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cindywilliams

The Key to Improving Our Health? Look Beyond Health Care.

Sep 28, 2011• 3

By AARON WERNHAM, MD

The United States spent $2.5 trillion on health care in 2009, more per capita than any other nation. Yet our country is ranked 32nd in the world in life expectancy, and rates of conditions such as diabetes and obesity have increased dramatically in recent years.

If we hope to address spiraling medical costs and improve the health of all Americans, we need to begin focusing on the policies — in fields such as transportation, energy, education and agriculture — that shape the world outside the doctor’s office.

But how? Policymakers are already juggling shrinking budgets, crumbling infrastructure and competing priorities. A recently released report from the National Research Council offers a solution. The study, “A Framework and Guidance for Health Impact Assessment,” points out that good health is determined by more than money spent on the health care system. An NRC committee on health impact assessments, of which I am a member, took an in-depth look at why they are needed.

Similar to the way a Congressional Budget Office score predicts the fiscal impact of a proposed policy, an HIA identifies the likely effect on health of a decision in another field, such as building a major roadway, revitalizing a neighborhood or developing energy or agricultural policy. HIAs can help decision-makers identify unintended risks, reduce unnecessary costs and leverage opportunities to improve the health of their communities.

As a doctor, I’ve often cared for diabetics who struggle to follow exercise recommendations because there’s nowhere nearby that’s safe to exercise. I’ve seen patients with frequent asthma attacks exacerbated by living in housing with mold and poor ventilation. I’ve given diet advice to parents of overweight children, only to find that they live in a neighborhood with no grocery store for miles and eat school lunches that should but often don’t meet current nutrition guidance.Continue reading…

Too Much Responsibility/Not Enough

Sep 27, 2011• 16

By ROBERT LASZEWSKI

The Health Leadership Council (HLC), a coalition of CEOs from many of the leading health care companies, has created a list of Medicare reform recommendations for the Super Committee tasked with finding at least $1.2 trillion in budget savings.

As we begin the national debate over what to do about Medicare’s unsustainable costs, I will suggest that the HLC proposal gives us one, of what will have to be many, outlines for discussion.

Their recommendations include:

Creating a new Medicare Exchange, beginning in 2018, where beneficiaries would have the choice of private Medicare plans as well as the traditional Medicare plan. The HLC proposal would be a defined contribution program much like the Republican Ryan plan but would differ from Paul Ryan’s in a couple of key ways. First, in the HLC proposal traditional Medicare would continue to be one of the options. Second, the annual increase in the beneficiary support premium would be more generous—the HLC is proposing an annual premium support increase equal to GDP plus 1%.
Gradually increasing the Medicare eligibility age from 65 to 67—starting in 2014.
Reforming Medicare’s cost sharing structure by increasing deductibles and co-pays as well as requiring high-income beneficiaries to pay the full cost of Medicare Part B.
Implementing medical liability reform including a cap on non-economic damages, a one-year statute of limitations, and a “fair share” provision that would limit damages commensurate with responsibility for the injury.

Making Sense of Health Care Prices

Sep 23, 2011• 43

By JOHN GOODMAN

Take a look at the chart below. It shows representative prices for a knee replacement for different patients in different settings. The most shocking thing about the chart is that prices for essentially the same procedure are all over the map. Here are some obvious questions:

Why is the price of a knee replacement for a dog — involving the same technology and the same medical skills that are needed for humans — less than 1/6th the price a typical health insurance company pays for human operations? Why is it less than 1/3 of what hospitals tell Medicare their cost of doing the procedure is?
How is a Canadian able to come to the United States and get a knee replacement for less than half of what Americans are paying?
How are Canadians getting knee replacements in the U.S. able to pay only a few thousand dollars more than medical tourists pay in India, Singapore and Thailand — places where the price is supposed to be a fraction of what we typically pay in this country?
Why do fees U.S. employers and insurance companies are paying vary by a factor of three to one, when foreign, and even some U.S., facilities are offering a same-price-for-all package?

It’s amazing how often people cannot see the forest for the trees. Think how many volumes have been written trying (and failing) to explain why our health care costs are so high. Sometimes the answers to complex questions are more easily found by asking the simplest of questions.

The Math of E/M Coding: When Does 5=1?

Sep 23, 2011• 6

By PAUL FISCHER, MD

My typical Medicare patient expects me to deal with 5 or more problems in a single routine visit. There are usually around 3 old ones (e.g., diabetes, hypertension, hyperlipidemia) and at least 2 new ones (e.g., low back pain, fatigue). For those who come with handwritten lists, there may be as many as 10, including every health question that has come to mind over the past 6 months (Should I take a holiday off of Fosamax? Should I add fish oil? Do I need another colonoscopy? Is the shingles shot any good?).

Physicians who do procedures get paid for each one done to a single patient on a particular day. Medicare’s rule for this – the Multiple Procedure Payment Reduction Rule (MPPR) – says doctors should be paid 100% for the first procedure and 50% for each subsequent procedure up to 5. However, for those of us whose work is primarily cognitive rather than procedural, there is an important exclusion: the multiple-payment rule does not apply to E/M codes. In fact, the definitions of 99213 and 99214 unambiguously state, “Usually the presenting problem(s) are of . . . complexity.” Note the “(s)”! It clearly creates a double standard that favors doing procedures and places thoughtful solving of patients’ problems at a disadvantage.

So in my case, 5 or 10 or more separate patient problems equal one payment. The “(s)” in the AMA’s CPT book is the most outrageous injustice to primary care of this generation. Because of it, the AMA’s CPT committee is accountable for even more damage to primary care than is their RUC! Think how different life in primary care would be if the “(s)” were removed and you were paid 50% for each additional patient problem you addressed in a single office visit!

How Obama Hits Health Providers in Deficit Plan

Sep 23, 2011• 4

By MERRILL GOOZNER

President Obama’s populist message on taxes was replicated on the health savings side of his deficit-reduction plan, which would cut spending on Medicare and Medicaid by $320 billion over the next decade and $1 trillion in the following decade.

The bulk of the savings would come from companies that provide goods and services to the programs. Payments to drug companies would be slashed by $135 billion by offering seniors in Medicare the same discounts currently mandated for poor people in Medicaid. An additional $42 billion in program savings would be achieved by reducing payments to nursing homes and home health care agencies.

And those are just the major hits taken by health-care providers in the plan, which is already drawing fierce opposition from lobbyists for industries that get whacked. Rural hospitals, big city teaching hospitals, biotechnology firms, and durable equipment manufacturers also would be in for payment cuts under the Obama blueprint.

Major trade associations representing provider groups immediately blasted the proposal, playing the same jobs card the president is using. The Pharmaceutical Research and Manufacturers Association “opposes implementing Medicaid’s failed price controls in Medicare Part D,” the group said in a prepared statement. “Such policies would fundamentally alter the competitive nature of the program, undermine its success, and potentially cost hundreds of thousands of American jobs.”

Why Patient Lab Data Should Be Liberated

Sep 22, 2011• 15

By MARYA ZILBERBERG, MD

I am admittedly not an expert on health IT, but I am a firm believer in the empowerment of patients to be the driver of her/his health decision making. So this whole discussion about lab data being available directly to the patient is of great interest to me. But it does seem like yet another instance of the two sides coming together not to listen to each other but to be heard by the other side. And as well know, this works so well for any relationship!

Each side’s view is represented roughly thusly:

Patients These are my data and I have the right to access them as soon as they are available.
Doctors We are worried that the sheer volume, complexity and irrelevance of (much) of the data will make it confusing and unnecessarily alarm the patient

Both arguments are valid, of course. But it is important to ask what lurks below the visible portion of each iceberg.

Let’s take the patient view. Why do I want immediate access to my data? Well, obviously, because it is mine, it represents the results of testing on my body, and the record should belong to me. I should be able to access it freely whenever I damned well please. I am also more than a little exasperated with having to wait sometimes days to hear from my doctor’s office about a result that has been available for a while, but was buried under the reams of paperwork on the MD’s desk or his/her assigning a low priority to my data. And I am most exasperated when my lab results get lost or otherwise never make it to me at all. Perhaps if I have direct and unfettered access, this will make thing more efficient for me as an individual.

Preparing for the Exchanges

Sep 22, 2011• 1

By John R. Graham

What is the biggest waste of effort in American health care today?

I’d suggest it is the hustle and bustle to establish PPACA’s Health Benefits Exchanges. The health insurers’ trade association, AHIP, has an entire educational series on “preparing for exchanges.” The likelihood of exchanges being up and running by January 2014 is vanishingly close to zero. Indeed, they may not exist at all except in very few states – whether or not President Obama wins re-election.

Last January, I wrote in The Health Care Blog that states should not collaborate with the federal government in establishing exchanges. Almost all states have taken this course. Recent days have brought forward new evidence that exchanges are facing even bigger problems than previously understood. The New York Times reports that Republican state senators are blocking a bill that would allow the state to establish an exchange and claim federal handouts to get it up and running. (A few weeks previously, Kansas governor Brownback actually sent a $31.5 million federal PPACA grant back to D.C.).

If they can’t get a PPACA exchange up and running in New York, of all places, where the heck will they? Only 13 states have passed pro-exchange legislation (and some of these bills don’t do much more than establish study groups).

Minute Clinics Threaten Doctors: Who Wins?

Sep 19, 2011• 16

By MICHAEL KIRSCH, MD

All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.

We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that patients should be rightly concerned about medical errors and missed diagnoses at these medical care drive-ins. These nurses, even with their advanced training, are not doctors. It is also true serious or even life threatening conditions can masquerade as innocent medical complaints and might not be recognized by a nurse who treats colds and ankle sprains.