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 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.
The federal government finally announces that it will open up its Medicare claims database to allow third party access (advocacy groups, insurers, hospitals, etc). This follows a few years of speculation on the part of pundits and legislators alike on what such a move could entail and how it would impact heatlhcare reform — in particular, enhancing quality parameters. The benefits of availability of such information gleaned from billing, requisitions, and payments will vary among groups seeking such data.
Though the data aggregate is invaluable for constructing tools for everything from clinical trials to arranging care delivery based upon demographics, there is always the specter of misrepresentation of that data. For years, many clinicians (including professional associations like the AMA) have lobbied against the release of such info on the gounds that internal reviews should be made before that info is released to the general public. End data may not always be reflected by the healthcare delivery means for many difficult-to-treat patients, for example.
Still, the move is a win for groups wanting to move beyond the formerly impenetrable wall imposed and maintained by physicians and physician groups in order to access that gold mine of clinical, financial, and parametric information. | LINK
A physician advocacy group has released a report detailing the costs to Massachusetts in the wake of its healthcare reform. The goal is to shed light on the potential costs to the country as a whole once reform begins in earnest. The single-payer advocacy group mainly cites that cost shifting of taxpayer subsidies to fund the private insurance marketplace is creating an access burden for the state’s impoverished and lower middle class by pricing them out.
Most of the gains in coverage have come from expansions in publicly subsidized insurance. This largely represented a shift of patients from the state’s former Free Care Pool, which compensated hospitals and community health centers directly for care of the uninsured, to private insurance plans, which is a more costly way to provide care.
Read the PDF of the entire report. The report appears to yearn for a less-than-market-based approach to solving this financial crisis as a way in which access to care can remain intact amid long-term reform sustainability. This report was released jointly among this group and via the state chapter of Physicians For a National Health Program.
Throughout one’s professional life as a physician, there are some things that are inevitable: changes to Medicare reimbursement schedules due to factors beyond our control, insurance denials, and the presence of the National Practitioner Data Bank — the omniscient arbiter of physician conformity and performance in the eyes of the public and watchdog groups. This latter factor is one many physicians manage to avoid, especially in this age of defensive medicine. But, sometimes lawsuits rear their ugly heads, and notifications of judgments (whether favorable, or not) follow the unfortunate clinician forever.
The NYT is reporting that groups of journalists are protesting the Obama administration’s apparent decision to remove the database access from the Internet, at the same time, imposing fines for confidentiality breaches as sources for articles.
“Reporters across the country have used the public use file to write stories that have exposed serious lapses in the oversight of doctors that have put patients at risk,” Charles Ornstein, president of the Association of Health Care Journalists and a reporter for ProPublica, an investigative newsroom, said in an interview. “Their stories have led to new legislation, additional levels of transparency in various states, and kept medical boards focused on issues of patient safety.”
Having used ProPublica as a source for many an article or post here on Doctor Pundit; I, too, am understandably concerned. The feds say that the issue was whether more private information — as opposed to the public database — was accessed and that the response to the original complaint letter was sent directly to a journalist upon database takedown. Further, a division spokesman from within DHS explains
“We are going to do everything we can to get the data back up in a public use file as quickly as we possibly can,” Mr. Kramer said. “We want to make sure the public, researchers and reporters have access to all the information that we can legally make available.”
Seems that it would be in the best interest of the public to get this resolved as quickly as possible, and without significant “changes” made to the public file by a government agency.
Clarence Thomas wrote for the 5-4 decision in which companies were shielded from lawsuits by consumers suffering from adverse effects of certain drugs. Anthony Kennedy, the SCOTUS justice often seen as the court’s swing vote, wrote for the majority opinion in another pharma case which strikes down a Vermont law that banned companies from using data mining techniques to obtain information about the prescription drugs individual doctors have a preference in prescribing.
Federal law requires the makers of brand-name drugs to label their products with FDA-approved warning information and to update the warnings when reports of new problems arise. But in a 5-4 decision, the high court said this same legal duty to warn patients of newly revealed dangers did not extend to the makers of copy-cat generic drugs.
I actually agree with Thomas on this decision. Fed law should trump state law in this case. Generic formulations are essentially chemical equivalents of their branded predecessors and, as such, really cannot be held accountable to novel warnings not appearing on the branded parent drug. A ruling in the reverse could open the door to flurries of suits for a range of untoward events for a multitude of generics — only adding to the cost of already fiscally overburdened healthcare delivery at the outset of reform (emphasis below, mine).
In the second decision, the court by a 6-3 vote struck down a Vermont law that barred pharmacies, drug makers and others from buying or selling prescription records from patients for marketing purposes. [...] Writing for the court, Justice Anthony M. Kennedy said that “information is speech,” and that under the 1st Amendment, the government usually cannot restrict speech because it does not approve of the message. “If pharmaceutical marketing affects treatment decisions,” he said, it does so because doctors find it persuasive”.
Exactly. This case highlights the effect Pharma representatives have always had on the prescribing patterns of physicians and protects the ultimate decision maker at the point of healthcare delivery — the provider. Is it any wonder why reps have been essentially banned from many healthcare systems in many markets nationwide? | LINK
Comparative effectiveness research — the direct comparison of care interventions to determine which work best for which patients and which pose the greatest benefits and harms — has long been a pet issue for President Obama.[1] Although the theory has really never been at the forefront of his very much publicized drive for the passage of the PPACA on his terms, it is a crucial foundation for his ultimate vision of quality healthcare delivery as the ultimate method of controlling costs.
Based upon the results of a new trial in JAMA, this vision has been sorely underutilized, even with stimulus funds to expand its availability. Of the almost 200 pharma products approved by the FDA between 2000 and 2010, only 100 had comparative-effectiveness data, researchers found. Whether or not such information was available depended on several factors, including the existence of an alternative treatment and research ethics. Additionally, the availability of comparative-effectiveness data varied based on treatment area, with proportions reaching up to nearly 90 percent for diabetes medications but only 33 percent for hormones and contraceptives.
It’s the overall lack of CER data and underrepresentation of much of that data into many facets of healthcare that will keep providers ignorant of the overall effectiveness with tried and true therapies versus expensive new agents constantly hitting the pharma marketplace. Although comparative FDA data need to be expanded and enriched, it is just the beginning of the long road in giving physicians all of the information — completely free of biases — to make the most medically informed, cost-effective decisions. This study should serve as a point from which CER can be better defined, as well. | LINK
A healthcare informatics company issues a report today that I really do not find surprising. The trends of Pharma of late are much fewer fast-tracked medications in the pipeline, decreased NDAs for many novel and like-classed (so-called “me-too” drugs) medications, and — are you ready for this? — much greater healthcare consumer spending on generics, which, according to the report, now make up almost 80 percent of the pharma marketplace.
It would be too easy to blame this on the economy. At the root of this and other findings detailed in the report are forces more complex in the healthcare economy than just the principles of supply and demand. After all, while there are fewer patient visits and greater demand by providers and health systems for payments by third parties, you can bet that Pharma still manages to turn a profit. Just take a look at the volume of sales by therapeutic areas: anti-cancer drugs continue to lead the way.
The top five therapy classes were: oncologics, with $22.3 billion in 2010 spending; respiratory agents, at $19.3 billion; lipid regulators, at $18.7 billion; antidiabetes drugs, at $16.9 billion; and antipsychotics, at $16.1 billion. Growth in spending among these classes ranged from 0.9 percent for lipid regulators to 12.5 percent for antidiabetes medications.
Although consumers, third party payers, hospitals, and providers all appear to be embracing quality provisions as a way to control costs, it is somewhat less clear what this pharmacologic austerity will ultimately mean for the management of chronic disease and how that will impact the cost of healthcare over the next 10 years. | LINK [PDF] to IMS report
A report detailing the numbers of cardiologists who engage in some sort of conflict of interest with firms or companies and the link this association has with the professional guidelines they write has been released. The results are a little troubling. Clinical guidelines for medical practice have been around for hundreds of years and serve as foundations for decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare. While not required by any one authority for the practice of a certain medical discipline, their utilization is no less profound — affecting physician perception and approach to many clinical disorders.
In the Archives of Int Med study, the numbers of physicians who reported an affiliation with a potential third party conflict hovered just over 55 percent, with a significant number of those disclosing major fiduciary relationships. Surprising? Not really. Outrageous? Depends on whom you ask. From the NYT (which is behind a paywall): “The conflicts are quite prevalent, but they’re by no means ubiquitous,” Dr. Kirkpatrick [study investigator and lead author], an assistant professor of medicine at the Hospital of the University of Pennsylvania, said in an interview about the research, which was led by Dr. Todd B. Mendelson, now in residency at the University of Pittsburgh. [...] Dr. Kirkpatrick said the study focused on cardiology because of its many guidelines and thorough disclosure requirements. Dr. Rothman, who was not involved in the study, said that it was also known that cardiologists, along with psychiatrists and orthopedic physicians, have been well-known for taking industry gifts, honoraria, consulting and speaking engagements.
All of this comes on the heels of an Institute of Medicine call for greater accountability and trustworthiness in developing medical/clinical guidelines. It’s a start, but some groups are proposing for outright bans of the practice. For some, simple disclosure is just not enough. | LINK
The shift to a sharp decline in the prescribing of neuroleptic (antipsychotic) medications to treat paranoid symptoms and behavioral instability in patients with dementia (no psychiatric indication/past medical history) was begun well before the unified FDA response in imposing a black box[1] warning as to its usage, according to a VA study.
According to the principal investigator, this demographic shift in the usage of these class of medications would not have occurred if it had not been for the adjustment (taking statistical account) with respect to patients over 65 — as opposed to those with longstanding psychiatric illness. This trial[2] just confirms what most geriatricians, including myself, have known about this class of medications all along: that since the early 2000s, the overall risks of death from all causes were specific to this class and this specific demographic of patients. It’s a far cry from the rather liberal use of these medications in the routine treatment of the non-mentally ill aged during my training.
The planned rollout for quality scores and transparent data from Minnesota’s second largest health plan has been requested to be delayed by the state’s medical association. Set to originally be released tomorrow, scores — based upon a starred system — will show consumers exactly how well the plan’s participating physicians follow established care guidelines. The rating system will, for the first time, show data which will tie in with individual physicians, by name.
Unsurprisingly, there is expected to be some PR fallout — even with the inclusion of a 1-month appeal period which occurred in December. Essentially all physicians in the plan have been told of their ratings, which measure adherence to national practice standards per specialty and each physician’s “cost-effectiveness”. The MMA called for the brief delay amid still pressing concerns among its physician membership on what it terms as the potential “misclassification” of physicians in the plan. | LINK
UPDATE/WED. 1/19/11: Quality postings can be found here.
President Obama’s push for the digitization of the medical (health) record continues its march toward the goal of complete adoption nationwide by mid-decade. The administration’s desire for this goal as a part of reform is as much a laudable task as it is a daunting one. Cost of complete market saturation among healthcare facilities and systems is one issue. The other? Some providers in more rural and urban areas where care is provided are concerned that EHR adoption will not immediately benefit healthcare delivery to the economically disenfranchised.
Call it the “digital divide” as it relates to the electronic record. Sure, cost of adoption is one thing — but the realization that private and government initiatives over the next four or so years will continue to favor larger systems with heftier resources is quite apparent. To be fair, the feds have allocated some $300M in stimulus funds for this problem. But, just how far will funds go not only to ensure access for the poor and uninsured in economically deprived care environments but also to begin to reverse the all too familiar correlation between poorer health outcomes and lower income levels among patients? | LINK
UPDATE & RELATED: A graphic shows the penetration of EMR adoption by state (criterion: any EMR component use as defined by the CDC in 2010). Happy to see Minnesota at the top of that list! | LINK [PDF]
Starting today, CMS will allow registration for its EHR incentives program. Designed to get providers and health systems on board with initiatives outlined by newly installed chief Don Berwick, the program’s availability launches today in a number of states. The balance of participants are to be in place by the summer.
The agency hopes that streamlined reimbursements to providers, along with more generous payment amounts, will be enough of an incentive for participation. Programs exist for eligible providers participating in both Medicare and Medicaid. There is the specter, however, of what CMS terms as “payment adjustments” for non-participants or those who fail to demonstrate “meaningful use of EHR technology” during the incentive program. | LINK
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.
