Thursday, August 8, 2013

Preparing for the medical home transformation



Preparing for the medical home transformationPhoto used with permission from Shuttershock.com
Medical homes are considered one of the most promising experiments under way to improve the quality of care and lower costs. The concept has been gaining momentum and shows no signs of slowing.
The principles of the medical home model aren’t new and are geared to ensure that patient-centered care is comprehensive and coordinated, and that it enhances patient access and focuses on the provision of quality and safe care.
The concepts of the medical home require a team-based approach that utilizes health information technology to identify and assist with the management of patient populations while allowing for the measurement of clinical outcomes. Although many of the principles and concepts of the medical home model are part of the day-to-day operations of the small primary care practice, the full adoption of the model can appear overwhelming. Solo practitioners and small practices must deal with a combination of scarce staff resources, small operating budgets and large demands to meet volume targets under fee-for-service payment. Those factors make it less feasible for small practices to hire extra staff (such as a nutritionist, data analyst or care coordinator) to support and sustain the transformation.
Although these barriers are real, they are not insurmountable. With appropriate planning and development, a small practice can achieve a successful medical home transformation. The following areas deserve attention if your practice is considering pursuit of medical home status:
Practice education – It’s important that each member of the practice care team fully understand the concept and principles of a medical home. This knowledge drives buy-in and promotes active participation in the successful transformation.
Practice roles -- Utilize limited resources to maximum abilities and scope. First identify what each team member is currently responsible for and look for opportunities to align responsibilities across the team to match skill sets. It’s important to utilize each staff member to his/her fullest capabilities in this team-based approach.
Care team responsibilities – Clearly define the role each team member will play in the medical home and develop the processes that support the following medical home concepts:
  • Patient tracking and follow-up;
  • Patient and caregiver education;
  • Health promotion and wellness care;
  • Care coordination;
  • Clinical outcome and performance monitoring; and
  • IT support and EHR system management and configuration.
Relationships within the medical neighborhood – Identify the community resources outside of the practice that provide specialty care, care management, hospital services, home care and behavioral healthcare. You must be able to coordinate and effectively manage your patients’ care. Establish formalized relationships with these resources to define referral protocols and follow-up processes, as well as admission and discharge coordination services. Think in terms of streamlining these processes.
Enhanced payment programs – Many payers across the country offer enhanced reimbursement for primary care providers that receive NCQA PCMH recognition with the purpose of providing financial support to assist the small practice in increasing necessary staff and services to support the medical home.
EHR configuration and utilization -- The cornerstone to success is to ensure your EHR is working for you. Having an in-depth understanding of how your EHR works and flows is key to streamlining clinical processes in the office. In addition, configure your system to provide meaningful care alerts, pertinent decision support, patient education materials and customized documentation templates to optimize workflow.
Health information exchanges – An HIE can serve as an excellent resource for collecting comprehensive clinical information for your patient population. HIEs build a “community record” of sorts; that record aggregates the pertinent information from specialists and hospitals, provides diagnostic testing results geared to quickly give primary care practitioners the information needed to assist in managing their patients’ care.
Engaging the practice to make a “system-wide” transformation can be challenging, but with appropriate planning and development the small practice can successfully transform into a true medical home.
Pam Minichiello is project director for the Massachusetts eHealth Collaborative (MAeHC). Courtney Beach is a practice consultant with MAeHC.



Feds up ante on Durrani with 10-count indictment

A federal grand jury returned a 10-count indictment against a Greater Cincinnati spine doctor, “alleging that, beginning in 2009, he convinced patients to undergo medically unnecessary spinal surgeries,” then billed health care programs millions of dollars, according to a news release from the U.S. Attorney’s Office.
The indictment, issued Wednesday, charges Abubakar Atiq Durrani, 44, of Mason, with five counts of health care fraud and five counts of making false statements in health care matters.
Durrani, who owns a private practice called the Center for Advanced Spine Technologies with offices in Evendale and Florence, previously told the Enquirer he would fight criminal and civil allegations against him.
Federal agents arrested Durrani last month at his Reading Road office on a complaint, which led to the indictment. In addition to the criminal charges, Durrani faces more than 150 civil lawsuits filed on behalf of former patients.
Federal authorities allege that Durrani “made false statements to patients, colleagues and hospitals in order to further his scheme,” the federal news release said.
Durrani allegedly would tell patients that they urgently needed back surgery and risked grave injuries without it, the release said. Durrani even allegedly asserted “there was a risk of paralysis or the head would fall off if the patient was in a car accident because there was almost nothing attaching the head to the patient’s body,” the federal news release said.
Health care fraud is punishable by up to 20 years in prison. The crime of making false statements in health care matters is punishable by up to five years in prison. Authorities also seek forfeiture of “any proceeds Durrani received as a result of the scheme,” the release said.

Wednesday, August 7, 2013

Feds arrest Dr. Farid Fata, accused of fraud & deliberately prolonging chemo for cancer patients

Posted: 08/06/2013
Last Updated: 11 hours and 45 minutes ago
ROCHESTER HILLS, Mich. (WXYZ) - Dr. Farid Fata’s website for his Michigan Hematology Oncology practice promises the “Best Cancer Care – Anywhere.” But, U. S. Attorney Barbara McQuade says otherwise. 
Federal agents arrested the 48-year-old Oakland Township doctor this morning at his Rochester Hills practice. McQuade says he’s charged with healthcare fraud for his role in a scheme to submit false claims to Medicare for treatments that were medically unnecessary. McQuade says the fraud scheme involves $35 million. 

Federal officials are alleging an even worse crime than cheating Medicare -- in their criminal complaint against Fata, FBI agents say “Dr. Fata directed the administration of unnecessary chemotherapy to patients in remission.”
The feds say he also deliberately misdiagnosed patients “as having cancer to justify unnecessary cancer treatment.” 
Federal agents say Fata directed the  “administration of chemotherapy to end-of-life patients who [would] not benefit from the treatment,” and deliberately misdiagnosed “patients without cancer to justify expensive testing.” 

Federal agents say Dr. Fata owns and operates Michigan Hematology Oncology Centers (MHO) which has offices in Clarkston, Bloomfield Hills, Lapeer, Sterling Heights, and Oak Park.

Federal agents also searched Fata’s house in Oakland township, as well as Fata’s other offices in Clarkston and Bloomfield Hills.
The FBI also took evidence from Fata’s United Diagnostics, which is just down the street from his Rochester Hills oncology office.
7 Action News was there Tuesday morning as the FBI took boxes into the Rochester Hills location to start executing their search warrant.  Agents were likely looking for patient records and other evidence.  We also saw federal agents remove about 100 boxes of evidence at the end of the day. 

Patients who have questions concerning their medical records and/or information regarding this investigation and prosecution can call the United States Attorney’s Office Information Line at 888-702-0553.

“I think it’s terrible if he’s giving them therapy and they didn’t have cancer,” said 85 year old Pat Winowiski.  She’s fighting cancer in her lungs and liver and she’s  shocked her doctor was arrested Tuesday.
“It’s very upsetting because I really liked him,” said Winowiski.
“I trusted him,” said patient Terri Mitchell
 “Are you going to get a second opinion now,” asked 7 Action News Investigator Heather Catallo.
“Yes I am,” said Mitchell.
After more than 7 years of treatment with Dr. Fata, Mitchell says she’s starting to doubt her diagnosis.
“I can’t understand – I’ve talked to many people and they’ve said I don’t understand why you’re still on Retuximab for the last 7 years – cause he told me at the beginning it would be a year of treatment and 2 years of maintenance,” said Mitchell.
It’s clear from court records that current and former employees have turned into informants – concerned about what was happening to patients.  One described working for Fata as “living with this hell.”
But nothing the feds can say will convince Sally Kelley that the doctor she calls “gentle and loving” could have harmed anyone.
“I don’t believe a word of it, I have total faith,” said Kelley.
Dr. Fata faced a federal magistrate Tuesday afternoon.  Assistant U. S. Attorneys assigned to the case argued Fata is a flight risk because he has access to about $14 million in liquid assets and a home in Lebanon.  The magistrate is temporarily detaining Fata until another hearing can be held on Thursday.  He faces up to 20 years behind bars if he’s convicted.
Fata’s wife is the CFO of his company, and the couple has three young children.


Read more: http://www.wxyz.com/dpp/news/region/oakland_county/doctor-arrested-offices-raided-by-fbi-in-connection-to-healthcare-fraud-charges#ixzz2bHITCQC6

Monday, August 5, 2013

Changes in hospital readmission rates by clinical severity

Medicare now penalizes hospitals for high readmission rates for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Anticipating the penalties,readmission rates have come down, though this does not prove a causal relationship.
medicare readmit trend
The chart illustrates a highly aggregated metric. Certainly readmission rates and changes in them vary by type of patient (in any number of dimensions). For example, recent work by Matthew Press et al. suggests that changes in readmission rates vary by condition severity.
In an analysis of Medicare fee-for-service beneficiaries nationwide, we found that those with the highest clinical severity had readmission rates in 1997 that were approximately 6.0 percentage points higher than those in the lowest severity quartile, with this gap increasing to 8.1 percentage points by 2007 for AMI. The difference in readmission rates for the highest versus lowest severity quartiles for CHF was 5.7 percentage points in 1997 and 6.4 percentage points in 2007. This relatively increasing risk of readmission for the highest severity patients occurred despite the fact that average severity scores decreased within each severity quartile over the 10-year period. Length of stay and in-hospital mortality also declined for all patients; however, postdischarge mortality increased for the highest severity patients, whereas it decreased for the lowest severity patients.
The authors offer two possible explanations for these findings. First, condition severity may have worsened more than observed for high severity patients and not accounted for in the risk adjustment approach applied in the analysis. That is, the highest quartile of condition severity in 2007 may have represented sicker patients than the highest quartile in 1997 in ways that were not controlled for. Sicker patients are expected to be readmitted more. Another is that actual care delivered (e.g., quality of care transitions) worsened for higher severity patients relative to lower severity patients. This might also lead to relatively more readmissions for sicker patients.
Unfortunately, their analysis ends in 2007, well before the readmission rate reduction exhibited in aggregate since 2011 in the figure. An open question is how this downturn might have varied by condition severity.

Dallas heart surgeon uses medicine as ministry

By MARC RAMIREZ
DALLAS (AP) — At 83, Carl Smith found himself facing quadruple-bypass surgery and the real possibility that he might not survive.
Within hours on this spring morning, Dr. Mark Pool would temporarily bring Smith's heart to a stop in an attempt to circumvent its blocked passages.
And to help his patient confront the uncertainty, Pool did something unusual in his profession: He prayed with him.
The power of healing: Medicine and religion have both had their day, and they haven't always been able to coexist. But as today's medical treatment becomes more holistic, doctors are increasingly taking spirituality into account.
The Dallas Morning News (http://dallasne.ws/1cbWHgS) reports that studies show a majority of patients want their spirituality recognized, and most med schools now have classes related to the topic. In general, the new thinking asks doctors to note their patients' spiritual leanings and open doors to expression, especially when life is at risk.
Pool, a highly regarded heart and lung surgeon at Texas Health Presbyterian Hospital Dallas, is fervent about his Baptist faith. For about a year, he's routinely asked patients if they'd like him to pray with them pre-surgery — a gesture he says is always appreciated but one that exceeds advocates' suggested bounds.
"A physician should be open to a patient's spirituality but shouldn't push religion on patients," says Nathan Carlin, assistant professor at the University of Texas Health Science Center at Houston. "That's confusing personal and professional roles."
An inherent power differential divides doctors and patients, says Christina Puchalski, director of George Washington University's Institute for Spirituality and Health and co-editor of the recently published Oxford Textbook of Spirituality in Healthcare.
"They're coming to us for something other than prayer," Puchalski says. "If I, as a patient, perceive (a surgeon) as having my life in his hands, and he asks me to pray and I say no, he may not treat me well. And that's putting undue pressure on the patient."
As the saying goes, there are no atheists in foxholes: The idea that your fate is out of your hands offers fertile ground for re-examination.
"The moment somebody tells you that you have cancer," says Methodist Dallas Medical Center's Rohan Jeyarajah, a gastrointestinal surgeon who prays with patients, "you're going to believe in something."
But the situation, he says, requires caution: "We have to be careful about being in a position of perceived authority and not overstepping that bound. This is like a teacher-student relationship. There's a chance you could be inappropriate."
Pool pushes forward, eager to share the belief that drives him without making people feel awkward or flouting that power imbalance.
"I don't want to exploit their situation," he says. "At the same time, I want to give them the opportunity to explore the faith that I know."
You could say Pool comes from a religious background. His father, his grandfather, his father-in-law, his brother-in-law: all ministers. The family joke was that he started going to church nine months before he was born.
By age 6, he was well versed in Bible basics, but then something odd happened. One day at a prayer meeting, Pool says, he was touched by — well, not quite a vision, but an awareness.
"I had already understood that Jesus came to save the world," he says. "That was nice. But then I understood: Jesus came to save me. And that changed everything."
He's pursued a path of faith ever since. Medicine seemed like a good way to help people. Even so, as a med student, Pool pondered ditching the whole thing to go to seminary instead.
As a member of First Baptist Church of Dallas, he and wife Jessica lead relationship classes on Sundays for dozens of young married couples. Even in his crisp, black-patterned suit, Pool is impossibly youthful — lean and rosy-cheeked, posture straight as a fence post.
And as a cardiothoracic surgeon, another realization has set in: "I have a ministry. I don't need to be standing in a pulpit. I have found a ministry I did not expect. I am able to minister to people in times of need."
Since Texas Health is a faith-based hospital system, he felt at ease taking that step.
"The vast majority of people believe in God," he says, "and yet when people come to the hospital, that's completely ignored by doctors. If anything, they call the chaplain. It's unfortunate that more doctors don't try to engage that part of a patient's life."
That's starting to change. Two decades ago, barely a few med schools offered classes on spirituality. Now, three-fourths of them do.
"Medicine has figured out that we ignore the more human sides of health care at our own peril," says Craig Borchardt, interim chair of humanities and medicine at Texas A&M University.
Studies show 60 to 80 percent of patients want their beliefs noted, he says — not as affirmation but as a sign that the doctor actually cares. But fewer than 20 percent of doctors bring it up.
The push has met with some backlash — from busy doctors reluctant to take time away from other concerns or others who don't like talking about it.
"Some staff are more comfortable with it than others," says Mark Grace, vice president of mission and ministry for Baylor Health Care System.
He doesn't reject the idea of doctors offering to pray, but "if you don't listen to the answer, that's where you get into problems. . The doctor needs to be prepared if the patient says no."
George Washington University's Puchalski says the bottom line is doing what's best for the patient.
"Physicians are generally not trained to lead prayer," she says.
To illustrate the power differential she says exists, she recalls a patient who was also a fellow parishioner. One day, she noticed the woman hadn't been to church for a while, then realized the woman hadn't come into her office either.
When the patient finally resurfaced, Puchalski pressed the matter: "She told me, 'I thought you'd be upset that I switched churches.' That gives you an idea of the power we have over patients. So I would really caution against (taking advantage of) that."
Pool gleans his patients' spiritual beliefs at their initial meeting. Then, on the morning of surgery, he says: "This is a time when a lot of people turn to faith. Would you mind if I prayed with you?"
No one, he says, has ever declined, not even those who believe differently or not at all.
It's 6 a.m., and Pool, shiny black boots poking from beneath blue scrubs, briefs Smith on his surgery. At 83, Smith is fit, mowing the yard occasionally, an active driver.
But coronary artery disease caught up with the retired Farmers Branch pharmacist, slowing his blood flow and causing chest pain. Over time, it could lead to a heart attack.
Madge Smith, his wife of 63 years, and Leah Wilson, his youngest daughter, are near. Scott Smith, his son, would join later.
Pool explains his plan: He'll make an incision down Smith's breastbone, then take arteries from his left and right side, and a vein from his leg, to form new channels for blood to flow through his heart.
"So," he tells Smith, "you told me you're a Sunday school leader. . Would you mind if I said a prayer for you?"
Smith is touched. Pool places his hand on Smith's shoulder and begins:
"God, thank you for Mr. Smith. We ask that you would guard his life, keep him safe and bring him through this operation. Replace any anxiety that he may have. Give him a great assurance of your love and your power.
"I ask you to watch over our team, that you give us all clarity of thought, that you guide my hands as they move. We pray these things in Christ's name. Amen."
"Amen," Smith says.
Later, as Smith's family awaits the outcome, his wife says: "I have never had a doctor do that. It just meant so much to us. We just thought it was sent from God."
At 6:45 a.m., Pool starts in, using a tiny electric saw to patiently work through Smith's chest and breastbone.
The arteries he wants dangle inside like strings of soaked cooking twine above Smith's quivering lungs. He snips one end of each, then applies small plastic clamps to stop the thin spurt of blood.
"See that?" he says. "That's the blood flow that will be going into the heart."
A shot of potassium literally stops Smith's heart cold, temporarily abdicating its work to a heart and lung machine. To the heart, Pool will divert the snipped arteries, and repurpose a vein taken from Smith's leg, to offset the blockages within.
But first he has to open the heart's protective sac, unveiling the still-beating organ as it heaves inside. Pool eases it to one side, to reach a portion underneath — and in that moment, Smith's heart, the force pumping blood and oxygen throughout his body, rests in Pool's cradling grip.
Out in the family waiting area, Smith's son Scott says: "God has his hand on everything. He's in control. We're not. It's in God's hands."
Pool initially wondered if his praying might give patients pause, whether they'd worry he wasn't confident enough in his own skills to get through the surgery.
"It's been the opposite," he says. "They value the humility."
Last year, Shea Bowen of Kaufman had just delivered a son at Texas Health Presbyterian Hospital Rockwall four weeks early. Suddenly, she became short of breath. Tests revealed a tumor in her heart.
She was rushed to the network's Dallas hospital, where Pool met with her and her husband. She was shaking then, a complete wreck.
"It was terrifying for me," Bowen says. "I had to leave my few-hours-old baby. We knew there was a chance that . Not everyone comes out of surgery.
"Dr. Pool could tell. His words were 'I don't know if you guys believe in God, but I do,' and as soon as he said that, we both burst into tears. He said, 'I can cut and I can sew, but God is going to heal you, and I'm going to do everything in my power to make sure that happens.'
"There's a lot that's a blur, but I remember the comfort of knowing the person who was literally going to stop my heart and cut me open was going to do that for me under God."
Not long ago, Pool contacted a local evangelistic organization. "So I could up my game," he says. He wants to learn how to share his faith without being a "turn or burn" proselytizer.
"I wouldn't want for somebody to make a decision in a moment of crisis that they wouldn't make otherwise," he says. "I don't want to say, 'It's your last chance: Smarten up or else.'
"It doesn't mean I can't share my faith just because it might upset somebody in the world. This nation was founded on Christian ideals."
Pool pauses when asked if he'd pray with followers of Islam, a faith he considers antagonistic and unforgiving.
"I don't think they would get the same meaning" from it, he says. "Not that they would feel offended, but . not comforted."
He tries to avoid a holier-than-thou air and — with patients, anyway — doesn't claim only certain believers get into heaven.
"It's not my job to get somebody to make certain decisions," Pool says. "All I can do is live a life that makes it appealing to somebody and then share it with them. If I share and they say, 'I'm not interested,' I say no problem and move on. But seeds can be sown that you never see the fruit of."
Smith's operation was a success. Six weeks later, Pool meets with him one last time.
"You're doing extremely well," Pool says. "I'm going to fade away now. You don't have to come back and see me."
"I'd be 6 feet under if it wasn't for you," Smith says.
Pool dismisses the thought. "I'd like to say a prayer with you," he says.
Smith bows his head and closes his eyes.
"Lord," Pool begins, "thank you for getting Mr. Smith out of the hospital and getting him home. We ask that you continue that process of healing and give him a spring in his step once again. In Jesus' name we pray."
Smith is upbeat. He believes the gesture will help him get better. And in the end, that might be the most important thing of all.
___
Information from: The Dallas Morning News,


ICD-10 Transition: Maybe it's time to panic a little




We are about 14 months away from the ICD-10 implementation deadline. Surveys report that healthcare providers are in various states of readiness.

QualiTest Group surveyed more than 300 professionals about their ICD-10 testing plans. The two major findings are:
  • Most respondents have either completed ICD-10 assessments or are in the process of assessments.
  • 75 percent of respondents have not yet begun ICD-10 testing.
While starting sooner than later is important, this survey doesn't raise too many alarm bells. It does report a great deal of planning and progress in the ICD-10 transition. Other surveys released in the past few months have found less preparation.

Perhaps a more troubling indicator is the amount of newly released literature that suggests there is an audience that hasn't heard of ICD-10 implementation. If the healthcare industry is on its way to a smooth ICD-10 transition, we wouldn't need so many guides to planning ICD-10 implementation.
Seriously. That's so 2012.

The latest example I found is the white paper ICD-10: The Top 10 Things You Need To Do NOW from the medical billing firm MediGain. They advise:
  1. "Set up a team and appoint a leader."
  2. "Evaluate current software systems and office procedures in which you use ICD-10."
  3. "Pinpoint possible changes to your workflow and office processes."
  4. "Communicate with your payers about any modifications that need to  be made  to your contracts due to ICD-10."
  5. "Think about training efforts and costs."
  6. "Converse with your trading partners."
  7. "Test with your trading partners."
  8. "Survey your current PM vendor."
  9. "Assess your internal office systems and functions."
  10. "Revise and account for any plan adjustments."
Healthcare providers should have completed half those steps by now.

If not, then they should download the MediGain white paper. It's actually a pretty good document to start. The more detailed ICD10 Watch Implementation Timeline will help explain what needs to be done.

MGMA anticipates problems, disruptions with ICD-10: Q&A

  • Robert M. Tennant, MA, Senior Policy Advisor at the Medical Group Management Association (MGMA), can't figure out why CMS won't conduct end-to-end testing.
  • Before the HIPAA 5010 transition, National Days of Testing were very helpful.
  • Healthcare payers need to test more than if they can accept ICD-10 codes. They need to see how their payment policies will be affected.
  • Clearinghouses report 20 percent of their clients are still using HIPAA 4010 — which cannot handle ICD-10 codes.
  • Tennant worries that state Medicaid agences won't be ready for ICD-10 implementation so healthcare providers will need to use dual coding practices to get reimbursed.
  • Healthcare providers need to start practicing assigning ICD-10 codes to medical claims.

Cash on hand: You'll need it for ICD-10

  • Expect delays in reimbursements after Oct. 1, 2014.
  • Hoard enough cash to cover three to six months of operational expenses.
  • Talk to banks now when you don't need it.
  • Ask healthcare payers about contingency plans.

Increasing Revenue and Planning for ICD-10: How Clinical Documentation Improvement Accomplishes Both

Mel Tully, senior vice president of clinical service and education at technology firm Nuance, has three tips:
  1. Improve documentation now for ICD-9 coding.
  2. Analyze the DRGs and procedure codes that account for most of your revenue.
  3. Medical coders should start clarifications and queries now for information that supports ICD-10 coding.

Dual-Coding: An ICD-10 Strategy You Can Take to the Bank

Bonnie Cassidy writes about why healthcare providers need to consider dual coding:
  • It will require time and effort but should be worth it.
  • There are risks by not dual coding:
    • Not assigning the right ICD-10 codes.
    • Losing revenue.
    • Increasing claim denial and audits.
  • Medical coders will gain practice.
  • ICD-10 transition team can assess its education and training programs.

Three questions to ask your payers about ICD-10

  1. Will you conduct external testing?
  2. Will you be dual processing, and if so, when will you start?
  3. What will happen if something goes wrong?

Getting to the Good Stuff: An Active User’s Opinion of ICD-10

Barbara Aubry sings the praises of specificity. (3M Health Information Systems)

Diagnosis and Procedure Codes: Abbreviated and Full Code Titles

CMS has released the final update for the ICD-9-CM code set. It goes in effect Oct. 1. (Centers for Medicare & Medicaid Services)



Friday, August 2, 2013

CMS: Last ICD-9 update before ICD-10 compliance date

Author Name Jennifer Bresnick   |   Date August 1, 2013
The final updates to ICD-9-CM codes will take effect on October 1, 2013. These updates will be in effect until the ICD-10 transition takes place on October 1, 2014. You can find the last official ICD-9-CM code titles, both full and abbreviated, posted on the CMS website.
“For those of us who have been maintaining ICD-9-CM codes since the code set’s implementation in 1979, this final ICD-9-CM code update is a historic occasion,” said Pat Brooks of the CMS Hospital and Ambulatory Policy Group. “We look forward to the implementation and maintenance of ICD-10 in 2014.”


Bill would prevent ACA from ending doctors' insurance contracts

■ A GOP lawmaker claims that medical practices are at risk under the law's health care quality measures provision.

By JENNIFER LUBELL amednews staff — Posted Aug. 2, 2013

 A Georgia congressman is trying again to promote a bill that he says seeks to protect a physician's decision-making ability under the health system reform law.
Rep. Phil Gingrey, MD (R, Ga.), has expressed concerns with a provision of the Affordable Care Act that enables the Health and Human Services secretary to determine whether a doctor is meeting health care quality measures under the statute. Dr. Gingrey has said physicians are at risk of losing their health insurance contracts and subsequently closing down their practices if they fail to meet these quality measures.
courtesy|unlim|free|mug|photo|100x150|
Phil Gingrey, MD (R, Ga.)
“This rule places another unelected bureaucrat in the middle of patients' health care decisions. It violates the sanctity of the doctor-patient relationship, as physicians are trained to treat patients individually and not with a 'one-size-fits-all' approach,” said Dr. Gingrey, a member of the House Energy and Commerce's health subcommittee, in a statement.
Should the HHS secretary decide, for example, that it would violate a standard of care to perform mammograms on women younger than 50, “the provider must comply, regardless of his or her concerns,” Dr. Gingrey wrote in a blog post in 2012.

“No business diagnosing patients”

The legislation, which had been introduced in August 2012, was reintroduced on July 25 and referred to the Energy and Commerce panel for consideration.
“Someone who isn't bound by the Hippocratic oath, isn't required to have medical expertise, and isn't held accountable by medical societies has no business diagnosing patients. The [Safeguarding Care of Patients Everywhere] Act keeps medical decisions where they belong: in the hands of patients and their physicians, not the federal government,” Dr. Gingrey continued.
The SCOPE Act would repeal this provision of the ACA, meaning that doctors would remain accountable to entities such as insurers, professional groups and state licensing boards without federal intrusion. The HHS position has been that it does not comment on pending legislation.
Although the Medical Assn. of Georgia hasn't taken a formal position on Dr. Gingrey's legislation, the association “is a staunch advocate for legislation that reduces the government's reach into the medical profession, as well as efforts to promote physician autonomy and the patient-physician relationship,” said Donald J. Palmisano Jr., the association's executive director and CEO.

http://www.amednews.com/article/20130802/government/130809999/8/?utm_source=rss&utm_medium=&utm_campaign=20130729

What Japan Can Gain from Sound Innovation

Masazumi Ishii and Derek Scissors, Ph.D.

Abstract
In Japan, four decades of economic success have been followed by more than two decades of stagnation. Genuine economic growth in any country is derived from labor, land, capital, and innovation. An aging society limits the returns from labor, and Japan is short of natural resources. The returns from capital would improve with reduced public borrowing from the domestic private sector, but this has proved very difficult politically. Innovation may be the most promising route to revitalization. Innovation for a specific technological goal, such as space flight, can be led by the government; innovation that drives sustained economic growth cannot. This kind of innovation requires tumult; it requires non-performing firms to fail and new firms to easily replace them. Growth is what Japan needs—and it can only be led by firms that must innovate to survive.
It has been increasingly forgotten over the past 20 years that Japan has a great deal to offer the United States and the world. In security affairs, a vibrant Japan and healthy Japan–U.S. alliance will help stabilize an otherwise volatile East Asia for another generation. In economics, post war Japan was a major force for greater global competition and the increasing prosperity seen around the world from 1950 to 1990.
Japan is being forgotten because four decades of economic success have been followed by more than two decades of stagnation. Genuine economic growth in any country is derived from labor, land, capital, and innovation. An aging society limits the returns from labor, and Japan is short of natural resources. The returns from the use of capital would improve with reduced public borrowing from the domestic private sector, but this has proved very difficult. Innovation may be the most politically promising route to start the revitalization process.
The foundation of this paper is that all innovation requires tumult; it requires non-performing firms to fail and new firms to easily replace them. Innovation toward a specific technological goal, such as space flight, can be led by the government; innovation that drives sustained economic growth cannot. The innovation that drives sustained growth—what Japan needs—is led by firms that must innovate to survive. The government’s role is to create and maintain the proper conditions for this, not to direct, fund, or take other dramatic short-term action.
This is not what the environment in Japan looks like. Japan has certainly pursued innovation, but in flawed fashion, overly concerned with existing firms, worker seniority, and the government role. In contrast, existing firms should be allowed to die, compensation should be tied more closely to performance and labor mobility should be increased, and deregulation should encourage private-sector financial specialization and durable support for entrepreneurial activity. Such steps will bolster innovation, long-term economic expansion, and Japan’s global role.

The Sources of Growth

From the preeminent example of an “economic miracle,” Japan has become the preeminent example of stagnation. There is not one lost decade, there are now more than two—dating back roughly to 1991, and with no end in sight. Japan is hardly the only economy facing problems, but its failures have unfortunately proved to be the world’s most durable.[1] The policies have been debated for centuries, but the fundamental sources of long-term growth are plain. For Japan, the prospects for land and labor are mixed, at best, and the contribution of capital has been erased by an addiction to government borrowing. Innovation is properly and widely understood to be vital.
The growth boosted by innovation does not necessarily refer to gross domestic product (GDP). Genuine, sustained economic expansion is about household wealth, whereas GDP is an accounting tool for annual production or expenditure. In particular, GDP mistreats government borrowing and imports. Because the private sector is better at creating wealth than the public sector, net government borrowing harms long-term prosperity even while adding to current GDP. Greater competition and choice for individuals to buy foreign goods and services boosts prosperity even while it may reduce current GDP.
A main reason for Japanese stagnation is that policy has been geared to artificially support short-term GDP, effectively at the expense of genuine prosperity. One error is the obsession with the balance of payments and exchange rates. Utilizing a cheap yen for GDP gains through net exports reduces purchasing power and makes Japan artificially and unnecessarily dependent on foreign markets.[2]External surpluses provide a pile of foreign money to invest overseas even while trillions are being borrowed at home.
This gigantic debt is another obvious example of flawed policy. The Heritage Foundation’s Index of Economic Freedom ranks Japan as the world’s 24th (of 176) freest economy, and falling. That rank would be far higher and Japan far more prosperous were it not for the stunningly low rank of 141 in fiscal freedom.[3]
Most capital transactions within the country involve the government borrowing or spending. There are vital public goods to be provided—the justice system, national defense, environmental conservation. Beyond those, borrowing relocates money, transferring it from the private sector to the public sector. This can be worthwhile, such as in the case of certain transfers from rich to poor, but it inhibits growth. Again and again, Japan has repeated the error of Keynesian “stimulus” for the sake of a short-term GDP boost.[4] When the economy is weak, which is all too often, spending is hiked as if there are always beneficial programs available. Instead, huge sums are wasted.
In addition, interest rates have been subverted by the need to make public finance cheap. As a result, the return on capital in Japan is impossibly distorted.[5] This is not about a higher price due to government intervention in capital markets. Any such “crowding out” has been prevented by excess liquidity provided by monetary authorities. This is about quantity. The government has become increasingly dominant as both user and provider of capital. It borrows and spends hugely during all-too-frequent downturns, while the size of the economy remains fixed.[6] That would damage growth if the market power were concentrated in a private actor. (No private actor would be allowed to be so large.)
But a private actor would at least seek profit, creating wealth. The government spends for many reasons, including extremely valuable goals such as enforcing contracts. It can create the conditions for wealth accumulation, but it does not seek wealth. Rather than financial return being the primary factor, capital is borrowed and spent without regard to return. The absence of foreign capital only makes matters worse,[7] since yet more domestic capital is drained off for low-return initiatives. Public borrowing blunts the contribution of capital to the economy.
This failure is crippling in light of a relatively poor land endowment and shrinking labor force. It is well understood by now that fast-rising property values do not make a sustainable contribution to growth. If money supply is pushed high enough, land prices will rise, but the wealth effect will be temporary and the inevitable contraction will be painful.[8] Japan has few natural resources to contribute to growth—in stark contrast to the U.S.—and land is further wasted on inefficient agricultural output and unneeded infrastructure projects.
The aging population leads to a smaller workforce, both in absolute terms and as a share of the population, which is less productive in certain sectors. This continues to harm growth prospects and will do so indefinitely. Traditional labor practices that emphasize job security, though they are becoming less pervasive, also lower labor productivity.[9]
The Keynesian response to the original property crash was to support GDP through public outlays and loose money. Whatever its value as a crisis response, it has utterly failed as a long-term economic strategy. Sadly, there appears to be no end in sight.[10] In contrast to the dismal prospects for fiscal and monetary policy, reforms that promote innovation have universal support, at least in principle. This makes encouraging innovation a top national priority.

Innovation and the State

Innovation’s role as a source of growth clarifies that the term is often understood too narrowly. Innovation applies to the whole economy, not just to the technology sector. It is not limited to introduction of technological gadgets or even technologies themselves. It is not limited to engineers and physical scientists. It includes services as well as manufacturing, business model and organization changes as well as new machines.
These features have powerful implications for policy. Governments can direct innovation toward specific goals (whether those goals are truly valuable or not). Governments cannot themselves drive the kind of broad innovation that pushes the entire economy forward. For one thing, innovation does not always respond positively to government assistance—such assistance may instead blunt the drive to innovate. This appears to have been part of what happened recently in the U.S. energy sector where “green” energy has been outperformed by shale gas.[11]
Moreover, not all activities can be subsidized as ostensibly desirable “winners.” Even when playing favorites brings short-term benefits, it runs directly contrary to encouraging innovation. Directing innovation rather than generally encouraging it brings the obvious risk of a bad choice. The narrower and more concrete the goal, the less likely government intervention is to distort a country’s technological and economic path. Yet while such narrow projects can be very valuable, they do not constitute the economy-wide innovation that brings prosperity. With its other sources of growth hampered, the latter is the kind of innovation that Japan needs.
Such innovation cannot be generated by yet another government project; it can only be generated by the private sector, which certainly includes foreign companies. The government’s proper role is to foster the right environment for the private sector. This can be done more effectively, or less. Three guiding principles for effectiveness are:
  • Innovation occurs throughout the private sector, not just in areas of advanced technology;
  • The government avoids pre-selecting specific outcomes; and
  • Innovation is driven by competition; it is therefore harmed when the government elevates certain firms or technologies above others.
The third principle has a critical implication: Innovation relies on instability and failure. Open, fair competition, again including foreign players, is indispensable for sustained innovation. The competition that breeds innovation is tumultuous, even chaotic. This is not a sign of trouble, far from it. In open, fair competition, firms will and should fail. Their failure creates space for other firms, with more successful innovations.
Government intervention to preserve failing firms, for the sake of preserving jobs or some other reason, runs directly counter to fostering innovation. New, often small, companies innovate more than their better-established competitors.[12] It is not enough to merely have small companies operating. If government intervention keeps failing companies afloat (typically the large ones), it blunts the incentives to innovate and leaves the corporate sector populated by inferior players. The proper task of government is to offer regulations that enable new firms to rise up quickly, whether due to breakthrough innovation or stagnation at existing firms.
Intervention that suppresses competition can take multiple forms; it is not limited to financial handouts. For example, regulations can be damaging when they introduce bias toward industrial integration. This may arise naturally, but absorbing competitors through acquisition will otherwise stunt innovation. Even vertical integration can be harmful if artificially encouraged. Specialization should be permitted to the greatest extent possible, both in terms of firms and in terms of individual skills. Barriers to foreign entry plainly suppress competition.
Perhaps more telling, the number of patents is not informative regarding the environment for innovation. If patent registration and protection permits large companies to file endless patents and easily claim infringement, it discourages innovation. Government patent review should reward those who incurred high fixed costs, not add to future fixed costs.[13]
A positive government role is to encourage a deep, versatile financial system, including but certainly not limited to an active stock market. The gross amount of liquidity available matters in supporting innovation, of course, but too much liquidity helps weak firms survive and may not be helpful. Monetary policy itself therefore has little value.
Instead, the key is a financial system that can properly identify and assess risk, and is specialized enough to have a sufficient number of institutions that engage high-risk endeavors. For any given monetary policy, the more liberalized the system, the better it is at identifying risk. Loose money hides risk, and government intervention, say, to drive down mortgage payments, distorts it.[14] Venture capital and other firms that respond to high-risk projects are most flexible when neither inhibited nor bolstered by tax policy or other government action. These firms, too, will often fail, and should be permitted to do so.
Government research and development is secondary to private finance in supporting innovation. The government can promote basic research that has little or no short-term commercial return. When the government ventures into applied research, it competes harmfully with the private sector. The harm is that public finance does not respond appropriately to risk, so that public-sector financing will skew to firms where the commercial return is inadequate compared to the risk.[15] This is one implication of the second principle—the government should not pre-select outcomes.
The appropriate quantity of government research spending is thus limited. This holds even when high and sustained research spending is called for in certain sectors, as many are calling for in green energy now and is frequently true in basic materials, which have multiple uses. When a new field for innovation materializes, or seems to, the government’s role is already concluded. Either it has created conditions for successful innovation, such as a well-functioning financial market, or it has not. Direct government intervention does more harm than good.
The government can also help foster long-term conditions that promote broad innovation. The more tangible effort is in education. As noted in the first principle—innovation is not just about technology—education should be strong in as many aspects as possible. If graduate training in science or engineering is found to be inadequate, government support is entirely reasonable. However, the same is true for other aspects of the education system.
Less tangible, but as important, is an environment of openness. This applies to the corporate sector, but, in light of the importance of education, it also applies more extensively. The government should leave the corporate and education sectors as open to competition (domestic and foreign) as possible, and individual firms and research institutions should be open to cooperation.[16] In this light, labor mobility, including transnational mobility, is a major boon for innovation.

Japan’s Innovation Gaps

Japan is eighth in the world in the number of Nobel Prizes received. Dr. Shinya Yamanaka won the Nobel Prize for Physiology or Medicine in 2012, the 19th Nobel Prize a Japanese citizen has won, as compared to nine for India, Taiwan, China, and Korea combined.[17] On another dimension, Japan is competitive with the U.S.—Japan’s top universities file as many patents as the top U.S. universities.[18]In this sense, Japan’s raw capability in science and technology is top-notch.
The ensuing question is whether these capabilities have been translated into innovative activities generating employment and wealth. The answer here is unfortunate. According to the competitiveness index published by Switzerland’s Institute for Management Development, Japan was first in the world in 1990 but fell all the way to 27th by 2012.[19] Among other things, this had a (delayed) impact on annual national income: In 1990, Japan ranked third in the world in GDP per capita, in 2000 it ranked eighth, in 2010 it ranked 17th.[20] If adjusted for purchasing power, Japan’s present annual income ranking is no higher than 24th.
The recent poor performance is reflected in the broad types of Japanese firms: comparatively old and large; newer but established; and true start-ups.
By the end of the 1970s, Japan had a set of large corporations that had emerged during the high-growth era. Most began as start-ups. They thrived by introducing management and operating systems that encouraged high-quality, low-cost manufacturing. Employee creativity was not encouraged in this kind of environment. Creativity has been suppressed for an extended period, and the original entrepreneurial spirit has been lost. The result is a risk-averse corporate culture with a natural tendency to continue or return to past successes, and where top management rejects genuinely new strategies.
Once business stalwarts, many of these companies are in danger of failing, missing opportunities to recover lost market share. It appears unlikely that most can change their management approach. A few will make radical changes, such as choosing outside CEOs and undergoing radical restructuring, others will be acquired, many will vanish. Those that survive will not just repeat the mantra of greater innovation, they will implement it.
The second category, newer but established companies, grew up primarily in the 1990s and 2000s. They are free of many past constraints, such as those imposed by the Keiretsu system of tight-knit corporate alliances, and they retain an entrepreneurial approach to management and operation. This has enabled them to succeed in the harsh climate of the past 20 years. However, these firms must continue to respond to the rapidly changing global marketplace or they could find themselves in the same position as their older cousins.
The third group is the current set of Japanese start-ups. These are typically spun out from research institutions such as universities or, less often, established corporations. Many possess the world-class technology that Japan develops and thus have high commercial potential. What they frequently lack is management skill to create a successful business, as well as financial resources. Because of this, they all too often marry up with larger firms, ceding technology and ultimately gaining little in return.
These corporate characterizations point to the bottlenecks that separate Japan’s technological capacity, seen in the start-ups, from the economic benefit that should be generated by successful, growing firms. Corporate features play out in four major ways:
  1. Venture capital should operate independently, with a tight link between performance and compensation, run by officers with entrepreneurial backgrounds. Japanese venture capital firms, however, typically are not distinct entities. “Venture” capital usually flows from subsidiaries created by banks and securities firms. Officers are rewarded with bonuses doled out by the parent company. Venture capital firms often sign deals with entrepreneurs requiring that shares be bought back if a firm does not perform as anticipated in the prospectus, effectively turning the investment into a conventional loan.
  2. Employees of large corporations are discouraged from creating spin-offs. Traditionally, Japanese corporate compensation is designed to foster life-time employment. Employees are encouraged to stay, to win higher salaries purely by climbing corporate ladders over time. Also, while a Japanese-style 401(k) retirement-savings plan exists, barely 6 percent of the 65 million-strong workforce have accounts.[21] And, the plans are not truly portable. Talent can be found in large corporations but is not leveraged to foster innovation.
  3. Start-ups with advanced technologies frequently cannot bring in the variety of skills necessary to continue to expand. Since employees are not as mobile as they would ideally be, start-ups often do not have the necessary personnel to deal properly with potential investors, including venture capital firms. This may explain why preferred stock options are not widely utilized; start-ups cannot manage them.
  4. Perhaps most important, exit avenues are limited. Inadequate initial public offers (IPOs) and mergers and acquisitions (M&A) harm entrepreneurship by eliminating the main exit options. If people cannot leave a business, they are less likely to start one.
Recently, IPO share prices have risen.[22] But this is primarily due to the liquidity injection component of “Abenomics”—Prime Minster Shinzo Abe’s growth strategy. While promises have been made to encourage start-ups, structural reform has yet to be offered, much less implemented. Examining a longer time period, the IPO market has not functioned properly. One issue is accounting scandals focused on false earnings reports, which are hopefully a thing of the past.[23] More important, there is insufficient specialization in underwriting. Securities firms treat IPOs as a risky side business because they lack the necessary expertise to reduce the risk.
Japan does not have a pressing jobs problem requiring that large employers be protected; it has a pressing stagnation problem requiring more dynamism.
The other avenue for exit is acquisition by large corporations. In the U.S., after the Internet bubble burst in 2000, the IPO market shrank considerably. The enforcement of the Sarbanes–Oxley Act in 2002 deterred companies from going public because the cost of compliance sharply increased and trade secrets were less protected. Even so, the total number of exits has been stable, as the vast majority of exits since 2002 have been buyouts.[24] Thus, capital mobility has been retained.
In contrast, Japanese M&A is stunted. Large corporations are not especially interested in fully acquiring ventures. Rather than seeing new firms as an opportunity, large firms tend to use their resource advantages to extract technology, and the new firms simply die. When a small firm is acquired, its technology is quickly deployed but entrepreneurship is smothered.

Fostering Japanese Innovation

It is common to emphasize the importance of the entrepreneurial spirit but, whether in Japan, the U.S., or elsewhere, people naturally hesitate to act in more difficult settings. In this sense, Japan would be well served by the fostering of an environment where job mobility is high and barriers to new ventures are low, an ecosystem where people can more easily “make things happen” instead of bracing themselves for hardship when undertaking a new venture.
In light of the weaknesses in the innovation ecosystem, there are three sets of improvements that need to be made.
The overarching set of improvements that needs to be made is in the realm of ideas and attitudes: The government must stop paying for the past and instead invest in the future. That is, it should stop subsidizing firms, and if that means letting them die, so be it.
This seems the most difficult aspect for people to accept. But Japan does not have a pressing jobs problem requiring large employers to be protected; it has a pressing stagnation problem requiring more dynamism. If failure is not punished, it will continue (and has). If market share is not available for potentially superior firms, the incentives to innovate are dulled. At the other end, and in the spirit of making life a bit easier for entrepreneurs, it should be as simple as possible in terms of regulation to create new firms. Most of these will fail very quickly—and that is exactly the kind of churn that foments entrepreneurship.
A second set of improvements has to do with people. Some changes will have a quick impact, others will require a decade or more. One step along these lines can be taken fairly quickly: increasing labor mobility. Human capital at the scale of a country cannot be built up quickly, but measures can be implemented quickly to permit human capital to respond better to new opportunities. Silicon Valley is said to foment high labor mobility.[25] In contrast, the labor market in Japan is widely considered to be segmented and in need of fundamental reform.[26] There is scope for government action here: Regulations should be as encouraging as possible for portable pension schemes. Not only should individuals be able to take pensions with them if they switch jobs, the process should be as painless as possible.
Beyond government, Japan needs more managerial talent. The spread of business degrees at home needs to continue, and greater efforts made to tap both accredited people and business training overseas. It will also be helpful to better integrate academic research institutions with industry. All these steps will produce more graduates who have the ability to build new companies, improving the quality of human capital in innovation activities. The increased popularity of business plan contests is hardly conclusive but it is encouraging.
Improved human capital and mobility is not enough. Risk-taking is naturally sensitive to the setting—during the post-bubble periods from 2002 to 2003 and 2009 to 2010 the rate of new entrepreneurial activity fell even in Silicon Valley.[27] In Japan, a challenging environment for setting up new ventures is the rule, not the exception. If more innovation is the goal, firms can lead in taking steps to create a better environment. The main step firms can take is internal. A mechanism is needed to tie employment to compensation more on a real-time basis, making the link between compensation and contribution more immediately apparent to the worker. In Japan, employees are often forced to wait years until the compensation rises to a level commensurate with previous contributions—this encourages tenacity, not innovation. The decoupling in time between work and benefit makes it more difficult to switch jobs as well. This may benefit a company when it comes to existing employees, but it harms the same company when looking for new employees. And it harms the entire economy. An accomplished individual with skills needed elsewhere should not fear to lose time on a job clock if she switches employers.
One method firms can employ along these lines, especially if revenue is tight, is equity options. To the extent that there is a government role, it should encourage variations in employee compensation from the seniority system.
The third set of improvements is financial. The reasons why Japanese venture capital units underperform their American counterparts include the financial side as well as the output side. Tax, regulatory, and legal reform can encourage domestic and foreign money to flow to venture capital and innovation in general.
Given Japan’s demographic trends and high technological capacity, it is crucial that investments by pension funds and universities be deregulated.
Financial mechanisms are a crucial element of the innovation environment. Venture capital is needed to help start-ups in their early stages. Specialization of financial entities in venture capital is generally superior to banks and securities houses treating innovation as indistinct from their traditional realms. In general, the financial side needs operational independence from parent institutions focused on other activities. It also needs entrepreneurial experience to better understand and assist innovative companies beyond the mere provision of capital.
Other helpful actions for the early stages include encouraging financial variation. Given Japan’s demographic trends and high technological capacity, it is crucial that investments by pension funds and universities be deregulated (not merely retargeted more to the government’s liking). Financial specialization should not be punished through taxation or regulation, thus enabling expansion of so-called angel financing (affluent investors who invest their own money directly in start-ups).
Almost as important as the start is the end. In order for money to move freely, there must be a well-established exit path. The obvious one is an IPO. IPOs need specialized underwriters, not merely securities firms that consider the business a sidelight. Japan’s IPO market has performed poorly, but there have been recent improvements, in part encouraged by the Action Plan for the New Growth Strategy,[28] announced in 2011 by the Ministry of Finance. Such reform must occur or the improvement in the IPO market will fade. Also on the exit side, M&A that passes antitrust standards should be made as easy as possible in terms of permits and taxes.

A Platform for Revitalization

Select actions will bolster innovation:
  • Struggling firms should be allowed to fail, not maintained by government aid. Moreover, the assistance should not instead go to new firms.
  • The seniority system for employees should be weakened and compensation tied much more closely to current productivity, for example, via stock options.
  • Related, labor mobility should be enhanced through portable pensions and easier visas.
  • Business education should expand and barriers between academic research and industry reduced, initially through the use of tax credits.
  • Financial specialization should be encouraged through regulatory reform, focusing on independent venture capital firms and IPO underwriters.
These are not the only steps that will be needed but they would make a fine start. With limitations on its labor and land supply, and having created a monster in public borrowing, Japan needs innovation in order to reinvigorate. There is no painless, perfect solution, but Japan has the capacity to again be a global economic leader.
Masazumi Ishii is a managing director of AZCA, Inc., a California corporate-consulting firm specializing in the Asia–Pacific markets. Derek Scissors, PhD, is Senior Research Fellow in Asia Economic Policy in the Asian Studies Center at The Heritage Foundation. Riley Walters, Research Assistant in the Asian Studies Center, contributed to this report.