Family-Medicine

H. Griffin Cupstid, MD, FAAFP

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Chronic Care Management: A Game Changer

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If you're at all familiar with the history of football, you know that the sport has evolved greatly over the past 200 years. American football arose in the early 19th Century from a disorganized game played by violent mobs. It was a sport in which injury—and death—were not uncommon. Even after standardized rules were introduced in the 1870s, the game remained extremely dangerous due to brutal tactics like the flying wedge formation.

The brutality of football reached its peak in 1905, when a multitude of deaths and horrible injuries shocked the public into action. There were calls from many quarters to outlaw the game. Harvard—birthplace of the flying wedge—considered banning the sport, and Stanford, California, Duke, Columbia, and Northwestern actually shut down their teams. At this point, President Theodore Roosevelt stepped in and convened a meeting of college coaches to determine how to make the game safer. Out of this meeting arose a number of changes, giving birth to a governing body that would eventually become the NCAA. The rules were reformed, the flying wedge was banned, and the forward pass was introduced. It was literally a game changer.

Last Updated on Tuesday, 10 February 2015 23:00 Read more...
 

The "Shut Up and Practice Medicine" Argument

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Recently, the Governor and HHS Director announced a pilot project to provide Medicaid services at Walmart retail clinics. Many physician groups, including our own Academy, have raised concerns about retail health clinics, warning that they undermine the medical home concept and may lead to greater fragmentation of care. Anticipating this criticism, the HHS Director was reported to have said, “South Carolina's significant physician shortage demands new solutions and leaves no room for detractors to complain.”

This seems to be the new strategy for countering physician advocacy on policy issues: Assert that we have “no room to complain” and therefore, should remain silent on these issues. Sometimes the argument takes the form of claiming that we have a conflict of interest. Other variations allege that we’re incapable of comprehending the nuances of the issue due to our narrow interests in health care quality and maintaining the integrity of our profession. Sometimes—as in this case—the implied message is that we ought to mind our own business and get back to work. It’s a powerful argument. It’s so powerful and effective, it needs a special name. I propose that we call it the “Shut Up and Practice Medicine” argument.

Last Updated on Sunday, 14 September 2014 22:55 Read more...
 

Vaccines and Personal Belief Exemptions

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If you want to board the family pet at your local kennel, you better have proof of an up-to-date rabies vaccination. It’s the law in every state: You must vaccinate your dog, cat, or ferret against rabies according to the recommended schedule. There are no exemptions for pet owners who might have religious or philosophical beliefs that conflict with immunization [1]. The rabies vaccine protects the pet who receives it—and other pets and people—from acquiring rabies. When you take your beloved pet to the kennel, you can rest assured that there is very little chance it will acquire rabies from another animal during the stay.

Believe it or not, there is an anti-vaccine movement for pets [2]. There are people (on the Internet, of course) who believe the rabies vaccine is harmful and unnecessary. Fortunately, the law is very clear, and it provides no accommodation for those who ascribe to an unscientific world view. The law does a very good job of protecting pets and people from irresponsible pet owners.

Unfortunately, the law is failing to protect our children.

Last Updated on Friday, 11 April 2014 18:58 Read more...
 

The Unsustainable Sustainable Growth Rate

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The ideological rift between Republicans and Democrats in Washington has never been wider, but there is one issue that enjoys broad bipartisan support: Fixing the SGR. Sure, it’s not a permanent fix, but as of December 18th, both houses of Congress have passed budgets that delay a 24 percent cut in Medicare fees dictated by the current Sustainable Growth Rate (SGR) formula. The budget deal also lays the groundwork for permanently repealing the SGR, and for creating a Medicare payment system that rewards quality and provides other incentives for primary care physicians.

The battle over Medicare physician payment rates has become an annual ritual for Congress—and a perennial headache for physicians. In 1997, Congress created the Sustainable Growth Rate formula as part of the Balanced Budget Act. The concept was based on the notion that growth in Medicare payments to physicians should not exceed the growth in Gross Domestic Product. The SGR formula is supposed to adjust the physician fee schedule such that total payment for all Medicare physician services does not exceed a “sustainable” level. This sounds like a good idea on paper, but in practice, the SGR has been a complete disaster. Two years ago, MedPAC (Medicare Payment Advisory Commission), the entity that advises Congress on Medicare fees, declared the SGR a failure and recommended a total repeal of the law.

Rather than restrain costs in the Medicare program, the SGR has actually exacerbated the problem. By restricting fee increases, the SGR incentivizes physicians to increase the volume of services provided to Medicare patients in order to maintain their share of the fixed budget “pie.” Even worse, the SGR harms primary care physicians by undermining efforts to maintain payment parity between procedure-based specialties and cognitive-based specialties. Specialties that derive the greater part of their revenue from procedures have greater latitude to increase their volumes, while cognitive services such as primary care are disadvantaged by having limited capacity to increase volume.

Wait, it gets worse.

Last Updated on Tuesday, 18 February 2014 00:37 Read more...
 

Medicaid Expansion: Reframing the Debate

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It has been a little over a year since the Supreme Court ruled on the constitutionality of the Affordable Care Act (ACA). While the Court upheld the individual mandate, it overturned the requirement that all states expand their Medicaid programs.

As originally enacted, the ACA would have required states to give Medicaid coverage to all citizens under age 65 with household incomes below 138% of the Federal Poverty Level (about $15,400 per year for an individual). By striking down this provision, the Court effectively made Medicaid expansion a state-by-state option.

Twenty-three states have announced that they will expand Medicaid eligibility and accept billions of federal dollars in additional matching funds. Twenty-two other states—including South Carolina—have declared their opposition to expansion.

Opinions on the Medicaid expansion split along party lines, and the arguments against expansion seem to be based on ideology more often than evidence. One exception to this observation is Anthony Keck, the Director of the South Carolina Department of Health and Human Services. Mr. Keck has been an effective critic of the ACA Medicaid expansion, framing his arguments with the well-documented shortcomings of our current healthcare system.

Last Updated on Monday, 17 February 2014 03:56 Read more...
 
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