Against the backdrop of the so-called safety net hospital (those with heavy Medicare, Medicaid claims utilization) as a healthcare-related industry and campaign ’12 meme, there is interesting data out in JAMA this week that either supports Mitt Romney’s assertion that the “very poor” are taken care of in this country quite adequately, or there is reason to believe that P4P measures (or, at least the idea, anyway) are superficially quite similar in non-safety net acute care centers in terms of ultimate patient dispositions.

Researchers studied whether patients were admitted to the acute hospital within eight hours ED admission or if they were to be discharged, transferred or moved to observation within four hours of coming to the ED. They found that

compliance with proposed ER length-of-stay measures for admitted, discharged, transferred, and observed patients to not differ between safety-net and non-safety-net hospitals

Although length-of-stay (LOS) data is interesting, it is not compelling — quite limited in its implications, actually. Currently there is no “accepted” ED LOS strict guideline in the U.S. Digging deeper into this study (abstract-only text cited above available without a JAMA susbscription), one can infer more from the upper decile of data — in which LOS significantly increased among both types of institutions (10-15 h in length), the authors citing mostly acute patient decompensations in mental illness as the reason for protracted admission LOS.

Still, the trial provides renewed attention over a surrogate care parameter just a few years ago was hailed as an agreeable target upon which to base healthcare reform on spending within the government sector. These days, the study may only serve as yet another reason why P4P as a quality measure is so derided by many as the ACA is just beginning to take hold.

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We’re inching closer to the multi-day arguments set to happen before the SCOTUS regarding the constitutionality of the ACA, specifically, the individual mandate provision. A Kaiser Foundation tracking poll indicates that a third of all voters (respondents) think that the entire law will be revoked if the high court finds the plaintiffs’ assertions has cause. Perhaps what is more important is the fact that Americans remain divided over the issue of the existence of the law.

As the anniversary of the Affordable Care Act approaches on March 23, Americans remain as divided on the law as ever, with 37 percent in January saying they have a favorable view of it, and 44 percent having an unfavorable view. At the same time, the share of the public that favors expanding the law (31%) or keeping it in its current form (19%) remains larger than the share who would like to see the law repealed outright (22%) or repealed and replaced with a Republican-backed alternative (18%).

Mitt Romney, the probable GOP nominee for president, will have to exploit the differences between presiding over the initiation of the reform law’s progenitor in his home state of Mass. and Obama’s finished product — backed by the full faith and support of Big Insurance. | LINK to study PDF

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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

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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

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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

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As a follow-up to a DP post on the unusual strategy pharma company Pfizer is implementing in trying to protect market share for the formerly solely branded drug Lipitor, here’s another take on the issue. According to one analyst profiled, Pfizer faces an uphill battle in trying to convince the pharma marketplace that its branded agent is more clinically efficacious than generic atorvastatin.

Pfizer is doing a so-so job of convincing health plans and [pharma benefit managers] that Lipitor is somehow better than a generic. On a scale of 1 to 10, Pfizer received a 4. Nonetheless, 54.8 percent say they will offer the authorized generic, which is being sold by Watson Pharmaceuticals. Meanwhile, only 30.4 percent report they will receive added rebates or discounts from Pfizer.

Of course, the pharma company stands to lose a ton during its loss of exclusivity over the next 6 months, but it will remain tenacious — as many analysts do not believe future antitrust issues will occur. Perhaps even more interesting is the new ground being broken here: can healthcare consumers be weaned off of generics and stay loyal to branded medications — if insurers and key third parties allow them to gain incentives by continuing to utilize them? | LINK

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Medicare will now expand its breadth of covered preventive services to include obesity treatment and management. In what could be a sign of the increasing population of beneficiaries who were weaned in the Boomer mentality, treatment coverage for such a hot-button topic among politicians, lobbyists, healthcare advocates, and physicians themselves — will remain, indeed, controversial. According to CMS, obese Medicare beneficiaries (defined as those with a body mass index of 30 or higher) may see their primary care physician for one face-to-face visit every week for the first month. Then, Medicare will pay for one face-to-face visit every other week for the next five months. If the patient loses at least 3 kg (6.6 lbs.) over the first six months, Medicare will pay for an additional six months of once-a-month face-to-face visits with the doctor.

Insurance remains above the fray here. While the feds may explain away this coverage as putting a dent in future healthcare costs associated with the obese patient, the fact remains, that outside of a universally defined pragmatic treatment regimen (ie, dedicated drugs = dedicated reimbursements/payments) — provider acceptance of this latest move by CMS will continue to advance at a trickle. It’s hard to get on board with yet another taxpayer funded government initiative whose intentions really haven’t been proven to lower across-the-board healthcare costs, lower all-cause mortality, and assume that all physicians are competent weight-loss counselors. Also: about 30 percent of beneficiaries are projected to qualify for this latest Medicare preventive care benefit. | LINK

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Political coalitions here in Minnesota have largely towed the Democratic line, having gone decidedly blue in the last presidential election in spite of reports that the state was a purple one “in play” in an ultimate result that was anything but close.  The building within the democratic base also stands to reap benefits with respect to the reform law by its inception in 2014.

This, according to an MIT healthcare economist.

[Jonathon Gruber] told members of a governor’s task force Thursday that the federal health care law will reduce the health insurance racial disparities in Minnesota. [...] Gruber projects that almost 300,000 additional Minnesota residents would gain insurance coverage by 2016, and that those who currently buy health insurance on the individual market could pay 20 percent less in premiums after taxes.

Gruber was speaking in terms of the savings generated by increased access to healthcare with the advent of exchanges under reform. Dem Governor Mark Dayton has recently formed a couple of healthcare task forces — one of which will exclusively work to develop an exchange to increase access to the state’s un- and under-insured. | LINK

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Robbing Peter to pay Paul — in terms of Medicare cost sharing, that is. A new Medicare benefit design will enable increased costs for lower utilizers of the government entitlement (relatively healthier beneficiaries). This limit on cost-sharing among beneficiaries would decrease the costs per sicker beneficiary for, say, acute visits to the hospital rather substantially, leaving those who do not use services as much shouldering the burden.

A melding of the services by hospitals (part A) and doctor visits (B) as they relate to deductibles, plus a requirement that participants pay 20 percent toward a $5500 limit would increase the payment of almost 75 percent of beneficiaries (the lower utilizers of acute care) by almost $200/month. My take? It’s potentially a mechanism for some savings by the federal government, and it may give more ammo to Republicans who are interested in tiering beneficiary eligibility — such as via so-called means-testing.

All this in an interesting study via Kaiser. | LINK

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Is it too early for this sort of news, or is a political agenda afoot? According to a new Gallup survey, the nascent reform law is still leaving a significant amount of uninsured without adequate coverage from employers. Ditto for the elderly and the government.

Some of the main components of the Affordable Care Act, such as tax credits for small businesses that provide health insurance to their employees, and the establishment of a pre-existing condition insurance plan, have done little to boost Americans’ health coverage, the survey found.

This report comes on the heels of a recent appeals court decision reaffirming the constitutionality of the law and its coverage mandates. It’s no secret, however, that the ACA is still struggling to get in the good graces of the majority of stalwart congressional Republicans and some Dems. Still a little early to say if the report will gain traction ahead of the first GOP primaries in less than two months; but, it represents another PR hurdle the law’s proponents must overcome on the road to reclaiming the White House in ’12. | LINK

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