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Month: June 2013

What’s Changed Since the Obamacare Verdict

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By Dan Diamond

Ever since its controversial passage in 2010, the Affordable Care Act has been plastered with a range of polemic labels. Critics say Obamacare is job-killing; supporters herald it as life-saving.

Here’s another, perhaps unexpected label: personally profitable.

If you were among the true believers in the law a year ago today, there was easy money to be made. Nearly 80% of bettors on InTrade expected the law to be found unconstitutional; strategically spending about $25 in favor of the ACA could’ve netted you $800, based on how InTrade’s short-selling rules worked.

Much has changed, certainly, since Chief Justice John Roberts cast the deciding vote to uphold the law. (Beyond those bettors’ account balances, and the existence of InTrade itself, which mysteriously shut down in March.)

Here’s a look at how the Supreme Court’s decision on June 28, 2012, affected five hot-button issues related to the health law.

States’ decisions on Medicaid expansion

As of June 27, 2012: Several states with progressive governors and legislatures, like California, had moved to expand Medicaid ahead of the Supreme Court’s ruling. The Golden State’s leaders also had pledged to pursue universal coverage if the ACA was ruled unconstitutional.

But most states were waiting on the resolution of the constitutionality battle.

Since June 28, 2012: After the Court’s decision that the mandate was constitutional but that the Medicaid expansion was optional for states — which “took everyone by surprise,” said Matt Salo, executive director of the National Association of Medical Directors — governors were suddenly forced to decide whether the expansion made financial, and political, sense. Within a week, about ten states had signaled they’d expand Medicaid under the ACA.

However, many wary governors chose to wait for the November elections, and the knowledge of who would hold the White House, before announcing their plans; following President Obama’s reelection, a flurry of governors clarified their Medicaid stances throughout the winter and spring.

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Healthcare Lands: Announcing the Journal of Delivery Science and Innovation

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By Ashish Jha, MD

There is an old saying that every unsustainable trend, by definition, comes to an end.  The U.S. healthcare system has been on an unsustainable trajectory, consuming more and more of our national income while failing to deliver the kind of care that Americans need and deserve.  But although every unsustainable trend eventually ends, how it ends is up to us.

The healthcare system has the potential to collapse under its own weight, requiring Americans to pay even more for healthcare, forcing draconian and blunt cuts in the kinds of services available, and putting high quality healthcare out of reach for the poor and the sick.

An alternative future is one in which payers pay for value, providers become more efficient and patient centered, and consumers become increasingly engaged in caring for themselves.  In this future, healthcare becomes an important force for improving the health of the American public.

What will determine which path our healthcare system will take?  While the fate of our healthcare system will be influenced by policymakers in Washington DC and the state capitals, it will ultimately be decided by each of us – providers and patients who are involved in the daily work of delivering and engaging in healthcare.

The journal Healthcare: The Journal of Delivery Science and Innovation is an effort to nudge us toward a better, sustainable path for our healthcare system.  The mission of the journal is simple:  to play a meaningful role in fostering real change in the healthcare delivery system.  The journal wants to be a venue for sharing the best ideas for delivery science, payment innovation and smart use of health information technologies.  The journal was conceived by Amol Navathe and Sachin Jain, who have been thinking long and hard about compelling new approaches to bring about change in the healthcare system.  It took years of persistence to line up a terrific publisher, put together a top notch editorial board and recruit some of the nation’s best minds to lead individual theme areas.  And it paid off handsomely.  Today, June 26th, Healthcare officially launches with its premier issue, and what an issue it is.

The two introductions are short, pithy and worth reading over and over again.  The first is by Don Berwick, the former Administrator of the Centers for Medicare and Medicaid Services but even more importantly (at least to me), the man who has done more to promote quality and safety than anyone in recent memory.  Don frames the issues in ways that only he can, reminding us that we can have the best healthcare system in the world – we have all the pieces – but we have to learn how to put it together.

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Toxic Stress

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By Susan Dentzer

“Speed kills,” warns the traditional highway sign about the dangers of haste and traffic deaths. Now, we know that stress kills, too.

Toxic stress, at any rate. The human body’s response to normal amounts of stress—say, a bad day at the office—is likely to be brief increases in the heart rate and mild elevations in hormone levels. But a toxic stress response, stemming from exposure to a major shock or prolonged adversity such as physical or emotional abuse, can wreak far more havoc.

In children, science now shows that toxic stress can disrupt the developing brain and organ systems.

The accumulated lifelong toll of stress-related hormones sharply raises the risk of chronic diseases in adulthood, ranging from heart disease and diabetes to depression and atherosclerosis.

Thus, the message from a panel of experts to the Robert Wood Johnson Foundation’s Commission to Build a Healthier America was at once simple and challenging: Create a healthier environment for—and increase coping mechanisms and resilience in—the nation’s most vulnerable and stress-ridden children and families.

At a June 19 meeting in Washington, DC, the commission heard testimony from a child development specialist, an economist, and community development professionals, among others. Together, they described more of the social and economic effects of toxic stress, but also the evidence that significant investments in individuals, families and communities can turn the tide.

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What Doctors Do When They Don’t Know What to Do

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By Allen Frances, MD

Medical care in the U.S. over-promises and under delivers. It costs about twice as much as in most other developed countries, but compared to them manages to produce only mediocre health outcomes. The profit motive has resulted in badly misallocated resources — too much testing and treatment for people who don’t need it and lousy access for many who do.

The impact of advances in medical science on the delivery of clinical care has also been over sold. The basic science revolution in medicine has indeed been brilliant, with powerful new tools yielding remarkable insights into how our bodies work. But translating this into better tests and treatments has been slow work and the practical benefits derived from all the brilliant science have been surprisingly disappointing.

There is a big disconnect between the daily enthusiastic reports of great new research results and the fact that treatment outcomes have improved only slowly and selectively. Clearest example — we have done a lot more to defeat cancer by dramatically reducing smoking than through the entire expensive forty year research war we have waged against it.

Certainly, we need to aggressively pursue medical research, but we also need to be realistic about the limits of our current understanding of disease processes and their treatment.

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Will the “Instagram for Clinicians” Be a Game-Changing Educational Resource?

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By Mike Miesen

Working with clinicians to set up forums where care teams would discuss their patients daily, I was privy to the excited eyes and cheshire cat smiles that accompanied the talk of “woah” patients – the medically rare, gross, or otherwise notable cases which made the day a bit more interesting. The patient with Anton-Babinski Syndrome. The child whose amputated hand was proof he shouldn’t have been playing with an axe. The all-too-common gunshot wounds of every type, notable for their stories more than the wounds.

With the release of Figure 1, a photo-sharing app for health care professionals, those conversations can leave the hospital and enter the cloud; physicians can upload a picture to their feed, and it’ll be instantly available to the world. It’s Instagram for health care workers, except instead of filtered “selfies” and pictures of brunch, it has pictures of rare medical conditions and x-rays of things inserted where they shouldn’t be. It’s a new, neat idea that could change the face of medical education or serve as stress-relieving entertainment. Or both.

Dr. Joshua Landy, co-founder at Movable Sciences, said in an email interview that he created Figure 1 to fill a gap he identified in clinician-to-clinician communication. Currently, “many physicians collect images of interesting or representative cases on their smartphones,” and share with colleagues. Sensing an opportunity, and “recognizing the educational benefit of these images,” Landy created an app that would “harness thousands of educational assets being collected by individuals each day.”

The app opened to the public three weeks ago, and has a user base “well into the thousands,” Landy said. Anyone can download it, but only health care professionals can upload images; once vetted, physicians will have a “Verified Physician” badge on their profiles. Users can search for images of specific conditions and have conversations with others through a commenting feature – which Landy said has already been used as a virtual classroom, with “experienced healthcare professionals answering questions for medical students.”

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Why Affirmative Action Still Matters in Medicine. And Probably Always Will…

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By Sheryl Heron, MD

I am an emergency room physician who has worked at Atlanta’s Grady Memorial Hospital for 17 years. I am also the first black woman to ever be hired as  a faculty member, and thus have had the opportunity  to teach students and doctors in training.  Given that 85% of the patients of the 120,000 patients that cross our threshold annually are black, my hiring carried enormous symbolic weight.

Beyond the symbolism, I’ve found a real effect on patient care. There are a few earlier studies which suggest that patients prefer doctors who look like them if given the opportunity.

Though we can’t yet confirm that physicians and patients of the same race improve health for minorities , we can still argue that increasing diversity in the healthcare professions is a worthy goal.  We must move to a place where physicians can comfortably care for people of all cultures and patients can feel comfortable being cared for physicians from different cultures.

In my own experience, African-American grandmothers, mothers, sisters, aunts all want to give me a hug when they see me walk in the room to treat them or their loved ones: “Go ahead sister,” they might say, “we’re so glad and proud to see you”.   I have also had many black patients tell me they were more comfortable talking with me about their history of abuse or addiction.  That kind of rapport leads to better care and a healthier population.

If the Supreme Court had ruled in favor of Abigail Fisher in Fisher vs. The University of Texas today, which they did not, opportunities for physicians of color who could establish that rapport might have been significantly diminished.

To eliminate or significantly weaken affirmative action, which would have been the result of a Fisher victory, would deal a significant blow to the ability of undergraduate programs to recruit and create a diverse student population—some of whom will continue on to medical school. To be sure, that blow would weaken medical schools nationwide.

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The Art of Measuring Blood Pressure

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By Country Doctor

Edna Lavoie has had horrendous blood pressure readings for several decades, but she has never had a stroke or heart attack. Her eye doctor swears her retinae are healthy. Whenever she takes a pill that even begins to normalize her blood pressure, she complains of severe dizziness.

Dwayne Lieber’s home blood pressure cuff never reads anywhere close to our manual office sphygmomanometers, even though it is a good brand that usually seems quite accurate for our other patients who own the same model.

Donald Dickinson and Jane Green seem to be a pair of Jekyll and Hyde characters as far as their blood pressures are concerned; every other visit they seem to have a normal blood pressure in the 125/80 range and the rest of the time their systolic pressures are between 180 and 200.

Blood pressure measurements are routinely done every time a patient visits the doctor and hypertension is one of the most common diagnoses in primary care. A patient’s blood pressure is sometimes done with an automatic cuff, sometimes by the nurse or medical assistant and sometimes by the doctor. It is actually a complicated matter, fraught with problems and potential pitfalls.

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Is Obesity a Disease? I Vote No

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By David Katz, MD

There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.

And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.

Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?

On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?

If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.

There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.

And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.

But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.

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My Name is Rob. And I’m a Recovering Doctor.

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By Rob Lamberts, MD

Yeah, I am recovering…doing a lot better, actually.  Things are tough, but they are a lot better since I left my destructive relationship with Medicare, Medicaid, and insurance companies.  I’ve had to learn how to manage my own money (now that I can’t count on them to bail me out any more), but things are looking a lot better.  I am beginning to see how much better it will be to be on my own.

The key was when I realized that the system wasn’t going to change no matter how much I accommodated its unreasonable requests.  I felt that if I only did what it asked of me, however unreasonable, it would stop hurting me and, more importantly, my patients.  But I’ve come to see that all the promises to take care of me and my patients were written in sand, and that it couldn’t resist the temptation to cheat on me.  I tried to do what it asked of me, but as time went by I couldn’t take how dirty it made me feel.

I want to believe it was sincere when it told me it wanted to change.  I think at its core, it wants to help patients and doesn’t want to go on those spending binges.  But no matter how sincere the promises sounded, I was always left alone as it threw its money at every sexy treatment, procedure, or drug that walked by.  Then it would go off on tirades about how much I spent and that I didn’t do enough to keep to our budget.  It was always my fault.  I think it’s just easier to pass blame on others than it is to do the hard things necessary to really change.  To be honest, I think it was terrified at how much real change would hurt.

But I can’t sit around and wait for the system to change any more.  My patients were getting less and less of my time, and I was getting to the breaking point.  I know there are a lot of other doctors who are willing to do whatever the system asks, but I can’t sit around and watch it self-destruct.  It’s not what’s best for the system, for us doctors, and for our patients.  Sometimes the best thing you can do for someone is to let them self-destruct and pray that they finally take responsibility and learn the hard lessons.  I just hope that happens soon.

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Physicians Aren’t Driving Up Health Care Costs

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By John I. Allen, MD

Recent interest in variability of cost for medical procedures is justified and long overdue. In an article in the New York Times on June 2, 2013, “The $2.7 Trillion Medical Bill,” Elizabeth Rosenthal writes from the point of view of a patient who has received a bill for colonoscopy. She then researches costs of the procedure in a number of markets in the U.S., finding a range of pricing from an average of $1,185 to a high of $8,577. There is an implication within this article that “doctors” are charging these prices. The truth is that physicians are often pawns in much larger negotiations among other entities.

While charges for procedures performed in an office setting or practice-owned ambulatory surgical center (ASC) are largely under the control of physicians, many of the highest prices come from hospital owned facilities — an area that is not at all controlled by physicians.

I called the lead negotiator for payor contracts at my institution and asked him about price variability for colonoscopy. It was clear from my conversation that the current arguments about colonoscopy price variation miss some key components. We need to better explore the true drivers of price variation.Continue reading…

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