Embattled WI governor, Scott Walker (R), issued a statement yesterday opposing the implementation of a state exchange as provisioned by the ACA — opting to defer action on the measure until the case is heard by the SCOTUS in March. In doing so, he will be returning almost $40 M in federal funding earmarked for the healthcare exchange. Whether this is earnest on his part or merely a symbolic gesture to Wisconsin GOP faithful in the wake of a pending certified recall vote on his office remains to be seen. Walker has always been against the passage of the reform law, instead focusing on efforts to deny federal assistance in doing so (states which choose this path will have to demonstrate fiscal independence on healthcare exchange creation by 1/1/13 or will be mandated a program by the feds).
Is this entire episode a game of chicken by Walker in light of his sudden vulnerability? It is, if one listens to the rhetoric from the state’s Democrats on the issue. Advocacy groups are also weighing their own disapproval of the governor’s intentions. The SOCTUS will hear testimony on the constitutionality of the reform law (notably, the mandate for coverage) over a two day period by the end of March. By the end of Februrary numerous amicus briefs will be filed by both Obama admin (DOJ) and plaintiffs (states) in the case. In spite of all the rancor surrounding this issue, it will difficult to envision striking of the mandate provision, much less the entire reform law as two lower courts have offered split decisions on the matter — prompting the SCOTUS to act quickly on a decision on the entirety of the ACA well before the election. | PDF brief from UCB Labor Center in support of the ACA’s constitutionality
The good news: the media have done a reasonably good job of getting the word out to consumers of healthcare with respect to the prevention of medical and surgical mistakes in acute care settings. The bad news? Here in Minnesota, the numbers of “wrong surgeries”, a collective term meaning never-events in this care realm, topped 2010′s tally by five cases — creating a surge in such cases last year.
The figure is the highest in eight years of self-reporting by Minnesota hospitals. Officials cited many reasons for the mistakes — from doctors filling out incorrect orders to sloppy inventories that make it easy to grab the wrong joint implants for orthopedic procedures.
While the surge appears to be from the absolute numbers of incorrect procedures performed, the rate of adverse events has globally decreased, bringing into question the efforts of many healthcare systems in the processes involved in preventing completely avoidable lapses in care delivery. | LINK
The long term care marketplace is one of those sectors in healthcare delivery on the cusp of markedly innovative practices in this young century, buoyed by the sudden proliferation of the senior Boomer demographic. Sky’s the limit on the impact of care services and offerings a market-based approach can muster on the eve of reform. Unfortunately, certain models are ripe for abuse.
The DOJ said today it joined a whistleblower case against AseraCare in federal court in Birmingham, Alabama, accusing the closely held company of seeking to cheat Medicare for the hospice care of patients who weren’t terminally ill. The U.S. is seeking three times the damages and a penalty of $5,500 to $11,000 per claim.
The hospice company is owned by a national company that provides services within LTC. Whistleblowers prompted the government action when the hospice operation recruited Medicare beneficiaries and continued to fraudulently collect payments by inappropriately cycling those patients under the hospice benefit. The process would continue upon initial termination of Medicare payments for those services once the initial LTC services ceased. Multiple referrals for covered services later, the LTC contractor would continue to collect those payments, based upon allegedly fraudulent qualifying practices by the LTC contractor/company.
The case is an interesting one which will, hopefully, provide Medicare reform in yet another overlooked care sector that will only increase in prevalence as the rate of patients diagnosed with chronic disease and disability skyrockets. More here
The cost of the delivery of healthcare in this country always seems to be independent of traditional models of demand in practically any other market-based, for-profit operation. That is, instead of relying on the parameters of patient (consumer) satisfaction or dissatisfaction; further innovation fuels the development of costlier, more advanced technology seemingly designed to break the bank (in one way or another) the very entity it is supposed to benefit: the patient.
An editorial reprint in today’s Minneapolis-St. Paul paper of record, the Star Tribune, makes the case for the unintended costly consequences this very innovation has on the big picture with respect to healthcare delivery in the 2010s. It focuses on the use of nuclear diagnostics developed by the Mayo Clinic as a superfluous and disruptive innovation which does the patient-as-consumer no favors…while benefiting the institution at the hands of government abetting.
Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. [...]
To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers.
But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year. [...]
With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.
But it is crazy medicine and unsustainable public policy.
Maybe so, but the practice of medicine depends upon the richness of technologies in which parties not only compete toward developing paths of effective treatments for chronic diseases (like cancer, in this case), but also race to spur further research on the nature and behavior of disease. It is within this self-fulfilling prophecy of the cycle of medical education that knowledge moves forward — something the creators of publications like this one thrived upon. And, that’s a good thing. | LINK
The cornerstone of the ACA is the provision for a coverage mandate — whether that coverage includes complete subsidized services (Medicaid or another fed subsidized program) or via private insurer. In order that individual states comply with this most essential of the reform law’s benefits, HHS has announced that states have the option to create “essential benefits packages” as a method of increasing compliance within the ACA.
“Flexebility” is the key, according to Secretary Kathleen Sebelius.
The national health law lists 10 categories of health care that all insurance policies must cover: hospitalization, emergency care, out-patient services, maternity and newborn care, mental health and substance abuse services, prescription drugs, laboratory testing, preventive and wellness care, pediatric services (including dental and vision examinations), rehabilitative care and habilitative care such as services for children with developmental disabilities. But within those categories, the federal government is allowing each state to determine its own basket of essential benefits by choosing a “benchmark” package offered by any of a variety of insurers.
Sebelius: This move protects consumers by respecting states’ role in healthcare delivery under the ACA. Obama administration: This is the only way in which the mandate can be upheld while making essential services affordable in all fifty states. Consumers? Increased standardization among offerings of basic services by states under the ACA raises the possiblity of mandated coverage rather than making things too onerous for the feds in getting the legislation off the ground in just a couple of years. | LINK
After a two-year investigation into disclosure issues surrounding a top University of Minnesota physician faculty member, the case is now closed — accompanied by a stern “cautionary letter” which
instructed him to take corrective measures to prevent further problems, but decided against further disciplinary action. A review committee found no evidence of fraud or misrepresentation. However, the committee found that Polly failed to sufficiently disclose the Medtronic relationship in connection with two medical journal publications and a conference presentation.
He no longer does work which requires scrutiny for disclosure since the investigation’s launch in November 2009. | LINK
In an effort to track physician referral patterns, some hospital systems are resorting to detailing to increase revenue. Much like the pharma reps hired by their respective companies back in the day, hospitals are hiring these paid ambassadors — many former pharma reps – to trumpet favorable care data in order to buffer the bottom line. Hospitals say they are doing this to better streamline care — especially among providers who split referrals among hospitals, thereby cutting administrative waste in this regard. Proponents call these detailing visits to primary care offices liaison-like – initiatives allowing providers a voice from beyond the hosptial arena in an affort to enhance patient care quality. They are also quick to point out that hiring former pharma reps displaced by shrinking sales, fewer NDAs, increased generic availability, and general prohibition of access by reps by healthcare orgs only benefits the economic sector in a flailing economy.
Hospitals say their new sales approach is part of a broader strategy to develop closer ties to physicians, who largely determine where patients go for care. Hospitals also are buying doctors’ practices or forming closer partnerships with physicians to improve care and drive admissions.
Like it or not, healthcare delivery is an industry in this country. In one sector in which market share is showing a tremedous decline, there jumps in another opportunity to create new platforms for innovation. As long as no antitrust issues occur, there should be room for the experimentation of new avenues to enhance quality of care delivery. As the components of care delivery (ambulatory versus inpatient, for example) become more specialized in their own right, it will be interesting to observe this effort by hospitals to grow and innovate in an increasingly crowded healthcare marketplace, allowing regulation by government entities only if patient care is truly at risk. | LINK
The wrangling back and forth in the US legislature concerning the upcoming vote on the payroll tax cut extension (which includes a provision giving providers a two-year break on Medicare payment cuts) continues to raise the ire of acute hospitals, which would shoulder part of the financing for such an action. The amount to be financed, at the literal expense of hospitals, approaches $17 billion. Essentially, the proposed offsets to direct provider payments would come from reduced payments to hospital administrative and evaluatory functions.
House GOP leaders are in the hospitals’ crosshairs, as the hospitals complain that, under the proposal, there is little incentive for them to continue to collect other payments (copays, deductibles) in the face of such financing, compromising care delivery in the process. Republicans are quick to point out, however, hospitals did agree to major cuts in Medicare as part of reform and that overall Medicare spending would fall by less than 1 percent over the next 10 years. | LINK
As a primary care geriatrician, I am especially fortunate to have the dual experience of meeting the difficulty of treating chronic disease and, at the same time, making a difference in the lives of patients and their families. But, I have also been bitten by the acute care bug. For the past couple of years, I have also done urgent care medicine part time. I really enjoy it. And it seems to be falling into a healthcare delivery niche, as far as reform is concerned.
Across the country, an estimated 3 million patients visit these centers each week, according to the Urgent Care Association of America, a trade group based in Chicago. To meet increased demand, the number of facilities has steadily increased from 8,000 in 2008 to more than 9,200 this year, the association said. About 600 new urgent centers opened this year. Fueling that rise are two longstanding trends — crowded emergency rooms and a lack of primary care doctors. Urgent care operators also say another factor is helping to propel business: the drive to lower costs.
I’m not sure what to make of the supposition that the cost savings derived from urgent care as an emergency department surrogate. In the long run, these presumed cost savings will likely be minimal if patients-as-conumers remain in the mindset that urgent care access is equivalent to primary care access. Yes, the decreasing numbers of primary care physicians may be entering a critical phase, and as this scenario demonstrates, urgent care as a delivery mechanism, will not replace the reality of impaired access to primary care. Paitents desirous of value as recipients of health care will always gravitate toward the path of least resistance. Only by increasing the primary care workforce can that level of access and value actually be realized. | LINK
When she was diagnosed with multiple sclerosis, a Minnesota woman thought that her carefully chosen neurologist had her best interests in mind when prescribing initial treatments to modify the disease. That was before a little detective work uncovered the real motivation for her physician’s patterns of prescribing that left her even more debilitated than when she was initially showing symptoms.
It worried me that none of them ever suggested that I discontinue treatment—or switch to another treatment—even after I reported that my injection site reactions were affecting my quality of life. Despite the fact that my neurologist insisted that I begin disease-modifying therapy, I was never contacted by him, his nurse, or anyone else in the neurology clinic with questions about how my Copaxone injections were going.
The patient, a U of M philosophy graduate student, puts into her own words the ethical issue she gradually uncovered while under the specialist’s care. Just how influential are pharma companies’ financial compensations for physicians who choose to prescribe their products? Just how willing are they to prescribe knowingly untested medications without concern as to their problematic and potentially lethal adverse effects? Her answer came at her next appointment, after enduring months of increasingly debilitating pain and enfeebling function from the trial with the first drug.
[M]y neurologist informed me that I’d begun to develop lesions inside my brain stem. He explained that this was a very bad place to have lesions, occupied as it is with regulating some of the body’s basic functions, such as breathing. He strongly recommended that I go back on MS treatment, suggesting this time a drug called Tysabri (natalizumab), which had worked wonders for some of his patients but also carried some amount of risk. Worried about the new lesions, but knowing little about the drug he was advising, I told him I’d think about it. I needed to be convinced through my own investigations that this drug would be worth taking.
Her investigations were not only telling, but they are also indicative of an all-to-familiar refrain for patients of (mostly specialist) physicians who pocket major coin from pharma companies to get these ridiculously expensive agents to the marketplace, at the risk of patient harm. In Minnesota, the patient was assisted by a database which lists pharmaceutical third parties with which a prescribing physician has a financial interest. She makes little doubt of her eagerness for this requirement to spread nationally as the result of the reform law. | PDF LINK
The federal government finally announces that it will open up its Medicare claims database to allow third party access (advocacy groups, insurers, hospitals, etc). This follows a few years of speculation on the part of pundits and legislators alike on what such a move could entail and how it would impact heatlhcare reform — in particular, enhancing quality parameters. The benefits of availability of such information gleaned from billing, requisitions, and payments will vary among groups seeking such data.
Though the data aggregate is invaluable for constructing tools for everything from clinical trials to arranging care delivery based upon demographics, there is always the specter of misrepresentation of that data. For years, many clinicians (including professional associations like the AMA) have lobbied against the release of such info on the gounds that internal reviews should be made before that info is released to the general public. End data may not always be reflected by the healthcare delivery means for many difficult-to-treat patients, for example.
Still, the move is a win for groups wanting to move beyond the formerly impenetrable wall imposed and maintained by physicians and physician groups in order to access that gold mine of clinical, financial, and parametric information. | LINK
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
#pharma news: 2 Biotech Acquisitions in 1 Day! Let's Throw a Party http://t.co/Dw3uJa12
Kaiser Permanente Lets Members Access Health Data Via #Smartphone - http://t.co/GljzYlrJ #HCSM #mHealth
RT @socialmedia2day: http://t.co/tcF1G2s8 Are You Engaged or Do You Ignore It? #HCSM Webinar on Jan 31 #hcmktg @barbaraficarra @edbennett @siemenshealth
The Jan. 27th, ed. is out w/one ed. to Resources pg: http://t.co/61a5FWAZ #hcsm #mhealth #hcsmca #hcsmeu #hcsmeu #HITsm #telemedicine
DOCTOR PUNDIT @ ONE YEAR | An occasional DP series from 2010 highlighting healthcare policy trends over the period from 2009-2010 in a compare/contrast format.
