Friday, October 28, 2011

NOTICE.

There will be no blog today and probably not in the near future since I am having renovations on my right wrist. Although my wrist is ancient by most standards I do not believe that I need the OK from the Historic Preservation Commission for these alterations.

The bloging problem is of course due to the fact that I am maldexterous not ambidextrous. If Dragon can do a reasonable job of transcribing my speech I shall attempt to write a blog is the subject matter is of interest.


I doubt that I will be at the Special meeting 11/1/11 but expect to be at the next agenda session.

Thursday, October 27, 2011

SPECIAL MEETING 11/1/11

This was sent to the two papers for publication 10/27/11. The text is reproduced here for your awareness.


CORPORATION NOTICE
CITY OF PLAINFIELD

NOTICE OF SPECIAL MEETING

PURSUANT TO ARTICLE 2, SECTION 2:2-10(A) OF THE ADMINISTRATIVE CODE OF THE CITY OF PLAINFIELD, 1971, A SPECIAL MEETING IS HEREBY CALLED BY THE PLAINFIELD CITY
COUNCIL AT 8:00 P.M. ON TUESDAY, NOVEMBER 1, 2011, IN THE CITY HALL LIBRARY, 515 WATCHUNG AVENUE, CITY OF PLAINFIELD, FOR THE PURPOSE OF CONSIDERING AND ACTING UPON THE FOLLOWING:

1. PUBLIC HEARING ON TEMPORARY YEAR 2011 BUDGET AMENDMENTS.

2. POSSIBLE ADOPTION OF THE TEMPORARY YEAR 2011 MUNICIPAL OPERATING
BUDGET AS AMENDED.

3. RESOLUTION AUTHORIZING TRANSFERS BETWEEN TY 2011 APPROPRIATIONS OF
THE GENERAL FUND OF THE CITY OF PLAINFIELD.

4. RESOLUTION AUTHORIZING THE EXECUTION OF AN AGREEMENT BETWEEN THE
CITY OF PLAINFIELD AND JERSEY PROFESSIONAL MANAGEMENT FOR CONSULT-
ING SERVICES.

5. RESOLUTION DESIGNATING THE HEALTH BENEFITS PLAN FOR THE CITY OF
PLAINFIELD UNDER THE NJ STATE HEALTH BENEFIT PROGRAM.

6. AN ORDINANCE TO AMEND AND SUPPLEMENT THE MUNICIPAL CODE OF THE
CITY OF PLAINFIELD AT CHAPTER 2, ADMINISTRATION, ARTICLE 10. BUDGET
AND PURCHASING PROCEDURES, BY CREATING SECTION 2:10-18, AWARD FOR
PROFESSIONAL SERVICES BY COMPETITIVE NEGOTIATION.

7. AN ORDINANCE TO AMEND AND SUPPLEMENT THE MUNICIPAL CODE OF THE
CITY OF PLAINFIELD AT CHAPTER 2, ADMINISTRATION, ARTICLE 10. BUDGET
AND PURCHASING PROCEDURES, BY CREATING SECTIONS 2:10-19 through 2:10-
22, INCLUSIVE PROHIBITION ON AWARDING PUBLIC CONTRACTS TO CERTAIN
CONTRIBUTORS.

8. AN ORDINANCE TO AMEND AND SUPPLEMENT THE MUNICIPAL CODE OF THE
CITY OF PLAINFIELD AT CHAPTER 17, LAND USE, ARTICLE III, ZONING BOARD OF
ADJUSTMENT, BY CREATING SECTION 17:3-15, CONTRIBUTION DISCLOSURE
STATEMENTS.

9. AN ORDINANCE TO AMEND AND SUPPLEMENT THE MUNICIPAL CODE OF THE
CITY OF PLAINFIELD AT CHAPTER 2, ARTICLE 10. BUDGET AND PURCHASING
PROCEDURES BY CREATING SECTION 2:10-23, INSURANCE PURCHASING.

FORMAL ACTION MAY BE TAKEN.

BY ORDER OF THE PLAINFIELD
MUNICIPAL COUNCIL
ANNIE C. MCWILLIAMS, PRESIDENT

/S/S/ ABUBAKAR JALLOH, RMC
MUNICIPAL CLERK
D A TE D :
PLAINFIELD, NEW JERSEY
OCTOBER 27, 2011.

HEALTH CARE REIMBURSEMENT

To continue the previous posting on health care; there are two other important factors that have decidedly altered the relationship between physicians and patients in the last five decades. The changes have been gradual, not abrupt, but noticeable.

The first change has been the segmentation of care notably the increased presence of the hospital as an institution in delivering all aspects including the physician. Hospitals a big up to employee physicians called hospitalists which assume care of the patient wants the patient enters its door. The primary care physician or family physician or referring physician is in many cases no longer allowed stead hospital privileges this is most marked when related to primary care generalist or internist without specific sub specialty.

This process began initially with the allocation of a concession to the emergency room groups. Their practice was limited to the emergency room. They had specific duty hours. Once the physician was off-duty he had no contact or responsibility to any patient seen by him in the ER. This was contrary to the old fashion idea that a physician was legally responsible 24/7.

The next group that appeared as hospital physicians were usually Critical Care specialist; who is most often pulmonary specialists trained in the administration of oxygen and maintaining of respiration. Much of this knowledge was foreign to most of the physicians who had outside practices but admitted patients to the hospital. This particular specialist was followed by other specific specialists to a point where the hospitals begin to employee full-time salaried doctors in all fields. They work shifts the covered all the different wards in the hospital. They excluded the primary care physician. Physician loved positions like this because their responsibilities ended when they were off-duty. They could now spend more time with their family; they were working a work week similar to those in business.

The other revolution which occurred started with the HMOs where the insurance companies attempted to instead of fee-for-service compensate physicians for treating their patients under a capitation program. Capitation meant that the physician was paid for the number of patients registered in his panel. The more patients he had the more money he could earn; therefore it would induce the doctor to spend less time per patient in order to increase numbers and his income. Panelists were also rated on their efficiency according to the insurance company, which in essence spent how they kept the patient from high-cost hospitalizations, referrals and tests irrespective the patient’s needs

Fortunately although capitation with its set panels met patient resistance usually because the patient was obligate to go to a specialist in the network. Specialist out of the network although perhaps superior most often would not be compensated by the plan.

I have copied an explanation of the newer ideas on paying health care providers.

In the late 1990s, physicians and consumers decisively rejected capitation on the grounds that it motivated doctors to skimp on care and made it difficult for patients to gain access to specialists. Today, capitation survives mainly in California and a few other managed-care hotspots.

The new payment models, like capitation, involve budgeting. But they combine that with quality measures to ensure that doctors aren't cutting corners on care. All of these systems pay doctors fee for service, although those fees and/or bonuses may go up or down with performance. The overall goal is to induce physicians to provide high-quality, cost-efficient care.

In 2009, Medicare began paying bonuses to physicians and other clinicians who qualified as "successful" e-prescribers — that is, they reported electronically transmitting a certain number of prescriptions from their computer to a pharmacy computer. In 2011 and 2012, the bonus equals 1% of a clinician’s fee-for-service (FFS) charges. It drops to 0.5% in 2013, the last year of the incentive program.

Meanwhile, physicians who have not satisfied the complicated rules for e-prescribing this year face a 1% reduction in their FFS charges in 2012. The penalty increases to 1.5% in 2013 and 2% in 2014.

Here's a brief summary of these payment models, all of which are either being piloted or will soon be tested by Medicare and/or private health plans.

Bundled Payment
: Unlike case rates, which apply only to individual procedures, bundled payments cover care provided across care settings and over specific time periods.
In Medicare's Bundled Payment Initiative, which is already underway, the Centers for Medicare and Medicaid Services (CMS) will bundle payments for a hospitalization, for post discharge care for 30 days, or for the inpatient stay plus post discharge care for 30 or 90 days, depending on which option a provider or group of providers chooses.

Physicians who participate in these arrangements will be paid fee for service and will share in the savings if total costs are less than the budget. Their payment will be reduced, however, if costs exceed the budget. Under a fourth option, CMS will prepay the hospital for an episode of hospitalization, and the facility will divide the prepaid amount with physicians and other providers.

Episodic Payment: In addition to bundled payment, other forms of episodic payment are being considered. For example, several large healthcare systems are piloting Prometheus Payment, which rewards physicians for practicing efficiently and avoiding complications.

Physicians are paid fee for service for performing a portion of an evidence-based guideline, and their payments are debited against a care team's budget for an episode of care. (The episodes may be built either around procedures or around chronic disease care for an extended time period.) If the care team avoids complications, the physicians share in the savings from averted emergency department visits and hospitalizations. They can also get bonuses for meeting quality goals.

Accountable Care Organizations: Accountable Care Organizations (ACOs) are groups of doctors and hospitals that agree to coordinate patient care across care settings and to deliver seamless, high-quality care. If they meet certain criteria, ACOs will be eligible to participate in a Medicare shared-savings program, starting in 2012.

CMS offers ACOs 2 options for reimbursement, both contingents on the providers meeting CMS' quality benchmarks: 1) share any savings they produce with Medicare for the first 2 years, and share in both surpluses and losses in the third year, or 2) take upside and downside financial risk for all 3 years. Physicians will be paid fee for service at the current Medicare rates; but, under option 2, their payments will be adjusted downward if the ACO goes over budget.

Global Prepayment: Some health insurers are testing new approaches to "global capitation," in which all care provided to patients -- including professional and hospital services -- is prepaid. For example, Blue Cross Blue Shield of Massachusetts offers an "alternative quality contract" that combines global capitation with quality bonuses.

A dozen large healthcare organizations have accepted this contract so far. The Blues plan pays physicians fee for service, and those payments, along with hospital and other costs, are reconciled against the budget at the end of the year. In groups with salaried physicians, however, the fee-for-service payments are only an accounting device. For example, at Atrius Healthcare, which includes six physician groups in eastern Massachusetts, physicians continue to receive salaries and production bonuses that are not affected by the alternative quality contract budget.

Wednesday, October 26, 2011

HEALTH CARE

There has been a weird absence of any political noise during these weeks prior to the November 8 election day, Perhaps this is a good time to return to a subject which should be of interest to all of us: Health Care.

Last Saturday in the business section of the New York Times there was an article which on the surface appears to be a positive trend in delivering care to the masses: Walgreen, a major drugstore chain is experimenting in the Chicago and in other areas with the moving the pharmacist from behind the counter to a separate isolated desk area in the store.

No longer will the pharmacist be responsible for filling or checking on the accuracy of prescriptions He will now become a full-fledged Health Care provider. No longer will he be involved in taking calls or contacting the insurance carriers. Instead his role will be to give medical advice to patients including recommendations on prescription drugs as well as the administration of immunization vaccine.

I quote in part from the article: What started out as a plan to give flu shots has already spread to include multiple other vaccines. In addition there is pressure. Placed before legislatures in many states are laws to permit the pharmacist to write prescriptions.

Federal Medicare drug laws allow for payment to pharmacists for “medication therapy management,” when patients have multiple chronic diseases like hypertension, diabetes and asthma and are taking multiple medications. In recent years, Walgreen and other pharmacy chains have lobbied aggressively for reimbursement and changes to rules that allow pharmacists to do more and to get paid for these additional services.

Walgreen already has aggressive lobbying efforts under way to get pharmacists the ability under state rules to administer more vaccines in the pharmacy. And the company is working with doctors and hospitals to develop relationships that include having a pharmacist involved in patient consultations and management of their diseases.

This is along with a trend which has been going on for several years with the advent of the HMO, to permit nurse practitioners and physician's assistance a greater role in the care of a patient. They are given more leeway in making diagnoses and in prescribing medication. Although they are still restricted in most states there is tremendous lobby pressure in all states and at the federal level to expand their role so that they can actually supplant the primary care physician.

What has brought about this movement? Of course it is money. The insurance companies who run the HMO would rather pay for less trained individuals to be the initial health caregiver for all patients instead of a trained physician. There are also various plans being presented by government Healthcare eggheads to reduce the costs of Medicare and Medicaid that will accomplish the same effect. Money, not you the patient will be the engine that drives healthcare.

Where physicians will still be involved in primary care it will not be as individuals but in a group where fee for service the traditional method of reimbursement doctors will have been eliminated. In its place I these physicians will be on a base salary with bonuses determined by productivity efficiency and other parameters to be determined by a check list. Physician involvement and cost will be also reduced by the use of nurse practitioners and physician assistants who treat the so-called routine case.

The ultimate goal is to exclude a well-trained medical practitioner from the initial care of patients. Of course is will be cost-effective but actually at the expense of the patient. You the patient, will be getting an individual who is training is not is as diverse or comprehensive as a physician. That individual may be very well-qualified in diagnosing and treating routine illnesses but by the nature of their training lack the capability of differentiation for more severe or obscure problems.


The sad thing is that you the patient can not differentiate between levels of expertice in care and that so many consider it to be only a matter of dollars and cents.

I will conceed that the great majority of visits to a primary care physician are low level and routine. Therefore, the Nurse Practitioner especially as a solo has a definitive place in that care. It is the patient who suffers from a condition not routine that is at risk and may more likely have a poor outcome.

Tuesday, October 25, 2011

ROADS AGAIN

As winter is fast approaching I have noted the minimal status of the South Ave repavement/reconstruction project which has reached the stage of removing a few of the roadway blocking peninsulas plus some new curbing. There are now areas of absent roadway that are “coned” off and probably will have temporary filling for the winter.

If some of our Councilors had not tried to make an unmakeable point that a State Highway should be the responsibility of the State; this project would have been completed by now. Instead, we will have to wait until early spring at best for completion of work. Let us hope that there will not be more increases in the cost then have already occurred due to the increase in petroleum product prices.

For several years the same issue was discussed and although Corporation Counsel apparently cannot find the 1950’s agreement where the City agreed to be responsible for the maintenance in exchange for the right to make 5th Street between Watchung Ave. and Planfield Ave. a one way street. To expect the State to find the papers or even to agree to now in these economic times to become responsible is the height of political naivety. That is something that I would never have expected from at least one of the First/Ward Councilors.

Be that as it may, the entire road infrastructure repair and replacement program this year has been a disaster. Blame must lie in the lack of Administrative direction including the procuring of grant monies.

All will agree that pothole repairs in the area have been abominable this year. Plainfield does not stand alone, but must be near the poorest. Perhaps that has been due to lack of funding or personnel or a combination of both. Too much effort and time is wasted on piecemeal cold patching which deteriorates after wet weather.

In the vein; Saturday as part of a brief posting I noted about a system of infra-red hot patching potholes which seemed to be a permanent repair and very cost effective. There were two commentaries by Michael Townley to that blog which I feel should be repeated for those who do not go back days later to old postings,: I have excerpted portion s of both which answer many questions:

“Road openings (excavations for water and gas line replacements, sewer repairs, etc.) don't lend themselves to the infra-red repair technique.

With road openings, proper backfill materials (stone tamped at regular intervals as the ditch is filled), followed by stabilized base (a stone and asphalt mixture that is also tamped in place) and then topped with the finish layer of asphalt, with the edges of the excavation first sealed with an asphalt-based emulsion, will give you an excellent, permanent repair.

Why doesn't this happen? 1. It is too costly to do it right. Contractors are quick to backfill with the dirt they excavated, "tamp" it with the bucket of the backhoe pressing on the dirt, and then asphalt over that - voila, a "permanent" repair.
2. No one follows up on the excavations and makes the contractor do it right.

A properly administered and enforced road opening permit system would facilitate proper repair work. I don't know if the City has such a system in place - it doesn't seem like it does.

DeleteBloggerThe City Engineer is usually responsible for all road openings, construction and re-construction, and any other work within the right-of-way. When permits are issued for openings, they come out of the engineer's office. I believe that most municipalities don't inspect every opening, but have the record to fall back on when the opening fails.

When I was "in the business," our engineering staff did require contractors and utility companies to return and repair their initial work when it failed. Our public works crews would make a temporary repair if needed, but the permanent fix was up to the contractor or utility.

We did not charge for the permits, but had a penalty provision in our ordinance for failure to comply. We rarely had anyone open a street without a permit’ (end)

If I recall rightly at a Meeting a while back Councilman Storch did asked if “infrared sealing of the edges of patches as required by ordinance was enforced? I do not know if there ever was a reply. I hope Mr. Townley's remarks are taken into consideration and the proper ordinances are in place.