California has perhaps replaced Wimpy as the most famous example of borrowing against the future to address today's appetite. This year marked another significant erosion of California's financial situation, forcing the governor and Legislature to grapple with a multibillion-dollar budget deficit. Political observers surely felt that Sacramento had fallen into a time warp as partisan bickering overshadowed problem solving, leaving Californians to endure another historically late budget. Other pressing matters, including prison reform, water shortages, and California's ever-increasing number of uninsured took a back seat to the budget deficit.
In 2008 the governor signed two separate budget accords that were supposed to solve California's budget woes. Those deals proved to be badly out of balance almost immediately after they were signed. Facing a $40 billion budget deficit, legislators were forced to reconvene in early 2009 and pass a new budget that would supposedly keep California solvent through 2010. That budget contained $15 billion in cuts, $12.5 billion in new taxes, $7.8 billion in federal stimulus money, and $5.4 billion in borrowing. That budget also fell short, causing the state to face a $21 billion deficit by July 2009.
The continual focus on the budget and the ongoing need to make massive cuts or find new revenues paralyzed lawmakers for months. Democrats refused to consider any additional cuts and Republicans were equally adamant that they would not support any new taxes. The partisan stalemate forced California to start the new fiscal year on July 1, 2009, without a balanced budget in place. Many thousands of state workers and businesses that contract with the state went unpaid, hospitals were left without reimbursements, and some patients lost their state-provided health insurance while the governor and legislators continued to feud over a solution.
Finally, on July 28, 2009, Governor Schwarzenegger signed a new "balanced budget" that primarily relied on massive cuts and billions in borrowing to fill the deficit. But even that budget is now $4 billion in the red as California's economy continues to struggle, and next year's budget deficit may exceed $10 billion based on current estimates. It is very likely that the Legislature will once again have to take midyear action to address the deficit now and in the future.
To make matters worse, the governor continued his well-worn pattern of veiled threats toward legislators for their failure to act on issues such as the budget, water, and prisons. The governor used a variety of methods to try to force legislators to act. At one point the governor sent Senate President Pro Tem Darrell Steinberg (D-Sacramento) a bronzed sculpture of bull testicles, insinuating that the legislature needed a pair. Not surprisingly, Steinberg and other legislators were not amused.
By the end of the legislative session, the governor threatened to veto all legislation sent to him until lawmakers sent him a water deal he found acceptable. That threat caused considerable consternation among Republicans and Democrats alike. Ultimately, the governor backed off from his threat and acted on the bills before him. The continuing strain between the Legislature and the governor does not bode well as major problems facing the state continue to loom. Is it any wonder that the Field Poll recently found that both the governor and Legislature suffer from historically low approval ratings of 27 percent and 13 percent respectively? The only governor with lower approval ratings than Schwarzenegger was Gray Davis, the man whom Schwarzenegger replaced through a recall election in 2003.
For CMA it was another busy year. State budget cuts consumed many hours of hard work as we defended the already abysmally low Medi-Cal reimbursement rates. Ultimately, CMA's Center for Legal Affairs was forced to sue the state to block the governor's attempts to reduce rates by 10 percent. Fortunately, the court found in favor of physicians and ordered an injunction against the state prohibiting implementation of the cuts.
In the Legislature we faced fights difficult and sometimes ugly — fights over scope of practice, peer review, the bar on the corporate practice of medicine, and rescission of insurance policies. Fortunately, CMA was able to defeat every bill that we opposed. Not a single bill we opposed made it to the governor and every scope bill was defeated in their first committee.
The pharmacists, nurse practitioners, and physical therapists all pursued scope of practice expansions this year. Pharmacists attempted to get legislative approval to administer vaccines directly to patients without a physician protocol; that bill was overwhelmingly defeated. The nurse practitioners finally abandoned their efforts to establish independent practice and worked proactively with CMA to provide greater clarity to their practice protocols. The physical therapist legislation proved to be the most contentious scope bill of the year with their legislative staff asserting that physical therapists were more qualified to diagnose patients than physicians. Needless to say, that argument did not carry the day and the bill was soundly rejected.
This year the fight to preserve the prohibition on the corporate practice of medicine was difficult, to say the least. Three bills were introduced to destroy or undermine the corporate bar and allow for the direct employment of physicians by hospitals. Both the California Hospital Association and the American Federation of State, County, and Municipal Employees union sponsored measures to take direct control of physicians through employment. The bills were passed out of the Assembly but were defeated in the Senate. Both organizations have made it clear that they intend to pursue their efforts next year, so the fight will continue.
CMA sponsored several bills and ultimately three made it through the legislative process and to the governor. The first bill, AB 2, would have prohibited insurance companies from rescinding a patient's insurance policy without proving that the patient intentionally misled the company when they sought coverage. Unfortunately, this bill was vetoed by the governor. Our second sponsored bill, which would have made needed changes to the peer review system, was also vetoed. The governor did sign our third sponsored bill, SB 606, to expand the Steven M. Thompson medical school loan repayment program to provide additional funding to physicians willing to practice in underserved areas.
Overall, it was another year that was lost to the budget morass that the state continues to find itself in. It is likely that the final year of Governor Schwarzenegger's term will again be dominated by budget deficits. The projected $10 billion shortfall will be extremely difficult to address since the state is out of easy or politically acceptable means of bridging the gap.
Perhaps Wimpy will take Minerva's place on the Seal of the Great State of California.
CMA-sponsored/supported Legislation and CMA-opposed Legislation
CMA-sponsored and Supported Legislation:
CMA-opposed Legislation:
Many medical malpractice claims occur with patients who request elective procedures and are then dissatisfied with the outcome. A well-planned patient selection process can not only be a valuable tool for loss control, but it can also help identify patients who are good surgical candidates. During the initial visit, asking the following questions may help avoid the stress and disruption of a lawsuit or an adverse outcome:
It is always beneficial to assess the patient's body language behavior. Red flags that may warrant additional assessment include, but are not limited to, the following:
Better integration of the patient's voice in the selection process, as well as increased personal attention to each patient, may help minimize the potential risks of the surgical outcome.
Approximately 1 million Americans will develop herpes zoster, more commonly known as shingles, each year, and everyone who has had chickenpox is at risk. Twenty percent of shingles sufferers go on to develop post-herpetic neuralgia (PHN), which is commonly defined as pain that persists or occurs at least one month after acute herpes zoster.
The Patchwork of Hope Network, an educational campaign led by the National Council on Aging and the National Pain Foundation, is designed to raise awareness of shingles and PHN. Featuring several live events throughout the year and in cities across the United States, the campaign combines online educational resources with expert opinion from physicians to help patients understand that they do not have to suffer alone. Event attendees learn about PHN signs and symptoms and treatment options from local physicians, hear patient testimonials, and meet others affected by the condition.
There is no cure for PHN, but both oral and topical medications are available to help treat the often-debilitating pain associated with the condition. If you have patients or know someone suffering from shingles or PHN, please direct them to AfterShingles.com, an online educational resource about shingles and PHN, its impact on people's lives, and steps to take to help manage this condition.
QUESTION: We have received a request from an attorney's office to release a patient's medical records free of charge because there is a pending Social Security disability claim. It also states that if the appeal is successful, the provider may bill the patient for the records at up to $0.25 per page, plus reasonable clerical costs. How would we know if the appeal was successful and when to bill the patient?
ANSWER: Since all of these records are public, you can track when an appeal is successful online if you know in what court the case is being heard (e.g., 1st District Court of Appeal) and the case number or parties in the case. With this information, you can check the online docket system and retrieve the status of the case. For further information, consult CMA's ON-CALL document #1150, "Patient Access to Medical Records" — available free to SDCMS-CMA members at CMANet.org.
QUESTION: I do not know if my DEA license has expired. How often do I need to renew my license, and how long does it take?
ANSWER: Your DEA license must be renewed every three years. Renewal applications are mailed out 45 days prior to the expiration date to the last address listed with the DEA; however, the United States Postal Service will not forward applications to a new address. Contact the San Diego DEA field office at (858) 616-4100 if you need to change your address. Renewal applications are processed within approximately four weeks.
FOLLOW-UP QUESTION: In the August issue of San Diego Physician, the article "Medical Records Frequently Asked Questions" included the question: "Can I thin and purge medical records prior to storage?" The answer was yes, they may be purged because the originals are maintained by the hospital. As a follow-up to this question, one of our SDCMS member office managers asked if hospice records and their progress notes under the category of hospital records can also be purged from records in storage.
ANSWER: The hospice organization should have its own medical records and, as such, the progress notes are maintained in the hospice record. If copies that are sent from the hospice organization to the physician are included in the office practice medical record, then yes, the notes can be thinned and purged. If the hospice organization does not have its own records, the physician should keep the copies of the progress notes in the office practice medical record. The "Medical Records" article from the August issue, along with all San Diego Physician magazine articles, are posted at SDCMS.org.
PHYSIDICANS AND OFFICE STAFF: DID YOU KNOW?
Did you know that SDCMS member physicians and their office managers have access to hundreds of practice management questions and answers at SDCMS' website? Go to www.SDCMS.org/faq to search from among hundreds of economic, legal, employment, licensure, and other questions critical to successfully managing your practice. To access the answers to the questions located in our online FAQ database, you will need to log in. Member physicians should contact Kyle Lewis for assistance in logging in at (858) 300-2784 or at KLewis@SDCMS.org, and member office managers should contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org. And if you don't see the question or answer you're looking for, go ahead and submit your question online as well at the bottom of the www.SDCMS.org/faq page!
CMA-SPONSORED LEGISLATION:
Bill: AB 2 (De La Torre) UNLAWFUL RECISSION: INDEPENDENT REVIEW • This bill would have provided protection to patients by requiring a healthcare service plan or health insurer to obtain final approval from an independent review organization prior to rescinding a health plan contract or insurance policy. This review would have used a clear legal framework to determine whether the rescission was appropriate while protecting the enrollee's rights during the review process. The bill would also have improved the process at the front-end by requiring plans and insurers to complete medical underwriting prior to issuing a policy and made applications easier to fill out accurately and completely. This was a reintroduction of AB 1945, which was vetoed in 2008.
Action: Vetoed by Governor on 10/11/09
Bill: AB 120 (Hayashi) PEER REVIEW • Nearly all peer review done in California is done efficiently, timely, and in a manner that protects patients from quality of care deficiencies. However, the current peer review system could have been strengthened. For example, improper or biased review could be utilized to remove physicians for non-quality of care concerns. In rare circumstances peer review can be delayed to the point that patients are placed in danger by the inability to promptly remove a physician that is providing substandard care. AB 120 would have improved an already robust system to make it even more effective in ensuring high quality care in CA hospitals.
Action: Vetoed by Governor on 10/11/09
Bill: AB 497 (Block) HIGH OCCUPANCY VEHICLE LANE ACCESS FOR PHYSICIANS • This bill would have allowed physicians to use the high occupancy vehicle (carpool) lanes on the freeway when responding to an emergency. This bill would have expanded current law which allows physicians, with the appropriate decal on their car, to exceed speed limits when responding to an emergency.
Action: Failed in Senate Transportation and Housing Committee, Reconsideration Granted
Bill: AB 526 (Fuentes) PUBLIC PROTECTION AND PHYSICIAN HEALTH PROGRAM ACT OF 2009 • This bill would have created the Patient Protection and Physician Health Program in California. The bill would have allowed physicians with mental health or addiction problems to seek help leading to appropriate treatment and monitoring prior to harming a patient. With the closure of the Medical Board Diversion Program there is not a sufficient program available for physicians seeking help. This was a reintroduction of AB 214 of last year.
Action: Held on Senate Appropriations Committee Suspense File
Bill: AB 583 (Hayashi) HEALTHCARE PRACTITIONERS: DISCLOSURE OF EDUCATION • CMA co-sponsored this bill with the California Society of Plastic Surgeons. It has become increasingly difficult for the public to identify the license, education, and training of healthcare professionals who practice in the state and many are unable to distinguish between physicians and non-physicians. To protect the public's health and safety, this "truth in advertising" legislation would have required a healthcare professional to disclose information in various healthcare settings to help patients understand who will be helping them with their healthcare, such as information about their license, education, and recognized board certification.
Action: Two-year Bill, on the Senate Floor
Bill: AB 1201 (M. Perez) ADEQUATE REIMBURSEMENT FOR VACCINES • CMA co-sponsored this bill with the American Academy of Pediatrics and the California Academy of Family Physicians. The bill required plans/insurers to adequately reimburse for both the acquisition and administrative costs of giving shots, such as purchasing the vaccine, storage, inventory, staff time, supplies, etc. This bill also would have prohibited plans from applying co-pays, deductibles and other cost-sharing mechanisms to immunizations.
Action: Held on Assembly Appropriations Committee Suspense File
Bill: SB 606 (Ducheny) STEVEN M. THOMPSON LOAN REPAYMENT PROGRAM: OSTEOPATHIC PHYSICIANS • CMA co-sponsored this bill with the Osteopathic Physicians and Surgeons of California to allow Osteopathic Physicians (DOs) to access the Steve Thompson Loan Repayment Program (STLRP). The STLRP is currently available to MDs, but not to DOs, who tend to focus on primary care and would be good candidates for the program. This legislation makes DOs eligible for the STLRP and requires them to pay an additional $25 fee toward the program, as MDs are now required to do.
Action: Signed by Governor, Effective 1/1/10
CMA-OPPOSED LEGISLATION
Bill: SB 726 (Ashburn) HOSPITALS: EMPLOYMENT OF PHYSICIANS AND SURGEONS • This bill, as amended in Assembly Health Committee, would have allowed virtually all Healthcare Districts and Rural Hospitals to directly employ up to 5 physicians in a pilot program. The CEO of a facility would have had to show they had been unsuccessful in recruiting a physician for 12 months, that no currently contracted physician or physician with privileges would be supplanted, and the physician was not recruited from an FQHC. Employment contracts could have been be up to 10 years but would be renewed if signed prior to December 31, 2017. The Medical Board of California would have been responsible for an interim report on the success of the pilot program due in 2013 with a final report due in 2016.
Action: Placed on Assembly Inactive File
Bill: AB 646 (Swanson) PHYSICIANS AND SURGEONS: EMPLOYMENT • This bill was amended in Assembly Health Committee to establish a pilot program to allow Healthcare Districts located in an underserved area to directly employ and charge for physician services. Districts would have been allowed to hire up to 5 physicians with an ability to request up to 5 additional contracts and to limit the pilot to 10 years.
Action: Failed in Senate Business and Professions Committee
Bill: AB 648 (Chesbro) RURAL HOSPITALS: PHYSICIAN SERVICES • This bill, as amended in Assembly Health, would have allowed a rural hospital that served an underserved area or population to directly employ and charge for physician services. The demonstration project would have lasted up to 10 years and allowed the hospital to employ up to 10 physicians. To be eligible, the hospital had to demonstrate that it could document that it had been unsuccessful in recruiting a physician for 12 months and the CEO certified to the MBC that there was a critical unmet need in the community.
Action: Failed in Senate Business and Professions Committee, Reconsideration Granted
Bill: AB 721 (Nava) PHYSICAL THERAPY DIRECT ACCESS • This bill would have substantially expanded the scope of practice for physical therapists in California by allowing them to evaluate and treat patients without a previous diagnosis or referral from a licensed physician. Current law does not specifically address physical therapy treatment without referral, but the law does prohibit therapists from making medical diagnoses.
Action: Failed in Assembly Business and Professions, Reconsideration Denied
Bill: AB 1126 (Hernandez) THE PUBLIC EMPLOYEES' HEALTHCARE ACT: BILLING DISPUTES • This bill would have prohibited a healthcare provider giving emergency services and care from seeking reimbursement or attempting to obtain payment for any covered services provided to an employee or annuitant enrolled under the Public Employees' Healthcare Act (PEMHCA). This bill specifically noted that the affected emergency services providers included but were not limited to hospitals and hospital-based physicians such as radiologists, pathologists, anesthesiologists, and on-call specialists.
Action: Two-year Bill, in Assembly PERS Committee
Bill: AB 1218 (Jones) HEALTH INSURANCE RATE REGULATION • This bill would have required the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to approve any increase in the amount of the premium, copayment, coinsurance obligation, deductible, and other charges under the healthcare service plan or health insurance policy. CMA opposed similar legislation in 2005 (SB 26) and 2006 (SB 425) because of concern that such rate regulation could lead to rate regulation of provider reimbursement.
Action: Failed in Assembly Health, Reconsideration Granted
Bill: AB 1458 (Davis) DRUGS: ADVERSE EFFECTS REPORTING • This bill would have required healthcare professionals to report "suspected serious adverse drug events that are spontaneously discovered or observed" to MedWatch, a drug safety and adverse event reporting system operated by the federal FDA. This bill would have placed an unnecessary mandate on the practice of medicine.
Action: Held on Assembly Assembly Appropriations Committee Suspense File
Bill: AB 1478 (Ammiano) WRITTEN ACKNOWLEDGEMENT: MEDICAL NUTRITION THERAPY • This bill would have required that a physician, prior to providing care for diabetes or heart disease, must inform the patient or the patient's legal representative of the option of "medical nutrition therapy" treatment for diabetes or heart disease, including a description of the potential risks, consequences, and benefits; and obtain written acknowledgment from the patient or the patient' s legal representative confirming that the patient received this information. The failure of a physician and surgeon to comply with this requirement would have constituted unprofessional conduct.
Action: Two-year Bill, in Assembly Business and Professions Committee
Bill: SB 700 (Negrete McLeod) PEER REVIEW • As amended April 13th, this bill would have required an 805 report to be filed with the MBC prior to the 809 hearing process. The bill would have circumvented the fair hearing process and not allowed a physician to test the validity of charges prior to an 805 report being filed. Further it would have required peer review at individual physician offices even though many are covered by medical staff membership, participation with groups of 25 or more physicians, or through contracts with insurers. The bill also called for more 805 reports for alleged misconduct.
Action: Placed Senate Inactive File
Bill: SB 810 (Leno) SINGLE PAYER HEALTHCARE • This bill was a reintroduction of SB 840 (Kuehl) from last session. The bill would have created a single-payer system of healthcare in California. Specifically, SB 810 created a single payer purchasing pool and would have prohibited most private health insurance from being sold.
Action: Held on Senate Appropriations Committee Suspense File
BILLS OF INTEREST
Bill: AB 1422 (Bass) HEALTHCARE PROGRAMS: CALIFORNIA CHILDREN AND FAMILIES ACT OF 1998 • This bill, supported by CMA, contains a 2.35% tax upon the total operating revenue of Medi-Cal managed care plans until January 1, 2011 in order to draw down federal funds that will help fund the Healthy Families Program (HFP). Approximately 1/3 of the revenue resulting from this tax will be returned to the plans through higher reimbursement rates and the remaining 2/3 of the revenue will be directed to the HFP. The bill also increases premiums in the HFP. The bill also allows the Managed Risk Medical Insurance Board, during the 2009-10 and 2010-11 fiscal years, to adopt regulations to modify benefits, program requirements and operations on an emergency basis. The bill also allows the state Children and Families First Commission (created by Proposition 10) to direct "unneeded revenue" from specific accounts into their Unallocated Account. This carefully crafted bill is a "win-win" that contains a temporary approach to restore desperately needed funding to the HFP and protect access to health care for uninsured children while a long-term solution can be identified.
Action: Signed by Governor, Took Effect 9/22/09
Bill: AB 542 (Feuer) NON-PAYMENT FOR ADVERSE EVENTS (Watch) • In the face of strong CMA opposition, this bill was dramatically narrowed by the author before its first committee hearing. The bill now would apply only to hospitals and merely requires the state to adopt regulations establishing uniform policies and practices governing the nonpayment to hospitals for hospital acquired conditions by public and private payers, consistent with those developed by the federal Centers for Medicare and Medicaid Services (CMS). The original problematic language creating a state Patient Safety Committee that would substantiate a broader list of adverse events and determine nonpayment policies for all providers was removed. CMA will continue to provide suggestions to further improve this bill and will stay engaged in the discussion.
Action: Two-year Bill, in Senate Health Committee
Bill: AB 613 (Beall) MEDI-CAL TAR REFORM (Support) • This bill would have required the Department of Health Care Services (DHCS) to improve and streamline the treatment authorization request process by, among other things, performing a cost-benefit analysis for each TAR and reducing the number of TARs required, developing alternative approaches for fraud and abuse detection, developing an alternative to the requirement that a patient obtain a TAR for each individual day of his or her stay in the hospital and consider adopting a single TAR for the entire length of a patient's hospital stay, and make publicly available the rules and criteria for determining medical necessity.
Action: Held on Assembly Appropriations Committee Suspense File
Bill: AB 832 (Jones) SURGICAL CLINIC LICENSING (Watch) • In the face of strong CMA opposition, this bill was completely gutted by the author before its first committee hearing. The original problematic and unnecessary language that would have required all physician-owned surgical clinics to be licensed by the state was removed and replaced with language requiring the Department of Public Health to convene a workgroup to discuss the licensing of ambulatory surgical centers. CMA will have a representative on the workgroup, as will other impacted physician specialty organizations, and we will continue to make the case that the existing accreditation process is more than adequate and protects patient safety.
Action: Held on Assembly Appropriations Committee Suspense File
Bill: AB 834 (Solorio) PEER REVIEW (Watch/Refer) • As amended April 14th, this bill would have established an alternative to the 805 process when a physician and surgeon accepts remediation in lieu of the filing of a report. The bill would have allowed a peer review body to impose, if the physician accepts, remediation in the form of mandatory proctoring, consultation, education or retraining. The peer review body could place limits on the physician's privileges during remediation. A report would be submitted to the MBC upon commencement and conclusion of the remediation or if the remediation was not successfully completed. This bill was referred to policy for development of this "805 lite" program.
Action: Two-year bill, in Assembly Business and Professions Committee
Bill: AB 877 (Emmerson) SCOPE OF PRACTICE REVIEW COMMITTEE (Support) • This bill was amended from an "intent" bill, to having substantive language creating a scope of practice committee to perform an occupational analysis on any bills seeking to substantively expand the scope of a healing arts practice. The American Medical Association (AMA) has sample language for this issue and has been supportive of state efforts to create scope review committees. The author took language from AMA, and worked with our office for suggestions on making the review committee one that does not recommend but rather gives a review as to education and training, current law of other states and evaluate the quality and cost of health for proposed scope expansions.
Action: Held on Assembly Appropriations Committee Suspense File
Bill: AB 977 (Skinner) PHARMACISTS: IMMUNIZATION ADMINISTRATION (Watch) • The author gutted her bill after it failed in committee in the face of strong CMA opposition. The bill would have allowed pharmacists to independently initiate and administer immunizations to children and adults and now only contains uncodified language requesting the California Pharmacists Association to provide information to the chairpersons of Business and Professions and Health Committees on the status of immunization protocols between independent pharmacists and physicians. CMA monitored the bill closely to ensure that any study conducted was unbiased and narrowly focused and ensured that objectionable language was not inserted at a later date.
Action: Two-year bill, in Assembly Health Committee
Bill: SB 58 (Aanestad) PEER REVIEW (Watch) • This bill was amended to require a peer review body to administer an Early Detection and Resolution Program to allow physicians to complete additional training, while privileges were limited, prior to the filing of a disciplinary quality report. The bill would also have allowed a physician to submit explanatory or exculpatory information when an 805 report was filed and required the MBC to remove expunged reports from a physicians file. This bill was heavily negotiated with peer review reforms.
Action: Held on Senate Appropriations Committee Suspense File
Bill: SB 196 (Corbett) EMERGENCY MEDICAL SERVICES (Support) • The transparency provisions previously contained in the bill were eliminated by amendments taken on 6/18/2009. The bill would have required a hospital to provide 180 days notice and hold public hearings prior to the elimination of emergency services.
Action: Vetoed by Governor on 10/11/09
Bill: SB 294 (Negrete McLeod) HEALING ARTS (Watch) • This bill was stripped of the two most egregious proposals, allowing nurse practitioners (NP) to admit patients and permitting NP's to be designated primary care providers. The current version allowed, in accordance with standardized procedures, to approve and modify home health services, certify disability and order durable home health equipment. The intent language was narrowed at CMA's request to more accurately reflect the bill and the scope of practice of NPs. Near the end of session, new language was added to the bill to address perceived deficiencies in several health related licensing boards. The bill would have taken disciplinary and investigatory provisions that applied to physicians and applied them to other professions such as dentists, nurses, and optometrists. There was little change for physicians since most amended code sections specifically exempted physicians.
Action: Two-year bill, in Assembly Business and Professions Committee
Below are some of the comments received by Marisol Gonzalez and Lauren Wendler — your full-time SDCMS physician advocate and office manager advocate respectively — from member physicians and their staff. If you have an issue you need help with, please feel free to contact Marisol and Lauren first. Marisol can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org, and Lauren can be reached at (858) 300-2782 or at LWendler@SDCMS.org.
"Wow. Amazing customer service. I'm so impressed. Thank you for the information. Have a wonderful evening."
— SDCMS Member Since 2006
"Marisol, You are the greatest! Please forward my email to Tom so that he knows what a great help you are to us! Thanks so much."
— SDCMS Member Since 1990
"Thank you so much for all your help."
— SDCMS Member Since 2007
"Thank you so much. I really appreciate how quickly you respond and get things done!!"
— SDCMS Member Since 2009
"Thanks for your help. You are great. I will call Tom personally to thank him. These are reasons for us to become members of the Society. Thanks for all the good work."
— SDCMS Member Since 2009
"Marisol, Thank you so much for your wonderful and prompt help with getting me started [...]. Thank you again."
— SDCMS Members Since 2009
"You are totally awesome! Thanks so much for your help with this!"
— SDCMS Member Since 2007
"Marisol, We got two old checks today re-mailed to us to the correct address and one check addressed to the correct address. I would like to thank you, your staff, and CMA for intervening swiftly and getting the results for us."
— Office Manager of SDCMS Member Since 1990
"Thanks for all your help. It's greatly appreciated."
— Office Manager of SDCMS Member Since 2006
"Lauren, Just wanted to say thank you for all of your help over the last few years. Words cannot fully express my sincerest gratitude!"
— Office Manager of SDCMS Member Since 2002
NOTE: This and Dr. Hertzka's article contain solicited opinions from two of SDCMS' physician leaders. Neither article reflects the opinions of SDCMS or CMA as a whole. They are published here to provoke thoughtful discussion and consideration of opposing views on the issue of healthcare financing reform currently underway in our nation's capitol. Please feel free to join the discussion by sending your letters to the editor to Editor@SDCMS.org.
In the months and years to come, there will certainly be no shortage of retrospective analyses of the events that currently comprise the efforts to reform what is, by all reasonable viewpoints, a most dysfunctional system of financing the healthcare provided to America's citizens. That there is a need for such reform is universally agreed upon, with the glaring exception of the one industry that continues to thrive with the status quo: private companies that sell health insurance policies. For the health insurance industry, it would be hard to imagine a more profitable system. For everyone else, it's hard to contemplate a less beneficial one. The United States pays far more than any other country for healthcare but ranks nowhere near the top in the quality of its citizens' health. This has been the case for at least the past 60 years. No wonder, then, that repeated efforts have been made to find a way to make the care we receive become worth what we pay for it. Despite these massive costs, there remain fully 47 million Americans who are uninsured.
The year 2009 will be looked back upon much like so many of these previous efforts. At this exact moment in time, it is anyone's guess as to what, if any, legislation will finally emerge from our Congress. There is, however, something unique about the present situation. Never before has there been such intense acrimony and hostility accompanying the debate. One can argue over why this is so. It's hard to imagine that either side looks upon what has transpired so far as an optimal and gratifying exercise in policymaking. The depth of feeling that has been created over this issue certainly has the potential to make future bipartisan and cooperative efforts on other issues just that much harder to secure.
For these reasons, then, it is, I believe, not unreasonable to look back over the past several months and consider whether it had to be this way. What strategies might have been employed by the "liberal" side that would have rendered the matter what it should have been: a reasoned, informed, and courteous negotiation with the goal of producing not only improved quality of healthcare but a sense of cooperative accomplishment with a focus on common ground instead of differences? In the following paragraphs, I will present some thoughts on how the liberal community, of which I proudly consider myself a member, could have and should have stepped forward to promote the well-being of its citizens by reforming the system by which healthcare is financed. I do so not out of any sense of impending failure or capitulation to those who are in opposition. I believe (and by the time you read this, I may be proven wrong) that there is still an opportunity for success. As Winston Churchill once said, "Americans always manage to do the right thing, but not until they've tried everything else first."
The most easily identified failing on the part of reform proponents was the violation of Santayana's timeless warning that those who do not study history are doomed to repeat it. Over and over again our presidents, dating all the way back to Harry Truman, have found their efforts to bring healthcare access to all citizens met by powerful resistance by those whose vested interests lay in avoiding any changes. As recently as 1965, the efforts of President Lyndon Johnson to pass Medicare were characterized as a Communist plot designed to take away freedom. None less than future president Ronald Reagan appeared in a propaganda film that warned of the dangers of this program. He said that if Medicare comes to pass, "We will spend our sunset years telling our grandchildren what America was like when men were free." One of the saddest features of this fear-mongering campaign was that the major promoter of it was none other than our own American Medical Association (AMA). In the more recent iterations of reform, such as that proposed by President Clinton in 1993, the role of chief naysayer had been passed to its present occupier, the health insurance industry. To its great credit, AMA this time around has displayed the wisdom and presence of mind to make efforts to work with the administration in a cooperative fashion so as to remain at the table and seek the changes it requires in a harmonious fashion.
It would have been ever so much more effective to have headed off the most frequently voiced argument against the offering of a "public option," i.e., that it will put the private carriers out of business. This could have been easily accomplished by citing the history of another form of insurance, that of workers' compensation. In the early 20th century, a number of states proposed the creation of state funds overseen and operated by governments to offer an alternative to businesses that were required to purchase this insurance so as to protect injured workers. Such funds were vehemently opposed by private insurers who complained that they would not be able to compete against the government (sound familiar?). When the funds were created, the private carriers reduced their premiums by an average of 30 percent and have continued to compete effectively to this day. This is quite likely what would happen if a public option for health insurance came into being at this time. To have put forward this historical event at the outset would have deprived the opponents of today's efforts of their favorite misrepresentation.
A lack of clear and precise language as to what the goals of reform are has created a good portion of the fear and anger that have been so prominent. The Obama administration, in an effort to avoid the Clinton mistakes, has failed to spell out its objectives, preferring to let Congress create the legislative package. This brings to mind the oft-quoted line that there are two things that are just too unpleasant to watch being created: sausage and legislation. As a result, Congress has created numerous proposals, with major differences among them. Even the term "universal coverage" suffers from vagueness. Does it mean that all people are provided with free healthcare with no personal expenses? Or does it mean that everyone is legally required to purchase a policy no matter what the cost? And what kind of policy is meant by that term? Is it to be comprehensive or catastrophic? What do we even mean by "insurance"? In its most traditional definition, insurance means the bringing together of large numbers of risk-sharers for the purpose of avoiding individual financial catastrophe. Somehow, that definition no longer seems to be in play as policies have become so comprehensive that often quite minor expenses are covered, such as doctors' office visits. Clearly, that is not insurance as it used to be known. If the individual mandate is to come to fruition, it must be made clear whether required policies are to be comprehensive or catastrophic. The latter should not engender major costs, but should largely eliminate medical bankruptcies. This distinction should have been made clear at the outset of the reform effort.
It would have been immensely helpful had it been appreciated that many perceive government involvement in healthcare in terms only of the single-payer systems of England and Canada, as they are so frequently cited as examples of how regulated care doesn't work. Little or no attention has been paid to the numerous universal coverage systems in place in Europe that work extremely well. France is recognized to have a system that employs private health insurance that is highly regulated and that provides high-quality care at reasonable costs. So too with Spain, Germany, and Switzerland, but no effort was made by the proponents of reform to educate both the public and Congress as to the wisdom of emulating these systems.
Finally, it has been discouraging to hear the term "public option" promoted and reviled in the absence of any clear definition as to what it means. One might well assume that it means a change in the Medicare system so as to open it up to anyone who wishes to buy into it, no matter what their age or disability status. Such a proposal is not only clear and easy to understand, but does not require the creation of new bureaucracies. This level of clarity has not been forthcoming.
This linguistic imprecision ties directly to the issue of failure to be clear about the monetary costs of reform. As stated above, costs are massively variable depending on the nature of the reform being sought. If Medicare membership were to be offered to all citizens, there would need to be a massive rededication to eliminating the so-called "big three": fraud, waste, and futility. Estimates range to 30 percent as the amount of money expended on these three features of care. Currently, Medicare pays very little attention to fraud, which is a major cost factor. Arguably the biggest cause of wasteful spending is defensive medicine, which nearly all of us feel compelled to resort to in an effort to protect ourselves against lawsuits. We patiently await proposals to include reasonable tort reform so as to dramatically reduce wasteful medical costs. Among the most sensitive reform issues is the problem of futility. It has been estimated that up to 50 percent of the money spent on an individual's lifetime of healthcare is expended in the final 30 days of life. It's hard to imagine that we can't do better than that. This, however, is a very sensitive issue, suggesting that we must bring an end to costly and hopeless medical endeavors. Is there, for example, any reasonable justification to fund treatments with the colon cancer drug Erbitux at a cost of $10,000 per month when it has been shown that it extends survival for an average of only 45 days? Try, however, getting Medicare to refuse to cover this treatment, futile though it may be, and the Sarah Palins of the world will rant about "death panels."
Another avoidable failure was the absence of any effort to enforce party discipline among congressional Democrats. In 1965, Lyndon Johnson took an extremely hard line in personally approaching and persuading any party member who may have been wavering. This resulted in the sort of unity that allowed Medicare to pass. It is difficult to understand how conservative Democratic congressional representatives, known as "Blue Dogs," mostly from under-populated states, can have been permitted to oppose their own president on his most difficult initiative. The law should have been laid down well in advance and in no uncertain terms. In Lyndon Johnson's terms, a "trip to the woodshed" would have been in order.
Finally, the Obama administration was remiss in not powerfully emphasizing the win-win nature of the proposed reforms. It has been a sad spectacle to witness lower-middle-class Americans fighting against a program that is so obviously in their best interests to support, especially those who have been rendered so hysterical and ill-informed as to shout about "keeping the government away from my Medicare!" It would have been remarkably easy to inform the citizenry about how the only losers in the reform package will be the insurance companies, the very same people who refuse to cover you if you've ever had any sort of illness in the past and who so often stand in the way of care recommended by your doctor.
Although I happen to believe that meaningful healthcare reform is an idea whose time has come, the process of generating public and Congressional support for it has been much harder than it needed to be. We've reviewed a few of the ways in which some of the difficulties could have been avoided. There are probably going to be more shortcomings before the matter is settled. The industrialized world is watching, perhaps with bemused detachment, to see if the United States can at long last join with the majority of countries that long ago settled upon the realization that universal access to quality and affordable healthcare is in everyone's best interests.
[Note: The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.]
Ineffective handoffs can lead to inappropriate treatment, delays in diagnosis, and potentially life-threatening adverse events. In the October 2009 article, "Who's in Charge? A Lesson From Litigation" by David B. Troxel, MD, medical director of The Doctors Company, each of the hospitalists in the case study missed opportunities to diagnose the patient's condition due to communication gaps and inattention to documentation among the members of the healthcare team:
In "Who's in Charge?" there are many examples of communication and handoff breakdowns that led to the patient injury. Because the hospitalists involved in the case study didn't use a standard set of critical elements to be communicated with each handoff or interaction, there were delays in diagnostic testing and treatment and failures in recognizing the patient's neurological deficits, which resulted in the unfortunate outcome.
By understanding the problems that can occur during handoffs and planning effective communications, the hospitalists in this case could have minimized risk and enhanced patient safety.
The Shift Toward Hospitalists
Over the past decade there has been a dramatic shift away from primary care-directed hospital care toward a model in which hospital-based physicians — hospitalists — provide care to inpatients.
In fact, the hospitalist field has now become the fastest-growing specialty in the history of American medicine, skyrocketing from 1,000 physicians nationally in the mid-1990s to more than 28,000 today.
Researchers at the University of Texas Medical Branch (UTMB) at Galveston have produced the first quantitative analysis of the increase in the number of hospitalists. In a paper appearing in the March 12, 2009, issue of the New England Journal of Medicine, UTMB Associate Professor Yong-Fang Kuo used Medicare data to calculate that the percentage of internal medicine physicians practicing as hospitalists jumped from 5.9 percent in 1995 to 19 percent in 2006. (1)
Hospitalists and Effective Communication
The goal of the hospitalist medicine model is to provide a coordinated approach to the care of inpatients. This requires the hospitalist to be skilled in effective communication between physicians and the rest of the hospital clinical team involved in the care of the patient. The processes and systems within the hospital environment create potential barriers to effective communication, in areas including:
In fact, studies have indicated that lack of communication is the single most common root cause that can lead to liability claims. However, all of the above concerns can be minimized with effective communication techniques and processes.
Handoffs
The primary objective of a handoff is to provide accurate information about a patient's care, treatment, current condition, and any recent or anticipated changes. Handoffs are interactive communications allowing the opportunity for questioning between the provider and the recipient of patient information. For hospitals, the handoffs that occur during the time when a patient is moved to another unit, sent for a diagnostic test, or transferred to a new physician can create continuity of care issues. Hospitalists can use the following tips to improve effective communication during handoffs:
Conclusion
The hospitalist is responsible for the co-management of patients involving a wide range of physicians and other clinicians. It is critical for the hospitalist to communicate effectively with the healthcare team, the patient, and the patient's family to limit risks and enhance patient safety.
References
Additional Resource
The Institute of Healthcare Improvement
As physicians struggle with the day-to-day challenges of healing patients and running a business, it's tough to remember that advocacy really matters. After all, advocacy is something someone else does, and physicians almost never see the results today.
In this, our annual advocacy issue, we want to remind you that advocacy matters to every physician — and it matters a lot!
First, the results are often hidden. In his short story "Silver Blaze," Sherlock Holmes speaks of the guard dog that didn't bark as the clue to solving a murder. Often, the "dog that didn't bark" is the bad legislation that wasn't enacted, the poor decision that was stopped, and the awful ruling that was never made. We all see the affirmative successes, but we seldom see the averted disasters.
Second, advocacy results often take years to show themselves. Consider that every candidate for state and national office from San Diego County is interviewed, educated, and contacted in a way that, as candidates, they understand physician issues, and, as office holders, they are frequently reminded. They may not always agree with every position we have, but they sure as heck understand the issues and their impacts.
Third, advocacy is not an arena where everything goes your way. So while a particular issue may not go exactly the way one would like, sometimes organized medicine has to compromise. Remember: It's not the operating room where the doctor has the final say!
Fourth, when you speak, the politicians listen. When you are quiet, the voices of our opponents win. So when we ask you to call your congressional representative or U.S. senators, to fax your California assemblyperson or senator, or to contribute to a campaign, your participation matters, and your failure to participate is noticed.
Lastly, we need you — all of you! Advocacy is the voice of one or two, but with a chorus behind them. That chorus is physician membership. It is the power of one to speak for many. Absent the many, we who do this all the time are just empty voices. We need your membership, we need your contributions to CALPAC, and we need you to get involved when we ask you to. Contact me anytime on my cell at (619) 206-8282 or email me at Gehring@SDCMS.org to discuss how you can get involved!
In your October issue ["Clinical Trials: Improving Patient Care and Our Ability to Provide It"], there are interesting and related articles concerning healthcare and practices in our area. Though initially seeming not directly related, the article on "Personalized Medicine" and the one dealing with "Who's in Charge?" speak to what I perceive as growing problems as we rush to government health control.
Too many private practitioners, particularly in family practice and internal medicine, are becoming triage specialists. They see their panel of patients, and, if care beyond prescriptions is needed, refer the "consumer" to another office or to a (so-called) "hospitalist."
If that physician shares his cover with other doctors, then the chain of patient custody stretches far too thin and, so often, breaks.
The "Lesson From Litigation" taught in that article should not have been a CPC on epidural abscesses but on maintaining close doctor-patient contact, even if the patient's primary care has been taken over by another doctor.
Primary care physicians should be warned that their responsibilities to their patient do not end upon referral!
Sincerely,
Lawrence Adler, MD, JD
San Diego Physician Response
SDCMS welcomes comments from our physician readers who are not SDCMS-CMA members [email Editor@SDCMS.org]. Moreover, we would welcome and encourage nonmember physicians to become part of the solution by becoming SDCMS-CMA members, i.e., by using their beliefs and talents to effect change rather than simply comment on it.
[Note: This article was originally published in the September 2008 issue of San Diego Physician.]
Over the past seven years as your executive director, I've had the pleasure of meeting and learning from many exceptional physicians and physician leaders. I want to share some of these pretty good rules about politics and advocacy, and start by thanking Dr. Bob Hertzka (past CMA president), Dr. Jim Hay (future CMA president), and Joe Dunn (CMA CEO).
1) Look at politicians as either those who view physicians as part of the solution or those who view physicians as part of the problem.
In the world of political parties, we are seduced into thinking that the party affiliation drives "goodness" or "badness." Not so. We in the leadership team use a very simple litmus test: Does the decision maker trust physicians or not? If they do, it matters not whether they are a Republican or a Democrat.
2) Respect the truth ... always.
This rule can't get any easier — and more difficult to adhere to in the heat of the moment. Never, ever BS. Never, ever fudge. Your reputation, and that of your organization, can be destroyed in 30 seconds by being (even inadvertently) untruthful. And remember, few are more respected than those who say, "I don't know, but I will find out," and then actually find out and inform the legislator.
3) The most powerful spokesman for your cause is someone who has no direct stake in the outcome.
When you speak to a decision maker, and you have a clear interest in the outcome, you will be politely listened to, but your words will be assessed in the context of a special interest. When those same thoughts come from someone without a (perceived) conflict, those words become (magically) much more compelling. So, for example, when a family physician speaks to the lunacy of letting optometrists operate on the eye, that's a powerful statement — much more so than if it came from an ophthalmologist, who may in fact be making a more fact-based argument (see rule #10).
4) Count your votes before the vote.
Don't find out you're close (or behind) during the vote. Do everything in your power to find out who is with you and who isn't, then lobby the heck out of the issue.
5) Focus on the persuadables.
While actual percentages may vary, on any given issue, about 30 percent will be in full-throated support, and roughly 30 percent are stridently opposed. Focus 90 percent of your energy on the 40 percent who are convincible.
6) No one bats 1.000 in advocacy.
If you expect to win every issue, you've chosen the wrong avocation. It's a game of percentages. Work for the long haul, and be patient.
7) It's about the relationship, not about the issue.
There are a million issues. Choose the ones you're willing "to die for" very carefully. So treasure the relationship. Those you lobby may not agree with you (see rule #8 below), but the value of the relationship is that you get a fair and fast hearing. Being able to pick up the cell phone (and having the cell phone number) and calling a state legislature is incredibly useful.
8) Today's opponent is tomorrow's ally, and vice versa.
Note, I did not say enemy ... I said opponent (see rule #9 below). Alliances come and go; accept that the greater good sometimes makes for strange bedfellows. Therefore, never, ever personalize a disagreement because you may be looking for a partner someday soon!
9) Respect the elected officials, their staffs, and your adversaries.
You haven't run for office. You haven't had to fly to Sacramento or Washington, DC, every week. You haven't spent interminable hours in meetings listening to ... well, let's just say that our legislators work incredibly hard, and every move they make is scrutinized, criticized, and second-guessed. Respect them for what they do and who they are.
The staff are just as, and sometimes more, important as the elected official. Never, ever, ever treat the staff with anything but respect. They may be young, they may be underpaid, they may work under very challenging conditions, but they have the ear of the decision maker. Make them your allies, even your advocates!
Badmouthing your opponents (or worse, not respecting the truth) will invariably cause you to be ineffective. And the word gets around. Quickly!
10) It's 90 percent on the politics, only 10 percent on the merits.
Deal with (and understand) the politics before you speak to the merits. Those of us educated in deterministic, objective, and data-driven disciplines (engineering in my case, medicine in my spouse's) are resolutely convinced that the merits of any argument will always prevail. Sadly, in the world of politics and advocacy, that is rarely the case. In fact, many decisions are made in the absence of, or even contravention of, the facts. Decision makers have to do things, e.g., their party leadership may demand a vote, maybe they need to vote against something we like that is passing easily but they have a constituency to appease, the list goes on. Get over it! That's the world we live in.
So who cares about advocacy and politics anyway? You do. If SDCMS and CMA are not building those relationships, making the case for physicians, walking the halls of power, then a nonphysician will tell you how to practice medicine and reach into your pockets — and directly affect your ability to provide patient care. Which brings me to the last, and most important rule (with apologies to the famous line from the 1992 presidential campaign): It's the patient care, stupid. Everything we do as advocates for physicians has to focus on the ultimate goal of healing the sick. Honestly framed as a patient care issue, it's hard to lose an argument!
Ruben Carmona, first-year medical student at UC San Diego, believes "whatever you can do to help people, you should do it." And despite a heavy class schedule, he walks this talk. Whether volunteering across the Mexico border with medical teams, caring for his disabled brother, transporting patients, or offering a shoulder of support to terminal cancer patients, Carmona gives his all. Promoting education among minorities and motivating youths in his community are also very important to Carmona.
His actions, combined with a deep belief in volunteer medical service, are what recently earned him the 2009 SDCMS Foundation Medical Student Scholarship of $1,000 per year for up to four years. The medical student scholarship has been helping future physicians since 2007.
After he graduates from the UCSD School of Medicine in 2013, Carmona plans to give back throughout his medical career because, as he states, "I am deeply committed to giving back in a way that honors all who have helped me find my way." He cited "hope and comfort" as two primary things he will offer his future patients, as he has witnessed the positive difference they make.
Ellen Beck, MD, chair of the Student Scholarship Committee, says "The selection committee was very impressed with the quality and depth of the applicants. Several finalists, including Ruben, have overcome obstacles, served the community with depth and commitment, and have dreams of service to the underserved."
Carmona is an inspiration and great role model for local youth interested in medicine. He is proof that with love in your heart, a desire to succeed, and a solid education, you can realize your dream of being a doctor.
Grateful for the scholarship assistance, Carmona says, "I'll be an advocate [of the Foundation] for the rest of my career."
You can read Ruben Carmona's full essay on the SDCMS Foundation website at SDCMSF.org.
Physicians are in many ways poorly suited to be legislative advocates. We function in a world that acknowledges our extensive training and experience and is respectful of scientific analysis. And despite all the difficulties of practicing in the 21st century, we still get what we want in most situations. When we make a diagnosis and propose a treatment plan, our patients usually go along with it. And when we want things to go a particular way in our clinical settings, be it the office or the operating room, they usually do.
However, in the world of legislative advocacy, we are back to square one: Important decisions are not necessarily made by the best trained or the most experienced, statistics and other data are manipulated if not ignored, and the influence we are used to exerting in our clinical settings seems not to exist.
In the legislative arena, it is not uncommon for a group of us to meet with a legislator who has had less than a third of our formal education. In such a meeting, we as a group will typically, and with great patience, explain our sage analysis and thoughtful recommendation regarding a piece of legislation. But not uncommonly we find out later that the legislator ended up voting "the other way."
While in the vast majority of cases it turns out that the legislator's preexisting beliefs would have in fact predicted their "vote," we physicians do not deal well with the frustration of having our advice going unheeded. In fact, we find it so frustrating that, over the years, I have seen it drive dozens of would-be physician advocates to just walk away from the process. And even worse, I have seen this frustration result in behavior that was counterproductive and even detrimental to what we were trying to accomplish.
For those of you who are interested in advocacy and willing to learn, there are three bottom-line points from the experience of those who advocate for you that will serve you well. Success is never guaranteed, but if you follow these three points, be assured that you will never really "fail." And to illustrate what can go wrong, I will relate three scenarios — all of which actually took place in the setting of a group of physicians meeting with a state legislator in his or her office in Sacramento or with a member of Congress in his or her office in Washington, DC. Each of these scenarios illustrates some of the behavior that simply must be avoided if one is to be a successful advocate.
Respect Elected Officials and Their Staff
Nothing you or I will ever do as a physician will put us in the position of constantly living in the crucible of public opinion as much as an elected official. Only an elected official knows what it is like to have their every action scrutinized by not just the public but the media, both of whom often lack all the facts but still have the constitutional freedom to publicly criticize at will. And at election time, every elected official knows that his or her every opinion and vote stands to be distorted by the opposition into something evil, which is then stuffed into every local, high-propensity voter's mailbox and/or displayed on television.
Whether you agree or disagree with an elected official about a given issue, or even about his or her entire political philosophy, you must give these folks their due. They have taken on something that the vast majority of us could never even attempt to do in a credible fashion.
I cannot emphasize this enough. If you are not capable of being respectful to a broad philosophical range of elected officials, stop reading now and instead seek out other physicians to be involved in legislative advocacy.
Finally, staff members are also worthy of our respect. The staff of elected officials are usually underpaid, underappreciated, and over-blamed. And, in many cases — particularly in Washington, DC — they are at times flat-out overworked.
How Not to Be a Successful Legislative Advocate, Example 1: After being told that a legislator was unavailable to meet with us and that we would have to meet with a staff member instead, one of the physicians in the group openly protested, along the lines of, "Doesn't he know that the Doctors are here?" Well, as it turns out, a legislator's first priority when in Sacramento or in DC is to attend his or her committee meetings, which often end up being in conflict with the times when groups wish to meet with them. In addition, an opportunity to educate legislative staff on an issue is usually well worth our time.
How Not to Be a Successful Legislative Advocate, Example 2: After a legislator stated to a group of physicians that he had decided to vote for a CMA-opposed bill, one physician proceeded to pepper the legislator with a series of escalating questions designed to change his mind, the last of which was, "Do you want people to die?" The reality in this case is that it is quite rare for a legislator to actually volunteer to a visiting group that they are voting in opposition to one of their top positions. When that happens, it means that the legislator has already given the issue significant thought and is highly unlikely to change his/her mind. A barrage of interrogative questions in that situation is basically saying that we believe that the legislator is being stupid — not a good idea (even if true).
Respect Your Adversaries
In the vast majority of cases, those who oppose us on issues actually believe what they are saying. They may be lacking in the appropriate background or experience, such as non-physicians seeking a scope-of-practice expansion, or just have an entirely different view of the world, such as attorneys who believe that med-mal lawsuits act to improve medical quality (bizarre but true). It is important that we never allow our disagreements with our adversaries to in any way diminish our fundamental respect for the fact that they, like us, are willing to stand up for what they believe.
To use the same example, I sincerely believe that the trial lawyers who want to weaken or repeal the MICRA law are wrong, wrong, wrong on that issue, but I also believe that most do in fact believe that MICRA infringes on the rights of those few truly harmed by medical malpractice. I have also fought for years with various "business lobbies" over their lockstep devotion to the agenda of health plans, but I have never doubted that most of their advocates truly believe that CMA's legislative successes against health plans have made health insurance less affordable.
To ascribe evil motives to one's opponents in the legislative arena is a losing strategy. Many of our opponents do it to us, and, in fact, it almost always ends up being to their detriment. The legislators know that those who are in their office disparaging others are only a tough vote or two away from disparaging them.
Respect the Truth
This should be an easy one. In the end, all that we really have as advocates for the profession is our credibility. As hard as it is, in a profession where we are always supposed to have all of the answers, many of us need to learn to say, "I don't know, but I can find out," when responding to the questions of an elected official or their staff member.
How Not to Be a Successful Legislative Advocate, Example 3: Some years back, in a burst of enthusiasm when discussing a CMA proposal to increase Medi-Cal fees, a physician in Sacramento for the first time volunteered that, in the past, CMA had never objected to Medi-Cal fee cuts when the state budget was in a bad situation, so it was only fair that we should receive an increase when the state budget was doing better. While enthusiastic and well intentioned, that statement was patently untrue (and that particular veteran legislator knew it) — CMA has always strongly opposed any cuts to the profoundly underfunded Medi-Cal program. But once you make an untrue statement, even with the best of intentions, your credibility with that legislator for anything else you might say drops to zero.
NOTE: This and Dr. Priver's article contain solicited opinions from two of SDCMS' physician leaders. Neither article reflects the opinions of SDCMS or CMA as a whole. They are published here to provoke thoughtful discussion and consideration of opposing views on the issue of healthcare financing reform currently underway in our nation's capitol. Please feel free to join the discussion by sending your letters to the editor to Editor@SDCMS.org.
Ten months ago, a Democratic president was being inaugurated with an approval rating in excess of 70 percent, and, on the other end of Pennsylvania Avenue, a Congress with Democratic majorities not seen in decades was ready to go to work. And, with all the lessons learned from the failure of the "Clinton Health Plan" in 1993-94, how could significant health system reform not be a fait accompli?
But as this is being written, it appears that not too much and perhaps even nothing of real significance will come to pass this year. How could this happen? What mistakes were made, both on the policy side and the tactical side? And can anything worthwhile for our patients and our practices be salvaged?
Let's start at square one: President Obama is not a healthcare expert. In fact, he spent the Democratic primary season last year being publicly schooled on the issue by no less than current Secretary of State Hillary Clinton — to the point where their interactions were regularly lampooned on TV satire shows such as Saturday Night Live. Included among the president's positions was support for the idea of "guaranteed issue," where one can wait to apply for health insurance until one has a problem — a policy that has more than doubled healthcare premiums for individuals in the states that have tried it. He also "guaranteed" to decrease the average annual family healthcare premium by $2,500 without increasing taxes on 98 percent of Americans (a promise long since abandoned). And in the area of tort reform, he articulated the stock position of the trial bar that high malpractice premiums have little to do with jury awards, but rather the excess profits of med-mal insurers, even though many med-mal insurers are physician-owned and most are nonprofit.
So it was clear from the start this year that the policy positions coming from the White House would be dependent on who the president chose to advise him on healthcare and what advice he would take from them.
That said, the early indications were promising. A major advisory role went to oncologist Ezekiel Emanuel, MD who, on the one hand, was the brother of the president's hard-nosed chief of staff, but on the other hand was someone who had at least some sense of the real world of medicine. In fact, his address to a cynical audience of more than 500 physicians at an AMA legislative conference in early March drew a standing ovation — in marked contrast to similar addresses by senior Clinton officials in a similar setting some 16 years ago.
And the early pronouncements from the president reflected what seemed to be sound advisory input. Four in particular boded well for the process: 1) that the goal of health system reform was not to replace the system but to repair it; 2) that covering the uninsured would in fact require upfront payment, even if cost savings might accrue in the future; 3) that the sustainable growth rate (SGR) formula governing physician payment in Medicare was so flawed that $228 billion should be allocated immediately to block the planned 40 percent, across-the-board cuts to physicians scheduled to take effect by January 2013; and 4) that Congress would take the lead in writing a bill, as opposed to a select secret group in the White House releasing their finished product, à la the Bill Clinton approach.
Perhaps the best of all was that the president seemed to be passing our key litmus test for politicians/elected officials. Those of us who proudly represent the physicians of San Diego County and of California have learned that there are two types of elected officials: those who believe that physicians are part of the solution to the problems facing healthcare, and those who believe that physicians are actually the problem. By responding to the urging of AMA with a "re-basing" of the SGR, and by then reaching out to AMA in a myriad of ways — both subtle and overt — the signal from the White House seemed to be that health reform needed to be done in ways that would make it easier, not harder, to be a practicing physician. This was good news, and stood in contrast to the usual government approach of overpromise, underfund, and then let the physicians and the hospitals pick up the pieces.
So what happened? How did things get so far off track? First, the president's rhetoric about the healthcare issue has shifted back and forth throughout the year, such that even many of his grassroots supporters have been left confused. Second, Congress had much more ambitious goals than anything the president campaigned on, and much more ambitious than what the American people, as it turns out, seem willing to pay for. But most importantly, the president and his White House team of political advisers (who supplanted the influence of the healthcare advisers over time) have underestimated the complexity of the issue of the uninsured.
To the latter, I have used the term "Guantanamo-ization of healthcare" to predict and now describe the challenges that the president and Congress have been facing this year in health system reform. Recall that the president precipitously announced his decision to close the infamous Guantanamo prison this past January without a clear plan. At that time most observers realized that the issue of relocating hundreds of committed terrorists was far more complex than the president realized, and that in one form or another, the president would end up with a difficult implementation, and perhaps even backtracking on that decision, as he is presently doing.
Similarly with health reform, it was not going to take long for the realities and the complexities of health system reform to overwhelm the politics. And while one could write an entire article on any one of these, here are just two of many examples of where the ambitions of this year's health system reform efforts have met with reality:
ONE: The uninsured are not nearly as affluent as most observers think. Most Americans who voted for the president and who want to see the uninsured get covered imagine that the uninsured are "just like you and me." That is to say, a person with a home and at least one car, saving for their child's college expenses, who happens to have just lost their job, or who works for some kind of unenlightened employer who does not provide health insurance. Most believe that the low-income worker at minimum wage has access to Medicaid or some other safety net program — perhaps even the president thought this.
However, the hard truth is anything but that. According to the most recent (October 2009) Kaiser Family Foundation survey, in California and 30 other states, childless adults are ineligible for Medicaid coverage, leaving them with only county indigent programs as an option. And parents do little better: Thirty-three states consider them "fat cats," ineligible for Medicaid if their income is at or above the federal poverty level (FPL), even though the FPL is only $10,830 for a single person and about $14,570 for a couple.
Who then makes up the bulk of the uninsured? Well, according to the latest figures from the Congressional Budget Office (CBO), some 29 million (65 percent) of the nation's 47 million uninsured live above their state's Medicaid eligibility level but below 150 percent of FPL, meaning that they are a single person with an income below $16,245 per year or a couple with income below $21,855 per year. These folks are poor, if not flat-out destitute, and cannot become insured with the assistance of a small government subsidy; they need the taxpayers to pay the entire bill. Oh, and by the way, at least 15 percent of those 29 million, and probably more, are undocumented.
TWO: The private-sector health insurers despised by all are not the big pot of money that everyone, including the president, thinks they are. We are all disgusted by the multimillion dollar salaries of the top management of the big insurers, but if you actually look up the compensation numbers and realize that the large private-sector health insurers cover more than 100 million Americans, the "rebate" if all the top managers of all the big for-profit health insurers worked for free would come out to no more than $1 per covered life.
And those much-disdained administrative costs that are there for the taking in a reformed healthcare system? Well, according to the Democratically controlled CBO, the Democratically controlled White House Office of Management and Budget, and the much-respected Kaiser Family Foundation, the amount of the healthcare dollar that goes to private-sector administration is 7 percent. And for those salivating to grab even that 7 percent of the healthcare dollar, it gets worse. Most of that 7 percent goes to: a) eliminating the kind of fraud that is rampant in publically administered programs (5-10 percent in Medicare, up to 20 percent in Medicaid); and to b) forming provider networks. That is why, despite the ongoing political rhetoric about setting up a nonprofit, government-run health insurance plan — or "public option" — to "compete" with private insurers, the CBO has scored zero savings from such a plan, unless such a government option "hijacks" existing Medicare providers at existing and underpaying Medicare rates.
But while these and other challenges may have been underestimated as the health system reform debate took shape this year, there were those who felt certain that the president's calm demeanor and unquestionable intelligence would carry him through.
And he certainly had a great message: Forty-seven million uninsured Americans is a national embarrassment, so a proposal that reduces that number would be a good thing. Even most Republicans agreed with that.
Why then did the president immediately start to use discredited statistics and hyperbole to sell the idea of health system reform? In his first address to the nation about reform back in February, one of the first things he said was that healthcare costs cause a bankruptcy every 30 seconds (more than 1 million people per year). How does that work? Does taking Lipitor make you miss your mortgage payment? It turns out that the president was advised to rely on discredited studies from single-payer advocates that included as victims of "medical bankruptcy" people whose bankruptcy filing showed that they had had $1,000 in medical bills over the prior year, even if their bankruptcy involved $500,000 or more in other debts. Folks who felt depressed prior to their bankruptcy filing and people who were filing bankruptcy solely from gambling debts were also included as "medically bankrupt," even if they had no medical bills. The true medical bankruptcy rate? At most 5 percent of all bankruptcies.
It just seemed odd. If you have a 70 percent approval rating and health reform is a good idea, why scare people? Why say that 14,000 people a day are losing health insurance when every day 11,000 people are signing up? What is the big rush? Why try to scare the American people, unless you suspect that you are about to try to sell them something that they may not want?
And as the year has proceeded, the president has never stopped trying to scare people and never really left "campaign mode" — yet has dramatically changed his message from month to month. In February, the message was that health system reform was the key to an economic recovery, even though our economic problems related more to a housing bubble than a healthcare crisis. By April, the new message was that health system reform was going to help with our long-term budget deficit, even though it was clear that more than $1 trillion would be spent over the next 10 years without any consensus on where that kind of revenue would be found. Remember, passing Medicare in 1965 was controversial, but the message was clear: Millions of retired seniors without access to job-based health insurance needed a program. Clear; simple.
But despite a need for such clarity, the message from the White House kept changing, alternating between a moral imperative to "do the right thing" and an economic imperative to save money. In May it was "bend the cost curve," highlighted by a series of orchestrated press events where physicians, hospitals, pharma, and others pledged savings — but had no real plans. And in June it was time to show some love to AMA with a nationally televised address skillfully written to draw a nonstop series of standing ovations.
Meanwhile, Congress had no time for speeches and little concern for arguments. The congressional leadership saw a once-in-a-lifetime chance to get all Americans covered and, as such, developed some very extensive legislation. Their bills all mandated that everyone would have to get health insurance (which is, in fact, a necessary step to get the "young invincibles" into the insurance pool and lower costs for everyone else), but the benefit packages mandated by all of the bills were extensive and expensive: comprehensive, all-inclusive insurance with limited co-pays for all, subsidized 100 percent by the taxpayers for at least 65 percent of the currently uninsured.
And most disappointing was that the mechanism for insuring many of the currently uninsured under these congressional proposals would be an expansion of the current Medicaid program, with enhanced funding for primary-care services only. Given that Medicaid has been largely abandoned by specialty physicians and is a major cost drain to most hospitals, calling this an expansion of access to care is at best wishful thinking and at worst a cruel joke.
The entire debate until mid-June was about how extensive the expansion of coverage in health system reform should be. That changed, however, that June day the president addressed AMA. But not because of the speech — it was because one hour after the speech, the CBO began to release a series of analyses detailing just how expensive these plans would be.
Overnight, the debate began to turn on not what was in these $1-trillion proposals, but rather how to make them "budget-neutral," i.e., pay for them. And the reality is that there are not enough rich people to tax to pay for health insurance coverage for 47 million people, nor are there enough vices (cigarettes, liquor, high-fructose soda) to tax. And the president's own idea — decreasing the value of home mortgage and charitable deductions by 30 percent for those families making over $250,000 — was dead on arrival in Congress.
But there remained one revenue source that the CBO estimated could provide more than $400 billion over 10 years, which was to tax those individuals with more luxurious healthcare coverage on the "high end" of their benefits.
If there ever was a tax that could make sense, this is it. Recall that the largest tax break — by far — in our entire tax code is that employees are not taxed on the value of the health insurance that is provided to them by their employers — no matter how generous. So the status quo is that tens of millions of Americans have health insurance that may give them any and all brand-name pharmaceuticals with no co-pay, and any and all scans with no co-pay — in fact little to no co-pay on any service. So while most of our patients in San Diego County have to pay extra for brand-name drugs and the like, these fortunate folks, numbering in the tens of millions (mostly in the unionized Midwest and Northeast), are positioned to receive most any healthcare service they wish — at little or no cost to them. Good for them, except that we taxpayers subsidize them to the tune of tens of billions of dollars per year. A better way would be that everyone could continue to receive health insurance that covers a standard set of services tax-free, but that those who receive so-called "Cadillac plans" costing up to $40,000 per family per year would pay income tax on the difference between a standard benefit package and their "Cadillac" level.
It looked promising. The critically important Senate Finance Committee appeared close to what would have been a bipartisan health reform bill funded half or more by this revenue. But this is where the president made what may end up being viewed as a big mistake by rejecting outright this funding option. Apparently, the labor unions that have negotiated these kinds of benefits were opposed to seeing them subject to taxation, and the president's political advisers reminded him that he had promised not to increase taxes on anyone making less than $250,000. [NOTE: The idea of taxing "Cadillac benefits" has since been resurrected, but now as a tax on the insurance companies themselves. This is not nearly as good an idea, as the insurance companies will just pass on the costs of those new taxes to the price of their premiums.]
However, despite removing the most promising funding source by far from consideration, the president insisted that legislation be fast-tracked to pass both houses by the end of July using other funding sources. That frenzied July effort failed in both the House and the Senate but made the public more uneasy about the whole process.
Heading into the August recess, the president pivoted again, this time to say that passing health system reform legislation was the only way to get insurance reform. The new message was that no one was safe from their private insurer, that any day your policy could be retroactively cancelled, or the life-saving treatment recommended by your physician could be denied. That message certainly had some truth, and certainly polled well, but the American people could not help but ask why eliminating preexisting-condition clauses and the like from their health insurance policies would cost the country $1 trillion.
Next came the town halls, which seemed like democracy reborn to one side of the partisan divide and domestic terrorism to the other. But for all the noise and fury, and putting aside all the death panel rhetoric, extensive polling by entities such as The New York Times and summarized just weeks ago by esteemed pollster Robert Blendon in The New England Journal of Medicine showed just how deep a hole the president and the Democrats in Congress have dug for themselves. No less than 65 percent of Americans now believe that if health system reform passes, their own healthcare costs, if anything, will go higher. An identical 65 percent believe that the quality of their healthcare, if anything, will get worse. And 91 percent believe that if health system reform passes this year, their own taxes will go up in order to help pay for it. (As a side note, 90 percent of Americans believe that they are already paying as much federal tax as they can handle, leaving 1 percent who are OK with having their taxes raised for health system reform.)
The response of health system reform proponents to the town halls was not helpful. Calling people un-American or pawns of insurance companies or spreaders of lies does not help the cause. Neither does a national call to send "fishy emails" to the White House — can one imagine the horror if President Bush had made a similar request?
And then, when the tone of the debate needed to get better rather than more contentious, the president made what in my mind was his biggest mistake of the year, which was to repetitively attack the rank-and-file physician. First came his statement that tonsillectomies are done to pad physician income. This was followed by a statement that implied that rather than counseling a diabetic, we physicians cannot resist the time efficiency and apparent "$30,000, $40,000, or $50,000" fee associated with a foot amputation (actual reimbursements range from $400 to $700 depending on the surgery). Who was won over by those statements and others remains a mystery, but there is no doubt that the president has lost considerable standing among physicians as a result of these statements — and for no apparent reason.
So where do we stand today as a nation? In Washington, DC, the president continues to speak out about health system reform, and has now added the "fiscal responsibility" message that he will sign no bill that adds to the deficit in the first 10 years. Fair enough, but since all the 10-year bills in Congress raise taxes for all 10 years but defer providing any coverage of the uninsured until at least year five, they are all in deficit by year 10 and will all then have a significant negative impact on the deficit in the second 10 years.
All this is hardly reassuring to those who assign a high priority to our nation's long-term fiscal stability. And it is terrifying to physicians looking at a 21 percent Medicare fee cut on January 1, 2010, with another 20 percent to follow by 2013. It is impossible to fix the flawed sustained growth rate (SGR) formula without adding to the deficit. [LATE NOTE: An attempt to pass a $228 billion SGR fix as a separate piece of legislation has failed.]
To the general public, peripatetic efforts notwithstanding, the president finds himself facing a situation where support for the current health system reform efforts stands at his Democratic base level of 30 percent, with a comparable number in vehement opposition. The remaining 40 percent tell pollsters that they are deeply confused, and this after the most public exposure ever on a single issue by one of history's most inspirational communicators.
On an individual level, seniors are worried about how they will be affected by hundreds of billions in Medicare "savings." And if there really are hundreds of billions to be saved within Medicare, should not those savings be applied to the looming multi-trillion dollar Medicare deficit?
And young people wonder about being mandated to buy comprehensive insurance when a catastrophic plan is all that most might really need. Can the president persuade more than half of those currently undecided that what he has been talking about 24/7 for months is actually good for them after all?
In Congress, the House of Representatives has 257 Democrats (218 constituting a majority), but 72 of those representatives are in districts that voted Republican for either Congress or president within the past four years, including 50 districts that voted for John McCain in 2008. Passage of comprehensive legislation is still possible, but far from certain.
The Senate has 60 Democrats (including two Independents that usually vote with the Democrats) but has nowhere near 60 votes for the kind of major health reform bill that may come out of the House. More specifically, there are not 60 votes in favor of any significant funding mechanism. The one exception might be the flawed "Cadillac tax" proposal, but 173 House Democrats (and every House Republican) are already on record as opposed to that. With that option gone, where does the Senate go? There are not 60 votes to tax rich people, or tax medical devices, or even to dramatically squeeze the so-called Medicare Advantage plans.
Finally, where do we stand as physicians? After what started out as a promising process that seemed to involve physicians as part of the solution to America's healthcare problems, we find ourselves in the uncomfortable — and incorrect — position of being identified as a big part of the problem. We are also looking at the potential of one more overpromised, underfunded government program that will make it impossible for many thousands of our colleagues to even stay in practice.
One more thing: As physicians, one has to wonder why, in a situation where everyone in healthcare will end up making economic sacrifices, the one group who will apparently walk away unscathed will be the lawyers.
What would have saved this whole process would have been to start over, to learn from this year's mistakes, and to put together policies that could easily garner support of more than 50 percent of the people. One of these would be an individual mandate geared toward catastrophic and preventative care, which would both prevent those medical bankruptcies that do occur, as well as allow for the kind of insurance reforms that Americans want. That is because once everyone has to obtain a minimum level of insurance, it is then feasible to reform the insurance market such that we could have "guaranteed issue" and a reasonable level of community rating.
Another good policy would be to establish insurance exchanges such as have been up and running in Massachusetts. Such exchanges have been very successful and save small businesses the hassle and expense of using brokers to shop for their health insurance (brokers often take 10 percent or more of premium in commission). Subsidies to participate in such an exchange could easily be made available for many millions of the uninsured, funded easily by the aforementioned tax on high-end healthcare benefits.
And still another good policy would be to nationalize the kind of student loan repayment program for primary care physicians that we have in California, where for all of $3.5 million per year, we have 100 full-time, board-eligible physicians working in underserved areas.
But this is not the time to suggest good policies in Washington, DC. Rather, it is the time when urgency, anger, bluster, and panic all come together in a frenzied attempt to "pass a bill." Then the politicians all go home and we physicians hope that they have not actually made things worse.
You missed the party — actually, several thousand parties.
On October 22, 2009, Microsoft released Windows 7 to much fanfare and somehow managed to convince tens of thousands of people around the globe to host their own "launch" parties. After all, positive word-of-mouth and subsequent referrals are the most flattering of all compliments. Microsoft desperately needed good vibes because we all know that the word-of-mouth for Microsoft Vista was definitely not positive and rather unflattering.
In fact the "buzz" around the launch parties was designed to get people to enter the contests and host them in order to receive a free copy of Windows 7 Ultimate and a chance at winning a PC. I personally did not attend, but maybe you did or someone you know.
Instead, what IT professionals and shops like ours did do over the past 12 months is use Windows 7 during its beta testing, release candidate (RC) stage and now in full Release to Manufacturing (RTM). As Computer Weekly magazine attests, "Windows 7 is Microsoft's most significant operating system since Windows 95."
In our testing, Microsoft Windows 7 has proven to be much more stable, faster — on same hardware — and more intuitive than both its predecessors, Windows Vista and Windows XP. As a matter of fact, this past summer most of our production desktop machines in our office were wiped and reinstalled with Windows 7.
It is therefore important that you acclimate yourself to Windows 7 and leverage your knowledge when making IT decisions in the coming months.
Why Is It Called Windows 7
Let us go back in time, shall we? Conventional wisdom suggests that because the current version is code-named Windows 7, previous versions of Windows must have had code names of Windows 6, Windows 5, etc. While that is partially true, like all things Microsoft, there is an explanation.
Windows 6 was in fact Windows Vista, and Windows 5 was Windows XP, but prior to that the logic breaks down. There was in fact Windows 1.0 back in November 1985, Windows 2.0, Windows 3.0, and in April 1992 the very popular Windows 3.1, then Windows 95, Windows 98, Windows 98 Second Edition, Windows ME, Windows NT, Windows 2000 — well, you get the picture. Let's just say there were too many versions and not enough whole number assignments, and they did not get it "right" until Windows XP.
What You Need To Know about Windows 7 Architecture
As little as possible if you can help it. Without getting into complexities of software development and subtleties of hardware platforms, all you need to know are the terms 32-bit and 64-bit. These terms refer to the way a computer's processor handles information and can fully leverage the amount of random access memory (RAM) installed in the system.
The 32-bit version of Windows 7 handles up to a maximum of 4 GB of RAM, while the 64-bit version of Windows 7 can theoretically handle 16 EB - if you must ask, that's exabytes.
Keep in mind that not all computer hardware is 64-bit capable, and, more importantly, your line-of-business (LOB) application or EMR suite at your office may not be 64-bit compatible.
So moving forward for the next six to 12 months, the safest hardware/software combination for your practice is 64-bit capable hardware and 32-bit version of Windows 7.
Windows 7 Versions
While many editions of Windows 7 were released worldwide, only five versions are for sale in the United States. These five main versions are available through retail or through a Microsoft licensing agreement with your IT vendor or reseller:
So take note: While there may be five versions of Windows 7 offered in the United States, only three are right for your practice. All three of them have a feature called XP mode.
XP Mode
There are many new features introduced in Windows 7, and while many of them improve on usability, stability, screen ergonomics, and performance, there are also numerous advances made to the operating system that offer compelling business advantages. Among them is a new feature that is called XP mode. This feature only comes with the aforementioned Windows 7 version recommendations of Professional, Ultimate, or Enterprise.
Without delving too deeply into the technical aspects, you need to know that XP mode within Windows 7 is a virtual machine that runs a full copy of Windows XP Service Pack 3 — in other words, Windows 7 runs a virtualized copy of Windows XP within itself — for free.
This is huge.
It effectively future-proofs your new hardware/software investment by allowing you to run new applications under Windows 7 in the foreground and legacy (i.e., EMR, financial, medical) applications under a virtual Windows XP session in the background. Of course, you will have to check with your software vendor to ensure that XP mode is supported, but the possibilities are endless.
The Bottom Line
The decision on how and when to move to Windows 7 may be easier than you think. Three scenarios:
In all cases with Windows 7 make sure the versions are business-friendly — Professional, Ultimate, or Enterprise — and that your specific line-of-business application (LOB) or EMR supports Windows 7 or XP mode. At this time we are recommending Windows 7 Professional or Windows 7 Ultimate.
Moving forward with proper planning, the selection of the right version and architecture of Windows 7 should allow you to bid "Hasta la Vista, baby."