EDITORIAL: Medicine & Politics

Jeffrey Stevenson, MD

This issue of Marin Medicine focuses on medicine and politics, a theme with many facets. First and foremost is Proposition 46, which would raise the statutory cap on pain-and-suffering awards, thereby increasing malpractice insurance rates. The proposition could cause patients to lose their doctors and restrict access to care across the state.

Prop. 46’s requirement that physicians use the CURES database when prescribing controlled substances will lead to workflow logjams and could also put patients’ sensitive medical information at risk. An even greater problem is that access to CURES can be shut down if multiple log-in attempts fail. A practice or an emergency room that can’t log in will be unable to prescribe adequate pain medications or necessary refills.

Trial attorneys have generated Prop. 46 as a revenue source from physicians, and it stands to add malpractice costs at a time when physicians are struggling to make adjustments for reduced reimbursements and increased work loads. In the interest of financial survival, many physicians have allied themselves with large groups or medical foundations. The greater challenge is whether doctors can work together politically. We need to stand firm for access to quality care. Both the California Medical Association and the Marin Medical Society provide state and national leverage for physicians.

One place where physicians need more leverage is with health care insurance companies, who commonly don’t give doctors a seat at the boardroom table. Physician medical directors at these companies provide advice, but the companies aren’t obligated to follow it. A voting physician “on the board” could probably impact policy at a higher level.

Another concern is treatment authorizations, which are time-consuming and costly for both providers and payors. Physician offices have to expend considerable effort preparing these authorizations, after which the insurance carrier processes the request, compares it to guidelines, and then approves or denies. This elaborate procedure is expensive for the insurance companies and adds tremendous costs, inefficiency and inertia.

Interested parties are developing a time-of-service treatment authorization portal to expedite this process and allow guidelines to be queried and applied to an individual situation in real time. Key to this revised process is the provider’s ability to upload or enter key information to designated algorithms, along with comments, reports and documentation. Part of the concept evolution is for nurses and on-call specialists to handle more detailed reviews in real time. This ability would allow them to focus on the subset of requests that are complex and warrant the extra review.

Meanwhile, fiber-optic infrastructure and emerging hardware promise to bring faster speed and better access. Emerging fiber-based products can download a fully loaded CD in 8 seconds vs. the 90 seconds required with current business broadband. Applying these fiber technologies within local networks as well as distant file transfers can not only speed things up, but also bring real-time streaming without sacrificing fidelity. Fiber-optic provides a more secure network. On the Internet, anything can be hacked, for a price.

I recently tried out a Google Glass real-time transcription product. It had many positive features but was limited in visual resolution in favor of optimizing audio for the transcriptionist. The limited resolution prevented me from getting a video “screen shot” of a page of information, such as a handwritten chart note with diagrams or a picture to the transcriptionist. These details are being sorted out by the developer.

The interconnectivity of different electronic health record systems, whether city-to-city or state-to-state, continues to evolve. Interconnection requires careful segregation of psychological and psychiatric reports, as well as particular infections, alcohol and drug conditions from the past. There are some records that are just too precious to transmit, despite HIPAA promises of security.

Fortunately, some of the world leaders in pain management are available in our community. The risks of opioids have to be balanced with the important need for pain control and the unique situations that apply with particular patients. They need pain-control resources that will give them adequate support.

In closing, I would like to thank my colleagues for the opportunity to serve you this year as president of MMS.

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Dr. Stevenson, a Novato general practitioner, is president of the Marin Medical Society.
Email: jeffreystevensonmd@gmail.com