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
Are the citizens of Minnesota ready to take a look at prototype models for healthcare exchanges? The marketplace stimuli as part of reform are being unveiled today. Although it may seem early for such exposure, MN must demonstrate that it can operate an exchange as part of reform much sooner — just over a year from now, in fact. Four companies have placed demo modules up for public review. Playing around with a couple of them, I get the feel of sites that are actually consumer portals into products that resemble reservation services, only instead of purchasing a flight or hotel accomodations, I am choosing a provider which can treat certain chronic conditions more cheaply, for instance, in one organization in comparison another based upon my personal situation.
States participating in this exercise which are not able to fully integrate these virtual exchanges at the outset of reform will get fed assists. Minnesota seems ahead of the curve here, as the governor has taken a seemingly personal role in getting this state’s offerings public and implementing diligent task-force support to the process early.
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
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
Twenty-eleven and 2012 are going to be remembered in the near term as very profitable periods of the generic manufacture of many formerly branded mega-sellers. Of course, the agent getting the most media ink this week is atorvastatin (Lipitor), the ubiquitous cholesterol lowering pill whose miraculous ways even prompted a short-lived lobby to go OTC.
The pharma company Pfizer, it could be reasoned, would still have some skin in the game in spite of generic availability. Specifically, partnerships with pharma benefit managers and insurers would still give the company a stake in orgs that would inhibit generic availability by offering rebates and discounts of branded Lipitor. It is the potential for actions like this which gets the attention of legislators (specifically Democrats) who want fair competition — as opposed to stymied innovations in generic marketing from pocketed profits by PBMs and insurance companies.
Detailed in an NYT piece last month, the prospect for limited availability of generics — specifically for Medicare Part D beneficiaries is a sobering one. Pfizer claims cost equivalencies (with respect to lower co-pays on branded Lipitor) for beneficiaries if the pharma company is able to offer those discounts to third parties. It is an interesting development in what is usually an uneventful and mundane process.
The year was 1989. Late summer. The pressure was on to perform. Whether it was due to studying inertia, laziness, or simply hubris — I elected to take the dreaded MCAT (the medical college admissions test) at the latest possible offering. Yes, I was reasonably confident of my standardized test-taking abilities, and I knew that my GPA could definitely hold its own. Still, as I look back on my senior year in college, delaying such an important and redoubtable requirement was pretty foolhardy.
Nineteen eighty-nine was also approximately the period in which the test gurus who formulated the exam took a curious turn and seemed to bend over backwards answering critics’ and educators’ assertions that the exam was too narrowly focused on the left-brain aspect of scholarship. What was needed, the sage designers of the MCAT decided, was a tool to measure the non-scientific literacy of those who were audacious enough to consider a career in medicine. Thus, the maligned essay question was introduced.
The body tasked with reviewing the MCAT’s current state of affairs has made its concerns with the exam’s future known, and it reflects a growing reality in the state of preparing those with an interest in medicine to be able to succeed in medical school. That medicine is constantly changing with respect to rapid advances in basic science research and social and economic healthcare policy trends is a complete understatement, one that is highlighted by the committee’s recommendations.
The new MCAT will preserve the best features of the previous exam, while ineffective sections (e.g.,the writing sample) will be jettisoned. The two natural science sections will be revised to focus on relevance to living systems, emphasis on critical analysis, and reasoning skills will increase in a revised verbal section; and a section on behavioral and social sciences will be added.
Yes, it has taken the testing gods some twenty years to kill the essay section. Well, here’s hoping that future practitioners of medicine will have the intestinal fortitude that successive iterations of the MCAT (starting in 2015) will now require — the quality of endurance. As it stands, testing length will increase by over 40 percent — to 6 hrs and 15 min. Ouch! Guess I’m glad my laziness didn’t get the best of me some 22 years ago! | LINK [PDF]
This item comes as no surprise to those of us who primarily treat the elderly.
According to researchers, nearly 100,000 hospitalizations every year are linked to adverse drug events such as allergic reactions and unintentional overdoses. Nearly half, or 48.1 percent, of those hospitalized were adults 80 years old or older.
Those agents? Insulin, older generation anti-diabetic drugs (oral), aspirin, and warfarin. It is quite true — and as equally disturbing — that these medications are not only responsible for discrete adverse drug reactions in their own right, but their pharmacological behaviors are responsible for a substantial number of interactions whose iterative clinical manifestations are truly logarithmic in scope. | LINK | Abstract LINK
For Don Berwick, MD, the path to greatness as head of the Centers for Medicaid and Medicare Svcs was essentially doomed from the start. President Obama’s choice to head the federal agency was one made via his executive powers, bypassing congressional confirmation and giving Berwick a scarlet letter on the forehead ever since. Sure, there were the efforts at priming the PR pump in the first year since the reform bill was signed into law — his efforts to eliminate the quality chasm in hospitals and other care settings, bringing new light and interest into so-called comparative effectiveness research to improve healthcare, and most recently, his support of a citizen-led innovation care advisory panel, of sorts, to create models of reform in cutting Medicare spending on the run-up to reform. But it was all for naught. Senate Republicans, miffed at the recess appointment at the outset, never were willing to give the new CMS head a chance. Rather than face an uphill battle with pending confirmation hearings amid a hellish re-election campaign, Obama decided to drop him in favor of a less controversial pick:
President Obama said on Wednesday he plans to nominate Marilyn Tavenner as administrator of the Centers for Medicare & Medicaid Services to replace Dr. Donald Berwick, who has never won the support of Congress. [...] Tavenner, Berwick’s principal deputy, was the Virginia secretary of health and human resources. She has served as a board member of the American Hospital Association and as president of the Virginia Hospital Association. Ms. Tavenner holds a B.S. in nursing and an M.A. in health administration, both from the Virginia Commonwealth University.
You can bet that this nominee will be a safer one — an administrator who can hold steady on policies of Medicare spending without being seen as a “rationer” of healthcare delivery whose ideas on cutting federal costs of healthcare will not be perceived as coming from a wealth redistribution model.
The DOJ decision has been handed down. Merck Co. will pay $321.6 million in criminal fines and $628.4 million as a civil settlement agreement. It also will plead guilty to a misdemeanor charge stemming from the premature marketing of the market-recalled drug targeted to treatment of rheumatoid arthritis, usurping FDA approval for that indication.
Merck agreed to pay an undisclosed sum to the states of Florida, New York and South Carolina to resolve suits alleging the drug maker failed to adequately warn patients of Vioxx’s risks before halting sales in 2004, Russ Herman, a lawyer for former users of the drug, said in the Nov. 10 filing.
For those who have already forgotten, Vioxx was yanked from the pharma marketplace in 2004 after evidence showed the drug doubled the risk of heart attack and stroke. In 2007, three years later, the company paid $4.85 billion to settle approx. 50,000 Vioxx-related lawsuits. | 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.
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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.
