Monday, December 29, 2014

Hey Doc, Please go Away

Aaron Carroll,  over at The Incidental Economist,summarizes a study suggesting that patients do better when cardiologists are away at academic meetings.

High risk patients admitted with heart failure during meetings had a 30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were there. Cardiac arrest 30-day mortality was 59% during meetings and 69.4% at other times. 
Why is this?
There are a number of ways to interpret this. Maybe the best cardiologists were the ones who stayed home. Maybe with fewer cardiologists available, fewer invasive procedures get done, and that leads to better outcomes. Maybe they tell more low-risk patients to wait when fewer cardiologists are available, which gets the higher risk patients more attention and better outcomes. Maybe it’s something else.
I favor the second explanation and am reminded of the excellent judgment of my PCP back in 2007 when I was asked by the touring company to take a stress test before a two-week long kayaking trip to Patagonia.
She says, “No. I refuse to order a stress test for you.”
“Huh?” I reply intelligently.
“Here’s the deal,” she says. “If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat.

 He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience.”

Minor ST segment changes, may be non-specific.
” I will not authorize a stress test.”

Sunday, December 28, 2014

The Ideal Medical Practice

What and where is the 'ideal' medical practice?  Is it a solo, group, or hospital based setting? Is it a government position, or a federally qualified medical clinic?

The answer is "It is in the eyes of the beholder".  Like a valuable family heirloom it is a treasured asset, not defined by assets, or market value.

For some practiioners it may be independence, creativity, flexibility, self initiative, and freedom for independent decision making. Contolling your own schedule is an important factor for many solo doctors. Others may hold freedom from administrative duties, collegial interactions, the economic power of a group credit worthiness, or belonging to a larger institution with a standing reputation and/or receiving referrals from within the group itself.

Many disruptions have been caused by government interference, HMOs and insurance companies.

Innovative organizations such as accountable care organizations, PQRS,  and health reform such as the Affordable Care Act create confusion, and contribute to increasing cost which is counter to the perceived goals of improving quality and the cost of healthcare.

Jean Antonucci M.D. describes her IMP in the video

John Brady M.D.  talks about how the IMP model not only benefits his patients but drives his joy in practice and hope for the future of primary care. Dr. Brady questions if he can continue his practice model, a common concertn for IMPs. 

Choosing your medical practice model begins in medical school or training. It may be effected by a mentor, or a practice setting in which a trainee works. There may be an economic incentive with rewards such as loan forgiveness, lifestyle, or geographic location.

Preparation for each of these goals begins in training. Independent medical practice requires additional preparation in business and administration as well as organizational abililties. 

Ideal Medical Practices

Tuesday, December 23, 2014

Unlocking DNA secrets with a Canadian genome search engine - The Globe and Mail

Unlocking DNA secrets with a Canadian genome search engine - The Globe and Mail

Health Train Express Search Upgrade

The number of posts increases monthly and I have incorporated a "search"  function, located at the top of the right sidebar.  Note the 'advanced' drop down tab.  This will enable more specific ranges, by date and other. I trust this will enable you to search and find related posts for the days topic. There is also a Google Web Search available. Happy Holidays from Health Train Express.

 See more at:

Sunday, December 21, 2014

Top stories in health and medicine, December 19, 2014

Top stories in health and medicine, December 18, 2014

Most health care news in the past two years has been about the Affordable Care Act. The new law provides neither care nor affordable health care.

More people are covered by insurance with the down side, it covers less, costs more, has fewer providers, and less access. This at the expense of everyone, except those in the bottom brackets and without previous insurance.. The gain is that previously uninsured must be enrolled no matter what pre-existing condition they have.

This last statement is a black hole for insurers as to what to expect in their new enrollees. Some of these patients are very ill and may be in SNFs for chronic care. In addition hospitals will face shortened stays to reduce cost, and fines if patients return for re-admission 30 days.  Shorteing stays will increase re-admission rates.

The highest rated doctors may not provide the best care

Doctor ratings generally focus on the patient experience, such as wait times, time spent with the doctor, and physician courtesy.  Those are obviously important issues, but they paint an incomplete picture.  Doctors with stellar interpersonal skills may not be the best at controlling patients’ blood pressures or managing their diabetes.  High ratings may identify surgeons with great bedside manner, but mask high surgical infection rates.
The quest for ratings perfection influences medical decision making, as patient satisfaction increasingly affects doctors’ salaries.  According to the management consulting firm Hay Group, more than two-thirds of physician pay incentives are based on patient satisfaction scores.  And Medicare withholds as much as $850 million in payments to hospitals who fail to meet various quality metrics, with patient satisfaction being a significant component. But doing what’s best for patients won’t necessarily make them happy.  Denying antibiotics for viral infections or saying no to routine MRIs for patients with back pain are both sound medical decisions, but can anger patients; some vent their frustration by poorly rating their doctors. It’s no wonder that many physicians acquiesce to patient requests. In a survey by Emergency Physicians Monthly, 59% of emergency physicians said patient satisfaction surveys increased the amount of tests they ordered.  In another survey by the South Carolina Medical Association, almost half of physicians said that pressure to improve patient satisfaction led them to inappropriately prescribe antibiotics or narcotics.  In fact, Senators Dianne Feinstein (D-California) and Charles Grassley (R-Iowa) wrote a letter to Marilyn Tavenner, administrator of the Centers for Medicaid & Medicare Services, saying that “there is growing anecdotal evidence that these [patient satisfaction] surveys may be having the unintended effect of encouraging practitioners to prescribe opioid pain relievers (OPRs) unnecessarily and improperly, which can ultimately harm patients and further contribute to the United States’ prescription OPR epidemic.”

Why Hospitals have to change their Mission

These are really difficult times for hospital executives. The system (and I use this term loosely) is rapidly shifting from a volume-based, fee-for-service business model to a population model that puts providers at financial risk. This means that hospitals have to rethink their core business. Instead of filling hospital beds with patients who need complicated treatments and expensive procedures, hospitals must now try to keep patients out of the hospital and do so with low costs.
Some areas of the country are more accustomed to HMOs and managed care models, but they are in the minority. For the rest of the country, this is disruptive stuff, particularly the part about taking on risk

What will the Future of Medicine look like

Enormous technological changes are heading our way. If they hit us unprepared, which we are now, they will wash away the medical system we know and leave it a purely technology–based service without personal interaction. Such a complicated system should not be washed away. Rather, it should be consciously and purposefully redesigned piece by piece. If we are unprepared for the future, then we lose this opportunity.
Here is the list of the real examples and practical stories demonstrating why we should all be ready for these changes.
These are some additional blogs that offer information on health reform.

Stop Wasting Doctors' Time (and Money)

Health IT Forecast for 2015 – Consumers Pushing for Healthcare Transformation

Doctors and hospitals live and work in a parallel universe than the consumers, patients and caregivers they serve, a prominent Chief Medical Information Officer told me last week. In one world, clinicians and health care providers continue to implement the electronic health records systems they’ve adopted over the past several years, respond to financial incentives for Meaningful Use, and re-engineering workflows to manage the business of healthcare under constrained reimbursement (read: lower payments from payors).
In the other world, illustrated here by the graphic artist Sean Kane for the American Academy of Family Practice, people — patients, healthy consumers, newly insured folks, kids and caregivers — are seeking convenient, pleasant, frictionless retail-style experiences from the health system. 

Demands from these people are pushing the health system to transform in ways that serve them the way Uber, Amazon, Nordstrom and Apple do. 
41 percent of caregivers in U.S. broadband households currently use a digital health device as part of their caregiving routine, including 8 percent who use online tools to coordinate their efforts, according to recent research from Parks Associates
The research firm’s latest report, 360 View: Health Devices and Services for Connected Consumers 2014analyzes multiple consumer surveys, including a 2Q 2014 survey of 10,000 U.S. broadband households, to analyze consumer health and wellness behaviors, calculate market potential for digital health solutions, and evaluate business strategies for consumer engagement and usage of wellness and fitness apps.
“Among U.S. broadband households, 22% have a head of household who currently provides care for a family member or anticipates doing so in the near future. At 2015 International CES, we’ll see many new digital health devices and software on display, including innovations from companies such as Sleep Number, Independa, Bosch Healthcare, and Grandcare, and wearable tech from iHealth Labs, Misfit, Sensogram, and Vancive Medical Technology.These innovative solutions will find strong interest among current caregivers, but they will also have high standards to meet in improving the ways caregivers can monitor their family members,”said Harry Wang, Director, Health & Mobile Product Research, Parks Associates in a statement.

For caregivers, 44 percent expressed having electronic panic button known as personal emergency response systems (PERS) that can signal can emergency if a family member falls or is unable to get help as their top concern. Also, 30% find an electronic tracking watch with a panic button appealing. Currently only 8% of caregivers use an electronic watch to track the family member under their care.

HealthWorks Collective

Friday, December 19, 2014

Top 25 Healthcare Blogs | Cision

Top 25 Healthcare Blogs | Cision

Covered California II

Enrollment for Covered California began one month ago, and will end on January 15, 2014. The online internet enrollment worked more smoothly and was easy to access. It functions fairly well and most of the time it proceeds without a hitch.

One problem I encountered was an inability to progress from {adding members}  to where the web page for adding new members. This attempt repeated itself a number of times when 'next' was selected. After several attempts the next page did appear, and the process proceeded without further difficulty.

The people who receive the 'best benefits/premium cost' are clearly in the Medi-Cal category if their income is at or below the poverty level. The web site performed fairly well with numerous pop-ups and drop down menu selection. Because of the relatively large number of selections and fields it was difficult to scan through deductibles, and/or co pays. The site allowed users to select and compare plans by checking the plans one wanted to compare.

The plans all have deductibles and co pays. The lower the premium the higher the copay and and deductible.  In many cases the insurance appears to be 'catastrophic coverage'  Common sense would make one wonder how many people could afford a deductible of $2500 to $10,000.

The financial algorithm was  designed by people who know little about health care or it's real expenses.  It seems the design was to fit health care into the budget process.

Jonathan Gruber, the principal economic adviser and designer is an expert in health economics at the macro level, and is no authority on patient care.  He has no medical experience or clinical credentials and is ignorant of patient-provider health process.  He had received numerous awards in healthcare economics.
Gruber has published more than 140 research articles (the majority of which were for NBER) and has edited six research volumes.[11] He is a co-editor of the Journal of Public Economics, an associate editor of the Journal of Health Economics, and the author of Public Finance and Public Policy.[12] In 2011, he wrote Health Care Reform: What It Is, Why It's Necessary, How It Works, a graphic novel delineating the Affordable Care Act, illustrated by Nathan Schreiber.[2]
An allegation and video content of Gruber testifying in several resulted in an eruption of public outrage and discontent.
In January 2010, after news emerged that Gruber was under a $297,000 contract with the Department of Health and Human Services, while at the same time promoting the Obama administration's health care reform policies, some conservative commentators suggested a conflict of interest.[18][19][20] Paul Krugman in The New York Times[21] argued that, although Gruber didn't always disclose his HHS connections, the times when he didn't were no big deal. 
In November 2014, a series of videos emerged of Gruber speaking about the ACA at different events, from 2010 to 2013, in ways that proved to be controversial. Many of the videos show him talking about ways in which he felt the ACA was misleadingly crafted and/or marketed in order to get the bill passed, while in some of the videos he specifically refers to American voters as ill-informed or "stupid." In the first, most widely-publicized video taken at a panel discussion about the ACA at the University of Pennsylvania in October 2013, Gruber said the bill was deliberately written "in a tortured way" to disguise the fact that it creates a system by which "healthy people pay in and sick people get money." He said this obfuscation was needed due to "the stupidity of the American voter" in ensuring the bill's passage.
Gruber's published works include:
Covered California web site illuminates the copay/deductible inverse relationship and premium subsidy.  The working of Obamacare  obfuscates the ACA bill which was passed by the Democratic party.  Very troubling is  it did not include Republcan legislators in the design process. 

Contrary to Obama's proclamations many patients did not keep their physician,or hospital. Nancy Pelosi's uncannily accurate comment 'we won't know what is in it until we pass it'. Jonathan Gruber's "stupid" must also mean 'congress' was too stupid as well.

Portions of this article are attributable to 
New York Times, Covered California (online enrollment)

Monday, December 15, 2014

Mobile Health, Telemedicine and Walgreens

Walgreens app makes virtual doctor visits a reality

The service is immediately available to residents of California and Michigan and will be rolled out in other states in the next few years. Illinois residents should be able to use the app by the end of 2015.  Appointments cost $49, most of which goes to physicians. That fee is also not much more than a copay for an in-person doctor's visit through some insurance plans. “Some insurance companies cover telemedicine”, Leider said.

Walgreens is launching a virtual doctor visit feature on its mobile app, the company announced Monday. The nation's largest drugstore chain is teaming up with MDLive, a provider of virtual health services, to connect Walgreens customers with certified doctors via video chat on a smartphone, tablet or computer. 

"Consumers are demanding to do everything through mobile," Parker said. "Everything else they can do through mobile, and now they can do this too."

MDLive stands to gain 2 million people a day through Walgreens' mobile app and website. CEO Randy Parker said the company has 2,000 doctors available.
Last year Walgreens launched a Pharmacy Chat feature on its app to allow users to instant message with pharmacy staff. The company said it averages 9,000 chats a week.
"I think this will become a normal part of health care in three to five years," Leider said. "We have got some real forces that are going to make this very compelling."
He said a shortage of primary care physicians coupled with more people becoming insured through the Affordable Care Act means the market is growing for people who might find telemedicine useful.
Dr. Leider made the bold statement, “"I think this will become a normal part of health care in three to five years," Leider said. "We have got some real forces that are going to make this very compelling."
In October, Deerfield-based Walgreen announced a similar telehealth initiative partnership with health information website WebMD to encourage customers to increase exercise to earn discounts at Walgreens stores. The company said it now awards points on its Balance Rewards loyalty card for logging activities on the WebMD Healthy Target app.

The service is immediately available to residents of California and Michigan and will be rolled out in other states in the next few years. Illinois residents should be able to use the app by the end of 2015, said Dr. Harry Leider, chief medical officer  for Walgreens.  Appointments cost $49, most of which goes to physicians. That fee is also not much more than a copay for an in-person doctor's visit through some insurance plans. “Some insurance companies cover telemedicine”, Leider said.

"Consumers are demanding to do everything through mobile," Parker said. "Everything else they can do through mobile, and now they can do this too."

Chicago Tribune

Saturday, December 13, 2014

CellScope’s iPhone-enabled otoscope, remote consultation service launches for CA parents

Parents in California who have children who get chronic ear infections will soon have a more convenient way to get their kids care.

San Francisco-based CellScope, a Khosla Ventures-backed Rock Health alum, has begun taking preorders for its FDA registered smartphone-enabled otoscope,called Oto Home. The director-to-consumer device is priced at $79 and will ship in four to six weeks. A feature-rich, $299 version of the system, called Oto Pro, is also available for preorder now to physicians located anywhere in the US.

There are caveats in using this device and parents should be trained how to insert the scope. The Otohome will come with an FDA approved label for  users, the same as any FDA approved device or medication.

Friday, December 12, 2014

Buffaloed ?

Thanks to Martin Samuel M.D. I now know why the Canadian Health System works as well as it does.

According to him:

"Some years ago, I was acting as a visiting professor in Canada. I was discussing a patient with a disorder that I thought required a rapid, though not urgent, intervention. I was discussing the optimal timing of the intervention, when a chuckle arose in the audience. I inquired about why people seemed so amused and they told me that considerations of that type did not apply to this particular patient because he was going to be “Buffaloed.”
What could that mean, I inquired?
It means that this patient had private insurance and would go to Buffalo for the procedure rather than wait in the queue in the regular Canadian health care system. The reason the Canadian health care system works as well as it does (and that is not by any means optimal) is because 90% of the population is within driving distance of the United States where the privately insured can be Seattled, Minneapolised, Mayoed, Detroited, Chicagoed, Clevelanded and Buffaloed, thus relieving the pressure by the rich and influential to change a system which works well enough for the other people but not for them, especially when they are worried or in pain."
In the United States, there is no analogous safety valve so the influential simply demand a different level of care and receive it. This includes all the authors of the major books, articles and policies that have been written to repair our allegedly hopelessly expensive and error prone system. The array of suggestions is practically incomprehensible partly because there is a secret hypocrisy. Will the pundit actually use their proposed system themselves?
Whenever anyone writes about the rehabilitation of our health care system, they should be required to publish their own health care history, so the public can see where these experts obtain their own medical care. To protect their privacy, specific diseases need not be declared; just the method by which the pundit handled his or her own medical problems. This would be analogous to requiring that politicians reveal their income tax records or that academic doctors report any real or perceived conflict of interest when publishing a paper. Articles, proposals and laws written by anyone who is unwilling to publish his or her own health care history would simply not be considered or published. If just the leading newspapers and opinion magazines would agree to this system the degree of credibility of proposals for changes in our health care system would be dramatically improved.
Where will you Buffalo ?
My thoughts exactly, and Dr. Samuel expresses it so well
reprinted from The Health Care Blog
Martin Samuels is a practicing neurologist and founder of two Harvard-affiliated neurology departments. He holds a membership in the American Neurological Association, a fellowship in the American Academy of Neurology and a mastership in the American College of Physicians.

Wednesday, December 10, 2014

Did Jonathan Gruber mean Congress is Stupid

Congress just completed it's hearing on the economic planning prior to  the passage of the Affordable Care Act.  The keynone witness was Jonathan Gruber, PhD, whose credentials include MIT.

This is a continuation of our last post here.

Gruber, who most know was the  financial economic planner for Obamacare.  Any clinician and hospital administrator knew that Obamacare is the 'Kool Aid' for liberals wishing  for change and hope. Since Obamacare became law insurance deductibles tripled.

Darrell Issa, chairman of the committee quizzed Gruber and pointedly, asking him if he  was "stupid'. Gruber, who is obviously smart enough  to be at MIT. Gruber responsed, no he was not, but smart people make stupid comments or decisions.  Jonathan Gruber, PhD is a  theoretical economist, observing and making decisions from orbit, with no clnical expereince based upon reality.

Wikipedia's article on Gruber includes the following,

"An American professor of economics at theMassachusetts Institute of Technology, where he has taught since 1992. He is also the director of the Health Care Program at the National Bureau of Economic Research, where he is a research associate. An associate editor of both the Journal of Public Economics and the Journal of Health Economics, Gruber has been heavily involved in crafting public health policy. He is an academic professor of economics at MIT

He was a key architect of both the 2006 Massachusetts health care reform, sometimes referred to as "Romneycare", and the 2010 Patient Protection and Affordable Care Act, sometimes referred to as the "ACA" and "Obamacare".[1]He became the focus of a media and political firestorm in late 2014 when videos surfaced in which he made controversial statements about the legislative process, marketing strategies, and public perception surrounding the passage of the ACA.

Most of the Affordable Care Act is based upon Gruber and President Obama's face-to-face meetings. It failed the self-proclaimed promise of openness and transparency promise of President Obama"