e. Colorectal cancer screening could prevent an estimated 9,600 deaths per year (not to mention the cases where multiple hospitalizations and chemotherapy are needed.)
2. From Diabetes Care - Vol 20, Number 12, Dec 1997 - Cost of diabetic with A1c at 6-7% is $378/year, with A1c of 9-10% is $1205 per year. Cost of Diabetic with CAD and HTN is $1505/year at A1c of 6-7%, $4116/year at a1c of 9-10%
3. Premier Report came out last month: Simple adherence to basic medical treatment guidelines for Medicare patients hospitalized for CABG, MI, and Knee replacement would save $1.35 billion per year. 5,700 deaths, 8,100 complications and 10,000 readmission to the hospital could be averted if clinicians followed medically prescribed treatment steps.
4. Bridges to Excellence (Bridgestoexcellence.org) has found that for every $1 bonused to a primary care doctor, there was a savings of $3 to the payor (not insurance company in this case, but employer). BTE is an initiative initally by fortune 500 companies and was outside of insurance companies.
Doctors say:
The doctors respond with their argument is not that P4P is the solution to all problems. Instead, the main focus now should be on the current reimbursement system that does not simply not pay for good care, but it encourages bad care.
The recent study that showed that over half of elderly patients leave the doctor's office without proper medication advice is a good example. Why is this? It happens because doctors are pressured to see as many patients as possible to meet overhead and consequently spend less time on each patient. Medicare cuts should only add fuel to this fire.
There’s plenty of data that shows that medical care in the US is not nearly at the quality it should be. It is not the doctors that are at fault (in their opinion) but the system that does not reward good care, but instead rewards doctors who spend as little time as possible with patients.
Doctors say:
The doctor’s main point, is that the current payment system is broken, CMS is dead set on fixing it via P4P.
But say the doctors instead of being judged for whether a test was done (without EMR, this is the only way to measure performance, as it is based on claims data), but whether it was addressed by the physician.
If a patient chooses to not have a mammogram, the doctor should be able to report that they refused it and get credit for addressing the issue.
If blood pressure is up and the doctor responds appropriately, he/she should be credited for doing the right thing, regardless of the outcome.
The concept should be that measuring physician behaviors on an EMR system so as to accurately record the intent of the physician.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Section III of III. The Debate.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Monday, November 16, 2009
Section I of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans
Doctors say:
"Pay for Performance" (often abbreviated P4P) is based on the false concept that doctors will take better care of patients if they're paid more.
Big insurers in each state; are discussing P4P as the next thing as they ratchet down reimbursements and pile on the denial hassles according to practicing physicians.
Why P4P?
Is it to save more money for medical insurance carriers.
Or is it truly to reward better quality medical care?
Capitation is broken say doctors.
Capitation is/was a way to shift the risk of having to pay for a doctor's visit away from the insurance company and onto the doctor. Somehow or another back in the early '80s enough people were fooled, but have since wised up say doctors. If no one's willing to take it on, capitation won't work. That's why it's fading away, say doctors.
Fee for service is broken say the insurance carriers.
Baloney- say the doctors. “Pay me a reasonable rate for what I do and I'll be happy as a clam.”
Insurance carriers say:
• Fee for service has no incentive for quality
• Thus we need Fee for service + bonus/incentive to reward quality
Doctors say:
At no point in P4P discussions has the word "Quality" ever effectively been defined in the context of medical care.
Insurance carriers say:
What percentage of your diabetic patients have A1C's under 7%; how many of your hypertensives' blood pressures are controlled?
What % of patients had mammograms and colonoscopies?
That’s what tells us that your patients are getting food or bad quality care.
Doctors say:
The central element of "quality" will forever remain fundamentally un-measureable; and here's why:
In the primary care context, the essence of a given encounter for medical care consists of an interaction between two people: the doctor and the patient. There are certain things doctors expected to do: ask appropriate question to elicit sufficient information to come to an accurate diagnosis; decide upon and discuss various treatment options with the patient; make sure that the patient has enough information, education and emotional support to understand and implement the treatment (or work up) plan; and so on.
But the key element is that the encounter is an interaction. There are two of us. The quality of that interaction is not 100% dependent on me. Any attempt to "measure" it implies that it is. And doctors don't buy it.
The discussions on P4P inevitably turns to EMRs (electronic medical records) as an integral part of P4P. Everyone has to have them; that's how they're going to get the performance data they're going to pay doctors.
But once all the numbers are crunched, though, it turns out a doctor will see only about $3,000 in P4P bonuses for a $30,000 EMR investment..
The response by insurance carriers is that the real return is more likely to be in the areas of quality and lifestyle.
Doctors reply:
Imagine presenting a proposal to an insurance company -- actually to any kind of business -- and saying, "Now, you'll only make back about 10% of your initial investment, but you're likely to see improvement the areas of quality and lifestyle."
Doctors see P4P as in the early 1990’s when the buzzword was "vertical integration." Hospitals and health systems were buying up medical practices. The idea was that by consolidating the referral base, the "system" would rake in the profits, which would then trickle down to the now employed physicians. The private office, especially solo, was considered an unworkable business model. Over the next ten years, it didn't work out quite the way the hospitals and health systems said it would. So docs were stuck either buying back their own practices, or being subjected to more and more outrageous working conditions (required to see 56 patients in 8 hours, etc.)
Doctors say:
This whole "pay for performance" thing doesn't sound quite right for many reasons. They believe that when everyone seems to think something is so, but can't explain it in a way that it makes sense to them, there's something wrong with what they're saying.
And what is quality they ask?
Openly discussing both benefits and risks of screening or just using scare tactic to get more patients screened?
If you are not mentioning the risks, if you using relative mortality reduction and not mentioning the real chance of your patient benefitting, are you not misleading the patient?
It happens already, but at least now, the doctors respect the right to choose.
Doctors say:
With P4P doctors will be loosing money for every patient with LDL 4 points above guidelines (even those with 10-year heart attack risk of 1%). A 40-something ballet teacher with no family history of heart disease and normal ratio, albeit slightly elevated LDL is complaining of muscle side effects that interfere with her ability to do her job (saw this woman's post on one of the forums) - "what would you rather have: a heart attack or muscle pain?"
No explanation of the actual magnitude of benefit for her; after all if you mention that you are only talking about 0.3 percentage points in ARR, a patient might refuse and here goes you P4P. "It'll reduce your heart attack risk by whopping 30%".
Very few patients would think to ask "n% of what number exactly?"
Incidentally, maybe P4P should also evaluate physicians on providing honest and accurate information (to the best of the existing evidence) to the patients and respecting their right of informed refusal?
Anybody thought of making this one of the criteria?
Whether or not it is cost effective depends on absolute risk reduction for a particular person. For diabetics or people who already had heart disease it may well be (although if someone doesn't take drugs and dies sooner, will this person save money or use more of it?)
But when you are talking about measures with small absolute benefit, it should be individual choice.
As a patient I have a right to decide for myself whether certain small risk reduction worth the risks or side effects for me or not.
I don't want an incentive for a doctor that would depend on the choices I have a right to make.
I want an incentive to provide accurate information but without the vested interest in my decision.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Section II of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
"Pay for Performance" (often abbreviated P4P) is based on the false concept that doctors will take better care of patients if they're paid more.
Big insurers in each state; are discussing P4P as the next thing as they ratchet down reimbursements and pile on the denial hassles according to practicing physicians.
Why P4P?
Is it to save more money for medical insurance carriers.
Or is it truly to reward better quality medical care?
Capitation is broken say doctors.
Capitation is/was a way to shift the risk of having to pay for a doctor's visit away from the insurance company and onto the doctor. Somehow or another back in the early '80s enough people were fooled, but have since wised up say doctors. If no one's willing to take it on, capitation won't work. That's why it's fading away, say doctors.
Fee for service is broken say the insurance carriers.
Baloney- say the doctors. “Pay me a reasonable rate for what I do and I'll be happy as a clam.”
Insurance carriers say:
• Fee for service has no incentive for quality
• Thus we need Fee for service + bonus/incentive to reward quality
Doctors say:
At no point in P4P discussions has the word "Quality" ever effectively been defined in the context of medical care.
Insurance carriers say:
What percentage of your diabetic patients have A1C's under 7%; how many of your hypertensives' blood pressures are controlled?
What % of patients had mammograms and colonoscopies?
That’s what tells us that your patients are getting food or bad quality care.
Doctors say:
The central element of "quality" will forever remain fundamentally un-measureable; and here's why:
In the primary care context, the essence of a given encounter for medical care consists of an interaction between two people: the doctor and the patient. There are certain things doctors expected to do: ask appropriate question to elicit sufficient information to come to an accurate diagnosis; decide upon and discuss various treatment options with the patient; make sure that the patient has enough information, education and emotional support to understand and implement the treatment (or work up) plan; and so on.
But the key element is that the encounter is an interaction. There are two of us. The quality of that interaction is not 100% dependent on me. Any attempt to "measure" it implies that it is. And doctors don't buy it.
The discussions on P4P inevitably turns to EMRs (electronic medical records) as an integral part of P4P. Everyone has to have them; that's how they're going to get the performance data they're going to pay doctors.
But once all the numbers are crunched, though, it turns out a doctor will see only about $3,000 in P4P bonuses for a $30,000 EMR investment..
The response by insurance carriers is that the real return is more likely to be in the areas of quality and lifestyle.
Doctors reply:
Imagine presenting a proposal to an insurance company -- actually to any kind of business -- and saying, "Now, you'll only make back about 10% of your initial investment, but you're likely to see improvement the areas of quality and lifestyle."
Doctors see P4P as in the early 1990’s when the buzzword was "vertical integration." Hospitals and health systems were buying up medical practices. The idea was that by consolidating the referral base, the "system" would rake in the profits, which would then trickle down to the now employed physicians. The private office, especially solo, was considered an unworkable business model. Over the next ten years, it didn't work out quite the way the hospitals and health systems said it would. So docs were stuck either buying back their own practices, or being subjected to more and more outrageous working conditions (required to see 56 patients in 8 hours, etc.)
Doctors say:
This whole "pay for performance" thing doesn't sound quite right for many reasons. They believe that when everyone seems to think something is so, but can't explain it in a way that it makes sense to them, there's something wrong with what they're saying.
And what is quality they ask?
Openly discussing both benefits and risks of screening or just using scare tactic to get more patients screened?
If you are not mentioning the risks, if you using relative mortality reduction and not mentioning the real chance of your patient benefitting, are you not misleading the patient?
It happens already, but at least now, the doctors respect the right to choose.
Doctors say:
With P4P doctors will be loosing money for every patient with LDL 4 points above guidelines (even those with 10-year heart attack risk of 1%). A 40-something ballet teacher with no family history of heart disease and normal ratio, albeit slightly elevated LDL is complaining of muscle side effects that interfere with her ability to do her job (saw this woman's post on one of the forums) - "what would you rather have: a heart attack or muscle pain?"
No explanation of the actual magnitude of benefit for her; after all if you mention that you are only talking about 0.3 percentage points in ARR, a patient might refuse and here goes you P4P. "It'll reduce your heart attack risk by whopping 30%".
Very few patients would think to ask "n% of what number exactly?"
Incidentally, maybe P4P should also evaluate physicians on providing honest and accurate information (to the best of the existing evidence) to the patients and respecting their right of informed refusal?
Anybody thought of making this one of the criteria?
Whether or not it is cost effective depends on absolute risk reduction for a particular person. For diabetics or people who already had heart disease it may well be (although if someone doesn't take drugs and dies sooner, will this person save money or use more of it?)
But when you are talking about measures with small absolute benefit, it should be individual choice.
As a patient I have a right to decide for myself whether certain small risk reduction worth the risks or side effects for me or not.
I don't want an incentive for a doctor that would depend on the choices I have a right to make.
I want an incentive to provide accurate information but without the vested interest in my decision.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
*Tune in later for Section II of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
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