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.