Robbing Peter to pay Paul — in terms of Medicare cost sharing, that is. A new Medicare benefit design will enable increased costs for lower utilizers of the government entitlement (relatively healthier beneficiaries). This limit on cost-sharing among beneficiaries would decrease the costs per sicker beneficiary for, say, acute visits to the hospital rather substantially, leaving those who do not use services as much shouldering the burden.
A melding of the services by hospitals (part A) and doctor visits (B) as they relate to deductibles, plus a requirement that participants pay 20 percent toward a $5500 limit would increase the payment of almost 75 percent of beneficiaries (the lower utilizers of acute care) by almost $200/month. My take? It’s potentially a mechanism for some savings by the federal government, and it may give more ammo to Republicans who are interested in tiering beneficiary eligibility — such as via so-called means-testing.
All this in an interesting study via Kaiser. | LINK
Could retail be the solution to comprehensive healthcare delivery? Well, if big-box retailer Walmart has anything to say about it — then, bring it on! Stretching the idea of retail minute clinics to extremely absurd heights, the retailer wants to partner with other entities to increase care access ahead of the tsunami of increased coverage sure to occur once reform kicks in a couple of years from now. It lays out its plans in a 14-page Request for Information [PDF].
In-store medical clinics, such as those offered by Walmart and other retailers, could also be players in another effort in the health law: encouraging collaborations of doctors and hospitals who want to win financial rewards for streamlining care and lowering costs. Such collaborations, known as “accountable care organizations,” might contract with in-store medical clinics, says Paul Howard, a senior fellow with the Manhattan Institute for Policy Research.
The other entities, sometimes labeled as “vendors” in Walmart’s RFI, appear to be (healthcare) organizations which have the potential to collaborate on best practices for many chronic conditions — enabling the partner vendor to benefit in terms of quality, accountability, delivery of healthcare services in order to maximize their bottom lines.
This mode of healthcare delivery raises concerns, to be sure. Could we be seeing an entirely new way of the delivery of healthcare as a pure commodity to be negotiated and priced like any other product? Will it encourage other major national retailers to follow suit? What will this do to the traditional model of healthcare organizational delivery of primary care? Will it enhance it? Will it make it more accountable to third parties? How will this model benefit insurance companies’ approach to premiums in an altered delivery marketplace? Quite an interesting development in the ongoing saga of the cost of healthcare in this country. | 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.
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
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.
The rise in prescription drug abuse in this country has been muted somewhat by the traditional messaging by anti-drug campaigns which advocate the overarching “just say no” philosophy … and have done so since the heady days of the Reagan administration some 25 years ago. A different kind of advocacy is needed, say the appropriate groups; that is, one of attention toward the ripple effect of the “other” illicit drug — the prescription narcotic (including, most notably, hydrocodone and oxycodone).
In scenarios in which the levels of violent crimes (pharmacy robberies and assaults) are belied by the common perceptions of acquisition of such drugs (petty theft, paper script forgeries, etc), it’s easy to see why some say the FDA has been lukewarm at efforts to control this burgeoning problem.
The 12-year delay in the federal regulators’ final decision about hydrocodone – the second most-abused pain drug – has been agonizing, to say the least — all the more so as the Drug Enforcement Administration and Food and Drug Administration are apparently still studying whether to move hydrocodone-containing medicines to Schedule II category of medicines from the less restrictive Schedule III. Advocates for tighter controls over hydrocodone opine that it is time the government took concrete action to save lives — since a study funded by the National Institutes of Health has shown that nearly 8 percent of the 12th-graders in the US have abused hydrocodone in the last year.
The agency says many factors — chief among them the logistics involved in augmenting widespread training and retraining of healthcare providers as to the merits of prescribing in this new climate of addiction — have complicated movement forward on the matter. It’s a problem that’s not going away anytime soon. Those hoping for a sweeping decision by the FDA to correct things are better off considering scenarios in which the government agency can partner with other entities to begin to address oversight in prescribing lapses, formulary monitoring, and drug utilization reviews in healthcare organizations. | LINK
An observational trial published in the latest issue of Annals shows that the initial savings to overall healthcare costs incurred by acute hospitals with hospitalist (hospital-based physician) care are offset by increased costs to Medicare in spite of the earlier discharges of beneficiaries (0.5 day on average shorter than those patients without hospitalist care).
Most of the extra costs stemmed from re-admissions and patients being sent to nursing homes instead of home. But there’s no clear explanation for the findings.
“Under pressure to shorten length of stay, hospitalists may be willing to discharge sicker patients, leading to increased re-admissions,” Dr. Lena Chen and Dr. Sanjay Saint of Ann Arbor Veterans Affairs Medical Center wrote in an editorial, according to Reuters, which was first to report the study.But they added that unmeasured differences could also play a big factor.
Besides the fact that this study is observational in nature, and therefore immediately affected by selection bias, it does shed light on areas to be studied further — including disease-based criteria for discharges based upon DRGs, the effect of preventive medicine on readmission rates in Medicare patients, and the impact of undocumented acute care complications at discharge (eg, medical errors). The proverbial tip of the iceberg is at play here. Still an interesting read, though. | PDF 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.
