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Medicare Advantage: Moving toward a Better Model for American Health Care

Robert PearlDespite the political angst, the doomsday predictions and a very rocky launch, the Affordable Care Act has enabled more than 8 million Americans to acquire insurance coverage through the public exchanges.

Health insurance increases the probability that patients will access the medical care they need. And my colleagues at Kaiser Permanente are already seeing some positive stories emerging as a result.

Beginning in 1978, Medicare beneficiaries had a second option. They could enroll in private Health Maintenance Organizations (HMOs) under a “risk contract” between CMS and the HMOs.

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A Declaration of Independence Is Only the Beginning

flying cadeuciiOn April 29, Dr. Daniel Croviotto published an editorial in the Wall Street Journal, “A Doctor’s Declaration of Independence,” in which he argued that it is time to “defy healthcare mandates issued by bureaucrats not in the healing profession.”

Dr. Croviotto does a good job of articulating his frustration with the increasingly burdensome bureaucracy and regulations placed on care. Many physicians and nurses share his frustration. I once did, until I saw a way out of the cynicism and frustration – a way that can improve the quality and lower the cost of care for all Americans.

No matter how misguided we think the federal government is in its electronic health record mandate or other requirements, simply defying mandates as Dr. Croviotto proposes is not  likely to accomplish much. Those who signed the Declaration of Independence knew it was only an initial step toward ridding the country of tyranny. They had to create a new vision for a better, more effective government.

Similarly, the medical profession needs to move beyond cynicism to create a vision for a better, more effective healthcare system.

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Rapid Advances in Health IT Adoption and Use in the Safety Net

safety net clinic
Federally funded health centers are making strides adopting and using electronic health records (EHRs) to treat some of the nation’s poorest and most at-risk patients since the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act, according to a new first-of-its-kind study.

We know that health IT can help improve care quality. ONC and the Health Resources and Services Administration (HRSA) are working hard to ensure that all providers adopt and use EHRs. In the past, some researchers External Links Disclaimer found that there might be a digital divide in health IT use, meaning that providers who mostly serve certain groups of people – particularly the poor and racial/ethnic minorities or people in rural areas – may be using health IT less than others.

Community health centers remain the largest provider of health care to underserved individuals in the US. They provide health care to more than 20 million Americans every year, including many who are poor, uninsured, or have no regular source of care.

In the past, health centers used health IT at a lower rate than other providers. In 2006, a survey showed that only 26% of health centers had any EHR capacity at all.

To ensure that the benefits of health IT and care transformation be available to all Americans, regardless of insurance, wealth, or location, the HITECH Act provided  federal resources to help health centers adopt EHRs.

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Button 2.0: Open Access

[youtube]http://www.youtube.com/watch?v=4AU4W8Yi1dk[/youtube]

Currently research is published in journals with expensive subscriptions, which hides knowledge behind paywalls away from the public who paid for it.

How we publish research is broken, but it can be fixed and the Open Access Button is here to help. Open Access has the potential to give everyone free access to the world’s cutting edge research. This will help your doctor save lives, families get access to the latest research on their loved one’s disease, researchers advance our understanding of the world, and students better further their education.

Learn more and contribute to the Indiegogo campaign herehttp://bit.ly/1fPHxkO.

Sign up for your Open Access Button at openaccessbutton.org.  

The Canadian Health Care System I Disparaged

Screen Shot 2014-05-06 at 6.44.13 PMWhen I recently returned home after a two-week speaking tour of Canada and began catching up on news about Obamacare, I was angry and upset, and not just at politicians and special interests that benefit from deception-based PR tactics.

I was — and still am — mostly angry and upset with myself. And I know I always will be.

Over the course of a two-decade career as a health insurance executive, I spent hours and hours implementing my industry’s ongoing propaganda campaign to mislead people about the Canadian health care system.

We spread horror stories about “rationed care” and long waiting times for medically necessary care. Our anecdotes were not at all representative of most Canadians’ experiences, but we spent millions of dollars to persuade Americans that they were.

At every stop between Halifax and Vancouver last month, I explained how the United States had achieved the dubious distinction of having both the most expensive health care system on the planet and also one of the most inequitable.

While Canadian lawmakers in the 1960s were implementing a partnership between the federal and provincial governments to create the country’s publicly funded universal health insurance system — known as Medicare — our lawmakers in Washington were establishing America’s own single-payer Medicare program, but only for folks 65 and older and some younger disabled people.

Congress also created the federal and state-administered Medicaid program for the nation’s poor.

Ever since, most of the rest of us have had to deal with private insurance companies and pay whatever they felt like charging us for coverage.

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Dad, You Have to Inhale

marijuana cancer patientsMy wife calls them “hand-me-ups”…  things we inherit from our kids.  My ex-fashionable shirt that my son wore in college.Our semi-vegetarian diet my daughter adopted in high school. The dog at my feet that came visiting for the weekend, three years ago.

Our lives are enhanced and modified by the most unexpected of teachers, our children. The mentoring of our progeny keeps those of graying years at least partially youthful.  Still, I was astonished to hear this week, the words, “Dad, you need to starting doing drugs.”

The “dad” being addressed is 93 years old and has advancing cancer. He is tired, nauseas, anxious and sleeps poorly.  Though he likely has a number of months to live, he has become withdrawn.  Despite my usual medical brew, his incapacitating symptoms are without palliation.

Dad is miserable.  Enter his daughter with the solution.  The “drug” she is talking about is the treatment de jour, marijuana.

How did this happen?  We raise our kids to be good, honest, mature citizens; we drive them to soccer, suffer through years of homework (do you remember dioramas?), and do the whole college obsessive-compulsive tour thing.  In addition, above all, we beg our offspring to stay away from pot, pills and addictive mind-altering potions.

Now they turn on us, pushing ganja in our time of need. How did we go wrong?  Actually, it is we that missed a great opportunity.

50% of Americans have inhaled marijuana at some point in their lives.  More than 25 million of our neighbors have used it within the last year.  Those that imbibe are of a decidedly younger demographic.  The oldest citizens, especially those of the Greatest Generation, are much less likely to have experience with cannabis.

Fortunately, once again, youth presents the solution.

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Adventures in Caring and Acting Affordable

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I’m back.  I’m recovering right now from trauma related to the Affordable Care Act.  I’m OK, but probably a few months until fully recovered.

Some would think that since I no longer accept money from insurance companies, the Affordable Care Act would have less of an effect on me.  Those folks may be right in how it directly impacts my practice (since I don’t know the actual impact on other doctors, it’s not easy to compare), but there has been a significant impact.  I’ve got plenty of ACA stories.

But that’s not what I am going to discuss in this post.

My personal adventures with this law are far more interesting from the other side of the insurance card: the health care consumer (AKA patient).  It has been quite a ride — one that has not yet reached its destination.

CHAPTER 1: December 9, 2013

Being the adventurous guy I am, I thought I’d give the Healthcare.gov website a whirl.  Expecting the worst, I set aside a lot of time for the experience.  It was actually quite a bit easier than advertised.  My family is as follows:

  • Me – Age 51, healthy
  • Wife – Around my age, but actual age disclosed only for legal reasons.
  • Child 1: Son, 21 years.  College grad but living at home for now.
  • Child 2: Daughter, 20 years.  In college
  • Child 3: Son, 18 years at time of application.  In college.  Birthday later in December.
  • Child 4: Daughter, 14 years.

I submitted the information about whether any of us smoke (no), any of us are pregnant (no), and how much money we earn (not much, as I am starting a new business).  I immediately got the following eligibility notice.

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The End of Antibiotics. Can We Come Back from the Brink?

Tom Frieden CDCAntibiotic resistance — bacteria outsmarting the drugs designed to kill them — is already here, threatening to return us to the time when simple infections were often fatal. How long before we have no effective antibiotics left?

It’s painfully easy for me to imagine life in a post-antibiotic era. I trained as an internist and infectious disease physician before there was effective treatment for HIV, and I later cared for patients with tuberculosis resistant to virtually all antibiotics.

We improvised, hoped, and, all too often, were only able to help patients die more comfortably.

To quote Dr. Margaret Chan, Director General of the World Health Organization: “A post-antibiotic era means, in effect, an end to modern medicine as we know it.”

We’d have to rethink our approach to many advances in medical treatment such as joint replacements, organ transplants and cancer therapy, as well as improvements in treating chronic diseases such as diabetes, asthma, rheumatoid arthritis and other immunological disorders.

Treatments for these can increase the risk of infections, and we may no longer be able to assume that we will have effective antibiotics for these infections.

Last September, CDC published our first report on the current antibiotic resistance threat to the United States.

The report conservatively estimates that each year, at least 2 million Americans become infected with bacteria resistant to antibiotics, and at least 23,000 die.  Another 14,000 Americans die each year with the complications of C. difficile, a bacterial infection most often made possible by use of antibiotics. WHO has just issued their report  on the global impact of this health threat.

It’s a big problem, and one that’s getting worse. But it’s not too late. We can delay, and even in some cases reverse the spread of antibiotic resistance.

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So What Do the Expanded Enrollment Numbers Mean?

State enrollmentLast Thursday, HHS released the final enrollment stats for health exchange enrollment for 2014.  Here’s what we learned:

  • 8.1 million enrolled in a plan in the Health Insurance Marketplace. 3.8 million (47% of total) since the end of February including 1.2 million in the much-watched 18-34 age cohort.
  • 54% are female; 28% are between the ages of 18-34; 63% are White, 17% Black, 11% Hispanic, 8% Asian/other.
  • 20% chose a bronze plan, 65% chose silver, 9% gold, 5% platinum and 2% catastrophic. Note: At the silver level, individuals who earn less than 250% of the federal poverty level — ($29,175 for an individual, or $59,625 for a family of four) — are eligible for assistance for out-of-pocket costs. 85% who picked an exchange plan qualified for a subsidy: 82% in the 14 state-run exchanges and 86% in the federally-run exchange.
  • Young adults 18-34 were 83% of those applying for the catastrophic coverage.

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Medical Devices and Patient Safety: A Promising Path Forward

flying cadeuciiIn an era of sophisticated information technology and rapid communication, the medical device community lags far behind other fields in its ability to alert patients about safety concerns.

For example, auto manufacturers and government regulators are able to quickly identify potential safety concerns by linking reports of crashes, malfunctions and defects with individual vehicle identification numbers (VINs).

They can then communicate recalls to affected customers by using their VIN. Manufacturers will issue notifications via mail or e-mail, or offer customers the ability to search the manufacturer’s website using their VIN.

In health care, drugs are tracked using a system established in the 1970s called National Drug Codes (NDCs). The 10-digit NDCs are assigned to all manufactured medications. The code tracks the vendor, product, and package code, which can then be captured in electronic health records and the FDA’s national database.

Unfortunately, we do not yet have a similar national system that can identify and communicate potential concerns for the tens of millions of patients with implantable devices such as pacemakers, glucose meters, artificial joints, and defibrillators.

Patients are bombarded by news stories about device recalls, but unless they have access to information about the exact make and model of their device, they have no way of knowing if they should be concerned. Since most medical device procedures take place in a hospital, a patient’s health care providers may also lack this critical, sometimes life-saving information.

The patient is then burdened with the task of tracking down their specialist or surgeon, in hopes that they documented the specific device information.

Clearly, the current health care information infrastructure does not yet support a robust surveillance system.

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