This quick article from the times made me think of our conversation last week in class. It summarizes a study done by the Department of Economics at Harvard about the career costs of family. Not surprisingly, the corporate world posed the highest penalty in salary for women who took time off to raise kids. In contract, MDs were found to have had the best outcomes.
Though the focus of the study is on having children, I think it follows that a job with more flexibility has implications on other work-life trade-offs.
http://economix.blogs.nytimes.com/2010/12/06/m-b-a-s-have-biggest-mommy-penalty-doctors-the-smallest/
Tuesday, December 7, 2010
Monday, December 6, 2010
“Patient-Centered” Patient-Centered Medical Homes
The Affordable Care Act (ACA) places a strong emphasis on illness prevention, promoting health, and management of chronic conditions. The Patient-Centered Medical Home (PCMH) has taken a front row seat in health nomenclature. For instance, In particular, the ACA requires some Medicaid enrollees to be in a “health home,” invests in primary care and family medicine, and initiates Accountable Care Organizations for Medicare.
While many are excited by the PCMH concept, providers and policy implementers are concerned that there is not a specific PCMH definition or a common understanding of what one is. Political task forces and major provider organizations are researching and discussing the specific requirements and goals that these entities should strive to achieve. But what if the answer is in our own backyard? For instance, when reforming a community clinic, why wouldn’t one start by asking what the community wants from their clinic?
At the North American Primary Care Research Group Meeting earlier this month, I met a few community physicians doing this type of patient engagement. They reached out to the community and asked them to sit on their redesign boards and to be active participants in the discussion of how the fundamental PCMH principals could be applied to their clinic.
One physician relayed his story of working with his community. When the providers in his clinic met alone, they decided that 48 hours was an adequate goal for returning a patient’s email. A patient had a very different opinion. She thought a few hours was even too long. She said that patients mainly contact their physicians when they are in need of an urgent medicine refill or if they have symptoms that aren’t quite concerning enough for the emergency room and that both of those situations deserve a quick response.
I found this idea very powerful because it is the beginning of a paradigm shift in medicine from the historical paternalistic patient-provider relationship to a new partnership in health. As a family doctor in training, I see a future where all community delivery systems (clinics, hospitals, or other providers) reflect the needs and values of the communities in which they serve. To do this, community involvement is key. Patient-engagement not only provides the clinic with effective quality improvement strategies, but also empowers the patients to take ownership over their local health system and over their own health.
For more information on patient-engagement in healthcare, please read Lansky, D. Patient Engagement and Patient Decision-Making in US Health Care. Foundation for Accountability. July 11, 2003. Accessed from www.gih.org/usr_doc/FACCT_Paper.pdf on December 2, 2010.
And for more on PCMH generally, I recommend checking out the PCHM page at HHS (http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483), the Patient Centered Primary Care Collaborative (http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home), and this nifty little video (http://www.emmisolutions.com/medicalhome/transformed/english.html).
While many are excited by the PCMH concept, providers and policy implementers are concerned that there is not a specific PCMH definition or a common understanding of what one is. Political task forces and major provider organizations are researching and discussing the specific requirements and goals that these entities should strive to achieve. But what if the answer is in our own backyard? For instance, when reforming a community clinic, why wouldn’t one start by asking what the community wants from their clinic?
At the North American Primary Care Research Group Meeting earlier this month, I met a few community physicians doing this type of patient engagement. They reached out to the community and asked them to sit on their redesign boards and to be active participants in the discussion of how the fundamental PCMH principals could be applied to their clinic.
One physician relayed his story of working with his community. When the providers in his clinic met alone, they decided that 48 hours was an adequate goal for returning a patient’s email. A patient had a very different opinion. She thought a few hours was even too long. She said that patients mainly contact their physicians when they are in need of an urgent medicine refill or if they have symptoms that aren’t quite concerning enough for the emergency room and that both of those situations deserve a quick response.
I found this idea very powerful because it is the beginning of a paradigm shift in medicine from the historical paternalistic patient-provider relationship to a new partnership in health. As a family doctor in training, I see a future where all community delivery systems (clinics, hospitals, or other providers) reflect the needs and values of the communities in which they serve. To do this, community involvement is key. Patient-engagement not only provides the clinic with effective quality improvement strategies, but also empowers the patients to take ownership over their local health system and over their own health.
For more information on patient-engagement in healthcare, please read Lansky, D. Patient Engagement and Patient Decision-Making in US Health Care. Foundation for Accountability. July 11, 2003. Accessed from www.gih.org/usr_doc/FACCT_Paper.pdf on December 2, 2010.
And for more on PCMH generally, I recommend checking out the PCHM page at HHS (http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483), the Patient Centered Primary Care Collaborative (http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home), and this nifty little video (http://www.emmisolutions.com/medicalhome/transformed/english.html).
Saturday, December 4, 2010
AZ Cuts Some Transplant Services for Medicaid Patients
The recent NY Times article on how Arizona is cutting financing for transplants patients on Medicaid, effective in October, is worth a read, even during this crazy finals week. While reading the article, I had many mixed emotions, from anger over the patients being turned away to seeing the financial constraints Arizona is facing and trying to come to terms with how to deal with providing health care in the face of economic constraints. This article provides many important takeaways to consider that reflect the horrible shape our health care system is in. The increasingly high expenditures is leading to rationing of care, leading to a real "death panel." Should Medicaid patients be turned away from having lifesaving transplant operations if they cannot afford to pay for it? Perhaps Arizona could reduce their health care costs by eliminating waste in their Medicaid operations/payments in order to keep transplant services. The article also brings up the question of how much we value an individual life, and how much extra time as a result of a treatment is worth what cost. Any thoughts on how AZ should proceed?
Wednesday, December 1, 2010
Federal Judge Rejects Health Law Challenge
http://www.nytimes.com/2010/12/01/health/policy/01lawsuit.html?_r=1&ref=health
On Tuesday a federal judge in Lynchburg, VA issued a ruling that the new health reform law is constitutional. The Liberty University (a private Christian college) had challenged the law on the grounds that requiring Americans to obtain medical coverage does not fall within Congress's authority to regulate interstate commerce.
This is the second time in two months that a federal judge has upheld the new health care reform law. However, over the next few months, Repbulican-appointed federal judges will also rule on the constituionality of the new law in Richmond, VA and Pensacola, FLA. It is anticipated that these judges may come to a different ruling. If disagreement does occur amongst lower federal courts, then the Supreme Court will get involved.
On Tuesday a federal judge in Lynchburg, VA issued a ruling that the new health reform law is constitutional. The Liberty University (a private Christian college) had challenged the law on the grounds that requiring Americans to obtain medical coverage does not fall within Congress's authority to regulate interstate commerce.
This is the second time in two months that a federal judge has upheld the new health care reform law. However, over the next few months, Repbulican-appointed federal judges will also rule on the constituionality of the new law in Richmond, VA and Pensacola, FLA. It is anticipated that these judges may come to a different ruling. If disagreement does occur amongst lower federal courts, then the Supreme Court will get involved.
How will CA handle enrollment of new Medi-Cal beneficiaries associated with health reform?
In California, Medi-Cal requires beneficiaries to enroll in person or, in limited areas, though a mail-in application. When the Medi-Cal FPL increases to 133% across all populations, there will likely be long wait times associated with enrollment. I see a comprehensive IT solution as the best way to prepare for increased eligibility and enrollment demand. Wisconsin developed a one-stop-shop web portal for beneficiaries to be screened and enroll in many public programs. This may be a viable option for California and other states if done well.
Click here to read the KFF brief about the Wisconsin IT solution.
Click here to read the KFF brief about the Wisconsin IT solution.
Tuesday, November 30, 2010
No Advancements in Patient Safety
As a strong advocate of improving patient safety and quality in hospitals, it was very disappointing to read this article. This reported study found that patient harm was common and that over time, the number of incidents didn't decrease. Researchers found that 18% of patents in the study were harmed by medical care and that about 63% of the incidents were preventable. This was especially disappointing since the hospitals participating in the study were more involved in patient safety improvement programs. It makes one wonder what the rate is in hospitals that aren't champions of patient safety.
Monday, November 29, 2010
Diabetes Expansion Info Graphic
It's startling to watch the rates go up and up so much, over just a 5 year period:
Map of CDC Estimated Rates of Diabetes in the US, 2004-8
Map of CDC Estimated Rates of Diabetes in the US, 2004-8
Quality Metrics: Outcomes Versus Process
An area that has caught my interest lately is the concept of quality metrics. In the third year of medical school, we get a two-week block on health policy, including one discussion section on quality metrics. In this section, we discussed some of the public reporting data from the New York CABG studies. In short, yes outcome reporting increases quality improvement activities at the hospital-level and in some cases decreases overall mortality rates. However, what was even more interesting were the unintended consequences reported in this data. In many instances, the sicker cardiac patients were selectively referred out of state and were less likely to receive not only CABG surgery, but also percutaneous coronary intervention (a more common and less invasive treatment) than patients in Michigan where there was not public reporting.
Although physician and future physicians including myself may like to think we are above incentives, it is human nature to respond to financial and peer pressure. Does it make sense to give physicians the incentive to risk adjust their patient populations and penalize those providers that treat the highest risk patients? We tried this incentive with health insurers and saw skimping of benefits, limits on preexisting conditions and underwriting. Health insurance is composed of insurance risk based on the patient’s demographics, adherence and genetics and performance risk based on the provider’s care. Outcome measures place the responsibility for both insurance and performance risk squarely on the shoulders of the provider.
There are two solutions I see to this problem. One would be to develop a comprehensive method for risk adjustment, which is not only difficult to develop for a certain population, but relatively impossible to extrapolate to a broad, diverse patient population. Personally, I believe process metrics make more sense—we should compare providers on whether they follow evidence-based best practice standards thus holding them accountable for their performance risk and not for the patient’s inherent risk factors. For instance, instead of measuring diabetic hemoglobin A1C at 6 or 12 months, we would check to see if the provider ordered this lab test to be done at least twice per year, according to the American Diabetes Association guidelines.
Some say that following evidence-based guidelines produces “cookie-cutter” medicine, where all patients receive average, standardized care. However, if we have proven the best algorithm for a specific condition why wouldn’t we provide this medicine where applicable and individualize therapy when necessary? I don’t think we should be threatened by the standardization of guidelines and best practices. There is no algorithm that can replace the doctor patient relationship, the professional instinct to know when the guidelines don’t apply and the educational and advisory role of the physician as the patient’s partner in medical care.
Fung, C., et al (2008). Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine, 148 (2) 111-123.
Although physician and future physicians including myself may like to think we are above incentives, it is human nature to respond to financial and peer pressure. Does it make sense to give physicians the incentive to risk adjust their patient populations and penalize those providers that treat the highest risk patients? We tried this incentive with health insurers and saw skimping of benefits, limits on preexisting conditions and underwriting. Health insurance is composed of insurance risk based on the patient’s demographics, adherence and genetics and performance risk based on the provider’s care. Outcome measures place the responsibility for both insurance and performance risk squarely on the shoulders of the provider.
There are two solutions I see to this problem. One would be to develop a comprehensive method for risk adjustment, which is not only difficult to develop for a certain population, but relatively impossible to extrapolate to a broad, diverse patient population. Personally, I believe process metrics make more sense—we should compare providers on whether they follow evidence-based best practice standards thus holding them accountable for their performance risk and not for the patient’s inherent risk factors. For instance, instead of measuring diabetic hemoglobin A1C at 6 or 12 months, we would check to see if the provider ordered this lab test to be done at least twice per year, according to the American Diabetes Association guidelines.
Some say that following evidence-based guidelines produces “cookie-cutter” medicine, where all patients receive average, standardized care. However, if we have proven the best algorithm for a specific condition why wouldn’t we provide this medicine where applicable and individualize therapy when necessary? I don’t think we should be threatened by the standardization of guidelines and best practices. There is no algorithm that can replace the doctor patient relationship, the professional instinct to know when the guidelines don’t apply and the educational and advisory role of the physician as the patient’s partner in medical care.
Fung, C., et al (2008). Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine, 148 (2) 111-123.
Monday, November 22, 2010
Interim rule on medical-loss ratios wins praise
With health insurance plans now mandated to spend 80-85% of premiums on direct patient care and quality improvement or else offer patients a rebate, perhaps those for-profit insurance companies may go the route of not for profit to get the tax exemption as profits will now be decreasing....but hopefully health outcomes will be increasing.
http://www.modernhealthcare.com/article/20101122/NEWS/311229957/#
http://www.modernhealthcare.com/article/20101122/NEWS/311229957/#
Friday, November 19, 2010
Senate Approves Bill To Block Scheduled Cut to Medicare Physician Pay Read more: http://www.californiahealthline.org/articles/2010/11/19/senate-appro
Will the House follow? Will we see history repeat?
Thursday, November 18, 2010
A bright spot for civil rights
A quickie - we talk a lot about payment policy and delivery system reform, and the intense need to change the way things work at a systematic level. Which makes a lot of sense, given the number of problems the current configuration creates. At the same time, it's good to remember that sometimes, changes in regulations that have no additional cost - procedural, how we do things changes - can make a big difference:
The Centers for Medicare & Medicaid Services (CMS) today issued new rules for Medicare- and Medicaid-participating hospitals that protect patients’ right to choose their own visitors during a hospital stay, including a visitor who is a same-sex domestic partner.
That's something I'm glad to hear.
The Centers for Medicare & Medicaid Services (CMS) today issued new rules for Medicare- and Medicaid-participating hospitals that protect patients’ right to choose their own visitors during a hospital stay, including a visitor who is a same-sex domestic partner.
That's something I'm glad to hear.
Follow-up to yesterday's class on doctors and pharmaceutical companies
The SF Chronicle must have known about our class yesterday, because they just came out with this article on doctors receiving money from pharmaceutical companies: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/11/18/MNJU1GDLRF.DTL&tsp=1
Although it mostly focuses on doctors who have been the subject of disciplinary actions, the article also mentions the increased restrictions on doctor-industry relationships (especially as concerns academics) that we touched on in class.
Although it mostly focuses on doctors who have been the subject of disciplinary actions, the article also mentions the increased restrictions on doctor-industry relationships (especially as concerns academics) that we touched on in class.
Monday, November 15, 2010
Easy and Incredibly Hard Solutions - Obesity & Nutrition
As promised, here is the crazy article I was talking about a few weeks ago which suggests that overarching causes/treatments for obesity may be much more complex and insidious than simply "eat less, exercise more." Among my favorite depressing yet little researched topic - reduction of variation in ambient air temperature. Unfortunately, this was the only article I could find on the topic, so take the findings with a grain of non-replicated salt.
Second, I wanted to share this infographic on how fortifying foods with vitamins/minerals can improve literally millions of lives in the developing world & the US. It brought home to me how cost- and results-effective population-level public health interventions can be, even though they rarely have the sex appeal of higher tech, "lifesaving" technologies. Unfortunately, sometimes we point to successes like these as solutions for the developing world and fail to see how effective they can and should be here at home.
Second, I wanted to share this infographic on how fortifying foods with vitamins/minerals can improve literally millions of lives in the developing world & the US. It brought home to me how cost- and results-effective population-level public health interventions can be, even though they rarely have the sex appeal of higher tech, "lifesaving" technologies. Unfortunately, sometimes we point to successes like these as solutions for the developing world and fail to see how effective they can and should be here at home.
Friday, November 12, 2010
Fresh air: What Dialysis Taught Us About Universal Health Care
Now that you're all done with your midterm and need something to do, this is a really great story on NPR's Fresh Air about coverage of ESRD (End-stage renal disease, or kidney failure) under Medicare and how the costs to cover this small fraction of Medicare beneficiaries eats up an enormous amount of Medicare spending. ESRD has been called "Socialized medicine for one organ" by some mentioned in the story. This brings up lots of questions about the monetary value of a life, the privatization & commercialization of care, and the burden of chronic disease.
Click and listen to both sections "What Dialysis Taught Us..." and "Medicare Chief MD Speaks...", it is well worth it.
Do you now feel shocked & dismal about the future of Medicare, if you did not already? :(
Wednesday, November 10, 2010
FDA gets feisty / personal choice?
My family had a friend visiting from Ecuador last year when the law passed allowing the FDA to regulate tobacco products. She was outraged. She was a smoker. And she could not believe that the US was going as far as intruding in people's private lives and personal habits. (Ecuador has very little social health movements, so I think this was pretty bizarre to her.) She understood that smoking was bad for her health, but she enjoyed it. And that was enough to keep her smoking.
She is not the only one who feels this way. Isn't personal freedom an American value most of us cannot imagine living without? Why is choosing to smoke any different? (Playing devils advocate here...) Check out the article below, it's about the FDA's new plan to "re-energize the nation’s antismoking efforts". It's a little graphic, but hopefully helpful. It will be interesting to see what kind of backlash this new regulation gets.
http://www.nytimes.com/2010/11/11/health/policy/11tobacco.html?src=ISMR_HP_LO_MST_FB
She is not the only one who feels this way. Isn't personal freedom an American value most of us cannot imagine living without? Why is choosing to smoke any different? (Playing devils advocate here...) Check out the article below, it's about the FDA's new plan to "re-energize the nation’s antismoking efforts". It's a little graphic, but hopefully helpful. It will be interesting to see what kind of backlash this new regulation gets.
http://www.nytimes.com/2010/11/11/health/policy/11tobacco.html?src=ISMR_HP_LO_MST_FB
Public Health Wax Poetics
As most of you may know, the American Public Health Association Annual Meeting ended today in Denver, Colorado. This year's theme was "Social Justice: A Public Health Imperative" and kicked off with inspiring speeches by Drs. Cornel West (Princeton University) and Bill Jenkins (University of North Carolina). If you need to take a break from working on the take-home midterm (ha!) and to remind yourself why we're so disillusioned yet driven to confront health inequities inside and outside of the delivery system, then take a listen:
http://www.youtube.com/aphadc
http://www.youtube.com/aphadc
Monday, November 8, 2010
Higher Premiums and Co-Pays for Employer Sponsored Health Insurance in 2011
A recent Washington Post article discussed the expected rise of health care costs for employers to increase to 9 to 12% for 2011. Employers plan to combat this by utilizing cost-saving methods to bring the increase down to 6%. Methods employers are considering include health management or wellness programs, increasing employee share of premiums, providing plans with less benefits, and selecting plans with higher co-payments and/or coinsurance.
LINK
The article provides a good example of how the rising health care expenditures, coupled with the economy and some health reform provisions, is having a significant impact on employer sponsored health insurance. If cost-shifting from employer to employee continues to increase, at some point, the United States' basis of coverage from employment might need to be revisited. Employers might not want to be responsible for providing coverage if it means they are going to be bankrupt. This makes me wonder about what subsidy amount for small businesses to provide coverage will be sufficient to incentivize them to continue doing so? What penalty amount on big businesses will be enough to motivate them to provide coverage?
LINK
The article provides a good example of how the rising health care expenditures, coupled with the economy and some health reform provisions, is having a significant impact on employer sponsored health insurance. If cost-shifting from employer to employee continues to increase, at some point, the United States' basis of coverage from employment might need to be revisited. Employers might not want to be responsible for providing coverage if it means they are going to be bankrupt. This makes me wonder about what subsidy amount for small businesses to provide coverage will be sufficient to incentivize them to continue doing so? What penalty amount on big businesses will be enough to motivate them to provide coverage?
Sunday, November 7, 2010
Health Reform and the House
http://www.nytimes.com/2010/11/07/health/policy/07health.html?hp
Interesting article in the New York Times this weekend about how the Republican leadership in the House plans to target Health Reform. They talk about limiting funding to the IRS, blocking insurance regulations, etc. As House Republican whip Eric Cantor says: “If all of Obamacare cannot be immediately repealed, then it is my intention to begin repealing it piece by piece, blocking funding for its implementation and blocking the issuance of the regulations necessary to implement it.”
Interesting article in the New York Times this weekend about how the Republican leadership in the House plans to target Health Reform. They talk about limiting funding to the IRS, blocking insurance regulations, etc. As House Republican whip Eric Cantor says: “If all of Obamacare cannot be immediately repealed, then it is my intention to begin repealing it piece by piece, blocking funding for its implementation and blocking the issuance of the regulations necessary to implement it.”
Thursday, October 28, 2010
CHCF New Resources on Insurace Exchanges
More details from the California Healthcare Foundation on California's Insurance Exchanges, just in time for Sandra Shewry's talk:
www.chcf.org/events/2010/briefing-california-health-benefit-exchange
Wednesday, October 27, 2010
Mr. Smith Goes to Washington and Political "Corruption"
So I just watched this old movie called, Mr. Smith Goes to Washington and it made me think about our class. For those who haven't seen it, it is about a young, inexperienced, idealistic boy scout leader (Mr. Smith) who the "political machine" appoints as a Senator because they think he will be a push over and support their bill to create a dam. Totally infatuated with the American political system, Mr. Smith decides to write his own bill that uses that same land for a boy's camp. He is then confronted with the behind-the-scenes deals and special-interest power that is prevalent in our political system. I won't spoil it for those who haven't seen it yet, but it is a great breakdown of our political system and an interesting way to spend 2 hours.
I have to say that over the years my view of our political system has become very much aligned with this movie. I have become cynical about the political process and believe that those who are innocent and truly believe in democracy and want to do good are either weeded out by the campaign and election process or used by the more politically savy politicians. We talked a little about back-room trades and "corruption" in Ann's class and I wanted to continue that discussion here with anyone who is interested.
It may be the idealist in me, but I believe that politicians are there to do what is best for the largest number of their constituents, not just those with the most amount of money or power. Thus, I believe that interest groups giving money to politicians with the implication that they will gain "access" to them later for a pivotal vote is Corruption with a capitol C.
I have to say that over the years my view of our political system has become very much aligned with this movie. I have become cynical about the political process and believe that those who are innocent and truly believe in democracy and want to do good are either weeded out by the campaign and election process or used by the more politically savy politicians. We talked a little about back-room trades and "corruption" in Ann's class and I wanted to continue that discussion here with anyone who is interested.
It may be the idealist in me, but I believe that politicians are there to do what is best for the largest number of their constituents, not just those with the most amount of money or power. Thus, I believe that interest groups giving money to politicians with the implication that they will gain "access" to them later for a pivotal vote is Corruption with a capitol C.
Tuesday, October 26, 2010
Health Care Reform Cartoon
Although we may know what health reform is, most people in the country still do not understand. The Kaiser Family Foundation made a cartoon in order to explain it..... definitely worth passing along.
http://healthreform.kff.org/the-animation.aspx
http://healthreform.kff.org/the-animation.aspx
Monday, October 25, 2010
The FDA is stepping up their regulatory game
In late September the FDA (and drug regulators in Europe) decided to essentially take Avandia off the market (completely in Europe and severely restricting it in the US). The FDA also used the occasion to announce a requirement for drug companies to conduct longer trials (2 years) to show that their diabetes drugs don’t have adverse heart effects. And now they’re doing the same thing with another diabetes drug, Bydureon, which the FDA just declined to approve. According to the manufacturers, the FDA wants them to conduct additional 2-year studies, specifically looking for adverse cardiac effects. (http://prescriptions.blogs.nytimes.com/2010/10/19/f-d-a-rejects-new-diabetes-drug/?ref=health).
The New York Times has been tracking the FDA’s recent trend toward increased regulation. This recent article looks at bisphosphonates (as well as Avandia) and brings up the larger issue of how to regulate drugs used to treat chronic diseases:
http://www.nytimes.com/2010/10/17/health/policy/17drug.html?hpw
The long-term, chronic use strikes me as an interesting dilemma, because our normal studies (pre drug approval) can only span a limited amount of time. Recently, the FDA has been prompted to act on Avandia and other drugs by the findings of academic researchers. But the FDA shouldn’t rely only on academics to do these studies. And, it’s generally harder to restrict drugs after they are already on the market anyway (although the FDA is willing to do so in some cases). Now that the FDA has the power to require studies after they have approved drugs, should they use this a primary regulation tool? Or should they require longer studies before approval? A combination?
The New York Times has been tracking the FDA’s recent trend toward increased regulation. This recent article looks at bisphosphonates (as well as Avandia) and brings up the larger issue of how to regulate drugs used to treat chronic diseases:
http://www.nytimes.com/2010/10/17/health/policy/17drug.html?hpw
The long-term, chronic use strikes me as an interesting dilemma, because our normal studies (pre drug approval) can only span a limited amount of time. Recently, the FDA has been prompted to act on Avandia and other drugs by the findings of academic researchers. But the FDA shouldn’t rely only on academics to do these studies. And, it’s generally harder to restrict drugs after they are already on the market anyway (although the FDA is willing to do so in some cases). Now that the FDA has the power to require studies after they have approved drugs, should they use this a primary regulation tool? Or should they require longer studies before approval? A combination?
Sunday, October 24, 2010
Health Reform and the Campaign
Here is an interesting editorial from the NYTimes that is explaining how various Health Reform topics are being completely misconstrued to the public during political recent campaigns: http://www.nytimes.com/2010/10/24/opinion/24sun1.html?_r=1&hp
The author highlights Medicare & Medicaid scare tactics, the source of premium increases, and the selling of health reform as government takeover. The author discusses how Republicans are misinforming the public about the truths of reform, and how democrats are failing to set the record straight. This seems like hardly a new tactic for the Republicans, so why have the democrats not been able to respond to these scare tactics?
Friday, October 22, 2010
Sleep-Deprivation Amongst Resident Physicians
Just read an interesting article in this week's edition of the New England Journal of Medicine "The ACGME's Final Duty-Hour Standards--Special PGY-1 Limits and Strategic Napping" by J Iglehart. This article brings up an issue that I believe affects quality of patient care and the mental health of physicians in the United States: severe sleep-deprivation while on duty. I don't know if you are all aware, but since 2003 physician residents are now only "allowed" to work 80-hours a week. I say "allowed" because resident physicians literally resided in hospitals in the past when they typically worked 120-hours a week. I don't even know how past physicians completed their training because working 80-hours a week (averaged over 4 weeks) year-after-year is difficult, stressfull, and definitely affects one's mental and physical health. Usually residents are on call every four nights. While call duties vary per specialty, as a surgery resident I was typically on call for 24 to 30 hours at a time. During that time period, I was operating, completing invasive bed-side procedures, seeing consults, and managing patients in the ICU or wards. I was so busy that I was grateful to even get an hour of uninterrupted sleep per call.
Research has shown that sleep-deprived and over-worked resident physicians are at an increased risk of being involved in motor vehicle accidents, getting more needle-stick/laceration injuries, developing depression, and giving birth to growth-retarded or premature babies. From my experience in residency, I can think of several post-call residents getting in minor car accidents on their way home and have, myself, struggled to stay awake at the wheel post-call.
This NEJM article describes slightly revised duty-hour standards released by the Accreditation Council for Graduate Medical Education (ACGME) last month. If residency programs do not adhere to these standards, then they are at risk of losing accreditation (which has temporarily happened to some big name programs) and losing Medicare suppport of $100,000 per resident. While reading this article I was expecting some major revision to the duty hour standards. However, the only revision I found was that now interns (PGY-1 residents) cannot exceed 16 hours per call shift without. More senior residents are allowed to be on call for 24 hours, plus an additional 4 hours for handing off patients or completing care (this really translates into maximum of 28 hour calls). Not suprisingly, the American College of Surgeons "expressed 'very grave concerns' regarding the PGY-1 limits, predicting 'a negative impact on patient safety and continuity of care unless there is a substantial increase in human resources to replace the residents.'" I also predict that by allowing only interns to go home early while on call, the more senior residents are going to be even more over-worked trying to cover for them. Several advocacy groups, including Public Citizen, have been try to petition OSHA to take over duty hour regulation and to limit continuous call duties to 16-hours for all residents.
Research has shown that sleep-deprived and over-worked resident physicians are at an increased risk of being involved in motor vehicle accidents, getting more needle-stick/laceration injuries, developing depression, and giving birth to growth-retarded or premature babies. From my experience in residency, I can think of several post-call residents getting in minor car accidents on their way home and have, myself, struggled to stay awake at the wheel post-call.
This NEJM article describes slightly revised duty-hour standards released by the Accreditation Council for Graduate Medical Education (ACGME) last month. If residency programs do not adhere to these standards, then they are at risk of losing accreditation (which has temporarily happened to some big name programs) and losing Medicare suppport of $100,000 per resident. While reading this article I was expecting some major revision to the duty hour standards. However, the only revision I found was that now interns (PGY-1 residents) cannot exceed 16 hours per call shift without. More senior residents are allowed to be on call for 24 hours, plus an additional 4 hours for handing off patients or completing care (this really translates into maximum of 28 hour calls). Not suprisingly, the American College of Surgeons "expressed 'very grave concerns' regarding the PGY-1 limits, predicting 'a negative impact on patient safety and continuity of care unless there is a substantial increase in human resources to replace the residents.'" I also predict that by allowing only interns to go home early while on call, the more senior residents are going to be even more over-worked trying to cover for them. Several advocacy groups, including Public Citizen, have been try to petition OSHA to take over duty hour regulation and to limit continuous call duties to 16-hours for all residents.
Sunday, October 17, 2010
High Cost of Hospitalization Rates of LTC Medicare Beneficiaries
A new Kaiser Family Foundation report provided insight into another method for reducing Medicare costs – reducing hospitalization among patients in nursing homes and other long-term care (LTC) facilities. The report estimated that a 15% reduction in hospitalization rates in Medicare LTC beneficiaries could potentially save Medicare $1.3 billion dollars in 2010. It is estimated that hospitalization rates for long-term care facility residents can be reduced by 30-67% since a lot of the hospitalizations are preventable if the appropriate interventions are given.
I think this is a wonderful potential source for reducing public health care expenditures. However, I wonder what methods CMS can use to attack the high hospitalization rate in this patient population besides not paying for “never events” and “preventable readmissions.” Can Medicare coordinate with Medicaid to restructure LTC payments to provide incentives for facilities to provide better care and reduce hospitalization rates for their residents? What are your thoughts on how to reduce this area of wasteful Medicare spending?
Wednesday, October 13, 2010
$200 million in Medi-Cal Cuts: Follow up from Today's Class
I came across this article briefly outlining where the cuts will be made to the Medi-Cal program by the Governor's line item veto. It looks like they will come from:
- Rate freeze on fee-for-service hospital payments ($84 million)
- Shifting mental health services for students from the counties to the school districts ($133 million)
- Cuts to community clinics, although the specific cuts are unclear
If I come across more detail I will post it, but it seems there will be efforts to challenge the veto. Here is the post from the California Healthline: http://www.californiahealthline.org/articles/2010/10/13/health-cuts-in-budget-package-could-face-legal-challenges.aspx
- Rate freeze on fee-for-service hospital payments ($84 million)
- Shifting mental health services for students from the counties to the school districts ($133 million)
- Cuts to community clinics, although the specific cuts are unclear
If I come across more detail I will post it, but it seems there will be efforts to challenge the veto. Here is the post from the California Healthline: http://www.californiahealthline.org/articles/2010/10/13/health-cuts-in-budget-package-could-face-legal-challenges.aspx
Tuesday, October 12, 2010
There's a lot to bend...
In preparation for Friday's talk on Cost-Sharing, and in response to constant conversation re: "bending the cost curve," I thought this graphic was interesting, because it shows our US cost curve as compared to the 31 other OECD countries. Technically, it shows total health spending as a percentage of GDP - but still, the way the US curve stands out from the pack is striking.
http://theincidentaleconomist.com/wordpress/why-its-time-to-panic/
Monday, October 11, 2010
Accountable care organizations friend or foe?
ACOs seem to be the next great hopeful for health care cost containment, but I have yet to read anything very optimistic about them. Writing them into Healthcare reform without actually defining them seems to be leaving a great deal of opportunity for the entire sector to spin it's wheels on ways to cope with it.
Sunday, October 10, 2010
Medical Student Distress and the Risk of Doctor Suicide
http://www.nytimes.com/2010/10/07/health/views/07chen.html
I saw this thought-provoking piece in the New York Times last week and wanted to share it with you. It sheds light on the high rate of suicide and unaddressed mental illness among the U.S. physician community, a truly under-examined problem within our hospitals and medical schools. The article noted that physicians have a far higher suicide rate than their peers (40 percent for men and a jaw-dropping 130 percent for women), an unhappy commonality that physicians share with other health care workers such as dentists and psychiatrists. Apart from the expected workplace stressors that we might assume would contribute to the problem, social pressures and worries about career advancement seem to provide powerful disincentives for seeking treatment and may drive doctors to cope with mental illness through substance abuse and other "dysfunctional behaviors."
Disproportionate rates of untreated mental illness among the physician community reaches far beyond their social circles. They present serious implications for quality and efficiency of patient care, and establish an unhealthy precedent for future physicians to follow. As future managers, policymakers and administrators within the healthcare system, we will likely inherit the challenge of dealing with a physician culture that discourages healthy coping mechanisms for its most vulnerable members. How can we develop policies and intra-hospital programs that foster a more treatment-friendly mentality that can cope with the frequent--and inevitable--workplace stressors facing the physician community?
I saw this thought-provoking piece in the New York Times last week and wanted to share it with you. It sheds light on the high rate of suicide and unaddressed mental illness among the U.S. physician community, a truly under-examined problem within our hospitals and medical schools. The article noted that physicians have a far higher suicide rate than their peers (40 percent for men and a jaw-dropping 130 percent for women), an unhappy commonality that physicians share with other health care workers such as dentists and psychiatrists. Apart from the expected workplace stressors that we might assume would contribute to the problem, social pressures and worries about career advancement seem to provide powerful disincentives for seeking treatment and may drive doctors to cope with mental illness through substance abuse and other "dysfunctional behaviors."
Disproportionate rates of untreated mental illness among the physician community reaches far beyond their social circles. They present serious implications for quality and efficiency of patient care, and establish an unhealthy precedent for future physicians to follow. As future managers, policymakers and administrators within the healthcare system, we will likely inherit the challenge of dealing with a physician culture that discourages healthy coping mechanisms for its most vulnerable members. How can we develop policies and intra-hospital programs that foster a more treatment-friendly mentality that can cope with the frequent--and inevitable--workplace stressors facing the physician community?
Thursday, October 7, 2010
Food Stamps and Obesity
For the policy-oriented people, something to ponder other than health care reform.
No Food Stamps for Soda - NYT (This article was circulated by GSPP's econ professor Steve Raphael)
New York City and State asked the USDA to prohibit food stamps from being used to buy sodas and other sugary drinks because they have low nutritional value and contribute to a growing obesity problem in New York.
This made me think about the conversations we've had in class addressing conservative attacks on "obamacare" and the government being "too paternalistic." There was also an article in SF Chronicle a couple weeks ago about a resolution they were considering that would limit the giving away of toys with foods that are unhealthy (i.e. happy meals from McDonalds). I'm all for encouraging people to make healthy choices, but is this the way?
We learn from economics that our choices are heavily influenced by our budget constraints, but how, or even should, our food consumption choices also be constrained by public policy? Is it OK to limit the choices of the poor (on food stamps) and not okay to limit the choices of the rich (because they make their choices with their own money)?
Where do we draw the bright line? Or, should we?
No Food Stamps for Soda - NYT (This article was circulated by GSPP's econ professor Steve Raphael)
New York City and State asked the USDA to prohibit food stamps from being used to buy sodas and other sugary drinks because they have low nutritional value and contribute to a growing obesity problem in New York.
This made me think about the conversations we've had in class addressing conservative attacks on "obamacare" and the government being "too paternalistic." There was also an article in SF Chronicle a couple weeks ago about a resolution they were considering that would limit the giving away of toys with foods that are unhealthy (i.e. happy meals from McDonalds). I'm all for encouraging people to make healthy choices, but is this the way?
We learn from economics that our choices are heavily influenced by our budget constraints, but how, or even should, our food consumption choices also be constrained by public policy? Is it OK to limit the choices of the poor (on food stamps) and not okay to limit the choices of the rich (because they make their choices with their own money)?
Where do we draw the bright line? Or, should we?
Tuesday, October 5, 2010
Healthcare's Lost Weekend - NYTimes
Healthcare's Lost Weekend - NYTimes 10/3/2010
This article addresses two areas in which NYC hospitals are attempting to improve quality and reduce cost: (1) More services on the weekends, (2) Quality assessments.
The article highlights that making physicians work weekends is both a necessity and a convenience, because it will improve quality and reduce cost, while also giving people the ability to see a physician more easily on the weekends. Also highlighted is the use of quality assessment and management to allow health providers to be more efficient and therefore reduce costs.
This article brings to mind a few questions:
In regards to expanding the physician's role to the weekend...
1. What types of physicians would this impact the most? Are we talking only emergency physicians available, or extending primary care services to the weekends? If so, is there enough physicians to meet these needs?
2. Does expanding the hours of healthcare provider add additional administrative costs that will then outweigh the cost savings?
3. Is this model encouraging more overall use of healthcare?
Thoughts????
Sunday, October 3, 2010
California 1115 Waiver Expected to Receive Federal Approval Shortly
The Medi-Cal program will likely face implementation of significant policy changes within the next year in addition to planning for expanding coverage with healthcare reform. The passage of the California 1115 Waiver will likely shift many Medi-Cal beneficiaries currently enrolled in fee-for-service Medi-Cal to managed care plans in 14 counties. Designed mainly as a cost-saving mechanism for the state, the waiver also attempts to improve coordination of care for seniors and people with disabilities, children with special health needs and Medicare and Medi-Cal dual eligibles.
The full implementation plan can be reviewed at: http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/Waiver_ImpPlan_5-2010.pdf
The California Healthcare Foundation is also monitoring the waiver passage and published a recent update: http://www.californiahealthline.org/capitol-desk/2010/9/final-days-looming-for-waiver-approval.aspx.
The full implementation plan can be reviewed at: http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/Waiver_ImpPlan_5-2010.pdf
The California Healthcare Foundation is also monitoring the waiver passage and published a recent update: http://www.californiahealthline.org/capitol-desk/2010/9/final-days-looming-for-waiver-approval.aspx.
Thursday, September 30, 2010
California in the lead
Governor Schwarzenegger signed several bills that aim to implement and improve upon health reform here in California, including key bills AB 1602 and SB 900 that were signed today. Both of these bills will create the health insurance exchange in California, and we are the first state in the nation to enact such legislation.
I thought I would share this press release with those of you who, like myself, appreciate those "short-term wins" every now and then.
Gov. Schwarzenegger Signs Legislation Making California the National Leader on Health Care Reform
I thought I would share this press release with those of you who, like myself, appreciate those "short-term wins" every now and then.
Gov. Schwarzenegger Signs Legislation Making California the National Leader on Health Care Reform
Saturday, September 25, 2010
Urgent Care and Retail Clinics as Alternatives to ER
A recent RAND study found that many emergency visits could be handled through retail clinics or urgent care centers. The article claims that this could reduce US health care spending by over $4 billion a year.
This redirection of most acute issues to retail clinics and urgent care centers seems like an appropriate and great recommendation considering the lack of PCPs, timely access to care issues, and high inappropriate use of ER for non-emergency care. However, I wonder about the quality of care patients will receive at retail clinics. Does anyone know if there are current guidelines for these clinics and if not, will or should there be guidelines? Also, I think it is important to discuss the implications for lack of coordination of care that might arise if consumers become reliant on retail clinics and urgent care centers.
Business Week Article: http://www.businessweek.com/lifestyle/content/healthday/642813.html
Original Article: http://content.healthaffairs.org/cgi/reprint/29/9/1630
Friday, September 24, 2010
Medicare Advantage Premiums to Fall in 2011
Whoa, total surprise.
(Everyone seems to like the NY Times today... )
http://www.nytimes.com/2010/09/22/health/policy/22medicare.html?_r=2&emc=tnt&tntemail1=y
What do you think best explains this? Curious about your thoughts.
Did the Federal government really just do a great job negotiating?
Do insurers think that with more people enrolling in plans, overall costs will lower due to increased risk-spreading?
Did plans that that don't want to comply with the increased benefits drop out, leaving cheaper plans in the market?
. . .
Thursday, September 23, 2010
Health Care Reform "Report Card" - Six Months Later
Hi All,
I came across this "progress card" for the provisions of health care reform. A quick read, nice graphics, but the grades seem a little optimistic to me.
http://www.nytimes.com/interactive/2010/09/23/opinion/20100923_opart.html?hp
Happy 6 months HCR!
-Dionne
I came across this "progress card" for the provisions of health care reform. A quick read, nice graphics, but the grades seem a little optimistic to me.
http://www.nytimes.com/interactive/2010/09/23/opinion/20100923_opart.html?hp
Happy 6 months HCR!
-Dionne
Poverty, Addiction, and Prescription Drugs
Did anyone see this article in the New York Times?
"Officers See More Sick and Elderly Selling Prescription Drugs"
http://www.nytimes.com/2010/09/19/us/19bcdealers.html?ref=sanfranciscobayarea
We touched in class on the incredible benefits that closing the Medicare doughnut hole will have for elderly beneficiaries who previously couldn't afford their prescription drugs. But as with any good thing, there are bound to be a couple of downsides - such as possibly increasing access to drugs for resale.
In my mind, this points to the intersection between pharmaceutical coverage and nationwide illegal drug policy issues, something I haven't yet heard many health policy folks talking about. (Except for those awful commercials telling parents their kids might be getting high from the medicine cabinet...) The other intersection is of course with the impact of the recession on older adults, although the article makes it seem that addiction is as much of the story as poverty. Thoughts?
"Officers See More Sick and Elderly Selling Prescription Drugs"
http://www.nytimes.com/2010/09/19/us/19bcdealers.html?ref=sanfranciscobayarea
We touched in class on the incredible benefits that closing the Medicare doughnut hole will have for elderly beneficiaries who previously couldn't afford their prescription drugs. But as with any good thing, there are bound to be a couple of downsides - such as possibly increasing access to drugs for resale.
In my mind, this points to the intersection between pharmaceutical coverage and nationwide illegal drug policy issues, something I haven't yet heard many health policy folks talking about. (Except for those awful commercials telling parents their kids might be getting high from the medicine cabinet...) The other intersection is of course with the impact of the recession on older adults, although the article makes it seem that addiction is as much of the story as poverty. Thoughts?
Tuesday, September 21, 2010
Welcome to Fall 2010 HPM Blog
Hi everyone - welcome to the Foundations of HPM class blog. You are welcome to review the past two years of posts (last one was early Dec 2009) and begin your own posting. Feel free to cite articles of interest, continue discussions from this class or others, ask questions, comment on each other's posts, etc
To kick it all off, as a follow up to last week's class, here is article from today's NYT (9/21/10) on what Republicans are likely to do to reform law if they get the opportunity http://www.nytimes.com/2010/09/21/health/policy/21repeal.html?_r=1&hpw
Kim
To kick it all off, as a follow up to last week's class, here is article from today's NYT (9/21/10) on what Republicans are likely to do to reform law if they get the opportunity http://www.nytimes.com/2010/09/21/health/policy/21repeal.html?_r=1&hpw
Kim
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