Sep 15, 2014

Is This Any Way to Treat a Doctor?

Our Facebook page is exploding with likes, shares, and comments on our new Doctors Are Under Siege by the Federal Regulatory Barrage flyer. It has garnered rave reviews from physicians around Texas and around the country for accurately portraying the weight of federal demands on a practice today. Please download it, print it out, and share it with your patients and friends in high places. TMA’s lobby team will distribute it on Capitol Hill next week.

Aug 11, 2014

Six Serious Problems with "Value-Based" Purchasing and How to Solve Them

By Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform.

Both patients and healthcare providers could be harmed by the measures of healthcare spending Medicare plans to use in its new Value-Based Payment Modifier for physicians and in the Value-Based Purchasing Program for hospitals.  Serious problems also exist with the spending measures that many commercial health plans are using to define narrow networks and that both Medicare and commercial health plans are using in various "shared savings" payment contracts with physicians, hospitals, and Accountable Care Organizations.

A new report from the Center for Healthcare Quality and Payment Reform - Measuring and Assigning Accountability for Healthcare Spending - explains how the spending measures used in so-called "value-based purchasing" programs can:

  • Inappropriately assign accountability to physicians and hospitals for services they did not deliver and cannot control, while at the same time failing to hold healthcare providers accountable for many of the services they do deliver. 
  • Financially penalize physicians and hospitals who care for patients with complex health problems and who deliver evidence-based services to their patients;
  • Fail to provide physicians, hospitals, and other providers with the kind of actionable information they need to identify opportunities to control healthcare spending without harming patients; and
  • Give patients misleading information about which providers deliver lower-cost, higher quality care.

The report details multiple, serious weaknesses in the simplistic "attribution" methodologies Medicare and other payers are currently using to retrospectively assign accountability to a single physician, hospital, or other provider for all of the spending on all of the healthcare services received by a patient over a period of time, regardless of which providers actually delivered those services.  For example, under current approaches:

  • Most of the spending that is attributed to a physician usually results from services delivered by other providers.
  • Physicians are assigned responsibility for services new patients receive before the physician first met the patient.  
  • Primary care physicians are assigned responsibility for services delivered by specialists to treat serious illnesses such as cancer; and
  • Specialists and hospitals are assigned responsibility for unrelated healthcare problems their patients experience in the future.

The report also describes how the "risk scores" currently used to adjust spending measures fail to recognize important differences in patient needs and can thereby mislabel physicians and hospitals as "inefficient" if they care for patients who have acute illnesses or complex problems.

In addition to documenting the many serious problems with current approaches, Measuring and Assigning Accountability for Healthcare Spending shows how they can be solved.  A detailed methodology is presented for assigning accountability to providers for the services they actually can control or influence.  The methodology also explicitly identifies which services might be changed in order to achieve the same or better outcomes for patients at a lower cost.  In addition, methods are described for comparing providers' performance in treating patients with similar needs rather than trying to use a single, simplistic risk score to "adjust" spending.  The report shows how these improved methodologies can use existing data to produce more valid, reliable, comprehensive, and actionable measures than those currently being used.

Better ways of measuring and assigning accountability for spending are necessary but not sufficient for achieving a higher-value healthcare system.  Even if they use better spending measures, value-based purchasing, pay for performance, and shared savings payment systems do not remove the fundamental barriers to better care that are created by the current fee-for-service system.  Measuring and Assigning Accountability for Healthcare Spending shows how better ways of measuring spending can help payers and providers move more quickly to true payment reforms such as bundled payments, warranties, condition-based payments, and global payments. 

Both the full report and the 7-page Executive Summary are available at no charge on the CHQPR website (  Comments on the report are welcome.

Jul 14, 2014

Veterans' Needs 'Should Drive Where They Get Their Care'

JUL 14, 2014
On Capitol Hill, lawmakers resume work this week to resolve differences over legislationaimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointments and that some VA staff falsified records to cover up excessive wait times.  Five senior VA leaders – including former department secretary Eric Shinseki – have resigned in the past six weeks.

Dr. Kenneth Kizer
Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.
Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outsideproviders for medical care. Kizer, the founding chief executive officer and president of the National Quality Forum, is now director of the Institute for Population Health Improvement at the University of California, Davis.
An edited transcript of that interview follows.
Q: Both the House and Senate bills include a provision allowing the VA to contract with non–VA medical providers to ease waiting lists.  What are some of the challenges the VA faces in creating new outside networks of providers. 
A: The challenges in creating new networks are the same that everybody faces. Who are the providers? What are their credentials? Can you find the types of providers that you need? What’s the quality of care? How will the information, the exam reports, the consultation reports, how will that information be fed back into the system?  It’s not unlike some of what you’re seeing being played out right now with the health plans which are competing under the Affordable Care Act provisions for the health insurance exchanges. Regardless of who the payer is, you have the same problems.
There are shortages of primary care physicians and mental health professionals everywhere. The VA has done a good job in bolstering the number of mental health providers that it has. But the mental health system in this country is broken. The system just doesn’t work well, so referring veterans out for mental health services may be problematic for a whole host of reasons.
Q: The VA currently has a program that allows it to contract with outside medical providers to make sure veterans receive timely and accessible care.  How would a new contracting program compare to what is currently being done?
A: That’s going to depend on the specific language [that Congress passes]. The VA currently spends about $5 billion a year on what’s called fee-basis care, basically sending people out for services. The need to send veterans out for services that the VA has difficulty sometimes providing is not a new issue. This has been going on for years. The amount of care that’s being provided outside of the VA has increased dramatically in recent years. 
There was a particular program Congress implemented called Project Hero. The VA contracted with some managed care providers – three providers in four geographic areas – to help ease the waiting list issue. Some of the problems they encountered there were the ones we’re talking about—getting into the [providers’] networks and ensuring [that providers] actually were in the network. Sometimes they have availability. You can get an appointment in a short time but they might be a long distance away. Veterans complain, “Yeah, they can get me in next week but I had to drive 100 miles to get there.” 
In that program there was difficulty getting information back to the VA. The private providers would often dictate their reports, which would have to be sent to the plan, which would then fax a copy and send it to the VA and then that had to be scanned into the electronic health record. Sometimes that might take weeks or more. 
Q: What level of reimbursement is needed to encourage non-VA providers to accept these patients?
A: The complaints you hear from private providers is not so much about the rate the VA pays – those rates are often determined locally -- but it’s the difficulty in getting paid.  It’s the contracting rules and cumbersome mess of the payment process that have been more of a barrier to providers often than the amount of payment per se.  It’s just part of government contracting.  Even if substantial amounts of money are appropriated--which it sounds like they will be--if the contracting mechanisms don’t get more facile, then there’s going to be a lot of frustration. 
Many of these private providers are happy to take care of veterans. They feel an obligation and they’re willing to do it for whatever the payment amount is. But it’s just getting it that is so difficult and frustrating for them.
Q: What can lawmakers do to assure the medical care given to these veterans is the highest quality, the most appropriate, the most efficient care?
A: Other than some general verbiage it’s hard for legislation to put those sorts of provisions into law. Certainly going forward if more care is going to be provided in the private sector, the VA needs to focus on a couple of things.
One is ensuring that the quality of care provided by contractors is as good as what’s provided in the VA, which has been an issue in the past. Because VA on quality performance, by and large, does quite well.  The other problem that needs to be addressed is getting the information back into the system. One of the problems with contracting out is that it is promoting more fragmented care, which is a problem. We know that fragmented care leads to bad things.
We need to focus on what the end game is, which is more rapid access to care, on higher quality care and we want integrated services.
Q: Are there veterans who may be best handled by VA personnel and not sent outside the VA system?
A: Every patient should be looked at, and what their needs are should drive where they get their care.  For many of the complicated patients, if they have amputations, they may have chronic medical conditions, if they have mental health issues, you really want as much of that care being provided within the system so that everyone on the team knows what’s going on. 
Someone may need a colonoscopy or some other procedure where you might be able to contract out if the information gets back into the system in a timely manner and if you’re confident in the quality of that exam.
Q: Both the House and Senate bills would sunset the non-VA care provision in two years. What happens then?
A: The access problems aren’t going to go away in two years. You have a backlog that you need to work through, but access is not a new problem in the VA, nor is it a new problem in any of the government-funded programs or in the private sector.  In some cases, there’s this delusion that access is rapid and speedy in the private sector and that’s not necessarily the case, as anyone who’s tried to get care can tell you.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.  

Jun 10, 2014

Russ Wins!

(CHICAGO) - We're so very proud of Russ Kridel, MD, of Houston, who won election today to the Board of Trustees of the American Medical Association.

Dr. Kridel is extremely dedicated to physicians and our patients. He ran a great campaign and will be an outstanding board member.

The AMA House of Delegates today also reelected three physicians to the board -- Drs. Barbara McAneny of New Mexico, Steven Permut of Delaware, and Carl Sirio of Pennsylvania -- and chose Jack Resneck Jr., MD, of California as a new board member.

Here is the official AMA news release announcing Dr. Kridel's election:

Houston Physician Elected to AMA Board of Trustees 

CHICAGO, IL - (June 10, 2014) - Today, the American Medical Association (AMA), the nation's largest physician organization, announced the election of Russ Kridel, M.D., a facial plastic surgeon from Houston, Texas, to the Board of Trustees.

"I am honored to be elected to the AMA Board of Trustees," said Dr. Kridel. "I hope to further the AMA's goals of preserving the patient-physician relationship and improving the health of the nation."

Dr. Kridel maintains a practice in Houston, where he is a facial plastic surgeon. He founded the Houston Face Foundation, and uses his surgical skills to help battered women and children who are victims of domestic violence. He also serves as a clinical professor and voluntary director of the Division of Facial Plastic Surgery at the UT Health Science Center in Houston.

Dr. Kridel is the chair of the AMA Council on Science and Public Health, a member of the Governing Council of the AMA Specialty and Service Society and a member of the AMA House of Delegates.

He has a distinguished record as a medical leader, having served as immediate past-president of the Harris County Medical Society. As a medical student, he was elected the national president of the Student American Medical Association. At the state level, Dr. Kridel chaired the professional liability committee of the Texas Medical Association, and served as president of its charitable foundation.

Dr. Kridel attended medical school at the University of Cincinnati College of Medicine, where he was awarded his M.D. He studied at Baylor College of Medicine, in Houston, where he did residencies in General Surgery and in Otolaryngology-Head and Neck Surgery.

Dr. Kridel was nominated by the American Academy of Facial Plastic and Reconstructive Surgery and the Texas Medical Association.

About the AMA

The American Medical Association is the premier national organization dedicated to empowering the nation's physicians to continually provide safer, higher quality, and more efficient care to patients and communities. For more than 165 years the AMA has been unwavering in its commitment to using its unique position and knowledge to shape a healthier future for America.

#AMAmtg Calls for Care for Vets Outside of Troubled VA

Dr. Lockhart

(Chicago) - Led by the delegations from Texas and Florida, the American Medical Association House of Delegates today called on President Barack Obama to "to take immediate action to provide timely access to health care for veterans utilizing the health care sector outside the Veterans Administration (VA) until the VA can provide health care in a timely manner."

Delegates also asked Congress to "act rapidly to enact a bipartisan, long-term solution" to the excessive delays in care that have been documented within the VA system.

"The problems are complex, they are longstanding, and they're not amenable to a quick fix," said Asa Lockhart, MD, an anesthesiologist from Tyler who took the lead on the issue for the Texas physicians. "The only answer is to ask the president to take some sort of immediate action in order for veterans to seek health care outside of the VA system."

David McKalip, MD, a neurosurgeon from St. Petersburg, FL, exhorted his colleagues in the House of Delegates to step up to the challenge. "American veterans are dying and suffering due to delays in care," he said. "Our AMA should ask for the only action that can fix this now."

TMA President Austin King, MD, who traveled to Chicago for the AMA meeting, added his voice to the chorus calling for immediate action.“Our veterans have stepped up and served our country, so physicians want to be able to step in and serve them,” Dr. King said. “It is tragic that our veterans have been forced to wait for the health care they need and deserve, so Texas physicians and our colleagues across the nation want to help care for them until the VA can right the ship.”

The AMA house also encouraged all physicians to participate, when needed, in the care of veterans, and recommended that state and local medical societies across the country create registries of physicians offering to see veterans and to share that registry with community organizations and local VA officials.

"This is a tragedy that needs to stop," said Massachusetts delegate Mario E. Motta, MD.

Jun 9, 2014

Texans Stand for Patients, Texas Docs at #AMAmtg

CHICAGO - From improving access to care for veterans to helping young physicians manage their mountains of student debt, Texas physicians, residents, and medical students lent their voices to important issues at the American Medical Association House of Delegates.

(Column 1) Dr. Henkes; Cynthia Jumper, MD, and Alex Valadka, MD, study
the issues at the Reference Committee on Medical Practice. (Column 2) Mr.
Savage; Colonel Ortega; Dr. Lockhart. (Column 3) Dr. Klawitter,
David Fleeger, MD, Ms. Solnick, Dr. Callas.

In the wake of the revelations of long delays in health care at Veterans Affairs (VA), the Texas and Florida delegations to the house asked AMA to push President Obama for immediate action. In an emergency resolution that was cleared Sunday for debate at the AMA meeting, Texas and Florida asked that AMA “publicly insist (by June 12, 2014) that the President of the United States take immediate action to provide full health coverage financial benefits to ensure that United States veterans can rapidly access the medical care they need outside the VA until the VA can provide promised care.” Texas delegation Vice Chair Asa Lockhart, MD, of Tyler; Irag War veteran Ray Callas, MD, of Beaumont; and Col. Ed Ortega Jr., MD, of San Antonio testified for the resolution Sunday at reference committee.

Many other issues brought the Texans to the microphone, while their colleagues closely studied the reports and resolutions at hand.

  • Delegation chair David Henkes, MD, of San Antonio, testified for a Texas resolution asking AMA to seek changes in a federal law that is imposing new paperwork burdens on private pathology labs.
  • Medical student David Savage of Houston rose to support a call for the AMA to investigate ways to work with private lending institutions to find lower interest rates on the big student loan debt that most graduating physicians carry today.
  • Medical student Rachel Solnick spoke on a public safety issue.
  • Art Klawitter, MD, of Needville, listened to hours of testimony as a member of the Reference Committee on Amendments to AMA Constitution and Bylaws.

Drs. Bailey, Lockhart Win #AMAmtg Elections

Clockwise from lower left: Ms. Hamouie and Ms. Bailey with Romero  Santiago,
UT Southwestern; Dr. Sue Bailey; Dr. Kridel; Dr. Ejesieme; and Dr. Lockhart

CHICAGO - Two Texas physicians secured leadership positions at AMA without opposition; a third must wait until Tuesday’s elections. The House of Delegates unanimously reelected Sue Bailey, MD, of Fort Worth to a fourth term as vice speaker. As one of four candidates running for four available seats on the AMA Council on Medical Service, Asa Lockhart, MD, of Tyler won his post by acclamation. Meanwhile, Russ Kridel, MD, of Houston is among eight candidates seeking the four available spots on the AMA Board of Trustees. We’ll know the outcome Tuesday morning.

Some younger Texans also won elections at the AMA meeting:

  • Nnenna Ejesieme, MD, of The University of Texas (UT) Southwestern Medical Center, is the newly elected chair of Region 3 of the AMA Resident and Fellow Section.
  • Elected to the Medical Student Section Region 3 Executive Council were: Angie Hamouie, UT Medical Branch at Galveston, secretary; and Tennessee Bailey, UT Health Science Center at San Antonio, membership chair.

Jun 7, 2014

AMA Foundation Honors Anu Atluru with National Leadership Award

CHICAGO -- Anu Atluru, a medical student at The University of Texas Southwestern Medical School, is a recipient of the American Medical Association Foundation’s 2014 Leadership Award. This national award recognizes medical students, residents/fellows, and early career physicians for achievements in community service, medical education, and public health.

Ms. Atluru is a second-year medical student who has applied her creative inclination and management consulting experience to expand the innovation ecosystem for rising physicians. She serves as the product track co-director for the Dallas-area Innovating Healthcare Solutions program and leads a team of MD/PhD candidates to develop a medical device for use in complicated cesarean section deliveries.

She is also an elected Administrative Board Member of the Association of American Medical Colleges Organization of Student Representatives. Anu envisions a multi-faceted career as a clinician and an educator. She hopes to drive the creation of novel, impactful technologies and approaches to patient care.

The AMA Foundation honored 15 outstanding individuals with Leadership Awards at its June 6 annual Excellence in Medicine Awards celebration in Chicago. Award recipients will receive special training to develop their skills as future leaders in community affairs and organized medicine.

The Excellence in Medicine Award program is presented in association with Eli Lilly & Co., Novo Nordisk Pharmaceuticals, Inc., PhRMA, and Pfizer Inc.

The AMA Foundation, a nonprofit, is improving the health of Americans through philanthropic support of quality programs in public health and medical education. To join the AMA Foundation in supporting medical heroes like the Excellence in Medicine Award winners, visit

Jun 2, 2014

Texas Takes Three Candidates, Six Resolutions to AMA House

The Texas Delegation will have plenty of work to do when the American Medical Association House of Delegates convenes in Chicago this month. Actually, it looks like the delegation can put a checkmark in the "done" box for two of its chores.

First, Fort Worth allergist and former TMA president Sue Bailey, MD, is running unopposed for reelection as vice speaker of the house. Also, Tyler anesthesiologist Asa Lockhart, MD, is running for the Council on Medical Service, and there are only four announced candidates for the four seats up for grabs. However, Russ Kridel, MD, of Houston, is one of eight men and women seeking five seats on the AMA Board of Trustees.

The delegation is also carrying six resolutions from the Texas House of Delegates to AMA:

  1. Work to prevent recoupments if an Affordable Care Act marketplace insurer has not notified the physician that a patient is in the last 60 days of the grace period for not paying his or her premiums;
  2. Push for a federal law requiring insurers to provide real-time claims adjudication;
  3. Have the AMA Council on Ethical and Judicial Affairs issue rulings on whether AMA's continued support for parts of ACA violates the AMA Code of Medical Ethics;
  4. Commission a study to compare the federal estimates of direct and indirect costs attributable to the Physician Quality Reporting System, meaningful use, and ICD-10 with the actual time and costs required by physicians to comply with these mandates;
  5. Organize an official protest of the "immediate-use" exception to the United States Pharmacopeia Chapter 797 guidelines on sterile compounding; and
  6. Eliminate the law requiring private sector laboratories to report to Medicare their payment rates for lab tests.