From the 28 May 2015 ScienceLife news release
ancer, all by itself, is bad enough. Although cancer treatment, especially chemotherapy, has become much gentler than it was a decade ago, most interventions still carry significant risks and side effects.
Recently, many physicians have focused on a different sort of hazard that they call “financial toxicity.” Along with the distress of a cancer diagnosis and the discomforts of treatment, patients increasingly have to deal with the cost, anxiety and loss of confidence inspired by large, unpredictable expenses, often compounded by decreased ability to work.
A team led by Jonas de Souza, MD, a head-and-neck cancer specialist at the University of Chicago Medicine, has developed the first patient-oriented website devoted to helping cancer patients understand and cope with financial toxicity (FT). Their goal is to increase awareness of this side effect prior to and during medical treatment so patients know what to expect and can better understand how costs impact them and their families.
Study: 23 pct of US adults with health coverage underinsured.
From the May 2015 Commonwealth Fund study
New estimates from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that 23 percent of 19-to-64-year-old adults who were insured all year—or 31 million people—had such high out-of-pocket costs or deductibles relative to their incomes that they were underinsured. These estimates are statistically unchanged from 2010 and 2012, but nearly double those found in 2003 when the measure was first introduced in the survey. The share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014. Half (51%) of underinsured adults reported problems with medical bills or debt and more than two of five (44%) reported not getting needed care because of cost. Among adults who were paying off medical bills, half of underinsured adults and 41 percent of privately insured adults with high deductibles had debt loads of $4,000 or more.
The Affordable Care Act has transformed the health insurance options available to Americans who lack health benefits through a job. Numerous surveys have indicated that the law’s coverage expansions and protections have reduced the number of uninsured adults by as many as 17 million people.1
But Congress intended the Affordable Care Act to do more than expand access to insurance; it intended for the new coverage to allow people to get needed health care at an affordable cost. Accordingly, for marketplace plans, the law includes requirements like an essential health benefit package, cost-sharing subsidies for lower-income families, and out-of-pocket cost limits.2 For people covered by Medicaid, there is little or no cost-sharing in most states.
But most Americans—more than 150 million people—get their health insurance through employers.3 Prior to the Affordable Care Act, employer coverage was generally far more comprehensive than individual market coverage.4 However, premium cost pressures over the past decade have led companies to share increasing amounts of their health costs with workers, particularly in the form of higher deductibles.5
In this issue brief, we use a measure of “underinsurance” from the Commonwealth Fund’s Biennial Health Insurance Survey to examine trends from 2003 to 2014, focusing on how well health insurance protects people from medical costs. Adults in the survey are defined as underinsured if they had health insurance continuously for the proceeding 12 months but still had out-of-pocket costs or deductibles that were high relative to their incomes (see Box #1). The survey was fielded between July and December 2014. This means that we could not separately assess the effects of the Affordable Care Act on underinsurance because people who were insured all year in the survey had insurance that began before the law’s major coverage expansions and reforms went into effect. People who had new marketplace or Medicaid coverage under the Affordable Care Act would not have had that coverage for a full 12 months, as it would have begun in January 2014 at the earliest. Similarly, people with individual market coverage who were insured all year would have spent all or part of the period in plans that did not yet reflect the consumer protections in the law.6
From the 20 May 2015 post at The Health Care Blog
Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.
How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as “We have the most sophisticated research and teaching hospitals,” or “It’s the for-profit health insurers” or “Doctors make too much”) all fail when we compare the United States with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction, but in reality no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.
What’s the Mechanism?
Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.
That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven fee-for-service reimbursements.
Cost Control Drives Costs Up?
How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs would often drop far more to the bottom line than the original procedure did.
The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.
If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (“volume”) rather than whatever would be the best, most appropriate, most efficient treatment path (“value”). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.
The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.
The Smoking Gun
The smoking gun is right there in the chart, at the big split between the trajectories of the United States and other countries. And today, at this moment, the code-based fee-for-service payment system is still by far the basis of the majority of all revenue streams across health care.
The unifying factor between multiple new strategies unfolding in health care right now, including patient-centered medical homes, pay for performance, bundled prices, reference prices, accountable care organizations, direct pay primary care and others, is to find some way around the strict code-based fee-for-service system, either by avoiding it entirely or by adding epicycles and feedback loops to it to counter its most deleterious effects.
There is no perfect way to pay for health care. All payment methods have their drawbacks and unintended consequences. But the code-based fee-for-service system got us here, and any path out of the cost mess we are in has to get us off that escalator one way or another.
From the 22 May 2015 post at The Healthcare Blog
I believe the concept of value-based care is good for healthcare. VBC encourages providers to make changes that put the patient at the center of care, so that different services can be provided across providers in a collaborative way. If all went according to the VBC vision, there would be fewer redundant tests, more emphasis on preventative care, and an effort to keep high-risk patients out of the emergency room. It’s also better for costs, something we desperately need in the US, where healthcare spending per capita is more than twice the OECD average.
But Lisa’s story, at the leading edge of the value-based experiment, is not good at all. ACOs and most other value-based models are new, constantly changing, and unproven. ACOs report on 33 metrics that are supposed to represent the quality of care provided by their networks of providers. While still extremely limited in scope, any more than 33 metrics would have made Lisa’s job impossible. So far, few ACOs have reported any savings. Worse — the metrics are unproven. What if they overemphasize standardized process over patient outcomes? And what if efficiency measures result in neglectful and impersonal care? A lot is riding on Lisa’s testing ground.
The administrative challenge
By engaging with and learning from people like Lisa, I have begun to understand the problems frontier administrators face — the same problems countless others will face if we don’t address the administrative burden early on. Here are a few of the top headaches being rolled out in the name of value:
For ACOs, 33 metrics are tracked today. Inevitably, these will expand and change as accountable care evolves. There are also countless other systems of metrics encouraged by other incentive programs: the Physician Quality Reporting System measures, Meaningful Use metrics, Agency for Healthcare Research and Quality Indicators, the Consumer Assessment of Healthcare Providers and Systems for patient experience metrics, indicators for each specialty (Stroke and Stroke Rehabilitation Physician Performance Measurement Set, Endoscopy and Polyp Surveillance Physician Performance Measurement Set, and the Heart Failure Performance Measurement Set, to name a few). The document outlining protocols for the Physician Quality Reporting System is 18 pages long, with a mouthful of a title to match: “The 2015 Physician Quality Reporting System (PQRS) Measure-Applicability Validation (MAV) Process for Claims-Based Reporting of Individual Measures.” Got that? A new piece of legislation that passed the House of Representatives last week — the “doc fix” bill — is about to revamp many of these requirements once again.
Lisa had to fumble through different electronic systems and paper charts to extract the relevant data for each patient in her panel at dozens of different clinics. In many cases, it was clear that care had been provided (e.g. an unstable patient had been upgraded from a cane to a walker), but the documentation wasn’t there (to fulfill the “Screening for Future Fall Risk” metric, documentation must state whether the patient had no falls, one fall without major injury, two or more falls, or any fall with major injury.) Therefore, even though care was provided to prevent future falls, the documentation did not meet the CMS requirement and no credit was given.
For the next reporting year, Lisa is designing her own reporting mechanisms for clinics and doctors. She says that her first reporting experience “was invaluable in learning ways to improve the reporting for year 2015 and beyond,” and she is putting processes in place to facilitate reporting next year. But each clinic is different: some need a page at the front of their paper chart with check boxes, and some have templates in their electronic health records. Her new processes may improve the situation, but additional tracking could also cut into time doctors spend with patients and add to the squeeze they already feel.
Lisa integrated all the data from each clinic manually, and this is a problem for small institutions who are trying to communicate and coordinate with each other. Right now it takes a long time and is not very scalable. Even at larger institutions with leading electronic health record systems, the data is locked away within proprietary databases, often in incompatible formats. Clinical data is rarely integrated with financial and patient-reported data in the way required to tie outcomes and claims to reimbursements in a value-based model.
After all of her data collection, Lisa still had to submit her data to a third part to produce reports, and she will wait many months for the results. The CMS websites are comically complex ; the instruction manual for using the CMS metric reporting interface is 127 pages long.
Putting patients at the center
If these problems aren’t addressed, we’re in for a long and painful healthcare reform. Administrative costs will continue to rise, along with another generation of frustrated physicians and admins. Moreover, value-based care could be deemed a failure not because it’s a bad idea but because of poor implementation. Instead of putting patients at the center of care, it could breed more bureaucracy and force doctors to spend more time reporting on metrics and less time with patients.
We can address these issues and we must — to give value-based care a chance at moving the US toward more patient-centered, less exorbitant healthcare.
From the 22 May 2015 HealthCare Blog post
A few days ago, we wrote an editorial for US News and World Reports on the scant or dubious evidence used to support some healthcare policies (the editorial is reproduced in full below). In that case, we focused on studies and CMS statements about a select group of Accountable Care Organizations and their cost savings. Our larger point however is about the need to reconsider the evidence we use for all healthcare-related decisions and policies. We argue that an understanding of research design and the realities of measurement in complex settings should make us both skeptical and humbled. Let’s focus on two consistent distortions.
Evidence-based Medicine (EBM). Few are opposed to evidence-based medicine. What’s the alternative? Ignorance-based medicine? Hunches? However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about 12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients. Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns. This mix of research with the messy reality of medical and hospital practice means that evidence, even if available, is often not fully applicable.
Relative vs. Absolute Drug Efficacy:
Let’s talk a tiny bit about arithmetic. Say we have a medication (called X) that works satisfactorily for 16 out of a hundred cases, i.e., 16% of the time. Not great, but not atypical of many medications. Say then that another drug company has another medication (called “Newbe”) that works satisfactorily 19% of the time. Not a dramatic improvement, but a tad more helpful (ignoring how well it works, how much it costs, and if there are worse side effects). But what does the advertisement for drug “Newbe” say? That “Newbe” is almost 20% better than drug “X.” Honest. And it’s not a total lie. Three percent (the difference between 16% and 19%) is 18.75%, close enough to 20% to make the claim legit. Now, if “Newbe” were advertised as 3% better (but a lot more expensive) sales would probably not skyrocket. But at close to 20% better, who could resist?
Policy: So what does this have to do with healthcare policy? We also want evidence of efficacy with healthcare policies but it turns out that evaluation of these interventions and policies is often harder to do well than are studies of drugs. Interventions and policies are introduced into messy pluralistic systems, with imprecise measures of quality and costs, with sick and not-so-sick patients, with differing resources and populations, with a range of payment systems, and so on and so on. Sometimes, randomized controlled trials are impossible. But sometimes they are possible but difficult to effect. Nevertheless, we argue they are usually worth the effort. Considering the billions or trillions of dollars involved in some policies (e.g., Medicare changes, insurance rules) the cost is comparatively trivial.
But there’s another question: What if a decent research design is used to measure the effects of a large policy in a select population but all you get is a tiny “effect?” What do we know? What should policymakers do? Here’s what we wrote in our recent editorial in the US News and World Report….
From the 19 May 2015 SHEA news release
New research finds that misdiagnoses lead to increased risk of incorrect antibiotic use, threatening patient outcomes and antimicrobial efficacy, while increasing healthcare costs. The study was published online today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.
“Antibiotic therapies are used for approximately 56 percent of inpatients in U.S. hospitals, but are found to be inappropriate in nearly half of these cases, and many of these failures are connected with inaccurate diagnoses,” said Greg Filice, MD, lead author of the study. “The findings suggest that antimicrobial stewardship programs could be more impactful if they were designed to help providers make accurate initial diagnoses and to know when antibiotics can be safely withheld.”
Additionally, researchers found that overall, only 58 percent of patients received a correct diagnosis, indicating that diagnostic errors were more prevalent in this study than in previous studies unrelated to antimicrobial use. The most common incorrect diagnoses identified by researchers were pneumonia, cystitis, urinary tract infections, kidney infections and urosepsis.
Contributing factors which the researchers said may lead to inaccurate diagnosis and inappropriate antibiotic use include:
- Healthcare workers (HCWs) relying on intuitive processes, instead of analytical processes which are more reliable, safe and effective.
- HCWs experiencing fatigue, sleep deprivation and/or cognitive overload more prevalent in inpatient settings.
- HCWs receiving patients with a previous diagnosis from another provider.
- Lack of clinical experience and minimal personal experience with adverse drug effects.
From a Ponemon Institute web page, May 2015
The Fifth Annual Benchmark Study on Privacy and Security of Healthcare Data by the Ponemon Institute, sponsored by ID Experts, reveals a shift in the root cause of data breaches from accidental to intentional. Criminal attacks are up 125% compared to five years ago replacing lost laptops as the leading threat. The study also found most organizations are unprepared to address new threats and lack adequate resources to protect patient data. Download the study to learn more.
From the 17 May 2015 post by Susan Abram
Patient dumping, or when a hospital discharges a homeless patient to Skid Row or onto the street, has become rare, but still does occur. With so many homeless people who require medical care, hospitals in Los Angeles and across the nation are trying to find ways to help the homeless recuperate after being discharged. There are programs in Los Angeles, but they still are few and far between. Jonathan Lopez, who is a former homeless navigator, has helped many. Many more like him are needed. From my story (Daily News, October, 2013):
From the 28 April 2015 post at Nordic EBM
Evidence-based medicine has been called “cookbook medicine” by some of its more vocal critics. This implies that evil faceless organisations like Cochrane aim to turn all healthcare workers into mindless automatons who blindly follow dictums derived solely from scientific evidence. I hope it doesn’t surprise many in that this has never been the aim of Cochrane, or EBM in general, nor will it ever be. EBM, or EBP if you prefer the term ‘practice’ rather than the more vague ‘medicine’, is a belief system that rests on three pillars (cf. five in Islam). The EBM pillars are: 1) best available scientific evidence (i.e. the purview of Cochrane and yours truly), 2) clinical experience and 3) patient preferences and values. So, the main gist is that evidence doesn’t matter – no matter how scientific – if we don’t have a clinician at hand to interpret it for the benefit of a particular patient equipped with a particular set of values. For example, in a situation where two very similar patients have the same condition, one might wish to achieve speedy return to work whereas the other might rather avoid pain at all cost. The clinician would then use his or her judgment to identify the best course of treatment for both based on experience and what us science types have to offer. However, let us now leave the two pillars of clinical experience and patient preferences to be explored in future posts so that we can chew the first a bit more.
Now, the evidence bit in EBM is often understood to mean results of systematic reviews(a fancy type of research). Inasmuch as they offer an abstracted truth devoid of context (see my earlier post on mathematical ghosts) they still need to be interpreted for use in particular circumstances. This doesn’t always have to be done for every single patient by every single clinician separately. Think of the usefulness of reinventing the wheel for every drive. Often the thinking behind the interpretation and application of evidence can be written down and made use of by many. On a population level this means drafting guidelines. However, it is important to note that when scientific evidence is freely available one does not need to wait for formal committees to grow their beards long enough to formulate official guidelines. Especially when even supposedly professional guideline developers can do a really poor job (see previous post by Margot Joosen). In fact, all informed people and communities should participate in making sense of and advocating for the use of research to back up health decisions. In the end it affects the quality of care they receive.
From the 8 May 2015 post at Science Health
Information about the quality and performance of health care facilities can be confusing to consumers. Dozens of government organizations, trade groups and websites rate doctors, hospitals and long-term care facilities on all kinds of scales, from patient satisfaction to medical outcomes.
In 2008, the Centers for Medicare and Medicaid Services (CMS) attempted to simplify some of this data by creating a five-star rating system for nursing homes. The idea was that public reporting would drive improvement in care, helping nursing home residents and their families choose higher quality facilities, in turn encouraging nursing homes to improve quality to retain residents.
This data can be of limited use, however, for people whose decisions are constrained by insurance networks, cost and geography. People who are enrolled in both Medicare and Medicaid, often called “dual eligibles,” are particularly limited in their choices for long-term care. They are much more likely to have lower incomes, disabilities or cognitive impairment, and to receive low-quality health care in poor neighborhoods than other Medicare beneficiaries.
A new study in the May issue of Health Affairs by public health researchers from the University of Chicago, Harvard, and Penn confirms that despite best intentions, the new rating system exacerbated health disparities between this dual eligible group and non-dual eligible nursing home residents, i.e. those with better financial support. By 2010, two years after the system began, both groups lived in higher quality nursing homes overall, but non-dual eligible residents were more likely to actively choose a higher-rated nursing home. The gap between the two groups also increased: dual eligibles were still more likely to live in a one-star home, and less likely than non-dual eligibles to live in a top-rated home.
From the 14 May 2015 post by the Association of Health Care Journalists
Most medical devices marketed in the United States do not need formal approval from the U.S. Food and Drug Administration.
Members of a panel at Health Journalism 2015 on medical device coverage provided a variety of advice for reporters covering and of the implants, instruments and diagnostic tools common to the modern medical machine.
Moderator of the session was Chad Terhune, aLos Angeles Times reporter who recently found himself chasing an outbreak of carbapenem-resistant enterobacteriaceae (CRE) linked to dirty duodenoscopes. Contributing to the discussion were panelists USA Today investigative reporterPeter Eisler and Scott Lucas, associate director of accident and forensic investigation at the ECRI Institute.
A recent CRE outbreak at Ronald Reagan UCLA Medical Center illustrates the broader issues of medical device approval and oversight. The Olympus scopes used at the Los Angeles hospital, and at other facilities around the nation where the superbug infected patients, did not require any formal study or approval from the FDA before hitting the market because they were considered “substantially equivalent” to a previous models. Equivalency, Eisler explained, allows thousands of devices to move from labs to patients with little more than a short 510K statement that the manufacturer files with the FDA.
Only 10 percent of devices, such as those which “sustain or support life, are implanted, or present potential unreasonable risk of illness or injury” fall into the FDA’s “premarket approval’” category requiring a greater level of regulatory scrutiny, including safety and effectiveness studies, before sale.
Things are not much better once devices hit the market.
It is important to understand that medical devices seldom stand alone, he said. They are usually part of much broader systems used to deliver care safely to patients. When a patient dies after a ventilator fails, for example, it may be that alarms, communications networks or staffing protocols designed to quickly detect and report the failure did not work.
Thus, if reporters want to understand what went wrong in a specific incident, they should ask about more than the device itself. “The system approach to an investigation is key to finding the answer,” Lucas said.
Also be aware that hospitals are supposed to have detailed plans that tell employees what to do when there is a problem with a device. Sequestering machines that malfunction, and downloading data from them before it is purged, are examples of best-practice steps that reporters can ask about.
Handling the pitch
So what should a reporter do when he or she receives a glowing pitch from a local hospital about the latest device?
Terhune suggests starting with Medicare’s open payments database to see if the doctors involved have a financial interest in the device that’s being pitched. While a financial interest is not necessarily a deal breaker for coverage, it is something reporters should know about going in and make sure they can adequately address in their coverage.
Next, look at whatever FDA approval process was required for the device
From the 18 May 2015 post from the Association of Health Care Journalists
When writing about transparency in health care prices and quality, journalists should expose the myths that health care providers promote. That’s the advice Francois de Brantes gave during a session on price and quality transparency at Health Journalism 2015 last month.
Providers promote the false ideas that gathering accurate price and quality data is difficult, if not impossible, and that variations in price result from the severity of illness in populations, de Brantes explained. By debunking these myths, journalists would inform policymakers and the public that there are ways to calculate the prices of medical episodes of care accurately, and that price variation can be controlled. “Price varies because of the way physicians practice,” he said.
Among those myths:
- Price is a trade secret
- Disclosing prices would impede the ability of health plans, hospitals and physicians to compete effectively
- Revealing prices enables collusion and thus violates antitrust law
- Publishing prices leads to higher health care costs.
Both Quincy and Suzanne Delbanco (@SuzanneDelbanco), executive director of the Catalyst for Payment Reform, made the point that price and quality transparency are similar in that both seem simple but are in fact extremely complex topics to cover. Most consumers, for example, are unaware of such quality measures as hospital infection rates and the CAHPS Hospital Survey from the federal Agency for Healthcare Research and Quality, Quincy said.
From the 3 September 2014 post at KevinMD.com
1. Always ask “why?” This seems obvious, but even in this modern era, many patients take it as an article of faith that a doctor’s recommendation is thoughtful and well informed. It may well be; but on any given occasion, it could also be a knee-jerk — born of prevailing tendencies, distractions, and want of time. The question “why” is easily addressed by those who have already thought it over; and is a necessary reality check for those of us who have not.
2. Always ask “what else?” In the case of the fluoroquinolone syndrome, it’s bad enough when a fluoroquinolone was a genuinely thoughtful, warranted choice. It’s downright tragic when a much-less-potentially-toxic, narrow spectrum antibiotic would have served at least as well. “What else?” is a reminder that there is generally more than one way to test or treat, and the one we want is the BEST of them: most likely to help, least likely to hurt. It prods our providers to do the extra work of getting us there when we remind them we want to know the options, and comparison shop them.
3. Always ask “then what?” This would certainly defend against a screening colonoscopy in an 85 year old with congestive heart failure. If I have this test, then what? The answer would have to be: We can find potential cancer early, and fix it now so it doesn’t cause you trouble in ten years. That would invite all concerned to revisit the relevance of that “help” ten years in the future of someone exceedingly unlikely to live that long.
Press Announcements > FDA launches drug shortages mobile app.
From the 4 March 2015 announcement
Today, the U.S. Food and Drug Administration launched the agency’s first mobile application (app) specifically designed to speed public access to valuable information about drug shortages.
The app identifies current drug shortages, resolved shortages and discontinuations of drug products.
Drugs in short supply can delay or deny needed care for patients. Drug shortages may also lead health care professionals to rely on alternative drug products, which may be less effective or associated with higher risks than the drug in shortage.
“The FDA understands that health care professionals and pharmacists need real-time information about drug shortages to make treatment decisions,” said Valerie Jensen, associate director of the Drug Shortage Staff in the FDA’s Center for Drug Evaluation and Research. “The new mobile app is an innovative tool that will offer easier and faster access to important drug shortage information.”
App users can search or browse by a drug’s generic name or active ingredient, and browse by therapeutic category. The app can also be used to report a suspected drug shortage or supply issue to the FDA.
The agency developed the drug shortages app to improve access to information about drug shortages, as part of the FDA’s efforts outlined in the Strategic Plan for Preventing and Mitigating Drug Shortages.
The app is available for free download via iTunes (for Apple devices) and theGoogle Play store (for Android devices) by searching “FDA Drug Shortages.”
The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.
From the 23 March 2015 MedicalExpress post
Various pills (Photo credit: Wikipedia)
Open the medicine cabinet of a senior and you’re likely to find scores of pill bottles. Physicians are often unaware of all the medications a patient is taking, which can result in unnecessary additional prescriptions, non-prescription medications and potential drug-drug interactions that cause unexpected adverse effects. When a cancer diagnosis is thrown into the mix, the drug-drug interactions can become even more complex. A new study evaluates the currently available screening tools for determining if and when seniors with cancer are taking too many medications and finds that a more comprehensive medication assessment and monitoring plan is needed to improve treatment for this population.
Centers for Medicare and Medicaid Services (Medicaid administrator) logo (Photo credit: Wikipedia)
From the 25 March 2015 Columbia University news release
Quality-Life Year Gains Average $62,000
March 26, 2015 — Researchers atColumbia University’s Mailman School of Public Health analyzed the results of the Oregon Health Experiment, where eligible uninsured individuals were randomly assigned Medicaid or to stay with their current care. Considered controversial because the experiment found no measurable gains for physical health it did reveal benefits for mental health, financial wellbeing, and preventive screening. In terms of quality-adjusted life years, the researchers showed that Medicaid is an excellent value—a $62,000 gain in quality-adjusted life years. Study findings are online in the American Journal of Public Health.
Date:March 26, 2015
Source:H. Lee Moffitt Cancer Center & Research Institute
Summary:The lesbian, gay, bisexual, transgender/transsexual, queer/questioning and intersex (LGBTQI) population has been largely understudied by the medical community. Researchers found that the LGBTQI community experience health disparities due to reduced access to health care and health insurance, coupled with being at an elevated risk for multiple types of cancer when compared to non-LGBTQI populations.
The study highlights that LGBTQI populations face barriers to health insurance such as when partnerships and marriages are not legally recognized; concerns about disclosure in a health care setting, discrimination, misconceptions, legal and financial barriers and the disenfranchised stress and distress of caregiving same-sex partners.
Additionally, there are higher rates of smoking and substance abuse and low screening rates resulting in poor patient outcomes and survival rates for LGBTQI populations. Her review, The Importance of disclosure: Lesbian, gay, bisexual, transgendered, queer/questioning, and intersex individuals and the cancer continuum, was published in the American Cancer Society’s journal, Cancer.
Researchers identified that the real or perceived limited access to care due to fear of discrimination and lack of sensitivity and knowledge of LGBTQI issues stood as roadblocks to patient care. In a study of family physicians only 1 in 80 reported routinely asking patients about sexual orientation, while the majority reported rarely or never asking. The National Institutes of Health and the Institute of Medicine now recognize gender identify and sexual orientation as vital aspects of a health history and the need for improved research in this population.
“For many years, physicians did not ask patients about their sexual orientation. The importance of recognizing gender identity and sexual orientation is critical to ensuring the best quality and evidence-based care is available to patients,” explained Quinn.
From the 25 March 2015 MedicalExpress item
Bacteria that cause many hospital-associated infections are ready to quickly share genes that allow them to resist powerful antibiotics. The illustration, based on electron micrographs and created by the Centers for Disease Control and Prevention, shows one of these antibiotic-resistant bacteria. Credit: CDC/James Archer
Antibiotic resistance is poised to spread globally among bacteria frequently implicated in respiratory and urinary infections in hospital settings, according to new research at Washington University School of Medicine in St. Louis.
The study shows that two genes that confer resistance against a particularly strong class of antibiotics can be shared easily among a family of bacteria responsible for a significant portion of hospital-associated infections.
Drug-resistant germs in the same family of bacteria recently infected several patients at two Los Angeles hospitals. The infections have been linked to medical scopes believed to have been contaminated with bacteria that can resist carbapenems, potent antibiotics that are supposed to be used only in gravely ill patients or those infected by resistant bacteria.
“Carbapenems are one of our last resorts for treating bacterial infections, what we use when nothing else works,” said senior author Gautam Dantas, PhD, associate professor of pathology and immunology. “Given what we know now, I don’t think it’s overstating the case to say that for certain types of infections, we may be looking at the start of the post-antibiotic era, a time when most of the antibiotics we rely on to treat bacterial infections are no longer effective.”
From the ScienceDaily article
Date:March 23, 2015
Source:Thomas Jefferson University
Summary:Cancer patients over the age of 65 often take multiple drugs, which can interfere with cancer treatment. A new study shows that currently used tools to prevent over-medicating senior cancer patients need improvement.
From the 16 March 2015 Brookings news release
Achieving better health outcomes at a lower cost and succeeding with payment reforms that shift from volume to value is difficult without health information technology (IT). Health IT can engage and support health care providers, patients, and consumers with access to timely and accurate clinical information from electronic health records (EHRs) and other sources. It can also provide access to cost and coverage information that avoids burdensome administrative processes and unexpected costs. Health IT can achieve these benefits through interoperability across information and data exchange platforms – avoiding duplicative parallel systems and additional data entry. Engaged patients and providers, supported by flexible, usable and useful health IT, can make informed shared decisions about testing and treatment which can lead to more timely, efficient, and higher-value health care.
Download the issue brief.
From the 18 March 2015 UCLA news release
UCLA health care policy analysis finds four key problem areas for Latinos under Affordable Care Act
Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.
Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.
Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:
- The consequences of not covering undocumented residents.
- The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
- The heavier demand on public and private health care systems serving newly insured Latinos.
- The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.
“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”
Insurance for the undocumented
Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.
For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.
For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.
In addition, previous research has shown that undocumented people often delay seeking care for medical problems.
As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.
“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”
From the 10 March 2015 EurekAlert!
Massive health program: $34 billion spent on women and children since 2010; New goal: End preventable deaths of women and young children
An ambitious 2010 initiative to improve the health of women and children around the world has turned into the fastest growing global public health partnership in history, attracting $60 billion in resources. Some $34 billion, nearly 60 percent of the total, has already been disbursed.
The Every Woman Every Child movement has now gathered more than 400 commitments by more than 300 partners around the world, ranging from governments and foundations to business, civil society and low-income countries themselves.
The movement stems from the Global Strategy for Women’s and Children’s Health, launched by United Nations Secretary-General Ban Ki-moon in 2010 to accelerate progress towards the Millennium Development Goals (MDGs) for health.
Every Woman Every Child has set off a major wave in attention to improving essential health care for millions of poor women and children. Major gains in the past five years include greater professional maternity care, family planning, prenatal and postnatal care, childhood vaccinations, oral rehydration therapy and improving access to drugs to prevent mother-to-child transmission of HIV.
The result of such increased care is that maternal and child death rates have fallen in every one of the Global Strategy’s 49-targeted countries in the latest four years.
“The synergy between education and health is evident. Education and health are, quite simply, the drivers of change and development. Education empowers women and girls to live healthier lives and as a result, fewer children are dying. The evidence is clear, better education leads to better health outcomes.
“One of the most important lessons we have learned through the Millennium Development Goals is that to make progress we need an integrated and multifaceted approach,” says Kathy Calvin, president of the UN Foundation. “Effective partnerships are not just about financing; they also tap into partner expertise, innovation, and resources to deliver results. Every Woman Every Child has shown that when each sector contributes its unique strengths and capacities, we can save lives.”
Keys to progress
Significant improvements in key health indicators mainly in 49-targeted countries during its five-year history of Every Women Every Child include:
- 870,000 new health care workers.
- 193 percent increase in prevention of mother-to-child HIV treatment.
- 49 percent increase in oral rehydration therapy for treating infant diarrhea.
- 44 percent increase in exclusive breastfeeding.
- 25 percent rise in post-natal care for women.
- 25 percent rise in skilled birth attendance.
From the 11 March 2015 post by Cindy Nayer at The Health Care Blog
In recent weeks, the market has reacted to a few noteworthy headlines, all involved with or touching upon value-based discretionary actions, and many with the not-so-hidden question: What’s In It for Me or WIIFM?
- CMS announced that by 2016 30% of fees in health care should be paid for through a value-based system, moving away from fee-for-service.
- ACO results have shown ambivalent outcomes.
- Outcomes-based contracts have permeated the Hepatitis C cost-nado (that’s a cost sharknado, the kind that fiercely defies cost controls and takes over all noise about payment reform and patient preferences).
- Reference-based pricing is a good/bad troublemaker in the middle of the value-based travails.
The latest rampages have appeared on two national and highly-regarded blogs: The Health Care Blog [Value-Based Reform] and The Health Affairs Blog [Go Slow on Reference Pricing].
As one of the loudest proponents on value-based designs, I lift the curtain again to show the thinking behind the movement from fee for service to value-based designs. All of these items above discuss the message of payment reform, or system alignment, but they are intensely linked to the patient-consumer ability to make the right choices, choose the right sites for care, and pay the right amount for services rendered to achieve health security.
From the 5 March 2015 post at Covering Health (Association of Health Care Journalists)
WSB-Atlanta recently explored what happens when hospitals buy physician practices, which has been happening all over the Atlanta area.
Prices for patients go up.
The same physicians – in the same offices, with the same treatments – start charging more.
“Everything is exactly the same,” said cancer patient Mike Rosenberg.
Except the bill.
Sometimes it’s an “outpatient facility fee.” And sometimes it’s a “treatment room fee.”
And it’s a lot of money – sometimes thousands of dollars, not covered by insurance.
And even patients who are savvy enough to know about these fees before they get the bill have a lot of trouble finding out about them, as Erica Byfield made clear in her strong 3-minute report.
It’s not unique to Atlanta. She quotes a University of California, Berkeley, studythat found that patients generally pay 10 percent more at hospital-owned practices.
The ACA does include incentives for “vertical integration,” or having doctors and physicians part of one organization. But it’s not supposed to raise costs. It’s supposed to bring them down by improving efficiency, creating economies and encouraging care coordination. (Some of the fee problems actually stem from Medicare billing practices, not specifically the ACA.)
What are Evidence Based Reports?
EPC Evidence-Based Reports (home page and links to reports)
The Agency for Healthcare Research and Quality (AHRQ), through its EPCs, sponsors the development of various reports to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. These reports provide comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies. The EPCs review all relevant scientific literature on a wide spectrum of clinical and health services topics. EPCs also produce technical reports on methodological topics and other types of evidence synthesis-related reports.
Where do Technology Assessments come from?
The Technology Assessment (TA) Program at the Agency for Healthcare Research and Quality (AHRQ) provides technology assessments for the Centers for Medicare & Medicaid Services (CMS). These technology assessments are used by CMS to inform its national coverage decisions for the Medicare program as well as provide information to Medicare carriers.
Fact sheets and reports can be found through The Technology Assessment (TA) Program
How can I order Evidence Reports/Technology Assessments (ERTAs) or Comparative Effectiveness Reviews? [From http://www.ncbi.nlm.nih.gov/books/NBK45610/ (accessed 3 March 2015)]
The Evidence Reports/Technology Assessments (ERTAs) and Comparative Effectiveness Reviews (CERs) are provided to Bookshelf by the Agency for Healthcare Research and Quality (AHRQ). AHRQ has a publications clearinghouse, which can be accessed through this link: http://ahrqpubs.ahrq.gov/OA_HTML/ibeCZzpHome.jsp
United Nations News Centre – Over 5 billion people worldwide lacking access to essential medicines, says UN report.
From the 3 March 2015 report
A patient in a hospital in Cambodia is given some pain killers. Photo: World Bank/Masaru Goto
3 March 2015 – Three quarters of the world population has no access to proper pain relief treatment, according to a report by the United Nations body charged with overseeing Governments’ compliance with international drug control treaties, which was released in London today.
Around 5.5 billion people still have limited or no access to medicines containing narcotic drugs such as codeine or morphine the Vienna-based International Narcotics Control Board (INCB) says in its Annual Report for 2014, which went on to point out that around 92 per cent of all morphine used worldwide is consumed by only 17 per cent of the world population, primarily living in the United States, Canada, Western Europe, Australia and New Zealand.
The report, which calls on Governments to address the discrepancy in order to comply with International Drug Control Conventions, notes that natural disasters and armed conflicts around the world can further limit access to essential medicines and the Board stressed that in cases of emergency medical care, simplified control measures can be applied.
For example in the Philippines following the destruction by Typhoon Haiyan in 2013, the Board pointed out to all countries as well as to providers of humanitarian assistance the simplified procedures for the export, transportation and delivery of medicines containing substances under international control.
In its Report, the INCB notes that drug control measures do not exist in a vacuum and that, in their implementation of the drug control conventions, States must also comply with obligations under other treaties, including international humanitarian law and their international human rights obligations, such as allowing civilians to have access to medical care and essential medicines during armed conflicts.
Additionally, the INCB noted that States were charged with deciding specific sanctions for drug-related offences, but should avoid application of the death penalty for such cases.
To achieve a balanced and integrated approach to the drug problem, Governments also should ensure that demand reduction is one of the first priorities of their drug control policies, while they should put greater emphasis on and provide support and appropriate resources to prevention, treatment and rehabilitation, the Report says.
Among the rest of the Report’s findings were an increase in the number of new psychoactive substances (NPS) by 11 per cent and a 66 per cent increase in global consumption of methylphenidate, a stimulant primarily used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD).
The Report also pointed out that the legalization of production, distribution, sale and consumption of cannabis and its derivatives for recreational purposes in Uruguay, together with the moves by States in the United States to legalise sale and distribution of cannabis for non-medical purposes, ran counter to article 4 of the 1961 Single Convention on narcotic drugs, which requires States to limit the use of narcotic drugs to medical and scientific purposes.
How the discussion on dying has changed over 40 years: A conversation with Nancy Berlinger | Association of Health Care Journalists.
From the 18 February 2015 post
If you want a refresher on how far society has come on dealing with end-of-life care issues — and what issues are still to be resolved — then this retrospective article in the Feb 12 issue of the New England Journal of Medicine from experts at The Hastings Center is a great place to begin. It reviews the history of the end-of-life care movement in the U.S., takes a look at the integration of palliative care into health care delivery, discusses the still controversial “death with dignity” laws and ethical issues like removal of feeding and hydration tubes.
I recently spoke with co-author Nancy Berlinger, Ph.D., a research scholar at Hastings, about how the conversation on death and dying has changed over four decades.
Q: Why did you and your colleagues develop this retrospective for publication in a medical journal?
NB: It stemmed from a recent revision of The Hastings Center Guidelines [for Decisions on Life-Sustaining Treatment and Care Near the End of Life].
We see lots of ads from hospitals advertising their standards of excellence and their programs. None of them ever advertise their end of life care.
it’s clear that financial incentives are very misaligned with what people need, what they want, what would be medically appropriate. This is a very complex issue – it can’t be undone by a patient, or by an individual doctor or nurse. This has to be the focus of very high-level attention.
Q: What should journalists be focusing on?
NB: Even if they don’t cover the deep medical end of things, they can still ask questions in the context of health and wellness, such as:
- How much power does a sick person have?
- How much power does a really stressed out family have?
- How much power does a doctor, seeing X number of patients, really have?
- And, what still do we want to try to help these people to do? To understand we’re all connected in these efforts.
More women now using compounded hormones without understanding the risks — North America Menopause Society
From the 28 February 2015 press release
From 28% to 68% of women using hormones at menopause take compounded, so-called “bioidentical” hormones, but women don’t understand the risks of these unapproved, untested treatments, shows an analysis of two large surveys, which was published online in Menopause, the journal of The North American Menopause Society.
Prescriptions of compounded hormones aren’t systematically tracked the way those for FDA-approved drugs are, so the analysts used two large internet surveys of middle-aged and older US women to gauge how commonly they use approved hormone therapy and compounded hormone therapy at menopause. Nearly 3,000 women completed the Harris Interactive Inc and Rose Research LLC surveys, and the researchers used their feedback and US Census data to estimate national use.
They calculated that each year 57 to 75 million prescriptions for all menopausal hormone therapies are filled. Thirty-six million prescriptions are written for FDA-approved hormone therapy, so the remaining 28 to 39 million prescriptions are likely for compounded hormones.
But it seems that women who take them don’t know what they’re getting into. One survey asked women “Do you believe that bioidentical hormone therapies compounded at a specialty pharmacy are FDA-approved?” Only 14% correctly answered “no.” Most–76%–weren’t sure, and 10% incorrectly answered “yes
My Doctor Just Gave Me His Cell Phone Number … | The Health Care Blog.
From the 17 February 2015 post
That’s right…it really happened.
At the conclusion of a recent doctor visit, he gave me his cell phone number saying, “Call me anytime if you need anything or have questions.”
In disbelief, I wondered if this was a generational thing – and whether physicians in their late thirties had now ‘gone digital’.
My only other data point was our family pediatrician, who is also in her late thirties. Our experience with her dates back nearly seven years when my wife and I were expecting twins. A few pediatricians we met with mentioned their willingness to correspond with patients’ families via email as a convenience to parents. The pediatrician we ultimately selected wasn’t connected with patients outside of the office at that time, but now will exchange emails.
Four insurers reveal what they pay for 70 health care services | Association of Health Care Journalists.
From the 26 February 2015 article at Covering Health
Health insurers are taking incremental steps to release information on what they pay to health care providers. Each month, they reveal just a bit more.
This week, Aetna, Assurant Health, Humana and UnitedHealthcare released state and local cost information through the nonprofit Health Care Cost Institute (HCCI) on a consumer site called Guroo.com. The data show the costs for about 70 common health conditions and services and are based on claims from more than 40 million insured individuals, HCCI announced.
No other organization has made these data available, HCCI said. In that way, this release is significant. Or, as the Guroo site says of the data: “The biggest collection of cost information is now at your fingertips, so you know what care really costs.”
Well, not exactly. The data show what insurers paid. Or, as Jason Millman pointed out in The Washington Post, “The site doesn’t break down what a consumer pays for services versus what the insurer pays.”
The release of cost-transparency data seems to be gaining some momentum. Last month, the North Carolina Department of Health and Human Services published what it said was “the most current price information” from hospitals and ambulatory surgery centers. In so doing, North Carolina joined Maine and Massachusetts as the only states that publish price data on the web, according to last year’s Report Card on State Transparency Laws from the Catalyst for Payment Reform and the Health Care Incentives Improvement Institute.
Within days of the publication of the state data, Blue Cross Blue Shield of North Carolina published data on what it pays hospitals and physicians. In an earlier blog post we covered those events in North Carolina.
One person’s journey through an unhealthy health care system. Definitely not patient centered. Have had similar insurance problems, mostly because of errors in the insurance company erring in my personal identifiers.
From the 19 February 2015 item By LISA SUENNEN at The Health Care Blog
Let me start this story by telling you the end: I am just fine. For those of you who like me, there is nothing to worry about and all is well. For those of you who don’t like me, sorry to disappoint you, but you’re stuck with me for a while.
I’m telling you these things—news to make you happy or disappointed, depending on your point of view about me—because this story is about my recent trip to the hospital, an unexpected journey that I wasn’t sure I was going to talk about publicly.
And from one of the comments…
You sound true and authentic to me too. I am embarrassed as to how often we do screw up. The only excuse I think is that we have so much internal and external regulation that we become nervous nellies, unable to relax and enjoy what we are doing. You should go to a Pharmacy and Therapeutics meeting in a hospital and listen to the barrage of complaints from everyone to everyone. Wrong dose, wrong timing, wrong drug, wrong patient. I have walked out of these meetings because of the hostility. We would all do better if we could start some little village clinic in the Congo, without the interminable watching from a thousand eyes.
From the 21 February 2015 item by Teagan Kuruna (the MPH formerly known as Teagan Keating)
…While at Boston City Hospital, [Dr.] Rich saw a steady stream of young Black men come through the emergency room with stabbing and gunshot wounds. He also began to realize that everyone, including the other medical staff, saw these men as perpetrators rather than victims. The general consensus was that these men had done something to get themselves injured instead of what was obvious to Rich: these young Black men were truly victims.
Because of his compassionate streak, Rich began interviewing these men to learn more about their lives and what led to them returning to the ER over and over. He learned that the injuries that brought them to him were often due events outside their control–a robbery, a few wrong words to the wrong person, a simple accident that escalated to violence. After talking with them as they received treatment, Rich realized that the men were suffering from post-traumatic stress syndrome. Even worse, their injuries were stitched up and they were sent right back out to the same environment that brought them to the ER.
Rich wrote a book about these experiences called Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men.
From the 20 February 2015 post by Joseph Burns at Covering Health (Association of Health Care Journalist)
At a conference last year, Michael Laposata, M.D., Ph.D., one of the nation’s best known pathologists, explained how clinical laboratories could deliver more value to patients, physicians, and health insurers. To do so, pathologists and laboratory scientists need to provide more detailed explanations about lab test results because even physicians who order genetic and molecular tests are often confused about the results, said Laposata, chairman of the Department of Pathology at the University of Texas Medical Branch.
When he explains test results to ordering physicians, he frequently refers to an “allele” which is one of two or more versions of a gene, he said. When he does, physicians sometimes ask, “What’s an allele?”
His anecdote is telling following President Obama’s announcement last month that he recommended spending $215 million on the precision medicine initiative. The announcement was correctly hailed as an important and needed investment in medical technology. “Precision medicine” is described by the National Institutes of Health as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.”
Given that there is and will continue to be a lot of hype about precision and personalized medicine, we may want to check our expectations, because the hurdles are daunting, as Tabitha M. Powledge wrote for the Genetic Literacy Project. “The plan embodies a wonderfully human let’s-climb-Everest-because-it’s-there aspiration. But you also have to wonder about the practicality of such a sweeping program,” she explained.
There is not much good, proven, scientific, medical uses for what we’re talking about as personalized or precision medicine,” Greely said. “And yet, we … sell and we hype as if there is much more.”
“Here’s the problem: because personalized medicine is in the realm of OMG-that’s-too-complicated science, the usual watchdogs don’t see it. Plus the big academic medical centers love the grants that it generates.”
Even health insurers are struggling to understand the full implications of genetic and molecular testing…
Precision medicine to prevent diabetes? Researchers develop personalized way to steer prevention efforts
From the 14 February 2014 item at The Health Care Blog
“…. many app developers have little or no formal medical training and do not involve clinicians in the development process and may therefore be unaware of patient safety issues raised by inappropriate app content or functioning.”
Without the insights of seasoned real-world doctors and nurses, apps could end up with the same safety issues that are plaguing electronic health records, many of which were also developed with little regard to physician or nurse input.
In other words, just because it’s a “health” app doesn’t mean its necessarily so.
Among other issues, this is definitely a mental health concern. As quoted above, Serious mental illness affects men and women in jail at rates four to six times higher in the general population.
Bill Branson (Photographer)
From the 14 February 2014 post at The Health Care Blog
A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?
How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.
Those economics of a “negative price” trump Dr. Emanuel’s advice, and have made preventive care the fastest-growing component of employer health spending. Though hard statistics on checkups themselves are elusive, Dr. Emanuel estimates about 45-millon adult checkups are conducted each year, the equivalent of roughly 8 percent of America’s PCPs doing nothing but checkups, a curious use of their time when experts say the country could soon face a shortage of PCPs.
Shortage or not, subsidies and incentives might make economic sense if checkups improved health. However, when generally healthy adults go to the doctor for no reason, just the opposite is true: the Journal of the American Medical Association (JAMA) supports Dr. Emanuel assertion that annual checkups for asymptomatic adults are at best worthless, saying that additional checkups are “not associated with lower rates of mortality” but “may be associated with more diagnoses and more drug treatment.”
The solution to this orgy of overscreening and overdoctoring is remarkably simple: remove the ACA provision that makes annual checkups automatically immune from deductibles and copays; if they are going to be free at all, it should only be every few years. The proposal could still allow employers to override this provision — and even to attach money (incentives and penalties) to checkups — if they are willing to summarize the above-cited clinical findings for their employees.
If the only way they can continue the subsidy is by summarizing the literature, corporate human resources departments would predictably and immediately curtail this expensive corporate medical campaign. That would free up PCP time to work with patients who actually need medical care, while reducing counterproductive and costly healthcare utilization by those who do not.
From the February 2015 Science 360 news article
Some bandages are embedded with medicine to treat wounds, but researchers at Harvard University and Brigham and Women’s Hospital have something much more sophisticated in mind for the future of chronic wound care. With support from the National Science Foundation, engineer Ali Khademhosseini and a multidisciplinary team are bringing together advances in sensors, biomaterials, tissue engineering, microsystems technology and microelectronics to create “smart bandages” for wounds that require ongoing care, such as burns, diabetic ulcers and bed sores. The new devices, known collectively as flexible bioelectronics, will do much more than deliver medicine. They will be able to monitor all the vital signs of the healing process, such as oxygen levels and temperature, and make adjustments when needed, as well as communicate the information to health professionals who are off-site. To fulfill the critical need for flexibility, the team is testing new materials, such as a hydrogel that would cover a wound with just the right amount of stretch to be comfortable.
Provided by the National Science Foundation
On a related note, during Peace Corps training in Nashville (1979) I came down with a bad cough, often coughing for 5-10 minutes at a time. Don’t think the rainy weather and me going around with an umbrella or raincoat helped. Anyways, was sent to an area doctor and after a few tests, told me and the Peace Corps staff not to be concerned. Just a dormant fungus (and I do live a bit north of the Ohio River Valley). Anyways, after a few days in Monrovia, Liberia (6 am temps of about 85), I stopped coughing.
PS We were boarded in motels. One late night was awakened by a few young men in the group coughing loudly and giggling outside my window. Chalk it up now to some late night drinking and the men still being, well, young.
On another note, my husband quit smoking back in the 80’s after about 25 years of smoking. He had a lung X-ray and a dark spot on the lungs was noticed. He had quit smoking the month before. So now I’m wondering…cancer or fungus? He has not had any firm diagnosis of cancer since.
Beschreibung: Konventionelles Röntgenbild des Thorax (der Lunge) mit rundlicher Verdichtung in der linken Lunge Quelle: selbst erstellt –Benutzer:Lange123 17:18, 11. Nov. 2004 (CEST) (Photo credit: Wikipedia)
From the 9 February 2015 article By MATT HAWKINS, MD at The Health Care Blog
…Histoplasma capsulatum is a fungus endemic to the Ohio and Mississippi River Valleys. It is everywhere. You get it by breathing. Prior studies suggest that >80% of those living in these regions have contracted the fungus. The majority of people with histo don’t get sick. But – they get lung nodules. Lots of them. The nodules are benign but often indistinguishable on imaging from “early” lung cancer.
The entrepreneurial owners of the pictured urgent care center likely know this. They also know that Medicare and other carriers have limited coverage (reasonably so) to patients between the ages of 55 and 74 with at least a 30 pack year history of smoking. If patients have quit smoking, they must have quit within 15 years to be eligible for coverage. At first glance, it may seem like offering cheap, $88 screening for Americans ineligible for lung cancer screening coverage, or those eligible citizens too busy to get a physician order for a screening exam, is a good deed. But, $88 is just the tip of the iceberg. Additional screening exams and subsequent procedures/biopsies will all incur additional costs.
Our collective fear of malignancy, the unfortunately high frequency of lung cancer, and the promise of low dose CT screening for this disease will drive people outside of the NLST’s strict inclusion criteria into these low-cost, high-volume CT-scanning conveyor belts to “catch the cancer early.”
And what will they find in the Ohio River Valley?
Lots and lots of lung nodules.
The markedly increased propensity of patients in this region to have pulmonary nodules is likely to lead to an increased number of image-guided and open surgical biopsies (when the image-guided biopsy provides insufficient tissue for analysis). More invasive procedures will naturally lead to more cost-inducing complications (such as pneumothorax and pulmonary hemorrhage) and, in some instances, death.
From the 5 February 2015 post at The Gerontological Society of America
|For Immediate Release
February 6, 2015
|Contact: Todd Kluss
A new report from The Gerontological Society of America’s Workgroup on Cognitive Impairment Detection and Earlier Diagnosis outlines a course of action for increasing the use of evidence-based cognitive assessment tools as part of the Medicare Annual Wellness Visit (AWV).
The AWV was established by 2010’s Affordable Care Act to allow Medicare beneficiaries to receive preventive and assessment services during visits with their primary care providers. And although detection of cognitive impairment is among the required AWV services, no specific tools are mandated and no data are available regarding tools used for this purpose.
The new report outlines a plan for addressing this shortcoming and shows how increased detection leads to earlier and optimal diagnostic evaluation, referral to post-diagnosis support and educational services in the community, and ultimately to improved health-related outcomes and well-being for Medicare beneficiaries with diagnosed dementia and their families.
“The Medicare AWV offers a universal opportunity for primary care providers to start a conversation with older adults and their families about cognitive changes that might be worthy of further investigation,” said Richard Fortinsky, PhD, chair of the workgroup. “Our workgroup’s report provides guidance for providers so they can start this conversation and, as appropriate, employ evidence-based assessment tools to detect cognitive impairment.”
The report is available at www.geron.org/ci. The website also contains a link to a companion webinar held in January, led by workgroup members Katie Maslow, MSW, and Shari M. Ling, MD.
“Increased detection of cognitive impairment is essential for earlier diagnosis of Alzheimer’s disease and related dementia — and also earlier diagnosis leads to more timely linkage of older adults and their families with community-based services and supports,” Maslow said.
In the report, the workgroup outlines a recommended for four-step process achieving its goals.
Step 1 is to kickstart the cognition conversation. To increase detection of cognitive impairment and promote earlier diagnosis of dementia in the Medicare population, the GSA workgroup endorses that primary care providers use the AWV as an annual opportunity to kickstart — that is, to initiate and continue — a conversation with beneficiaries and their families about memory-related signs and symptoms that might develop in older adulthood.
Step 2 is to assess the patient if he or she is symptomatic. The GSA workgroup endorses use of a cognitive impairment detection tool from a menu of tools having the following properties: it can be administered in
five minutes or less; it is widely available free of charge; it is designed to assess age-related cognitive impairment; it assesses at least memory and one other cognitive domain; it is validated in primary care or community-based samples in the U.S.; it is easily administered by medical staff members who are not physicians; and it is relatively free from educational, language, and/or cultural bias. The report provides a list of tools that may be suitable for this purpose.
Step 3 is to evaluate with full diagnostic workup if cognitive impairment is detected. The GSA workgroup recommends that all Medicare beneficiaries who exceed threshold scores for cognitive impairment based on the cognitive assessment tools used in step 2 undergo a full diagnostic evaluation. Numerous published clinical practice guidelines are available to primary care providers and specialists to help them arrive at a differential diagnosis.
Step 4 involves referral to community resources and clinical trials, depending on the diagnosis. The GSA workgroup recommends that all Medicare beneficiaries who are determined to have a diagnosis of Alzheimer’s disease or related dementia be referred to all appropriate and available community services to learn more about the disease process and how to prepare for the future with a dementia diagnosis.
“The GSA workgroup views this suggested four-step process as a framework for communicating with a wide variety of stakeholders about the critical importance of incorporating cognitive impairment detection into everyday clinical practice with older adults,” Fortinsky said. “We look forward to building on this report by helping to plan additional activities intended to disseminate and implement the report’s recommendations in communities throughout the country.”
The Gerontological Society of America (GSA), the nation’s oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,500+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA’s structure also includes a policy institute, the National Academy on an Aging Society, and an educational branch, theAssociation for Gerontology in Higher Education.
From the 5 February 2015 post By JACK COCHRAN, MD and CHARLES KENNEY at The Health Care Blog
Technology occupies an unusual place in health care. Some people say that electronic health records are clumsy barriers between patients and their doctors. Others suggest that technology is a kind of secret sauce.
In many places physicians and other clinicians are stymied by awkward technology. In other organizations — Kaiser Permanente included — electronic health records enable some of the finest individual and population health care ever.
This humorous equation speaks volumes about technology and health care:
NT + OO = COO
New technology + old organization = Costly old organization. In other words, technology doesn’t change an organization. Change is about leadership and culture. It is about thinking in new ways and asking new questions.
For example, rather than ask how many patients can you see, let’s ask how many patients’ problems can you solve?
Instead of asking how can we convince patients to get required prevention, let’s ask how can we create systems that significantly increase the likelihood that patients get required prevention?
Instead of asking how often should a physician see a patient to optimally monitor a condition, let’s ask what is the best way to optimally monitor a condition?
When we begin asking these kinds of questions, we see technology as a tool — not a solution by itself, but as a powerful tool we can use to deliver better individual and population care. Technology, like data, is only useful when it enables clinicians and teams to work effectively to provide the highest quality care for patients.
Read the entire post here
From Deloitte Review 16 WRITTEN BY Sheryl Coughlin, Jeff Wordham & Ben Jonash, 26 February 2015
The intersection between rising consumerism and a growing retail orientation in the health care sector presents challenges, some unprecedented, for existing players. We explore three shifts that health industry players should respond to, and that can set the scene for greater consumer involvement.
Could it ever be that easy in health care?
The cost of health care is high and rising. For the past 10 years, health care costs have exceeded US economic growth by an average 2.5 percent annually. The anticipated average annual growth rate of health care costs is 5.7 percent per year through 2023, well above gross domestic product (GDP), average wages, and productivity gains.1 Improving economic conditions, the impact of the ACA’s insurance coverage expansions, and an aging population are expected to drive health care expenditure growth.2 Average annual growth of out-of-pocket health care expenditure is projected to rise to 5.5 percent by 2023 from 3.2 percent in 2013.3
The health care system in the United States is edging toward a recalibration. Existing business models are being challenged to find and deliver new sources of value and to develop innovative approaches to make health care less complicated, and to improve outcomes:
Health care is moving toward value, not volume, as a central organizing principle. That impacts how patients are cared for, how physicians and hospitals are paid, and how life sciences companies approach the market.
Those paying the bills—employers, government, health plans, and increasingly, individuals—are looking for better value and better outcomes.
Entrepreneurs, retail organizations, and communications and technology companies see opportunity in the large and growing health care market. Taking advantage of developing trends, they are slipping across the industry’s increasingly permeable boundaries.
Read the entire review here
From the 4 February 2015 article through the Association of Health Care Journalists
Independent journalist Lola Butcher reports that debate about the government’s 340B Drug Pricing Program continues to build as the program expands.
“Like all good controversies, this one has enthusiastic advocates and wild-eyed opponents, and it’s easy to get snagged by the passion of the partisans,” she writes in a new tip sheet.
The program, which started in 1992, requires pharmaceutical companies to sell outpatient drugs to eligible health care organizations at significantly reduced prices.
Over the years, the eligibility criteria to participate has expanded repeatedly. Currently, safety-net hospitals, children’s hospitals, critical access hospitals, federal health centers and other organizations are eligible; organizations that fall into those categories must register and enroll in the 340B program.
Butcher, as a 2014 AHCJ Reporting Fellow on Health Care Performance, wrote about the migration of cancer care from physician-owned clinics and community centers to hospital outpatient departments. She found that the 340B program helped fuel that trend.
In this tip sheet for reporters, she explains the program, including the program’s winners and losers, how much money is involved and story ideas.
Surgical metrics do not provide a clear path to improvement
From the 4 February 2015 Mayo Clinic press release
PHOENIX – While surgical outcomes have improved nationally over time, surgical outcome reporting does not necessarily lead to better outcomes, according to a Mayo Clinic study published this week in the Journal of the American Medical Association.
Systems that capture, analyze, and report surgical outcomes are an increasingly important part of the quality improvement movement in health care in the United States. Within the U.S., the most widely used surgical outcomes reporting system is the National Surgical Quality Improvement Program (NSQIP), which is coordinated through the American College of Surgeons.
The study analyzed data regarding surgical outcomes — complications, serious complications, and mortality — in over 345,000 patients treated between 2009 and 2013 at academic hospitals throughout the United States. Of these patients, approximately half were treated at hospitals that participated in the NSQIP. The study showed that surgical outcomes significantly improved overall in both study groups during the period of analysis.
“In our study we weren’t interested in whether patients had better outcomes in NSQIP vs. non-NSQIP hospitals,” says David Etzioni, M.D., chair of Colorectal Surgery at Mayo Clinic in Arizona and the study author. “We wanted to know whether the outcomes experienced by patients treated at NSQIP hospitals improved, over time, in a way that was different from patients treated at non-NSQIP hospitals.”
The study found no association between hospital-based participation in the NSQIP and improvements in postoperative outcomes over time, suggesting that a surgical outcomes reporting system does not provide a clear mechanism for quality improvement. According to the research team, the failure of these types of outcomes monitoring systems to produce measurable improvements in outcomes may be related to difficulties in identifying mechanisms that translate reports into changes in how surgical care is provided.
“I think if there is one lesson that we have learned at Mayo Clinic; real quality is achieved through a system — not just a doctor, not just a nurse or other staff,” Dr. Etzioni says. “All of these elements of care have to work together closely to provide patients with the best possible outcomes.”
Care of patients prior to making a diagnosis rarely assessed by quality measures
From the 3 February 2015 press release
An examination of process measures endorsed by the National Quality Forum finds that these measures focus predominantly on management of patients with established diagnoses, and that quality measures for patient presenting symptoms often do not reflect the most common reasons patients seek care, according to a study in the February 3 issue of JAMA.
Health care reform efforts, such as accountable care organizations, focus on improving value partly through controlling use of services, including diagnostic tests. Publicly reported quality measures that evaluate care provided prior to arriving at a diagnosis could prevent financial incentives from producing harm. The National Quality Forum (NQF) currently serves as the consensus-based quality-measure-endorsement entity called for in the Affordable Care Act. Endorsed measures are often adopted by the Centers for Medicare & Medicaid Services in payment and public reporting programs, according to background information in the article.
Hemal K. Kanzaria, M.D., M.S.H.P.M., of the University of California, Los Angeles, and colleagues examined NQF-endorsed process measures that evaluate the prediagnostic (prior to making a diagnosis) care of patients presenting with signs or symptoms. There were 372 process quality measures listed on the NQF website as of June 4, 2014; from these, 385 codings were determined, by categorizing the process quality measures by a system developed by the Institute of Medicine. Approximately two-thirds (n = 267) targeted disease management and 12 percent (n = 46) targeted evaluation/diagnosis. The remaining were evenly distributed among prevention, screening, and follow-up.
Of 313 measures pertaining to evaluation/diagnosis or management, 211 (67 percent) began with an established diagnosis, whereas 14 (4.5 percent) started with a sign/symptom. The sign/symptom-based measures focused on geriatric care (e.g., memory loss, falls, urine leakage) or emergency department care (e.g., chest pain). In contrast, many common reasons for which patients seek care, including fever, cough, headache, shortness of breath, earache, rash, and throat symptoms, were not reflected by the quality measures. The performance of a lab test or medical imaging study was the action required by 59 of 313 (19 percent) endorsed quality measures; many others required actions related to medication prescribing.
From the Wiley press release (February 2015)
Recent research indicates that most of the variation in hospital readmission rates in the United States is related to geography and other factors over which hospitals have little or no control. Access and quality of care outside of the hospital setting seem to be especially important.
A new editorial that addresses these findings notes that a broader focus on community health systems, not just performance of individual hospitals, may be needed to reduce hospital readmissions.
Because high readmission rates trigger reductions in Medicare reimbursements to hospitals, facilities in socioeconomically disadvantaged and underserved communities may be disproportionately penalized. The editorial is published in Health Services Research.
Access and quality outside the hospital may affect the degree to which the HRRP can achieve its intended outcome, fewer readmissions, but other factors are likely to determine whether the policy is an operational success. For the HRRP, operational success could be defined as whether hospitals respond in a manner consistent with the underlying motivations of improving quality of care and reducing costs. In terms of improving quality, a recent meta-analysis of randomized trials found that interventions designed to prevent readmissions tended be moderately effective (relative risk of 30-day readmission 0.82, 95 percent CI, 0.73–0.91). The studied interventions addressed care both during and after hospitalization, such as through case management, patient education, home visits, and patient self-management support, among other activities. Multifaceted interventions were more common and were 30–40 percent more effective than one-dimensional ones (Leppin et al. 2014), yet they may also be more challenging to implement and more costly. The degree to which hospitals nationwide are implementing quality improvement interventions that target readmissions does not appear to have been described.