The cornerstone of the ACA is the provision for a coverage mandate — whether that coverage includes complete subsidized services (Medicaid or another fed subsidized program) or via private insurer. In order that individual states comply with this most essential of the reform law’s benefits, HHS has announced that states have the option to create “essential benefits packages” as a method of increasing compliance within the ACA.
“Flexebility” is the key, according to Secretary Kathleen Sebelius.
The national health law lists 10 categories of health care that all insurance policies must cover: hospitalization, emergency care, out-patient services, maternity and newborn care, mental health and substance abuse services, prescription drugs, laboratory testing, preventive and wellness care, pediatric services (including dental and vision examinations), rehabilitative care and habilitative care such as services for children with developmental disabilities. But within those categories, the federal government is allowing each state to determine its own basket of essential benefits by choosing a “benchmark” package offered by any of a variety of insurers.
Sebelius: This move protects consumers by respecting states’ role in healthcare delivery under the ACA. Obama administration: This is the only way in which the mandate can be upheld while making essential services affordable in all fifty states. Consumers? Increased standardization among offerings of basic services by states under the ACA raises the possiblity of mandated coverage rather than making things too onerous for the feds in getting the legislation off the ground in just a couple of years. | LINK
In an effort to track physician referral patterns, some hospital systems are resorting to detailing to increase revenue. Much like the pharma reps hired by their respective companies back in the day, hospitals are hiring these paid ambassadors — many former pharma reps – to trumpet favorable care data in order to buffer the bottom line. Hospitals say they are doing this to better streamline care — especially among providers who split referrals among hospitals, thereby cutting administrative waste in this regard. Proponents call these detailing visits to primary care offices liaison-like – initiatives allowing providers a voice from beyond the hosptial arena in an affort to enhance patient care quality. They are also quick to point out that hiring former pharma reps displaced by shrinking sales, fewer NDAs, increased generic availability, and general prohibition of access by reps by healthcare orgs only benefits the economic sector in a flailing economy.
Hospitals say their new sales approach is part of a broader strategy to develop closer ties to physicians, who largely determine where patients go for care. Hospitals also are buying doctors’ practices or forming closer partnerships with physicians to improve care and drive admissions.
Like it or not, healthcare delivery is an industry in this country. In one sector in which market share is showing a tremedous decline, there jumps in another opportunity to create new platforms for innovation. As long as no antitrust issues occur, there should be room for the experimentation of new avenues to enhance quality of care delivery. As the components of care delivery (ambulatory versus inpatient, for example) become more specialized in their own right, it will be interesting to observe this effort by hospitals to grow and innovate in an increasingly crowded healthcare marketplace, allowing regulation by government entities only if patient care is truly at risk. | LINK
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
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.
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
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
Just under 13 percent of skilled long term care facilities here in Minnesota are part of a project that is aimed at reducing the “supply side” of potentially unnecessary hospitalizations in the care of their elderly patients. The three year initiative is based upon data already gleaned from smaller tests and it essentially involves going back to the fundamentals of physical diagnosis — from all members of the skilled provider team.
“The problem is the doctors,” [Dr. Robert Kane, a University of Minnesota aging expert who is helping lead the experiment, said.] “Physicians familiar with nursing homes learn quickly to trust the precise information from nurses using the Interact tools. But for the others, especially nights or weekends, the default is hospitalization.”
I like to think of this as a recognition about what physicians have always known about medicine. Nothing substitutes for a thorough physical exam, regardless of who the examiner is. Any effort to utilize the good ol’ noggin to diagnose and treat without the knee-jerk rush to the hospital ED to provide primary care is always preferred, and it saves the proverbial bean counters on the acute care side of things (hospitals) of having to deal with yet another inappropriate admission. | LINK
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
With the continued destigmatization of some forms of mental illness in the community (namely, the diagnoses of depression and anxiety), it comes as no surprise that we are more willing than ever to discuss treatment and prevention more openly. Oh, and it also doesn’t hurt that — within the general population at any given time — 10 percent of Americans are taking an antidepressant.
According to the Centers for Disease Control, the rate of antidepressant use has skyrocketed by a factor of 4X over the past 25 years. Females lead the pack in all age demos save for the youngest — ages 12-17. Interestingly, income status was not a predictor of use, the agency cites; although, slightly more than 1 in 12 persons taking the drugs is Caucasian. Most disturbingly, though, is the apparent lack of care access or followup once these drugs are prescribed: just under a third of patients have seen a mental health professional (or primary care physician — assuming the drugs are possibly given for off-label uses) within the previous 12 months. Excellent survey data here.
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
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.
