Widening gap between brand and generic

The gap between brand and generic drug prices is widening, according to this New York Times piece published this week.
It says that generic prices fell 22 percent in the past year while brand-name drug prices rose 13 percent. The rise in brand prices is due to the host of expensive new specialty drugs coming on the market, for example, many of the recent releases are drugs used to treat advanced cancer when other drugs don't work.
It echoes the debate we discussed in class, between PhRMA defending the need to support drug innovation and advance new treatments, and the pushback about whether the potentially marginal benefits are worth the high costs.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, is quoted saying that drug benefit managers are going to have a tough time deciding how and whether to cover many of these drugs:“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Medicaid expansion in Texas

It's interesting to contrast liberal and conservative media's discussion of Medicaid expansion.

1. The Atlantic, arguing that Texas should expand Medicaid. 

"Maybe governors like Perry don't believe in higher spending or a bigger social safety net. But surely they believe on getting a good deal on insuring a large number of their residents, rather than a bad deal on insuring just a few of them. Failing that, they have to believe in retrieving as much of their citizens' tax dollars as they can. Really, that's just fiscal conservatism."

2. The Texas Public Policy Foundation published an article a few days ago (and another today) defending Texas' decision to reject Medicaid expansion. 

Their argument is based off of:

-fear of post 2020 costs, fueled by doubt that the government will, as promised, fund 90% of these costs

-worry about what effect changing the system would have on existing Medicaid recipients in their state. 

They don't, however, suggest alternatives for what they see as "our nation’s worst health care program," and  don't discuss their state's poor performance among most measures of health outcome.

Are their other conservative media think tanks engaging in discussions about the benefits and drawbacks of expansion, or proposing alternate solutions within the parameters of the ACA? 

ACA Infographics

Hello,

Check out this infographic that helps explain the ACA to Americans.  Keith and I helped work on it for a Health Information class at the School of Information. http://imgur.com/lPFHQ

Profiles Of The Robert Wood Johnson Foundation's Young Leader Awardees

• http://www.healthaffairs.org/young_leaders.php
• 
  
• "Each winner has made an exceptional contribution to improving the health of the nation. Their accomplishments range from building a network of urban community gardens to addressing disparities in treating chronic kidney diseases." 

It's inspiring to see how young leaders are improving the health of communities nationwide through using leadership, innovation, creativity, and strategic tools. 

HHS releases Health Insurance rules

This Article I found on the Forbes website discusses that the recent release of the HHS regulations for Health Reform. It focuses on the rule that will not allow health insurers to make consumers pay a surcharge or be excluded for pre-existing conditions. The author suggests that this ban will make premiums increase for everyone. The author further speculates that people will opt to pay the penalties as opposed to paying high monthly premiums.

Frivolous ACA Lawsuits?

As some of you may know, despite the SCOTUS upholding the ACA, there are still legal challenges being fought. Chief among them, at least in terms of newsworthiness, is Liberty University's claim that the ACA violates First Amendment rights in requiring employers to provide health insurance for employees where that insurance covers contraception. Their argument is essentially that the requirement violates their religious freedoms--contraception being against the religious beliefs of the Christian evangelical school's doctrine.

A quick primer on First Amendment and religion: there are 2 primary 'rights' under the First Amendment related to religion. The first is the Establishment Clause, which essentially enforces the concept that church and state should be separate--another way of saying this is that the Federal government cannot favor one religious institution over another. The second is the Free Exercise of Religion clause which protects the beliefs of individuals from encroachment by the government (which is why, for example, we have laws protecting the right of refusal of treatment in favor of prayer).

So how exactly would the ACA be violating one or both of these rights? I am curious as to their Establishment Clause argument, as the law makes no mention of any religion, let alone favoring one over another. This leaves the Free Exercise clause.

A classic First Amendment case on point is the practically stone-age Reynolds vs. United States (1878) which held that laws banning polygamy did not violate the free exercise clause. The Court drew a clear distinction between beliefs and practices, saying that laws could not touch beliefs, but could regulate practices which may be extreme (i.e. polygamy, human sacrifice, etc.). The practice here, would be the failure to provide health insurance in furtherance of religious beliefs (guarding against sinful contraception).

Without going into the whole mess, I believe very strongly that Liberty University will lose this lawsuit. Among other reasons, the ACA does not require Liberty University to directly provide contraceptive services. It requires Liberty University to provide health insurance, a requirement which has been upheld by SCOTUS. The fact that health plans are required to provide contraceptive services is irrelevant. Liberty University's lawsuit is a poorly-veiled dig at the Obama Administration and, I believe, verges on the edge of frivolity.

A little humor

Pearls Before Swine is one of my favorite comic strips.  I think today's strip is just to make us smile as we go into crunch week(s)!!

Liverpool Care Pathway

End of life care, while one of the most important questions for anyone facing a terminal illness has turned into a dirty political issue in US. This article talks about an approach taken in the UK known as the Liverpool Pathway. While this type of end of life care may or may not be feasible in the US, I think the Liverpool Pathway can frame the discussion we currently have about end of life in a different manner. Instead of focusing on cost-benefit analysis that drive a majority of policies in U.S. perhaps end of life care should be driven by a different philosophy. The philosophy that patients deserve a kinder death than is currently afforded to them by our medical system, cost shouldn’t matter and we should resist the temptation of pushing palliative care based on a cost benefit analysis. http://www.guardian.co.uk/society/2012/nov/13/importance-open-end-to-life

Dr. Berwick's Pink Slip

This is an old NYTimes op-ed, but it does a good job of summing up what Republican's lost when they refused to confirm Don Berwick as head of the Centers for Medicare and Medicaid Services last year.

Namely: the country lost someone who dared to think of the agency as an improvement organization, and a powerful force for healthcare improvement. In 17 months, he trained executive agency staffers as "improvement coaches" and made strides toward helping health insurers and hospitals find simple ways to improve things like preventing hospital readmissions for chronic conditions.

Imagine what he could do with four more years... Is anyone pushing for this? (Shouldn't we be?)

Dr. Berwick's Pink Slip

Parkinson's Voice Initiative

In the context of our "value" discussions, thought I'd post something about an interesting project I recently heard about, called the Parkinson's Voice Initiative.

Researchers are trying to fine-tune their ability to diagnose Parkinson's over the phone through a 30-second voice test. This method would be much faster, easier and cost-effective than how people are currently screened for Parkinson's, a neurological test performed at a clinic or doctor's office. They're hoping that this will lead to more screenings, earlier diagnosis, and better monitoring for those who already have the disorder.

The initiative aims to collect 10,000 voices (with or without Parkinson's) from around the globe, so if anyone wants to participate, the number's on their website. You'll hear a lovely British lady asking you questions and prompting you to sit up straight and say your vowels.

Here's a Ted Talk about the effort for more details.

Republican concerns about health exchanges

Since the beginning of this course, I have been trying to learn how the Republicans can be so against the insurance exchanges mandated by the PPACA when the original idea was, in fact, a Republican idea.  This week, Forbes magazine has a column written by Avik Roy, who was also a healthcare policy advisor for the Romney campaign, outlining his (Roy's) primary concerns with the exchanges.  As it turns out, his complaint is not with the exchanges themselves but with the mandated minimum requirements for the plans included on the exchanges, and to some extent the requirement for community rating.

I don't necessarily agree with his ideas, but it's refreshing to actually know which ideas I'm not agreeing with!!  I wish he had put forward this coherent of an argument during election season; I would have understood Romney's position better.

Here's the link:
http://www.forbes.com/sites/aroy/2012/11/19/what-states-should-build-instead-of-obamacares-health-insurance-exchanges/

The Impact of Provider Consolidation on Rising Costs

Interesting article on Health Affairs Blog. We have focused on several reasons why health care costs are rising, including technology and changing standards of care, an older and relatively healthier population, and inefficiencies/waste. One thing we almost never talk about is the impact that provider consolidation has on unit price of doctors and hospitals. As insurers and hospitals are continually merging in light of health reform and the impending health exchanges, it will be important to keep an eye on how these consolidations impact rates--particularly for the private insurance market.

Basic Health Plans?

As some of us know, the ACA includes a provision for states to set up a Basic Health Plan (BHP) that would essentially prevent families from churning (the process of losing and gaining coverage) between Medicaid and the exchange, and reduce coverage disruptions. I thought this was an interesting new article that discuss the pros and cons for states thinking about establishing a BHP. The article also notes that California will be considering a bill to establish a BHP in the upcoming special session. It will be interesting to see how the BHP debate in CA will play out, especially since this only now being seriously considered by states on the brink of 2014.

Throughout the ACA conversation, it has been said that little was included to expand the supply of doctors that would meet the needs of the newly insured. This article suggests that the demand for additional doctors is not mainly driven by the ACA, but instead by an aging population:

http://www.washingtonpost.com/blogs/wonkblog/wp/2012/11/16/maybe-obamacare-isnt-driving-the-doctor-shortage/

Here is an article from the Wonk Blog on changes the insurance industry is seeking on ACA implementation: Four ways Blue Cross Blue Shield wants to change Obamacare

Shrinking CA budget

The last week (OK, 8 days) have held plenty of good news, right? Election results, cancelled final exam for PH220, California's budget deficit nearing elimination... Wait, what? Yep, per the Legislative Analyst Office (and covered in plenty of news sources, so you can read the executive summary), it'll be down to $1.9 billion by summer 2013. But the full report (I skipped to the "Health and Human Services" section towards the bottom of the page) relies on several assumptions. Some of these seem predictable--of course CA will adopt the Medicaid expansion--and others not so much.

What do we think of this projection overall? In terms of the HHS section, are these assumptions realistic?

One thought of mine: Below there is a section that mentions reduced costs for other state health programs, including the Family Planning, Access, and Care Treatment Program (FPACT). That's the program that folks are enrolled in when they access family planning services at pretty much any CA safety-net clinic, including Planned Parenthood, La Clinica, Lifelong, and teen clinics, such as those at local high schools. It covers to low-income individuals without health insurance, regardless of documentation status, and also to those who are unable to use their parent, guardian, or spouse's insurance for reasons of confidentiality. Many of the low-income individuals will be able to purchase Medical with subsidies. But this does bring up questions about how safety-net clinics will provide services for those who are ineligible for Medical. Not to mention how they'll continue reassuring notoriously wary teenagers that they can access sexual/reproductive health care safely under a program who's reputation for confidentiality is poor.

• Several Key Assumptions and Remaining Policy Decisions Result in Significant Fiscal Uncertainty. Our fiscal estimates related to ACA implementation are subject to substantial uncertainty and depend heavily on several key assumptions, meaning that actual costs could be several hundreds of millions of dollars higher or lower over this period. In addition, the state is still awaiting additional federal guidance on ACA implementation and several major state–level policy decisions have yet to be made that would be critical to informing a projection of the net fiscal impact of the ACA. Some of the major policy decisions facing the Legislature include:
• Determining whether to adopt the Medicaid expansion and how to fund it.
• Selecting the benefits that would be provided to the expansion population.
• Determining how the state and local governments will fund medical care provided to the remaining medically uninsured population.
• Determining how the existing Medi–Cal eligibility standards and enrollment processes will change in response to the new ACA requirements.
• Evaluating whether to modify existing state health programs that provide services to persons who would become eligible for Medi–Cal, or other federally subsidized health coverage, in 2014.

• Implementation of Federal Health Care Reform. Our spending projections assume that implementation of the ACA will have several significant fiscal effects on the Medi–Cal Program.
  
• Medi–Cal Expansion. As mentioned above, our forecast assumes the state will adopt the Medicaid expansion authorized under the ACA. While this expansion would have a significant impact on the program’s total caseload beginning in 2014, the federal government will pay the large majority of the costs of the expansion during our forecast period. Our forecast projects costs in the low hundreds of millions of dollars in 2016–17 and 2017–18.
• ...
• Reduced Costs for Other State Health Programs. As a result of ACA implementation, we project reduced General Fund spending for some non–Medi–Cal state health programs, such as the Breast and Cervical Cancer Treatment Program and the Family Planning, Access, and Care Treatment Program. These programs currently pay for services for populations that will become newly eligible for Medi–Cal or other subsidized health insurance coverage in 2014. We project about $100 million in reduced General Fund costs in 2013–14, with annual ongoing reductions of about $200 million. There is a significant amount of uncertainty surrounding these estimates as the fiscal effects will largely depend on future policy decisions about the potential modification of these existing programs in response to the ACA coverage expansions.

Junk Food Ads on the School Bus

ChangeLab Solutions just put out an interesting fact sheet about advertising on school buses.  A practice that some desperate school districts are employing to try to raise money.  It is sad that our public schools are in such a position and it is understandable that they would resort to creative ways to get more money, but these ads have potential negative public health impacts.

The link below will take you to a brief fact sheet with more information about the legal issues associated with advertising on school buses.

Also, ChangeLab Solutions is based in Oakland (formally Public Health Law and Policy) and does some interesting work.  BARHII (Bay Area Regional Health Inequities Initiative) which I co-chair, has collaborated with them on some projects.  Might be a good internship possibility for someone.

http://changelabsolutions.org/publications/school-buses-ads

On Monday, the American Medical Association’s House of Delegates voted to approve a resolution in support of the Prevention and Public Health Fund.  The resolution calls for the AMA to “oppose policies that aim to cut, divert, or use as an offset, dollars from the Prevention and Public Health Fund for purposes other than those stipulated in the Affordable care Act of 2010.”  Support for protecting these funds from a group as powerful as the AMA is good news for Public Health.

A little expansion support in Alabama

I thought this was a refreshing local op-ed piece coming out in favor of Alabama expanding their Medicaid program. I've noticed that much of the rhetoric coming out of states opposed to the expansion have seldom mentioned the basic fact that expanding health coverage is in the interest of the state both from a societal standpoint as well as an economic one. Hopefully more states can do analysis, like this one out of Texas, that actually shows what states have to gain or lose through expansion. Hopefully all is not lost!

Rise of Social Entrepreneur

Good morning All! I thought this was a neat op-ed piece that discussing the increasing number of social entrepreneurs. It somewhat ties into the new innovations that are leading to change and how private industry is getting involved with "social problems." Alecia

Social behavioral sciences used to move votes... could it work for healthcare?

This was an interesting article on the use of behavioral social science research by the Obama re-election team -- not just in generally applying concepts, but in consulting with top experts in the field. Couldn't help but think that this approach could have positive results on a national and state level if it were incorporated in increasing support for health care improvement efforts.

http://www.nytimes.com/2012/11/13/health/dream-team-of-behavioral-scientists-advised-obama-campaign.html?ref=health

No more wait-and-see on health reform

With election uncertainty behind us, it looks like the U.S. Department of Health and Human Services is getting down to business on health reform implementation.

By this Friday, we'll know which states will opt to set up their own health insurance exchanges for 2014. That's the deadline for states to notify HHS of their intent, although the department has extended the deadline for states to submit their blueprints until Dec. 14. Politico reported last week that 13 states and Washington, D.C., have told HHS they'll run their own exchange, and at least five Republican governors say they won't (including Texas, Louisiana, Florida).

HHS has also started issuing more regulations on health reform. This also from Politico:

We all saw this one coming, now that the election’s over and the Affordable Care Act lives. HHS is starting to send regulations out the door like they’re going out of style. The department on Friday sent three more ACA documents to OMB for review: a proposed rule on wellness programs, a request for information on the law’s health care quality provisions and a “notice” on the enhanced FMAP for 2014. The document delivery came a day after HHS also sent over proposed rules on health insurance market reforms and another on exchanges covering essential health benefits and actuarial value, quality and accreditation.

Less Experience Physicians Have Higher Cost Profile

I just came across this article in Health Affairs that discusses the level of experience of physician and their cost profile. They found that less experienced physicians had a higher cost profile. They speculate that the difference may be due to newer physicians using newer and more costly treatments, have a panel of patients with more complex health conditions,and/or lack of experience.

role of the courts

For those of us in Health Policy and Decision Making, I was intrigued to see the food policy writer Mark Bittman blatantly acknowledge the power of the courts to set policy in this article.  About halfway through this piece which plays off of the defeat of the GMO-labeling proposition here in California, he suggests that sugar is the tobacco of the 21st century but until somebody successfully sues for getting type II diabetes from it, policy initiatives will languish.  Maybe I was more intrigued to recognize that I now understand a whole background to a sentence in an article that wouldn't have meant much to me a couple of months ago.

Here it is:  http://opinionator.blogs.nytimes.com/2012/11/10/the-food-movement-takes-a-beating/

The link below is to a really good comprehensive analysis of the impacts of the 2012 election. Amazing that something like this could come out so quickly after the election. There is a concise and easy to read section on the impacts on "Health" that starts on page 44.

Enjoy!

http://www.cgagroup.com/news/2012ElectionAnalysis.pdf

It's not over yet...

In the midst of my avid (and borderline irritating to those around me) use of the internet to get minute-by-minute updates of election results on Tuesday, I noticed that several states were voting on state-level measures that directly contradict the PPACA.  In Alabama, Montana, and Wyoming, the measures passed, and in Florida it narrowly failed (which I'm guessing coincides with the narrow win for Obama).  Here's the wording of a brief description of each bill as described by politico.com:

• Alabama: Would prohibit any person or employer from being forced to participate in any health care system
• Florida: Would create an amendment to the state constitution to prohibit laws from requiring a person or employer to purchase health care coverage. (FAILED)
• Montana: Would prohibit state and federal governments from requiring the purchase of health insurance or imposing any penalty for those who do not.
• Wyoming: Would reserve health care decisions of residents, allow them to pay for any health care and give the state legislature authority to regulate health care.

I've been looking for some discussion online about the implications of these measures and haven't been able to find much.  The only hint I am seeing is a quote from Jonathan Turley, a law professor at GW Law School, who says that "these laws may promise more than they can deliver... What the laws certainly do is to give state officials more of a basis to go to court and challenge the national health care law." (CNN election coverage, URL: http://m.cnn.com/primary/cnnd_fullarticle?topic=newsarticle&category=cnnd_latest&articleId=urn:newsml:CNN.com:20121106:ballot-initiatives:1&cookieFlag=COOKIE_SET)

I'm hoping to crowdsource more information from our class - do any of you know more about these measures?  Have you seen any reporting or analysis of their impact?

Hospitals, Urgent Care Clinics, and the Value of Health Care

Interesting story on NPR this morning about the role that pop-up urgent care clinics are playing in our ever-changing field and how these clinics fit into a hospital's bottom line.

Bringing new drugs to market

This article was an interesting read after yesterday's class discussion: on a current effort to get new cholesterol reducing drugs to market. Two drug companies are currently starting a Phase 3 trial of a drug that looks promising for people who don't respond well to or can't take Lipitor, and a handful of other drug makers are working to bring similar drugs to market. Now their use of the words "racing to market" and "still two to three years out" make far more sense!

http://www.nytimes.com/2012/11/06/business/new-drugs-for-lipids-set-off-race.html?hp

Red State Blue State

Interesting podcast about politics, family, and friends.

512 Paths to the White House

The NY Times published a great interactive infographic yesterday showing how each candidate might win based on the outcomes of seven swing states plus North Carolina and Nevada. Obama has more ways to win at the outset, but a lot rests on Florida and Ohio. Check it out: 512 Paths to the White House.

Welfare use in US

I have the elections on my mind, as I'm sure most of you do too.  I am constantly amazed by groups of people who consistently vote against their own best interest and nothing highlights this better than healthcare.  This article came out in the NY Times in February and perhaps everyone has already seen it, but I wanted to post it because the image of this map keeps resurfacing for me.  It's a powerful visual, especially when compared to the red and blue maps we've all been seeing during election season.  It saddens me that some of the people who are in greatest need of government services are those who vote for a president who vows to deeply cut the programs that deliver these services.

Hospitals Sue Obama Administration

A quick little article, but I thought it was interesting that hospitals filed a federal suit against HHS over Medicare payments. Apparently, government auditors decide whether hospitals should have admitted Medicare patients or arranged for their care on an outpatient basis. If an auditor finds that the hospital did not need to admit the Medicare patient, the hospital will need to return the money it received for the patient's care.

I had a difficult time figuring out where I fall on this policy. On one hand, hospitals typically have a financial incentive to admit patients which may result in overutilization when it isn't appropriate. However, the admitting physician should be making a medical judgment based upon the patient's health status at the time they present to the hospital. The medical judgment in this instance can be a gray area and I don't understand how a government auditor can retrospectively quantify if it was an appropriate decision or not. I imagine it might take a while for this lawsuit to play out.

Evacuation insurance?

Caught my eye: a Slate article juxtaposing Republican governor of New Jersey Chris Christie's comments regarding evacuation before the hurricane with his comments around health care reform, with a reference to the "free-rider problem" (*cough* Stone's chapter on Interests *cough*) for good measure. 

"Hurricanes and health care are different in many ways, of course...  But in both cases, the question is whether you should be allowed to make your own choices when the cost of bailing you out will fall on others. If the state has no business forcing you to buy health insurance, even when the premiums are subsidized, why should it be empowered to order you out of your home in a storm, just to save your skin?"

http://www.slate.com/articles/news_and_politics/frame_game/2012/10/hurricane_sandy_why_does_chris_christie_think_it_s_selfish_to_ignore_evacuation.html

After our discussion on Monday about EHR I wanted to post an article I read regarding the implementation of EHR and the effects on medical education. This particular article discusses more of the subjective comments of physicians, but also highlights the lack of programming to focus on how to integrate EHR with medical education. Article

Temporary Medicaid Pay Hike

Interesting article regarding how the temporary pay hike in Medicaid reimbursement rates for primary care doctors may affect access to care. The ACA has a provision which will raise rates for primary care doctors beginning on January 1, paid for by the feds - however, this is a short-term fix and will only be implemented for the next two years. While it is intended to encourage more physicians to accept Medicaid, for which rates are so low that many refuse to take it - there are several questions raised about how many doctors will actually be incentivized to participate. One question is regarding the temporal aspect of the pay hike - two years is a limited time frame with no guarantee that states will continue the pay hike. Not to mention the uncertainty with the impending election - if Romney is elected, what will happen to this provision?

With California gearing up for the Medicaid expansion, I think it is crucial that we consider long-term solutions and innovations to motivate doctors, particularly primary care, to accept Medi-Cal. With California having some of the worst Medicaid reimbursement rates in the country, any temporary pay hike that returns to previous levels could have serious consequences on access issues. One suggestion would be updating California's Relative Value Scale, which is highly outdated and should account for geographic disparities.

US Rankings

Came across this interesting site that ranks global attitudes.  One of the rankings is which country's have the most favorable view of the United States.  In 2011, the US had only the 3rd most favorable view of the US in the world (behind Japan and Kenya).  But this year, the US loves the US the most....

USA! USA!

Electronic Medical Records in the NYT

As someone interested in health care management, administration, and practical application of new practices and policy decisions, electronic medical records are of particular interest to me. I was excited to see an article in the NYT about EMRs, but it felt a little sensationalist to me, and raised more questions than it answered.

There are clearly problems with electronic medical records, both within and between individual platforms as well as with the security and legal issues involved with moving to digital record-keeping. This article's evidence of the flaws of EMRs are a little bit of a stretch, however. An example close to home: The system that the author sites in Contra Costa County in California that "slowed to a crawl" was based on Epic, a system that's been widely, and successfully, used in large health systems nationwide, including Kaiser. It has only been in place in Contra Costa County for 3.5 months, and the problems cited in the article likely have more to do with poor planning and support for implementation than problems with the system itself. There were reasons for Epic's rocky roll-out in CCC, including that the county was committed to "going live" before a July 1st federal grant deadline, and the rushed customization/building and training process that preceded that deadline. No surprise that there were difficulties when patients first walked through the door on July 1st.

Here is an article the same author wrote in January about that system, Epic, and its beginnings 30 years ago.

Questions this article leaves me with:
The "Impact of IT" article for Monday clearly shows the benefit of these systems. But how can we make them work better for us?
What are the most pressing practical, ethical, and legal problems as we as a nation transition to EMR?
Where will these questions be answered, who will set guidelines?
What will it take for platforms to talk to each other? Will Health Information Exchanges (HIE) be embraced by programs like Epic?

The Policy Behind Measuring Health Outcomes

We are discussing in our Foundations class right now the concepts of value, both in defining what value means in health care, and also, how to measure it. I came across this Health Affairs article through the California Health Care Foundation website. It discusses a research institute which was funded by the ACA and will attempt to look at outcomes which are particularly relevant to patients. The institute only has funding until 2019. This gets at yet another issue in measuring our system's progress: many of the evaluators are funded through the government and only for a very short time. How can an institute that is essentially brand new put together a research agenda and execute it in such a short time period? Even if this program were to advocate and receive more funding in 2019, the way that evaluation of outcomes is treated as an afterthought in our healthcare system will only ensure that we never get the data adequate to learn from our mistakes.

Just when I think I'm getting too jaded...

...An article like this comes along.  What a great example of how advocacy really can make a difference!

http://www.kevinmd.com/blog/2012/10/lance-armstrong-hero.html

Factcheck.org takes on the VP debate

Hi all,

Unfortunately, I missed last night's VP debate because I was in class/in transit, but I feel like I know it all (once again) based on real-time social media commentary!  I couldn't help but notice that with Biden taking a much more offensive role (as opposed to defensive, that is), none of my favorite liberal followers were citing counts on lies and mis-statements for this debate.  I hunted down the factcheck.org article, and although they don't explicitly count the lies it appears to be 10 for Ryan and 4 for Biden.  Here's the link to their analysis:

http://factcheck.org/2012/10/veep-debate-violations/

If anyone else has seen other counts, I'd be very interested!  I've started to believe we learn more useful facts from following coverage of lies than from any other source.

Health Care Comparison

I wanted to share this easy-to-read chart from UCLA which breaks down each component of the Affordable Care Act and compares what the Romney/Ryan plan would do to it. It offers a clear picture of just how much Romney and Obama differ and what it might mean for folks if Romney is elected.

http://www.healthpolicy.ucla.edu/pubs/files/ProposalsPNoct2012.pdf

1. newsmap.jp  = This is a visual representation of trending news stories. The newest stories are lighter colored, the older, darker. The more read the subject is, the bigger the square. And you can set it to look only at a certain topic of news (like Health), as well as broadening or restricting the countries and languages of news sources. It's mostly AP-sourced, and unfortunately NYT, CNN, and other big-players are not sourced for this website. But it is an interesting way to visualize news, and gives an idea of what the general public is reading and interested in, health-wise.

2. The Atlantic's article "The Cost of Assuming Doctors Know Best "(http://www.theatlantic.com/health/archive/2012/09/the-cost-of-assuming-doctors-know-best/262993/) touches on several issues, including: new technology, shared decision making, payment methods (FFS vs. other), and lean management. It succinctly recommends various cost-cutting and care-improving ideas, and discusses a few barriers to implementation, but doesn't delve into how to get beyond the barriers.

3. While we're on the Atlantic... social media in the OR. The article below documents how photo-sharing social media apps can be used to document surgeries, especially as a way to relieve other potential patients' anxieties about the procedure. This idea, along with the recent study about releasing medical records to patients as a way to improve compliance and patient involvement, seem incredibly useful for many reasons. I also wonder if increased access to these photographs (and records) might increase lawsuits, as patients, patient advocates, and others who are given access may be able to comb for errors in a way they haven't before. Thoughts?
http://www.theatlantic.com/health/archive/2012/10/instagram-in-the-or-hearing-restoration-surgery-live-tweeted/263145/

Coverage Disruptions

I came across this story on NPR this morning that discusses the difficulty of navigating the insurance market for individuals that experience coverage disruptions. The article points out a few scenarios that may occur when a spouse retires, becomes eligible for Medicare, and loses private insurance. For example,

1) A spouse that retires and becomes eligible for Medicare risks their dependent spouse having to shop for health insurance in the individual market,
2) A dependent child (under age 26) may have to purchase expensive COBRA insurance when their parent retires and loses private insurance coverage (even though the ACA mandates their coverage on the private plan), or
3) An employee of a small employer (20 employees or less) decides to keep working and stay enrolled in the companies private plan even though they are eligible for Medicare, risking the private company recouping the costs provided to a technical Medicare beneficiary.

I think the article points out very complex scenarios that are not that rare. My main concern is the ability of the average person to shop for health insurance in a complex environment. How will Medicare and insurance companies provide transparency for enrollees facing these situations? Will this result in higher  premiums as companies increase administrative costs to meet patient demand (Thanks, Justin!)? Moreover, assuming vouchers become the Medicare reality, how will new Medicare enrollees and the elderly without a health care advocate make informed plan decisions? I think these are issues the current administration and potentially a new administration will have to answer prior to 2014.

Romney's Post-Debate Hangover - Pre-existing Conditions

Of all the glaring inaccuracies in Romney's debating last Wednesday against President Obama, the most egregious was likely his claim that under his health plan, people with pre-existing conditions will be guaranteed coverage. What he should have said, according to his own staff, was that he will leave it up to the states to decide whether to protect individuals with pre-existing conditions. It isn't surprising that Romney would make this misleading statement, considering how popular that provision of the ACA is.

It's about kindness, not a cost-benefit analysis

http://www.nytimes.com/2012/10/08/opinion/keller-how-to-die.html?_r=1

The perspective of these British palliative care physicians is refreshing.  Potentially having the same backlash as their US counterparts, they place sole emphasis on kindness and gentleness as the motivating factor in their care, and not a cost-benefit analysis.

How does ACA help the homeless

Of about 650,000 homeless in America 63 % are individuals, the rest are families. Prior to the ACA childless individuals and individuals without disability could not be enrolled under Medicaid. A large number of the homeless face mental health conditions, substance abuse, and alcohol abuse issues and could benefit from regular medical care instead of relying on ER's. ACA’s expansion of Medicaid coverage to include low-income childless-adults is a huge step in providing a large number of America’s homeless with access to healthcare. Kaiser Family Foundation recently issued a report on this, the 5 page executive summary of the report can be found at the link below

http://www.kff.org/medicaid/8355.cfm

The Future of HIV

We've been talking a lot about the health system at a macro level and I just thought it might be interesting to look at how policy and technology interact in the context of a specific disease. Recently, two new products received FDA approval that have far-reaching implications for HIV/AIDS. The first is called PrEP (which stands for Pre-Exposure Prophylaxis) which essentially is an antiretroviral that uninfected people take daily to help guard their chances of infection. My colleague at CREGS recently wrote about the implications for PrEP as a "cure" for HIV, especially for young men of color.

The second product is home testing for HIV. While this test was invented for the purpose of testing yourself privately in your own home (the idea being that many at-risk folks won't get tested in public), the NY Times just looked at an obvious "off label" use of the test: to screen potential sex partners. A test costs about $40 -- you can order it online so as not to shame yourself at the drug store.

The emergence of such products is still relatively novel, but I'm curious as to how the use of these products will play out in marginalized communities and within communities of privilege. Think of all the over-the-counter products we might have in the future... Perhaps we don't need medical intervention for such things. Maybe preventing HIV/AIDS, which still infects approximatley 50,000 new cases annually in the U.S., is just important enough to require them. And yet, I can't help but think that we are somehow jumping the gun. I won't be surprised if there is some law or regulation that limits the use of one or more of these interventions down the road.

For any of you interested in the Patient Centered Medical Home (PCMH) model and particularly the scopes of practice for primary care providers, the American Academy of Family Physicians (AAFP) just put out an interesting report.  perhaps not surprisingly, they feel that physicians not Nurse Practitioners should lead the medical home.  You can find the full report at:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf

A friend recently sent me this great site, that I did not know about.
https://www.coursera.org/courses


This website has tons of great high quality content on various topics, some of these are particularly relevant to policy, management, and public health. I have gone through the list of courses on the website and here are just a few of the really high quality courses (in my opinion). All the courses are free.

1. Community Change in Public Health -- William Brieger, Johns Hopkins
2. Model Thinking -- Scott E. Page, University of Michigan
3. An introduction to Operations Management -- Christian Terwiesch, University Of Pennsylvania
4. Organizational Analysis -- Daniel Mcfarland, Stanford University
5. Principles of Obesity Economics -- Kevin Frick, Johns Hopkins
6. Introduction to U.S. Food Systems: Perspectives from Public Health -- Robert S. Lawrence, Johns Hopkins

And just because I love history and if there are any other who do too --
7. A History of the World since 1300 -- Jeremy Adelman, Princeton University

Report: Mitt Romney Plan to Leave 72M Uninsured

A new report was issued by the Commonwealth Fund, indicating Mitt Romney's plan would make the uninsured problem in the United States worse than it was before Obamacare was enacted. Two primary reasons cited for this is the conversion of Medicaid into a block grant program and the expansion of Medicaid that would occur under the ACA.

The article does mention that the Commonwealth Fund tends to issue reports that portray the ACA in a favorable light, so perhaps the numbers can be taken with a grain of salt. However, leading up to the election, it will be interesting to see if this report might have an effect in shaping public opinion.

http://www.politico.com/news/stories/1012/81900.html

http://well.blogs.nytimes.com/2012/10/01/when-doctors-stop-taking-insurance/?src=dayp

Is this what a primary doctor shortage going to look like?

How do the candidates' policies impact you?

There's a cool website, Politify.com, that let's you look at the financial impacts of policies on you.  Just enter in some demographic information and have fun (or not)!

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/