The Health Care Blog – Page 351 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Iora Health Fellowship: A Call For Applicants

Aug 21, 2016

BY JAY MATHUR, D.O. and SUMAIR AKHTAR, MD

With STEPHEN GORDON, MD

flying cadeucii As physicians, we pride ourselves on our clinical wins – nailing the diagnosis of a rare disorder or helping a patient achieve control of their long-standing diabetes. However, we commonly face intense frustration and high rates of burnout due to socioeconomic, political, and bureaucratic forces that prevent us from delivering impactful patient care. This frustration is compounded by the constant proliferation of changes in healthcare policy and care delivery to address alarming increases in healthcare cost and waste. Between the deluge of paperwork, regulations, and resource constraints, we often ask ourselves: Why does the system often hinder rather than enhance the physician-patient relationship?

The truth is that physicians can no longer sit on the sidelines. The questionable value of so many clinical procedures and the immense cost baked into the system are clearly unsustainable. Given that physicians – with their patients – ultimately make decisions regarding care plans, they are uniquely positioned to move the healthcare system to one that rewards doing only what is best for the patient. Yet, current physician training rarely incorporates curriculum designed to create systems thinkers capable of leading multi-discplinary care teams.

Enter Iora Health and its unique fellowship in primary care innovation and leadership. Iora is an innovative primary care delivery startup that is committed to restoring humanity to healthcare. It advances a high-impact, relationship based primary care model that is backed by talented health coaches, robust technology, and payment that is focused on patient outcomes.

Value-Based Government (GACRA)

Aug 20, 2016• 5

By MICHAEL BANKS, MD

We decided that if MACRA is good for physicians, then the same thinking is probably a pretty good idea for the US government. We need Value-Based Government. It’s clear that past methods of paying for US Government services have been terribly inefficient. Costs keep going up. Quality keeps going down. We thought about doing this nationwide, with all US government personnel, but we will just do CMS leaders for now. Let’s call it a demonstration, we’re calling it GACRA, Government Access and CMS Revaluation Act.

Eventually we want all US government employees to be value- based, no more salaries. This is an obvious improvement on how we will pay you, The way you are paid now does not seem to work. Everyone agrees our government is too expensive to run and nothing gets done.

Here’s how value-based government works:

Every CMS leader will send in a code for every 10 or so minutes of work and exactly what they did. Yes, Andy Slavitt and Sylvia Burwell, you will not be paid as you were previously.

You will now be paid for value.

The American Medical Association Takes a Step In the Right Direction

Aug 20, 2016• 1

BY LAURIE LEONARD

flying cadeucii I am very glad the AMA is studying the issue of aid in dying. Opponents to the legalization of aid in dying put quotes around the term, apparently to indicate that it is a euphemism for what they believe is physician-assisted suicide. But aid in dying is not suicide.

On 9/11 witnesses saw a number of people trapped in the World Trade Center intentionally jump to their deaths. None of those deaths were ruled suicides by the medical examiner. The death certificates for the jumpers list the cause of death as homicide.

Similarly, in the states in which aid in dying is legal, the death certificates do not list “suicide” as the cause of death; instead, they list the underlying terminal disease as the cause. Just as the 9/11 jumpers chose death by falling over death by burning, those terminally ill people fortunate enough to live in an aid in dying state can choose a peaceful, quick death at the time and place of their choosing over a drawn-out, miserable death that may end alone, intubated in an ICU rather than at home with loved ones present.

Capping Co-Pays Doesn’t Lower Drug Costs

Aug 18, 2016• 2

By DEVON HERRICK

flying cadeucii Politicians are concerned about your drug costs. Unfortunately, their proposals could actually raise drug prices and force you to pay more, albeit indirectly. For instance, presidential candidate Hillary Clinton proposes to cap your prescription drug co-pays at no more than $250 per month. Rising drug costs are now a political issue because the number of diseases and conditions that can be treated using drug therapy has grown tremendously over the past 25 years. Arguably, one of the main reasons patients visit their doctors is to obtain or renew prescriptions. When they visit their doctors’ offices, Americans leave with a prescription in hand about three-fourths of the time. This is hardly a travesty; and few patients are drowning under the cost of prescriptions drugs. Most prescription costs are paid for by prescription drug plans sponsored by insurers and health plans.

Insurers and health plans use multiple techniques to make drugs affordable. One of the ways employers, insurers and pharmacy benefit managers (PBMs) hold down costs is through drug formularies with multiple tiers. The purpose of tiered formularies is to steer enrollees to lower-cost alternatives when appropriate, using differing levels of cost-sharing and co-pays. Drug plans typically encourage generic use by requiring little if any cost-sharing when a generic drug is dispensed. Prescriptions are dispensed in generic form about 88 percent of the time. Generic drugs are cheap compared to brand drugs — accounting for less than three percent of national health care expenditures.

Patients Without Borders

Aug 18, 2016

By WHITNEY BOWMAN-ZATZKIN

More about Jess Jacobs, who died on Saturday–also known as #UnicornJess. (That link will take you to the twitter memorial on Sunday night, but also check out remembrances from Ted Eytan & Carly Medosch). Today I’m re-running a beautiful, and very personal piece (on Medium) from her friend Whitney Bowman-Zatzkin who was a key patient advocate for Jess in Washington DC–Matthew Holt

Whitney_Jess

I attended a walking tour once where the guide was going on about Von Gogh’s quest to paint yellow in the most yellowy of yellow ways. Even NIH articles talk about it. Theories abound.

As we walked, I gained an appreciation for the lengths this guy went to on his quest for a single portrait of yellowy yellowness. I remember the guide saying something like:

“Van Gogh sought his whole career to paint in a way that demonstrated how yellow made him feel.”

The tour was years ago but that line stuck with me. Has anything ever trapped you like that? Like a quest to craft a brushstroke for how something made you feel?

My treasured friend Jess Jacobs died this weekend. She flooded my life with laughter and jokes, expanding what I knew in what it is to love a friend in the very best of ways.

Jess and I met in a classroom at Georgetown where she swiftly passed out in front of me when I returned for the final pitches of my first-ever code-a-thon. Later she’d tell of waking up to a blur of people and a certain bow tie being in focus.

Shortly thereafter, she fainted in front of me again and I soon learned how to trust a new friend and be there for her more than I ever had before. That pattern continued throughout my whole friendship with Jess. She gifted me a new definition of trust and capability.

Some of the scariest words I’ve ever known in health care existed in Jess’ medical profile, yet she was always the outlier redefining what it meant to have those diagnoses.Continue reading…

The American Medical Association Goes Wobbly on Physician-Assisted Suicide

Aug 18, 2016• 16

By RONALD PIES, MD

flying cadeucii 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.

Community Health Centers Are Essential to a Safety Net

Aug 18, 2016• 15

By STEVEN FINDLAY

Steve 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.

European and American Efforts to Tackle AMR: Great Minds Think Alike (Almost Always)

Aug 17, 2016• 2

By JIRKA TAYLOR and ELTA SMITH

flying cadeucii 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.

Building Better Metrics: Invest in “Good” Primary Care and Get What You Pay For

Aug 16, 2016• 11

By NIRAN Al-AGBA, MD

flying cadeucii In 1978, the Institute of Medicine published A Manpower Policy for Primary Health Care: Report of a Study (IOM, 1978) where they defined primary care as “integrated, accessible services by clinicians accountable for addressing a majority of heath care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” The four main features of “good” primary care based on this definition are: 1. First-contact access for new medical issues, 2. Long-term and patient (not disease)-focused care, 3. Comprehensive in scope for most medical issues, and 4. Care coordination when specialty referral is required. These metrics ring as true today as they did many years ago.

Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients. An average workday of 8 hours extrapolates to an ideal panel of 909 patients; let us make it an even 1000 to simplify. A primary care physician could easily meet acute, chronic, and preventative needs of 1000 patients, thereby improving access. Our panels are much larger due to the shortage of available primary care physicians and poor reimbursement which keeps us enslaved. Pay us what we are worth and then utilize this “first-access” metric to judge our “quality.”

Welcome to My World: Perpetual Alarm Fatigue

Aug 15, 2016• 1

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.