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Health IT and the Other Disparities

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By MARGALIT GUR-ARIE

On October 18 2010, Dr. Blumenthal published a letter to EHR vendors titled "Health IT and Disparities"  urging them to “include providers who serve minority communities in their sales and marketing efforts”. Reiterating the assumed benefits of Health IT to both quality of care and efficiency of care delivery, the National Coordinator for Health Information Technology stressed the importance of EHR vendors working together “to provide EHR adoption opportunities for physicians and other healthcare providers working within underserved communities of color”. This is obviously an important and welcome appeal. Physicians who provide care for impoverished minority communities usually lack the means to purchase EHRs and perhaps some EHR vendors will heed Dr. Blumenthal’s request and make special arrangements for these doctors and their clinics. The stimulus incentives may also help. But how about those who serve equally impoverished populations and are practically barred from incentives?

In my home State of Missouri there are about 350 Rural Health Clinics (RHC) serving a state which with very few exceptions is one big Medically Underserved Area/Population (MUA/MUP) which is a geographical area or a population designated by the Health Resources and Services Administration (HRSA) as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. For the uninitiated, RHCs are designated by CMS and have to meet certain requirements. The practice has to be located in a rural area and it has to provide team care, which is all the rage now, meaning that a Nurse Practitioner or a Physician Assistant and a Certified Nurse Midwife have to be on premise and team up with the physician in providing patient care. RHCs can be independent practices or they can be owned by rural hospitals. Either way RHCs are paid by Medicare differently than a practice without RHC designation. RHCs are required to submit reports of their operational costs and their total number of visits. Based on these two parameters the reimbursable cost per visit is calculated by Medicare. The entire process is complex and subject to rules, regulations and caps. The main point here is that RHC providers are not reimbursed according to the regular Medicare physician fee schedule and therefore will be unable to receive EHR incentives under Medicare. A few RHCs may qualify for Medicaid incentives, but in most cases they don’t have the prerequisite 30% Medicaid patients.

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Hospital Price Dispersion

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By DAVID DRANOVEDranove_foreman, PhD

A study by the Center for Studying Health System Change that will be released today shows that hospitals receive different prices for treating the same diseases. Center President Paul Ginsburg says this about the findings:

“The variation in hospital prices found in this study are (sic) inconsistent with highly competitive markets—at least for markets outside of health care,” said HSC President Paul B. Ginsburg, Ph.D.,

Hospital markets may not be highly competitive, but this argument is silly. One might as well say “The variation in automobile prices is (not “are”) inconsistent with highly competitive markets.” But one would be wrong in either case.

Vertical quality differentiation (i.e., some sellers are better than others) generates price dispersion in competitive markets. It is only in the most basic treatment of competition — in the first week of an intro economics course — that vertical differentiation is ignored. Observed price dispersion is not incompatible with competition.Continue reading…

Rating the Raters: Physician Compare

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By NAOMI FREUNDLICH

Let’s say you’ve enrolled in a new health insurance plan and need to find an internist who participates. How do you decide which doctor to choose? My (long deceased) grandmother made her choices by using the following criteria: She looked for a male doctor with a Jewish-sounding last name who graduated from an American medical school—preferably one located in New York City. Nowadays her narrow (and culturally biased) criteria would have excluded some of the most esteemed practitioners around.

If you are like most people, you don’t depend on your grandmother’s advice to find a physician, but rather ask friends, colleagues or other doctors for recommendations. But taking one person’s experience with an internist or surgeon as a signal that he or she is “really good” is still far from the optimal way to choose a practitioner.

Over the years, several commercial websites like HealthGrades and Angie’s List have cropped up that provide such consumer-friendly information as the distance a doctor’s office is from the patient, and whether foreign languages are spoken there. They usually include ratings that reflect consumers’ personal experiences with the practitioner. For people who want to dig deeper, most state medical boards collect data that can be searched to find out where your doctor went to medical school, where he did his residency and what board certifications she has. In some states you can also search to see if the doctor in question has received disciplinary action or been sued for malpractice.

This is a lot of on-line legwork for the average person—a task that even professionals can find difficult. Chip Amoe, assistant director for federal affairs at the American Society of Anesthesiologists told a group recently, “When I tried to go find a primary care physician, I couldn’t. You know, it was very difficult. I had to go on several different Web sites to be able to find [one].”

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Hospital Discharge Without a Net

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Picture 3 By JESSIE GRUMAN, PhD

By the time I reached the sixth day of my hospitalization for stomach cancer surgery, I was antsy to go home and I quizzed each nurse and physician who came into my room about what must happen for me to be liberated the following day. Their responses were consistent: my surgeon would visit in the morning and write orders for my release.  Then I would have a comprehensive discussion with my nurse about my discharge plan, after which I could leave.

I was pretty curious about getting that discharge plan.  The Patient Protection and Affordable Care Act raised the stakes for hospitals to reduce high readmission rates and new data on those rates are available.  The rates and approaches to reduce them through improved discharge planning are the subject of news reports, journal articles and conferences. And I, a patient in a modern, quality-conscious hospital, was going to experience this process myself!

Here’s a rough transcript of my discharge discussion:

Nurse: Good news!  The orders came through!  You can go home.

Me: (in the corner untangling wires from my cell phone and iPod chargers) Wonderful.  What do I need to know?

Nurse: Here are a couple prescriptions for pain medication.  Don’t drive if you take it.  Call your surgeon if you have a temperature or are worried about anything.  Go see your doctor in two weeks.  Do you want a flu shot? I can give you one before you leave.  If you need a wheel chair to take you to the door, I’ll call for one.  If not, you can go home.  Take care of yourself.  You are going to do great!

That was it: 8:45 a.m. and I could leave.

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Money and Healthcare Reform

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By JANE ORIENT, MD Jane Orient 1

Congress handed the Congressional Budget Office (CBO) some assumptions, the computers came up with the mix of adjustments needed to give a magic number under $1 trillion in 10 years, and the “Affordable Care Act” (ACA) emerged.

The “affordable” trillion apparently means net additional federal government expenditures, with the Treasury envisioned as one big pot of liquid gold. All the revenue gets mixed in, and the financial engineers turn the valves to direct the outgo. Less will go into some channels (“savings”), and more into others.

Numbers are thrown about—but where’s a spreadsheet of the money flows? The President couldn’t exercise a line-item veto even if he had one because there aren’t any line items. For example, how can you budget for each of the new bureaucracies if you don’t even know exactly how many there are (159—more or less)? And are they counted in the $1 trillion cost?

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Swamp Creature

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By JEFF GOLDSMITHPicture 60

Many people forget that before Washington DC was our nation’s capital, it was a pestilential swamp, whose few hardy residents regularly succumbed to tropical diseases like malaria. It was virtually uninhabitable in the summer (some say it still is), and like Houston and New Orleans, really began to boom only after the advent of affordable air conditioning. It is also a political swamp, infested with lobbyists and special interests, and Washington “lifers” – commentators, political operatives, consultants, intellectuals and bureaucrats who outlive increasingly fragile Presidential administrations. The electorate despises Washington, and sends waves of “outsiders” (e.g. ordinary Americans) to drain the swamp.

Though President Obama signed it into law in March, the new Affordable Care Act of 2010 is a swamp creature. Written by an exhausted Congress, half beast, half plant, the ACA is a seething, octopus-like tangle of well meaning but opaque government projects intended to expand health coverage and fix the health system’s numerous problems. Far more than “insurance reform”, it sprawls over and touches virtually every corner of our $2.5 trillion health system, bringing change, uncertainty and a ton of taxpayer dollars. It also has sunk its taproots deep into the national treasury and extends its feeding tentacles to an obese and hungry industry that already claims 17% of the national wealth.

A new wave of Republicans are about to hit town, fired up by their stunning mid-term election victory and control over the House of Representatives. One of their campaign pledges is to kill the swamp creature. They will shortly charge off into the swamp to try and kill it, like the British army tried to kill Francis Marion. In doing so, they expose themselves to a whole bunch of hidden hazards, including the beast itself. Handled thoughtlessly, the Republican campaign against health reform could damage the party’s prospects in 2012, even if the economy continues to sputter.

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The Republican Landslide and the Affordable Care Act

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By GLENN LAFFEL, MDGlenn Laffel

After their resounding triumph in yesterday’s midterm elections, House Republicans will likely act on their promise to repeal the Affordable Care Act, the health reform bill President Obama signed into law last March.

Their efforts could be blocked by the Democratically controlled Senate or, if necessary, by a veto from the Big O himself. But the Boehners might still get the final say, since they have the power to halt appropriations funding for large swaths of the law.

These realities have health-industry groups, some of whom vigorously supported Democratic efforts to pass the law, cozying-up to the GOP like a Snuggie on a cold winter night.

Private insurers want Congress to nix that $70 billion tax that will be levied against them beginning in 2014. They’d also like lawmakers to permit them to widen the rating bands which cap the amount of money they can charge older enrollees.

Insurers and providers want Congress to add a tort reform rider to the law, preferably one that protects physicians against malpractice lawsuits if they adhere to best practice guidelines. Drug companies want to kill the proposed Independent Payment Advisory Board, whose job it is supposed to be to control the rate of growth in Medicare spending. The Board’s recommendations would, after all, likely include reduced federal spending on prescription drugs which is very bad for their business.

Yet these same groups are worried sick that Republicans might go too far in their zeal to repeal the deal. The baby in the bathwater for these trade groups is the individual mandate: a provision in the law that requires most Americans to carry health insurance.

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How Reform Law Funds Itself, Strengthens Medicare, and Cuts the Deficit: Part 1

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By MAGGIE MAHAR

The Mainstream Media Rarely Tries to Explain the Congressional Budget Office’s nearly unbelievable claims that the Patient Protect and Affordable Care Act can:

1)  Pay for itself

2)  Provide coverage for 32 million uninsured Americans

3) Trim this nation’s deficit by some $143 billion over the next ten years

And, that’s not all. Medicare’s Trustees say that the reform legislation puts Medicare on the road to financial solvency–while limiting co-pays and beefing up benefits.

You might well ask: How can this be? How can we provide insurance for an additional 32 million people, improve Medicare, and simultaneously save money?

The media has not been a great help in answering these questions. This is, in large part, because the good news lies in the details—dozens and dozens of details. Fleshing out the myriad ways that the ACA generates new revenues while reining in health care spending would take up far too much time on a cable television show—and way too much space in most newspapers.

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The Politics of Health Reform

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By JOHN GOODMAN, PhD

There will be two national elections before the new health overhaul is substantially implemented (in 2014) and a third election the year it is supposed to be implemented.

Question: Will the voters reward office holders who supported the Affordable Care Act (ACA), or will they vote for their opponents? In thinking about this question, forget all the public opinion polls. Can you predict the outcome based on what you know about political science alone?

My prediction:  Supporters of the new law are going to get creamed. As I explained at my own blog the other day, there are four reasons: The law violates two bedrock principles of coalition politics that have been successful for the past 80 years; it abandons core Democratic constituencies; and it ignores the fundamentals of the politics of the health care sector.

Franklin Roosevelt’s First Principle of Successful Coalition Politics: Create benefits for people who are concentrated and organized, paid for by people who are disbursed and disorganized.

The ACA  violates this principle in spades. The main beneficiaries are many (but not all) of the new law are 32 million to 34 million newly insured people who otherwise would have been uninsured. Far from being organized and focused, most people in this group do not even know who they are. Indeed, it is probably fair to say that never in American history have so many benefits been conferred on so many people who never even asked for them!

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Medicare Costs Rise, Health Outcomes Suffer When Seniors Are Over-Medicated

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By NAOMI FREUNDLICH

The problem of elderly people taking too many medications is not new, but continues to pose a serious risk to health as well as contribute significantly to rising Medicare costs. The fact is that nearly 20% of adults aged 65 years and older who are not hospitalized take 10 or more medications daily. This number is not the result of shoddy care, but rather achieved when doctors simply follow practice guidelines for several common, co-existing conditions like diabetes, high blood pressure and depression, for example. If you look at all seniors (those both in and out of the hospital) the American Society of Consultant Pharmacists reports that the average 65-69 year old takes nearly 14 prescriptions per year; by ages 80-84 that number averages an astounding 18 prescription drugs per year.

What’s troubling is that instead of improving the health of seniors, evidence is growing that the more medications an elderly person takes, the more likely he is to experience falls, cognitive decline, loss of mobility, depression and even cardiac problems. These adverse drug effects may be mistaken for Alzheimer’s disease or other dementias too. The bottom line: Experts estimate that up to one-third of the elderly in our communities may be over-medicated and some 20% of their hospital admissions are due to adverse drug events. The costs related to over-medication in the elderly are thought to exceed $80 billion each year.

Although the problem of so-called “polypharmacy” among seniors results in significant economic and public health costs, little has been done to remedy the problem. In fact, in a recent commentary in the Journal of the American Medical Association, Jerry Avorn, associate professor of medicine at Harvard Medical School and author of the book “Powerful Medicines,” says that “many aspects of the US health care system act to discourage optimal prescribing” for the elderly.

For example, elderly Americans are highly underrepresented in the clinical trials for many of the drugs that doctors commonly prescribe for them. Seniors may metabolize these medications differently and they are often more sensitive to side effects and counter-indications with other drugs than younger people. They also take many more drugs (often all at the same time) than any subjects who take part in controlled clinical trials. Disturbingly, doctors sometimes end up prescribing a new medication to treat the adverse effects of a pill the elderly patient has been taking for years.

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