Originating from Saint Paul, MN, Doctor Pundit is all about the intersection between healthcare policy, science, politics, and all surrounding points and issues. Although the entire scope of healthcare delivery and policy is much too encompassing for just one blogger to cover, I'll try my best. Enjoy! From time to time, you'll also see other items of interest that probably have nothing to do with health policy in the least. Try and keep an open mind. :) Proprietor & Editor -- Michael Douglas, MD, MBAHow Can Primary Care Physicians and Nurse Practitioners Coexist in a More Collaborative Fashion?
This week’s issue of the NEJM features an original article on the role of midlevel providers — specifically, nurse practitioners (NPs) — in the ongoing evolution of the delivery of ambulatory primary care in this country. As we move closer toward a reality in which access to primary care is essentially mandated, the harsh reality of facing the logistics in providing that increased access is often overshadowed by the current honeymoon period in which proponents of the ACA continue to reside. Perhaps stepping out of that healthcare ivory tower for a moment will shed light on the pending crisis that looms once Obamacare makes its official entrance into the healthcare marketplace next January.
The NEJM blog features this issue in a post that describes the attitudes NPs and MDs have toward each other within the scope of primary care. Both camps are surveyed on not only their biases on how primary care should be delivered in the 21st century in an environment of enormous strain; but also on how they should be reimbursed for services rendered, how they saw their roles within the concept of the medical home, and how their abilities compared with tackling complex medical problems in a collaborative atmosphere. Suffice it to say that responses were unsurprising and unquestionable in their candor — the essential takeaway being that primary care MDs were wary of skill encroachment by NPs, and the latter group favoring a major increase in responsibility in delivering an expanded breadth of primary care. | LINK
Headline Roundup: Jolie Does It Right
Here’s a sampling of what’s making the rounds in healthcare headlines today.
(1) Angelina Jolie makes the right decision for many. [LINK]
(2) Apparently, oncologists are in agreement. [LINK]
(3) U.S. House gears up for yet another vote on ACA repeal. [LINK]
(4) And, speaking of breast cancer — yep, coffee has a role in fighting that, too. [LINK]
(5) KFF: Just 5 percent account for over half of healthcare spending. (2010) [LINK]
New CMS Chief Confirmed by Senate
Under the radar, perhaps? One would think that that news of the first Senate-confirmed CMS head in 7 years would get some media play. Yesterday, the U.S. Senate confirmed Marilyn Tavenner to the post. The last confirmation came at the hands of George W. Bush in 2003, Mark McClellan MD, PhD. Tavenner — a non-physician — served in the interim after recess appointee Donald Berwick, MD stepped down. Berwick was never confirmed by the Senate after remarks he made which were somewhat praiseworthy of the healthcare delivery system in the United Kingdom.
Prior to this installment, Tavenner worked as a healthcare exec for HCA for a quarter century. She started her career as a nurse in her home state of Virginia more than 30 years ago. Her appointment comes with support from advocacy groups such as the AMA, and confirmation was largely a non-controversial event — with bipartisan holdouts (Tom Harkin, D-IA; Orrin Hatch, R-UT) ultimately coming around.
Tavenner assumes the CMS head position at a time when the ACA begins its next chapter — the pending arrival of healthcare exchanges, a reintroduction of the reform law to masses, and ongoing issues surrounding the optional expansion of Medicaid funding by states as a provision of the law. | LINK
Vermont Poised to Pass End of Life Legislation
Vermont becomes the fourth state to legalize a physician’s ability to prescribe lethal medication to the terminally ill patient. The act is significant in this state because it is the result of legislative action. Three other states have had similar measures approved by either referendum (WA, OR) or judicial action (MT). To refresh one’s memory on the breadth of allowable actions a physician and patient may take in this care delivery scenario, Vermont will pattern its approach after methods used in Oregon: stopgap measures to prohibit patient coercion by requiring a waiting “change of heart” period of 15 days, and an evaluation by another provider.
However, the state’s law will prevent criminal charges and investigations filed against participating physicians’ beginning July 1, 2016 — three years after this legislation is to be signed into law in Vermont. Apparently, this gives physicians time to become familiar with the law. At that time, physicians will only be required to utilize informed consent regarding lethal prescriptions only after all reasonable modes of death with dignity have been discussed with the patient, including all available hospice and palliative measures. The patient will then be able to independently make a decision on whether to ask for a lethal treatment. | LINK
MN Legislature Approves Marriage Equality
Yes, I know that I am late to party on this one. Minnesota has become the 12th state to codify marriage equality into law. Governor Mark Dayton will make it official.
Minnesota will become the first Midwestern state to legalize same-sex marriage by legislative vote, and it signals the latest victory for those working to extend marriage rights to gay and lesbian couples across the nation. Monday’s action technically repeals a state statute that had prohibited such unions.
Yesterday, the Senate majority leader gave an impassioned speech on the precipice of the vote.
House GOP Brings Obamacare up to a Vote (Again) This Week
Republicans are going after the red meat in the wake of not one, not two — but three concurrent potential “situations” that make damage control somewhat imperative for the Obama administation. Unsurprisingly, some GOP senators are using these events as a means to undermine the SCOTUS-sanctioned ACA. Whatever becomes of that effort, Republicans have (yet again) been scheduling a time to formally vote on an Obamacare repeal.
Depending on whom you ask, this will be the 33rd or 37th time that lawmakers have attempted to repeal all or part of the health-care reform law, now called “Obamacare” by both critics and supporters. The House is scheduled to vote again this week on a bill to repeal the entire law, a move designed to put about 30 House GOP freshmen on the record as opposing the legislation and supporting a full repeal.
Perhaps playing to the GOP’s base may gain some traction again in the wake of Benghazi, the IRS, and now, the AP scandals. A 37th vote (who’s counting?) on Thursday this week may also serve as a message to new GOP members in the 113th Congress that Republicans have their sights set firmly on 2014. Although this is nothing more than a Groundhog Day moment for the House (the Senate was never considered to take these multiple attempts seriously at potential passage), it is a possible mechanism for stoking the flames of increasing bipartisan concern over how President Obama’s WH is handling things in this very critical moment in his young second term.
House Majority Leader Cantor (R-VA) likes the odds, because apparent support of the ACA is little more south than previous polling has demonstrated — an April Quinnipiac survey [PDF] found voters disapprove of the ACA, 46 percent to 41 percent. By a 37 percent to 15 percent margin, respondents say it would hurt them more than help them personally, while 41 percent say the law wouldn’t affect them. But when it comes to allowing more people in their state to qualify for Medicaid, 48 percent to 41 percent believe expansion is a good idea. Still, the anti-sell on Obamacare is an uphill battle for the GOP, who appear to be taking its current strategy on Obama’s #1 signature domestic achievement from the Election ’10 playbook that drove the House majority back to the GOP.
Report: Greater Than 80M Under- or Uninsured in 2012
The Commonwealth Fund has released statistics that paint a rather hopeless picture regarding the un/underinsured in this country ahead of full implementation of refrom, come January.
Eighty-four million people―nearly half of all working-age U.S. adults―went without health insurance for a time last year or had out-of-pocket costs that were so high relative to their income they were considered underinsured, according to the Commonwealth Fund 2012 Biennial Health Insurance Survey. …
The report, Insuring the Future: Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act, finds that the percentage of Americans who were uninsured, underinsured, or had gaps in their health coverage grew steadily between 2003 and 2010, with the number of underinsured nearly doubling from 16 million in 2003 to 29 million in 2010.
Sobering numbers, but the silver lining is one of access once Obamacare kicks in. Problem is, access, only, will not guarantee a ROI of decreased healthcare costs. Other measures needed to grant sustainability to, say, the availability of healthcare exchanges — have to come into play: increasing primary care numbers, expanding Medicaid, and the aggressive promotion of preventive care. | LINK
HHS Secretary to Create Transparency Mechanisms to Address Medical Billing Costs
Back when TIME published its now classic mainstream longform piece “Bitter Pill”, the buzz in the healthcare blogosphere centered around the waste involved in the final point of delivery of care to the patient. Stories of patient woes as they faced outrageously escalating medical bills for treatments for which they thought they were covered were replete in the report. Today, word comes from the piece’s author, Stephen Brill, that HHS Sec’y Kathleen Sebelius will create yet another office of accountability.
Sebelius will release a data file that shows the list—or ‘chargemaster’—prices by all hospitals across the country for the 100 most common inpatient treatment services in 2011. It then compares those prices with what Medicare actually paid hospitals for the same treatments – which was typically a fraction of the chargemaster prices… In the same announcement, Sebelius is offering $87 million dollars to the states to create what she calls ‘health care data pricing centers.’ The centers will make pricing transparency more local and user friendly than the giant data file she is releasing this morning.
After one reads the TIME article, all of this is placed into perspective, and it is easy to see Sebelius’s response to the ongoing inequity between the price, cost, and service (delivery) of healthcare; but, is creating yet another bureaucratic knee-jerk truly the answer here, especially when it is created to simply track public-private cost differentials? Back when this article was published in February of this year, Brill offered his take on some short term responses by public and private entities alike in addressing this problem. Calling upon hospitals to recoup its profits to improve themselves from within; increasing tax liabilities on profits at ambulatory care centers; and proactive approaches on comparative effectiveness research are just some of the conclusions Brill reaches. He goes on to say
There are two reasons why Sebelius’ release of this newly crunched, massive data file is a great first step. First, it reveals the vast disparity between what hospitals charge for pills, procedures and operations and the real cost of those services, as calculated by Medicare. … The second reason the compilation and release of this data is a big deal is that it demonstrates that … chargemaster prices are wildly inconsistent and seem to have no rationale. … and … the release of … data … should become a tip sheet for reporters in every American city and town, who can now ask hospitals to explain their pricing.
Demonstrating transparency is nothing new for regulatory bodies, including the feds — but the devil is in the details. Providing cold comfort to healthcare consumers serves no purpose unless action occurs to address these startling findings. As reform begins to envelop healthcare access and delivery in this country within the next 12 months and beyond, cogent plans to combat pricing and cost will be needed to demonstrate the real reason for reform — increasing access to quality care at a lower cost while abolishing waste.
MN House to Schedule Vote on Same-Sex Marriage on Thursday
The vote on marriage equality here in Minnesota is just two days away. The Democratic-controlled Senate for certain has the votes to pass muster. The House, also Dem-controlled, a little less so (or, maybe not as uncertain). However, the Speaker has noted that a vote would not be scheduled until it was certain that there were enough votes to pass the measure. Foes of marriage equality in the state are revved up about this week’s potentially historic vote, which comes as the result of a concerted effort by marriage equality lobbyists and activists alike after a measure by the then GOP-controlled House to pass an amendment to the state’s constitution to ban same-sex marriage failed via referendum on election day ’12. The Dem governor, Mark Dayton, has vowed to sign the bill into law should it reach his desk.
Yesterday, the House Ways and Means Cmte. voted on whether to get the marriage bill out of its final committee after it was determined how much the ability for same-sex couples to wed would impact Minnesota’s subsidy of healthcare and other benefits with respect to state employee coverage. A paltry amount, to be sure. The bigger issue, at least as it relates to healthcare coverage. For the first time, gay and lesbian married couples – whether they be state employees or not — will have access to partners’ health benefits, giving them parity in the for-profit healthcare marketplace.
Florida Governor Scott Slammed on Own Support of Obamacare Provision
No doubt about it, Florida Governor Rick Scott is a wounded warrior — his leadership becoming completely emasculated on the issue of Medicaid expansion under Obamacare. Recall that the SCOTUS made it optional for states to expand funding for Medicaid under the ACA. It’s essentially up to the chief executives of states to determine just how far their share of taxpayer funded healthcare will go in the age of reform.
Scott, who shifted his stance on the measure, apparently does not have the support of the Florida legislature. On Friday of last week, the GOP-controlled legislature passed its budget without a cent going to Medicaid expansion. Scott, a “severe” conservative on fiscal issues, is apparently operating within a leadership vacuum here. Republican lawmakers have been sparring over this issue for months.
In a way, this is a bit surprising. No one ever expected to hear Scott extoll the benefits of President Obama’s signature legislative accomplishment. That being said, the Medicaid expansion is a really big deal for state budgets—the budget that Scott is charged with overseeing. If his state had participated in the Medicaid expansion, the Urban Institute estimated it would bring $66 billion of federal funds into the state over the course of a decade.
Unless a special session is called, over 1M FL residents will be affected. Of course, this will spill over to hospitals and other acute care realms — driving up the eventual cost for the delivery of care in that state. Scott is not the only GOP chief executive facing down the gauntlet of similarly minded GOP-controlled legislatures; Ohio’s John Kasich, Ariz.’s Jan Brewer, and Michigan’s Rick Snyder are all having trouble navigating state budgets to include this measure. Expect a fight in Florida, where the GOP has expressed free market alternatives for coping with the onslaught of care access under Obamacare.
Government Institute Announces Distancing from Psychiatric “Bible”
Just mere weeks before the next edition of the “bible” of psychotherapeutics hits doctors’ offices nationwide, the federal government entity tasked with overseeing medical research is announcing a plan to conduct its investigations away from using the principles of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM V). This “bible” has for years defined how many psychiatric disorders are evaluated, diagnosed, and treated.
The federal National Institutes of Mental Health cites the “lack of validity”, as opposed to the intergenerational constant of “reliability” seen in the previous editions of the manual in approaching the workup of psychiatric disorders. The NIMH notes that symptom clusters drive diagnosis and treatments within psychiatry, rather than objective measures. The increase in research involving genetics and cognitive science and how it applies to the diagnosis of mental illness appears to be the compelling force in driving the change for the NIMH. Continue Reading →
