The application of the philosophy that is at the core of medicine: first do no harm — is a little at play in an article in the NYT. The rise of so-called concierge practices in the wake of healthcare reform has touched off a debate of sorts on the ethics of delivering such care. That is, you essentially pay for what you get — nothing more, nothing less. Perhaps its the myriad names by which its central workings are known that give it some ethical cover: membership medicine, concierge health care, cash only practice, direct care, boutique medicine. These terms convey one basic fact — the patient pays an annual fee (with other possible charges). In exchange for the retainer, doctors provide enhanced care.

[I]t’s hard not to wonder whether it is possible to practice in a way that reconciles concierge medicine with all the ethical concerns. One group of doctors in Boston believes it is possible. [...] But unlike other boutique practices, the retainer fee of $1,800 per year that these patients pay does not go directly to the doctors’ coffers. Instead, it is used to support the traditional general medical practice, the teaching of medical students and trainees and free care to impoverished patients.

Thinking of the delivery of this type of “specialized” primary care in which fees go to the process of delivery itself before direct provider revenue is another way some primary care practices hope to regain some lost footing in practices on the brink of dissolution or acquisition under the brave new world of reform. For some of these practices, for now, arrangements seem to be paying off — ethically, if not fiscally. | LINK

The U.S. Preventive Services Task Force, an independent, non-partisan body made up of primary care physicians involved in developing preventive medical guidelines based upon evidence-based medicine, has always reveled in its staunch self-governance. That could change ever so slightly in the new age of health reform.

The academic research-oriented group will continue to make recommendations on best-preventive practices and supply ratings (“A”, “B”, etc.); but this time, under reform, insurers will be required to cover services that receive such a rating. The Obama administration hopes that this increase in access (which will require a small premium increase by insurers in the near term) will reap savings in the future — as costs for preventive testing, screening for certain chronic diseases, vaccinations, and well-child visits would be covered (without health plan co-pays and deductibles) if so rated by the USPSTF.

Besides having to consider methodology involved in formulating its ultimate recommendations, the group will also have to contend with the specter of political agenda setting if lobbying groups and disease advocacy organizations have their way under this bit of legislation — scheduled to go into effect in September. | LINK

Research into better treatments and possible cures of Alzheimer dementia is one of the bright spots in the potential for better healthcare delivery in the decade of the 2010s. There are many signs that bode well for the approach to this disorder at the dawn of the second decade of the 21st century.

New research into alternate pathways of disease development is starting to generate excitement among primary care physicians and geriatricians (such as myself) as potential arenas for new classes of drugs to combat Alzheimer’s. Better care delivery models in long term care of the elderly as part of new initiatives in the Affordable Care Act are already starting to impact chronic disease care management strategies.

Perhaps most important, there is new evidence to suggest that earlier detection of this cognitive disorder can enhance those developments, and more. At an annual meeting of top dementia researchers, guidelines were proposed to expand on the research from the ’00s to diagnose the disorder earlier — a strategy that benefits more than just those potentially afflicted with Alzheimer’s.

If the guidelines are adopted in the fall, as expected, some experts predict a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.

Heavier use of newly discovered biomarkers for earlier detection of the pathology behind Alzheimer dementia will be a closely watched process by both physicians and health policy analysts alike. | LINK

• It’s on. The mega union only needed 66%. They got over 80% ‘yea’. [LINK]
• At ninety days into the new reform law, Obama makes public safeguards inherent within. [LINK]
• FDA approves new diagnostic test that more rapidly detects antibodies and antigens. Excellent. [LINK]
• More controversy than there needs to be? The president’s pick to be new CMS chief engenders strong feelings on both sides [LINK]

Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. [..] Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system.

If anyone needs any proof of how irrelevant the American Medical Association has become in its advocacy of the physicians the organization is supposed to represent, one needs look no further than in the last minute unexpected rejection of the postponing of cuts (21%) to Medicare reimbursement schedules. So much for being in the physicians’ corner on this issue. Senate Republicans essentially killed the measure via a vote along party lines. Initially, there was hope for a compromise fashioned at the eleventh hour by Max Baucus (D-MT) — one of the key figures in the establishment of many of the provisions set forth in the reform bill’s passage earlier this year.

The Senate had rejected a Finance Committee compromise^[1] that would have delayed the cut in Medicare payments to physicians until 2012, along with measures to extend unemployment benefits and provide $24 billion to states to cope with their Medicaid programs. Senate Republicans have apparently had enough — as CMS now has the greenlight to move forward on the cuts which were to have initially been implemented on June 1. This entire episode is a reminder of how serious matters are for primary care to sustain itself in a slowly recovering economy and increasingly prudent healthcare marketplace — which now, in a new reform-minded environment, has to manage to do more with less. The calling for innovation for the recruitment of primary care physicians has never been greater this century than as a result of this moment.

1. The compromise would have decreased the total cost to $118 billion and the overall deficit impact by some $20B;  it would have delayed the planned Medicare cuts and provided a 2% raise for physicians through November 30, rather than for the 19 months as part of the original bill. Essentially, the compromise would have amounted to a short term “fix” of the SGR — the method by which the cuts are computed in the face of increasing healthcare expenses by the government. [↩]

A new twist on old news. While practically everyone with a vague association to healthcare delivery in this country knows that there is a primary care shortage, it is always refreshing to see fresh innovation to lure more talented docs to the specialty on the part of some medical schools and educational entities (…even hospitals):

[Johns Hopkins] has launched programs to bring cheap specialty care to the uninsured and primary care to those who tend to go to the emergency room. And [John ]Feldman’s [director of the school's Urban Health Residency Program] six-year residency program aims to annually produce four primary care physicians who eventually could become leaders in the field by opening a federally backed health center, directing a primary care clinic or becoming a city health commissioner.

LINK

It is well known that at this point in the debate on healthcare reform, one major benefit for the healthcare consumer is the retaining of adult children under their parents’ plan until the age of twenty-five. Not only does coverage in this demographic become extended over previous plans, it also creates a comparative level of coverage in policyholders whose benefits lapsed prior to passage of the healthcare reform law — closing potentially troublesome gaps in coverage. Although it is somewhat unclear how much this provision will cost the taxpayer upon initiation later this year, it is here to stay. Apparently, this is music to the ears of young patients who either let policies lapse because of prohibitive costs or considered themselves not especially desirous of coverage due to their generally good health and young age (the so-called ‘invincible’ demo).

The potential for subsidized coverage has recently forced many in this age group to reconsider forgoing it — mainly because that coverage is increasingly within reach.

Many young adults will be covered through other provisions of the health act. About 7.1 million, more than half the total, will be eligible for Medicaid beginning in 2014 because their income is less than 133 percent of the federal poverty level, or about $14,404 for a single person and $29,327 for a family of four.

Provided they take the leap and participate in insurance exchanges, the healthy young stand to qualify for much in the way of taxpayer subsidized care — offsetting traditionally higher premiums without such legislation. After all, it’s either this, or pay a penalty. As reform begins to unfold over the decade of the 2010s, the social engineering involved in creating collective thought with regard to healthcare coverage as being the norm — and not the previously regarded far-flung option in this age demo — is a goal of Obama’s administration as it seeks to transform preventive healthcare delivery. | LINK

Preauthorization as a requirement by insurance companies to continue providing coverage for treatments that end up outside of a policyholder’s terms is nothing new; it is a necessary evil providers must deal with on a daily basis to make sure their patients get the care they need if current covered treatments are no longer adequate. Pharmacologic therapies make up the bulk of treatment reviews Insurance requires as part of preauthorization. But adult mental health services (particularly within the discipline of psychology) in the state of Massachusetts are playing an increasingly controversial role in these administrative matters that place employers, providers, and patients in a protracted battle against insurance companies to continue these types of treatments.

“We are seeing what seem to be excessive preauthorization and other reviews that we don’t typically see for other medical services,’’ said Matt Selig, executive director of Health Law Advocates, a public interest law firm based in Boston.

The advocacy legal firm will probably join other groups in filing legal challenges on behalf of therapists and patients. The largest insurer of workers’ mental health services in Massachusetts says it tries to contain costs by making sure patients continue to receive the covered care they need. It seems as though patients in dire need of those services requiring preauthorization feel otherwise. | LINK

The use of medical technology is as commonplace today as the doctor’s ubiquitous black bag was sixty years ago. Technological advances have been both blessing and bane, allowing those who benefit to live longer, as with their chronic diseases. Of course, for many patients, this means being sicker longer. In end of life care scenarios, one such advance is creating complications — the automatic internal cardioverter-defibrillator (AICD), a life changing device use to pace and assist heart failure patients whose disorder would have shortened lives just a few years ago. An interesting tidbit of medical news today notes that the willful disconnection of such a device rarely occurs in such end of life discussions with patients and families in the way that cessation of drugs and other aspects of medical care are. An advocacy group of cardiologists and other medical subspecialists is out to change that. It has released guidelines on the withdrawal of support in the hospice and palliative patient and the ethics surrounding such an action. | LINK

Are they doing this out of the goodness of their hearts? A number of insurance companies are opting to provide agreed upon provisions as part of the healthcare reform bill much earlier than they need to. Among the benefactions are the cessation of the practice of policy rescission (denying previous coverage after claims scrutiny) and the extension of dependents’ coverage as part of guardians’ plans.

“Our focus right now is on implementing these reforms in a way that’s going to minimize disruption and provide greater peace of mind for the more than 200 million people we serve,” Robert Zirkelbach, a spokesman for the industry group America’s Health Insurance Plans, said Thursday.

Peace of mind for patients from Big Insurance? What about the primary care physicians who have to deal with these changes on top of the administrative roadblocks they now so adeptly navigate? If this NYT column by Pauline Chen is any indication, Insurance’s newfound goodwill is PR cover for the physicians who act as middlemen in making sure that their patients continue to receive the care they were trained to provide amid all these changes. An unforseen by-product of health reform may be the quixotic notion of insurance companies’ benevolence which belies the angst of so many physicians who simply want to continue to provide the best care for their patients.

A study out this week [PDF] in the NEJM highlights the uncompensated “care”^[1] family physicians — correctly referred to in this NYT piece as medicine’s “embattled frontline” — must carry each and every day they continue to earn, at most, 50% of what many specialists pull in as income.

The study set out to show that the daily non-patient logistical workflow is a both a critical and burdensome task needed to be mastered in order to provide appropriate healthcare to patients — and as such, should be compensated. The study also highlighted the need for streamlined health information technology to incorporate these administrative tasks into a model that allows for the determination of compensation for primary care physicians.

Read the rest of this entry »

1. This is in reference to the myriad background logistical workflow issues family physicians must deal with on a daily basis on top of the direct patient interaction once thought of as the discrete point of care. [↩]

There’s some good news/bad news on the immediate post-reform bill economics front. HHS and Kathleen Sebelius are releasing a report that seems to contradict the CBO’s analysis on the long-term economic viability of the Obama reform bill. In adding over 30 million to the coverage rolls, the new Affordable Care Act may not control costs as keenly projected by the Democrats — raising healthcare spending by 1 percent over the next 10 years.

The report is actually the product of CMS actuaries; it suggests a solvency of Medicare up until, at least, 2019 — twelve years longer than originally anticipated. However, the real issue is looming cuts to Medicare and their effect on acute hospitals’ operations and revenue — not to mention the ongoing debate on how to address those cuts to physicians in the short term. | LINK

In the wake of the recent Minnesota legislative action to provide an alternative means of reaching the impoverished with healthcare subsidies, a study provides confirmation that the state has a long way to go if that taxpayer-subsidized healthcare is on parity with those who receive it via private insurance.

Validating concerns from the fiscal conservative right, the study’s results imply that simply guaranteeing access to this patient population does not represent a panacea for financing the broken healthcare delivery system. At least on the state level, it’s another blow to Obama Democrats who support reform on its most basic level — getting the uninsured basic preventive and acute care.

The parameters studied in this year’s report included cancer screening and disparities among chronic diabetes and hypertension management. Among the latter, the gap in adequate treatment and secondary prevention actually widened. In a state which values greatly preventive healthcare interventions, the message to proponents of healthcare reform is that guaranteed access may cost more in the long run if these healthcare disparities aren’t overcome — lending greater ammo to Tea Partiers and fiscal conservatives in their battle against health reform. | LINK