What is the Independent Payment Advisory Board? Why is better than RUC?

[Bill Peckham]

The Independent Payment Advisory Board was created by the Affordable Care Act as a way to reign in costs. The IPAB is designed to discover and authorize ways to reduce the rate of growth of Medicare and other categories of health spending. Granted the IPAB is risky. Expert boards always run a high risk of being captured by the industry they are supposed to regulate but to evaluate this risk you have to understand how the system works now.

I would be surprised if anyone reading this has heard of the American Medical Association's Relative Value Scale Update Committee (aka RUC). I think this committee must shoulder much of the blame for our system of reimbursement based on effort rather than outcomes. We all know a prime example - the case of EPO - which was paid per unit rather than as part of a bundle of care which led to overuse. The IPAB is an effort to use evidence-based medicine basing payment decisions on outcomes. The issue is that the current system does not include the value to the patient of a service and  there is not a financial incentive to help the patient or an incentive to control costs. The way the docs want it is to base payment on how hard the service is so we end up where we are today in a world where doctors have large payment incentives to use the most complicated procedures without regard to effectiveness.

Big picture basing payment on complexity is a important reason that we have a lack of primary care physicians - the system is skewed to reward complex procedures delivered by medical specialists. And while the IPAB could be captured by industry the RUC is privately run and a prime example of regulatory capture. You hear worries about IPAB being non transparent or secretive but today RUC meetings are closed to the public and their deliberations are not known. Even more astounding the RUC basically copyrights their data which allows them to charge anyone who wants to use RUC values. The AMA generates in excess of 70 million dollars in fees from licensing their RUC data. This should be considered when evaluating the AMA's criticism.

Against this, you can see the IPAB as an effort to yank the process out the AMA's back rooms and into the light of a public agency. In fact, on January 7 of this year an appeals court ruled that RUC is free to operate outside the public interest rules that would govern the IPAB. To end RUC we need the IPAB or something better, but until that something better comes along the IPAB will serve a valuable purpose.

The IPAB is a superior model for determining the fair cost of care when compared to the RUC. In addition, the IPAB is barred by law from rationing care, restricting benefits or changing eligibility criteria. If spending exceeds certain thresholds the IPAB can make binding recommendations to Congress but, as of today, the Congressional Budget Office has said that it is expecting Medicare spending to remain below the threshold that requires action for the next decade. Plenty of time to defang RUC and develop an ideal process.

Finally, the concerns that have been expressed that this agency will cause Medicare to change reimbursement in a way that harms seniors or other Medicare beneficiaries ignores the fact that seniors have political power in this country and there is really no chance that "death panels" will come to pass. People vote and no act of Congress can prevent action by Congresses in the future. That is a simple political truth that gives lie to the claims of pending doom.

[cariad]

Thanks, Bill! I am one of those people that knew almost none of this, and your post provided an excellent foundation for me to follow these discussions and add my own point of view.

I especially appreciate that you state that this is the best that we have right now. All of these people (Republicans mostly, I imagine) saying 'what's the rush' when it comes to reforming healthcare. The rush is everything you said and more. The rush is working poor Americans suffering disastrous health outcomes while the richest among you - including the ones who are paid handsomely to serve the public good - have every medical intervention at their disposal.

Controlling medical costs is such an overwhelming issue to tackle, but I think it needs to be seen as a process. We makes changes now, then continue to improve, never reaching a point where we say we are 'done', adapting with changing times and populations. Demanding perfection at a stroke is a ridiculous stall tactic from people who have enjoyed the current health inequalities for decades.

I do think that any discussion of health costs must include a way to advise people - not decide for them, but advise - when they would not benefit from further intervention. There was a nurse in my public health class I took a year ago, and she would say they would too often have individuals in their 90s who had suffered some cataclysmic event like stroke, but the families would demand heroic measures to keep them existing. There needs to be some way to address this with families without hearing the shriek of 'death panels'. My uncle was very wealthy, and he was only 69 when he suffered a stroke. For a brief time it looked like he might recover, but then he stopped responding on a Sunday. That following Wednesday my family assembled at his bedside and he was taken off life support. I am grateful that the doctors did not just see him as a blank check, because it could still be dragging on.

[Bill Peckham]

This is pretty typical of the reporting on the IPAB cariad
http://thehill.com/blogs/healthwatch/health-reform-implementation/298733-gop-wont-offer-input-on-nominees-to-controversial-obamacare-panel

GOP won't offer input on nominees to controversial ObamaCare panel
By Sam Baker    - 05/09/13 10:00 AM ET
Congressional Republicans are refusing to recommend members for a controversial panel designed to slow the growth of Medicare spending.

The panel was created by President Obama's healthcare law and structured to ensure some level of bipartisan input. But House Speaker John Boehner (R-Ohio) and Senate Majority Leader Mitch McConnell (R-Ky.) said Thursday they will not recommend anyone to serve on the board.

They say the panel — known as the Independent Payment Advisory Board (IPAB) — ought to be repealed. It's one of the controversial sections of the law Republicans have singled out for repeal votes.

"We believe Congress should repeal IPAB, just as we believe we ought to repeal the entire healthcare law … We hope establishing this board never becomes a reality, which is why full repeal of the Affordable Care Act remains our goal," Boehner and McConnell wrote in a letter to Obama.
The IPAB is a 15-member panel of healthcare experts. The healthcare law gives Boehner and McConnell three recommendations each, and another three to each of their Democratic counterparts. All 15 board members would have to be confirmed by the Senate.

Once in place, the IPAB would make targeted cuts in Medicare's payments to doctors and other providers if the program's overall spending grows faster than a certain rate. The board is not allowed to alter Medicare benefits or "ration" care.

"These reduced payments will force providers to stop seeing Medicare patients, the same way an increased number of doctors have stopped taking Medicaid patients. This will lead to access problems, waiting lists and denied care for seniors," Boehner and McConnell wrote.

Obama has not yet nominated anyone to the IPAB.

The panel was supposed to come into existence in 2014, but Medicare spending has not grown slowly enough that the IPAB would not be triggered next year.

The only actual criticism from Bohner/McConnell is that "These reduced payments will force providers to stop seeing Medicare patients, the same way an increased number of doctors have stopped taking Medicaid patients. This will lead to access problems, waiting lists and denied care for seniors" which is saying if Medicare paid Medicaid rates it would be a problem but Medicaid, where it is a problem, pays 80% of the Medicare allowed rate, while the IPAB would, at some point in the future (the most recent CBO data says at some point over ten years in the future) propose to decrease the rate of Medicare reimbursement growth for particular services. The dynamic marginally affecting Medicaid isn't possible due to any action by the IPAB.

I have never seen any engagement on the issue from the IPAB's political opponents, that acknowledges the current system is fully captured by medical doctors in specialty practices. There is actually a lot of push back in health policy circles against Medicare for relying upon the RUC as the primary source of recommendations for determining physician work values, accepting over 90 percent of the committee’s recommendations, but you never hear about this in the context of the IPAB. For one the Society of General Internal Medicine has stood for diminishing the RUC's influence but even so many internists are not aware of the AMA's committee's corrosive role in setting Medicare reimbursement.

The IPAB is the first alternative to be signed into law (Congress McDermott proposed legislation in 2011 that went nowhere) and now with cynical disregard for fixing the problem the IPAB is being demonized by those playing political games, chief among them Bohner and McConnell.

[Hemodoc]

This is pretty typical of the reporting on the IPAB cariad
http://thehill.com/blogs/healthwatch/health-reform-implementation/298733-gop-wont-offer-input-on-nominees-to-controversial-obamacare-panel

GOP won't offer input on nominees to controversial ObamaCare panel
By Sam Baker    - 05/09/13 10:00 AM ET
Congressional Republicans are refusing to recommend members for a controversial panel designed to slow the growth of Medicare spending.

The panel was created by President Obama's healthcare law and structured to ensure some level of bipartisan input. But House Speaker John Boehner (R-Ohio) and Senate Majority Leader Mitch McConnell (R-Ky.) said Thursday they will not recommend anyone to serve on the board.

They say the panel — known as the Independent Payment Advisory Board (IPAB) — ought to be repealed. It's one of the controversial sections of the law Republicans have singled out for repeal votes.

"We believe Congress should repeal IPAB, just as we believe we ought to repeal the entire healthcare law … We hope establishing this board never becomes a reality, which is why full repeal of the Affordable Care Act remains our goal," Boehner and McConnell wrote in a letter to Obama.
The IPAB is a 15-member panel of healthcare experts. The healthcare law gives Boehner and McConnell three recommendations each, and another three to each of their Democratic counterparts. All 15 board members would have to be confirmed by the Senate.

Once in place, the IPAB would make targeted cuts in Medicare's payments to doctors and other providers if the program's overall spending grows faster than a certain rate. The board is not allowed to alter Medicare benefits or "ration" care.

"These reduced payments will force providers to stop seeing Medicare patients, the same way an increased number of doctors have stopped taking Medicaid patients. This will lead to access problems, waiting lists and denied care for seniors," Boehner and McConnell wrote.

Obama has not yet nominated anyone to the IPAB.

The panel was supposed to come into existence in 2014, but Medicare spending has not grown slowly enough that the IPAB would not be triggered next year.

The only actual criticism from Bohner/McConnell is that "These reduced payments will force providers to stop seeing Medicare patients, the same way an increased number of doctors have stopped taking Medicaid patients. This will lead to access problems, waiting lists and denied care for seniors" which is saying if Medicare paid Medicaid rates it would be a problem but Medicaid, where it is a problem, pays 80% of the Medicare allowed rate, while the IPAB would, at some point in the future (the most recent CBO data says at some point over ten years in the future) propose to decrease the rate of Medicare reimbursement growth for particular services. The dynamic marginally affecting Medicaid isn't possible due to any action by the IPAB.

I have never seen any engagement on the issue from the IPAB's political opponents, that acknowledges the current system is fully captured by medical doctors in specialty practices. There is actually a lot of push back in health policy circles against Medicare for relying upon the RUC as the primary source of recommendations for determining physician work values, accepting over 90 percent of the committee’s recommendations, but you never hear about this in the context of the IPAB. For one the Society of General Internal Medicine has stood for diminishing the RUC's influence but even so many internists are not aware of the AMA's committee's corrosive role in setting Medicare reimbursement.

The IPAB is the first alternative to be signed into law (Congress McDermott proposed legislation in 2011 that went nowhere) and now with cynical disregard for fixing the problem the IPAB is being demonized by those playing political games, chief among them Bohner and McConnell.

Actually, I believe GP's in Britain have a relatively higher worth than GP's in the US. I don't have source for that, but I will try to confirm from a documentary I saw quite  while ago. Internal medicine is going through difficult times not only because of the pay gap with specialists, but also because of the artificial division in the last few years with internists that are primarily hospital docs and those that primarily work in the office.

When I went through my Internal Medicine training, we did both but were focussed predominantly on hospital based medicine. When I first started at Kaiser, I spent about a 1/3rd of my time in direct hospital practice, the rest of my time was mainly in my office but we also did rotations on a regular basis in urgent care. It was a very diverse practice experience  That I enjoyed.

However, we were soon taken off urgent care duty and docs were hired to do that full time. A few years later, they hired full time hospital docs with the same exact training I had and kept us in the clinic. I kept my hospital privileges by doing 24 hour call every other Saturday until my renal disease precluded those kinds of hours. My last hospital call was Labor Day weekend 2005. Since hospital practice was my main reason for going into Internal Medicine, being confined to pushing an enormous amount of paperwork in the clinic took a lot of my personal enjoyment of medicine away.

It also worsened coordination of care between the hospital setting and the clinic. So, in addition to the pay issues, Internal Medicine has other significant challenges at a time when general internal medicine is a key element of Obama's healthcare plan.

Family Practice is also not as much in vogue as it once was. Now with a looming physician shortage, medical schools are trying to encourage more medical students to engage in primary care.

http://www.nytimes.com/2012/09/10/us/10iht-educlede10.html?pagewanted=all&_r=0

One interesting bit of information is that specialty programs are also suffering because of the decline in enrollment of internal medicine programs which does not bode well for the entire medical community.

[Bill Peckham]

Reimbursement drives practice - the framework the RUC enables is a zero sum game. If the committee thinks docs should be paid more for providing an endoscopic ultrasound some other procedure has to be paid less. The problem with the framework is that it is based on how hard the procedure is to provide not on how effective it is, the RUC doesn't value a doctor who keeps their patient from getting sick in the first place. This is the rotten heart of our healthcare reimbursement and why a functioning IPAB is important.


I just found this website today http://www.replacetheruc.org/  it is an eye opener.

[Hemodoc]

Reimbursement drives practice - the framework the RUC enables is a zero sum game. If the committee thinks docs should be paid more for providing an endoscopic ultrasound some other procedure has to be paid less. The problem with the framework is that it is based on how hard the procedure is to provide not on how effective it is, the RUC doesn't value a doctor who keeps their patient from getting sick in the first place. This is the rotten heart of our healthcare reimbursement and why a functioning IPAB is important.


I just found this website today http://www.replacetheruc.org/  it is an eye opener.

Why would the IPAB be any less politically motivated than the RUC when filled with 15 health care experts?  In addition, it has powers that have previously only been granted to congress. The corruption of the RUC is just as likely to be present in the IPAB especially given the only check and balance being a super majority of the Senate.

Once again, it is modeled after the NICE in Britain that sets policy based in large part on QALY. It is essentially a rationing system in England. Although the IPAB has different constraints and rules, it likewise will be essentially a rationing body likely operating under Donald Berwick's philosophy of shunting more monies to younger patients with longer expected longevity.

For the dialysis population with a very limited average life expectancy of only about 3 years and QALY's approaching $100,000 per year, I am not sure why folks in dialysis would support this proposal.

[Bill Peckham]

I think I addressed your concerns in my initial post - let me know where my post comes up short.

This idea about QALY doesn't come into play in the least. PCORI's IPAB's job is to look at procedures, not who receives them, just as the RUC does in fact. For instance, in dialysis the obvious one is catheter/graft/fistula. Which procedure should be reimbursed more? Should placing a catheter be more lucrative than placing a graft? Should placing a graft be more lucrative than placing a fistula? Currently reimbursement rewards docs who place and maintain a catheter to a greater degree than docs who place a successful fistula. That's the RUC way, but it is far from ideal. I can imagine a reimbursement policy that rewards a successful fistula placement. I would endorse a payment policy that continues to give some nominal sum to the surgeon that placed my fistula 23 years ago (this week). The RUC would not ever consider such a scheme while PCORI IPAB has the latitude to offer such a scheme as a solution, as a way to improve patient's well being and keep down Medicare's costs by avoiding hospitalizations.

Something like hemodiafiltration is another example. If hemodiafiltration improved clinical outcomes and decreased the disease/treatment burden of CKD5 than PCORI IPAB would make providing HDF more lucrative than providing conventional HD. RUC wouldn't distinguish between the procedures since they require the same physician effort. These examples are from just one small corner of medical practice that we are familiar with but I think there are examples from just about every field of medicine. I think it is to dialyzors clear advantage to support PCORI IPAB and stand opposed to the RUC.

[Hemodoc]

I think I addressed your concerns in my initial post - let me know where my post comes up short.

This idea about QALY doesn't come into play in the least. PCORI's job is to look at procedures, not who receives them, just as the RUC does in fact. For instance, in dialysis the obvious one is catheter/graft/fistula. Which procedure should be reimbursed more? Should placing a catheter be more lucrative than placing a graft? Should placing a graft be more lucrative than placing a fistula? Currently reimbursement rewards docs who place and maintain a catheter to a greater degree than docs who place a successful fistula. That's the RUC way, but it is far from ideal. I can imagine a reimbursement policy that rewards a successful fistula placement. I would endorse a payment policy that continues to give some nominal sum to the surgeon that placed my fistula 23 years ago (this week). The RUC would not ever consider such a scheme while PCORI has the latitude to offer such a scheme as a solution, as a way to improve patient's well being and keep down Medicare's costs by avoiding hospitalizations.

Something like hemodiafiltration is another example. If hemodiafiltration improved clinical outcomes and decreased the disease/treatment burden of CKD5 than PCORI could make providing HDF more lucrative than providing conventional HD. RUC wouldn't distinguish between the procedures since they require the same physician effort. These examples are from just one small corner of medical practice that we are familiar with but I think there are examples from just about every field of medicine. I think it is to dialyzors clear advantage to support PCORI and stand opposed to the RUC.

Well, first of all, PCORI only does the research as you know, it is not a decision making entity. That will be the IPAB. However, you may be a bit too generous in the findings of PCORI. For instance, to date daily dialysis, or quotidian dialysis is still viewed as "controversial" especially be the man who is the CER rep, or whatever his actual title is for dialysis, Glen Chertow. If it were up to Chertow to recommend paying for quotidian dialysis, all his writing would suggest he would state it has not been proven better than conventional in-center hemodialysis. That is the current state of belief by academic nephrologists. In such a system, although I have no doubt that Chertow is wrong, how would you petition the government to proceed? As you have admitted, all of our advocacy to date has essentially failed to change the system. Why would we trust CER headed by Chertow and the IPAB?

[Bill Peckham]

I think I addressed your concerns in my initial post - let me know where my post comes up short.

This idea about QALY doesn't come into play in the least. PCORI's job is to look at procedures, not who receives them, just as the RUC does in fact. For instance, in dialysis the obvious one is catheter/graft/fistula. Which procedure should be reimbursed more? Should placing a catheter be more lucrative than placing a graft? Should placing a graft be more lucrative than placing a fistula? Currently reimbursement rewards docs who place and maintain a catheter to a greater degree than docs who place a successful fistula. That's the RUC way, but it is far from ideal. I can imagine a reimbursement policy that rewards a successful fistula placement. I would endorse a payment policy that continues to give some nominal sum to the surgeon that placed my fistula 23 years ago (this week). The RUC would not ever consider such a scheme while PCORI has the latitude to offer such a scheme as a solution, as a way to improve patient's well being and keep down Medicare's costs by avoiding hospitalizations.

Something like hemodiafiltration is another example. If hemodiafiltration improved clinical outcomes and decreased the disease/treatment burden of CKD5 than PCORI could make providing HDF more lucrative than providing conventional HD. RUC wouldn't distinguish between the procedures since they require the same physician effort. These examples are from just one small corner of medical practice that we are familiar with but I think there are examples from just about every field of medicine. I think it is to dialyzors clear advantage to support PCORI and stand opposed to the RUC.

Well, first of all, PCORI only does the research as you know, it is not a decision making entity. That will be the IPAB. However, you may be a bit too generous in the findings of PCORI. For instance, to date daily dialysis, or quotidian dialysis is still viewed as "controversial" especially be the man who is the CER rep, or whatever his actual title is for dialysis, Glen Chertow. If it were up to Chertow to recommend paying for quotidian dialysis, all his writing would suggest he would state it has not been proven better than conventional in-center hemodialysis. That is the current state of belief by academic nephrologists. In such a system, although I have no doubt that Chertow is wrong, how would you petition the government to proceed? As you have admitted, all of our advocacy to date has essentially failed to change the system. Why would we trust CER headed by Chertow and the IPAB?

When I wrote PCORI I meant IPAB - should have waited for coffee. Chertow is exactly the sort of person who meets in secret on the RUC, again IPAB has to be judged against what we have now. If everything we have done has not changed the system then maybe we should try a new system.

[Hemodoc]

I think I addressed your concerns in my initial post - let me know where my post comes up short.

This idea about QALY doesn't come into play in the least. PCORI's job is to look at procedures, not who receives them, just as the RUC does in fact. For instance, in dialysis the obvious one is catheter/graft/fistula. Which procedure should be reimbursed more? Should placing a catheter be more lucrative than placing a graft? Should placing a graft be more lucrative than placing a fistula? Currently reimbursement rewards docs who place and maintain a catheter to a greater degree than docs who place a successful fistula. That's the RUC way, but it is far from ideal. I can imagine a reimbursement policy that rewards a successful fistula placement. I would endorse a payment policy that continues to give some nominal sum to the surgeon that placed my fistula 23 years ago (this week). The RUC would not ever consider such a scheme while PCORI has the latitude to offer such a scheme as a solution, as a way to improve patient's well being and keep down Medicare's costs by avoiding hospitalizations.

Something like hemodiafiltration is another example. If hemodiafiltration improved clinical outcomes and decreased the disease/treatment burden of CKD5 than PCORI could make providing HDF more lucrative than providing conventional HD. RUC wouldn't distinguish between the procedures since they require the same physician effort. These examples are from just one small corner of medical practice that we are familiar with but I think there are examples from just about every field of medicine. I think it is to dialyzors clear advantage to support PCORI and stand opposed to the RUC.

Well, first of all, PCORI only does the research as you know, it is not a decision making entity. That will be the IPAB. However, you may be a bit too generous in the findings of PCORI. For instance, to date daily dialysis, or quotidian dialysis is still viewed as "controversial" especially be the man who is the CER rep, or whatever his actual title is for dialysis, Glen Chertow. If it were up to Chertow to recommend paying for quotidian dialysis, all his writing would suggest he would state it has not been proven better than conventional in-center hemodialysis. That is the current state of belief by academic nephrologists. In such a system, although I have no doubt that Chertow is wrong, how would you petition the government to proceed? As you have admitted, all of our advocacy to date has essentially failed to change the system. Why would we trust CER headed by Chertow and the IPAB?

When I wrote PCORI I meant IPAB - should have waited for coffee. Chertow is exactly the sort of person who meets in secret on the RUC, again IPAB has to be judged against what we have now. If everything we have done has not changed the system then maybe we should try a new system.

No problem, a cup of coffee is always useful to shock the system and wake it up. Can't hurt for sure.

The question is that of an advocacy issue. Once again, it is my understanding the Glenn Chertow is the CER advocate for dialysis who would report his findings on dialysis issues to the IPAB. If the IPAB followed his recommendations, how would you petition your government to go against the Chertow advice which at present is quite negative towards quotidian dialysis given the fact that the IPAB can only be over ruled by a super majority, i.e., 60 votes in the senate. That leaves medical decisions best made between doctor and patient at the feet of an unelected board with some new and perhaps extreme powers.

Given also the lack of attention to dialysis advocacy at the CMS level which is fully under the authority of congress and the administration, it appears we would now have even less influence than the miserable lack of influence we have now on these issues. That is the level of my objection to the IPAB in a nutshell.

[Bill Peckham]

The IPAB doesn't simply endorse the view of a physician, while apparently the RUC does but I will say the data on more frequent dialysis is still being developed. As an HHD advocate I have no fear of anything that mines and or develops data because I believe in the efficacy of HHD. But what I think, my N=1 does not count for much in the real world. We are seeing a tremendous push back against the buttonhole because the data has raised concerns. I say that as an example of something I believe in as beneficial not being fully, unequivocally supported in the data. People of Dr Chertow's generation were snake bit by EPO and I think their caution is a reflection of their professional experience. If HHD ever generates enough data points to be convincingly compared to conventional HD then I am confident HHD's superiority will shine through, if it doesn't then reality will have to be accommodated.

However, right now more frequent HHD is being reimbursed at a level never dreamed of by more frequent advocates and yet we see a failure to thrive. I think it is well past time to move on from reimbursement to other factors not related to IPAB's work. I think my example of the access question is more relevant and pressing for a greater number of people and has more important potential impact. I am still interested in your take on the access issue and how it should be addressed if you see a problem.

And one other thing to consider when comparing IPAB with the RUC is that IPAB members will receive executive level federal compensation, they are not allowed to hold other positions. Compared to the RUC where practicing specialists work on policies that directly impact their livelihoods.

[Hemodoc]

The IPAB doesn't simply endorse the view of a physician, while apparently the RUC does but I will say the data on more frequent dialysis is still being developed. As an HHD advocate I have no fear of anything that mines and or develops data because I believe in the efficacy of HHD. But what I think, my N=1 does not count for much in the real world. We are seeing a tremendous push back against the buttonhole because the data has raised concerns. I say that as an example of something I believe in as beneficial not being fully, unequivocally supported in the data. People of Dr Chertow's generation were snake bit by EPO and I think their caution is a reflection of their professional experience. If HHD ever generates enough data points to be convincingly compared to conventional HD then I am confident HHD's superiority will shine through, if it doesn't then reality will have to be accommodated.

However, right now more frequent HHD is being reimbursed at a level never dreamed of by more frequent advocates and yet we see a failure to thrive. I think it is well past time to move on from reimbursement to other factors not related to IPAB's work. I think my example of the access question is more relevant and pressing for a greater number of people and has more important potential impact. I am still interested in your take on the access issue and how it should be addressed if you see a problem.

And one other thing to consider when comparing IPAB with the RUC is that IPAB members will receive executive level federal compensation, they are not allowed to hold other positions. Compared to the RUC where practicing specialists work on policies that directly impact their livelihoods.

First, Buttonholes. The issue is not whether the technique works, that answer is an absolute yes and reduces aneurysm and stenosis. However, in the hands of folks that are not as careful to detail, it fails. Those of us that do the buttonhole understand it is a bit unforgiving. You MUST do it the same way everytime to work.

THe issue of infections is an issue of failed technique at the tech level in my opinion. With six years and counting without a single buttonhole infection, I understand it is safe to perform buttonholes. Point of fact, I believe Stuart Mott has solved all of these technical problems and needs support getting that news out to all but he is meeting a great deal of resistance which I am hopeful he will overcome. I believe his techniques will eliminate the issues with buttonholes, they are that good.

The access issue. Put it this way, I have the training to place a catheter even though I am not current certified, but I placed dozens if not hundreds of catheters. However, I have NO training to put in a fistula. It is a no brainer to me which should be paid more, the fistula.