The questions and lingering concerns surrounding the overuse of antibiotics is an age-old and well-worn conundrum for physicians and patients. Even the latter group, well-informed as consumers of healthcare, can agree that most acute upper respiratory infections are most often the result of viral infestations which play themselves out in spite of antimicrobial treatment.The decision to (over)use them in standard medical practice is often the point of debate, as physicians weigh factors such as patient satisfaction and lingering medical and health policy issues surrounding resistance.

Last year, this blog reported on these issues as background for a program in which some retail pharmacy chains were giving away for free antibiotics to patients with prescriptions from their physicians as a way of helping with affordability in the wake of the debate on reform. The CDC offered a statement promoting the responsibilities providers, pharmacists, and patients should consider in taking part in such a program.

Smaller chain pharmacies are trying to compete with the big boys, and in trying to earn store-brand loyalty among their (un- and underinsured) consumers, they are throwing free antiobiotics their way. Last week, the CDC sent out letters those several chain pharmacies that offer no-cost prescription antibiotics to low-income consumers urging them to promote responsible use of antibiotics.

While the program was essentially successful in its efforts to bridge the gap between affordable, accessible healthcare and patient responsibility, no one was really prepared for the massive policy decisions that would have to be made as the June ‘09 H1N1 pandemic loomed — after its initial discovery just one month after this initial Doctor Pundit posting.

It had all the trappings of a political football; a blue state’s extremely unpopular Republican governor — looking toward a possible presidential run a year after his term ends — used his partisan hardline to threaten veto of one of the most well-funded social programs for healthcare delivery to the state’s working impoverished, all the while setting the stage for a political attack on his character for all of the nation to see at the hands of the opposing party. The apparent newfound conciliatory stance taken by Minnesota governor and 2012 prez hopeful Tim Pawlenty concerning the threatened veto of GAMC headed this scenario at the pass, however, as the healthcare delivery safety net for thousands of the state’s working poor got a last-minute reprieve to continue being funded, albeit scaled back. Of course the negative PR surrounding a pending lawsuit by three beneficiaries of the program didn’t make eating crow any easier for the chief executive.

Though funding for the program was supposed to end on April Fools Day, the brokered change in funding commitment means that service providers will see less in reimbursements. Also,

[u]nder the agreement, hospitals will receive $71 million from the state’s general fund for the year starting July 1 and $131 million the following year. About 12 to 15 hospitals likely can start serving patients in the new program on June 1. For others not yet ready, $20 million will be set aside to pay for uncompensated care for six months.

The key is in acute care — often the first and only mode by which this underserved patient population will continue to receive care. With a decrease in monies to provide it — even with a grace period of sorts for charity care — the level of participation of acute hospitals is emblematic of both ongoing problems with funding (providing care) and simply surviving as they continue to operate in a program whose demand will only increase until reform is achieved on the national stage. | LINK

Pennsylvania and Hawaii are the only two states in the country that do not have a mechanism in place for the regulation of premium rates set forth by insurers as it applies to their small businesses — a demographic courted heavily by both Republicans and Democrats as players in the final direction of pivotal health reform. The Pandora’s Box cast wide open by the recent Anthem BC scandal is adding a new critical layer of scrutiny not only to Barack Obama’s reform trajectory, but also to the ways in which Insurance market fluctuations influence the overall cost of healthcare delivery and access.

Implications for the these two states are obvious, as government regulatory oversight could go a long way in keeping the relationship between small business and the insurance they purchase an open, transparent, and freely accessible system for consumers of healthcare (patients), giving states’ insurance commissioners added muscle. Alternatively, control of regulatory processes by the federal government could add just another layer of bureaucracy (read: increased administrative healthcare costs to the taxpayer and shifting rising costs to other entities — like Pharma) to an already overburdened HHS Dept. Over the next few days, the unfolding issue of federal gov’t Insurance regulation over state’s private insurance markets will become a hot-button one, adding some eleventh-hour drama to the health reform debate. | LINK

It’s often said that the beleaguered emergency department (ED) is the initial point of care for many patients. In this current broken healthcare delivery system, that means an umbrella which “covers” the uninsured as well as those who are underinsured. The total cost for these points of acute care notwithstanding, how is the best way to explain new numbers out of the CDC this week?

The CDC’s National Center for Health Statistics reported the numbers in its annual summary of U.S. data on disease conditions, health behaviors and use of medical services. The scan figures are based on visits to roughly 500 hospitals and 3,000 doctor’s offices and outpatient clinics.

According to this survey data, the CDC says that the use of imaging modalities in the ED has quadrupled since the mid-1990s. Besides being just another point of confirmation of the origin of skyrocketing healthcare costs in this country, the heavy emphasis placed on tech will not abate anytime soon. Issues pertaining to defensive medicine, integration of such tech into ingrained training of new physicians, and the cost of using such technology within the medical device market are all good reasons to try to begin attacking this startling — yet, unsurprising — statistic. | LINK

What’s the healthiest county in the state in which you live? A new survey just published by the RWF finds what is essentially common knowledge in the healthcare policy blogosphere —  that persons in more rural counties fare worse than their urban counterparts with respect to decreases in healthcare access, increases in premature death, increases in hospital admissions for the treatment of highly preventable conditions, among other findings.

These findings should come as no surprise, because all (healthcare) politics is local, right? Here in Minnesota, research findings such as these take on an entirely prescient meaning — as our Governor is proposing enormous cuts in spending within the budget this cycle in order to balance it. The vast majority of those cuts are occurring in within the Dept. of Human Services, particularly its wholly funded General Assistance Medical Care public payer program. | LINK

A year ago, this blog cited a study which detailed the difficulties cancer patients faced when navigating the byzantine nature of health plans which essentially made it difficult, if not impossible, to receive life-saving treatments. The paper [PDF] went on to describe the problems these patients would still face even when eligibility requirements for government assistance via Medicare or Medicaid were at least partially met.

Either through ignorance of policyholders’ plans limitations or via the inability for their out-of-pocket costs to cover the difference, cancer patients have continued to face significant challenges in accessing crucial care. The verdict may still be out on the finer points of President Obama’s goals for reform, but Insurance does not really seem to be waiting for his signature on legislation to react.

With respect to one insurer, news comes of a cancer patient’s current fight to obtain treatment oncologists thought could save his life. Relapsing neuroblastoma has sidelined a five year-old’s life right now; his insurer has refused a new treatment option it deems as expiremental — in spite of covering a cheaper treatment in 2007 that was also called such, resulting in a full remission. The child’s parents are suing the carrier.

Advocates for insurance reform have taken a backseat in the reform debate, which is not surprising. Although, Obama has described his reform plans are not a referendum on reform of Insurance in a strict sense, it is apparent that sound arguments based upon solutions in the way coverage is paid and delivered need to transcend the rather simple promise of non-discrimination based upon claims denials.

If Obama ever wished he could tell Insurance to just go and “take a hike”, I’m sure he wouldn’t mean it in a literal sense. A California-based insurance company’s decision to raise policyholders’ premium rates by as much as near 40% has prompted a state inquiry and the ire of HHS Sec’y Kathleen Sebelius. The attention the White House is giving this case at a time when reform efforts are rocky is somewhat of a balm for the president’s increasingly wounded pride on the effort to promise wider healthcare access and affordability as dictated during his campaign for the nation’s highest office. Why would an insurance company, even if it is for-profit, create such a negative PR issue for itself at a time when unemployment — and by extension, healthcare inaccessibility — in California and nationwide are at such cripplingly high levels?

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All it took was an inch — as the GOP is going the whole mile, and then some. I’m talking about the stalemate in getting Obama’s reform bill passed. The election of Scott Brown to fill the seat once held by the legendary health reform stalwart Ted Kennedy seems to be only the beginning of an effort by the GOP to take over the parameters of what “reform” really means at this point.

The WaPo has an interesting analysis into the Democrats’ missteps leading to where the party finds itself today: a wounded warrior with very little to show in the way of valor in upholding Obama’s original plans for an overhaul.

Looking back, Obama and his congressional allies failed to appreciate the depth of frustration with Washington – people’s desire for health care legislation that would respond to their anxieties, not the clamor of interest groups.

There’s more. Some GOP lawmakers are upping the anti-reform rhetoric with fiesty language meant to energize its base and incite debate for their benefit. Invoking states’ rights arguments, a VA congressman calls reform measures at the hands of Democrats “mobster mandates”, and such issues “cross the line” as far as he’s concerned.

Del. Robert G. Marshall (R-13th District) has filed the “Virginia Health Care Freedom Act” (HB 10), which would “protect an individual’s right and power to participate or decline to participate in a health care system or plan,” according to a summary of the bill.

Mobsters and missteps. February is getting off to a rollicking start for the party that was supposed to have had a bill on Obama’s desk by now.

Pennsylvania’s Corrections Department is getting creative in the healthcare delivery to its aging prison population. With funding courtesy a grant from the National Institute of Nursing Research, the state will be bringing together the appropriate caregiving provider contingent to study the cheapest and most effective ways to deliver end of life (EOL) care. This pro-active move will likely be a point of reference as state budgets come under increasing pressure to provide this level of service to this patient population in the unique ”perfect storm” of declining state budgets devoted to healthcare delivery; exponential growth of geriatric populations/units in correctional facilities; and competition for federal healthcare dollars as the result of the Obama reform package (whenever that occurs).

The project will develop an intervention toolkit for use by staff at any prison in the country. [..] Prison workers, including health care professionals, chaplains, prison society volunteers and corrections officers, will provide information on current limitations, strengths, existing perceptions of end-of-life care among prison stakeholders and areas of care that bear improvement. Using the data collected, researchers will create a set of educational strategies for use by prison staff that they can tailor to fit individual prison’s needs.

The devotion of grant money to fund this type of research is appealing and compelling on many fronts — not the least of which is a shared national discourse which is sure to follow on such unique EOL care initiatives. | LINK

State budgets are straining nationwide. Healthcare for the poorest citizens (children, the disabled, pregnant females, and poor elderly) and the ability to finance it has always been a political boilerplate, but — in a healthcare economy that will see looming crises in response to expected explosions in many of the the country’s neediest populations in the next 10 years — individual states are trying to get a handle on pre-empting the tsunami of expense.

There is legislative action in Congress that will make it possible to for the Medicaid program to cover nearly 20% (1 in 5) of Americans. Never mind the fact that the government chipped in almost 60% in total costs for Medicaid within the past year; the cost of expansion would mushroom to 90 percent^[1].

When one controls just for these variables, the issues of looming primary care provider shortages (to render the care that will overwhelm potential beneficiaries who sign up as a result of the expansion) and increased administrative costs to cover the expansion on the states’ end have yet to even be considered by many states. Dire, indeed. | LINK

1. The CBO projects states would pay about $33 billion. [↩]

One thing that Massachusetts has learned from its experience as a guarantor of healthcare coverage for all of its citizens is that the noblest of intentions does not come cheaply. Recently, it was announced that the state’s premiums for private insurance not only increased but also at the highest rates in the nation for family coverage. State budgets are straining, as a result. On the heels of such findings as this, Mass. Gov. Patrick (a Democrat) today announces the utilization of state government regulators to oversee rates imposed on another coverage sector — the small business.

Good news for small businesses which have sought some sort of leverage in negotiating rates for coverage for employees. The increased power the governor will impose for the state’s Division of Insurance in this role will no doubt be opposed by Insurance, but it offers another reason for Obama to monitor closely the guaranteed access healthcare microcosm that is Massachusetts. | LINK

The relationship between Medicare funding/reimbursement patterns and nursing home operational expenses has always been a factor in long term care delivery — often taking the brunt of state Medicaid systems’ lapses in payments to facilities for healthcare services. That relationship just became a little more tenuous. Faced with looming cuts courtesy of Medicare adjustments that call for at least a $15B drop in long term care funding over the next 10 years, skilled nursing facilities could see more urgent staff layoffs and outright closure. For example, some facilities in Connecticut were forced to shut doors when proposed state Medicaid payment increases promised by lawmakers there fell by the wayside — presumptively because of recession influenced budgetary issues.

Could long term care delivery to the nation’s rapidly increasing elderly population (last year, nursing homes housed almost 1.9M elderly and disabled residents — an increase of around 4% over the previous year) be getting short shrift in the entire healthcare debate? It would certainly appear so — setting up a perfect storm of deep federal and state cuts and sharp increases in geriatric patient care needs. | LINK

For many primary care providers, days are hectic enough when dealing with just English-speaking patients. I can attest to that. But something I can also confirm is the maturation over the past 15 years since graduating medical school of the technological advances made in streamlining the process of medical translation to make the physician-patient encounter extremely more efficient. I can remember when family practice residency programs built in certain “medical fluency” protocols for residents-in-training to meet the needs of an underserved non-English speaking population in many affected areas nationwide.

These protocols, which involved a level of instruction and patient simulation, were quite time consuming from the aspect of the already-stressed intern who had more than just a modicum of responsibilities outside of his/her FP clinic duties. Today, more than 15 years since receiving that training, I’m really not better off for it (and that’s coming from someone who took four years of Spanish in high school and received complete advanced placement credit — forgoing any foreign language requirement for college graduation).

Throughout my residency training, advances in telephony allowed many practices to integrate remotely stationed interpreters to provide services. Now, with the use of video conferencing technology, some university training programs are combining the on-site presence of interpreters with these methods to create a “cultural immersion” of sorts. The harried family physician will have more time to provide care to the patient, and less time to deal with the issues fraught by the misdiagnoses, cultural misunderstandings, and administrative (insurance) nightmares inherent in practices without such integrated medical interpreter services. | LINK