Newsletter 83 December 06
Contents
An Ailing U.S.
Healthcare System Needs Doctors to Help Cure It
Malpractice Filings Against
Health Care Providers, Jan 2001 – Oct 2006
ED Article THE
PHYSICIAN SHORTAGE, ACCESS, AND "PHYSICIAN EXTENDERS"
Southern Nevada Health Officer Report
Medicare and Medicare Part D help offered by
State Health Insurance Assistance Program (SHIP)
An Ailing U.S.
By John C. Nelson,
MD, MPH
Immediate Past
President, American Medical Association Medical Director, HealthInsight
There is an
old story about three people who had spoken out against the French Revolution
and were to be executed by the guillotine.
The blade stuck about half way down and the first person, a church
official was spared by French law.
"God lives!" he shouted.
The second person, an attorney, had the same fate. "Justice is served!" said he. The third person, a physician, said,
"You know, I think I can fix that thing!"
Unfortunately,
as we look at an amazingly complex and costly healthcare system in the
Some things that we should be doing are obvious. First, we should practice exemplary medicine. That means being on time, being available, communicating better with our patients, practicing in a culturally competent manner, explaining medical situations better, being kinder, caring more, using older often less expensive medications and procedures where possible, and keeping up to date by utilizing continuing medical education (CME). Patients expect no less and these characteristics for the most part describe successful practices. But this is not nearly enough.
Many decisions now being made in health care are being made by people other than physicians. Of course, I am talking about the Centers for Medicare & Medicaid Services, legislatures, business groups, and even the courts. It seems that everyone wants to be a doctor, but nobody wants to go to medical school! As a profession, we need to unite and face these entities head on. They need to know a whole lot more about clinical medicine than they want us to believe they already know.
On the other hand, we need to do a much better job of following accepted clinical guidelines. You probably read the recent article in the New England Journal of Medicine by Beth McGlynn stating that physicians only follow clinical guidelines about 54.9 percent of the time. Of course, there are times when it is not appropriate to follow guidelines and we need to make sure that we get the same credit for not following a guideline when it is not appropriate as we would when we follow it correctly.
It is also
true that as a profession, we lag behind much of the rest of
We need to participate in the research that will be necessary to determine which of the developing guidelines are the right ones. We need to assist researchers by sharing clinical information with them. And we need to insist that all such research focus on what is best for our patients. After all, that is the group that we are duty bound to serve. Indeed, we must insist as a profession that all that is done in health care is patient centered above all else.
And, we need to become involved in the difficult and sometimes messy process of politics. It is a challenge for me to think that what we know to be true as shared in journals and at meetings can be subject to partisan political debate. But that is the system of government that we have. It reminds me of Winston Churchill's classic comment that "Americans will always do the right thing once they have exhausted all the other possibilities!" So, Doctor, roll up your sleeves after you leave the clinic or hospital and get involved in some meaningful way with the political process that will surely shape the way medicine will be practiced in this country.
I would not
be honest with myself if I did not also include a plea for all of us to be
involved somewhere in organized medicine.
It can be at the county, state, national, or specialty level. Better still, it could be at all of those
levels. It is clearly time for us to
respond to a slight permutation of John F. Kennedy's fabled quote: "Ask not what
I have practiced medicine for 30 years and served in organized medicine at every level. I am now working at HealthInsight as a medical director with people I respect and admire on the long path to an improved American healthcare system. I pledge to continue my efforts to make a more reasonable, more efficient, higher quality, more affordable, more evidence-based, more culturally competent, more patient-centered system. Some of my efforts and ideas will be good. Others will not be good. But, I am counting on your personal pride and professionalism to cause the debates and ultimately the actions that will lead us to where we need to be. I look forward to the day when all Americans have access to healthcare coverage, when the lifestyle issues will be a higher priority for all of us, where quality improvement will be valued, where disparities in health care due to race and ethnicity will be eliminated, and where my beloved profession will once again be revered as it was when I started all of this.
Come on Colleagues! We can surely do better than this.
PRESIDENT’S MESSAGE
By
The Doctor Is In…
…And
the doctor is making a significant contribution to the campaign and election
results! More and more doctors are
becoming politically engaged and the results reflect their involvement. Our
After working so hard there is a sigh of relief that the election is over. It was well worth the hard work, and I'd like to thank everyone who did their share and got involved.
To the
elected officials who may read this article, thank you for volunteering to
serve your community and for taking all the heat of the campaign. Thank you for
your unwavering determination and your commitment to serving the community. In
Statewide we did very well. Only four incumbents lost. Sadly, Sandra Tiffany was one of them who was narrowly defeated. We will miss Sandra very much and the work she did for the medical community. Joyce Woodhouse, who won the senate seat in District 5, is an outstanding individual who has a proven track record of community leadership and will undoubtedly work to help the medical community.
Our state
senate is represented by a majority of republicans, 11:10. Our Republican Lieutenant Governor, Brian Krolicki, may be called upon to vote in the event of a tie,
if someone is sick. He is a strong
doctor advocate. Although, Dina Titus
will not be the governor of
Governor Gibbons has assured the medical community of his strong support. Despite debilitating alleged scandals, he won by a significant margin. In conversations with him over the past year, he seemed well-aware of the dilemmas that we face as a professional community and has pledged to help us.
Catherine Cortez Masto is a proven professional who will help uphold our laws in the state as Attorney General. We look forward to working with her, as well.
The
Assembly that will meet in February is ably headed by Barbara Buckley. Though not an advocate of tort reform, she
has worked with organized medicine on multiple issues, including the Pharmacy
Bill and expanding the language provisions and protections under the Good
Samaritan law. Her help on the Good
Samaritan law now enables physicians to have protection if they see patients
gratuitously in their office who were referred by a county agency or non-profit
entity. This step will open the door for
physicians to see members of the indigent population in their office, instead
of having to go to a county facility to provide care. It will facilitate more physicians whose
schedules are too busy to participate in volunteer activities. I believe Barbara will be a strong ally of
medical reform in
Garn Mabey,
MD, has won again and is to be congratulated for his willingness to serve. As a fellow physician, he has worked hard for
advances in medicine in
Also,
congratulations to Joe Hardy, MD, of District 20, my home town of
The Nevada Supreme Court races were critical for us. We are indeed fortunate that Michael Cherry and Nancy Saitta were victorious. These judges will no doubt avoid interpreting the constitution and will uphold the people's initiatives. Judge Cherry has sent us a letter of appreciation. In it, he says, "I'd like to thank the entire physician community in our great State of Nevada for the fantastic support given to me during my campaign for the Supreme Court…I have spent my entire legal career preparing to be your Supreme Court Justice."
Tort reform is not the ultimate answer, but it's what we have to work with now. We must protect it until a better answer comes along.
Physicians have helped to make a huge impact over the last two election cycles. We now have four judges we have helped to elect who sit in the Supreme Court of Nevada, Hardesty, Parraguirre, Cherry and Saitta. We are seeing that organized medicine can make a difference.
We are witnessing a major change of attitude in the juries on liability lawsuits. They are becoming more pro-physician, with physicians winning 90% of the cases. This is, in part, a result of the campaign on Question 3 along with improved education of the public.
The
Surprise Initiative this time was Question 5, winning, and Question 4, losing.
This was a monumental victory for smoke free environments that was orchestrated
by Michael Hackett. Despite the fact
that the opposition outspent Question 5 by a margin to 6 to 1, they lost. The voters demonstrated that they recognized
the issue and were not fooled by the deceptive advertising. Physicians and organized medicine in
This
election is over but we are just beginning to learn how to participate in an
election. Each election we are getting
wiser. We may develop strategies and
raise money, but our greatest asset is still our own patients. If we educate them, they will do the
rest. They can affect our destiny and
the future of medicine and community in
In the
past, the casinos, the teachers, the Culinary Union, etc. were recognized for
their political power. Doctors are now
being recognized as significant players in politics in
"Recent changes in the way government and insurance companies reimburse for surgical care are making it difficult, if not outright impossible, for many surgeons to meet their business expenses. So, many are retiring early or limiting the kind of services they provide. Unless congress acts now, things are going to get lot worse when payments for services are cut even more starting June 1st, 2007".
Congress must reform the current Medicare system that most insurance use to determine what their services are worth. Call your Senators and Congressmen now at 202-224-3121 and tell them to fix Medicare's broken payment system before it is too late.
Clark County District Court Medical Malpractice Filings
Against Health Care Providers, Jan 2001 – Oct 2006
2001 2002 2003
2004 2005 2006
Jan 39 33 108 61 41 50
Feb 20 14 98 72 63 61
Mar 35 30 169 123 64 38
Apr 37 34 111 81 70 58
May 37 35 126 65 14 71
Jun 27 24 103 90 65 83
Jul 19 100 114 45 66 74
Aug 54 51 76 67 33 82
Sep 20 65 105 79 36 51
Oct 37 83 110 59 26 74
Nov 38 184 59 78 68
Dec 9 170 67 47 30
Sum
372 823
1246 867 581 642
Member News
Applicants to Go Before Credentialing Committee
If you have any pertinent information about the following membership candidates, please contact:
·
Judy M
Jackson, MD - Radiation Oncology
·
Paul J Michaels, MD - Pathology
·
Dipti S Patel, DO - Family Practice
For information on becoming a member of the
THE PHYSICIAN SHORTAGE, ACCESS, AND "PHYSICIAN EXTENDERS"
By Weldon (Don) Havins, M.D. Esq.,
Executive Director, Special Counsel and President-Elect of the
The Physician Shortage
The AMA has determined that
Two years ago, the Southern Nevada
Medical Industry Coalition surveyed practicing physicians in southern
Touro University Nevada College of
Osteopathic Medicine (TUN) matriculated its third class of medical students
this year. The initial class size was 78
students. These students will graduate
in 2008. The second class admitted
consisted of 104 students. This past
fall, TUN admitted a class of 140 students.
The class size will grow to slightly over 150 entering students each
year and remain at that level for the foreseeable future. Thus,
Physicians also come to
What does all this mean? If UNSOM was expanded to matriculate 96
medical students per year, and IF all those students were trained in Nevada
residency programs, and IF Touro University graduated 150 students per year and
trained all those graduates in Nevada residency programs, and IF 80% of those
finishing training programs remained in Nevada to practice medicine, Nevada
would move from its ignominious 47th place in physicians per capita toward the
national median number of physicians per population. However, even if all these "ifs"
became reality at the earliest possible time, there would be no measurable
impact on the per capita ratio for a decade, and no significant movement toward
the national median for two decades.
Thus, under any assumption of optimistic calculations, there is, and
will continue to be for the foreseeable future, a growing disparity between the
ration of physicians providing patient care and the burgeoning population in
How
will
The Rise of Physician Extenders
Physician extenders fall into two basic categories: Physician Assistants and Nurse Practitioners. Physician extenders will foreseeably fill the access threat to sufficient physician medical services. As described below, it is apparent that physician extenders will provide more and more routine medical services previously the province of licensed physicians.
Physician Assistants
Physician Assistants (PAs) are college graduates who attend a two year or 30 month post-graduate education program. Upon graduation, they receive a master's degree and take a national certification exam. Under the Nevada State Board of Medical Examiners (NBME), PAs apply for and are individually licensed by the NBME. Under NRS 630.271, "a physician assistant may perform such medical services as he is authorized to perform by his supervising physician." The regulations of the NBME, NAC 630.280 through NAC 630.415 govern PA licensing, continuing education requirements, authorized medical services, supervising physician duties, and licensure discipline. All PA licensees of the NBME must have passed the certification examination of the National Commission on Certification of Physician Assistants. Curiously, while almost all PA programs grant a master's degree, the NBME only requires that a PA licensure applicant to possess a high school diploma or general equivalency diploma.
Until recently, all PAs practicing in
Osteopathic physicians (DOs) can also employ PAs. The statues and regulations governing those PAs are quite distinct from those governing PAs licensed under the NBME. This disparity will likely be closed in the next legislative session, in which the Nevada Board of Osteopathic Medicine (NBOM) has a Bill Draft Request which, if passed into law, will provide for licensing of PAs under the NBOM. PAs licensed under the NBOM will have statutory equivalent status to PAs licensed under the NBME.
Nurse Practitioners
Nurse Practitioners are nurses
licensed by the Nevada State Board of Nursing.
Currently, to be licensed as an Advanced Practice Nurse (APN), a nurse
must have completed a master's in nursing program in the relevant field of
practice. The most common APN is a
Family Nurse Practitioner (FNP). There
are also Pediatric Nurse Practitioners (PNPs) and
Certified Nurse Anesthetists (CRNAs). UNLV and UNR Departments of Nursing have
programs for FNPs.
UNLV has recently revitalized their PNP program. There are no CRNA programs yet in
Nurse Practitioners as Doctors
UNLV and
The Current and Future Utilization of "Independent" Physician Extenders
While physician extenders currently
must have either a "supervising physician" (PAs)
or a "collaborative agreement" (APNs),
neither PAs nor APNs
licensed in
Within the urban
While MinuteClinic
apparently is the only entity of this type operating in
The success of this business concept relies upon patients who feel they can immediately access medical services for routine medical problems in extended hours not available at their physician's office (if the patient has a physician), obtain their prescription and have it filled at the same locale with a minimum of inconvenience and at a reasonable cost. Receiving those medical services from a PA or APN apparently has not been an impediment to utilizing these services. Supervising or collaborating physician compensation varies among the clinic corporations and within states which have differing requirements governing oversight responsibilities.
Again, for physicians licensed by the NBME, a maximum of three physician extenders (PAs/APNs) can be supervised by a physician licensee. Contracting to oversee more than three can, and likely will, result in licensure sanction actions by the Nevada Board of Medical Examiners.
Summary
While medical student training
programs in
1 AMA Physician Characteristics and Distribution in the
2
John Packham, PhD,
3
4
5
American Association of Colleges of Nursing, Position
Statement on the Practice Doctorate in Nursing.
Southern Nevada Health District Report
Tuberculosis cases are
increasing in Southern Nevada
By Donald S. Kwalick,
MD,
The
Southern Nevada Health District is committed to eliminating tuberculosis
infection in
Despite our ongoing efforts TB remains a public health threat as the second leading cause of death by infectious disease in adults worldwide, with more than 2 million TB-related deaths each year. It is estimated that approximately 9 million people become ill with TB worldwide.
Complicating the TB epidemic is the increasing number of multi-drug resistant strains or MDR-TB. Up to 4 percent of cases worldwide are MDR-TB. Specifically these cases are resistant to the most effective drugs of the four drug standard, isoniazid and rifampin. The causes include interrupted, erratic or inadequate therapy.
The costs of treating MDR-TB are extremely high. This form of TB cannot be adequately treated through the standard short course therapy. As a result treatment entails up to two years of treatment with "second line drugs".
The Southern Nevada Health District is currently treating four MDR-TB cases.
Tuberculosis
rates have consistently declined nationally, decreasing from a rate of 5.8 per
100,000 in 2000 to a rate of 4.9 per 100,000 in 2004. In contrast,
In March, 2006, in a paper published by Morbidity and Mortality Weekly Report (MMWR), the term XDR was first defined. Extensively drug resistant tuberculosis (XDR-TB) is defined as resistance to at least rifampicin and isoniazid from among the first line anti-TB drugs (which is the definition of MDR-TB) in addition to resistance to any fluoroquinolone, and to at least one of three injectable second line anti-TB drugs used in TB treatment (capreomycin, kanamycin, and amikacin).
Globally, XDR-TB poses a grave public health threat, especially in populations with high rates of HIV and where there are few health care resources. CDC estimates that patients with XDR-TB are 64% more likely to die during treatment than patients with MDR-TB.
However, the availability of new diagnostics for latent TB infection is good news. On May 2, 2005, QuantiFERON-Gold received final approval from the U.S. Food and Drug Administration. In December, 2005, CDC published new TB guidelines advising that blood assays for M. tuberculosis can be used as an alternative to the traditional skin test method (TST). The advantages include: results can be available less than 24 hours after testing; it is not subject to biases and errors of TST placement and interpretation and does not trigger an anamnestic response.
A technical bulletin regarding respiratory protection in health care settings is under development. It is imperative for health care facilities to maintain infection control programs in order to promptly detect tuberculosis infection, ensure airborne precautions are in place and the appropriate treatment of the patient is initiated.
We need to raise the "index of suspicion" for tuberculosis. Through the collaborative efforts of public health and health care professionals we can make progress toward eliminating TB in our community.
Alliance
By Pauline Lee &
Andrea Yu, 2006-07 CCMS
Medicare and Medicare Part D help offered by State Health Insurance Assistance Program (SHIP)
By Jeannie Pearce, Nevada SHIP Director
Medicare patients can access Medicare and Medicare Part D
information and assistance through
·
Which Medicare Part D plan do you think would be best for me?
·
Can I continue to take my current medicines on this plan?
·
Do I need to do anything if I like my current plan?
·
I have both Medicare and Medicaid. What do I do?
·
My pharmacist says I have to pay for my drugs, now what do I do?
·
I didn't enroll last year in Part D; can I enroll now?
To provide comprehensive assistance, Nevada SHIP has a
During the Annual Coordinated Election Period, which
starts on November 15th, Medicare beneficiaries can pick, switch or change a
plan. The number of plan choices for Part D increased this year, and plans vary
in premiums, deductibles, co-pays and coverage. SHIP arranges private
appointments for anyone who wants to come into a SHIP office and meet
personally with a counselor. Walk-ins are always welcome at 3100
Important dates for Medicare Part D enrollment are:
·
November 15 to December 31 Annual Coordinated Election Period
·
December 8, 2006 -If possible, everyone should enroll or select a plan
by this date.
·
January 1, 2007-Coverage begins.
·
January 1 through March 31-2007 Open Enrollment Period for Medicare
Advantage Plans.
SHIP is a national program that offers
one-on-one counseling and assistance primarily to people with Medicare and
their families. It provides free counseling and assistance via telephone and
face-to-face interactive sessions, public education presentations and programs,
and participating in health fairs or other media events.
Nevada SHIP welcomes questions, comments, or suggestions. Call the SHIP Program at:
1-800-307-4444 (Statewide)
486-3478 (
Classifieds
seeking internist or f.p.: to join a fully operational medical practice attached to St. Rose Siena hospital. Outstanding opportunity to take over a departing physician’s practice of over 2000 patients in a desirable location. Call (702) 614-0850 ext 108.
office space available So Hills Area - Russell & Ft Apache time share or permanent space, new 3,000sf medical building. For information please call 939-1900.
death by any means a novel by Leonard Kreisler MD was added to the Clark County Library District in August 2006. You can request the book by calling your local library of choice. Dr. Kreisler appreciates comments, 255-3545. Have a good read.
SEEKING BOARD CERTIFIED/ELIGIBLE MD OR DO: UNSOM's Family and Community Medicine in
Pain Management Physician Wanted: Established (8 years) practice seeking a Board Certified Pain Management physician. Work part time and earn a full time income. Flexible scheduling. Perfect position for supplementing income.
Fax CV to (702)974-0108, or e-mail CV to PmsJim@msn.com.free
Henderson/Green valley office space to lease and share with established internal medicine practice. 3 rooms - fully furnished, ideal for start up, 2nd location - daily/weekly/monthly. Available now. If interested contact by email msmith@imalv.com or call 702-466-7109.
OFFICE
IN SOUTHWEST FOR LEASE:
OFFICE
FOR LEASE IN SOUTHWEST:
PHYSICIANS WANTED: With the opening of the new Southwest Office, established Eye, Ear, Nose & Throat practice is looking for both an Ophthalmologist and an Otolaryngologist to compliment group. For more information contact Judy Duncan, Nevada Eye & Ear or jduncan@nee-nv.com
Office
space available:
CME
CALENDAR
Bechtel
NV
Chapter
Pri-Med Institute (877) 4PRI-
Sierra
Health Services 242-7735
Dec 14 - “Evaluation of Sinus Disease,, Sinus Headaches - Diagnosis and Treatment and When to
Refer”
Jan 11 - “Dermatology for Primary Care
Practioners”
Southwest
Medical Associates 242-7735
Dec 1 - “Update on Inflammatory Bowel Disease
in Children”
Dec 8 -”Vaccine Preventable Diseases - Part 2
- Viral Diseases”
Dec 13 - “Anti-Fungal Update: New Diagnostic
Tests & Anti-Fungal Review”
Dec 15 - “HIV Aids Update”
Education
Opportunities for Practice Managers, Call the NV Medical Group Management
Association:
697-5471
ext 134
Only
Southern Nevada
Health District Disease Statistics* - October 2006
SOUTHERN NEVADA HEALTH DISTRICT
DISEASE STATISTICS* - October 2006
DISEASE CASES REPORTED YEAR TO DATE
Oct
2005 Oct 2006 2005 2006
VACCINE PREVENTABLE DISEASES
DIPTHERIA 0 0 0 0
HAEMOPHILUS
INFLUENZA 0 . 10 9
HEPATITIS A . 0 11 7
HEPATITIS B . . 20 27