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Above the Fold

Reports of the Death of Disease Management Are Greatly Exaggerated

Jan 19, 2012• 17

By AL LEWIS

There have been unsavory rumors flying around the internet that disease management as practiced today may not be all that effective. I’m not going to reveal who started these rumors but her name rhymes with Archelle Georgiou. This person says disease management is “dead.” Since there are still many disease management departments operating around the country apparently oblivious to their demise (and disease management departments are people too, you know), I suspect this commentator was using the word “dead” figuratively, as in: “The second he forgot the third cabinet department, Rick Perry was dead.” (Another example of presumably figurative speech in the death category would be: “After he denounced gays while wearing the Brokeback Mountain jacket, you could stick a fork in him.”)

And if the rhymes-with-Archelle commentator intends “dead” as a synonym for “not in very good shape,” she certainly has a point. Not only does she have a point, but I would add more items to her list of reasons for the field’s current troubles:

(1) The interval between diagnosis (the point where readiness to change is usually greatest) and successful patient contact can exceed three months;

(2) Predictive modeling “risk scores” that tell you only how sick someone was, dressed up as a “risk score,” not how sick they will be, even though they aren’t already high utilizers;

(3) Some interventions are so expensive that they exceed the cost of the disease;

Weighing in on Paula Deen

Jan 19, 2012• 4

By Marion Nestle

The huge fuss over Paula Deen’s type 2 diabetes is understandable. She is, after all, the queen of high-calorie Southern cooking. And diabetes rates are especially high in the South.

Perhaps less understandable is the reaction of the American Diabetes Association. As reported in the New York Times,

Heredity, according to the American Diabetes Association, always plays some part. “You can’t just eat your way to Type 2 diabetes,” said Geralyn Spollett, the group’s director of education.

Wrong. You most definitely can eat your way to type 2 diabetes.

Type 2 diabetes is closely linked to overweight and obesity. No, not everyone who is overweight develops type 2 diabetes. But most people who have type 2 diabetes are overweight.

Reduce the Budget Deficit Through Innovation

Jan 19, 2012• 3

By Jon Baron and Ron Haskins

The solution to the nation’s long-term deficit problem is generally portrayed as a choice among sharp budget cuts, major tax increases or a combination of the two. Given the magnitude of the problem, some level of sacrifice is probably unavoidable. But there is a third, overlooked approach to major budget savings — innovation — that the new congressional supercommittee should also include as a key component of its deficit-reduction strategy.

Innovation in this case is the process of trying a range of promising approaches and using rigorous evaluation methods to determine which of them really work. In many areas of the economy — such as information technology, agriculture and manufacturing — innovation has often identified ways to both reduce cost and improve performance. This has led to amazing progress over time, including exponential gains in computing power over the past half-century at a steadily decreasing price. So a logical question is: Can innovation in policy produce more effective government at lower cost?

The answer is yes. There are proven examples, from U.S. welfare policy and other areas, where innovative reforms produced major budget savings while simultaneously improving people’s lives. This suggests that part of the answer to our deficit problem lies in American ingenuity and not just sacrifice.

Another nail in the DM coffin?

Jan 18, 2012• 3

Just when you thought it was safe to go back to the water, the CBO is out with the bad news that in its analysis of over 30 disease management programs, and none of the independently run ones saved Medicare any money. Even the ones that succeeded, which put the medical groups at risk and generally lodged the DM nurses with them (rather than have them call in on the phone), didn’t save enough to justify the costs of the program.

Now the first group isn’t a surprise to those of us who followed the fate of Medicare Health Support. The second group includes a series of demonstrations paying physician groups to save money. They did better, but not well enough to save once the extra costs of the program are included. (Details here). We can only hope that using more lightweight technologies with better understanding of patient behavior does in fact end up saving money–as has been shown in some commercial medical home settings. But we must also be prepared to admit that we don’t yet know how to save money in the care of the chronically ill under Medicare. Which means that the only obvious way to do it is to cut payments to providers!

Doctors Going Broke

Jan 18, 2012• 6

By Tom Emerick

According to an article in CNN, some doctors in the U.S. are going broke. Read it here . I feel sorry for anyone who goes broke, but this is not unexpected.

According to the author, some doctors have unsustainable debt and are facing reimbursement reductions by insurers. A good question is why the unsustainable debt? After all, many of our institutions have become bloated and can’t adapt to the economic downturn.

The article mentions a cardiologist who is going broke. According to a StudentDoc survey, the average cardiologist makes $403,000 per year. The average cardiovascular surgeon makes $558,719 per year. That’s not bad in either case.

My point is a lot of very highly paid people in every walk of life end up in bankruptcy. No matter how much you make, you can always spend more. I believe the health care industry has been as guilty of over-optimism as the real estate and finance sectors.

People have been saying for years that many clinics and hospitals will face a solvency crisis brought on by excessive borrowing to fund sleek new facilities and excessive purchases of uber-costly medical equipment. Some doctors became wealthy during the good years, and some of them made purchases not easily retracted now that the economy has turned down.

Med School: It’s Not What You Think It Is

Jan 18, 2012• 10

By DINOSAUR, MD

I am so tired of seeing statements like these:

– Nutrition is not taught in medical school.
– Pain management is not taught in medical school.
– Practice management is not taught in medical school.

All three of those statements, and the vast majority of others bemoaning the shortcomings of medical education just because “XYZ isn’t taught in medical school” are right, but oh so wrong.

“Nutrition” is not taught in medical school. What we learn is biochemistry, metabolism, gastrointestinal and endocrine anatomy and physiology. We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”. This also means we understand nutrition differently — and more completely — than anyone without that same level of medical education can, however much they’ve read about nutrition.

“Pain management” is not taught in medical school. What we learn is neuroanatomy, pharmacology, behavioral psychology, and neurophysiology, so that we have the basic knowledge to understand pain management. Narcotics dosing, epidural steroid injection techniques, rehab protocols and so on are learned in residency. I agree that pain is often not well managed, but not because “it’s not taught in medical school.”Continue reading…

Only Handle It Once (OHIO)

Jan 18, 2012• 1

By John Halamka, MD

In my recent post Work Induced Attention Deficit Disorder, several commenters asked how I stay focused and productive, speculating that I leverage my limited need for sleep.

Although having a 20 hour day helps, the real secret is that I end each day with an empty inbox. I have no paper in my office. I do not keep files other than those that are required for compliance purposes.

The end result is that for every document I’m asked to read, every report I’m ask to write, and every situation I’m asked to management, I only handle the materials once.

What does this mean?

In a typical week, I’m asked to review 4 or 5 articles for journals. Rather than leaving them to be read at some later time or reading them then deferring the review, I read and review them the day they are assigned. This enables me to read them once and write the review very efficiently since all the facts are fresh in my mind.

Restoring Office Workflows to the EMR: Or How I Restored Patient Face Time and Got Back the Joy in Medicine

Jan 17, 2012• 28

By MARGARET POLANECZKY, MD

A report from The Blog That Ate Manhattan:

The Problem : Lost Face Time = Lost Joy

One day, about 5 years into using the electronic medical record in my practice, I came to the realization that I wasn’t having fun anymore. I was sitting throughout most of every office encounter facing a computer screen, my back to the patient on the exam table across the room. The joy of face to face interaction with people, the real reason I went into medicine in the first place, had been replaced with the more pressing urgency of data entry.

My revisit routine went something like this – I’d enter the room, briefly greet the patient (undressed and sitting on the exam table) and then, apologetically saying “Let me just open your chart”, I’d log on and begin interacting with the more immediately demanding presence in the room – the EMR. I’d turn around as often as I could to look at my patient, but mostly I listened but kept my back to her and I typed. After which I’d rush over to her side, do the exam, then head back over to the computer to make sure I got all her orders, refills and charges in as required. A brief goodbye, and I was on to my next patient.

As more and more mandatory clicks were demanded from the EMR to prove I was a good doctor – smoking history reviewed (click), medication reconciliation (click, click, click,click), problem list review (erase duplicates from ENT , remove resolved problems, add today’s, then click that I had reviewed what I just did) – the actual moments of face time with my patients had became smaller and smaller, till they were almost an annoying distraction from the real task at hand – finishing my charts.

Health 2.0 News

Jan 17, 2012

Over on our sister site, the Health 2.0 News Blog, you’ll find this week’s news bites – Take Care Clinics launch online scheduling, BitGym releases a new fitness app, Ford to embed wireless health devices in its vehicles of the future and a new study evaluates the impact of online diabetes tools.

Should Your Doctor Be Thinking About Society’s Healthcare Costs?

Jan 17, 2012• 5

By David Shaywitz

You probably want your doctor to care about people, but how much do you want her to care about all of them? That’s the question I ask when I read articles – generally by bioethicists, often respectable ones – asserting that one of the moral responsibilities of physicians is to be responsible stewards of the healthcare dollar.

This rhetoric concerns me, because I worry it may ultimately degrade the already-challenged physician-patient relationship.

The cornerstone of medicine, the most fundamental principle, in my mind, is the absolute, rock-solid belief that your doctor is your unqualified advocate and will work as hard as possible to provide you with the best medical treatment possible, as if you were a member of her own family (Dr. Marty Samuels and I originally described this as “The Uncle Marvin Test”).

To be clear: this doesn’t mean the most expensive pills – by all means prescribe or substitute an equivalent generic, when available. This doesn’t mean the most expensive diagnostic studies – it’s generally in the patient’s medical interest to avoid unnecessary procedures that usually carry some intrinsic risk and also can lead to false positive results that can in turn lead to needless anxiety — and on occasion, permanent harm. This doesn’t mean extra days in the hospital – a hospital is one of the world’s most dangerous places, and it’s often in a patient’s best interest to be discharged as soon as possible (see here if you need more convincing).