The Health Care Blog – Page 736 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Shaken, Flooded, Stressed by Power Outages, Fukushima Daiichi Moves into Second Place

Mar 31, 2011• 17

By ROD ADAMS

Fukushima Daiichi, ca 1975

Two weeks ago, I wrote an article titled Nuclear plant issues in Japan are the least of their worries that attempted to provide a realistic prediction of the worst case consequences of the one-two punch from a very large earthquake and tsunami on a large nuclear power station on the coast of Japan. It has become increasingly apparent during the past week that my view from afar was not as clear as I would have hoped. I was overly optimistic about the final consequences of the events at Fukushima Daiichi.

On the catastrophic scale of commercial nuclear energy accidents, where Three Mile Island was in second place and Chernobyl was the clear leader, Fukushima Daiichi has moved into second. It is likely that it will end up to be far closer to Chernobyl than to Three Mile Island in overall economic, public health and geographic consequences.

Update: (Posted on March 27, 2011 at 0234) The above paragraph has been changed to specify commercial nuclear energy accidents to avoid complications with discussions about accidents that have occurred in the other aspect of nuclear technology. The commercial and military sides of nuclear are complicated enough to merit two mostly separate conversations. End Update.

There has been enough damage to the plants and enough radioactive material released to pose a danger to public health for someone who does not take any precautions, though actions to evacuate, shelter and monitor contamination have minimized the actual effects – so far. There have also been a fair number of plant workers and other emergency responders who have received substantial radiation doses in the range of 100-200 mSv (10-20 Rem). Those doses are about 20% of the dose required for early signs of radiation sickness (1 Sv or 100 REM) and at the threshold where there is a statistically significant increase in long term cancer risk.Continue reading…

Accountability? Heaven forbid!

Mar 31, 2011• 11

By PAUL LEVY

At a recent talk, Dartmouth’s Elliott Fisher facetiously remarked that we cannot yet be sure whether accountable care organizations (ACOs) will actually be accountable, caring, and organized. Well, if some providers have their way, they certainly won’t be accountable.

This story by Jordan Rau in the Washington Post relates comments being made as Medicare writes its rules governing the ACOs. Here are some quotes:

[S]ome prominent doctor and hospital groups are pushing for features that some experts say could undermine the overall goal – improving care while containing costs. They’re seeking limits on how the quality of their care will be judged, along with bonus rules that would make it easier for them to be paid extra for their work and to be paid quickly.

Here’s the one I like best:

The Federation of American Hospitals, representing for-profit facilities, goes further, urging that ACOs be allowed to choose their patients. “Providers are better positioned than CMS to determine which of their patients would be appropriate candidates,” the federation wrote.

So, we are happy to be held accountable, but only if we get to choose which patients are part of our network.

The Thing to Watch in the Medicare ACO Regulations

Mar 30, 2011• 6

By VINCE KURAITIS

Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico

What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?

Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule. His list of five key design issues includes:

How will patients be assigned to ACOs?
To what cost benchmark will ACOs be compared?
How will bonuses be calculated and paid?
For which quality metrics will ACOs be responsible?
What is the application process?

I’d like to add a sixth item — which actually would be #1 on my list.

As I’ve previously written, IMHO the central issue around ACOs is:

Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.Continue reading…

Does My Doctor Trust Me (and Does It Matter)?

Mar 30, 2011• 8

By JESSIE GRUMAN

Source: The Edelman Trust Barometer 2011

Members of the American public are frequently surveyed about their trust in various professionals. Doctors and nurses usually wind up near the top of the list, especially when compared to lawyers, hairdressers and politicians. Trust in professionals is important to us: they possess expertise we lack but need, to solve problems ranging from the serious (illness) to the relatively trivial (appearance).

How much professionals trust us seems irrelevant: our reciprocity is expressed in the form of payment for services rendered or promised, our recommendations to friends and families and repeat appearances.

So I was surprised to read an article in the Annals of Family Medicine describing a new scale to measure doctors’ trust in their patients. This scale, based on input from focus groups and validation surveys of physicians, was developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.”

Hmmm. I hadn’t really thought about trust being a two-way street in my relationship with the doctors and nurses who take care of me. But given the push for us patients to become actively engaged in our health care, it’s not surprising that questions would arise about how dependable we are as partners. And it is a sign of the times that as clinicians increasingly face incentives to deliver evidence-based medicine and are held accountable for our health outcomes, our trustworthiness as partners has become professionally, if not economically, important to them.

While this new scale is only a research tool, its creation nevertheless raises interesting questions about how traditional notions of trust in medicine are changing in the new clinician-patient relationships that the media urges us to forge. So let’s examine it as a reflection of the idea of physicians’ trust in their patients.

Here are nine of the 18 items of the trust scale. Clinicians are asked:Continue reading…

Remember: Technology is but a Tool

Mar 30, 2011• 8

By JOHN MOORE

Yesterday, Chilmark Research participated in the CRG conference, Driving Change Through Managed Care IT from Provider Payments to Quality, which was held in New York City. Despite having a title that no one will be able to remember, the overall theme of the event and presentations therein gave one a bird’s eye view into what payers are thinking as we march forward with healthcare reform and the digitization of the healthcare sector.

A common theme that repeated itself numerous times over the course of the day was the lack of business process maturity in the healthcare sector. Meg McCarthy, EVP of Innovation at Aetna was the first to make this statement citing this issue as arguably the number one challenge for this industry sector to overcome. (McCarthy provided some interesting details on the Medicity acquisition but we’ll save that for a later date.)

Later that day, Jessica Zabbo, Provider Technology Supervisor at RI-BCBS gave a very detailed presentation on her company’s experiences working with providers on the adoption and use of EHRs. Over the last several years RI-BCBS has done a couple of small pilots. In both cases a defining parameter of success was business process maturity. For example, the company did a Patient Centered Medical Home (PCMH) pilot that coupled pay for performance metrics (P4P) with EHR use. Basically P4P measurements were to be recorded and reported through the EHR. One of the key lessons learned was that P4P program success was highly dependent on the EHR being fully implemented and physicians comfortable with its use (process maturity). But in a Catch-22, to successfully incorporate P4P metrics into the EHR requires a very deep understanding of practice focus and workflow. Without that understanding, failure of the P4P program is almost certain.Continue reading…

Oregon Death with Dignity Act vindicated

Mar 30, 2011• 2

To no one rational’s surprise, a study confirms that those few Oregon patients (400 over 10 years) who chose legal physician assisted suicide in case of terminal illness had a better quality of death than those who didn’t. Sadly because those attacking it aren’t rational, this won’t end the debate–but if you’re terminally ill you have better choices in Oregon (and Washington & Switzerland).

ACOs: Unicorn breeding rules emerging

Mar 30, 2011

Mark Smith, the President of the California Health Care Foundation, jokes that ACOs are like unicorns–mythical beasts that no one has yet seen. Well today Politico reports that–just like the Kennel club certifying a new breed of dog–CMS is about to come out with 1,000 pages of regulations telling us what an ACO is and what it can and can’t do. Should be fun.

The Cost of Apples

Mar 30, 2011• 16

By SAMUEL YANG

Up until last May, my experience of medical costs was limited to the $100 per month premium I contributed towards my employer-sponsored insurance and the nominal co-pays associated with well-child checkups and generic prescriptions. There was never any hesitation in seeing a doctor or filling a prescription. That all changed when went I back to school.

I blindly signed up for the school-recommended family insurance and naïvely assumed myself, my wife, and my two young children would receive whatever health care we needed at a relatively small co-pay. The upfront premium of $10,000 was high, but I believed that this would cover whatever life threw at us. However, two experiences woke me up from my ignorance: my wife’s endoscopy and a visit to the pediatrician.

In July, my wife was sent by her doctor to get an endoscopy to determine the cause of her stomach pain. In the weeks following her procedure, we started receiving statements from our insurance company.

The statements declared that we were responsible for the full amount. We received the following explanation from our insurance company, “We don’t cover preexisting conditions.”

As we argued with the insurance company, the hospital bills started trickling in: $1200 from the outpatient center, $200 from our family physician, $400 for the anesthesiologist and $200 from the lab. We received six bills demanding $2600 for one procedure. As I examined the bills I was shocked by the redundancy—why is the cost for the anesthesiologist not included in the outpatient center bill? Why do I need to pay my family physician twice (the initial visit and the follow-up) for a procedure she ordered us to do? Besides feeling hung-out-to-dry by my insurance company, I felt taken advantage of by the medical system. It seemed as if everyone in that hospital wanted to include something for our visit. Continue reading…

Potassium Iodide Pills

Mar 30, 2011• 3

By DEREK LOWE

Well, the nuclear crisis in Japan seems to be causing a run on potassium iodide (KI), and not just in Japan. If news reports are to be believed, people in many other regions (such as the west coast of the US and Canada) are stocking up, and some of these people may have already started dosing themselves.

Don’t do that. Don’t do it, for several reasons. First, as the chemists and biologists in this site’s readership can tell you, it’s not like KI is some sort of broad-spectrum anti-radiation pill. It can protect people against the effects of radioactive iodine-131, which is a major fission product from uranium. It does that by basically swamping out the radioactive iodine a person might have been exposed to, keeping it from being taken up into the body. Iodine tends to localize in the thyroid gland, and that uptake and local concentration is the real problem. An unfolded newspaper will shield you just fine from the alpha particles that I-131 gives off, but not if it’s giving them off from inside your thyroid. Correction: I-131 is a beta/gamma emitter – my apologies! The point about not wanting it in your thyroid, of course, stands. . .

And this is why potassium iodide won’t do a thing to help with the other radioactive isotopes found in nuclear reactors. That includes both the uranium and/or plutonium fuel, as well as the fission products like strontium-90 and radioactive cesium. Strontium-90 is a real problem, since it tends to concentrate in the bones (and teeth), and it has a much longer half-life than I-131. Unfortunately, calcium is so ubiquitous in the body that it’s not feasible to do that uptake-blocking trick the way you can with iodide. The only effective way to deal with strontium-90 is to not get exposed to it.Continue reading…

A Normal Pregnancy Is a Retrospective Diagnosis

Mar 29, 2011• 63

By J.D. KLEINKE

The names in this article have been changed to protect the privacy of all individuals involved.

If every medical specialty has its homily for indoctrinating new members, “a normal pregnancy is a retrospective diagnosis” is the cynical soundbite for obstetrics. It is a patronizing and alarmist statement, meant to distance weary practitioners, terrify patients, silence objections from families, and establish the first defensive perimeter in the legal fortress that defines obstetrical practice in the US.

It is also the perfect, if inadvertent expression of how little obstetricians really know – and how limited the specialty is in its ability to test and expand that knowledge – thanks in part to the visceral fear inspired in patients by statements like “a normal pregnancy is a retrospective diagnosis.”

This homily serves as the opening taunt to one of the more quietly rebellious obstetrician/gynecologists (OB/GYNs) in my new book, Catching Babies. For reasons I’ll explain momentarily, the book began as an expose of the practice of high-risk obstetrics, but it quickly morphed into a novel, an ensemble drama about the brutalization of OB/GYNs during their residency training.