The Health Care Blog – Page 545 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

What the EMR Saw

Jul 3, 2013• 2

By Country Doctor

Lately, my virtual inbox in our electronic medical record has seen a surge in requests for prescriptions for the vaccine against Herpes Zoster, shingles. This has made me think a lot about our responsibility as physicians to inform patients about the evidence behind our recommendations – but who informs the patients when doctors are kept out of the loop or put under pressure to prescribe without seeing the patient?

What has happened is that our local Rite-Aid Pharmacy started to give these shots, covered by many insurers, but still requiring a doctor’s prescription.

I cannot give the shots in my clinic, because as a Federally Qualified Health Center, we are reimbursed at a fixed rate. The shingles vaccine costs more for us to buy than we charge for an entire office visit. I used to have the discussion about the shot, and would give patients a prescription to take to the pharmacy if they wanted it.

The pharmacy can give the shot at a profit, because it is considered a medication, just like a bottle of Lipitor.

The new system creates a bit of a dilemma for me. I get a message through the pharmacy that the patient wants the shot, and I don’t have the opportunity to sit down and review the effectiveness, side effects and long-term efficacy according to the available evidence with the patient.

For example, the shingles vaccine only cuts the risk of getting shingles in half. This is about the same effectiveness as the flu vaccine, but far less than, say, the vaccine against smallpox, which has now been eradicated.

Most patients are very surprised to hear about the 50% efficacy when I catch up with them at some later date; so many health care interventions are portrayed as both completely effective and absolutely necessary.

I see my role as a primary care physician as a guide and resource for patients, who are bombarded with overly optimistic claims and recommendations by mass media, drug companies and retailers.

White House Delays Employer Mandate-But What About Small Employers?

Jul 3, 2013• 51

By Robert Laszewski

The administration suddenly announced last night that the requirement that all employers with 50 or more workers offer health insurance has been delayed until 2015.

If an employer with 50 or more workers did not provide health insurance to their full time workers in 2014, they would have been subject to a fine of $2,000 per worker. The employer would have also been subject to a $3,000 fine for each worker that went to the insurance exchanges if the employer package was not affordable.

Why did the administration delay the large employer mandate?

Because many employers have been in the early stages of planning to cut back the hours of workers in order to avoid having to offer insurance to those customarily considered part time, those who work at least the 30 hours per week the law established for defining a full time worker––and they haven’t been bashful in telling their employees why. In addition, there has been growing evidence that some employers were holding back on hiring in order to avoid more of the mandate costs at a time of high unemployment.

While the administration cited employer administration issues with mandate reporting as the reason for the delay, the bottom line is that the Affordable Care Act (“Obamacare”) was looking like it was about to be successfully labeled a job killer and the administration wanted to avoid that.

You also have to wonder if all of the reporting challenges were just with employers or was the administration also having trouble with the complex employer mandate information systems they will ultimately have to build?

The Pointless Search for Meaning in Exchange Prices

Jul 2, 2013• 11

By Alan Weil

With ten states and D.C. having reported preliminary information on the prices of plans in their new health insurance exchanges, partisans on both sides of the Affordable Care Act have pounced on the news to reinforce their preconceived notions.

Supporters of the law report that “rate shock is a crock” and that prices are “surprisingly low,” while opponents look at the same data and conclude that “Obamacare will increase individual health insurance premiums.” Gary Cohen of CCIIO’s recent announcement that rates on the federal exchange will be made public in September will surely raise the fevered pitch of commentary.

But what do these numbers actually represent? Carriers submitting bids start with the prices of their current products and then adjust them for the myriad changes in the insurance market that go into effect on January 1, 2014.

Those changes include: elimination of health status underwriting, compression of rates by age, partial standardization (and in most instances significant expansion) of the benefit package, expansion of the market to a largely unknown population due to premium subsidies, effects of the “three Rs” (risk adjustment, reinsurance, and risk corridors), a completely new product distribution system, and a host of other changes in the health care and health insurance environment.

Needless to say, these many changes introduce a tremendous amount of uncertainty.

Are Young Doctors Failing Their Boards? Or Are We Failing Them?

Jul 2, 2013• 26

By David Shaywitz, MD

A short piece in The Health Care Blog reveals (albeit unintentionally) why so many outside of healthcare think the medical establishment still doesn’t get it.

The post, written by a general internist and residency program director, asked why an increasing number of internal medicine doctors are failing their internal medicine board exams. The pass rate has reportedly declined over the last several years from 90% to 84%. (Disclosure: I passed this required test about a decade ago.)

His differential included two possibilities:

(1) The test is getting harder – The testing agency said this wasn’t the case.

(2) Millennials lack the study habits of their elders, and have become great “looker-upers.” – The author suggested this was a key factor, and several commentators enthusiastically agreed.

The basic thesis here that in the Days of Giants, doctors worked harder, learned more, and were better. Nowadays, doctors are relatively complacent, less invested, less informed, and are generally worse – which is what’s reflected on the board exams.

Let me suggest a third possibility – perhaps today’s doctors are providing better care to patients than their predecessors were a generation ago. Maybe today’s doctors have figured out that in our information age, your ability to regurgitate information is less important than your ability to access data and intelligently process it. Maybe what makes you a truly effective doctor isn’t your ability to assert dominance by the sheer number of facts you’ve amassed, but rather how well you are able to lead a care team, and ensure each patient receives the best care possible.

In other words, what if the problem isn’t the doctors, who are appropriately adapting, but rather the tests (and the medical establishment), which may not be?

Can a Portable Hand Sanitizer System Reduce Hospital-Acquired Infections in America’s Hospitals?

Jul 1, 2013• 6

By Mike Miesen

Ignaz Semmelweiss was laughed out of his Viennese hospital when he suggested that physicians should wash their hands in between conducting an autopsy and delivering a baby.

150 years later, we know just how right he was, but hand sanitation compliance rates at hospitals still hover in the 30% to 50% range. This makes it easy for hospital-acquired infections (HAIs) such as MRSA and VRE to run rampant, a (literally) dirty, not-so-little, and not-so-secret reality for American patients.

A Healthbox-backed startup is trying to change that. SwipeSense, founded in 2012 by Northwestern University graduates Mert Iseri and Yuri Malina, is a system designed to improve sanitation practices in hospitals using portable hand sanitizers and wirelessly-collected data on their use.

The organization wants to help stem the tide of avoidable HAIs. Each year, about 100,000 Americans die from infections they contract during their time in the hospital – more than the number of Americans killed by guns, motor vehicles, and leukemiacombined. In addition to the direct human toll, HAIs cause patient length of stays to increase by 8.0 days in ICUs and 7.4 to 9.4days in acute care wards, taking up expensive capacity and preventing others from accessing needed hospital beds. They’re also expensive, causing an estimated $4.5 to $5.7 billion in excess costs.

Iseri and Malina were inspired to create SwipeSense by a project they did for Design for America, a student group created to catalyze social change using human-centered design (also founded by Iseri and Malina). It took them to Northwestern Memorial University Hospital in their college town of Evanston, Illinois, where they identified two salient issues with hand sanitation: convenience and compliance.

“It’s obvious it’s not the fault of the nurse or physician…it’s something wrong with the system,” Malina told me in an interview. Even though alcohol foam and soap dispensers are ubiquitous in American hospitals, they often aren’t at the immediate point of care: “medical staff need to sanitize four or five times per patient encounter,” Malina said, making proper sanitation an arduous, time-consuming, and unrealistic task. “Our philosophy at SwipeSense is that the right thing to do should be the easiest thing to do… We want to make something that people love.”

Not Walking Away From Medicare

Jul 1, 2013• 12

By Leslie Kernisan, MD

This past week, the NYT New Old Age Blog featured a post about me and my practice. Titled “Walking Away from Medicare,” it describes my decision to opt-out of Medicare and create a different kind of geriatric practice.

It has generated quite a lot of comments: 163 at my latest count. Most of them judge me pretty harshly. It seems that many people feel that I’m doing this for the money. And that I don’t care about society or older people.

Of course, if you know me or if you’ve been reading this blog, then you’ll know that nothing could be further from the truth. My practice is fairly small, in part because my goal in having this practice was to have a way to keep working with patients and families, while having the flexibility to pursue my other professional interests. Since I started the practice, I’ve spent most of my time writing for this blog, learning about the worlds of digital health and healthcare innovation, and thinking about how we can teach geriatrics directly to caregivers.

Why Are So Many Younger Doctors Failing Their Boards?

Jul 1, 2013• 23

By John Schumann, MD

An interesting conversation recently took place among residency program directors in my field of Internal Medicine.

At issue was the declining pass rate of first-time test takers of the ABIM Certification Exam.

It’s a mouthful to say, but the ABIM exam is the ultimate accolade for internists; one is only eligible to take the exam after having successfully completed a three-year residency training period (the part that includes “internship,” right after medical school).

An easy analogy is to say that the board exam is for a doctor what the bar exam is for a lawyer. The difference is that a doctor can still practice if s/he does not pass–they might be excluded from certain jobs or hospital staffs; but certification, while important, is a bit of gilding the lily. [Licensure to practice comes from a different set of exams.]

There’s no doubt it’s a hard test. I was tremendously relieved to have passed it on my first try. Over the last few years, the pass rate for first time takers has fallen from ~90% to a low of 84%.

It may not seem significant, but for 7300 annual test takers, the difference in pass rates affects about 365 people–or one additional non-passing doctor for every day of the year.

In any event, we program directors have taken note. And the falling pass rate has raised questions:

Has the test increased in difficulty? No, says the ABIM.
Are the study habits of millennials not up to the level of Baby Boomers and Gen X’ers? Now you may be on to something.

Fast Food Economics: How Medium Became the New Large

Jul 1, 2013• 9

By Lisa Young

As a nutrition researcher tracking portion sizes and labels manufacturers use to describe such sizes, I have seen food portions not only grow larger over the years, but the labels to describe foods and drinks have also changed.

For example, when McDonald’s opened in the 1950s, the company offered one size soda, which was 7 ounces; today’s 12 ounces is labeled a kid’s size and the 16-ounce is labeled small. Similarly, when Burger King opened, the company offered a 12-ounce small and a 16-ounce large soda. The 12-ounce is no longer sold and the 16-ounce comes as part of the value meal. Burger King’s small soda is now 20 ounces, the medium is 30 ounces, and the large is 40 ounces.

Does anyone pay attention to these label descriptors? And do they influence how much we really eat? Apparently yes, according to a new study published in Health Economics by Cornell University researchers David Just and Brian Wansink.

The study found that labeling a food as “regular” or “double size” affects how much consumers will eat, regardless of how big or small the portion size actually is.

The researchers served subjects two different portions of pasta in either a one cup-portion or a two-cup portion. For some of the subjects, the two different size portions were labeled “half-size” and “regular.” For the other subjects, the identically-sized portions were labeled “regular” and “double-size.” The labels for the first group of subjects indicated that the two-cup pasta portion was the regular size, while it was suggested to the second group of subjects that the one-cup pasta portion was the regular size.

The study concluded that varying the “regular” portions affected how much the subjects actually ate. Subjects ate more food when the portion was labeled “regular” than when it was labeled “double-size” despite the fact that the two sizes were actually the same size.

The subjects were also willing to pay more for a larger sounding portion size.

A Time of Change at the American Board of Internal Medicine

Jul 1, 2013• 2

By Bob Wachter, MD

Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”

He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed.Continue reading…

Would We Be Better Off If Employers Stopped Paying for Health Insurance?

Jun 30, 2013• 16

By Uwe Reinhardt

In his “Are Employers to Blame for Our High Medical Prices?,” David Dranove takes issue with my statement in a New York Times blog post:

“One reason for the employers’ passivity in paying health care bills may be that they know, or should know, that the fringe benefits they purchase for their employees ultimately come out of the employees’ total pay package. In a sense, employers behave like pickpockets who take from their employees’ wallets and with the money lifted purchase goodies for their employees.”

He writes:

“The correct economic argument is a bit more nuanced. Employees do not care about the cost of their benefits; they care about the benefits. If an employer can procure the same benefits at a lower cost, the employer need not increase wages one iota. In this regard, there is nothing special about health benefits. Suppose an employer offers employees the use of company cars. Workers don’t care what the employer paid for the cars, and if the employer can purchase cars at a deep discount, it will pocket the savings.”

So far I can buy the nuance. It is something we could theorize about.

But then David he notes that:

“Employers may have an incentive to reduce benefits costs yet they are passive purchasers. With a few exceptions, nearly every American corporation outsources its healthcare benefits to insurers and ASO providers and then looks the other was as the medical bills pile up. Sure, they complain about the high cost of medical care, but they don’t take direct action by aggressively shopping for lower provider prices. Doesn’t this passivity demonstrate a lack of interest? No more so than the fact that auto makers do not aggressively shop the lowest rubber or silica prices implies that they are disinterested in the costs of tires and windows. Auto makers outsource the production of tires and windows (and most other inputs) and let the Michelins and PPGs of the world worry about rubber and silica prices. By the same token, American companies outsource the production of insurance and let the Blues and Uniteds of the world worry about provider prices. This is entirely appropriate.”

Forgive me if by now I am lost. Do we really believe that modern corporations, whose management and board of directors agonize even over an extra penny of earnings per share (EPS) – believe me, I know whereof I speak – simply outsource the procurement of major inputs and then look the other way?

They do seem to do it in health care – which is the puzzle – but they surely do not in connection with other important inputs where smart buying can add pennies to EPS.