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Above the Fold

Clinic: A Cautionary Note About the Risks of Blood Pressure Treatment in the Elderly

Feb 28, 2014• 16

By Leslie Kernisan, MD

When it comes to high blood pressure treatment in the elderly, the plot continues to thicken.

Last December, a minor controversy erupted when the JNC hypertension guidelines proposed a higher blood pressure (BP) treatment target (150/90) for adults aged 60+.

And now this month, a study in JAMA Internal Medicine reports that over 3 years, among a cohort of 4961 community-dwelling Medicare patients aged 70+ and diagnosed with hypertension, those on blood pressure medication had more serious falls.

Serious falls as in: emergency room visits or hospitalizations for fall-related fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In other words, we talking about real injuries and real patient suffering. (As well as real healthcare utilization, for those who care about such things.)

How many more serious falls are we talking? The study cohort was divided into three groups: no antihypertensive medication (14.1%), moderate intensity treatment (54.6%), and high-intensity treatment (31.3%).

Over the three year follow-up period, a serious fall injury happened to 7.5% of those in the no-antihypertensive group, 9.8% of the moderate-intensity group, and 8.2% of the high-intensity group. In a propensity-matched subcohort, serious falls happened to 7.1% of the no-treatment group, 8.6% of the moderate-intensity group, and 8.5% of the high-intensity group. (Propensity-matching is a technique meant to adjust for confounders – such as overall illness burden — between the three groups.)

The methodologists in the audience should certainly read the paper in detail and go find things to pick apart. For the rest of us, what are the practical take-aways?

Transparency a Go Go?

Feb 28, 2014• 4

By Katherine Hempstead

As the fashionistas might say, transparency in health care is having a moment. It made the PricewaterhouseCoopers top 10 list for 2014 industry issues, and there is every reason to expect transparency to be very visible this year and beyond.

Without a doubt, transparency is hot.

Despite this, there is increasing grumbling by observers who say that transparency is complicated and hard to operationalize. We also hear that transparency is “not enough” to constrain costs in our dysfunctional system, especially in the face of provider market power.

The word itself invites skepticism, in that it seems to over-simplify and promise a magical solution, as if daylight will provide health care pricing with a glow of rationality.

As usual, the truth lies somewhere in the middle. Transparency can and will provide information about price, quality, and consumer experience that market participants need in order to better understand the health care system and increase its value.

While this information is surely necessary, we have seen many examples of when it is not sufficient. Clearly, transparency is not the only tool that we need.

Here are a few thoughts about transparency issues for 2014.

Transparency tools will hit Main Street.

Increasingly, consumer-facing tools with various kinds information about health care prices are being created, whether it is okcopay or Change Healthcare. These entries join a growing list of transparency tools from carriers or third-party vendors.

The Robert Wood Johnson Foundation’s Hospital Price Transparency challenge, designed to promote awareness of hospital charge data, had a record number of entrant and the winning submissions are downright inspiring. RWJF also awarded grants for research on the use of price data in health care, including a number of studies of promising transparency tools aimed at consumers and providers.

The field is becoming more crowded, and it is increasingly important to determine the optimal way to reach the consumer with price and quality information.

There will be greater focus on the customer experience.

There is no doubt that the customer experience in health care lags behind the rest of the service sector, and consumers are increasingly demanding responsiveness and convenience in their encounters with the medical profession. The growth of evening and weekend hours, email communications with physicians, and patient portals are all harbingers of a new age where medicine is far more customer friendly.

RWJF’s Open Notes initiative allows patients to share notes with their doctors, while the Foundation’s Flip the Clinic program completely reimagines the doctor patient encounter in the ambulatory care setting.

Medicare Advantage Round Two: Negotiation Will Not Be the Same

Feb 28, 2014• 2

By Paul Keckley

Late last Friday after the financial markets closed, the Centers for Medicare and Medicaid Services (CMS) issued its annual notice of 2015 payments to private insurers who sell Medicare Advantage plans to seniors. Its determination that a 3.55% cut is in order was spelled out in a complicated 148-page explanation of its methodology.

The net impact of changes to “coding intensity” adjusted for geographic variation essentially means insurance companies would see a 1.9% cut in their payments per Avalere’s calculations.

But there’s more to the story than the Medicare Advantage payment adjustment. The difference between last year’s Round One rate negotiation and this year’s Round Two is significant.

Background

Medicare Advantage (MA) plans enroll 28% of seniors. It is popular: enrollment increased from 5.3 million in 20104 to 16 million today—a 9% increase last year alone. MA plans are required to offer a benefit “package” at least equal to Medicare’s covering everything Medicare allows, but not necessarily in the same way.

The Legacy of the Tarceva Diva

Feb 27, 2014

By Brian Loew

About three years ago, a new member of our Lung Cancer Survivors Support Community posted a message: she was taking Tarceva and wanted to discuss with fellow members everything about that cancer drug.

She titled her post, TARCEVA DIVAS AND DUDES DISCUSSION & SUPPORT. She saw a need to create a community within a community, and beginning with that modest post, she did it. She didn’t ask permission. She didn’t wait for us, or another member, to organize and lead a top-down discussion about Tarceva.

The ongoing discussion string became the place for our members to go to talk about Tarceva and next-generation lung cancer treatments.

The member became known by some as the Tarceva Diva, and for the purposes of this story, that’s what I’ll call her. This story is not specifically about Tarceva, or even about lung cancer, but instead, it’s a celebration of an unsung hero who helped thousands of people.

There have been well over 8,000 posts in less than three years’ time–about 250 posts per month–in just that series of hundreds of “Divas and Dudes” discussion strings. That’s a constant, dedicated stream of treatment insights from-the-front-lines of people worldwide affected directly by lung cancer.

“WELCOME TO TARCEVALAND!!!” she’d proclaim to a new member, or “newbie.” She could insert humor into the discussions without making light of the seriousness of members’ illnesses. The activity in the Tarceva sub-community grew so quickly that the Tarceva Diva created another discussion topic, TARCEVA SIDE EFFECT BUSTERS, which created yet another resource for members.

Amazon.com as a Delivery Model for Population Health

Feb 27, 2014• 7

By NICK DAWSON

There’s that line about art, “good artists copy, great artists steal.” There’s some debate about if Picasso said it first, but most of us geeks know it from Steve Jobs.

Often, I see things from companies and industries outside of healthcare —processes, products, best practices —which inspire me. I like these little inspirations because they often aren’t rocket science, but nonetheless fuel some creative thoughts about their applicability in healthcare.

The other night, around 9:00 PM on a holiday Monday, I ordered some obscure aviation stuff from Amazon. I needed a new headset, a leg-mounted chart holder, a paper calculating tool called an E6B computer and a portable canister of oxygen.

I have Amazon Prime, their subscription service which provides expedited 2 day shipping, so I expected to see my stuff on Wednesday afternoon. I was blown away when there was an Amazon box outside my door by 9:00 AM the next morning, Tuesday.

A box showed up early, big deal, right?

Here’s what I think happened and why I’m so impressed. I had been browsing for some aviation stuff for a few days. Amazon clearly knows and tracks my window shopping. It’s how they suggest items when you come back to the site.

I believe they preemptively moved some of those obscure aviation items to the closest distribution center in anticipation of my purchase. In fact, Amazon was awarded a patent for exactly that process last week.

By predicting my purchasing behavior, Amazon was able to beat my expectations for delivery – a known threat to their model is the instant gratification of local retail – and get my package to me in 12 hours.

We’ve got a lot of data in healthcare. That’s to the lagging but persistent implementation of electronic medical records, doctors and health systems are beginning to apply some big data science to their patient populations. For instance, any credible EMR can tell a physician how many of her patients have asthma.

More advanced systems, including bolt on solutions can look at disease panels and cross sample against last visit date. Mr. Smith, we see it’s been a year since your last visit, how’s your arthritis? Can we schedule you and appointment with Dr. Jones?

How Mayo Clinic Is Using iPads to Empower Patients

Feb 26, 2014• 8

By Cook, Thompson, Dearani & Prinsen

Throughout the world, companies are embracing mobile devices to set customer expectations, enlist them in satisfying their own needs, and get workers to adhere to best practices. An effort under way at the Mayo Clinic shows how such technology can be used to improve outcomes and lower costs in health care.

Defining the care a patient can expect to receive and what the road to recovery will look like is crucial. When care expectations are not well defined or communicated, the process of care may drift, leading to unwarranted variation, reduced predictability, longer hospital stays, higher costs, poorer outcomes, and patient and provider dissatisfaction.

With all this in mind, a group at the Mayo Clinic led by the four of us developed and implemented a standardized practice model over a three-year period (2010-2012) that significantly reduced variation and improved predictability of care in adult cardiac surgery.

One of the developments that germinated in that effort was the interactive Mayo myCare program, which uses an iPad to provide patients with detailed descriptions of their treatment plans and clinical milestones, educational materials, and a daily “To Do” list, and to report their progress and identify problems to their providers.

Reflecting on Health Reform–Narrow Networks: Boon or Bane?

Feb 25, 2014• 40

By David Blumenthal, MD

Some health plans sold through the Affordable Care Act’s (ACA) health insurance marketplaces use “narrow networks” of providers: that is, they limit the doctors and hospitals their customers can use.

Go to Doctor A or Hospital A and the plan will pay all or most of the bill. Go to Doctor B or Hospital B, and you may have to pay all or most of the bill yourself.

The narrow network strategy emerged long before the ACA, during the managed care era in the 1990s, and insurance companies and large, self-insured employers have used narrow networks ever since to control health care costs.

In fact, for the first time, the ACA creates new consumer protections requiring that insurers provide a minimum level of access to local providers. A number of states have exceeded these federal standards using their discretion under the new law.

Nevertheless, some consumer advocates and ACA critics still find narrow networks objectionable. Narrow networks mean that some newly insured people are no longer covered for visits to previous providers, or, if they didn’t have a doctor before, are limited in their new choices. Not infrequently, narrow networks exclude the most expensive doctors and hospitals in a community, including some specialists and academic health centers.

More expensive doctors and hospitals are not necessarily better, but for patients with a rare or complex health problem, such restrictions can be problematic.

Welcome to the world of competition in health care, because that is what narrow networks are about. Narrow networks are used by competing plans to control health care costs, and perhaps improve quality as well. In fact, if you don’t like narrow networks, you’re saying, in effect, that you don’t like competitive solutions—as least under current market conditions—to our health system’s problems.

That Vitamin There Could Kill You

Feb 25, 2014• 20

By James Salwitz, MD

Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.” There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand. That is no longer true.

Now we have published data on many vitamins and we can say that for most people they do not work. More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.

For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much. Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.

When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.

To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”

Bill’s response, he lack of trust in my advice, disturbs me at several levels. He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.

Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin. They do not prevent or fix anything. Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.

More importantly, there is increasing data that people taking a multivitamin may become less healthy.

HxRefactored: Win Complimentary Passes During HIMSS 2014!

Feb 24, 2014

In the spirit of HIMSS 2014 and improving the health experience, we want to give two attendees the chance to take what they have learned from HIMSS and take it to the next level. That’s why we are giving away TWO FREE passes to the HxRefactored conference!

All you have to do is:

Tune-in on Twitter during the following sessions:
- Session – Five Proven Methods for Multidisciplinary Teams to Create Clinical User Experiences , Tuesday, February 25th from 1:00 – 2:00PM. Presenter: Lorraine Chapman, Macadamian.
- Session – I nnovation in Healthcare – The future of Healthcare is Here Today, Wednesday, February 26th from 11:30AM – 12:30PM. Presenter: Timothy J Theriault, Walgreens.

Doctors Without State Borders: Practicing Across State Lines

Feb 24, 2014• 18

By Robert Kocher, MD

In the United States, a tangled web of federal and state regulations controls physician licensing. Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).

This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.

We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses. To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.

The Current System And Its Drawbacks

State licensure of physicians has been widespread in the United States since the late nineteenth century. Licensure laws were ostensibly enacted to protect the public from medical incompetence and to control the unrestrained entry into the practice of medicine that existed during the Civil War. However, it no longer makes sense to require a separate medical license for each state.

Today, medical standards are evidence-based, and guidelines for medical training are set nationally through the Accreditation Council for Graduate Medical Education, the Centers for Medicare and Medicaid Services’ Graduate Medical Education standards, and the Liaison Committee on Medical Education. All U.S. physicians must pass either the United States Medical Licensure Examinations or the Comprehensive Osteopathic Medical Licensing Examination.

Although the basic standards for initial physician licensure are uniform across states, states impose a patchwork of requirements for acquiring and maintaining licenses. These requirements are varied and burdensome and deter doctors from obtaining the licenses required to practice across state lines.