The Health Care Blog – Page 713 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Another Legal Round – With a Major Misstep?

Jun 16, 2011• 10

By ROGER COLLIER

The appellate court hearing in Atlanta a week ago on the Affordable Care Act’s constitutionality, one of a series along the inevitable road to the Supreme Court, showed that the opposing legal arguments are beginning to be firmly established—with each seeming to confuse the purchase of health insurance with the purchase of health care.

The Atlanta panel of three judges, with both Republican and Democratic appointees, heard arguments for and against the earlier ruling by Judge Roger Vinson in Pensacola that the individual mandate was unconstitutional and so central to the ACA that the entire act should be invalidated, and specifically that while the Commerce Clause of the Constitution gave the government authority to regulate interstate commerce, it did not allow Congress to penalize people for the “inactivity” of declining to buy a commercial product.

Former Bush administration Solicitor General Paul Clement, arguing in support of the Vinson decision, agreed that while it could be permissible for Congress to require insurance or other payment by those being treated in an emergency room, because they would already be in the “stream of commerce,” it was a very different matter to require them to pay prospectively for future care.

Agreeing with Michael Cannon on Medicaid, somewhat

Jun 16, 2011

Michael Cannon from Cato doesn’t like the idea that we’re going to cover children by putting them into Medicaid. To tell the truth I don’t like it either. He points to a NEJM study that shows–in the no shit, Sherlock department–that Medicaid recipients wait longer for care. My guess is that Michael’s solution is to a) do nothing or b) give Medicaid recipients a fund to pay for their own care–a fund that real life shows us will be cut as soon as budgets get tight (and as has happened nation-wide under S-CHIP). My solution is to put those kids in the same system as everyone else. But the real politics of the US is that–for now–Medicaid expansion is the best we’re getting. As soon as it’s done we should be working to abolish Medicaid by integrating it into a rational single system so that children (and adults) do not get discriminated against in medical care simply because they chose their parents poorly.

Caregivers: The Advocate and the Adminstrator

Jun 16, 2011• 1

By Matthew Holt

Just thought that I’d share this photo taken by @drjmob at the Partnership for Patients meeting today. (P4P is a safety initiative kicked off by HHS a few weeks back). Here’s patient data advocate (and BFF of Health 2.0) Regina Holiday getting to grips with CMS head Don Berwick. In fact they had remarkably similar experiences with spouses who endured terrible hospitalizations made worse by incomplete data and poor provider team communication. Here’s Regina’s story from her blog and here’s Don’s (starts on Page 20 of Escape Fire but read the whole thing if you haven’t before). It’s an unlikely couple–the pre-school teacher without a college degree and the Harvard policy wonk. But they share a human experience both are working hard to eradicate.

Obama-ney Care

Jun 15, 2011• 3

By SENATOR DAVID DURENBERGER

Tim Pawlenty used a recent appearance on Fox News Sunday to show a tougher demeanor and to prove he will not make health care cost containment and access a priority. As Governor of Massachusetts Mitt Romney worked with the Democratic legislature and the health care industry to expand access to all residents of the state and to commit to cost containing behavior change. The coverage reforms came right out of conservative health policy playbooks at Wharton (in the 1980s) and the Heritage Foundation (in the 1990s) and the cost containment was to be accomplished by voluntary action of Massachusetts health systems and health plans. On which they have since foundered, leaving Romney to take the heat.

When President Obama made his commitment to reform of national coverage, access, insurance, payment, and delivery system policy, national Republicans refused to cooperate. The legislative policy approach he advocated came mostly from a bipartisan Senate Finance Committee report from 2008. Elements of it came from the bipartisan approach Romney took in Massachusetts. Congressional Republicans unanimously refused to participate in the process. Today every elected Republican has committed to repealing Obamacare (and now Obama-ney care).

What changed? The definition of Republican. The election power of Sarah Palin, Michele Bachmann, Jim DeMint and the Rupert Murdoch/WSJ/Fox version of facts to bring out the “just vote No on government and on Obama” in a substantial enough minority of Americans turned the trick. While Pawlenty and Bachmann represent a state which has been committed to universal coverage and healthcare cost containment for decades, neither has done much to make it a reality in our state. Assuming “repeal and replace” implies state action is preferable to national, they’ve nothing to show for their efforts so far.

Senator David Durenberger, Minnesota, served in the US Senate from 1978 – 1995.

Five Things EHR Vendors Should Do Right Now

Jun 15, 2011• 1

By SHAHID N. SHAH

Last week I was invited to attend the second annual NIST forum for EHR Usability called “A Community-Building Workshop: Measuring, Evaluating and Improving the Usability of Electronic Health Records.” NIST, in collaboration with the ONC, unveiled its initial discussion points for what it might consider as the “Usability Criteria” in the upcoming Meaningful Use Stage 2 regulations. At the event I met with Dr. Melanie Rodney, Distinguished Researcher at Macadamian and a member of the HIMSS Usability task force; I was impressed by the work that she and her firm were doing in EHR usability space. At the NIST forum I was able to spend time with experts in the both the fields of EHRs (like me) as well as in usability and user experience (like Melanie). We learned that the government believes that while usability can be key in increasing product effectiveness, speed, enjoyment, etc., NIST is going to focus on EHR usability for the improvement of patient safety. I asked Melanie and Lorraine Chapman, Director of User Research at Macadmian, to share with us what we in the EHR technical community should do in light of what we learned at the NIST forum last week. Here’s what Melanie and Lorraine said:

While the specifics are still forthcoming, vendors have a window of opportunity today to get ahead of NIST – and ahead of competitors – by proactively addressing meaningful use in advance of the 2013 deadline. Let’s look at what vendors can do, combining the information NIST has given so far with fundamental usability best practices:

Step 1: Set Usability Goals related to Patient Safety

These are specific, measurable goals such as “Our EHR must provide a 99% error-free rate of medication entry”. NIST has given the following examples of use error categories, each of which might be driving 1 or more goals.

patient ID errors
mode errors [e.g., dose related]
data accuracy errors
visibility errors [e.g., tapered dose 80-20mg – 80 shows vs. 20]
consistency errors [ e.g., pounds vs. kilos ]
recall errors [e.g., 1 time dose]
feedback errors [1 tablet vs. 1/4 tablet]
data integrity errors [ next vs. finish to enter injection just administered]

The Future of American Healthcare, Ctd

Jun 15, 2011• 6

By EVAN FALCHUK

Almost half of health plans in the US have deductibles of at least $1,000 according to a new study. It’s called “cost shifting” and it’s a big part of the future of American health care.

There are two major reasons why employers are doing this.

First, higher deductible plans are cheaper, since there is less risk to insure. Think of your car insurance – why would you make a claim for a ding on your door when it’s cheaper for you to just pay to have it fixed (or fix it yourself)? The higher the deductible, the lower the premium, even if it means more out-of-pocket cost for you for the small stuff.

Along these same lines is the second reason. If employees spend more of their own money on health care, maybe they’ll be smarter about how they spend it.

It sounds good – but does it work?

Yes. And No.

Studies show that consumers in high-deductible health plans do spend less than those in traditional plans. But, they spent less in some worrisome ways:

Childhood vaccination rates dropped. . .Rates of mammography, cervical cancer screening, and colorectal cancer screening also fell among those with high-deductible health plans relative to those in traditional plans. . . . even though high-deductible plans waive the deductible for such preventative care.

As another study put it: “Deductibles can create powerful yet potentially indiscriminate and blunt incentives for consumers to alter their care-seeking behavior.”

Of course, this is a complicated way of saying higher deductibles work, and are smart choices for employees and their employers. But the research tells us they aren’t enough.

There’s No Choice but Change

Jun 14, 2011• 52

By GRACE-MARIE TURNER

The outrageous distortions about the Ryan Medicare reform plan are coming from people who are accelerating the program’s path to insolvency.

Medicare is being used as a piggy bank by Democrats, with $575 billion in payment cuts used to finance two massive new entitlement programs in Obamacare. And this April, the president proposed taking another $480 billion out of the program to lower the deficit.

Payments to providers will be cut so deeply that seniors will find it harder and harder to get care. Doctors will stop taking Medicare or go bankrupt. A whopping 87 percent of doctors say they will stop seeing or will restrict the number of Medicare patients they see, further shrinking the pool of providers and further restricting access to care.

The powerful, 15-member Independent Payment Advisory Board will use price controls to meet ever-elusive spending targets. Rationing is inevitable, especially of newer medicines and technologies.

House Energy and Commerce chairman Fred Upton explained, “Last year, Medicare expenditures reached $523 billion, but the income was only $486 billion — leaving a $37 billion deficit in just one year. And with 10,000 new individuals becoming eligible each day, it’s only going to get worse.”

Medicare is $38 trillion in the red, and it accelerated five years toward insolvency in just the last year, according to the Medicare Trustees’ latest report.

A Look Back – 30 Years Later – At The Impact Of AIDS On Residency Training

Jun 14, 2011• 2

By BOB WACHTER, MD

Last week marked the 30th anniversary of the first reports of a cluster of cases of pneumocystis pneumonia in gay men in Los Angeles. While I’ve recently heard a number of reflections on these early years, I’ll focus on a topic that I haven’t seen covered: how AIDS transformed training – including my own – and what the emergence of AIDS taught me about innovation and, yes, opportunism.

In early 1982, I was a 3rd year student at Penn on my first medicine ward rotation. One night, my team admitted a young gay man with a bizarre story: progressive wasting, spiking fevers, profound dyspnea, and diffuse infiltrates on his chest x-ray. The next morning, I presented the case to my attending, David Goldmann. Having just read reports of a similar illness galloping through urban gay communities, at the end of my presentation David said gravely, “This thing” – the disease didn’t yet have a name – “is changing the way we practice medicine.”

When I arrived at UCSF in 1983 to begin my internal medicine residency, it didn’t cross my mind that this decision would guarantee that my training would be dominated by this new scourge. In 1985, as a third year resident, I jotted down some of my reflections in an essay. It began:

Like many of today’s interns and residents training in San Francisco, New York, and Los Angeles, I have cared for many more patients with Pneumocystis carinii pneumonia than pneumococcal pneumonia, more patients with Kaposi’s sarcoma than breast cancer, and more patients with cryptocococcal meninigitis than meningococcal meningitis… This realization has prompted me to consider the impact of AIDS on medical residency training.

I sent this paper, entitled “The Impact of AIDS on Medical Residency Training,” off to the New England Journal of Medicine. Of course, this was a naïve and hubristic thing for a resident to do, but I really didn’t know any better. A few weeks later, while on the wards at the VA, I received a page for an outside call. “Hi, this is Dr. Marcia Angell,” said the voice on the other end. “I’m an editor at the New England Journal. We really liked your article but we’ll need a few changes before we publish it.”

The Stunning Shift Toward Employed Physicians

Jun 14, 2011• 85

By DAVID E. WILLIAMS

I’m amazed at just how quickly physician employment has swung from small independent practices to hospital-based employment. I’ve heard about it anecdotally from medical societies and malpractice carriers who are seeing their constituents shift, and have certainly observed the shift from individual physicians, but I’m still surprised how fast it’s occurring. A new report from recruiter Merritt Hawkins tells the clearest story I’ve seen:

In the last 12 months, 56% of physician search assignments have been for hospital jobs, whereas 5 years ago it was just 23%
Just 2% of assignments were for independent, solo practice docs compared with 17% 5 years ago

Doctors are becoming more like regular wage earners, albeit high paid ones. There are some strong drivers of this trend including the need to support health information technology, comply with regulations and deal with health plans. There’s also a desire on the part of a younger, increasingly female physician workforce to have a better balance between work and home life. If anything the forces pulling physicians into hospital employment will strengthen in the near term with the arrival of Accountable Care Organizations and other forms of deep integration.

Yet when a pendulum swings it tends to swing too far. Especially considering how quickly things have moved, I do expect that there will be some backlash to the rush into employment. It’s really not all that much fun having a boss, especially when that boss is a big, bureaucratic hospital with other things on its priority list besides MD satisfaction and career development. Patients may not like it so much either. I know I’d rather see a physician who’s not too tightly tied to a hospital.

So what will the reversal look like? I don’t think it’s going to be doctors rushing to put up their own shingles or buy practices of retiring docs like in the old days. Instead I expect to see a new breed of physician employers who recognize what’s needed to make docs happy, treat patients well, manage compliance, and still make money. One example is so-called direct primary care practices such as Qliance. Time will tell what other forms develop.

Getting to the Heart of the Industry Transformation

Jun 14, 2011• 1

By CHAD HARRIS

Documents are heart of the healthcare industry – providers rely on them to provide critical, up-to-date and real-time information on a patient’s health and care. It makes sense, then, that documents are the central figure in the radical transformation the industry is in the middle of. It’s critical that an organization have a system in place to manage documents with pinpoint precision and efficiency, yet document inefficiency continues to be an enormous cost driver and cause of errors.

Providers have a lot on their plates – develop a system that works best for their organizations, physicians and patients, and that also meets meaningful use guidelines and deadlines. It’s not a one size fits all. Overhauling the patient record system can be a long journey, and requires the careful selection of appropriate systems, proper implementation, and the understanding and cooperation of staff members. It can be daunting in that organizations understand just how important it is to get it right.

Botsford Hospital is an example of an organization that understands how much is on the line in implementing an electronic medical record (EMR) system. The 330-bed hospital located in Farmington Hills, Mich., is less than a year away from a fully operational EMR, and put a lot of thought and effort into the decision-making process, including these steps:

Evaluated existing processes to make them more efficient and effective before moving to an EMR.
Established an Office of Clinical Process Improvement along with a steering committee to guide the process and develop objectives for a new EMR system.
Engaged ACS, A Xerox Company, a long-time IT services partner, to assist in the selection of an EMR solution.
Involved employees in the decision-making process by asking for routine input from the nurses, physicians and IT staff.

Botsford chose the McKesson Paragon solution, an all-inclusive and fully-integrated hospital information system, and is currently entering the final phases of implementation, which includes integrated testing and end-user training. The hospital is on track to meet its financial and productivity goals with this endeavor.