Category: Uncategorized

Does Life Expectancy Matter?

Dec 12, 2016• 88

By NIRAN AL-AGBA, MD

U.S. life expectancy declined in 2015 for the first time in more than two decades, according to a National Center for Health Statistics study released last week. The decline of 0.1 percent was ever so slight ― life expectancy at birth was 78.8 years in 2015, compared with 78.9 years in 2014. However, this reversal of a long-time upward trend makes these results significant.

While many researchers are scratching their dumbfounded heads in utter astonishment, I hypothesize the decline in life expectancy is partly due to the decrease in the primary care physician supply. Studies have shown the ratio of primary care physicians per 10,000 people inversely correlates with overall mortality rate. It is a well-known and reproducible statistical relationship that holds true throughout the world. In the U.S., increasing by one primary care physician per 10,000 population, decreases mortality by 5.3%, ultimately avoiding 127,617 deaths per year.

Headlines last week highlighted how much these unexpected results left the researchers baffled. Jiaquan Xu, a lead author of the study told The Washington Post, “This is unusual, and we don’t know what happened…so many leading causes of death increased.” Age-adjusted death rates went up by 1.2 percent, from 724.6 deaths per 100,000 people in 2014 to 733.1 in 2015. Death rates increased for eight of the ten leading causes of death, including heart disease, chronic respiratory illness, unintentional injuries, stroke, Alzheimer’s disease, diabetes, renal disease and suicide. Differences in mortality were most prevalent in poorer communities, where smoking, obesity, unhealthy diets, and lack of exercise are ubiquitous.

The HIT Emperor Has Never Had Any Clothes

Dec 12, 2016• 13

By HAYWARD ZWERLING, MD

Over the last several months, I have worked to make the following the official policy of the Massachusetts Medical Society:

That the MMS will advocate to our State and Federal Representatives to end all legal constraints and financial inducements arising from the use or non-use of Office of National Coordinator (ONC) Certified EHR Technology.

That the MMS will encourage our Massachusetts Federal Legislators to introduce legislation to end the ONC’s EHR certification program, and will ask the President of the United States to immediately request that such legislation be introduced.

While the MMS’s Committee on Information Technology voted unanimously to support the above proposal, the MMS rejected the above and choose instead to make the following official MMS policy:

That the MMS will work with appropriate government entities to foster EHR innovation, affordability, and functionality by modifying the certification process for EHRs to improve patient care.

Without a doubt, ONC’s EHR certification program has stifled innovation in EHRs in particular and in health information technology (HIT) in general. In addition, the data accumulated to date has shown these ONC’s Certified EHRs have failed to have a meaningful impact on either the cost or quality of healthcare.

The 6 December 2016 issue of Annals of Internal Medicine has an article which shows that for every hour a physician is involved with direct patient care results in an additional 2 hours of EHR work (in the office/clinic) and then more EHR work from home. No wonder MDs are so dissatisfied with the practice of medicine. The accompanying editorial (Ann Intern Med. 2016;165:818-819) concludes “Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system ”

Lead Time Bias and Court Rooms

Dec 11, 2016• 3

By SAURABH JHA MD

In 2014, a jury in Massachusetts awarded $ 16.7 million in damages to the daughter of a Bostonian lady who died from lung cancer at 47, for a missed cancer on a chest x-ray. The verdict reminds me of the words of John Bradford, the heretic, who was burnt at the stakes: “There, but for the grace of God go I.” Many radiologists will sympathize with both the patient who died prematurely, and the radiologist who missed a 15-mm nodule on her chest x-ray when she presented with cough to the emergency department few months earlier.

The damages are instructive of the tension between the Affordable Care Act’s push for both resource stewardship and patient-centeredness, and between missed diagnosis and waste. But the verdict speaks of the ineffectualness of evidence-based medicine (EBM) in court. If EBM is a science, then this science is least helpful when most needed, i.e. when trying to influence public opinion.

EBM tells us that had the patient’s cancer been detected thirteen months before it actually was, it would have made little difference to her survival, statistically speaking. Researchers from Mayo Clinic examining the impact of frequent chest x rays in screening for lung cancer in a large number of smokers found that the intensively screened group knew about their cancers earlier, had more cancers removed, but did not live longer as a result. This is known as lead time bias, where early detection means more time knowing that one has the cancer, not more time one is actually alive. This means had the nodule been seen on the patient’s initial chest x-ray she would probably, though not certainly, not have survived much beyond 47.

Could Price Be Right?

Dec 8, 2016• 10

By GILBERT WELCH, MD and ELLIOTT FISHER, MD

If confirmed as Secretary of HHS, Tom Price will oversee a $1 trillion budget – roughly one-third of all health expenditures. His proposed legislation “Empowering Patients First” seeks to control costs by giving patients more choices and providing the information required to make them. He calls for publicly available standardized information on the price and quality of physicians, hospitals and other health care institutions.

It sounds like Dr. Price is prescribing a single data system.

Medicare has had a single data system on the over-65 population for decades. Since 2005, these data have informed Hospital Compare, a consumer oriented website comparing the quality of over 4000 hospitals. And while prices in Medicare are relatively fixed, these same data have shown substantial variation in costs because the quantity of service – the number of hospital admissions, procedures and physician visits – varies substantially from place to place.

But Medicare is only one piece of the data puzzle. A National Bureau of Economic Research report[nber.org] added another piece last year with data from large insurance companies like Aetna and United. For the under-65 commercially insured population, it’s not just the quantity of services that are all over the map – it’s also the prices.

The Case For a Medicare Buy In

Dec 8, 2016• 3

By BOB HERTZ

Here is why we need a Medicare buy-in:

Take the case of a male age 62, in Omaha Nebraska , whose Income is $50,000 a year

His only offers of ACA-qualified health insurance are from Medica and Aetna.

With Medica, he can choose a bronze plan that has a monthly premium of $1,242, a deductible of $6.850.

What an awful policy! For a premium that equals about 35% of his after tax income, he gets no benefits until he paid over $20,000 a year. The insurance company is essentially trying not to cover this person- they are just offering the worst policy they can.

The ultimate solution is simple — this man should be on Medicare.

A Different Kind of Meaningful Use Penalty

Dec 8, 2016• 5

By HANS DUEVEFELT, MD

Our clinic is worried about qualifying for this year’s Meaningful Use incentive payments. We have this hastily purchased EMR that was supposed to make life easier and quality better for all of us. The EMR vendor got paid a long time ago but we are still dealing with the administrative burdens imposed by our new system.

By attesting that we can use this thing reasonably properly, we can receive some Government incentive monies, which even under the best of circumstances don’t even begin to make up for all the extra expenses and productivity losses we have incurred through going digital.

What we are up against is a product that doesn’t do, or doesn’t easily do, what we were told it could.

Moonshots, Opioids and Incentives

Dec 8, 2016• 2

By MARSHALL CHIN, MD

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Major disparities in health outcomes have stubbornly persisted throughout both democratic and republican administrations. If you have diabetes and you live in a predominantly African-American neighborhood of Chicago, you have a two-to-five times higher risk of having your leg amputated than if you live in one of the city’s white neighborhoods. If you are a Hispanic child with asthma, you are 50% more likely to be admitted to the hospital than if you are white. And if you are a Vietnamese woman, you are five times more likely to develop cervical cancer than your white counterpart. The incoming Trump administration’s vow to repeal the Affordable Care Act presents a great danger for vulnerable populations. However, incentive principles that underlie Republican Party health policies could be designed to encourage health care organizations and clinicians to reduce health disparities.

Does It Matter If You Get Along With Your Doctor?

Dec 6, 2016• 4

By NATHAN MOORE, MD

Seems like a silly question, right?

No one ever asks if you get along with the cashier at the grocery store or the barista at your neighborhood coffee shop. For most folks choosing a doctor means finding someone in your area who’s taking new patients with your insurance, which usually isn’t too many.

Simply getting an appointment is hard enough, so expecting a pleasant experience and a good relationship with the doctor seems to be an unreasonable request, like asking for a unicorn who also speaks fluent Spanish. Many people don’t think patient-physician relationship is particularly important; they’re looking to the doctor for medical advice, not to be a friend. In these days of electronic medical records and 15 minute appointments, many physicians simply don’t have the time to get to know patients and find out their motivations, goals and fears. It’s even harder for patients with language and cultural barriers; for example, physicians talk more and listen less to black patients than to white patients.

So why do we care?

Why the Affordable Part Didn’t Work

Dec 6, 2016• 7

By PAUL KECKLEY

Paul Keckley On March 23, 2010, Congress passed the “Patient Protection and Affordable Care Act”. It soon became known as the “Affordable Care Act aka ACA” before being labeled “Obamacare”.

Its aims were two: to reduce costs and cover everyone. In the 79 months since passage, it remains arguably the most divisive public policy platform since FDR’s New Deal in the ‘30s and Lyndon Johnson’s Great Society in the 60s. Per Kaiser Family Foundation’s Tracking polls since its passage, the public’s view about the ACA remains split: half think it’s an overreach by the federal government that has resulted in sky-rocketing health insurance premiums across the board, and the other half believe expansion of insurance coverage for 25 million justifies the effort. Each side cherry-picks elements of the law they like and decry parts they despise.

But all concede the law has not addressed affordability as originally intended. News about insurance premium spikes, has dogged the ACA since its passage lending to critics’ conclusions that the law was fundamentally flawed and had to go.

In 2009, I facilitated several meetings for the White House Office of Health Reform seeking industry input into reform legislation.

Letter from Washington:
Don’t Jump … Yet

Dec 5, 2016• 12

By GREG FULTON

Washington, D.C. hardly seems like a town on suicide watch.

As November turned to December, from the venerable Old Ebbitt Grill near the White House, to Charlie Palmer Steak at 101 Constitution and over to The Capital Grille at 601 Pennsylvania, revelers abounded, in both food and drink.

At the Capitol Hyatt on New Jersey Avenue though, some contrasts were evident. While contestants from the Miss World 2016 pageant moved in and out of the upper lobby to awaiting buses, in the lower-level meeting rooms, also from November 30 to December 2, the mood was hopeful optimism meets whistling past the graveyard.

There the Jefferson College of Population Health summit brought forth Andy Slavitt, Michael Leavitt, Farzad Mostashari, NCQA President Peggy O’Kane, former advisors from the George W. Bush and Obama administrations, officials from Johns Hopkins, the Henry Ford Health System, Brookings, Deloitte, AMA, AHA and the American College of Physicians and many more to dissect MACRA and ponder “population health strategy under the new administration.”

The consensus on where value-based care (VBC) is heading?

Wait and see.