The huge drive to immunize the masses against threat of H1N1 in the 2009/10 influenza season (which the WHO has officially declared concluded) has created more than a watershed moment in 21st century public health response to a potential biological catastrophe, it has also touched off a political debate that’s just getting started. And it all has to do with authoritarian mandate of the vaccine for healthcare workers.

Contrary to popular thought, many healthcare workers do not receive the vaccine; in fact, approximately 40 percent of said workers actively refused [PDF link] the vaccine last year — during infection’s peak. This notion does not sit well with a couple of policy organizations — one academic and one medical. Both groups say mandatory influenza vaccine should be a condition of employment. The groups stress increased availability of the vaccine, a steadier supply of healthy workers to administer care in times of a crisis, and an overall decrease in the incidence of influenza-related deaths in already compromised inpatients with other medical problems.

Already, the state of New York is hard at work in developing regulatory actions for its public healthcare workers. | LINK

Just how effective are vaccines at keeping mass pandemics of infectious disease abated? Well, it may not be so easy to estimate.

[T]he number of annual flu-related deaths in the United States has ranged from a low of about 3,300 to a high of about 49,000. This is a revision of the static estimate of 36,000 annual deaths that has been reported consistently for years by the U.S. Centers for Disease Control and Prevention.

The CDC has revised its projections on the preventive care of the seasonal influenza vaccine, moving from statistical dead targets to ranges of mortality among influenza outbreak figures. Its projections cover most of the past 30 years (up to 2007, and not inclusive of last year’s H1N1 pandemic). | PDF  LINK to latest issue of CDC’s Morbidity & Mortality Weekly

Health care coordination seems to the mechanism by which many healthcare pundits on either side of the the debate agree on how significant waste in spending can be cut. North Carolina’s Medicaid program is utilizing the medical home model as an example of that type of care coordination.

Moving beyond Medicaid FFS and traditional managed care partnerships, the delivery of care in this context identifies the appropriate patient populations based upon services meeting certain primary care needs. Physicians are paid higher reimbursements and a specialized “care-coordination” fee as incentive to continue participation. Community care networks made up of primary care teams in multiple locations serving Medicaid enrollees are headed by physicians and serve as the de facto health plan for those patients.

This model is another example of putting state healthcare spending to practical use, empowering physicians who manage it not only to have a stake in its success but also to remain intimately involved in quality healthcare delivery at the state level. | LINK

What do you get when old-fashioned community activism meets 21st century social media tech? Perhaps the best politics-is-local example of reforming healthcare access so far after its passage on a national scale. Howard County, Md. – approx pop. 250 000 — is partnering with a tech firm with one simple goal in mind: to guarantee access to healthcare for its uninsured.

Its mechanism looks to be a harbinger for reform-based enterprises such as local healthcare exchanges/cooperatives (whether subsidized or not) within which members pay a monthly fee for basic services. These services may run the gamut of primary care — as acute hospitalizations, preventive medical treatments and screenings, and emergency medical access would be covered.

Perhaps even more important, the utilization of concierge providers as healthcare “coaches” as both an empowerment mechanism and compliance tool, ensures continued healthcare access, sound preventive care, and decreased future healthcare costs. Will it serve as a model for state-based healthcare exchanges under reform? Looks like it’s on its way. | LINK

In a reform environment in which appearances are everything, providers could be looking to the AMA for some help. Some physician groups/health systems, the AMA says, could be unfairly targeted by insurers’ quality ratings to steer patients toward systems they deem more “efficient”, creating a somewhat dubious practice reputation for those health systems cited as “inefficient”. Insurance companies counter that, in this age of reform, the delivery and coverage marketplace will have to adapt to measures, they say, are being mandated by the Obama administration as necessary mechanisms of reform and quality.

The AMA is particularly worried about individual physicians being rated by insurers. The doctors’ group says physicians who are deemed expensive may be looking after sicker patients, or the claims data may simply be inaccurate.

A very simplistic view by the AMA, as the 21st century patient and healthcare consumer is able to make informed decisions on provider networks based upon resources unavailable to them just a few years ago. Patient advocacy groups, disease advocacy organizations, support groups, and … even insurance companies themselves are sources of care informatics designed to “steer” patients to where they should be seeking care based upon the best available data matching their unique chronic care needs. Healthcare quality doesn’t just appear out of nowhere; it must be earned. Patients cannot benefit from it without physicians who are capable of providing it.| LINK

As President Obama’s vision of healthcare reform begins to gel in the minds of physicians, health systems, insurers, and policymakers alike; the phased rollout of coverage mechanisms by Big Insurance will provide a timeline of sorts into the character of reform from a third-party perspective.

Via mandates, deadlines, and tax breaks; insurance coverage will be moving forward in the first half of the 2010s at a deliberate and measured pace — eventually covering some 30 M Americans without coverage and adequate access, as promised by Obama. One of the care delivery mechanisms is in the coordination of care of those with chronic diseases (such as diabetes, obstructive lung disease, and asthma) and the incentivization of primary care providers in those systems who choose to embrace such a plan.

Coordination of care reduces the fragmentation of delivery to those with chronic illness. Improving referral systems, rewarding primary care providers’ participation in innovative models such as the medical home, and emphasizing the importance of preventive care services in reimbursement schemes are important first steps to increasing access, decreasing acute care costs, and increasing quality in healthcare delivery. | LINK

The U.S. Preventive Services Task Force, an independent, non-partisan body made up of primary care physicians involved in developing preventive medical guidelines based upon evidence-based medicine, has always reveled in its staunch self-governance. That could change ever so slightly in the new age of health reform.

The academic research-oriented group will continue to make recommendations on best-preventive practices and supply ratings (“A”, “B”, etc.); but this time, under reform, insurers will be required to cover services that receive such a rating. The Obama administration hopes that this increase in access (which will require a small premium increase by insurers in the near term) will reap savings in the future — as costs for preventive testing, screening for certain chronic diseases, vaccinations, and well-child visits would be covered (without health plan co-pays and deductibles) if so rated by the USPSTF.

Besides having to consider methodology involved in formulating its ultimate recommendations, the group will also have to contend with the specter of political agenda setting if lobbying groups and disease advocacy organizations have their way under this bit of legislation — scheduled to go into effect in September. | LINK

What is known about the H1N1 epidemic that plagued the world in 2009 was its influence in global approach to this infection — for good or bad — and the costs to nations which chose to meet its threat head on. What wasn’t known at the time (but may be increasingly apparent if many European countries have their say) is that the trajectory of the influenza strain’s influence as a major media event may have been manufactured, by, of all entities, Pharma and its association with the World Health Organization. The concerns are outlined in an 18-page report criticizing costs deemed by many nations as unnecessary, as were “amplified” fears at the hands of the organization in galvanizing support for guidelines influenced by Pharma makers of the H1N1 vaccine.

Calling the WHO and its response to the H1N1 epidemic “exaggerated” and “lacking credibility”, many European nations are quite vexed that, among other things, guidelines issued by the WHO in response to what it termed as an epidemic came from consultants who received much in the way of fees from two leading Pharma manufacturers of the vaccine that would prevent the virus’s spread: Roche and GSK. The WHO has opened up its own international investigations into the matter — one of which involves the Institute Of Medicine on these shores.

The WHO asserts no potential for conflict of interest within its ranks, as this appears to be the central question in this entire matter. | LINK

Until today the major significance of June 1 was important for two healthcare policy-related developments: the initiation of the restructured GAMC safety net here in Minnesota, and the one-day nursing walkout. Since the latter is rescheduled for the 10th, the former kicks off today with as much uncertainty for its future stability as those ongoing nursing-hospital talks are currently demonstrating.

With the new focus of GAMC as one of operating within a strict healthcare (capitated) budget of sorts, many beneficiaries of the program in its former incarnation are not only finding it as challenging to negotiate it in order to retain the level of care they have gotten used to; they are also realizing that its current policy is somewhat finite and inflexible.

That is, until they are able to take advantage of a state-run program using matched federal funds later this year, they are realizing that access to that care has just become as complicated — almost intentionally so. Such is the case of a Duluth man with schizophrenia who now has to travel to the Twin Cities in order to receive the care he has become accustomed to, by necessity.

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The battlelines are drawn in the latest medicolegal war which tests how far patient activism can go when the patient asks for, rather demands, a particular treatment regimen unproven in the pantheon of well-studied and documented clinical medicine. The treatment of Lyme disease, an infectious disorder in which the deer tick (found in abundance here in Minnesota) acts as a vector of transmission, is under fire from patient activist groups who say that they aren’t being treated effectively for the disorder’s possible long-term effects, which can be disabling.

Pity the role of infectious disease experts who are often called upon to consult and produce national guidelines based upon sound medical and clinical research. These intrepid physicians now have to navigate and overcome the legislative process which appears to be siding with patients who feel as though they are being maltreated. In Minnesota, the state medical board (which regulates, disciplines, and licenses physicians) has had to initiate a moratorium against actions that may arise out of patient complaints with respect to the treatment of Lyme disease. Elsewhere, activist groups are gaining steam and appear to be influencing its evaluation, classification, and treatment^[1] without the involvement of physician specialists and experts…and with the support of lawmakers. | LINK

1. which often involves the unproven use of chronic antibiotics, for a year or more.. [↩]

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