Match Day 2012 is practically upon us. Me? I’m about 18 years removed, but the drama surrounding where I would be receiving my OJT after medical school was palpable. I still feel the goosebumps from that day; it’s that exciting and unnerving. Each year, I have tried to chronicle briefly what the tea leaves hold for primary care. Last year, there was some reason to hope for an increased representation of the collective discipline in the overall scheme of matches of graduates to training programs, but feelings were still mixed on the issue. Though, this year could be even more of the same.
As we approach health reform in this country, the need to increase the numbers of primary care physicians has never been greater. The White House has a stake in this interest, as the ACA will dramatically increase that need for presumptive increases in demand for this mode of care delivery. Last year, there was some wind in the sails of primary care. Many more medical students chose the discipline than were expected, citing looming changes via the ACA and the need to “make a difference” with respect to preventive medicine and public health. The WH has an initiative in place to address primary care’s dwindling numbers, but it is only a modest amount needed to stem the projected approximately 30,000-numbered provider deficit by 2015.
If representation compared to medical and surgical subspecialties continues on this uneven pace, healthcare costs will continue to rise as more and more people are guaranteed access to basic (primary) care under reform. Throw in the costs to Medicare (a significant funding source for most residency programs), one can only hope that changes (cuts) in reimbursement will not negatively affect those who continue to see such patients. While the entire fiscal future of healthcare delivery will most certainly not rest upon the primary care results of Match Day ’12, it will be interesting to see if last year spurs a trend.
The cost of care associated with dementia never fails to make news. Just as another cure-less disease continues to spike in its incidence and prevalence in this country (diabetes), healthcare delivery to those with dementia — in particular, Alzheimer dementia — fuels the debate on just how sustainable current symptomatic treatments really are. While the bigger issue is the ultimate cost to taxpayers, as most patients are Medicare beneficiaries, there is also the underlying nagging element in this news: how much closer are we to a cure, or anything resembling it?
As we enter the second decade of the 21st century, research into a cure for the most common type of dementia is being carried out at a rather brisk pace. Investigations of neural markers, central nervous system lipoproteins, inflammatory mediators, and other factors in their possible roles as causes of Alzheimer dementia are opening up new avenues for potential reversals. Also, among treatments to stem symptoms palliatively, more data will be forthcoming that will allow treatment flexibility with drugs that were formerly meant to only treat patients in moderate- to later-stage disease.
The sad fact is that dementia is the only major prevalent disorder for which there is no singular means of prevention — only adding to the crisis in this sector of health care. Numbers like 200 billion are, indeed, sobering; but education continues to be the best weapon against all that this negative about this desease. In the near term, patients and their caregivers know that being forewarned is being forearmed — and that may be the best strategy of dealing with dementia until there is a certain cure. | LINK of report from Alzheimer org website
Is this the obligatory Leap Year Day post (as this would be this blog’s first since its inception) or is it what it should be — informative and representative of the most of the content therein? While you ponder that, consider this: the state of Washington, hot off the heels of one “culture war” issue — the passage of a same-sex marriage law — comes another hot button issue. The legislature is considering passage of the Reproductive Parity Act, a first-of-its-kind law that would require insurers to cover “voluntary” abortions.
As it would apply to state-run exchanges under the PPACA, healthcare consumers would have to pay a premium to insurers in a given virtual marketplace (online exchange) in addition to the base premium for all other services offered in a coverage plan. (There is also an insurer opt-out exemption clause in the legislation.) The bill has made it through the House and is expected to sail through the Senate there on the way to Gov. Gregoire’s desk, as she is expected to sign it into law. Although the law makes this coverage quite voluntary for the consumer, anti-abortion groups are expected to fight it. But, the bigger issue is how this will play out nationwide, as other states consider similar legislation in the law’s wake. It will also be interesting to see how demand for this service will affect its availability in exchange marketplaces, and how insurers will continue to pay for that coverage under the mandate of affordability as laid out by the reform law. | LINK
A rather excellent initiative is afoot in the state of Mississippi. The unsurprising fact of life for many of that state’s African-American patients is that African-American representation among physicians in that state remains startlingly low. Though they make up more than a third of Mississippi’s population, fewer than 3 percent of its active physicians is black. An African-American myself who was raised in a bordering state — Tennessee — I wish that a similar plan had been offered.
Dr. Kameron Matthews explains to a group of mostly black college students options for paying for an expensive medical degree. Matthews is one the organizers of the Tour For Diversity in Medicine, which is a group of minority physicians visiting historically black colleges like Jackson State University talking to students about the medical field. She says that having more black doctors can lead to much better health care outcomes for black patients.
Though I did not attend a predominantly black college, I see the richness in such a strategy. The art of medicine is ripe with anecdotes accurately portaraying the capable, diligent, caring, and inspirational physician; it is what continues to make our profession desirable and reflective of the talent exemplified by the majority of its workforce. That is why I support any initiative to make the profession truly a reflection of the people who are served by it. | LINK
When training as a geriatric medicine fellow many, many years ago, I was always taught to be rather prudent but resolute in the use of atypical neuroleptics for the treatment of behavioral problems related to dementia-associated psychosis in the elderly. I recall the recently approved medication (at the time) risperidone was, in many respects, the agent of choice — as it was seen as a “safer” alternative to more odious preparations which had been used with abandon for years (think haloperidol). It was even gamely called “vitamin R” in our treatment circles.
Fast forward a decade or so, not only do we know that for many atypicals (especially with risperidone) the side effects are major – and dependent on dose — but we are also armed with a blanket black box warning on these drugs: elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death from all causes. We have the careful analyses of multiple placebo-controlled trials that demonstrate this.
Such uses in the community now come with quality controls and regulatory mandates that allow physicians to discuss this overall risks with patient’s families and healthcare proxies (informed consent). This is a good thing, and its implementation is as important as ever today — mainly because of new data like this.
An analysis of tens of thousands of people in nursing homes in the U.S. suggests that residents who take certain antipsychotic drugs for dementia are at about double the risk of dying compared to residents not taking those specific medications.
Amazing information, especially when the investigators in this study controlled for such disparities as age, gender, and the presence of concomitant physical illness. As more patients with or without mental illness age, the use of agents like these will drive the need for a greater understanding of how to approach the treatment of psychosis in the elderly, from whatever cause; it appears that treatment considerations will one day mirror the same considerations physicians agonize over when treating much younger patients. Yet another reason more and more elderly patients are needed for pharma trials. PDF LINK here
The federal government has given opponents of the ACA another reason to gripe: it has announced the formation of loans to initiate health plans on the new exchange platform in individual states. Think of the offering has a cooperative of sorts, built for the delivery of services within an exchange. CMS intends to oversee the adoption of at least one co-op per state via this method. Of course, emergency stopgaps are in place for the recipients of loans that may have problems satisfying the terms set forth by the feds; interest rates will be typically less than 1 percent.
Naturally, the behavior of such a healthcare delivery system is a reflection of the acronym used by the ACA’s program promoting it: the Consumer Operated and Oriented Plan. Proponents of the initiative are bullish on it, as the GOP-led legislature has incrementally cut initial CMS plan estimates earmarked for this purpose. Skeptics wonder if these loan startups will carry the heft needed to compete with established private insurers in the newly formed exchange marketplace in two years. The best intentions of non-profits in this case will have to be tempered by the new reality of such competition for healthcare consumer loyalty come 2014 under the law. Should be interesting to watch. | LINK
Against the backdrop of the so-called safety net hospital (those with heavy Medicare, Medicaid claims utilization) as a healthcare-related industry and campaign ’12 meme, there is interesting data out in JAMA this week that either supports Mitt Romney’s assertion that the “very poor” are taken care of in this country quite adequately, or there is reason to believe that P4P measures (or, at least the idea, anyway) are superficially quite similar in non-safety net acute care centers in terms of ultimate patient dispositions.
Researchers studied whether patients were admitted to the acute hospital within eight hours of ED admission or if they were to be discharged, transferred or moved to observation within four hours of coming to the ED. They found that
compliance with proposed ER length-of-stay measures for admitted, discharged, transferred, and observed patients to not differ between safety-net and non-safety-net hospitals
Although length-of-stay (LOS) data is interesting, it is not compelling — quite limited in its implications, actually. Currently there is no “accepted” ED LOS strict guideline in the U.S. Digging deeper into this study (abstract-only text cited above available without a JAMA susbscription), one can infer more from the upper decile of data — in which LOS significantly increased among both types of institutions (10-15 h in length), the authors citing mostly acute patient decompensations in mental illness as the reason for protracted admission LOS.
Still, the trial provides renewed attention over a surrogate care parameter just a few years ago was hailed as an agreeable target upon which to base healthcare reform on spending within the government sector. These days, the study may only serve as yet another reason why P4P as a quality measure is so derided by many as the ACA is just beginning to take hold.
Probable GOP nominee for president, former Mass. Gov. Mitt Romney, came under attack over the past couple of days for comments on discounting the “very poor” as this demographic benefits from the existence of a societal “safety net” for the delivery of essential services — presumably basic healthcare among them. Terming the gaffe as simply a “misspoken” choice of words, the GOP frontrunner initially found it difficult to run from those words and their implications from members of his own party and the Democrats.
Chief rival Newt Gingrich jumped on the metaphorical bandwagon early.
Gingrich said both Romney and Democratic President Barack Obama think poverty can be solved with a safety net.”What the poor need is a trampoline so they can spring up,” he said. “So I want to replace a safety net with a trampoline.” Romney spokeswoman Amanda Henneberg responded that Gingrich was joining Democrats in “distorting Mitt Romney’s comments.”
South Carolina Gov. Jim Demint, a prominent force of social conservatism within the party, was a little more sanguine.
“He needs to address it,” DeMint told Roll Call. “Because I know he does care about the poor. But I think he was trying to make a case that they’re taken care of. But, in fact, I would say I’m worried about the poor because many are trapped in dependency, they need a good job; they don’t need to be on social welfare programs. I think he needs to turn that around because — the middle class is key, and we have to focus on that. And, really, the problem with the middle class is not successful people, it’s politicians — but the key to making our country successful it to get everyone on that economic ladder.
Typical “bootstrap” rhetoric, to be sure, but a teachable point for Romney; because, as it applies to healthcare — let’s take Medicaid, for example — his disavowal of basic healthcare delivery to the poor (and elderly) runs in stark contrast to his pledge to “fix it” — meaning the “safety net”. What does Mitt Romney want to fix, exactly? Continued taxpayer subsidied care for the indigent without further acknowledgement, or does he want to weaken an already painfully inadequate payor of healthcare in chronically cash-strapped states — threatening any stake they have as the reform law takes hold? In his efforts in trying to explain away his current campaign gaffe, Romney has made his stance on healthcare reform much murkier in this young election season. | LINK
Embattled WI governor, Scott Walker (R), issued a statement yesterday opposing the implementation of a state exchange as provisioned by the ACA — opting to defer action on the measure until the case is heard by the SCOTUS in March. In doing so, he will be returning almost $40 M in federal funding earmarked for the healthcare exchange. Whether this is earnest on his part or merely a symbolic gesture to Wisconsin GOP faithful in the wake of a pending certified recall vote on his office remains to be seen. Walker has always been against the passage of the reform law, instead focusing on efforts to deny federal assistance in doing so (states which choose this path will have to demonstrate fiscal independence on healthcare exchange creation by 1/1/13 or will be mandated a program by the feds).
Is this entire episode a game of chicken by Walker in light of his sudden vulnerability? It is, if one listens to the rhetoric from the state’s Democrats on the issue. Advocacy groups are also weighing their own disapproval of the governor’s intentions. The SOCTUS will hear testimony on the constitutionality of the reform law (notably, the mandate for coverage) over a two day period by the end of March. By the end of Februrary numerous amicus briefs will be filed by both Obama admin (DOJ) and plaintiffs (states) in the case. In spite of all the rancor surrounding this issue, it will difficult to envision striking of the mandate provision, much less the entire reform law as two lower courts have offered split decisions on the matter — prompting the SCOTUS to act quickly on a decision on the entirety of the ACA well before the election. | PDF brief from UCB Labor Center in support of the ACA’s constitutionality
The good news: the media have done a reasonably good job of getting the word out to consumers of healthcare with respect to the prevention of medical and surgical mistakes in acute care settings. The bad news? Here in Minnesota, the numbers of “wrong surgeries”, a collective term meaning never-events in this care realm, topped 2010′s tally by five cases — creating a surge in such cases last year.
The figure is the highest in eight years of self-reporting by Minnesota hospitals. Officials cited many reasons for the mistakes — from doctors filling out incorrect orders to sloppy inventories that make it easy to grab the wrong joint implants for orthopedic procedures.
While the surge appears to be from the absolute numbers of incorrect procedures performed, the rate of adverse events has globally decreased, bringing into question the efforts of many healthcare systems in the processes involved in preventing completely avoidable lapses in care delivery. | LINK
The long term care marketplace is one of those sectors in healthcare delivery on the cusp of markedly innovative practices in this young century, buoyed by the sudden proliferation of the senior Boomer demographic. Sky’s the limit on the impact of care services and offerings a market-based approach can muster on the eve of reform. Unfortunately, certain models are ripe for abuse.
The DOJ said today it joined a whistleblower case against AseraCare in federal court in Birmingham, Alabama, accusing the closely held company of seeking to cheat Medicare for the hospice care of patients who weren’t terminally ill. The U.S. is seeking three times the damages and a penalty of $5,500 to $11,000 per claim.
The hospice company is owned by a national company that provides services within LTC. Whistleblowers prompted the government action when the hospice operation recruited Medicare beneficiaries and continued to fraudulently collect payments by inappropriately cycling those patients under the hospice benefit. The process would continue upon initial termination of Medicare payments for those services once the initial LTC services ceased. Multiple referrals for covered services later, the LTC contractor would continue to collect those payments, based upon allegedly fraudulent qualifying practices by the LTC contractor/company.
The case is an interesting one which will, hopefully, provide Medicare reform in yet another overlooked care sector that will only increase in prevalence as the rate of patients diagnosed with chronic disease and disability skyrockets. More here
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.
