OA
3 Two reminders dated 12th October 2010 and ............. elicited no response
4(D) The Applicant wrote to Department of Personnel & Training to modify their Order dated 13th April 2010 to grant relief to all its employee, who had suffered due to lacunae inherent in earlier policy which they themselves have rectified by order dated 13th April 2010 but had limited its apllicabiility to only those employee who were waiting for Department Promotional Committee.
The Applicant maintained that he should not be discriminated against simply because he does not have pending Department Promotional Committeewhile 392 of his colleague are all getting their Annual Confidential reviewed just because they were awaiting Department Promotional Committee.
4(E)Department of Personnel & Training forwarded his application to Ministry of Health who never replied about this order.However in their reply to another letter of Applicant on 28th June 2010 (Annexure-7, Page -),they simply reiterated the Department of Personnel & Training order dated 13th April 2010 as the reason for not furnishing Annual Confidential report for representation.
6 The Applicant submitted representation to the Department of Personnel & Training vide letter dated 13th May 2010 (Annexure-7, Page -)which was forwarded by them to Ministry of Health vide letter dated 24th May 2010 (Annexure-8, Page -).No specific reply was ever sent by Ministry of Health. Ministry of Health reply to another letter of Applicant on 28th June 2010 (Annexure-7, Page -), simply reiterated the Department of Personnel & Training order dated 13th April 2010 as the reason for not furnishing below benchmark Annual Confidential Report for representation. Two reminders dated 12th October 2010 and ............. elicited no response.
Monday, May 30, 2011
squandering medicare money
Squandering Medicare’s Money
By RITA F. REDBERG
Published: May 25, 2011
o
Opinionator | The Conversation: Does It All Come Down to Medicare? (May 25, 2011)
MEDICARE has suddenly taken center stage in American politics, with Democrats now trying to score an advantage from the unpopularity of the Republican plan to overhaul the government health insurance program. Apart from the politics, though, Medicare’s financing challenges are worsening: this month, Medicare’s trustees projected that the insurance program would become insolvent by 2024, five years earlier than previously estimated.
Much has been said about the growing gap between the program’s spending and revenues — a gap that will widen as baby boomers retire — but little attention has been focused on a problem staring us in the face: Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:
• Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them (and against any colonoscopies for patients over 85), because it takes at least eight years to realize any benefits from the procedure. Moreover, colonoscopies carry risks of serious complications (like perforations) and often lead to further unnecessary procedures (like biopsies). In 2009, Medicare paid doctors more than $100 million for nearly 550,000 screening colonoscopies; around 40 percent were for patients over 75.
• The task force recommends against screening for prostate cancer in men 75 and older, and screening for cervical cancer in women 65 and older who have had a previous normal Pap smear, but Medicare spent more than $50 million in 2008 on such screenings, as well as additional money on unnecessary procedures that often follow.
• Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. Besides being ineffective, these procedures carry considerable risks. Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.
• Multiple clinical trials have shown that cardiac stents are no more effective than drugs or lifestyle changes in preventing heart attacks or death. Although some studies have shown that stents provide short-term relief of chest pain, up to 30 percent of patients receiving stents have no chest pain to begin with, and thus derive no more benefit from this invasive procedure than from equally effective and far less expensive medicines. Risks associated with stent implantation, meanwhile, include exposure to radiation and to dyes that can damage the kidneys, and in rare cases, death from the stent itself. Yet one study estimated that Medicare spends $1.6 billion on drug-coated stents (the most common type of cardiac stents) annually.
• A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation.
The full extent of Medicare payments for procedures with no known benefit needs to be quantified. But the estimates are substantial. The chief actuary for Medicare estimates that 15 percent to 30 percent of health care expenditures are wasteful. Medicare spending exceeded $500 billion in 2010, suggesting that $75 billion to $150 billion could be cut without reducing needed services.
Why does Medicare spend so much for procedures and devices on patients who get no benefit and incur risks from them?
One reason is that Medicare’s reimbursement procedures are not sophisticated enough to track the appropriateness of the care provided. Medicare delegates its claims administration to private local contractors based on how quickly and cheaply they can process claims.
These contractors have few incentives to audit the taxpayer dollars they are paying out, and even if they wanted to, they would need information often not available on the claim form. For example, a claims administrator, processing a claim for a screening colonoscopy, does not know when the patient’s last colonoscopy was, or whether there was a new clinical reason for repeating it. While this information is available, finding it would require extra steps, and there are no incentives to do so.
Moreover, denying payment after a procedure is performed invites the wrath of both patient and physician. Medicare and private insurers are also keen to avoid situations that could be viewed as telling doctors how to practice medicine — even if such advice is in the patient’s best interest. The political sensitivity of limiting services based on age, for example, was illustrated by the uproar over the Preventive Services Task Force’s finding two years ago that women in their 40s do not benefit from routine mammography.
Another factor is the shocking chasm between Medicare coverage and clinical evidence. Our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test. So while Medicare is obligated to follow the task force’s recommendations to cover new preventive services, it has no similar mandate to deny coverage for services for which the task force has found no benefit.
Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view.
Of course, doctors, with the consent of their patients, should be free to provide whatever care they agree is appropriate. But when the procedure arising from that judgment, however well intentioned, is not supported by evidence, the nation’s taxpayers should have no obligation to pay for it.
Rita F. Redberg, a cardiologist, is a professor of medicine at the University of California, San Francisco, and the editor of Archives of Internal Medicine.
By RITA F. REDBERG
Published: May 25, 2011
o
Opinionator | The Conversation: Does It All Come Down to Medicare? (May 25, 2011)
MEDICARE has suddenly taken center stage in American politics, with Democrats now trying to score an advantage from the unpopularity of the Republican plan to overhaul the government health insurance program. Apart from the politics, though, Medicare’s financing challenges are worsening: this month, Medicare’s trustees projected that the insurance program would become insolvent by 2024, five years earlier than previously estimated.
Much has been said about the growing gap between the program’s spending and revenues — a gap that will widen as baby boomers retire — but little attention has been focused on a problem staring us in the face: Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:
• Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them (and against any colonoscopies for patients over 85), because it takes at least eight years to realize any benefits from the procedure. Moreover, colonoscopies carry risks of serious complications (like perforations) and often lead to further unnecessary procedures (like biopsies). In 2009, Medicare paid doctors more than $100 million for nearly 550,000 screening colonoscopies; around 40 percent were for patients over 75.
• The task force recommends against screening for prostate cancer in men 75 and older, and screening for cervical cancer in women 65 and older who have had a previous normal Pap smear, but Medicare spent more than $50 million in 2008 on such screenings, as well as additional money on unnecessary procedures that often follow.
• Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. Besides being ineffective, these procedures carry considerable risks. Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.
• Multiple clinical trials have shown that cardiac stents are no more effective than drugs or lifestyle changes in preventing heart attacks or death. Although some studies have shown that stents provide short-term relief of chest pain, up to 30 percent of patients receiving stents have no chest pain to begin with, and thus derive no more benefit from this invasive procedure than from equally effective and far less expensive medicines. Risks associated with stent implantation, meanwhile, include exposure to radiation and to dyes that can damage the kidneys, and in rare cases, death from the stent itself. Yet one study estimated that Medicare spends $1.6 billion on drug-coated stents (the most common type of cardiac stents) annually.
• A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation.
The full extent of Medicare payments for procedures with no known benefit needs to be quantified. But the estimates are substantial. The chief actuary for Medicare estimates that 15 percent to 30 percent of health care expenditures are wasteful. Medicare spending exceeded $500 billion in 2010, suggesting that $75 billion to $150 billion could be cut without reducing needed services.
Why does Medicare spend so much for procedures and devices on patients who get no benefit and incur risks from them?
One reason is that Medicare’s reimbursement procedures are not sophisticated enough to track the appropriateness of the care provided. Medicare delegates its claims administration to private local contractors based on how quickly and cheaply they can process claims.
These contractors have few incentives to audit the taxpayer dollars they are paying out, and even if they wanted to, they would need information often not available on the claim form. For example, a claims administrator, processing a claim for a screening colonoscopy, does not know when the patient’s last colonoscopy was, or whether there was a new clinical reason for repeating it. While this information is available, finding it would require extra steps, and there are no incentives to do so.
Moreover, denying payment after a procedure is performed invites the wrath of both patient and physician. Medicare and private insurers are also keen to avoid situations that could be viewed as telling doctors how to practice medicine — even if such advice is in the patient’s best interest. The political sensitivity of limiting services based on age, for example, was illustrated by the uproar over the Preventive Services Task Force’s finding two years ago that women in their 40s do not benefit from routine mammography.
Another factor is the shocking chasm between Medicare coverage and clinical evidence. Our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test. So while Medicare is obligated to follow the task force’s recommendations to cover new preventive services, it has no similar mandate to deny coverage for services for which the task force has found no benefit.
Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view.
Of course, doctors, with the consent of their patients, should be free to provide whatever care they agree is appropriate. But when the procedure arising from that judgment, however well intentioned, is not supported by evidence, the nation’s taxpayers should have no obligation to pay for it.
Rita F. Redberg, a cardiologist, is a professor of medicine at the University of California, San Francisco, and the editor of Archives of Internal Medicine.
Saturday, June 13, 2009
Book by Dr. Anjan Prakash Review
Medical Audit
It is being increasingly realized that while quantitative development is an important requisite for ensuring accessibility, it is also the qualitative aspect that determines the outcome of the services provided. Quality of medical care denotes the degree of excellence of the care delivered. Evaluation of quality care involves two basic concepts, firstly the quality of technical care i.e. adequacy of structure and procedure including diagnostic and therapeutic procedures and secondly the quality of the art of care, relating to the manner in which the care is provided and perceived by the consumers. Quality of medical care can be assessed to a large extent by the analysis of medical records and this is what is meant by Medical Audit.
This monograph ‘Medical Audit’ by Dr. Anjan Prakash provides comprehensive information about the complex issue of medical audit which could possibly serve and provide educational benefits for the medical staff and beneficial for the patients. The book gives an introduction to the subject of medical audit in a step-wise manner i.e. beginning with the most fundamental aspects and building up successive levels of knowledge. Thoughtful & practical guidelines in relation to the implementation of medical audit in hospitals have also been included. The text is thoroughly updated and exhaustively referenced.
The book is a comprehensive and thorough exercise on the subject by the author who has a vast experience of over two decades both as a clinician and hospital administrator pas excellence. Though the book will not only be appreciated by the hospital administrators, it will be acclaimed as a handy reference guide for clinicians and other specialists working in the health care delivery system and who constantly to provide their patients with what the modern medicines have to offer.
The textual matter has been reviewed by Dr. P. C. Chaubey, Addl. Professor, Hospital Administration AIIMS, New Delhi.
Author Affiliation: Dr. Anjan Prakash. M.B.B.S., M.H.A.(AIIMS), PGDMM; PGDMLS; CDM. Chief Medical Officer, Directorate of Health Services, Govt. of NCT of Delhi, F-17, Karkardooma, Delhi-110032.
E-mail: prakashanjan@rediffmail.com.
Book Available at: JAYPEE PUBLISHERS (P) LTD
EMCA House, 23/23B Ansari Road,
Daryaganj, New Delhi. 110002, (India)
E-mail: jpmedpub@del2.vsnl.net.in; jpvij@hotmail.com
Medical audit By Sr. CMO Safdarjung Dr. Anjan Prakash
Success of medical audit depends on its implementation
Dr Anjan Prakash
Dr Anjan Prakash
Thus, while there is a general agreement on the need of evaluating the healthcare provided and to conform to the regulations requiring the monitoring of this care, there is little agreement as to what constitutes quality care or what is the form that evaluation and/or monitoring should take. There are enormous pressures the health and hospital administrators have to deal with, like political, financial and medical emergencies. Within this framework medical professionals are striving for continued improvement of their performance and the highest standards of excellence.
Self-evaluation of any degree and of any value is improbable and therefore evaluation by audit and peer review is more likely to achieve its objectives. Medical audit is an important component of quality assurance, which in turn is an essential part of any management process. Though the present system of evaluating quality is primitive, non-systematic and episodic, its theory and techniques are reasonably well developed. It is the implementation that is not proper. For the implementation to be proper certain pre-requisites must be met with before starting to evaluate the medical care provided by the hospital. There should be set standards and the criteria that are outlined should also be met with. It should be established as to who will evaluate the services provided and how often will it be done. Also qualitative and quantitative assessments have to be made.
Medical audit is this professional review of services provided by the hospital against given standards. It is defined as the retrospective evaluation of quality of medical care through the scientific analysis of medical records.
The term quality as used in the above definition refers to the degree of conformity with standards, with the best of medical knowledge and with accepted principles and practices. The phrase medical care is used in a restrictive sense to include only those elements of care which are provided by, or under specific direction of the physician. The evaluation is carried out by matching the procedures against the approved standards, which are laid down on the basis of medical knowledge that provides us with the information about what should be done in order to achieve the best results.
Medical audit is far more important to a hospital than financial audit. Financial deficits can be met eventually but medical deficiencies can cost lives, or loss of health thereby resulting in unwanted agony. It is being increasingly felt that while on one hand quantitative development is an important pre-requisite for ensuring accessibility of services, another equally essential requisite is the right quality of services. The evaluation of quality of patient care in hospitals through medical audit has assumed significant importance because it provides valuable feedback to the administrators and to the clinicians who are responsible for efficient and effective running of hospital services.
There are inherent difficulties in medical audit but the aim is to evaluate the quality of medical care to maintain the standard of excellence and improve the standards that fall below the accepted levels.
It is in conformity with the traditions of hospitals and ethos of healthcare that the institutions should maintain high standards of patient care thereby taking a lead in the latest revolution in the healthcare delivery system. They can initiate by forming a medical audit committee that lays down the evaluation procedures. The evaluation procedures can be random analysis of case records and hospital performance indicators like average length of stay, bed occupancy rate, bed turnover rate, infection rate, gross and net death rates, etc.
In order to facilitate the evaluation by the Medical Audit Committee, the clinical faculty should be advised to develop pre-determined acceptable norms, with respect to common diagnoses handled under their specialties. Deviations from these norms will then be easily detected. In some of the major hospitals, the general specialties of surgery, obstetrics and gynaecology and super-specialties particularly, gi surgery, CTVS, paediatric surgery and orthopedics have developed their own norms for the diagnostic group in terms of investigation schedule, clinical management and antibiotic practices.
As regards medical specialties like general medicine, dermatology, paediatrics and psychiatry no established norms for any disease category are known to exist. The clinicians concerned have an explicit view that such norms in their specialty cannot be possibly adopted as a routine. However, in contrast to this, a few hospitals can be found where some of the medical specialties like, gastroenterology; endocrinology, haematology have such norms in existence.
The foremost point expressed by the clinicians is that a dynamic science like medicine cannot possibly have standardized norms for treatment and management of any clinical disease. So, the working norms for disease groups can be made available. They can later be changed from time to time depending on the scientific advancement and discoveries. Such available norms can also be adapted rather than adopted. The clinicians and surgeons have to develop the norms of medical or surgical practice particularly for medical audit individually and not by any outside agency. Norms for diagnostic groups like GI bleeding; gall bladder diseases and for procedures like LSCS; hysterectomy, cardio-vascular surgery, joint replacement surgery are available at many hospitals, based on tome tested practice and development of science and newer antibiotics and diagnostic procedures.
The basic norms for introduction of medical audit like improved support services, availability of material supplies, strict disciplinary authority to junior clinical staff and autonomy of professional practice are a must before any sincere effort of introducing medical audit in a hospital is made. It is important to recognize that the implementation of medical audit is fundamentally an exercise in the management of change. The success of medical audit will depend on how it is implemented. Given the complexity of the evaluation, it is not unreasonable that full implementation might encompass a number of stages or phases and several years of work. The key to the entire process, therefore, is the management leadership to begin with and perseverance to follow it in a sensitive way.
(The author is sr. chief medical officer, Safdarjang Hospital, New Delhi. The article is an excerpt from her book Medical Audit)
Subscribe to:
Posts (Atom)