One axiom is certain in medicine: there is always room for controversy. And that’s good, because it spurs further scholarly thought and research — both qualities can only help patients and providers in the long run. With the current discussion in the media regarding the utilization of the PSA in determining the course of action in prostate cancer screening, so many fundamental issues surrounding patient informed consent, unnecessary treatments, and the potential harms from treatments — can serve as valuable teaching points for patients and current and future physicians alike. The discussion — highlighted in the current NEJM — really brings this point home.
Watchful waiting and active surveillance may help prevent the conversion of overdiagnosis to overtreatment, mitigating the harms of screening that are so accurately portrayed by the task force. … we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostate-cancer treatment. We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve…
New rules for accountability care organizations out today from CMS may please providers amid reports of inefficient care delivery models and quality. When the feds released initial ACO rules earlier this year, the process was met with major rounds of criticism with physicians barking the loudest. As a group, its top concern was the financial risk involved (lowered reimbursements amid higher penalties) in agreeing to participate.
Quality benchmarks in EHR adoption and clinical outcomes in certain key chronic medical diagnoses as part of the ACA-mandated rules have all but been retooled with the release of new ACO parameters.
The regulations reduced the number of quality measures by about half and increased the financial incentives for providers. The changes won preliminary praise from major trade groups and professional associations, which moved quickly to digest hundreds of pages of rules from multiple federal agencies, including the CMS, the Federal Trade Commission and the Justice Department.
Enhanced opportunities in order to improve quality amid a decrease in the perceived risks of doing so. With this new credo in place, many initial hostilities toward the inclusion of ACOs within the scope of reform may be tempered just a bit. | LINK
A new study out of Harvard finds that approximately a third of all Medicare beneficiaries in the last year of life chose to have a major surgical procedure. The operative (excuse the pun) issue here is whether such timed, elective surgeries are necessary — implying a possible increase in life expectancy. Problem is, no one knows when the beneficiary will die.
By analyzing Medicare claims data the study authors found that, in a group of almost 2 million elderly beneficiaries, all of whom died in 2008, almost one-third had inpatient surgery in the year before they died, almost one in five in the last month of their lives and almost one in 10 in the week before they took their last breath.
The study itself is a good lesson in who exactly “benefits” in these cases. As futile as these findings may sound, there is no question that any procedure done within FFS Medicare coverage remains a reimbursement cache for the provider and hospital, crudely suggesting a financial incentive. While this scenario is entirely possible, it really doesn’t seem to be the impetus for the study’s findings, in my humble opinion. Besides being reflective of a cynical and laconic way of approaching the study’s results, it really makes no sense in a healthcare delivery system increasingly focused on positive outcomes (read: anything but mortality or unacceptable morbidity). The study, however, does usher in the need to discuss the perennial issue of quality of life versus the “appropriateness” of acute surgical treatment among consenting patients with significant chronic illness.
As a geriatrician, another reminder of the work that I do and why it is so important in today’s delivery of healthcare as it relates to chronic, complex diseases (especially with the explosion in the sheer numbers of Boomers into that hallowed 65-and-older territory):
Some 89 percent of the state’s medium and larger hospitals offer palliative care — which focuses on easing pain and discomfort while often continuing aggressive treatment. That placed Minnesota among seven states getting an A in a report released Wednesday by the Center to Advance Palliative Care at Mount Sinai School of Medicine in New York City.
The report also cites cost-of-care decreases in aspects of delivery of care to the very infirmed while noting the provisions of dignified, compassionate care characteristic of established palliative care programs. Imagine that. | PDF LINK to report
The rise in prescription drug abuse in this country has been muted somewhat by the traditional messaging by anti-drug campaigns which advocate the overarching “just say no” philosophy … and have done so since the heady days of the Reagan administration some 25 years ago. A different kind of advocacy is needed, say the appropriate groups; that is, one of attention toward the ripple effect of the “other” illicit drug — the prescription narcotic (including, most notably, hydrocodone and oxycodone).
In scenarios in which the levels of violent crimes (pharmacy robberies and assaults) are belied by the common perceptions of acquisition of such drugs (petty theft, paper script forgeries, etc), it’s easy to see why some say the FDA has been lukewarm at efforts to control this burgeoning problem.
The 12-year delay in the federal regulators’ final decision about hydrocodone – the second most-abused pain drug – has been agonizing, to say the least — all the more so as the Drug Enforcement Administration and Food and Drug Administration are apparently still studying whether to move hydrocodone-containing medicines to Schedule II category of medicines from the less restrictive Schedule III. Advocates for tighter controls over hydrocodone opine that it is time the government took concrete action to save lives — since a study funded by the National Institutes of Health has shown that nearly 8 percent of the 12th-graders in the US have abused hydrocodone in the last year.
The agency says many factors — chief among them the logistics involved in augmenting widespread training and retraining of healthcare providers as to the merits of prescribing in this new climate of addiction — have complicated movement forward on the matter. It’s a problem that’s not going away anytime soon. Those hoping for a sweeping decision by the FDA to correct things are better off considering scenarios in which the government agency can partner with other entities to begin to address oversight in prescribing lapses, formulary monitoring, and drug utilization reviews in healthcare organizations. | LINK
It’s not every day that the typical Veterans Admin medical clinic sees a burgeoning number of female vets. Perhaps that’s why the VA has employed only around 60 percent of its female providers in all of its nationwide community-based clinics. Although there is a dedicated provider of womens health services at its more than 150 medical centers, the VA is acknowledging that there is a definite treatment deficit in this area of healthcare delivery.
The VA has been bringing doctors and nurse practitioners by the hundreds to mini-residency programs like this one outside Orlando, Fla., focused on women’s health. A key component of the training is performing pelvic exams on live models — typically volunteer nurses — who critique them.
These mini-residency type programs could grow in number in other (private, non-profit) settings as healthcare reform gets ramped up. In the case of the VA, the federal government is calling the shots to improve healthcare delivery to meet a patient-as-consumer need. In the general healthcare marketplace, Insurance could be making that call. | LINK
An observational trial published in the latest issue of Annals shows that the initial savings to overall healthcare costs incurred by acute hospitals with hospitalist (hospital-based physician) care are offset by increased costs to Medicare in spite of the earlier discharges of beneficiaries (0.5 day on average shorter than those patients without hospitalist care).
Most of the extra costs stemmed from re-admissions and patients being sent to nursing homes instead of home. But there’s no clear explanation for the findings.
“Under pressure to shorten length of stay, hospitalists may be willing to discharge sicker patients, leading to increased re-admissions,” Dr. Lena Chen and Dr. Sanjay Saint of Ann Arbor Veterans Affairs Medical Center wrote in an editorial, according to Reuters, which was first to report the study.But they added that unmeasured differences could also play a big factor.
Besides the fact that this study is observational in nature, and therefore immediately affected by selection bias, it does shed light on areas to be studied further — including disease-based criteria for discharges based upon DRGs, the effect of preventive medicine on readmission rates in Medicare patients, and the impact of undocumented acute care complications at discharge (eg, medical errors). The proverbial tip of the iceberg is at play here. Still an interesting read, though. | PDF LINK
Much has been written of late regarding the initial media presentations of the virus that causes AIDS and the de rigueur comparisons to how far awareness, activism, and innovation have propelled its discussion to every corner of the planet in 2011. Its chilling descriptions more than thirty years ago cannot belie the fact that, in spite of advances, there is still much to be done on the road to eradication and cure. Within this paradigm is the notion that an entire generation or two have witnessed how the existence of HIV/AIDS has shaped healthcare policy in this country and worldwide.
Here in the U.S., the specter of the aging patient with this now “manageable chronic disease”, the numbers of patients this will represent, and the availability of physicians knowledgeable enough to not only treat chronic HIV disease but also its unknown effects in the increasingly “geriatric” patient — are gaining consideration and acknowledgement in policy circles. Discussion almost always leads to the role of the primary care physician in not only screening but also becoming an active treatment provider.
In 2009, a record 82.9 million American adults were tested for HIV. [...] By 2015, the IOM estimates that half of Americans living with HIV/AIDS will be older than 50. For primary care doctors, this means a growing number of their patients will need care for chronic diseases as well as HIV.
Today’s generation of physicians has inhereted the mantle of providing care for a disease whose spurred innovations ranks as one of the greatest medical achievements of the last century. It is time to consider the primary care approach to chronic HIV disease as another fundamental skill set as reform redefines healthcare delivery in the 21st century. | LINK
How does obtaining health coverage (insurance) compare to not getting it at all? According to a trial published via the National Bureau of Economic Research (Harvard/MIT), beneficiaries’ quality of life was enhanced and made a “big difference” in those patients’ self-health perceptions and their daily outlook — according to the study’s lead author. A quick glance at the results confirms that all encompassing statement, especially since the study employed the diagnostic “gold standard” in trial research by utilizing a randomized, controlled design.
Taking a look at approximately the first year of coverage for Medicaid beneficiaries in the state of Orgeon, the study showed that healthcare expenditures for those who got coverage increased by almost $800/year. Those who received Medicaid were around 60 percent more likely to get mammograms. Medicaid recipients were over 50 percent more likely to have a regular primary-care doctor. They were also in better shape financially and less likely to have unpaid medical bills. Those who got Medicaid were also far more likely to report themselves in good or excellent health. ED admissions did not decrease; however, the increase in ED utilization by beneficiaries was not statistically significant.
It is clear from the results that coverage, in and of itself, has a positive effect on patients’ perceptions of health and wellness. What is not documented as much at this time is how this translates into outcomes with respect to various chronic problems such as obesity, diabetes, and risk factors (such as serum cholesterol, blood pressure, etc.) for heart disease. Also, it is unclear how these results translate into real numbers once reform increases Medicaid rolls substantially by 2014. Researchers plan on following the participants for at least another year. | LINK
For the first time, a major private coporation is partnering with a local hospital in assisting Medicaid beneficiaries in obtaining legal assistance in squabbles with the entitlement over public health care delivery, housing, medical equipment, and other basic needs guaranteed by Medicaid. It’s not just any partnership. The corporate entity is Wal-Mart, and it insists it will not be an adversarial force to the feds. The retailer’s involvement with a local Arkansas hospital is being piloted and could become a model for future national rollout. These medical-legal partnerships, as they are called, are designed to promote changes in the healthcare public-private policy sphere by becoming part of the beneficiaries’ heatlhcare team — alongside providers and hospitals.
Onsite, legal professionals become a part of the healthcare team. Doctors will refer patients to lawyers for legal assistance when appropriate. Just as a pediatrician refers a patient to a radiologist for a broken bone, a healthcare provider may refer a patient to an onsite attorney when an underlying social circumstance impairing a patient’s health is detected.
Lest one believes that this is some conservative vs. progressive battle implemented by activists to inflame further the current drive toward reform in this administration — think again. These MLPs have the backing of the traditionally liberal-leaning American Bar Association. It is the hope of the parties involved that providing this type of legal assistance to Medicaid beneficiaries will usher in a new area of accountability by building broad public-private networks with a common goal enriching Medicaid care delivery as reform begins to take shape. | LINK
Getting the word out about all the preventive services available to Medicare beneficiaries is about as easy as wiping out fraud within CMS completely. But that’s not stopping HHS from pulling out all the stops in an effort to curtail future spending on preventable medical problems.
On Monday, HHS Secretary Kathleen Sebelius announced that the agency was launching a publicity campaign, known as “Share the News, Share the Health” to alert Medicare patients, their doctors and their relatives that the services are available at no charge. “Our job is to make sure every single Medicare beneficiary in the country knows,” Sebelius said.
Chalk it up to a (political) campaign by the federal government to get patients knowledgeable and accepting of the benefits afforded them under the reform law. Overall, this effort is a good thing. At its most superficial, it is a way to catch disease earlier, implement higher quality care delivery for less ill patients sooner, and it represents a time saver for the primary care physician, freeing him from informing the beneficiary in order to make the most of the covered physician service/visit. More profound, however, is the stark effect this initiative could have on patient empowerment — as only slightly more than 10 percent of beneficiaries takes advantage of at least one of the covered preventive medical screenings and services.
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.
RT @Ziggy_Daddy: Hunger Growing Problem Among Seniors | Crooks & Liars http://t.co/FRRGv4d4 But hey #GOP, let's turn #Medicare into a voucher system, right?
The First Wearable Computer Was Used For What? http://t.co/fEb902GA #WearableComputing #DigitalHealth #mHealth (Spoiler alert: #Gambling)
RT @FierceHealthIT: #FCC expands wireless spectrum for mobile medical monitoring http://t.co/UdFc8aAa #HealthIT
On my way to the airport for Your Death Your Choice Community Forum! #YDYC http://t.co/GyBMh8kw #hpm #eol #palliativecare
RT @ScrubsMagazine: "Knock knock"..."Who's there?"..."#HIPAA"..."HIPAA who?"..."Sorry, I can't tell you that!" What's your favorite #nursing joke?!
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.
