Author Archives

John Irvine

The Politics of Hillary’s Pneumonia

Sep 14, 2016• 7

By SAURABH JHA, MD

Screen Shot 2016-09-14 at 3.15.10 PM

It is selfish of a leader of a nation to drop dead during office. Jawaharlal Nehru, India’s first prime minister, died suddenly at 74, apparently from a ruptured aneurysm. His aneurysm, allegedly, had something to do with Edwina Mountbatten – the wife of Lord Mountbatten, the last Viceroy of India. Shortly after Nehru’s death, Pakistan attacked India. Nehru’s replacement, Lal Bahadur Shastri, died mysteriously in Tashkent two years after Nehru’s death, and was succeeded by Indira, Nehru’s daughter. India’s future was forever changed by a burst aneurysm or, if rumors are to be believed, by a flagellating spirochaete which left the Raj in bliss.

Clearly, the death of a leader creates turmoil for a republic. So it is understandable that a nation obsessed with health is obsessed with the health of its presidential runners. Mr. Trump’s doctor declared he’s the healthiest presidential candidate ever. Mr. Trump has drawn attention to his super health by pointing to the size of his hands – by Mr. Trump’s standards a rather decorous allusion. It matters not what has hypertrophied Mr. Trump’s hands, what matters is that Mr. Trump’s large hands signal vigor and imagination. The American Psychiatric Association, to their credit, in ruling out a new diagnostic code for Mr. Trump’s colorful soundbites in the next edition of their Diagnostic and Statistical Manual, ended all hopes of banning Mr. Trump from the presidential race on health grounds.

Cybersecurity Check In

Sep 13, 2016• 12

By the CYBERSECURITY TASK FORCE

No one likes to think about the possibility that patients might be hurt or killed as a result of cyber attacks. But all signs indicate that this is a real possibility and a serious problem. Attacks on Health IT systems such as EHRs or patient portals, electronic medical devices, or on standard healthcare digital systems can be a threat to patient safety.

To combat the cybersecurity threat, Congress and the Obama administration passed the Cybersecurity Information Sharing Act of 2015, which established mechanisms for the US Government to collaborate with private industry to respond to cybersecurity threats. Lawmakers recognized the unique problems with cybersecurity in health technology and created the Health Care Industry Cybersecurity Task Force, charged to make recommendations to Congress regarding specific cybersecurity issues. To paraphrase, we are to investigate:

What can the healthcare industry learn from other industries about cybersecurity?
What are the special challenges that we face with cybersecurity in healthcare?
What are the difficulties protecting electronic health record (EHR) systems and networked electronic medical devices?
What cybersecurity study materials should the healthcare industry be exposed to?
How should an organization designed to coordinate the sharing of cybersecurity threats between healthcare industry players and the US Federal Government operate?
Finally, we were asked give Congress a written report summarizing all of the above.

Our Task Force is asking the healthcare, patient and technology communities for help in this assignment. We are asking for discussion on these issues to be on platforms like The Health Care Blog, Reddit and Twitter, so the community may contribute new ideas as well as refine the ideas contributed by others. We are taking a crowdsourcing approach to cybersecurity ideation so we can aggregate and assess what people have to say about these issues.

An Update on Price / Cost Transparency + A Promising New Service

Sep 13, 2016• 1

By STEVEN FINDLAY

flying cadeucii Transparency for consumers on prices and costs is a bipartisan goal in healthcare. The good news is progress is afoot. The bad news: that progress is still painfully slow. This blog presents a quick status update with discussion of and links to some recent reports and events.

The Healthcare Incentives Improvement Institute (HCI3) and Catalyst for Payment Reform (CPR) have tracked state healthcare price transparency laws and their implementation for the past four years. In a July 2016 report they found the following: on an A to F scale, three states got As (Colorado, Maine, New Hampshire); one got a B (Oregon); two scored Cs (Virginia and Vermont), one got a D (Arizona), and 43 got Fs.

That’s an improvement over 2015 when only one state—New Hampshire—got an A.

The two groups primarily assessed whether the states’ price transparency web sites presented the information in an understandable and consumer-friendly way.

Despite the poor scores for most states, Francois de Brantes of HCI3 and one of the report’s authors told me: “We’re actually optimistic. A lot of states are beginning to pay more serious attention to this…we think a third to half of them could get As or Bs in the next few years… if they take the right steps.”

A Hole in the Heart, Part II

Sep 11, 2016• 3

By ANISH KOKA, MD

Click here for part 1 “A Hole in the Heart, Part I” If you have NOT read part I, we highly recommend that you go there now and then come back and read the continuation. – The Editors

Analysis of the Randomized Control Trials

The 3 randomized trials performed tested two closure devices – CLOSURE I tested the STARFLEX device (NMT Medical, Boston, MA). The PC and RESPECT trial tested the AMPLATZER device (St. Jude Medical, St. Paul, MN). Let’s look at each study closely.

CLOSURE I (Starflex device)

This study looked at patients between 18 and 60 years of age who had a prior stroke or a transient ischemic attack within the prior 6 months. This was a resoundingly negative study. At two years, the 12/447 patients in the closure group suffered a recurrent stroke, while 13/462 patients in the medical therapy suffered a recurrent stroke. The trial, however, reveals one of the important chinks in the armor of the randomized control trial (RCT). Randomized control trials are only as good as the patients they enroll. Enroll the wrong patients, and the results don’t tell you much. CLOSURE-1 didn’t provide closure because they included patients with transient ischemic attacks (TIAs).

Plans For the Quality Payment Program in 2017: Pick Your Track

Sep 8, 2016• 10

By ANDY SLAVITT

Screen Shot 2016-07-07 at 2.30.28 PM As the baby boom generation ages, 10,000 people enter the Medicare program each day. Facing that demand, it is essential that Medicare continues to support physicians in delivering high-quality patient care. This includes increasing its focus on patient outcomes and reducing the obstacles that make it harder for physicians to practice good care.

The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) offers the opportunity to advance these goals and put Medicare on surer footing. Among other policies, it repeals the Sustainable Growth Rate formula and its annual payment cliffs, streamlines the existing patchwork of Medicare reporting programs, and provides opportunities for physicians and other clinicians to earn more by focusing on quality patient care. We are referring to these provisions of MACRA collectively as the Quality Payment Program.

We received feedback on our April proposal for implementing the Quality Payment Program, both in writing and as we talked to thousands of physicians and other clinicians across the country. Universally, the clinician community wants a system that begins and ends with what’s right for the patient. We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians. We will address these areas and the many other comments we received when we release the final rule by November 1, 2016.

The Top Five Recommendations For Improving the Patient Experience

Sep 7, 2016

By KATHLEEN MERKLEY and ANNE MARIE-BERKMORE

Healthcare organizations are working diligently to improve patient satisfaction and the patient experience of care. After all, patient experience of care is a critical quality domain used to evaluate hospital performance under the 2016 CMS Hospital Value-Based Purchasing (VBP) Program (accounts for 25 percent of a hospital’s VBP score)—and comes with the potential for a penalty or bonus.

Patient experience of care is also one of three essential dimensions of the industry-guiding IHI Triple Aim (a framework for optimizing health system performance):

Improving the patient experience of care.
Improving the health of populations.
Reducing the per capita cost of healthcare.

Improving the patient experience can seem like a moving target influenced by a variety of factors. For one, despite the fact that healthcare organizations have been talking about and focusing on patient experience and patient satisfaction for a long time, universally accepted definitions don’t exist. For example, patient satisfaction survey vendors use contrasting language, leading to varying patient interpretations. The industry also lacks conclusive research that proves the connections between patient satisfaction and outcomes. And with so many resources focused on improving patient satisfaction, it’s no surprise healthcare leaders want to understand the connection.

A Hole In the Heart, Part I

Sep 6, 2016• 5

By ANISH KOKA, MD

Strokes are the third leading cause of death in the United States. 800,000 people suffer a stroke every year, and the consequences are frequently devastating. Lives are not just lost, but changed forever – speech permanently silenced, arms and legs turned into useless appendages. The brain is very expensive real estate and it is little surprise that a clot the size of a pinhead lodged in a blood vessel feeding the brain is all that is needed to wreak a devastation most fear worse than death.

Most of the time the source of the debris that results in a stroke can be readily identified, but at least one-third of the time no source can be found. These have been termed cryptogenic strokes by the medical community mostly because it is an intelligent sounding phrase when your doctor does not know why something happened. Almost 30% of strokes in patients under the age of 55 are found to be cryptogenic. Until the mid 80’s there was little progress in identifying the cause of these strokes, but around the same time I was wondering why Duran Duran was running through jungles in Sri Lanka on MTV, cardiologists began injecting air into the heart to shed light on this mystery.

On the Wondrous U.S. Market For Prescription Drugs

Sep 4, 2016• 18

By UWE REINHARDT

Citing a recent report in the Los Angeles Times, an article in FirecePharma entitled “Some generic drug prices soar despite heavy competition” rises questions on the ability of market forces to reign in drug prices – for example, on the idea that the price of Mylan NV’s EpiPen would not have risen to $614 per 2-pack from about $100 per 2-pack or less in 2007 if the Food and Drug Administration (FDA) had not prevented Sanofi’s and a new product by Teva to come on market, leaving Mylan NV in full monopolistic control, of this blockbuster market.

According to data assembled by the Los Angeles Times, prices of generic drugs can rise sharply even if multiple manufacturers compete for market share. As an illustration, the article cites the generic drug ursodiol for gall stones, produced by no less than 8 manufacturers. “Several years ago, the wholesale price ran as low as 45 cents a capsule. In May 2014, Lannett Co. ($LCI) bumped its price for ursodiol to $5.10 a capsule, a price hike of more than 1,000%. Rather than keeping their own generic versions of ursodiol low to steal market share, each competitor followed Lannett’s lead and priced their versions the same or close.”

I Wish My Doctor Knew …

Sep 4, 2016• 3

By NIRAN AL-AGBA, MD

flying cadeucii Recently the New York Times published an article What Kids Wish Their Teachers Knew. As a pediatrician, I have spent a good part of my lifetime fighting for the health and welfare of our young people. They are the future. We owe our children a safe, caring, stable childhood whenever possible. Outside of a supportive family, a long-term family physician or pediatrician can be an important role model for impressionable youngsters.

For confidentiality reasons I have altered identifying details, but will give you some of the great things heard over the years and a few tragic ones as well.

I Wish My Doctor Knew… there is not enough food at home. Many years ago, I was seeing twins for a yearly checkup and giving them shots when one, older by 4 minutes, blurted out there was not enough foods to eat at night when she was hungriest. I contacted the school counselor to ensure both children were offered free breakfast and lunch at school. They were added to the program sending home a backpack full of food every weekend. At Thanksgiving, this family received one of the donated dinner baskets with turkey, mashed potatoes, and all the trimmings. The children grew better and crossed percentiles in the positive direction; their grades improved as an added bonus.

EpiPenEconomics

Sep 3, 2016• 2

By DEVON HERRICK

U.S. Patent No. 4031893, Hypodermic Injection Device Having Means for Varying the Medicament Capacity Thereof

Americans throw away unused epinephrine auto-injectors worth more than $1 billion annually. Or maybe it would be more accurate to say that Americans waste more than $1 billion annually on $50 million worth of epinephrine auto-injectors that are discarded unused. The devices should only cost $20 a pair. So, why do they cost $608 instead?

First, a little background. Severe allergic reactions can result in anaphylaxis, including skin irritation, hives and a person’s windpipe can even begin to swell closed. Children allergic to peanuts or tree nuts are especially a concern since their parents are not always there to supervise them. By some estimates, perhaps 4 percent to 6 percent of children have some type of food allergy. Yet, the likelihood of children suffering anaphylaxis is low. Estimates vary, but a study from Washington State back in the 1990s found only 1 kid in 9,524 had an episode in any given year. A similar study from Minnesota found the rate was one in 1,400. The difference in the prevalence had to do with how strict a definition was used.