The Health Care Blog – Page 484 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The End of Antibiotics. Can We Come Back from the Brink?

May 5, 2014• 38

By Tom Frieden, MD

Antibiotic resistance — bacteria outsmarting the drugs designed to kill them — is already here, threatening to return us to the time when simple infections were often fatal. How long before we have no effective antibiotics left?

It’s painfully easy for me to imagine life in a post-antibiotic era. I trained as an internist and infectious disease physician before there was effective treatment for HIV, and I later cared for patients with tuberculosis resistant to virtually all antibiotics.

We improvised, hoped, and, all too often, were only able to help patients die more comfortably.

To quote Dr. Margaret Chan, Director General of the World Health Organization: “A post-antibiotic era means, in effect, an end to modern medicine as we know it.”

We’d have to rethink our approach to many advances in medical treatment such as joint replacements, organ transplants and cancer therapy, as well as improvements in treating chronic diseases such as diabetes, asthma, rheumatoid arthritis and other immunological disorders.

Treatments for these can increase the risk of infections, and we may no longer be able to assume that we will have effective antibiotics for these infections.

Last September, CDC published our first report on the current antibiotic resistance threat to the United States.

The report conservatively estimates that each year, at least 2 million Americans become infected with bacteria resistant to antibiotics, and at least 23,000 die. Another 14,000 Americans die each year with the complications of C. difficile, a bacterial infection most often made possible by use of antibiotics. WHO has just issued their report on the global impact of this health threat.

It’s a big problem, and one that’s getting worse. But it’s not too late. We can delay, and even in some cases reverse the spread of antibiotic resistance.

So What Do the Expanded Enrollment Numbers Mean?

May 5, 2014• 4

By Paul Keckley

Last Thursday, HHS released the final enrollment stats for health exchange enrollment for 2014. Here’s what we learned:

8.1 million enrolled in a plan in the Health Insurance Marketplace. 3.8 million (47% of total) since the end of February including 1.2 million in the much-watched 18-34 age cohort.
54% are female; 28% are between the ages of 18-34; 63% are White, 17% Black, 11% Hispanic, 8% Asian/other.
20% chose a bronze plan, 65% chose silver, 9% gold, 5% platinum and 2% catastrophic. Note: At the silver level, individuals who earn less than 250% of the federal poverty level — ($29,175 for an individual, or $59,625 for a family of four) — are eligible for assistance for out-of-pocket costs. 85% who picked an exchange plan qualified for a subsidy: 82% in the 14 state-run exchanges and 86% in the federally-run exchange.
Young adults 18-34 were 83% of those applying for the catastrophic coverage.

How Much Will It Cost to Let Me Die?

May 5, 2014• 1

By JaBaris Swain, MD

It was probably the most awkward question I had been asked before, and I did not have an answer…

He was a middle-aged gentleman, neatly dressed—very simple and unassuming. He blended like a lifeless statue in the waiting area. What sparked my notice of him was his accompanying robust file, crammed with familiar pink discharge slips from the ED.

He was clearly what we call a “frequent flyer”, but this would be his first visit in our surgical clinic.

I escorted him into the assessment room, exchanging the usual salutations as he edged unto the exam table, wincing with discomfort. His chief complaint read, “acute abdominal pain and constipation x 1 week.”

Vying to understand more about his issue, I asked, “Sir, how long have you had this problem?” Embarrassed, he lowered his head.

Silence.

I retreated and instead remarked, “Ok. Let’s start from today. Where do you have the most pain?”

Tenderly, his frail digits unbuttoned his shirt, exposing a wasted torso, which hoisted an extraordinarily distended abdomen. It appeared rigid and tense. I reached out to gently palpate it to confirm the realism of my observations. He flinched. His stoic affect instantly collapsed into an aching frown.

Tears welled in his eyes. Something terrible was going on inside. Cancer.

He needed to be admitted and surgery would be very likely, if not too late. I was aplomb in my explanation of his condition, feeling proud of my thoroughness and precision. Yet, seemingly unengaged, he politely interrupted and asked, “How much will it cost to let me die?”

I paused. It was probably the most awkward question I had been asked before, and I did not have an answer. During my training, I was taught to order tests wisely, to avoid superfluous exams and to minimize inefficiency of resources; in spite of this, I had not ever stopped to think about cost in this context.

In my mind, it was my duty to provide the best, quality care to extend life, foremost. Yet, his concern was different. How much would it cost to die?

Nothing.

Doximity Raises $54 Million. But What Value Will They Add?

May 4, 2014• 2

By JOSH HERIGON

Last week’s news that Doximity has raised another $54 million got me thinking ..

On one hand, I’m glad to see these guys continue to raise money and continue their development.

On the other hand, I’m disappointed that we don’t have a better physician-centric social network. While they have been successful at signing up doctors, it seems (at least anecdotally) few are engaging with the network. I have connected with many of my classmates and some physicians I know on the network. I have never interacted with any of them through Doximity.

The article quotes LinkedIn co-founder and Doximity board member , Konstantin Guericke:

I think a lot of doctors will have a LinkedIn profile and Doximity profile. But the key is which part is really going to get ingrained in their lives.

The key question is—what value does Doximity provide over other, non-physician centric social networks? More plainly, what is going to make me open up Doximity on my iPhone instead of my favorite Twitter client?

The current answer to that question is: nothing.

In their smartphone app, the news feed features medical journal articles from the likes of NEJM, JAMA, Lancet, etc. It is unclear exactly how these are selected, but quite clear they are not tailored to my interests. Twitter, on the other hand, provides a constant stream of thoughts and articles related to my interests because of the people I’ve chosen to follow.

Medical Devices and Patient Safety: A Promising Path Forward

May 4, 2014• 3

By Daniel, Gardina & Strait

In an era of sophisticated information technology and rapid communication, the medical device community lags far behind other fields in its ability to alert patients about safety concerns.

For example, auto manufacturers and government regulators are able to quickly identify potential safety concerns by linking reports of crashes, malfunctions and defects with individual vehicle identification numbers (VINs).

They can then communicate recalls to affected customers by using their VIN. Manufacturers will issue notifications via mail or e-mail, or offer customers the ability to search the manufacturer’s website using their VIN.

In health care, drugs are tracked using a system established in the 1970s called National Drug Codes (NDCs). The 10-digit NDCs are assigned to all manufactured medications. The code tracks the vendor, product, and package code, which can then be captured in electronic health records and the FDA’s national database.

Unfortunately, we do not yet have a similar national system that can identify and communicate potential concerns for the tens of millions of patients with implantable devices such as pacemakers, glucose meters, artificial joints, and defibrillators.

Patients are bombarded by news stories about device recalls, but unless they have access to information about the exact make and model of their device, they have no way of knowing if they should be concerned. Since most medical device procedures take place in a hospital, a patient’s health care providers may also lack this critical, sometimes life-saving information.

The patient is then burdened with the task of tracking down their specialist or surgeon, in hopes that they documented the specific device information.

Clearly, the current health care information infrastructure does not yet support a robust surveillance system.

A Swedish Country Doctor’s Proposal for Health Insurance Reform

May 4, 2014• 7

By HANS DUVEFELT, MD

In the forty years since I started medical school, I have worked in socialized medicine, student health, a cash-only practice and a traditional fee for service small group practice. The bulk of my experience has been in a government-sponsored rural health clinic, working for an underserved, underinsured rural population.

Today, I will pull together the threads from my previous posts in the series “How Should Doctors Get Paid?” I will make a couple of concrete suggestions, borrowing from all the places I have worked and from the latest trends among the doctors who are revolting against the insurance companies by starting Concierge Medicine and Direct Primary Care practices.

Because I am a primary care physician, I will mostly speak of how I think primary care physicians should be paid.

I will expand on these concepts below, but here are the main points:

1) Have the insurance company provide a flat rate in the $500/year range to patients’ freely chosen Primary Care Provider, similar to membership fees in Direct Care Medical Practices.

2) Provide a prepaid card for basic healthcare, free from billing expenses and administration.

3) Unused balances can be rolled over to the following years, letting patients “save” money to cover copays for future elective procedures.

4) Keep prior authorizations for big-ticket items, both testing and procedures, if necessary for the health of the system.

5) Keep specialty care fee-for-service.

6) Have a national debate about where health care ends and life enhancement begins and who should pay for what.

Health insurance needs to be simple to understand and administer. It needs to promote wellness, and it needs to remove barriers from seeking advice or care early in the course of disease. It needs to empower patients to use health care services wisely by aligning patients’ and providers’ incentives.

Health insurance should not be deceptive. It should not promise to pay for screenings (colonoscopies and mammograms) and stop paying if the screening reveals a problem (colon polyps or breast cancer). It should offer patients the right to set their own priorities for their health while demanding concern for our fellow citizens’ right to also receive care.

A Holistic View of Evidence-Based Medicine

May 2, 2014• 23

By DAVID KATZ, MD

On Tuesday of this week (4/29/14), I was on the Katie Couric Show to discuss Integrative Medicine.

Somewhat ironically, I returned from Manhattan that same day to a waiting email from a colleague, forwarding me a rather excoriating critique of integrative medicine on The Health Care Blog, and asking me for my opinion.

The juxtaposition, it turns out, was something other than happenstance. The Cleveland Clinic has recently introduced the use of herbal medicines as an option for its patients, generating considerable media attention.

Some of it, as in the case of the Katie Couric Show, is of the kinder, gentler variety. Some, like The Health Care Blog — is rather less so. Which is the right response?

One might argue, from the perspective of evidence based medicine, that harsh treatment is warranted for everything operating under the banner of “alternative” medicine, or any of the nomenclature alternative to “alternative” — such as complementary, holistic, traditional, or integrative.

One might argue, conversely, for a warm embrace from the perspective of patient-centered care, in which patient preference is a primary driver.

I tend to argue both ways, and land in the middle. I’ll elaborate.

What Healthcare Can Learn from Pixar’s Braintrust

May 2, 2014• 6

By KATIE McGRAW

I am reading Creativity, Inc. right now by Ed Catmull, the president of Pixar Animation and Disney Animation.

One particular quote by Catmull that has stuck with me personally over the last few days is this:

“At some point, every Pixar movie sucks.”

Which got me thinking – are we in the “suck” part of transforming healthcare right now?

In my opinion, all roads lead to yes. Still, I don’t want to dwell on the suck part, I want to focus on how one of the world’s most innovative companies, Pixar, transforms their “ugly babies” (mediocre ideas) into something magical (a la Toy Story 2 or my personal favorite, Up) – and how the healthcare industry can learn fromPixar’s “Braintrust” model.

Forget that it’s cliché – celebrate failure

One of the key things that make the Braintrust at Pixar unique is the fact that candor and honesty are truly placed on a pedestal. More so, failure is celebrated to a certain degree in the culture Catmull outlines.

He writes, “If you aren’t experiencing failure, then you’re making a far worse mistake: You are being driven by the desire to avoid it.”

Which leads me to something failure related that many in the healthcare industry have debated – whether the government did the right thing by incentiving providers to adopt electronic health records (EHRs). I think many would agree that the answer to that is no.

Instead of touting the percentage of organizations reaching certain stages of meaningful use attestation, would the government’s honest admittance of a certain degree of failure provide a chance to successfully redirect efforts?

I think yes.

Yet, due to the risk adverse nature of the healthcare industry and the engrained fear of failure in all of us, we (not just government) are all too often guilty of pushing forward with similar mediocre ideas merely to see them through when they may have been better served by being put to rest.

Keas Poll on Workplace Stress and Disease Burden Provides an Education

May 2, 2014• 12

By VIK KHANNA & AL LEWIS

Al’s son once complained to Al’s Aunt Tillie about an overbearing supervisor. Aunt Tillie suggested that he try to work under a different supervisor. Tillie was one of those people – and we all know them – who could be counted on to inadvertently provide punchlines when needed. Conversely, Al is one of those people – and we all know them – who can’t resist setting up those punchlines. So I lamented that this suggestion may not work because, “Aunt Tillie, it’s a sobering fact that 50% of all supervisors are below average.”

Tillie replied, “I blame our educational system for that.”

Likewise, we may need to blame our educational system for Keas’ new poll on workplace stress. To begin with, the lead paragraph from Keas — which like many other companies is “the market leader” in wellness – “reveals” that “4 in 10 employees experience above-average stress.”

SAN FRANCISCO, CA – (Apr 2, 2014) – Keas (www.keas.com), the market leader in employer health and engagement programs, today released new survey data, revealing four in ten employees experience above average levels of job-related stress. Keas is bringing attention to these findings to kick off Stress Awareness Month, and is also providing additional insight and tips to bring greater awareness to the role of stress in the workplace and its impact on employee health.

Wouldn’t that mean some other employees – mathematically, also 6 in 10 – must be experiencing average or below-average levels of stress? It would seem like mathematically that would have to be the case. However, the Keas poll also “reveals” that while some employees are average in stress, no employee is below-average – a true paradox. Hence Keas’ selfless reasons for publishing this poll: All employees being either average or above average in the stress department means we have a major stress epidemic on our hands. This perhaps explains why Keas is “bringing attention to these findings.”

In a further paradox, Keas also uses the words “average” and “normal” as synonyms, even though they are often antonyms: All of us want our children to be normal but who amongst us wants their children to be average?

Who Should Pay Doctors?

May 1, 2014• 29

By Hans Duvefelt, MD

Honest Pay for Honest Work.

Times have changed. And it’s time they change again.

In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications.

There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.

In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.

Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.

Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.