Obama/Romney Face off in NEJM

I don't know how many of you have seen this yet, but this week's NEJM has head-to-head editorials written by Obama and Romney on their approach to healthcare.  I couldn't figure out how to download the PDF, but the two editorials can be found at this links:

Obama: http://www.nejm.org/doi/full/10.1056/NEJMp1211514?query=featured_home

Romney: http://www.nejm.org/doi/full/10.1056/NEJMp1211516?query=featured_home

Just in time for our class discussion this week and next!!

Patient's right to access his own data

Hi all,

Here is a really interesting TEDx talk given by a man who would like to be able to access the data from his ICD.  He's obviously a very unique patient but he brings up some important questions about how far a patient's right to access his own records should go, as well as the potentially powerful role of mHealth.

http://boingboing.net/2012/09/28/why-cant-pacemaker-users-rea.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+boingboing%2FiBag+%28Boing+Boing%29

Personally, I think that the device manufacturer is missing a huge opportunity here, which is to develop a highly simplified app for the patient that alerts them each time a cardiac event occurs.  It seems like that would be a boon not only to the patient, but also to the physician ( and thus becomes good business for them as we'll as good medicine!)

NJ Death With Dignity Act

For those interested in end-of-life issues, there’s apparently a new right-to-die bill proposed in New Jersey that would let doctors prescribe life-ending drugs to patients with less than six months to live. According to this Star-Ledger article, there would be a lot of hoops for patients to jump through to make sure the person is nearing death and capable of making the decision, including multiple patient requests, witnesses, doctor certifications and counseling. If the Death With Dignity Act passes, New Jersey would fall in line with Oregon and Washington, which enacted similar measures in 1997 and 2009.  (An LA Times article says a total of 809 people in those two states have since died by taking the drugs they requested from their doctors.)

As with all end-of-life issues, it’s an ethically and emotionally charged debate. There are the medical ethics surrounding whether doctors should be able to prescribe medication to help a patient die when their goal is usually to keep patients alive. Here, the line between “healing” and “harming” can be nebulous.

From a public health perspective, we talk about the disproportionate amount of health care spending in the last years of life and the need for a cultural shift surrounding end-of-life issues. Is this a step in the right direction? Or should a culture shift be more focused on other options such as hospice care and getting people to fill out advance directives?

I'm not sure I have the answers to these questions, although I do think that a comprehensive approach to this issue should involve getting people to think about end-of-life early on, making sure they have options when they're nearing death, and giving them the information and support they need to make those choices. Regardless of the outcome, I hope the bill will spur some honest public debate about the issue.

Money and Medicine

Money and Medicine - A documentary

This documentary explores healthcare spending that is devoted to unnecessary care. The documentary compares healthcare spending at UCLA medical center and Intermountain healthcare, Utah. The documentary compares healthcare spending at these centers during first 2 years of life, the last two years of life, excess imaging use, spending related to mammography screening and breast cancer treatment, PSA screening and prostate cancer treatment. The documentary doesn’t really discuss much in terms of solutions but does provide a good basic framework to understand differences in healthcare spending across geographic areas and discusses some factors that drive physician and patients to seek excess care.

The full  documentary is available at the link below
http://video.pbs.org/video/2283573727/

In our PH Policy class we recently had an excellent class presentation on the Sugar Sweetened Beverage (SSB) tax that is going to appear on the ballot (measure N) in Richmond in November.  Dr. Wendel Brunner, the PH Department Director in Contra Costa County and a leader in state-wide efforts to address chronic diseases, recently shared with me the following statistics:  "In Richmond, 52% of the elementary children are overweight or obese, and the typical Richmond youth consumes 150,000 calories of sugar a year from SSB alone. There are an average of nine major outlets for SSB within a five minute walk of every elementary school in Richmond."

When the city board of Richmond voted to put this tax on the ballot they also approved an ordinance requiring special interests groups to declare their funders in all publications. Big soda sued the city and a U.S. District Court judge in San Francisco ruled in favor of the beverage industry stating that the ordinance went too far, violating first ammendment rights.  The city of Richmond has acted quickly to pass a new  scaled-back ordinance that still requires disclosure of funding sources on all mass mailings of political fliers.    This is particularly important because the group acting on behalf of big soda is called "The Community Coalition Against Beverage Taxes", a misleading title on a couple of counts. 

The disparity in spending on this campaign is huge with big soda spending over $350,000 compared to $7,335 being spent by the pro-soda tax side (see below).  There has been national media coverage and big soda knows that cities, counties and states are watching to see what happens.  A win for SSB tax in Richmond will encourage others to follow and a defeat will discourage others.  It will be interesting to see how this plays out.  If you would like to donate to the "Yes on N" effort go to http://www.fit-for-life.org/

 

The Waiting Room

Hi all - quick diversion for you: Just read about this documentary shot at local safety net facility Highland Hospital in Oakland - sounds powerful. Here is review/commentary from NYT http://movies.nytimes.com/2012/09/26/movies/the-waiting-room-about-highland-hospital-by-peter-nicks.html?hpw Looks like playing in SF at Sundance Kabuki on/around October 19th - might be worth a field trip....

Solutions leading to un-anticipated problems

http://www.nytimes.com/2012/09/25/business/us-warns-hospitals-on-medicare-billing.html

Modernization of medical records has been one of the keys elements of healthcare reform and was thought to lead to a decrease in administrative cost by decreasing inefficiencies in the way medical records were previously maintained. I didn't anticipate that electronic medical records could lead to increases in Medicare fraud and providers billing for a higher level of service than the care actually given to the patient. This New York Times article discusses the increase in billing for healthcare services and increase in Medicare fraud noted after the implementation of electronic health records. Some of this increase in billing for higher level services is driven by the relative ease with which providers can clone information from one medical record to another i.e. essentially copying one patient’s information into another patient's medical record. This practice allows certain unethical providers to bill Medicare and private insurance companies for higher level of service while actually providing the patient with a lower level of medical service. 

The other side which is not reported in this article and is often cited by hospitals and providers is that now they are billing the customers more accurately than they were prior to the introduction of medical records. The rationale being that prior to introduction of medical records, patients and insurance providers were being under billed due to errors in reporting of ICD 9 codes for diagnoses and lack of proper documentation. EMRs have made proper documentation easier and have reduced the coding errors by automation of this process, hence leading to billing which is actually a much better representation of the level of medical service provided to the patient. 

As always, the truth lies somewhere in the middle. I personally think the trend is probably more towards overbilling, with elimination of fee for service payment structure being the most logical but politically difficult solution of this problem.

Group Project: Interest areas?

A few of us spoke after class today about using this blog as a space to share what we may be interested in working on for the group project, since our smaller cohorts (MPH, MPH/MPP, 11-month-ere) don't routinely see each other outside of Foundations class. Perhaps that's due to schedule differences that will be difficult to work around, but perhaps not!

So here's a starting point. Post interests and ideas to the comments section, so if folks are gravitating towards specific issues, we'll have a centralized place to find that out and clump up!

"Have you recently experienced a medical mistake?"

With the goal of making health care safer, the Obama administration is drafting a novel system for patients to report medical errors.  No system of this scale currently exists.  The primary questions in the draft are, "Have you recently experienced a medical mistake?  Do you have concerns about the safety of your health care?"  Respondents are also asked to indicate potential reasons for the error such as "A health care provider was too busy" or "Health care providers failed to work together."  They even have the option to report specific names of providers (physicians, nurses, etc) and their addresses. 

After reading this article, a few questions came to mind and I'd be interested in hearing other people's thoughts.  

1.  Are consumers the best source of information for medical errors?  

While I absolutely agree that patients' perceptions are a key components of their health care experience and they often have helpful insights to improve their care, I do not think that they are the best judge of what went wrong.  And focusing on vague reasons such as excessive provider workload and cultural competency do not get to the heart of the problems nor do they offer specific solutions.  Further, it is unlikely that patients can provide enough detail of their care to allow adequate evaluation of the holes in a health care system.  However, this information may be useful to identify broad trends in patient care over time.  

2.  How should this information be used?  Will it be made public? 

In other industries where workplace safety is a significant concern, the threat of punitive action impedes error reporting.  The ultimate goal is to minimize preventable adverse health effects from medical errors not just reduce the apparent number of errors.  Also, I think patients who experience medical errors but have them acknowledged and explained by the provider would actually be reluctant to use this reporting system if it could get their provider "in trouble." 

3.  Are there better alternatives? 

I think so.  Focusing on quality measures, requirements for all health care organizations to have a process for medical error reporting and evaluation, and making specific health outcomes (eg. surgery mortality rates) transparent are more effective solutions, in my opinion.  

http://www.nytimes.com/2012/09/23/health/new-system-for-patients-to-report-medical-mistakes.html?_r=1&ref=health

A closer look at public opinion

Hi all,

Here is a different look at American's opinions on ACA, in which Michael Sakes pulled together disparate data from a variety of public survey polls to show that disapproval may not be as widespread as high-level polling sometimes suggests.  I am particularly interested in his point that a lot of the apparent disapproval is correlated to a poor understanding of how the ACA will affect individuals.  The author is confident that as people start to experience it, and thus understand its effect on them, in 2014, approval ratings are likely to rise.

http://healthaffairs.org/blog/2012/09/21/what-do-polls-really-tell-us-about-the-publics-view-of-the-affordable-care-act/

This touches on a question I have been toying with for the past couple weeks - is the high level of disapproval of the ACA due to the policy itself being unpopular, or due to the government doing a poor job of selling this new idea to the public?  Whose job is it to educate the public about new legislation that will affect them?  The government?  The media?  It seems like information dissemination *should* be a much easier problem to solve.

Big Med & the Cheesecake Factory

In case you, like me, missed Atul Gawande's August 13 article in the New Yorker, here's a link to it, titled 'Big Med.' It leads off with lessons for medicine taken from the Cheesecake Factory.

Yup, you read that right. After recovering from my knee-jerk foodie reaction (what??? trade Oakland/Berkeley/SF local fare for the Cheesecake Factory?? no way!!!), I read on and have been thinking about challenges and opportunities for innovation, change and improvement in healthcare ever since, including two thoughts:

1. You can't get good care without some thoughtful coordination across team(s) of care providers. 
• Great description of an experience with uncoordinated care on page 4.
• Astute (and challenging) prescription for improvement from a Cheesecake Factory manager: "...study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute."
• Why don't we put more resources into this in provider/system workflows? 
2. Standardization has numerous cost and quality of care outcome benefits. But how you implement standardization matters immensely.
• Remote ICU oversight stations as a second set of eyes
• Poorly received if just catching errors; sought out and respected if praising what was done well by the teams the oversee

If you haven't seen it yet, it's worth the read. Would love to hear what folks think about standardization, care coordination, and team-building to improve care.

Oregon Medicaid Program and the Rand Experiment

Many of us are currently in Health Economics and just learned about the famous Rand Health Insurance Experiment of the 1970s which found that people with health insurance coverage used it--they spent approximately 50% more on health care than those without it. The study also found that copayments reduced the use of services. This famous experiment was a classic demonstration of moral hazard at work: the concept that when people are detached from the costs of behavior, they are more willing to take risks.

I came across this article this summer discussing Medicaid in my home state of Oregon. This “experiment” by the Oregon government essentially turned the Rand study into reality: Medicaid coverage was randomly assigned to certain individuals and not to others through a lottery system. One of the original Rand researchers, Joseph Newhouse, is watching this scenario unfold carefully with a group of researchers to determine the effect this lottery has on health care costs and health outcomes. The results essentially show exactly what the Rand study did: those with coverage spend more than those without. Moreover, those with coverage had better health outcomes.

What is striking however, from the story, is the level of impact that coverage really has on those in poverty. This article really gets to the heart of a question posed to us in class: what should we be spending on health care? We focus so much in this country on how much health care costs us, but perhaps this article is highlighting that for many, these costs are worth it. Quality of life improves to such a degree with insurance coverage that maybe health care is worth spending approximately one fifth of our GDP. I just thought I’d share it.

Medicaid Block Grants: Theory vs. Reality

Although the debate about converting Medicaid into a block grant program has been lingering on partisan lines for decades, the Paul Ryan budget proposal is again bringing the debate to the forefront. Under Ryan’s proposal, states would receive a set amount of federal funds to sustain their Medicaid programs, but then bear the financial risks should their programs exceed their grant allotments.  While Ryan believes this will curb federal Medicaid spending and give states increased “flexibility” in running their programs, the reality of this drastic change at the state level is proving to be a contentious issue.

In the worst case scenario, it seems like converting Medicaid into a block grant program could inevitably lead to rationing care. Conservative state leaders believe block grants will allow states to run their own programs without government intervention and tailor their programs to their own populations. However, I seriously doubt states will welcome this freedom at the cost of bearing the risks once their funds are depleted. If states already want to cut Medicaid spending under the current system, what would prevent them from making dangerous cuts to Medicaid beneficiaries without guaranteed federal assistance in the horizon? Another shortcoming of this system is the fact the block grants may not be adjusted for inflation and in the event of another recession, low-income families may be worse off.  For example, lessons learned from the TANF program, another block grant program for needy families, shows that states may be able to funnel block grant funds to free up state funds that may not directly benefit low-income families and children.

All in all, I think the block grant debate if more an issue of political ideology. I understand that states want flexibility to run their programs, but this should not be done at the expense of limiting access and care to those that need it most. I would hope that if Medicaid does become a block grant program in the future, states would develop ways to limit the impact of budget shortfalls on Medicaid budgets. But perhaps this is why entitlement programs have been left to the federal government: to ensure equitable access and guaranteed financial support for those eligible in all states, not just those that can afford to do so.  

Iran vs. Mississippi

Not sure how many of you read this New York Times Magazine article from a few months back but it has stuck with me and I have been reminded of it several times since starting school.  SO, I thought I would share it with you.
One way in which I found this article interesting was the way it addressed the issue of community health workers and ancillary providers, and how in developing countries they are relied upon to bridge the gap between the abundance of patients and the few doctors often available to care for lage populations.  It is a way to address the issues of cost and access, among others.
In the US we also have a great need for this sort of "gap" care which for many people could be in place of the majority of their primary care and if provided in a proactive way, could not only eliminate unnecessary hospitalizations and reduce healthcare costs, but could improve the quality of life for many people.  I think Americans tend to be very closed minded to the idea of someone other than a doctor providing medical care, exhibited by many peoples' reluctance to see nurse practitioners, etc.  Our healthcare system doesn't put enough emphasis on the "medical team" approach, although there have been several attempts to bring this to the forefront with managed care, etc.  I think more people would get the care they need if more resources were put into programs like the one profiled in this article.