Accountable Care Organizations as a tool to help control exploding cost of diabetes?

I came across this article posted on cnn.com: http://www.cnn.com/2009/HEALTH/11/26/diabetes.projections/index.html

A study predicts that the cost of diabetes may triple over the next 25 years, from $113 billion to $346 billion. This figure is absolutely astounding. As we know, diabetes is one of the most preventable diseases, yet we as a society are not doing a particularly good job at preventing or managing it.

This article argues that part of the reason that diabetes is so hard to manage is because its effects are not seen until years later, when the disease has progressed to more severe stages. Accountable care organizations, which offers incentives for insurers and medical providers to encourage early treatment, may hold promise. This is not a novel idea as the UK has a similar system in place.

However, what is needed is greater incentives for patients to take control of their own health care. According to one Dr. Jonathan Gruber, an economist at MIT, putting the patient in control of their own care may help. In particular, he "likes the idea of allowing insurers to charge higher premiums to people who don't meet certain health benchmarks, such as losing weight if they're obese."

As someone with some clinical experience, I believe that one of the most difficult things to achieve in health care is patient compliance. Perhaps directly integrating cost incentives or dis-incentives may be the catalyst to help patients wake up and place their health as a top priority.

Paying for Quality, not Quantity

A new study from the UCLA School of Public Health (I know, I know - groan groan groan...) shows evidence that Pay-for-Performance programs can be more effective if they incentivize better quality in patient-clinician interaction and clinical outcomes rather than physician productivity.

http://newsroom.ucla.edu/portal/ucla/medical-pay-for-performance-improves-112787.aspx

A fitting warning to help avoid making health reform look like the old fee-for-service model...

Health Care: GE Gets Radical

Here's a story on how GE, one of the USA's largest corporations, has moved to offer its employees ONLY consumer directed high deductible health plans. While many companies offer such plans, most offer them as just one of several options. It will be interesting to see if other major corporations follow suit, and compel their employees to take on a bigger share of their healthcare costs.

http://www.businessweek.com/magazine/content/09_48/b4157030792130.htm

US view on global health spending

Sorry for two posts at once, but here's another really interesting study on US views on spending on global health, by he Kaiser Family Foundation - http://www.kff.org/globalhealth/upload/8013.pdf Of note is that even between March and October of 2009 more people shifted towards thinking that US should spend money on global health. At the same time, perhaps contradictorily, more than half of those polled believed that spending to improve health in developing countries would help health in the US (by preventing epidemics), yet less than half believed the US should spend money on global health issues. YET, at the same time, more people thought the US was spending too little money on global health than those who thought it was spending too much. There are lots more interesting trends all graphed out - definitely worth checking out.

Viral load mapping for HIV in SF

SF created a map showing viral loads in HIV patients by neighborhood. Measuring in this way is new, as compared to tracking individuals with the disease or, earlier (before medications made it more controllable) deaths. The map now gives a picture of how HIV is being addressed in different neighborhoods, not just how it's being transmitted. In other words, it's one way of visualizing disparities in care. Could have interested implications for how care is planned and improved. One point it raises is that more work needs to be done to rebrand HIV as not just a "gay disease" (already there's been a lot of work, but not enough) and also to reach out to more diverse cultural, racial and SES groups. Here's more info: http://www.nytimes.com/2009/11/06/health/research/06sfvirus.html

Senate Votes Secured

This is exciting! The system should hopefully become somewhat progressive with the additional half a percentage point increase in Medicare payroll tax for people with an income over 200,000 and a tax on expensive insurance plans.

http://news.bbc.co.uk/2/hi/americas/8372210.stm

Botax

an excerpt from an article I saw today:

"Something called 'Botax' might help pay for health care reform. The name derives from a tax on Botox... which in the case of some Hollywood types could raise millions.

Senate Democrats are proposing a 5% excise tax on elective cosmetic procedures... that includes things like Botox injections, breast implants, tummy tucks, face lifts, liposuction, teeth whitening, eyelid repairs, etc."

interesting...well, the money has to come from somewhere?

Health care moving away from actual human care?

A really interesting article in the NYT about how the focus of the medical system is trending towards "checking off the boxes" (i.e. quality indicators, EHRs, etc.) which is indeed contributing to a higher quality of care, but at the same time providing less patient care since doctors pay less attention to patients.

Here's an exerpt:

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from Checking the right boxes, but failing the patient, By DENA RIFKIN, M.D.
http://www.nytimes.com/2009/11/17/health/17case.html?_r=1

"None of these interventions, however well meant, address a fundamental problem that is emerging in modern medicine: a change in focus from treating the patient toward satisfying the system. The effects of focusing physicians’ attention on benchmarks and check boxes are not, I think, to the patient’s advantage.

A close family member was recently hospitalized after nearly collapsing at home. He was promptly checked in, and an electrocardiogram was done within 15 minutes. He was given a bar-coded armband, his pain level was assessed, blood was drawn, X-rays and stress tests were performed, and he was discharged 24 hours later with a revised medication list after being offered a pneumonia vaccine and an opportunity to fill out a living will.

The only problem was an utter lack of human attention. An emergency room physician admitted him to a hospital service that rapidly evaluates patients for potential heart attacks. No one noted the blood tests that suggested severe dehydration or took enough history to figure out why he might be fatigued.

A doctor was present for a few minutes at the beginning of his stay, and fewer the next day. Even my presence, as a family member and physician, did not change the cursory attitude of the doctors and nurses we met.

Yet his hospitalization met all the current standards for quality care.

As a profession, we are paying attention to the details of medical errors — to ambiguous chart abbreviations, to vaccination practices and hand-washing and many other important, or at least quantifiable, matters.

But as we bustle from one well-documented chart to the next, no one is counting whether we are still paying attention to the human beings. No one is counting whether we admit that the best source of information, the best protection from medical error, the best opportunity to make a difference — that all of these things have been here all along.

The answers are with the patients, and we must remember the unquantifiable value of asking the right questions."

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I find it difficult not to completely agree with Dr. Rifkin. To me, being in a hospital is scary enough because you're feeling icky. Add to that the fact that doctors are completely impersonal (I haven't seen the same doctor since I was 11)... I and many others have good incentives to stay away from seeking health care. Even preventative care - sure it's good for you, but it seems like such an ordeal.

Medical homes would be a good way to address this issue - Healthy San Francisco seems to be doing a good job at this. HSF provides low cost medical care to low income residents of SF; they've been getting patient satisfaction reviews that have been incredibly good.

Fundamentally though, for real change to occur, I think that the amount of time spent with patient should be a clinical quality indicator. And, perhaps doctors should also be required to undergo multidisciplinary training. Medicine is never purely about science - the biggest reason we bother to take care of our physical health is because it affects our emotional well being. Hmm...maybe M.Ds should be required to take psych classes instead...?

Equity and new technology

I just saw this interesting talk by Ian Goldin, director of the 21st Century School at Oxford. He brought up quite a few issues, but the one that especially drew my attention was his point that we've seen vast improvements in the past half century but increasing inequity. As we move ahead, we'll see even more improvements and improved technology that we can't even imagine. There's a huge and likely danger, though, that that improved technology will not be evenly distributed, and that improved health technologies will only be available to the very top of the pyramid. Then, what happens with the bottom? Inequity in distribution of life-saving and -extending and -improving technology is not "fair," but it's also dangerous. I'm interested, then, to hear both your feedback on this issue and also ideas to increas equity.

No more flu vaccine shortages in the future?

The Wall Street Journal had an interesting article this week on a new procedure that will shorten the time it takes to produce influenza vaccine. Current technologies include the growth of real influenza viruses inside chicken eggs, which can take up to six months. The new technology that is up for FDA approval next week uses genetic material from an influenza virus, which is then inserted into a virus that infects caterpillars. The manipulated cells are then grown in a stainless-steel fermentation vessel for three or four days. This new process will take less than two weeks, and safety and efficacy testing will take another month. Aside from the implications this will have for emergency responses for flu outbreaks in the future, the article also raises the question of how the FDA approves new drugs versus how regulatory bodies in other countries approve drugs. Novartis already has a flu vaccine that is grown in a dog-kidney-derived cell-culture system, which takes one month less than the traditional chicken-egg technology. This vaccine has been approved for use in a number of countries outside the U.S.

Source:
http://online.wsj.com/article/SB125815143285947561.html#articleTabs%3Darticle

In defense of the health insurance industry

Will Ferrell (and celebrity friends) recently created a spoof video speaking out against insurance companies and in support of the public option: http://www.youtube.com/watch?v=B98muhufAGE

It uses sarcasm to portray the insurance industry as the arch enemy of health care reform, claiming that greedy insurance companies make billions of dollars in profit while intentionally taking advantage of those who cannot pay for care. While it's easy to scapegoat insurance companies, it got me thinking that it's important to get the facts. In actuality, for every dollar spent on healthcare in America, 99¢ goes to hospitals, doctors, pharma, other medical services, and other health related spending. Only 1¢ goes to health plan profits. And we need to remember that employees are generally satisfied with their coverage - about 2/3 of employees rated their employer-based insurance coverage as “excellent” or “very good” in a recent survey (National Business Group on Health Employer-based Health Benefits Survey, 2007). Also, the insurance industry has formally supported many of the reform proposals.

Private insurance companies are making profits, but they are certainly slim. Finger-pointing at health plans to portray them as immoral, corrupt, and money-hungry will get us no closer to progress on health reform. I acknowledge there are MANY problems with insurance companies, but I argue that the American system of care is designed to make this the case, not the alleged greed of for-profit insurance CEO's.

Comments? Other opinions?

House, Senate differ sharply on health care reform

http://www.cnn.com/2009/POLITICS/11/09/health.care.congress/

This past weekend marked a major step forward with the House approving a major overhaul of the United States' health care system. There are still major hurdles to overcome, however. The more conservative Senate still has to pass its own version, and this could prove difficult with a smaller Democratic majority and stronger Republican minority. What does everyone think, will the Senate bill contain the public option? Will the employer mandate in the House bill hold up in the Senate? Let me know your thoughts.

Abortion Coverage Debate

This article:

http://www.nytimes.com/2009/11/09/us/politics/09abortion.html?hp

is about the debate on whether federal subsidized insurance plans would cover abortions. I found it helpful because of its information on how abortion is currently covered by health plans.

Some of my takeaways from this article were:

• In 2003, only 13% of abortions were billed directly to insurance.
• About half of employee-sponsored insurance plans currently cover elective abortion.
• A ban on federal-financing of abortions is currently in place. Seventeen state Medicaid programs currently cover abortion by using state funds, the rest do not cover it.
  
• Even if abortion is not covered by federally subsidized health insurance plans, women will be able to buy supplemental insurance coverage for abortions. But it is unlikely that many would, because, as the article puts it, "few [women] plan for unintended pregnancies."

Texting as a Health Tool for Teenagers

Here's a link to a NY Times article that talks about a study in which text messaging was used to help teens with chronic diseases and transplants remember to take their medicines and to come in for regular appointments and lab tests:

http://www.nytimes.com/2009/11/05/health/05chen.html?_r=1&ref=health

There is even talk in the article of a desire for insurance companies to cover some sort of text messaging cell phone plan in the future, as a response to the fact that this technology worked so well in this study until 1/3 of the teens had to drop out because they lost cell phone privileges or could no longer afford to have a cell phone.

Text messaging and other newer technologies (facebook, twitter, email, etc) seem to be coming up more & more as easy & efficient ways to reach the younger part of the population.
In fact, Danielle, Doug, and I were just discussing this today with a few administrative people at Sutter East Bay Medical Foundation. We explained to them why it could be beneficial to get younger patients' email addresses for contacting them, and also revealed an idea of using Twitter for preventive health reminders & information. This just might be a great way for a medical office to show its teen patients that even their doctor has jumped onto the technology wagon :)

Thoughts on new technology? Any other articles that any of you have seen out there on similar topics?

And Speaking of Sugar...

I couldn't help but notice an interesting article about the controversy over American Academy of Family Physicians partnering with the Coca-Cola Company to develop soft drink educational materials. All this reminds me of the debate over tobacco-funded research at Berkeley (the School of Public Health banned tobacco funds in 2004). I take it the the AAFP needs outreach money very desperately, but must it do so in a way that compromises its reputation? We'll just have to see what happens.

http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2009/11/04/national/a135617S45.DTL

A spoonful of sugar

Dennis Herrera, SF's City Attorney, just got Kellogg's to stop claiming that Cocoa Krispies boosts children's immune systems. The reporters here, as well as the commentariat, seem to think it's a laughable effort, but I think that if the effort was minimal, it was worth it. It's the kind of intervention we dream up in class exercises, and it's useful to see it pitted against the average citizen's exhausted call for increased focus on more substantive things, like, say, violent crime. Anyway, worth it, I say...

http://www.sfgate.com/cgi-bin/blogs/matierandross/detail?entry_id=50979&tsp=1

The Swine Flu Affair Part II?

Blowing the Shot: What we can learn from the shortage of H1N1 vaccine

As I was reading this article today, I couldn't help but think...this sure sounds like the Swine Flu Affair in its approach to pointing out the shortcomings in the response to H1N1, except that this one is more or less in real time. In the same way that the Swine Flu Affair attempted to bring to light the missteps in the swine flu scare of 1976 in order to learn lessons from the past, this article is quick to point out what lessons there are to learn in our current shortage of H1N1 vaccines.

Here are some of the main criticisms:
* We are using slow and outdated technology to grow these vaccines in hen eggs rather than developing quicker methods culturing the virus in mammalian cells.
* "The Centers for Disease Control and Prevention and the Department of Health and Human Services decided to finish making the seasonal flu vaccine before transitioning to the new vaccine, even as evidence suggested that the new pandemic was going to crowd out the yearly flu."
* "Baxter Pharmaceuticals' H1N1 vaccine Celvapan utilizes the much speedier process of culturing mammalian (monkey) cells rather than hen eggs." This vaccine was tested and determined to be safe, but the FDA was apparently unwilling to take the risk of using a new vaccine technique.

On the policy level, I have not been following H1N1 closely enough to know how valid some of these criticisms are. However, one issue that I found particularly interesting was this repeat issue of seasonal flu vaccine versus swine flu vaccine...which one to focus on. In the swine flu scare of 1976, one of the early issues that the CDC had to decide on was whether to continue to manufacture the Victoria flu vaccine or concentrate all efforts on the swine flu vaccine. They pretty much chose to focus on the swine flu vaccine (making small amounts of the bivalent type). And that was determined later to be the wrong choice. This time around, the focus was put on the seasonal flu. And once again, it is being criticized as the wrong choice because the H1N1 hasn't been following the pattern of the normal "flu season." Well then...it appears that learning from the past may be more difficult than it seems.