Category: Uncategorized

Please Don’t Feed the Morons!!

Feb 9, 2014• 7

By DAVID KATZ, MD

With the exception of rare and particularly bleak days, I don’t tend to think of myself as a moron — nor, as far as I can tell, do those who know me well and love me. I will hazard a guess that neither you nor those who love you think of you as a moron, either.

So let’s be bold, proffer one another the mutual benefit of any disparate doubts, and declare: We are not morons!

I propose, then, that this be the year we stop ingesting as if we were. Still with me? Let’s find out.

On the matter of morons, I think they are very much the exception rather than the rule. I have met a lot of people over my years. I’ve taken care of many patients over decades and come to know their intimate thoughts as the privilege of doctoring uniquely allows and requires. So I know firsthand that most of us are endowed with our fair portion of both sense and sensitivity. Formal education, the color of a collar, degrees and credentials don’t distinguish us nearly as much as some might like to think. In most ways that matter, most people have that practical brand of folksy wisdom and intelligence that serve most handily on any given day.

And yet, as a matter of routine we are fed a steady diet of both food and food for thought as if we were abject morons. That’s how it’s served to us — but of course, only we get to decide whether or not to swallow such insalubrious slop. It’s a New Year, and time for new chances. Here’s our chance to stop the slop.

On the matter of common sense, I have been driven many times over the span of my career to lament the fact that it isn’t nearly common enough. But as just noted, I think it really is — in most areas. We apply it routinely to finances, home care, our careers and our families. We just turn it off when captivating promises about effortless weight loss, miraculous vitality, or age reversal waft our way. The result, of course, tends to be that even as we get fatter, sicker and older, we get poorer — spending our sensibly earned money on a senseless parade of false promises.

Don’t Be Fooled, Prospects for Long-Term SGR Fix Still Dim

Feb 9, 2014• 5

By Billy Wynne

In light of Thursday’s bicameral, bipartisan release of a Medicare physician payment policy to permanently replace the Sustainable Growth Rate (SGR) formula – an achievement to be celebrated in its own right – some are seeing momentum toward passage of such a deal before the current doc fix expires on March 31.

But the scope of what the committees issued Thursday represents as much of a step back as a step forward, at least relative to their aspirations and timeline for accomplishing them.

Once the appointment of Senator Baucus to be Ambassador to China was announced, the committees agreed to make it “as far as they could” toward a comprehensive SGR replacement policy prior to his confirmation, including identifying offsets to pay for the $125-150 billion (over 10 years) bill. For those who missed it, Senator Baucus was confirmed on Thursday.

Only in the past week did the key committees acknowledge that achieving agreement on offsets by this deadline was unattainable, but finalization of the so-called “extenders,” a hodge podge of Medicare payment plus-ups and other polices perennially included with the doc fix, was still the goal.

(Recall that the Senate Finance Committee passed an SGR replacement bill with extenders in December, but their House counterparts have yet to do so.)

In negotiations on that extenders element, House Republican leads reportedly would not agree to include beneficiary-oriented policies, such as funding for outreach to Medicare enrollees regarding low-income subsidy programs and for Family-to-Family Health Information Centers.

While some Democrats involved in the talks may have been inclined to make this concession, others sharply objected, scuttling a deal on this front and demonstrating the difficulty of compromise on this relatively non-controversial topic.

Furthermore, and has always been the assumption, identifying offsets for the package continues to be an exponentially heavier lift than any other aspect of the process. On that front, the key camps have outlined their broad parameters for what they might accept.

House Republican leads desire and likely require meaningful cuts to ACA-related spending as well as a substantial balance of Medicare beneficiary-impacting cuts, such as those relating to premiums and coinsurance.

Focusing on High-Impact Comparative Studies: Cardiovascular Disease in the Spotlight

Feb 8, 2014• 21

By JOE SELBY, MD

Fifty years ago, President Lyndon Johnson signed designated February as American Heart Month to acknowledge and combat the “staggering physical and economic loss to the nation” caused by cardiovascular disease.

Unfortunately, that proclamation is proving to be a timeless document.

Even with broad awareness of heart disease, expansive research and a number of clinical and public health efforts to prevent, diagnose and treat cardiovascular conditions, it remains the leading cause of death in the nation. About 600,000 people die from heart disease in the United States each year—making it responsible for one out of every four American deaths.

As a research institute dedicated to helping patients and those who care for them make better informed decisions that lead to better outcomes, the Patient-Centered Outcomes Research Institute (PCORI) is acutely interested in producing new information that supports more effective cardiovascular care. The directive in our establishing legislation to consider “disease incidence, prevalence, and burden” when prioritizing research funding is a clear call for studies of cardiovascular conditions.

I’m proud to say that PCORI has answered that call. Cardiovascular disease, including heart disease and stroke, is the most commonly studied topic in our research portfolio. It is addressed in several dozen of the 192 primary research studies that PCORI has funded to date, including projects that conduct a comparative assessment of heart disease interventions, as well as those that test the effectiveness of decision support tools. Communicating information and providing tools to patients in ways that motivate them to make healthy choices is often a major challenge for clinicians.

Our comprehensive approach funds research that addresses the gaps in both information and communication that are responsible for poor outcomes in cardiovascular care.

Why the SGR Fix Won’t Work and Could Actually Make Things Worse

Feb 7, 2014• 57

By Jeff Goldsmith

Partisan gridlock in Washington regarding health policy has been so pervasive and bitter that any bipartisan co-operation on any important health issue should be applauded by a frustrated public.

That is why the emerging bipartisan compromise regarding the fifteen-year long policy embarrassment known as the Sustainable Growth Rate (SGR) problem needs to be taken seriously.

Remarkably similar solutions — a new hybrid physician “value-based” payment methodology — have emerged from three of the four key committees in Congress, and seemingly the only stumbling block is finding the $115-120 billion to pay for it.

Moreover, key physician interest groups, including the American Medical Association, appear to have signed off on this approach.

This makes it all the more troubling that the approach taken is unsound health policy that will damage practicing physicians in diverse settings: private practice, medical school practice plans, and hospital employment.

This is because the proposed legislation casts in concrete an almost laughably complex and expensive clinical record-keeping regime, while preserving the very volume-enhancing features of fee-for-service payment that caused the SGR problem in the first place. The cure is actually worse, and potentially more expensive, that the disease we have now.

The SGR fix would basically freeze or severely limit future physician fee updates for Medicare Part B (a serious problem for primary care), while permitting physicians to earn modest “value-based” bonuses if they can document quality measure attainment, cost reductions, participation in alternative payment schemes, practice enhancement activities, or meaningful use of EHRs.

Physicians who meet all these standards could expect to supplement their existing Part B fee by about 4 percent in 2016, going to 10 percent in 2020, with the aggregate bonuses subtracted from the pool of total Part B physician payments to preserve budget neutrality. Non-compliant physicians would see corresponding reductions in their updates.

There are sensible opt-outs for physicians who can report in groups, virtual or real, as well as for physicians who participate in as yet unspecified “advanced payment models” (APMs).
Continue reading…

Too Many American Physicians Or Too Few?

Feb 7, 2014• 11

By Robert Pearl, MD

The goal of the Affordable Care Act, also known as “Obamacare,” is to make affordable, quality health care coverage available to more Americans. But how many physicians will America need to satisfy this new demand?

The debate over doctor supply rages on with very little conclusive evidence to prove one case or the other.

Those experts who see a shortage point to America’s aging population – and their growing medical needs – as evidence of a looming dearth in doctors. Many suggest this shortage already exists, particularly in rural and inner city areas. And still others note America maintains a lower ratio of physicians compared to its European counterparts.

This combination of factors led the American Association of Medical Colleges to project a physician shortage of more than 90,000 by 2020.

On the other side of the argument are health policy experts who believe the answer isn’t in ratcheting up the nation’s physician count. It’s in eliminating unnecessary care while improving overall productivity.

The solution, they say, exists in the shift away from fee-for-service solo practices to more group practices, away from manually kept medical records to electronic medical records (EMR), and away from avoidable office visits to increased virtual visits through mobile and video technologies. Meanwhile, they note physicians could further increase productivity by using both licensed and unlicensed staff, as well as encouraging patient self-care where appropriate.

The Doctor Divide: Global And Domestic Insights

Among the 34 member countries of the Organization for Economic Co-operation and Development (OECD), the U.S. ranks 30th in total medical graduates and 20th in practicing physicians per 1,000 people.

Despite these pedestrian totals, there is one area where the U.S. dominates. It ranks first in the proportion of specialists to generalists – and there’s not a close second.

These figures don’t resolve the debate on America’s need for physicians but they do reveal an important rift in the ratio of U.S. specialists to primary care practitioners.

Uber for Health Care?? Not So Much.

Feb 6, 2014• 27

By Khan, Bongiovanni, & Ansary

Let’s get the disclaimer out of the way:

We love Uber.

As physicians with roots in the Bay Area, we use Uber all the time. The service is convenient, (usually) swift and consistently pleasant. With a few taps of a smartphone, we know where and when we’ll be picked up — and we can see the Uber driver coming to get us in real time.

When the vagaries of San Francisco public transit don’t accommodate our varying schedules, it’s Uber that’s the most reliable form of transportation. (It might be that we like having some immediate gratification.)

So when we caught wind of the news that Uber’s founding architect, Oscar Salazar, has taken on the challenge of applying the “Uber way” to health care delivery, there was quite a bit to immediately like. From our collective vantage point, Uber’s appeal is obvious. When you’re feeling sick, you want convenience and immediacy in your care — two things Uber has perfected.

And who wouldn’t be excited by the idea of keeping patients out of overcrowded emergency rooms and urgent care waiting rooms? The concept of returning those patients to their homes (where they can then be evaluated and receive basic care) seems so simple that it’s brilliant.

What the New York Times Got Wrong about Medicare’s Innovation Center

Feb 5, 2014• 2

By Dan Diamond

Since CMS’s Center for Medicare and Medicaid Innovation launched three years ago, its staff have been frequently hailed for undertaking an ambitious research agenda.

But a New York Times story this week was eye-catching for a different reason: author Gina Kolata mostly assailed Medicare’s researchers for how they’re choosing to do that research.

“Experts say the center is now squandering a crucial opportunity,” Kolata wrote in a front-page article. “Many researchers and economists are disturbed that [CMMI] is not using randomized clinical trials, the rigorous method that is widely considered the gold standard in medical and social science research.”

But many researchers and economists that I talked to at this week’s Academy Health conference say that’s not the case at all. (And some were disturbed to learn that they were supposed to be disturbed.)

“RCTs are helpful in answering narrowly tailored questions,” Harvard’s Ashish Jha told me. “Something like—does aspirin reduce 30-day mortality rates for heart attack patients.”

“However, for many interventions, RCTs may be either not feasible or practical.”

“While RCTs may be the gold standard for testing some hypotheses, it is not necessarily the most effective or desirable model for testing all hypotheses,” agrees Piper Su, the Advisory Board’s vice president of health policy.

CMMI’s ambitious goals

On its surface, Kolata’s article is built around a reasonable conclusion: RCTs offer plenty of value in health care, and we’d benefit from more of them.

As Jha alludes to, think of a double-blinded pharmaceutical study where half the participants randomly get a new drug and the other half get a placebo; that’s an RCT.
The famous RAND study that found having health insurance changes patients’ behavior: An RCT.
The ongoing Oregon Health Insurance Experiment: Also, an RCT.

And it’s fair to examine how CMMI is pursuing its research, too.

Is There Really a Physician Shortage?

Feb 5, 2014• 28

By David Auerbach

Large coverage expansions under the Affordable Care Act have reignited concerns about physician shortages. The Association of American Medical Colleges (AAMC) continues to forecast large shortfalls (130,000 by 2025) and has pushed for additional Medicare funding of residency slots as a key solution.

These shortage estimates result from models that forecast future supply of, and demand for, physicians – largely based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment. Here are a few reasons why.

1. Most physician shortage forecast models assume insurance coverage expansions under the ACA will generate large increases in demand for physicians. The standard underlying assumption is that each newly insured individual will roughly double their demand for care upon becoming insured (based on the observation that the uninsured currently use about half as much care). However, the best studies of this – those using randomized trials or observed behavior following health insurance changes – tend to find increases closer to one-third rather than a doubling.

2. A recent article in Health Affairs found that the growing use of telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25% or more.

3. New models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians. If these models, fostered by the ACA, continue to grow, they could reduce predicted physician shortages by half.

Google Glass: A Paradigm Shift in Assessing Procedure Competency?

Feb 5, 2014• 1

By David E. Stein, MD

I recently had the privilege of becoming a Google Glass Explorer. Basically, this means I walk around with a funky pair of glass frames and look strange – even for an urban hospital setting.

The Glass has a built in camera, and a small display that you can see with numerous apps ranging from GPS navigation to searching the Web. As cool as this the technology is – is there any utility in the healthcare setting?

There is the capability of video chat, where a consulting physician can see what I would be seeing in the operating room, and tell me what I may be looking at and what to do next. Pristine Eyesight, based in Austin Texas, is trialing this use of Glass in University of California, Irvine. Applications for nursing are being developed as well. Yet will this truly impact quality? I am not sure.

Yet one thing that intrigues me about the Glass is the perspective given when using the video function. I recorded some small surgical procedures and reviewed the video afterwards. I watched where I placed my hands, how I held the needle driver, where I took my bites, and in general – what I looked at during the case.

I felt like an NFL Coach reviewing game tape. For the first time in my surgical career, I was able to really see what I did, a perspective that I had never before experienced. This lightweight device with built in eye protection was far more comfortable than any helmet-cam I had used, and the line of sight was right in tune with my visual field. So I began thinking – is there a way this tool can improve outcomes in healthcare?

According to the American College of Surgeons, almost 5,000,000 central venous catheters are placed annually in this country. Complications including placement failure, arterial puncture and pneumothorax range from 15-33% in numerous studies. So how is this common procedure taught?

The classic “watch one, do one, teach one” methodology has been modified over the years. Now, after watching a few lines placed, house staff must perform a certain number of central line placements (usually 5) under the supervision of a senior resident, fellow or attending. Once the appropriate number is reached, the trainee is “competent” to perform the procedure on his or her own. Yet are they truly competent? Perhaps the high complication rates result from a flaw in this classic teaching methodology?

An Urgent Request

Feb 5, 2014• 1

By Michael Painter, MD

“‘Let’s go.’ ‘We can’t.’ ‘Why not?’ ‘We’re waiting for Godot.’” ― Samuel Beckett

For the economists in our midst, demand is a critical but pretty dry idea: the quantity of a good or service a buyer is willing to purchase at a given price. It’s presumed to be part of working health care markets.

It’s one of the first things an undergraduate might learn in Econ 100.

There’s no urgency in this demand; it just is.

Of course, nothing—even general economic principles—is simple in health care. Still, you can look longingly at a few nice supply and demand curves and dream about how things might be—if only.

If only health care consumers picked up their role and skittered up and down those demand curves.

If only they helped us find those elusive market equilibriums for this health care service or that. For some time, lots of people have seen that enormous and powerful potential—and drooled over it.

We’ve been waiting a long time for our consumer to show up in health care. We’ve been waiting for the consumer to obtain and use the information she needs to demand great care.

We’ve been waiting for lots of consumers to do that over and over to help us out of our unfortunate health care jam.

It’s that jam where we pay too much for lots of care of marginal quality riddled with safety problems and delivered by a bunch of dissatisfied, demoralized health professionals.

Indeed we have been waiting a long time for our health care consumer. Certainly, there have been and continue to be countless reasons why consumers haven’t arrived to help save us.

“Health care is different!”

“There’s no evidence that consumers will behave like normal consumers in health care!”