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Letter From London

Dec 13, 2010• 5

By BOB WACHTER, MD

I’ve just returned from a few days in London, scoping things out for a planned sabbatical next fall. In what may be a pale echo of the late Alistair Cooke’s always fascinating “Letters From America,” here are a few of my initial observations:

The dominant issue, of course, is the Cameron government’s new austerity program, with its planned deep cuts to government services and benefits. While the program (or programme, I guess I should say) has created some upheaval – witness the recent semi-violent demonstrations by university students, whose tuitions may treble – it has not torn apart the society, the way belt tightening of this magnitude undoubtedly would in America. My sense is that the relative acceptance (yes, I know Charles and Camilla had a frightfully awful limo ride to the West End the other night, but this was, er, theater rather than a defining moment) can be explained the Brits’ stronger trust in their government. It is this same trust that leads to near-universal support for the National Health Service, the UK’s tax-funded healthcare system. This wellspring of support gives the government a little leeway when it says, “We can’t afford to do all this anymore, folks, and we can’t just print money. We must cut programs and benefits.”

In the US, of course, there is no such trust today, nor harbingers of its return any time soon. In a recent issue of Time that outlined this past decade’s mega-trends, Nancy Gibbs observed that the cumulative effect of 9/11, Katrina, BP and the subprime crisis was to markedly shrink Americans’ already scanty faith that their government can do anything competently. So our response to the recent announcement that Chinese kids are shellacking us in educational achievement is hand wringing and statistical nitpicking, not the call for vigorous government action that characterized our nation in the Sputnik era.

Year End Pondering

Dec 10, 2010• 2

By JOHN STEUERT

It’s the end of the year – an opportune time to forecast how 2011 will unfold in health care. We are likely to see some surprises, such as the sharply rising importance of primary care physicians.

Here are some predictions about the new year:

More consolidation is on its way in healthcare under Obamacare, which heightens the pressure to improve the efficiency of healthcare delivery. As part of this, more and more healthcare provider groups, even the small ones, will feel compelled to go electronic once and for all.

Valuable new, cost-effective medical tools will begin to become widely embraced. One is telemedicine. Just imagine how much more effective doctors can be if they interact with patients remotely via cameras. The technology exists now, has been successfully used in a number of situations, and it is not expensive. Soon insurance reimbursement models will permit and remunerate physicians for telemedicine “visits,” and then this will take off.

The use of genetic testing to segment patient populations and better target therapies will be one of the fastest growing segments of healthcare as a new wave of accurate, clinically actionable tests hits the market.

As health reform increasingly kicks in, there will be heightened emphasis on the importance of primary care physicians – a sharp contrast to the elevated importance of specialists for so many years. They will become the linchpins of health care and make more pivotal care decisions as more than 30 million more people enter the healthcare system and require access to them.

More Can Also Be Less: We need a more complete public discussion about comparative effectiveness research

Dec 9, 2010• 9

By JESSIE GRUMAN, PhD

Media coverage of the government’s new investment in comparative effectiveness research leans heavily toward the effects of such research on new drugs and technologies: Will such evaluations lead to restricted access to the latest innovations? Will insurance no longer cover a drug that might give my aunt another year to live? Will such research hinder the development of a drug that could cure my nephew of type I diabetes?

The focus on how results from comparative effectiveness research might affect new approaches obscures for the public and for policymakers the vital role of such research in evaluating current approaches to diagnosis and treatment that may not only be ineffective but in fact harmful to us.

I am now slogging through chemotherapy for stomach cancer almost certainly caused by receiving high doses of radiation for Hodgkin lymphoma, which was the standard treatment until long-term side effects (heart problems, additional cancers) emerged in the late 1980s. So I am especially attuned to the need for registries and trials to track the short- and long-term effectiveness of treatments.

So choosing a surgeon in September to remove my tumor shone a bright light for me on the importance of research to evaluate current practices. Two of the three surgeons I consulted wanted to follow “standard treatment procedures” and leave a six-centimeter cancer-free margin around my tumor. This meant taking my whole stomach out, because of the anatomy of my stomach and its arterial supply.

The McVictim Syndrome Could Kill Us

Dec 9, 2010• 57

By DAVID GRATZER, MD

Call it the McVictim syndrome. Too many pundits, public health experts and politicians are working overtime to find scapegoats for America’s obesity epidemic.

In his latest book, former FDA Commissioner David A. Kessler argues that modern food is addictive. In it, he recounts how he was once helpless to stop himself from eating a cookie. In a paper in this month’s Journal of Health Economics, University of Illinois researchers join a long list of analysts who blame urban sprawl for obesity. In November, former Carter administration advisor Amitai Etzioni argued that it’s so hard for Americans to keep weight off that adults should simply give up and focus attention on the young instead.

The peak of the trend: A recently released Ohio study, using mice, suggests “fine-particulate air pollution” could be causing a rise in obesity rates.

How long before we’re told that the devil made us eat it?

The McVictim syndrome spins a convenient — and unhealthy — narrative on America’s emerging preventable disease crisis. McVictimization teaches Americans to think that obesity is someone else’s fault — and therefore, someone else’s problem to solve.

Bending the Curve, Beginning with Birth

Dec 9, 2010• 4

By AMY M. ROMANO

As I prepare for next week’s webinar on payment reform to align incentives with quality, I have been thinking a lot about how we pay for maternity care in this country, and the opportunities to rein in costs while improving the quality of care. I have concluded that we face both an unprecedented opportunity and an unprecedented responsibility to get serious about maternity care payment reform.

Pregnancy, childbirth, and newborn care are collectively the most common and expensive hospital conditions billed to both Medicaid and private insurers. The national hospital bill for maternity care totaled $98 billion in 2008 – and no other condition came close to this figure. (See more facts about costs on Childbirth Connection’s updated Facts and Figures page), With states across the country facing budget crises, strategies that responsibly reduce the Medicaid bill for births ought to be on the table, especially if we can do so while simultaneously improving quality. (More on that in a minute.)

What are the arguments for payment reform? They fall into a few categories:

We’re paying too much
Incentives and idiosyncrasies built into the current system virtually guarantee that we’ll continue to pay too much
The payment system offers no accountability whatsoever for providing high quality care. In fact, it incents poor quality care.

Although maternity care seems to have been off the radar of those debating strategies to bend the cost curve, that seems to be changing. A flurry of recent articles and reports have demonstrated the points above:

$978 American Dollars

Dec 9, 2010• 7

By JESSA HARFORD

On 4/29/10 I received a Mirena IUD. I thought about this a lot; I read forums and articles on the device and its side-effects. I decided that because I already have a beautiful son who is 2 years old with my wonderful boyfriend of 7 years and we do not need any more children at this point in our lives, that it would be a good idea. You see, we both have been unemployed for a little over a year now. And while on Unemployment we made too much to receive Medi-Cal for any members of our family. So, while on Unemployment I was paying about $300/month out-of-pocket in premiums for medical insurance for my son and myself. (My boyfriend thinks his body can heal itself.) Anyway, after paying $75 for the visit and only being in the appointment for about 30 minutes, and another $75 for a mandated follow-up appointment, I received a bill on 8/18/10 for $978. (That is 978 American dollars, just to clarify.)

As I stated, while I got this device I was paying out-of-pocket for my insurance premiums because I could not be approved for Medi-Cal. A couple months after getting the IUD both of our Unemployment checks stopped coming. We had no income. Zero dollars a month coming into our home. So I instantly went down to the DHA and applied for pretty much anything I could. I started receiving Medi-Cal for all 3 of us. (This was all before I got the bill, or knew how much it was going to be.) When I went to Kaiser’s Customer Relations Department they informed me that Medi-Cal would take care of whatever cost the IUD would be, but now that I have gotten this bill and spoken to them again, they are saying that they were mistaken when they told me that because I was not receiving Medi-Cal during the time I got the IUD.

The Next Generation of Communities Part 2: Integration Within the Delivery System

Dec 9, 2010

By BIANCA GROGAN

The notion that an online community could be embedded in a health care delivery system is still mostly foreign, but at the Health 2.0 Fall Conference in San Francisco, October 7-8 , 2010, we saw two examples. The Next Generation of Communities session introduced a collaboration between dLife and Geisinger Health System and a presentation from the UK’s iWantGreatCare.

Spent

Dec 9, 2010• 2

By ROB LAMBERTS, MD

“I need you to do me a favor,” my nurse asked me at the end of our day on Friday.

“Sure,” I answered, “what do you want?”

“Please have a better week next week,” she said with a pained expression. “I don’t think I can handle another one like this week.”

It was a bad week. There was cancer, there was anxiety, there were family fights, there were very sick children. It’s not that it’s unusual to we see tough things (I am a doctor), but the grouping of them had all of us trudging home drained of energy. Spent.

I think that this is one of the toughest thing about being a doctor (and nurse, by my nurse’s question): the spending of emotional reserves. I am not physically active at work, yet I come home tired. I don’t have to be busy to feel drained. It’s not the patients’ fault that I feel tired. They are coming to me to get the service I offer to them, and I think I do that job well. The real problem is in me. The real problem is that I care.

Analysis: Aetna Jumps into HIE Market Acquiring Medicity

Dec 9, 2010• 2

By JOHN MOORE

First it was United Health Group’s (UHG) Ingenix Division’s acquisition of leading HIE vendor (and top competitor to Medicity) Axolotl. Then this morning Aetna counters by acquiring Medicity. In just a few short months these two payers have completely changed the landscape of the HIE market by acquiring the two leading HIE vendors in the market today. Now that both of these vendors are in the hands of payers what are the implications both to the HIE market and more broadly the healthcare sector? Following is our assessment based on our continuing research of the HIE market and a number of interviews today, not only with the Aetna and Medicity, but also several other active participants in the HIE market.

The Deal:
Aetna acquired Medicity for a King’s ransom of $500M, a handsome multiple of Medicity’s 2010 gross revenue. Medicity will operate as a separate entity under the Aetna brand maintaining its current headquarters in Utah. According to Medicity, initial conversations began in late October/early November and quickly accelerated to the deal announced today. Aetna plans to close the deal before the end of year. As part of the deal, the senior management team of Medicity has agreed to stay in place for the next few years.

The Motivation:
While some may argue that Aetna was simply looking to counter the move by UHG or Aetna’s new CEO was looking to make a mark, Chilmark sees a more thoughtful and strategic move at play here which in the end may justify the price paid.