Sunday, May 23, 2010

The Days of Opening a Car Door for the Lady Are Over

The week's catchy dance tune. Also, thank you to the Brother, for taking the psycho hussy off our hands.

Before you ask, the name is Nadya Nepomnyashaya.

Saturday, May 15, 2010

Muhammad Yunus at Rice University: Genius, Yes, But...

What an intelligent student body, selecting this brilliant economist as their graduation speaker.

I have always believed poverty is a cultural choice at least, but not necessarily an individual's choice. In a culture of wealth accumulation such as that of the USA, poverty is a lifestyle choice, similar to choosing between a marina community or a golf development.

Prices are the same around the world. I thought the extreme poor required superhuman powers to survive on $1000 a year or less, with a family of 8. I admire the extreme poor for skills I do not have and am unlikely to be able to learn. For example, in a Third World country, people went to the bathroom in latrines. I just could not. I held it in until I could reach the lobby bathroom of the local Holiday Inn.

That being said, Dr. Yunus came up with a simple idea. It is counter-intuive until it works well and for a long time. That is the nature of genius.

Points Made

For an effective business model, take each point in the business model of banks and do the opposite.

Lend to the poor.

No collateral.

No contract with illiterate people.

No lawyers.

Lend to females, not males only as the banks do.

Find beggars and propose adding value to their visits to homes, for example, sell something small, such as cookies, toys, trinkets. The beggars then learn market stratification learning the best homes for begging, and the best homes for selling.

Next, offer the children of beggars tuition loans. He has produced 10's of 1000's of professionals that way.

Point Not Made

That female who buys a sewing machine with the $12 lent to her, starts to make clothing. She may end up earning $1000 a year. That then makes her the wealthiest, cash engorged person in the village. She may hire people, and begin to have influence. The bosses running that village then visit her because she may end up taking their power away. They offer her to end her business or to be driven out or killed. She will likely stop, and that explains why the village is poor. It may be that poverty is a lifestyle choice not just in the USA, but also in Bangla Desh, because it promotes power interests.

Saturday, May 8, 2010

Less Painful Pre-Authorizations

The cancellation of a prescription by refusal to pay for it is the same as making a prescribing, an act of medical practice. Assume the prescription was cancelled by a doctor in the same specialty as the prescriber. It remains unprofessional conduct to make a medical decision on a patient whom one has never seen, and whose records have not been reviewed.

I would like to see an ethics complaint for unprofessional conduct filed after every denial. The pre-authorization itself is a joke. It implies, the prescribing doctor was not serious in writing his prescription, or only meant it a little. I disagree that the time and effort are built into the encounter fee, without causing a conflict of interest. The fee is to see the patient. It is not to do work for the insurance company. If the doctor is on the payroll of the insurance company and owes a duty of performance, he cannot be 100% committed to the medical interest of the patient.

In any case, here is some advice on trying to make it easier.


Insurance preauthorizations: How to make the process less painful

Practice Management. By Victoria Stagg Elliott, amednews staff. Posted April 5, 2010.
The process can be automated. Or, practices can note what issues trigger a denial, and adjust their processes to quicken and gain approval.

And while insurers normally view precertification as a nonbillable service because it's considered part of a medical visit, evidence of how much time it takes can be used as a negotiating chip with insurers.

"It's supposed to be built into the revenue for the services that doctors are providing, but it can be an administrative nightmare for practices. Every insurance company requires something just a little bit different," said Rhonda Buckholtz, vice president of business and member development at the American Academy of Professional Coders. "But we can simplify the process as best we can."

The first step is to analyze how the office handles the process. Is it possible to get some preauthorizations completed before the patient comes in? Are there insurer-provided online tools that the practice is not taking full advantage of?

For example, Elizabeth Woodcock, principal of Woodcock & Associates in Atlanta, said she worked with an endocrinology practice that entered precertification information into an insurer's online system. But, rather than submitting it electronically, staff printed it out and faxed it, which took additional time.

"Make sure you are using all the automation that the payer allows," Woodcock said.

Experts also suggest creating some kind of tool that staff can refer to with all the policies and procedures of various insurers. This does not have to be particularly high-tech. For instance, Buckholtz has set up three-ring binders at several medical practices she has worked with. The binders can be particularly handy if the person who usually handles preauthorizations is out of the office.

Dealing with denials of the initial request for precertification also can be time consuming, but experts say the situation is another opportunity to look for time savings. Are there consistent issues that trigger a denial? Are certain codes always left off? Are necessary lab tests not being noted?

Pre-Authorizations Denials End When Investigations Begin

Insurance preauthorization denials spark inquiries

By Emily Berry, amednews staff. Posted April 15, 2010.

Years of physician complaints about Delaware health plans' utilization management programs have culminated in inquiries from a U.S. senator and the state's insurance commissioner.

Sen. Jay Rockefeller (D, W.Va.) wrote to Blue Cross Blue Shield of Delaware March 25, citing news reports that said the plan, through contracted utilization manager MedSolutions, was routinely denying requests for prior authorization for cardiac stress tests, even in cases where they appeared to be obviously medically necessary.

Rockefeller, who chairs the Senate Committee on Commerce, Science and Transportation, asked the company to give his office its records, including an explanation for every denial of a cardiac diagnostic test in the last five years.

Then on March 27, state Insurance Commissioner Karen Weldin Stewart announced she had formed a task force and was investigating prior authorization denials by the Blues, Coventry Health Care and Aetna, all of which have hired MedSolutions.

In a statement released that day, she said that until her department had completed its work, the Delaware Blues had agreed to eliminate preauthorization requirements for high-tech radiology services.

Assessment of Costs by Clerk of Court Despite Wealth Disparity

The Third Circuit covers Pennsylvania. Given the fact that 80% of malpractice claims are weak, this decision should result in more requests for costs. In this case, two claims were not filed on time, and summary judgments for the hospital were granted.

The decision is here.

Federal Rule of Civil Procedure 54(d)(1):

(d) Costs; Attorney’s Fees.

(1) Costs Other than Attorneys’ Fees.

Unless a federal statute, these rules, or a court order provides otherwise, costs — other than attorney's fees — should be allowed to the prevailing party. But costs against the United States, its officers, and its agencies may be imposed only to the extent allowed by law. The clerk may tax costs on 14 days' notice. On motion served within the next 7 days, the court may review the clerk's action.

Friday, May 7, 2010

Lawyer Deceit Statutes

Recommended reading for all victims of lawyer deceit.

Attorney Deceit Statutes: Promoting Professionalism Through Criminal Prosecutions and Treble Damages

Alex B. Long
University of Tennessee College of Law

February 25, 2010

University of Tennessee Legal Studies Research Paper No. 103
UC Davis Law Review, Forthcoming

Unbeknownst to many lawyers, numerous jurisdictions - including New York and California - have statutes on the books that single out lawyers who engage in deceit or collusion. In nearly all of these jurisdictions, a lawyer found to have engaged in deceit or collusion faces criminal penalties and/or civil liability in the form of treble damages. Until recently, these attorney deceit statutes have languished in obscurity and, through a series of restrictive readings of the statutory language, have been rendered somewhat irrelevant. However, in 2009, the New York Court of Appeals breathed new life into New York’s attorney deceit statute through its decision in Amalfitano v. Rosenberg. This Article discusses the extent to which, in this age of widespread distrust of the legal profession, this type of external regulation of the legal profession is a desirable approach. The Article concludes that although the utility of existing attorney deceit statues is undermined by the broadness of the language, the symbolism of the statutes is important. By relying on the development of tort law to address the same subject matter, courts can achieve the same educational and symbolic goals while dealing with attorney deceit on a more practical basis.

Sunday, May 2, 2010

Medical Students Learn About Safety

The modern view of catastrophes is that a cluster of factors come together, often 12 for an airline crash. The chain of causation view of the lawyer is from Scholasticism and the 13th Century.

This article provides a good review of what should go into medical error correction. I can say what they cannot. The unit of the hospital should be closed until the remedy has been found and incorporated.

Safety on the syllabus: Patient safety becoming part of medical education
Training in quality improvement is also being added. But some physician leaders say it's happening too slowly.

By Kevin B. O'Reilly, amednews staff. Posted April 19, 2010.

Robert O. Bonow, MD, chief of cardiology at Northwestern Memorial Hospital in Chicago, is pursuing a master's degree in quality and safety so he can be a better teacher and "transmit this to the next generation." [Photo by Tori Soper /]

Robert O. Bonow, MD, graduated from medical school in 1973. Caitlin Schaninger will graduate in June. Despite training in different generations, they see similar gaps in quality and safety education.

Much has changed in medical education in the nearly four decades that separate their medical school experiences.

What has remained largely unchanged is the lack of education most medical school graduates receive in the science and skills of quality improvement and patient safety -- how to deliver the right care to the right patient at the right time, and how to prevent a patient from being harmed.

Dr. Bonow is chief of the cardiology division at Northwestern Memorial Hospital in Chicago. He directs the Center for Cardiovascular Quality and Outcomes at Northwestern University's Feinberg School of Medicine and has served on several guideline and measure development bodies. Yet even with all his experience and expertise, Dr. Bonow felt compelled to pursue a master's degree in health care quality and patient safety.

* Boosting quality instruction
* Learning how errors happen
* Links
* See related content

"There's a knowledge gap that I think I personally have," he said. "I've been involved with a lot of quality initiatives, but have never had necessarily formal training in this stuff. I've learned it by osmosis for a decade and a half."

Northwestern University's program, launched in 2006, was believed to be the first of its kind. At least four other universities now offer similar master's degree programs aimed at addressing this training gap and helping to educate the faculty who will teach medical students and residents skills such as how to analyze errors and how to measure quality performance. Many medical schools and teaching hospitals are working to integrate quality and safety into their training, but critics say the pace of change is too slow and too inconsistent.
"Unmet needs"

Schaninger is among medical students across the country looking outside the formal curriculum of medical school for quality and safety training. As a student at the University of Chicago Pritzker School of Medicine she helped found a campus chapter of the Institute for Health Improvement's Open School for Health Professions.

The Open School offers free online quality and safety training to medical, nursing and other health professions students, and boasts chapters on 204 campuses in 41 U.S. states and 26 other countries.

Learning how errors happen

Medical educators often use a case-based approach on patient safety. Here is a sample lesson plan in which trainees are asked to do a root cause analysis of a real-life, fatal medication overdose given an infant. The chain of errors began when the resident writing the order was distracted by a phone call. Students are asked to answer these questions:

What happened? What were the gaps in quality of care? Did near misses, errors without harm and/or adverse events occur in the case? Hint: Make a chronological listing or flow diagram of events.

Why did it happen? What are the contributing factors? What are the active and latent factors?

What would prevent it from happening again? What are prevention strategies?

Trainees are then asked to describe how the following systemic factors may have contributed to the error:

Equipment: Design, availability and maintenance.

Environment: Staffing levels and skills, workload and shift patterns, administrative and managerial support, physical plant.

Teamwork: Verbal and written communication, supervision and assistance.

Staff: Knowledge and skills/training, competence, physical and mental health.

Institutional context: Economic and regulatory situation, availability and use of protocols, availability and accuracy of tests.

Organization/management: Financial resources and constraints, organizational structure, policy standards and goals, safety culture and priorities.

Patient: Complexity and seriousness of condition, language and communication, personality and social factors. Each group then presents its top three contributing factors, top three prevention strategies and its explanation of how the root cause analysis could improve safety in practice.

Source: "Modified Root Cause Analysis (RCA): Improving Patient Safety/Quality of Care," University of Missouri-Columbia School of Medicine, 2004

Virginia Now One of Dozen States Mandating Pay for Telemedicine

People should pay for their own visits, and forget about insurance coverage at the low cost of telemedicine. If it costs $10 to reach the doctor, and $10 to return home, $100 to take off a half day from work, the average person should arrange for it at their own expense. A $60 brief visit would still be half as expensive. There is also some chance the impaired person may get into a car crash. What would people pay to prevent one of those? What else can the states do, of greater importance to doctors is to rein in the states goofy, mad dog licensing boards. Any charge involving telemedicine should be immunized.

Virginia Gov. Bob McDonnell has signed into law a bill that requires insurers to cover services provided through telemedicine.

With enactment of the legislation on April 5, Virginia becomes the 12th state to mandate that health plans cover telemedicine. Under the new statute, telemedicine services include the use of interactive audio, video or other electronic media used for the purpose of diagnosis, consultation or treatment.

It does not include services provided using an audio-only telephone, e-mail message or fax transmission. Continuing medical education and call center services are not required to be covered, either.

The enactment of the bill was supported by several physician organizations, including the Medical Society of Virginia, the American Heart Assn., the American College of Emergency Physicians and the Virginia Telehealth Network.

"With telemedicine, physicians in all areas of the state who have the technology will be able to consult with specialists, regardless of location or other circumstances, such as foul weather," said MSV President Daniel Carey, MD. "It is extremely beneficial in areas of the state which are underserved by certain specialties, such as ob-gyn, and also when transporting the patient is not an option."

The American Medical Association supports payment to physicians for any telemedicine services they provide.

The 12 states as of today.

* California: 1996
* Colorado: 2001
* Georgia: 2006
* Hawaii: 1999
* Kentucky: 2000
* Louisiana: 1995
* Maine: 2009
* New Hampshire: 2009
* Oklahoma: 1997
* Oregon: 2009
* Texas: 1997
* Virginia: 2010

Source: The American Telemedicine Assn.

Saturday, May 1, 2010

Is Psychiatry Finished?

The craven and treasonous AMA and APA lent support to this Trojan Horse for Commie Care, health care reform. But, no. Psychiatry will not end. No one has ever done psychiatry any favor. It exists and does well because there is no choice, no alternative for the care of people with severe mental illness. Only a minority of such people are getting any care. They will not be welcome in the offices of primary care doctors, nurses, social workers. As uninsured people get access to care, psychiatry will be swamped. It will have to stick to the essentials of the service. It will have to get more rapid, efficient, and effective.

Here is something the public can do to cut the psychiatry bill in half. Stop using illegal drugs and and alcohol.