Last Februrary, Medicare fraud once again took center stage; a Tampa, FL-based managed care outfit was outed by the federal government for intentionally hiding Medicare payments in a specially created private entity called Harmony Behavioral Health. Citing administrative costs as the reason for diversion, WellCare Health kept for itself state funds meant for mental health services and delivery. If there were any reason in the heat of Obama’s reform rhetoric in 2009 to rail against the government’s mishandling of its own Medicare reimbursement policies (as part of shoddily run MA plans) as being part and parcel of the overall increase in the cost of healthcare delivery — it was quite apparent with this case.

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What’s the healthiest county in the state in which you live? A new survey just published by the RWF finds what is essentially common knowledge in the healthcare policy blogosphere —  that persons in more rural counties fare worse than their urban counterparts with respect to decreases in healthcare access, increases in premature death, increases in hospital admissions for the treatment of highly preventable conditions, among other findings.

These findings should come as no surprise, because all (healthcare) politics is local, right? Here in Minnesota, research findings such as these take on an entirely prescient meaning — as our Governor is proposing enormous cuts in spending within the budget this cycle in order to balance it. The vast majority of those cuts are occurring in within the Dept. of Human Services, particularly its wholly funded General Assistance Medical Care public payer program. | LINK

I’m not a big fan of medical dramas. From my earliest memory as a child, I can recall my mother’s whimsy with the TV show “Medical Center”. At the tender age of five, I never really understood her fascination with the show at that time (although I’m sure the eye candy was a big part of the draw for her, if you know what I mean); perhaps it was the fact that she was a registered nurse and could relate on some visceral level. Okay, that’s probably stretching things a bit — as medical dramas in the 1970s didn’t utilize the high-powered medical knowledge and muster of physician consultants in the manner they do today.

Well, one would think in this age of “transparency” and disclosure among source materials for dramatization, consultants would make sure medical pathology portrayed on television would be as accurate as possible. Don’t they owe it to the audience (along with a riveting storyline)? According to a study getting some Internet meme ink, they do.

There were 59 seizures in the 327 episodes included in the study. Inappropriate responses — such as holding a patient down, trying to stop involuntary movement, or putting something in the person’s mouth — occurred in about 46 percent of the seizure depictions. Appropriate first-aid management was shown about 29 percent of the time, while the appropriateness of first aid couldn’t be determined in 25 percent of the seizure scenes, the study authors noted.

Using current and relatively recent dramas as subjects for the study, the authors note that emergency first aid for seizure was appropriately given about 50% of the time. Perhaps the bigger issue here is why this was studied in the first place. If society relied on medical drama to provide the appropriate instruction rather than, say, medical school; then healthcare reform would probably take on an entirely different meaning. | LINK

• The Wellpoint saga continues…as well as the blame game for significant premium hikes.
• Study: alcohol + energy drinks (like Red Bull) = recipe for disaster.
• Has the H1N1 pandemic peaked?
• The first study of the anti-CSF prototypes for treatment/reversal of Alzheimer dementia is underway.

The trial will measure in the cerebrospinal fluid (CSF) and blood plasma of amnestic mild cognitively impaired (MCI) patients the biochemical changes that are associated with AD and correlate them with the pharmacokinetics of the drug and its metabolites.

• For California, the bleeding never ends. Today, Gov. Schwarzenegger releases his spending plan for 2010-11 which details even deeper cuts to its Dept. of Human Services.

A couple of weeks ago, I interviewed the CEO of the EHR/PHR tech company MediConnect, Amy Rees Anderson. What follows is the second half of that interview here on Doctor Pundit.

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DP: How important is portability of the health record for patients beginning to benefit from EHR adoption?

Ms. Anderson: The cheapest way to facilitate the portability of the records is to have the doctors adopt electronic medical records at point of care. Once this occurs the ability to retrieve and transfer records will become substantially more affordable. Again, I don’t think we will see this adoption for doctors really start to boom until we incent the current providers to do so. I do, however, believe that the rising generation of physicians who grew up with their handhelds and tablet PCs will come right out of school using these systems already. But it’s the physicians who have been practicing for years that we need to incent to switch over. Without electronic health records we can still retrieve and digitize the paper records like MediConnect has been doing since 1996, it just comes at a higher cost than if we dealt with all electronic records.

DP: Do you see any immediate barriers to adoption with respect to hospitals, vendor interface, or broadband availability in resource-poorer regions of the country?

Ms. Anderson: I don’t think broadband availability is the barrier to adoption today. The majority of records are stored in offices in the metropolitan areas of the country where the highest numbers of people live anyway, which has ample availability for high speed. In the smaller areas, where the Internet is slower, the doctors can keep records on a local server that can connect and upload to secure online storage in batch mode, so it won’t prohibit them from the changeover to electronic records. With regard to vendors, I think it’s important to let doctors choose whatever electronic records software works best for them in their own practice. Trying to force everyone on to one system is just not practical. That said, every system should allow for the transmitting secure health data to other systems as requested by the patient controlling that data.

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You just have to hand it to Minnesota and its spirit of rugged self-determination. Its citizen individualism and desire to pioneer are just a couple of the qualities that are part of the state’s storied history as innovator and trendsetter. The concept of managed care as a healthcare delivery ideal had some of its roots in Minnesota, a concept going back over 35 years. Designed as a way to create a balance between providers and payments for services rendered, it has evolved — for better or worse — into a system upon which today’s healthcare marketplace has codified current business practices. That is, the very dynamic which has given the current President of the United States such a strong (though somewhat misguided) desire to overhaul the way healthcare is delivered in this country.

Pharma, Insurance, and the physician are the core triptych at which so much in the debate to reform healthcare is directed. Many primary care physicians feel as though they are at the epicenter of this reform morass, and many are left feeling dismayed over why they chose medicine as a profession at all. For many family docs, for example, navigating the complexities of day-to-day practice; feeling the pressure of seeing enough patients to justify employment in many manage care systems; and dealing with Insurance and public payers in order to simply get paid are essentially too much for them to deal with. Attrition from the profession usually results.

Imagine the self-determination of one Minnesota family physician — an employee of a primary care group in the Twin Cities for decades — when he simply could not “take it any more”. With actions that can at once be described as both narcissistic and noble, this doc decided to go it alone and get Insurance out of the mix altogether. Armed with $80 000 and a desire to accept only cash, he’s jumping into uncharted territory in 21st century healthcare delivery and going back to the pre-managed care days of Dr. Marcus Welby — and he’s doing it in one of the most heavily-penetrated managed care states in the country. The spirit of Minnesota innovation shines again, at least for one physician. | LINK

A year ago this week, it was full steam ahead on Barack Obama’s healthcare initiatives. It seemed as though the new president, who was sworn in just four days earlier, was wasting no time standardizing his imprimatur in preparation for the debate-turned-referendum on healthcare legislation. In addition to finding a CDC head, one of the key high-profile posts Obama and his administration were keen on filling at any cost (or so it seemed) was one that was finally and dutifully filled by the middle of the year – that of the U.S. Surgeon General.

The initial number one prospect? Dr. Sanjay Gupta, of course. The good doctor, who is reporting and (incidentally) practicing medicine in Haiti at this time, was subsequently the target of ridicule from those on the left and right. That the administration had the audacity (of hope?) to suggest a media darling with much in the way of perceived corporate influence with little, if any, legislative experience to qualify him for the position was the most appropriate candidate was, at best, naive … at worst, very shortsided and indifferent (read: too “corporate”) to those whom Obama wanted to help with his plans for health reform. A head scratcher the administration never fully addressed with critics.

Today, the position is filled, not by a neurosurgeon media megalomaniac, but by a family doc with an MBA (just like me!) who appears to have a passion for what the office stands for: the promotion of low-cost preventive medical services and a commitment to the president and to the American people for compassionate and accessible delivery of care. | LINK

Though this has essentially nothing to do with healthcare policy (okay it does, but not on a purely direct level), the town of Noorvik, AK — an Eskimo village — will be the first to be counted in the 2010 census.

The first citizen selected to be counted in the 2010 census — an 89-year-old Noorvik resident and World War II veteran — will be paid a home visit. ”What an honor to be the first,” Wells said. “Our community really pulled in and supported this census event.” To welcome Groves, Alaska Lieutenant Governor Craig Campbell and other dignitaries, there will be a traditional native feast featuring caribou, moose and beaver meat as well as other fare such as turkey and ham, the mayor said.

Yum. | LINK

President Obama’s healthcare initiatives are, once again, upfront in the 24-hour news cycles this week — albeit for reasons he probably would prefer not experience in the one-week run-up to his second SOTU address. Before all of the current negative sentiment surrounding health reform became the norm, there was a halcyon period for the new president, and it was about a year ago when he took office. Barack Obama’s election as the 44th U.S. President arrived fresh with bold promises of a completely revamped healthcare delivery system that would revolutionize access for the vast majority of U.S. citizens like no other piece of legislation since the Medicare entitlement over 40 years ago.

The talent pool from which the new president was to draw resources to revolutionize healthcare delivery included, at its centerpiece, the drive for innovation in the age of the electronic medical record. The ability for patients-as-consumers not only to have control over their healthcare information, but also have immediate access to it holds great promise for positively influencing efficiency in health information dissemination. Lower costs and less waste are to be the results of this innovation. Obama’s penchant for tech only adds to his administration’s zeal in making this happen.

Search giant Google made headlines when it entered the hallowed space of patient information and medical record retrieval. Of course, this caught the attention of the Obama administration, as it has already implemented Google as one of four key players in a demonstration project involving Medicare beneficiaries’ health information and records retrieval. Another up-and-coming HIT company targeted by the Obama administration as part of this CMS demo project is MediConnect. This company has emerged as one of the few major players in the new and thriving electronic medical records industry after growing nearly 800 percent in the past four years and is now serving some of America’s largest health payers and life insurance carriers.

I recently had a chance to interview its CEO, Amy Rees Anderson, and gauge her thoughts on the brave new world of this patient-as-consumer driven technology and what it means in the overall plan for healthcare reform. Part II of this interview will be posted on Doctor Pundit next week.

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DP: You are the CEO of a company fresh off an acquisition and explosive growth over the past 4 years. Where do you see the impact of the electronic health record (EHR) and the patient’s utilization of it in driving healthcare delivery efficiency over the next decade?

Ms. Anderson: I believe it is critical for patients to get involved in overseeing their own health care. If you really think about it, as consumers we often spend more time researching what car to drive then we do on our healthcare decisions.

In order to get consumers involved, it will take two main components 1) help them gain access to their medical records and 2) help them understand what is in those records so it becomes more meaningful to the consumer.

As we can accomplish these two things, which we believe MediConnect now offers with the combination of our record retrieval services and now the acquisition of PassportMD, the online Personal Health Record system, we can help consumers to get involved in knowing and understanding their own healthcare. As the adoption of these types of services grow, consumers will ultimately be what forces the facilitation of transferring medical information between their own medical care providers. The patient is really the only person who can build their entire health record by keeping every record from every care provider in one central repository which they can either directly access or grant access to certain portions to the people they feel need that information in order to best guide their healthcare.

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When smaller hospitals in rural areas seek relief in tough economic times, they usually have to resort to merging with larger systems to stay afloat while continuing to serve the rural communities in which they are located. For one troubled tiny 15-bed facility in western Minnesota, the road to eventual acquisition by the largest system in neighboring North Dakota was a long and bumpy one. Fraught with a saga involving three rotating physicians over a period of fifteen years and the involvement of one of them resorting to whistleblowing the federal government to investigate protracted shady Medicare billing practices, the acute facility is ready to simply “move on”.

“The fact is that medicine is practiced differently in rural areas than urban areas,” said Hill,^[1] executive director of the national Rural Health Resource Center in Duluth. “In the Twin Cities, you can be practically anonymous as a doctor, but not so in small cities. There, if you make a mistake by under-treating a patient — say you send 91-year-old Mr. Jones home alone and he falls and dies — everybody in town knows about it.

It’s a great read — and one which gives serious thought to the issue of what constitutes appropriate reimbursement for appropriate medical care in very rural areas as opposed to even moderately-sized suburban populations, and how far one facility will go to stay in business for the sake of the community it serves. | LINK

1. Terry Hill — a rural health expert [↩]

As with any specialized year-end list it is only natural to speculate what all of the changes described in those recaps will mean for the year, or in this case, the decade ahead. Already, niche pundits are eagerly awaiting the arrival of high profile events in early 2010 which highlight everything from the new winter Fox TV broadcast schedule (American Idol’s 9th season) to what’s next in gadgetry (CES 2010, Las Vegas) — and let’s not forget the biggest upcoming showcase of them all, at least among Mac Heads: the Mac World Expo in San Francisco.

But what about health policy?

Although Washington gets back to business next week, the hoopla surrounding the merging of the Senate and House versions of the reform bill is rather lukewarm — for innumerable reasons spelled out in this blog and all over the healthcare blogosphere in 2009. In spite of this historic bill pending Obama’s signature making it into law, the focus of health policy — for this year at least — will be on what will happen to healthcare delivery in spite of the language expressed in the final passage of the merged bill into law. Because of this, many health policy pundits, like myself, will be closely watching forces which will continue to define the heatlhcare marketplace — the economy within the economy which drives the institutions of Pharma, Insurance, and medical tech and devices in this country in influencing our health coverage. In turn, these two-ton pachyderms in the ongoing debate of health reform will spur interest in how the processes of healthcare systems, IT, patient-centered issues (the patient safety movement, consumer directed healthcare, patient healthcare disparities), and myriad other forces will set the trends for care delivery in the coming decade of the 2010s.

The groundwork has been laid. Now, we’re off and running.

On this obligatory blog post (because all blogs have them on days like this) I acknowledge the transition from one decade to the next. Sure, it may be easy to recap the previous year at this time. But the decade? Many media outlets seem to carry the extra heft it takes with such decade-ending recaps and seem to do it with relative ease. I won’t even attempt to do that in one post; it will just have to take me the entire year to do it.

So, on this day, New Years Eve, I will resolve to only make one resolution — one that is practically already filled: that I will try to find the perfect symbol to make that transition from one year to the next; one decade to the next; and, one healthcare era to the next. What better way to do that than with song?^[1] Kenny G., take it away.

1. Actually, this gives me an excuse to try out my new Grooveshark music widget… [↩]

I crave writing on topics from which I seem to directly benefit. For one thing, plopping down in front of the keyboard with one eye on my browser’s feed reader and the other on the steering wheel (just kidding) and pontificating on the next big healthcare policy point can take some energy. The only thing that can supply me with another bolus is — you guessed it — coffee. And I’m not talking about calorie- and fat- laden $4 cups of caffeinated status symbols — I mean the basic brain-jolting, heart-pumping, mania-inducing black stuff (hold the sweetner, please!). There’s nothing like it.

And seeing as how a simple unadulterated cup of morning joe definitely benefits me, you can imagine the relative ease and speed it took me to get this post up today. That’s right, as a physician, it’s very easy to relate a health benefit to one’s audience of patients if said physician benefits from the intervention himself. Apparently, I have been benefiting from my low-calorie, high-nutritive brown energy drink for almost 20 years now; and I think the medical establishment will continue to publish the health benefits of something your parents always told you stunted your growth. That’s very cool. | LINK