The Health Care Blog – Page 536 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Exchanges Won’t Be Ready in Time. And it Probably Won’t Matter.

Sep 5, 2013• 7

By Dan Diamond

As states race to implement health reform, California doesn’t want to settle for second.

“We don’t want to be a pace car state” when it comes to implementing health reform, state HHS Secretary Diana Dooley told Politico back in January 2011. “We want to be the lead car.”

It’s a metaphor that California leaders have returned to time and again. And to their credit, they’ve often succeeded.

While other states waffled, Golden State officials quickly embraced key Obamacare provisions like expanding Medicaid and creating insurance pools for individuals with pre-existing conditions.

At the same time, lawmakers crafted legislation intended to conform California’s health insurance plans to new standards under the Affordable Care Act.

And Covered California, the state’s health insurance exchange, also has drawn national attention for its speedy implementation. Among the 17 states that opted to run their own exchanges, California has “certainly [been] in the lead on getting their health plan information out … and getting the contracts signed,” Rachel Dolan, who monitors exchange activity for State Refor(u)m, a project of the National Academy of State Health Policy, said.

But the driving metaphor only extends so far.

“I don’t think it’s a race,” Dolan added, cautioning that each state might take unique approaches to exchange implementation — and objectively judging those individual strategies is impossible.

And a more essential issue might be getting lost, amid the growing number of questions over which state exchanges will be open for business on Oct. 1.

“Lots of people are asking about readiness,” said Caroline Pearson, who leads Avalere Health’s efforts to track health reform implementation. “But no one is asking about whether it matters.”

Where the States Stand on Readiness
The sprint to get the exchanges off the ground — which for some states didn’t really begin in earnest until after the Supreme Court’s June 2012 decision to uphold the ACA — has led to repeated delays and ongoing concerns.

What Keeps Me Up At Night – 2013 Edition

Sep 5, 2013• 11

By John Halamka, MD

Now that Labor Day has come and gone, I’ve thought about the months ahead and the major challenges I’ll face.

1. Mergers and Acquisitions

Healthcare in the US is not a system of care, it’s a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers. As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations. The workflow to support systemness may require different IT approaches than we’ve used in the past. We’ve been successful to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via “magic button” viewing and state HIE summary exchange. Interfacing is great for many purposes. Integration is better for others, such as enterprise appointment scheduling and care management. Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2. Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline? All indications in Washington are that deadlines will not be changed. Yet, I’m concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation. Will all aspects of the new HIPAA Omnibus rule be enforced including the “self pay” provision which restricts information flow to payers? Hospitals nationwide are not sure how to comply with the new requirements. Will Meaningful Use Stage 2 proceed on the current aggressive timeline? Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1. With Farzad Mostashari’s departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3. Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine. One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems. I have 25 developers and a part time analyst available for the task. I’ve read every script and there are numerous areas in certification which go beyond the functionality needed for attestation. Many EHR vendors have described their certification burden to me. I am hopeful that ONC re-examines the certification process and does two things – removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.

Why Nurse Practitioners Will Not Solve the Primary Care Crisis

Sep 4, 2013• 11

By Nicole Fisher

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

A Powerful Idea From the Nuclear Industry

Sep 4, 2013• 2

By Peter Pronovost, MD

Where health care has fallen short in significantly improving quality, our peers in other high-risk industries have thrived. Perhaps we can adapt and learn from their lessons.

For example, health care can learn much from the nuclear power industry, which has markedly improved its safety track record over the last two decades since peer-review programs were implemented. Created in the wake of two nuclear crises, these programs may provide a powerful model for health care organizations.

Following the famous Three Mile Island accident, a partial nuclear meltdown near Harrisburg, Pennsylvania in spring 1979, the Institute of Nuclear Power Operators (INPO) was formed by the CEOs of the nuclear companies. That organization established a peer-to-peer assessment program to share best practices, safety hazards, problems and actions that improved safety and operational performance. In the U.S., no nuclear accidents have occurred since then.

A more devastating nuclear incident in Chernobyl, Ukraine in 1986 spurred the creation of the World Association of Nuclear Operators (WANO), which serves a similar purpose but on an international scale. Since WANO’s inception, no severe nuclear accidents had occurred until the nuclear accident in Fukushima, Japan, caused by a devastating earthquake and tsunami in March 2011.

These programs have succeeded because their purpose and approach is very different from review processes by regulatory agencies. Instead of a punitive process that monitors compliance with minimum standards, peer-to-peer evaluations are thorough, confidential and—importantly—voluntary. They are viewed as mutually beneficial and help advance industry best practices, which are shared widely. The goal is to learn and improve rather than judge and shame. The reviews are done by experts, using validated tools and are ruthlessly transparent yet confidential.

Peer-to-peer review has not been widely used in health care. A couple notable exceptions are the Northern New England Cardiovascular Study, which used organizational peer-to-peer review to improve the care of cardiac surgery patients, and the National Health Service in the UK, which used it to improve the care of patients with lung disease. While provider-level reviews are more common in health care organizations, they fail to capture the scale needed to achieve system-wide improvements.

At the Armstrong Institute, we have been pilot testing peer-to-peer review and early results are encouraging. We have evaluated specific outcomes, like blood stream infections; specific areas, like the operating room; and whole quality and safety programs.

Morbus Propedeuticus

Sep 3, 2013• 1

By COUNTRY DOCTOR

It was spring. My medical school class, two years along in our five-and-a-half year endeavor, had earned the “medicinae kandidat” degree. We were now worthy of leaving the basic sciences and research center on the outskirts of town and starting our preparatory clinical, “propedeutic” semester at the University Hospital. In Sweden, at that time, we used a lot of Latin words and phrases. Crohn’s disease was Morbus Crohn, chart notes listed physical exam findings by Latin names for the bodily organs: Cor for the heart, Pulm(ones) for the lungs, Hepar for the liver, etc.

Uppsala Academic Hospital was an imposing campus, with several tall, white towers, housing the most modern wards, laboratories and operating theaters. We were relegated to a pink stucco building that housed the old tuberculosis clinic.

The physical exam course was taught by a couple of older pulmonologists. At first they struck many of us as relics from a bygone era, but as the course went on, our respect grew. These unassuming physicians could percuss a patient’s chest wall and describe in detail what the x-ray would look like, they made us feel the tip of the spleen by turning the patient on his right side, they measured jugular venous pulsations and pedal pulses.

Sometimes we had real patients with remarkably abnormal findings to examine, but we often were charged with examining each other for assessment of normal physical exam findings.

My partner for the Lymphatic System module was Sven Björk, a slow-talking kid from the very north of Sweden. He had jet black, completely straight hair and a broad face with eyes set wide apart. He was part Same, the native, reindeer-herding nomadic population from north of the Arctic Circle.

Pathologizing the Human Condition

Sep 1, 2013• 9

By Dan Peters

The American Psychiatric Association recently published a new version of the Diagnostic and Statistical Manual (DSM). The DSM-5 is what medical, mental health, and chemical dependency professionals use to diagnose developmental, mental health, substance abuse and dependence, learning, and personality “disorders.” Now in its 5^th edition, the DSM was first published in 1952. At that time, the DSM was 129 pages containing 106 diagnoses.

Now, 61 years later, the DSM-5 consists of approximately 950 pages and roughly 375 diagnoses. The DSM-5, while researched far more than previous editions, is based on the medical model or the model of disease. Simply put, the medical model finds the causes of disease and illness and then prescribes a treatment to cure the disease or illness. This means a person has a pathology or pathogen that needs to be treated and cured.

The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:

Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
If so, is there a “treatment” for every identified “condition?”
Does it mean there is a treatment that works?
Do you need a diagnosis to get help?

Over the years, many have been critical of this approach to mental “health” issues. Referring to mental “health” is actually a newer name as people have historically been thought to have mental “illness.” This makes more sense for people who are unfortunately compromised by severe conditions termed schizophrenia, bi-polar (manic-depressive), and severe depression and anxiety. But does this make sense for children, adolescents, and adults who are challenged with some other, and possibly less severe, aspect of their functioning and development? Do all human problems warrant a medical or mental health diagnosis? When did a weakness become a “disorder” that requires “intervention” and/or “treatment?”

To be fair, the DSM provided structure and guidelines for approaching the complicated business of determining who had a “problem” that required help. However, it seems things have gone too far. Critics of the DSM believe that this latest edition has taken the business of diagnosing to a new level, one where approximately 50% of the population can be diagnosed with something. Critics also believe that this pathology finding approach supports the continued trend of medication prescribing as the number one mode of treatment, and continued trend of increased health care costs and premiums with increased utilization of individuals who need a “diagnosis” to meet “medical necessity” to receive services. What does that mean? It means if you don’t have a diagnosis, you don’t get help. It means you have to have a problem (pathology) to get help (treatment and intervention).

Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:

Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
Gluttony will be diagnosed as Binge Eating Disorder
Grief will be diagnosed as Major Depression
First time substance users and college partiers will get a diagnosis of Substance Use Disorder
Everyday Worry will be diagnosed as Generalized Anxiety DisorderContinue reading…

When Opting Out Is Not an Option

Aug 31, 2013

By Katherine Chretien, MD

Henrietta Lacks did not give researchers permission to take her cancer cells and study them. After she died in 1951, her family was not asked permission as her immortalized cells were used in countless laboratories. This month, the National Institutes of Health finally took a step in righting that wrong, announcing that the Lacks family would help decide who can access Henrietta’s DNA.

Today, getting a patient’s permission, often in writing, is standard in experimental medical research. Well, not always. Currently, there are at least nine ongoing studies involving 62 U.S. cities and towns with a combined population of more than 45 million that do not involve getting permission. They take place during emergencies, such as when ambulances arrive at an accident where patients are too injured to give permission.

For example, imagine this scenario based on a recent study sponsored by the University of Washington. You are involved in a car accident. Paramedics find you bleeding severely. They give you fluids to keep your blood pressure up, but they intentionally give you a bag of fluid that is smaller than the standard. Then they monitor your medical outcome and compare it with patients who received the larger amount of fluids. During the emergency, neither you nor your family know about the study.

Vital research

Research on medical emergencies is vital in determining how to care for people with life-threatening injuries because we often do not have proof that standard methods are the best. People involved should be told that is how their records are being used.

In 1996, the Department of Health and Human Services and the Food and Drug Administration passed regulations allowing research about emergency treatment to occur without permission. For a study to qualify, patients need to have a life-threatening condition, current standards of care must be unproven or performing poorly, and obtaining permission must not be feasible (such as an unconscious patient or a patient whose condition does not allow time for informed consent).

Prostate Cancer: Not a Good Week

Aug 30, 2013• 11

By James Salwitz, MD

The general practice of oncology seems to come in waves of disease. One week every breast cancer patient is in trouble, another sees multiple new cases of lymphoma or leukemia, the next it as if someone is giving away lung cancer (or perhaps cigarettes) and then three patients with pancreatic cancer end up in the ICU. This week a portion of the 240,000 yearly USA cases of prostate cancer walked in our door. The rush of cases served as a reminder that when it comes to this illness, we have a long way to go.

First, Allen. He is 73 years old and has prostate cancer in one out of twelve biopsies. The cancer has a Gleason’s Score of 6 (a measure of aggressiveness of the cancer tissue: more then 7 is particularly bad), which means it is not fast growing. We recommended that given the small amount of slow growing cancer, Allen should be watched without treatment (“Active Surveillance”). What Allen found so difficult about this recommendation is that his son was diagnosed with prostate cancer just one month ago and his son, who is 49, has a Gleason’s 8 Prostate Cancer on both sides of the prostate, and is scheduled for robotic surgery. More than having cancer, Allen is hurt by the feeling it should have been him.

Then there was Robert and Mike. Robert was in the office at 10:00am for evaluation of his newly diagnosed prostate cancer, PSA blood test 32 (high), Gleason’s 7, with evidence of invasion through the capsule of the prostate gland. Fortunately, because prostate cancer likes to spread to bone, his bone scan is normal. Despite Robert’s relatively young age (66), the surgeon recommends external beam radiation therapy (RT) instead of operating. What is bizarre and makes my head spin, was that at1:00pm, in the same exam room, in the same chair, I saw Mike. He has recurrence of prostate cancer, previously treated with surgery. Now Mike needs RT. Although Robert and Mike do not know that the other has cancer, they have worked together in the same small company for 28 years, and consider each other friends.
Continue reading…

Data Points: Why Delay of the Employer Mandate May Not Actually Mean That Much

Aug 29, 2013• 9

By Carter Price & Evan Saltzman

Last month, the Obama Administration announced that it would delay enforcement of the employer mandate component of the Affordable Care Act (ACA) in part due to opposition from the business community. Opponents of the ACA cited the delay as evidence that the law was collapsing under its own weight, while ACA proponents downplayed the importance of the employer mandate in realizing the primary objective of the law – extending affordable coverage to millions of uninsured Americans.

Will delaying the employer mandate lead to the ACA’s demise?

Using economic modeling, we have found that the primary goals of the ACA will not be impacted by the delay, but the delay may impact one of the law’s key revenue sources designed to offset the costs of the coverage provisions.

Under the ACA, only firms with 50 or more full-time employees can be assessed penalties for not offering coverage under the employer mandate; small businesses with fewer than 50 employees are exempt. Furthermore, more than 95% of large firms already offer insurance, implying that only a small pool of firms would need to alter their current benefit offerings to comply with the employer mandate. Our model estimates that less than 1% of firms, employing about 2% of the workforce, would be penalized for not offering insurance to their workers if the employer mandate is enforced.

In fact, only about 300,000 workers (approximately 0.2% of the workforce) would lose their employer’s health insurance as a result of the employer mandate delay, according to our economic analysis. And many of those losing coverage would be able to get affordable coverage through a spouse, the newly created health insurance exchanges, or Medicaid. Hence, delaying the employer mandate will have only a nominal impact on the ability of workers and their dependents to obtain health coverage.

What I Need

Aug 29, 2013• 18

By Rob Lamberts, MD

So, the question has been raised: why am I doing this? Why re-invent the EMR wheel? What is so different about what I am doing that makes it necessary to go through such a painful venture? I ask myself this same question, actually.

Here’s my answer to that question:

What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

What I need:
No focus on billing codes, instead a focus on work-flow.

What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit. It results in massive over-documentation and obfuscation of pertinent information.

What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.

What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.

What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.