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

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.

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

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?

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?

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.

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?

The report can be found here.

$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

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/

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.

http://www.kaiserhealthnews.org/Stories/2010/October/11/health-care-interests-ACOS.aspx

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?

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?

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????

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.