By RONALD PIES, MD

Physician-assisted suicide. Physician-assisted dying. Physician Aid in Dying. All these terms have been used to describe a terminally ill patient’s use of a lethal, prescribed medication. Sometimes the medication is used to end the patient’s life; sometimes, it is held “in reserve” to provide a sense of control over the timing of death. Historically, the American Medical Association has stood squarely against physician-assisted suicide (PAS). But recently, in approving “Resolution 015”, the organization has resolved to study the issue of “aid in dying”, with an eye toward reconsidering the AMA’s longstanding policy. As a medical ethicist, I find this resolution deeply troubling.

Consider this scenario from an ethical perspective. Your loved one is facing a terminal illness, and is expected to live only another month or two. He is sitting in his doctor’s office, and knows that the doctor owns a gun, which she keeps locked up and loaded in her office. The patient, who is mentally competent, requests use of the physician’s gun, in order to end his life. Would it be ethical for the physician to grant the patient’s request? I suspect most of us would be horrified at the thought. Indeed, most U.S. states have laws that prohibit someone from “knowingly and willfully assisting” another person in the commission of suicide.

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By STEVEN FINDLAY

Since we are in a political season, I’ll begin with one of the candidate’s positions on a facet of healthcare: Hillary wants to double funding for Community Health Centers (CHCs) over the next decade.

Is that a good or bad thing?  If you’re inclined to think that’s good, please read on; I’ll reinforce your views.  If your impulses are in the opposite direction….well, I hope you’ll still read on; I’ll hope to convince you.

By the way, I could find no mention by Trump of CHCs—no surprise there.

The role CHCs play in healthcare has gone largely unheralded for years, eclipsed by sexier health policy topics and debates.  But that role has expanded in recent years and become more important than you might think.  And not incidentally, CHCs have had broad bipartisan support for many years.

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By JIRKA TAYLOR and ELTA SMITH

Antimicrobial resistance (AMR) is a major threat to public health and the global economy. Indeed, a RAND Europe study found that failure to address AMR could result in worldwide economic losses of $3 trillion and annual population decreases of 10 million people every year until 2050.

In May 2016, the UK’s Review on AMR, headed by economist Jim O’Neill, delivered its final report, which stressed the need to find global and cooperative international solutions. It is good news then that the United States and European Union (EU) are among the most important international actors in this area committed to making an effort to tackle AMR, both domestically and in collaboration with their international partners.

The United States adopted a National Action Plan to tackle AMR in 2015, and the Obama administration nearly doubled federal funding for 2016 to more than $1.2 billion. Similarly, the EU’s activities in the area are guided by an EU Action Plan on AMR, which RAND Europe is evaluating, with the EU dedicating substantial resources to AMR-related efforts, including about €2 billion on AMR-related research from 2012-2015.

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By HANS DUVEFELT, MD

Part of a series on primary care challenges and their solutions.

I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.

The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.

The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite honestly, I am so used to getting irrelevant warnings that it has become a reflex to bring the cursor to the spot where I can make the warning go away after a quick glance at it. Even though I have chosen the setting “Pop up drug interaction window only when the interaction is severe”, I get the pop up with almost every prescription.

Today I went back to Barton’s chart and looked at his interaction screen.

With the Bactrim DS no longer there, the first of the red boxes was a major interaction between his 81 mg aspirin and his Pradaxa (dabigatran) – two blood thinners are more likely to make you bleed than one. That is basic knowledge, even common sense.

The next red box was a moderate interaction between his baby aspirin and his lisinopril. Theoretically, higher doses of NSAIDs can interfere with the blood pressure lowering properties of ACE inhibitors. That is very basic knowledge, too.

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By JACOB REIDER, MD

Two and a half years ago, John Halmaka posted an entry with this title – and I recall that it was a good summary of the state of the industry.  While I didn’t agree with all of his suggestions, I enjoyed the review and it offered a good set of guiding principles.  Since I was Acting National Coordinator for about the same duration as Vindell will serve, (Fall of 2013 – after Farzad Mostashari departed, and before Karen DeSalvo arrived) I’ll offer some thoughts from one who has been in his position.

1. Certification.  The health IT certification program is the core of ONC’s responsibility to the nation.  While some have called for the eradication or reduction of the certification program, I would argue that this would be akin to scaling back Dodd-Frank.  Yeh – crazy.  As a product of ONC’s certification program, we now have health IT systems that do what their developers claim they do.  Before this program existed, creative health IT salespeople would assure customers that systems had functionality that simply didn’t exist, or was nonfunctional.  The program, like certification programs in other industries (telecommunications, transportation, etc.) is in place to assure the purchasers of products that these products do what developers claim.   Is the certification program perfect?  No.  Of course not.  The program needs to iterate with the evolution of the industry and the standards that are evolving.  Revisions to the certification program must therefore continue, so that the certification requirements don’t point to obsolete standards.  A focused “2015R2” certification regulation would therefore be an appropriate component of ONC’s fall work – so that something can be “shovel ready” for a new administration for ~ February release – with final rule in ~ April/May of 2017.

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By KIP SULLIVAN

In the first article in this three-part series I reviewed the findings in CMS’s latest report on one of its “medical home” experiments – the second-year evaluation  of the Multi-Payer Advanced Primary Care (MAPCP) Demonstration.We saw that the “patient-centered medical homes” (PCMHs) in that demo have failed to cut costs or improve quality during the first two years of the demo. We also saw that the sloppy definition of “medical home” put the author of the report, RTI International, in a bind: They did not identify a single feature of PCMHs to treat as an independent variable, and were forced to offer an impressionistic, on-the-one-hand-on-the-other-hand account of what the PCMHs are doing.

In the second article of this series I examined the report’s explanation for why the PCMHs have so far been unable to outperform non-PCMHs despite receiving substantial subsidies from CMS and other sources that non-PCMHs don’t get. The report seems to say that insufficient subsidies explains the PCMHs’ failure. I noted, however, that the report contains no evidence indicating how much more money PCMHs might need.

At the end of my second article I characterized the problem presented by the report as a conundrum. On the one hand, PCMH staff and many other observers feel PCMHs are severely underfunded, but on the other hand no one can say by how much or which PCMH services need more money.

So what do we do? Do we just pick a number out of thin air and say that’s how much more money PCMHs need, and pour that money down the PCMH black hole along with the other subsidies PCMHs receive now? That appears to be CMS’s position judging from its endorsement of yet another “medical home” program (CPC+ as an “alternative payment model” in its proposed MACRA rule despite the fact that all three of CMS’s “home” demos are failing.

Salvaging what we can

Throwing more money down the PCMH black hole is not a good idea. I recommend that CMS allow PCMHs to focus, and that CMS do so by radically sharpening and cutting down the definition of “PCMH” so that the concept refers to a uniform set of medical and social services provided to a subset of the chronically ill. [1]

Once CMS has clearly defined what services it wants “homes” to provide, it can then determine what the extra services cost and make adequate payment for them. It would help if, in addition to paying adequately for the extra services, CMS would let doctors and patients decide when the extra services should be provided rather than stick its nose into the doctor-patient relationship with pay-for-box-clicking schemes. Paying adequately for additional services and eliminating pay-for-clicks schemes would increase the physician “flexibility” that CMS claims it seeks to promote with PCMHs. Eliminating pay-for-clicks schemes would also lower physician overhead and reduce physician burn-out.

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By JEREMY WALLMAN

Customer centricity has been a mantra of managed care organizations for well over a decade. If you listen closely, you can hear plaintive cries of our care providers, lamenting the labyrinthine, almost Kafka-esque system of prior authorization, reimbursement, meaningful use, and near-real-time obsolescence of medical technology. The crushing weight of reform, the perverted incentives created by volume-based reimbursement, and the soaring costs of doing business have created a situation, much like in public education, where our system is fueled primarily by the power of a dedicated and passionate community whose members are motivated by their desire to care for other human beings.

“How can we possibly think about self-service websites when we are holding back an imploding healthcare delivery system”. Maybe we need to ask a more basic question…..is the U.S. healthcare system viable in the long-term? That question might simply be too hard to answer. So instead, we try to convince ourselves that, like educating our citizens, delivering medical care should be treated as a business. Innovation and value are fueled by financial incentives and healthcare is no different.

But it is different. It is very different.

In some particularly competitive/ wealthy markets, Providers are offering differentiated services….delivery rooms with hotel-style amenities, upgraded menus, concierge services, etc., usually available for an extra charge. But these services are not adding to anyone’s bottom line…they are just attracting those few patients who have the luxury of choice. Where is the value here?

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