The Health Care Blog – Page 646 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

What to Do on the Day After ObamaCare

Apr 9, 2012• 25

By JOHN H. COCHRANE

Two weeks ago, the Supreme Court heard arguments on the constitutionality of the administration’s health law, aka ObamaCare. Opponents are giddy with the possibility that the law might be struck down.

But what then? Millions of uninsured, both those who choose not to purchase coverage and those who can’t due to pre-existing conditions, will still be with us. The rising costs and inefficient delivery of health care will still be with us.

The country can have a vibrant market for individual health insurance. Insurance proper is what pays for unplanned large expenses, not for regular, predictable expenses. Insurance policies should be “guaranteed renewable”: The policy should include a right to purchase insurance in the future, no matter if you get sick. And insurance should follow you from job to job, and if you move across state lines.

Why don’t we have such markets? Because the government has regulated them out of existence.

Most pathologies in the current system are creatures of previous laws and regulations. Solicitor General Donald Verrilli explained as much in his opening statement to the Supreme Court: “The individual market does not provide affordable health insurance,” he noted, “because the multibillion dollar subsidies that are available” for the “employer market are not available in the individual market.”

Start with the tax deduction employers can take for their contributions to group health-insurance policies—but which they cannot take for making contributions to employees for individual, portable insurance policies. This is why you have insurance only so long as you stay with one employer, and why you face pre-existing conditions exclusions if you change jobs.

Entrepreneurs Don’t Need Work-Life Balance

Apr 9, 2012• 4

By Jeffrey Stibel

I was always encouraged from an early age to be balanced in everything that I do. Generally speaking, I’d say that’s pretty reasonable advice — but it’s not always right. Sure, achieving a perfect work-life balance should be a top priority for most professionals, but the same advice just doesn’t apply to entrepreneurs — we’re a different lot.

As entrepreneurs, we have zero sense of balance. We’re all in, all the time. It doesn’t matter if it’s day or night, weekday or weekend — each of us focuses on our vision with a single-minded passion. I even know an entrepreneur nearing retirement age who plans on working 80 hours a week until he dies, at which point he says he’ll cut his hours in half. He’s not alone. Many of us skip meals, showers, and social gatherings, meaning we avoid anything that diverts our attention from turning our visions and passions into reality. We’d probably work in our sleep if we could. In fact, I bet some of my more creative colleagues actually do.

If you’ve ever seen Thomas Edison’s laboratory in Fort Myers, Florida, you may have noticed the little cot he kept next to his desk. Edison worked long hours, took small catnaps, and then went right back to work. I wouldn’t be surprised if Edison kept a basin under his desk, and used it for something other than garbage.

Edison, of course, isn’t alone in his persistence. We’ve all heard the stories about Bill Gates and Mark Zuckerberg during the early days of their respective companies. And it’s no coincidence that both Gates and Zuckerberg dropped out of Harvard to pursue their passions. Clearly, the more “balanced” decision for both of them would have been to stay in school and to pursue their projects after graduation. But that’s not the entrepreneur’s way.

The Drug Shortage Wars

Apr 9, 2012• 6

By Sanjay Bansu, MD

“I should have gotten cancer last month,” she told me.

That was the first thought from my patient after she’d heard the news: her ovarian cancer would remain untreated for weeks, due to a critical shortage of the chemotherapy agent doxorubicin. Like her, several thousand patients have been affected by critical shortages of chemotherapy agents like doxorubicin (Doxil) and methotrexate—common medicines that are essential backbones of cancer chemotherapy. But hundreds of other people have also been affected by critical shortages of pills around the country—limiting the supply of critical ICU medications like intravenous versed, or tuberculosis drugs like isoniazid.

Why are these shortages happening, and what can be done about them?

The state of the problem

Doxil and methotrexate are among 287 drugs in “critical shortage” in the United States, according to the University of Utah’s Drug Information Service, which has been tracking the problem. Shortages have been mounting in recent years, up from about 74 in 2005.

At present, the US Food and Drug Administration and independent researchers have tracked the status of major drug shortages occurring throughout the country. The FDA keeps an online catalog of these shortages. What this catalog reveals is that among 178 drugs that were in shortage during the year 2010, a vast majority (132) were sterile injectable drugs. These are generally cancer drugs, anesthetics used for patients undergoing surgery, as well as drugs needed for emergency medicine, and electrolytes needed for patients on IV feeding.

Much Ado About Broccoli

Apr 9, 2012• 17

By Michael Turpin

As the Supreme Court debates the boundaries of government’s role in mandating the purchase of insurance, the discussion continues on whether the public or private sector is best positioned to drive market reforms necessary to meet our goals of lower costs and higher quality. As the son of a Phi Beta Kappa neo con who believes government should be the size of a sand gnat and as the husband to a British citizen who loves national healthcare and was born through a midwife, I often find myself lost in a political no man’s land with volleys being exchanged from the right and left. To complicate Thanksgiving dinner further, thirty years of healthcare consulting, including a three-year stint in Europe, hospitalization for pneumonia in the NHS and a tour of duty as a senior executive for a national insurer has left me with my own conflicted convictions about how we might fix our broken system.

On the eve of the Supreme Court determining the fate of PPACA, strong opinions are in full bloom like cherry blossoms along the Mall. In his particularly sharp remarks to government attorneys, Justice Kennedy, considered a swing vote by many, cautioned that Congressional intervention to mandate citizens the “duty ( to buy coverage) to act “ was a slippery slope that sets dangerous precedent and impinges on individual rights. Justice Roberts added, “And here the government is saying that the Federal Government has a duty to tell the individual citizen that it must act … That changes the relationship of the Federal Government to the individual in the very fundamental way.”

Justice Scalia was quick to wade in after Justice Roberts questioning, ” what would be next in the role of the government dictating to its citizens ( if the mandate were to be upheld). “I will tell you the next something else (we will next tell Americans to do) is exercise, because we know that lack exercise contributes to illness.” It seems that this debate is indeed creating odd bedfellows as civil liberties advocates are joining conservatives in warning that the next thing the government will be telling people is that they cannot drink sugary soft drinks or that they have to eat broccoli. It is hard to find a time when a conservative Justice and the ACLU share a common opinion about anything.

TEDxMaastricht Paul Levy: Balls and Beds; Building Champions

Apr 8, 2012

[youtube width=”560″ height=”270″]http://www.youtube.com/watch?v=69sMwY7vNFo[/youtube]

On Being Gay In Medicine

Apr 7, 2012• 6

By Mark Schuster, MD

Dr. Mark Schuster is the William Berenberg Professor of Pediatrics at Harvard Medical School and Chief of General Pediatrics at Children’s Hospital Boston. This essay is based on a speech he gave the featured speaker at the Children’s Hospital Boston GLBT & Friends Celebration in June, 2010.

The first time I stood before a large audience to speak was when I was 13 years old. It was at my Bar Mitzvah. I walked up to the podium, looked out over the sea of faces, and thought to myself, I am a homosexual standing in front of all of these people. And I wondered what would happen if I told them.

That was in 1972, and even mentioning the word homosexual, unless paired with an expletive or derogatory adjective, would have been unacceptable at my synagogue. It would have been unacceptable in my home, my school, or any place I knew. I could not have conceived of telling my doctor. I assumed that I would never say out loud that I am a homosexual. The idea that I would someday be able to stand in an auditorium, stand anywhere, just a few miles from where I live with my husband, our two sons, and our dog, with everything but the white picket fence, was not something I could imagine.

Today I stand on a different stage. The Children’s Hospital Boston GLBT and Friends group asked me to share my story as part of its celebration day. How I got here, what I learned along the way, especially at Children’s, and how the world changed — these are what I will talk about.

A decade after I considered turning my Bar Mitzvah into a public confessional, I entered medical school at Harvard. Some students had started a gay group the year before. They had scoped out the territory, searched for role models, and come up nearly empty. In a creaky old closet, tucked way in the back, they found a world-renowned senior physician at Children’s. He advised against starting the group, offering that it was much better to be secretive about being gay so that no one would bother you. I’ve heard that same advice many times from men and women from earlier generations who had fewer options in their day.

Commission Tackles Physician Payment Reform

Apr 6, 2012

By Steven Schroeder, MD

How physicians are paid and what services they choose to recommend are key drivers of today’s escalating health care costs. The Society for General Internal Medicine (SGIM) has convened an independent commission to assess physician payment and physician-influenced expenses as well as issue recommendations on how to reform physician payment to restrain health care costs while at the same time optimizing patient outcomes. The 13-member National Commission on Physician Payment Reform will work together over the upcoming year, with a final report expected in early 2013.

Payment incentives and systems directly impact medical services that physicians provide as well as the overall approach to their patients. For example, the current fee-for-service system aligns payment with services provided rather than overall care outcomes. While the Commission will examine existing formulas that determine physician payment, such as the Resource-Based Relative Value Scale (RBRVS), we will also investigate promising payment methods that could lead to higher quality of care and better patient outcomes. More specifically, the Commission will evaluate optimal incentives and safeguards surrounding the three principal forms of physician payment: fee-for-service, capitation, and salary, as well as variations of these forms such as episode-based payments, global payments, pay-for-performance and partial capitation that attempt to incorporate quality into the equation.

The Commission appreciates that many have already put considerable effort into payment reform. We would like to complement, not duplicate, these efforts. We will review new approaches in the Affordable Care Act designed to constrain costs, including bundled payments and Accountable Care Organizations, as well as disincentive payment strategies that penalize providers for avoidable costs. We will also draw on the factual findings of The Medicare Payment Advisory Commission. A key difference is that the National Commission on Physician Payment Reform will look at the entire physician payment system, including both public and private payers.

The Letterman Approach to Cost Awareness

Apr 6, 2012• 3

By Christopher Moriates, MD

Who doesn’t love a Top 10 list? Creating them is an art form. So when it was formally proposed by Dr. Brody in 2010 in the NEJM that each specialty create their own “Top 5 list” of unnecessary care, it seemed like a straightforward – if not downright provocative – suggestion.

“The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit,” he wrote.

And yet, thus far the only groups that have seemed to have taken him up on the suggestion have been the primary care specialties of Internal Medicine, Family Medicine and Pediatrics – notably amongst the least compensated fields in health care.

This is a great start, but c’mon guys, where are the rest of you? Dr. Brody wrote you a “prescription.” We have a term for your behavior: “noncompliance.”

Not to say that there hasn’t been some progress. The ABIM Foundation has indeed put together an impressive list of organizations participating in their “Choosing Wisely” campaign. They also have begun to be instrumental in funding projects towards this goal. Costs of Care has highlighted far-reaching areas of non-value-based care, including a recent thoughtful essay about robotic surgery. We must now consolidate on these small gains and move this forward across all specialties in medicine.

HealthTech: Glen Tullman, AllScripts

Apr 6, 2012• 1

[viddler id=aaf2f43a&w=560&h=275]

Matthew Holt interviews Allscripts CEO Glen Tullman at HIMSS12. Tullman recaps what happened this year at his company and explains how Allscripts can help small companies innovate.

Will Doctors or Patients Bend the Cost Curve?

Apr 6, 2012• 44

By Davis Liu, MD

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don’t provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU). The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is – will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won’t likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor’s income. Some on the list of Choosing Wisely, however, will.