The Health Care Blog – Page 679 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Doc Fix

Nov 28, 2011• 15

By Merrill Goozner

Holiday cheer and bipartisan bonhomie are still possible on Capitol Hill.

For evidence, one need only look at the so-called “doc fix,” where Congress every year overrides a previous effort at health care cost control to ensure physicians get paid at least as much as they did the year before. Expect another present to arrive at physicians’ offices sometime between Thanksgiving and Christmas, now that the Super Committee has failed to permanently resolve the issue as part of Medicare’s contribution to long-term deficit control.

The heretical thought that the salaries of physicians who treat Medicare patients could be held in check dates from the mid-1990s. The optimistically entitled 1997 Balanced Budget Act created a “sustainable growth rate” (SGR) for physician reimbursement that said any increase in total pay for physicians could not exceed the growth rate of the rest of the economy.

That was wishful thinking, as it turned out. Health care costs and physician pay far exceeded economic growth, largely because of Medicare’s fee-for-service system. While the Center for Medicare and Medicaid Services could fix the reimbursement rate for the 7,000 price-controlled services offered by physicians, it could not put a brake on the quantity that physicians ordered.

“This system, which ties annual updates to cumulative expenditures, has failed to restrain volume growth and, in fact, may have exacerbated it,” the Medicare Payment Advisory Commission (MedPAC) noted in its non-binding recommendations to Congress in mid-October.

The Constitution Is Not a Turkey

Nov 26, 2011• 79

By DAVID DRANOVE

I think the world of Jon Gruber, the MIT economist who helped design both the Massachusetts Health Plan and the Health Insurance Exchange provisions of President Obama’s Affordable Care Act. So I was more than a bit dismayed to read this quote from Jon: “I’m frustrated that the future of the American health care system rests in the hands of one or two of these unelected people who might make the decision based on political grounds.” The “unelected people” that Jon is referring to are justices of the Supreme Court. Jon almost seems surprised that the Supreme Court has a say in the matter.

The Health Insurance Exchange is an idea that economists have floated for more than three decades and thanks to his hard work, that idea has become a reality in Massachusetts and perhaps the rest of the nation, provided that the Supreme Court doesn’t block this fine bit of economics. Unfortunately for supporters of the exchange (including myself) the health insurance purchase mandate – an essential element of any economically viable exchange – might be unconstitutional. God forbid that the U.S. Constitution might interfere with beautiful economic theories.

There is a solution. I am almost too modest to say it but I proposed this idea in my book Code Red long before Barack Obama put his hand on the bible to be sworn in as Regulator-in-Chief. The beauty of the solution is that it respects, nay, was inspired by Jon’s work in Massachusetts, and is constitutional to boot! The solution is in its own way conservative, because it does not mandate a single approach to health reform. Congress should have given each state a block grant conditional on expanding health insurance coverage. The states could have chosen how to proceed. The U.S. Constitution might prohibit a federal mandate to purchase insurance, but it says nothing about what the states may do.

Some states might have chosen to adopt their own versions of the Massachusetts Health Plan. A few states may have centralized insurance, creating their own versions of single payer systems. Others may have given individuals vouchers and encouraged the growth of private insurance exchanges. This would be the closest to a free market solution, keeping the government out of it, except as a vehicle for transferring wealth. Perhaps all of these ideas would have been better than the status quo. Perhaps states could have learned from each other. Even Jon Gruber might have learned something new! Through this experimentation, we could have rapidly expanded health insurance coverage and also put lots of theories to the test. I still think this is a terrific idea. But in 2009 when politicians and economists huddled together to write the Affordable Care Act, no one invited me to the party. Alas. Continue reading…

Drawing a Hard Line on Resident Work Hours

Nov 26, 2011• 6

By Sammy Almashat, MD, MPH and Sidney Wolfe, MD

Last year, Public Citizen and other groups filed a petition – the second in 10 years – calling on the Occupational Safety and Health Administration (OSHA) to take over responsibility for enforcing medical resident work hours from the Accreditation Council for Graduate Medical Education (ACGME). This past September, the Obama administration denied our groups’ petition on the grounds that the ACGME is the appropriate entity to handle the issue, an identical argument to one put forward by the Bush administration nine years earlier to justify the denial of our first petition.

Both petitions were filed as a result of the long-standing failure of the ACGME to adequately protect residents from the proven deleterious effects of long work hours. Six years after the ACGME implemented the first limits on resident work hours in 2003, the Institute of Medicine (IOM) concluded an exhaustive 12-month review examining the existing system of medical training and the evidence regarding fatigue, resident physicians, and patient safety. The IOM concluded that the 2003 ACGME rules were not adequately protective and that major changes were needed, including a limit of 16 hours in a row for all resident work shifts.

In response, the ACGME updated its guidelines in 2010, but unfortunately, the new rules failed to incorporate the majority of the IOM’s recommendations. The rules limited medical interns ― first-year residents ― to 16-hour shifts but inexplicably allowed all other residents to continue to work up to 28 hours straight. There is no biological rationale to support the notion that residents suddenly become able to withstand the adverse effects of extended shifts upon completing their first year of residency. In addition, the new rules, in permitting averaging over several weeks to achieve the 80-hour weekly limit, continued the practice of allowing residents to work 100 or more hours in certain weeks.

Are Doctors Becoming Obsolete?

Nov 26, 2011• 9

By David Shaywitz, MD, PhD

The idea that physicians are going to be far less important in the medicine of the future seems to be a central assumption of many next-generation health companies, an assertion that, like undergraduate Shakespeare productions set in the present day, may once have felt daring and original, but now seems merely tedious.

The logic goes something like is: Patients are accustomed to seeking insight from their doctors but doctors are far less good at providing this advice than most patients realize. As more consumer-based tools for managing health become available, patients will recognize that they now have the means and the motivation to take care of their health better than their physicians, and medical care will move directly into their hands.

Arguably, a form of this already happens today, as patients make extensive use of non-prescription products (e.g. the Vitamin Shoppe reported net sales of $750 million in fiscal year 2010), non-traditional practitioners (e.g. total revenue received by chiropractors is estimated by Hoovers to be about $10 billion), and seek medical advice from friends on Facebook (which may have directly saved at least one life).

What these data don’t convey, however, is something I’ve had the privilege to experience first-hand: Doctors enjoy an exceptionally durable bond with patients — especially those patients with chronic illnesses. The level of trust reported by patients for their physicians is remarkable, and the role of physician as trusted adviser is difficult to overstate. It’s a huge burden to manage disease on one’s own, and it’s generally reassuring to know your physician is with you at every step — something I believe still happens, by the way, although obviously not in every case.

Starting Solids: An Exciting Reason to Be Thankful

Nov 26, 2011

By Alan Greene

I’ve been helping Alan Greene and his all volunteer team on the Whiteout campaign. And today Alan has exciting news about the progress so far! Talking about starting solids you can see how my daughter Coco did in this video that we made with Alan!-Matthew Holt

Last Thanksgiving I announced a bold campaign, spearheaded by an amazing band of volunteers, to upgrade babies’ first foods to real foods – and babies’ first grains to whole grains – and to do this in 2011.

It’s November, and we still have a ways to go, but we also have an exciting reason to celebrate!

Over 10,000 physicians, mostly pediatricians, took part in a July/August 2011 survey by Medscape.com that demonstrated an historic shift in their feeding recommendations this year. The first question in the survey was “What do you recommend for baby’s first food (check all that apply)?” The options were white rice cereal, whole grain cereal, a vegetable, a fruit, egg yolk, meat, or other. Of those who answered as of August 31, the number one choice was white rice cereal – garnering nearly twice as many votes as the next most common.

But after reading an article about WhiteOut Now, our public service campaign the survey results were strikingly different. Responding to,” What will you recommend for baby’s first food (check all that apply)” only 3% even included white rice cereal among their recommended choices. Physicians were also asked, “Do you think white rice cereal is the best choice for baby’s first food?” About 3% of those who responded had “No opinion” and an overwhelming 93% responded, “No.”

As of now over 12,000 physicians have taken part in the survey, and the change continues to spread. To me this major reversal suggests that the old white rice cereal recommendations were based on well-meaning habit rather than on science or even on careful consideration. When asked to reconsider, an overwhelming majority of physicians were quickly able to see advantages of abandoning the old recommendation.

Evidence is mounting that changing early feeding habits is critical to reversing the childhood obesity epidemic. This stunning survey suggests that first feedings are poised to change. A reason to be thankful indeed!

More BYOD Worries

Nov 25, 2011• 1

By John Halamka, MD

I’ve written about the increasing trend to Bring Your Own Devices (BYOD) to work and the accountability it brings to the CIO.

Every day I receive articles highlighting the increasing risk of mobile devices on the network:

The explosion of Android malware

The hacking of Siri

The vulnerabilities of the iPad

It’s very clear that in 2012 and beyond we will have to move beyond policy-based controls and we’ll have to implement technology based controls that may cost up to $10 per device per month. Given our 1000+ mobile devices, that could be a $150,000/year increased operating expense to protect consumer devices brought from home.

In many ways, 2012 at BIDMC will be the year of increased compliance and we’ve just named an interim Senior VP of Compliance to build an enterprise-wide compliance team.

CIOs – it’s time to tell your CFO to expect an unplanned 6 figure expense to protect your institutional data while at the same time embracing the mobile devices that will enhance productivity and user satisfaction.

Occupy with Grace

Nov 23, 2011

By Alexandra Drane

Every Thanksgiving, Engage With Grace has a blog rally asking everyone to take time to start that most difficult of conversations–what do you want to happen near the end of your life? And as ever THCB is honored to take part — Matthew Holt

Once again, this Thanksgiving we are grateful to all the people who keep this mission alive day after day: to ensure that each and every one of us understands, communicates, and has honored their end of life wishes.

Seems almost more fitting than usual this year, the year of making change happen. 2011 gave us the Arab Spring, people on the ground using social media to organize a real political revolution. And now, love it or hate it – it’s the Occupy Wall Street movement that’s got people talking.

Smart people (like our good friend Susannah Fox have made the point that unlike those political and economic movements, our mission isn’t an issue we need to raise our fists about – it’s an issue we have the luxury of being able to hold hands about.

It’s a mission that’s driven by all the personal stories we’ve heard of people who’ve seen their loved ones suffer unnecessarily at the end of their lives.

It’s driven by that ripping-off-the-band-aid feeling of relief you get when you’ve finally broached the subject of end of life wishes with your family, free from the burden of just not knowing what they’d want for themselves, and knowing you could advocate for these wishes if your loved one weren’t able to speak up for themselves.

Massachusetts and Hawaii Offer the Most Cost-Effective Health Insurance Coverage

Nov 23, 2011• 28

By Al Lewis

What makes a state’s health insurance successful for its citizens? It should be affordable, it should cover a lot of people, and it should manage its members well, keeping people healthy as measured both by preventive care as well as actual health outcomes.

It turns out that, using those criteria, the state with the highest Health Insurance Success Score (HISS) is Massachusetts. One would expect high quality, good outcomes and of course close to 100% coverage in the Bay State, but it also — quite surprisingly — ranks 5^th in affordability, as described below.

Hawaii is a very close second. (One could also argue that Hawaii’s circumstances are unique and non-comparable because that state differentially attracts and retains healthy residents, but the analysis eschewed all subjectivity and second-guessing of the data.) Texas is last, one point behind Arkansas. In both the best and worst listings, there is a noticeable gap between the two states at the extremes and their respective runner-up pelotons.

FTC Commissioner: Accountable Care Organizations Will Likely Lead to ‘Higher Costs and Lower Quality Health Care’

Nov 23, 2011• 6

By Avik Roy

In August, I wrote about how hospital monopolies are the biggest driver of health costs that nobody talks about. These powerful hospital chains know that insurers have no choice but to accept their jacked-up rates, and the cost of health insurance goes up whenever it suits their needs. Now, according to remarks by Federal Trade Commissioner J. Thomas Rosch, it turns out that accountable care organizations—one of Obamacare’s most touted policy gizmos—could make this problem far worse. “The net result” of ACOs, says Rosch, “may therefore be higher costs and lower quality health care—precisely the opposite of its goal.”

Rosch spoke last Thursday before the American Bar Association’s Antitrust Fall Forum, where he lambasted the “unintended consequences” of Obamacare’s headlong rush into the buzzword-filled land of accountable care organizations. ACOs, you will recall, are meant to improve the degree to which various physicians treating the same patient cooperate with one another. In theory, this would lead to better, more integrated care and reduced waste. In reality, ACOs will also stimulate mergers between hospitals and physician groups, worsening the problem of provider consolidation.

ACO’s purported savings shift costs to private insurers

The Congressional Budget Office, much to the dismay of Obamacare’s advocates, didn’t put much stock in ACOs, projecting that the law’s new Medicare ACO initiative would save $5.3 billion over ten years: eight-hundredths of one percent of Medicare’s projected spending over that period. “In other words,” Rosch points out, “the savings to Medicare from the ACO program are no more than a rounding error. Yet even the CBO’s modest cost savings projections are likely overstated.”

My Minute with Andy Rooney

Nov 22, 2011• 5

By Michael L. Millenson

Pat Mastors, a patient safety advocate, has written a clever blog post called, “A Few More Minutes with Andy Rooney.” Channeling the curmudgeonly tones of a 60 Minutes commentary, it begins:

I died last week, just a month after I said goodbye to you all from this very desk. I had a long and happy life – well, as happy as a cranky old guy could ever be. 92. Not bad. And gotta say, seeing my Margie, and Walter, and all my old friends again is great.

But then I read what killed me: “serious complications following minor surgery.”

Now what the heck is that?

The blog goes on to have Rooney ask for someone to find out what actually killed him. This has offended some respondents who, blinded by their own biases, think a writer using a celebrity’s death to push for information that could be used to improve care is the same thing as accusing his physicians of negligence or hauling Rooney’s family into court to publicly disclose private details.

Don’t you hate people like that?

OK, that was a cheap Andy Rooney imitation. But as it happens, I did have a phone conversation with Rooney about patient safety. It came right after the Institute of Medicine released its landmark report, To Err is Human, in November, 1999. The appalling toll of medical errors wasn’t exactly a secret back then, but doctors and hospitals had gotten used to publicly tut-tutting about the “price we pay” for medical progress every time a new study came out and then going back to doing exactly what they’d been doing before.