The Ethics of Waste Avoidance

And the majority of waste is not fraud and abuse, but our current system of procedural reimbursement, redundant, unnecessary testing, and unproven treatments.

When I was a medical student, intern and then a resident we were taught to go the distance in order to find the correct diagnosis or render optimal treatment. Ethically there were no other options.

Weighing in heavily was the fact I trained at what would now be designated a tertiary medical center.  Patients were referred to our center when their family physician or general internist was stumped in making a diagnosis or referred for an expert treatment or to receive specialized treatment from a specialist who had multiple experiences with a particular disease or surgeries.

Physician outcomes differ radically between community hospitals, amongst themselves and tertiary centers.  In some cases outcomes are ‘better’ at a higher level of care for elective surgery And in other cases, such as infectious disease or critical illness, less common acute or chronic diseases they will be worse. Many times incurable illness or those with lower survival rates are referred to a tertiary center.

In this week’s New England Journal of Medicine an article by Howard Brody, M.D.,  PhD explains the”transition from the ethics of rationing to that of the ethics of waste avoidance”.

(From the Institute for the Medical Humanities, University of Texas Medical Branch, Galveston)

Admirably Dr. Brody does an exemplary, articulate and admirable job of desensitizing  an issue that is an emotional conundrum which is rightly anathema to physicians, patients and families.

Rationing is a dirty word….especially in medicine.  It conjures up the idea that some patients are worth saving while others are not, and it also conjures up thoughts about “death panels”.  This was clearly an anxious moment for Health Reform to remove the idea of a committee of physicians and ethicists making life and death decisions for patients and their families.  Clearly, politicians quickly dismissed any idea of ‘death committees’.  Any further mention would have doomed “health care revolution”.

To quote Dr. Brody,

A case study for the shift in ethical focus is the treatment of advanced, metastatic breast cancer with high-dose chemotherapy followed by autologous bone marrow transplantation. This treatment was initially thought to offer perhaps a 10% chance of a significant extension of life for patients who would otherwise be fated to die very soon. Insurers' refusal to pay the high costs of this last-chance treatment did much to torpedo public trust in managed care during the 1990s. Data now suggest that the actual chance of meaningful benefit from this treatment is zero and that the only effect of the treatment was to make patients' remaining months of life miserable. In this case, the ethical debate over rationing was misplaced.

We have for too long ignored how much money is spent in the United States on diagnostic tests and treatments that offer no measureable benefit.3 Redirecting even a fraction of that wasted money could expand coverage for useful therapy to all Americans, while reducing the rate of overall cost increases.

The ethical question therefore shifts to waste avoidance. Even though the concept of medical futility has had a vexed history, this new ethical question is a subcategory of the futility debate. We now realize that futile interventions may be administered not solely because of patients' demands but also by physicians acting out of habit or financial self-interest or on the basis of flawed evidence. The ethics of waste avoidance is thus in part a component of the ethics of professionalism.5

The two principal ethical arguments for waste avoidance are first, that we should not deprive any patient of useful medical services, even if they're expensive, so long as money is being wasted on useless interventions, and second, that useless tests and treatments cause harm. Treatments that won't help patients can cause complications. Diagnostic tests that won't help patients produce false positive results that in turn lead to more tests and complications. Primum non nocere becomes the strongest argument for eliminating nonbeneficial medicine.3

Physicians, as loyal patient advocates, must invoke the process when (according to their best clinical judgment) a particular patient would benefit from an intervention even if the average patient won't. Few tests and treatments are futile across the board; most help a few patients and become wasteful when applied beyond that population. But the boundary between wise and wasteful application will often be fuzzy.

The Ethics of Eliminating Waste

Berwick and Hackbarth note a relatively minor ethical point, but a serious policy concern2: a substantial reduction in health care spending would seriously disrupt a $2.5 trillion industry, and thus the U.S. economy as a whole, and would require careful planning and gradual implementation. A stepwise strategy also makes good ethical sense in the face of the current limitations of evidence-based medicine. Given our patient-advocacy duties, it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit. We can then extend the policy gradually as comparative-effectiveness research identifies other sources of waste with reasonable confidence.

An ethical mandate to prioritize waste avoidance doesn't address the political hurdles, of course. Given that one person's health care expense is another person's income, we can anticipate pitched battles, accompanied by demagoguery such as talk of “death panels.” Medicine's role in this campaign will pose a serious challenge to physician professionalism. Will U.S. physicians rise to the occasion, committing ourselves to protecting our patients from harm while ensuring affordable care for the near future?

This fresh approach gives hope to those who are suspicious of what will happen in health reform.

It is critical that patients and physician have voice in ethical decision making, and not become powerless or ‘victims’ of a changing system

 

Technorati Tags: Berwick,Hackbarth,Ethics,Waste,rationing,medicine,medicare,outcomes,tertiary care,community hospital

More on Big Data

 

fig.1

A data visualization created by IBM shows that big data such as Wikipedia edits by bot Pearle are more meaningful when enhanced with colors and position.

During the past 25 years or more Medicare and private insurers have gathered data on diagnosis codes,, reimbursement patterns and demographics for providers and patients. Gradually the amount of data has increased enormously.

Now with the implementation of electronic  medical records and health information exchanges the collection and retrieval of clinical information will explode.

From Google Plus comes this information on BIG DATA. This is a new term which seems to be #trending in Health IT the past month.

The term is not confined to Health IT, and appears now in social media circles, including Google Plus.

Big Data can be defined….Wikipedia:

“In information technology, big data^[1] consists of data sets that grow so large that they become awkward to work with using on-hand database management tools. Difficulties include capture, storage,^[2] search, sharing, analytics,^[3] and visualizing. This trend continues because of the benefits of working with larger and larger data sets allowing analysts to "spot business trends, prevent diseases, combat crime."^[4] Though a moving target, current limits are on the order of petabytes, exabytes and zettabytes of data.^[5] Scientists regularly encounter this problem in meteorology, genomics,^[6] connectomics, complex physics simulations,^[7] biological and environmental research,^[8] Internet search, finance and business informatics.”

While common knowledge in IT circles among health providers it is important to recognize the world’s technological per capita capacity to store information has roughly doubled every 40 months since the 1980s (about every 3 years)^[11] and every day 2.5 quintillion bytes of data are created.^[12]

^{This can also be assumed to have taken place in HIT.}

Big  Data  has been around for a long time…at the IRS, Census results, NASA, NOAA, and others.  The CIA probably has  ‘Mega Data” when it comes to Big Files.I

Health Information Technology now offers a fertile ground for ‘Big Data’.

One current feature of big data is the difficulty working with it using relational databases and desktop statistics/visualization packages, requiring instead "massively parallel software running on tens, hundreds, or even thousands of servers".^[13] The size of "big data" varies depending on the capabilities of the organization managing the set. "For some organizations, facing hundreds of gigabytes of data for the first time may trigger a need to reconsider data management options. For others, it may take tens or hundreds of terabytes before data size becomes a significant consideration."^[14]

^{The standard display of tables with contents and rows of data do not properly  represent results, and it may require A data visualization created by IBM shows that big data such as Wikipedia edits by bot Pearle are more meaningful when enhanced with colors and position. (figure 1)}

^{Providers must be aware of how the information their EMR contributes to the pool of data, how it will be extracted and manipulated to make public health decisions, create treatment paradigms, and develop outcome studies.  Insurers and public entities are very interested in these numbers..  Incentivization by government funding for EMR reinforces the need of government and health planners to have accurate information.}

^{Now for Chapter 2, in addition to Big Data we have:}

Massively Coordinated Care

By Ian Morrison
May 01, 2012

Author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.

“Big data and new thinking can transform the care of heavy users. In health care we are throwing off big data as we increasingly digitize the health care system. One analyst estimated that in 2011 alone, health care would generate 150 exabytes of information (by my calculation that is equivalent to 6 million times all the published works in the Library of Congress). “

Big IT Vendors stand to reap significant rewards:

“Global consulting players and industry gurus such as McKinsey and IBM are talking up big data, big time. McKinsey, for example, estimated that big data could create $300 billion in value by reducing health care spending by 8 percent. They argued that big data adds value to industries by:

• making information transparent and usable more quickly;
• enabling better performance measurement through digital capture;
• allowing finer grain segmentation;
• improving business analytics and decision support;
• enabling new products and services.

All of these changes are plausible in health care, and we should welcome them, particularly if they are applied to the challenge of predicting, analyzing, segmenting, treating and coordinating the care of the heavy users of health care.

Big data and the processing power of massive computers like IBM's Watson can help sort through tough analytical problems and provide guidance and support, maybe even replicating at scale and at speed the really tough work of clinical decision-making “

Accountable Care Organizations will catalyze development of new software and data analysis . All of this explained further by "Six Key Technologies to Support Accountable Care

 

Technorati Tags: big data,hit,aco,accountable care,information technology,informatics,analytics,ibm,pearlbot,watson

Health Care Wasn't Broken

Have the Politicians been fed a bucketful of false beliefs and half truths about the American health system? Are statistics from foreign countries relevant and can they be compared to U.S. statistics.  Mr. Conover posits these comparisons.

by:

Christopher J. Conover is a Research Scholar in the Center for Health Policy & Inequalities Research at Duke University, an adjunct scholar at AEI, and a Mercatus-affiliated senior scholar. He has taught in the Terry Sanford Institute of Public Policy, the Duke School of Medicine and the Fuqua School of Business at Duke. His research interests are in the area of health regulation and state health policy, with a focus on issues related to health care for the medically indigent (including the uninsured), and estimating the magnitude of the social burden of illness.

Indeed, the fierce battle over reform was based on the perception that Americans did not get good value for their money. Many of the global comparisons that informed this view, however, were flawed, incomplete or misleading. It's time to set the record straight.

The U.S. spends too much compared to other countries.

This is a pervasive misconception encouraged by reformers who sought to argue that other countries, especially those with single-payer systems such as Canada or Britain, outperform the United States. Thus it was feasible to imagine that the U.S. could dramatically expand access to care without spending more money.

But throughout the world, as income rises, so does willingness to pay for healthcare. In fact, differences in income per capita explain about 85% of the variation in health expenditures per capita across industrialized countries.

Conventional models purportedly show that the U.S. spends 60% more on healthcare than it should given its level of per capita income. These models treat all nations the same so that the United States and its 300 million people is compared with very small countries such as Iceland, population 500,000. But a more precise model that compares apples to apples shows that the U.S. spends only 1.5% more than it should. By contrast, France spends about one-fifth too much, while Canada and Britain spend about one-fifth too little.

What really matters is how much the average person has to spend on everything else once healthcare has been purchased. And on this score, Americans have a huge advantage. In real dollar terms, the U.S. margin of advantage in nonhealth spending increased between 1960 and 2007 compared with every country in the then-G7 except Japan. The U.S. spends more on healthcare in large part because it can afford to do so.

The U.S. has abysmal infant mortality rates.

This is a half-truth. The U.S. ranks 43rd internationally in infant mortality, according to United Nations figures for the years 2005 to 2010. Unfortunately, there is no consistent standard for reporting infant deaths across countries. The U.S. scores lower because doctors here count as failures extreme cases in which the odds of survival were so low that foreign doctors don't count them at all.

Specifically, many nations also do not report any live births at less than 23 weeks, even when vital signs are present, according to a study published in 2000 in the American Journal of Public Health. That same study found that when all deaths to infants delivered in Philadelphia at 22 weeks' gestation were excluded, the city's measured infant mortality rate declined by 40%.

So it will take a little longer to decide how to fix a ‘non-broken system’

Technorati Tags: christopher conover,broken healthcare

Medical Social Media Factoids….Breaking News

 

Facebook, the “F-Word” for Doctors  Doximity a private MD Social Network. What happened to SERMO?

 

        

Is Facebook Poised to Revolutionize Health Care?

Zuckerberg will appear on Good Morning America, and later on Tuesday, Sandberg will appear on World News With Diane Sawyer. Facebook is declining comment, but almost all observers are expecting them to introduce a tool that will “save lives.” That could be an expanded version of its Lifeline program, which allows people to alert the company when they think a friend is expressing suicidal intentions, a broader rollout of anti-cyberbullying initiatives or perhaps something altogether different.

Facebook announced this week that it plans to include in user profiles their intent to donate  organs after death. I am not quite sure why they would include this as a choice in a profile when it could easily be included electively in anyone’s profile. Perhaps this unique ‘field’ allows them to search for specific health issues.  It will be interesting to see if they include or add other items such as allergies, and other previously confidential issues. It’s one thing having it on your driver’s license or identification card and another to put it on a billboard.  It may also serve to increase donors which at times are relatively scarce.  If users give implicit permisson by posting this information it may become common occurrence.  A precautionary note that some may abuse this and use it as a means to sell body parts.

1-in-20 U.S. Physicians Now On Doctors-Only Social Network

They're not Facebook-like numbers just yet, but after just seven months Doximity has signed up about one out of every 20 U.S. physicians for its LinkedIn-like networking service.

That amounts to more than 30,000 doctors, or twice as  many on LinkedIn. The reason doctors shy away from LinkedIn and other mainstream social networks is, unlike Doximity, there are no privacy protections in place that will keep physicians on the right side of patient privacy laws. Previous attempts at a doctor-only social network required physician anonymity, which made it all but useless when it came to make referrals or conferring on a diagnosis.

"For a lot of these guys, Facebook is the F-Word."

Doximity, the largest professional network for physicians, announced today it has partnered with several expert network firms to power their medical expert searches.

Physician network signs major partners guaranteeing minimum honoraria for members who opt-in to research interviews .

Doximity launched ExpertFinder, a new service the company says will make it easier for doctors to find experts and opt-in to research interviews. The announcement seems to position Doximity as an early leader in the mobile health care device market, which could quadruple to $400 million in annual revenues by 2016.

Now here is the ‘Kicker”

ExpertFinder automatically integrates data from PubMed, Clinicaltrials.gov and other public databases into physicians’ profiles. Doximity members can then fine-tune their profiles to reflect past and current academic positions, publications, lectures, awards, and clinical interests.  All done seamlessly, and transparently.

For a brief video demo of Doximity ExpertFinder 

 

 

iOS Health & Fitness Apps Will Grow to 13K by 2012

The average cost of a health app has risen from $2.77 this February to $3.21 in June, about the same price as a gallon of gasoline in some places. There are also significantly fewer health apps than are listed as such in Apple's Health and Fitness category. Of the 9,000 apps available now, say analysts, many are novelties.

These are items that are billed as being for the health and wellbeing of the sick and suffering but are really no more than gimmicks that play into fears about our health and our bodies.

We reported a few weeks ago about the FTC levying fines against two app makers that claimed users could erase their acne using colored lights from the iPHone.

 

Technorati Tags: Sermo,Facebook,Doximity,Social Media,acne,iOS,health,fitness,mobile apps,mhealth,expert finder,iPhone,ftc fines

Health Care Social Media Channels

 

Social Media for Young People

ePatients are savy about social media

Part I

Part II

Part III

Best Practices in Social Media

 

Technorati Tags: hcsm,social media channels,youtubehealth

What’s Your Poison ?

 

As we talk more an more about ‘Patient Centric” healthcare, surveys reveal patient and consumer opinions on health reform and resources.

Krames Staywell (A research survey company) has tabulated their interests and the means for which they use different forms of communications. Not surprisingly the differences are clearly age-related.  It also differs for office, insurance, hospital, and health information. Social media communication is on the rise as well.

HOW THE STUDY WAS CONDUCTED

• quantitative online survey of consumers 21 years of age or older who are responsible for health care decisions for their households
  •     conducted by a full-service market research firm focused solely in the health care environment
  •     interviewing conducted October 21–November 1, 2011
  •     400 interviews completed with a sample error of +/- 4% at the 90% confidence level

 

The study covered consumer opinions and attitudes on a wide range of health care issues:
•     Level of concern about health care
•     Factors that influence provider selection
•     Interest in electronic medical record
•     New media habits –        awareness and use of mobile technologies
•     Paying for care
•     Importance of quality information
•     Advertising formats and themes with impact

When seeking for information outside the doctor’s office, people use a mix of old school and new school  sources for answers to their health questions.
Where do consumers turn first for health care information? 

The question:

“Besides your physician, from which of the following have you sought health-related information from in the past year?  In rank order from the most frequently consulted to the least:

Consumer health website
Google
Friend/Family
Books, magazines, newspapers
Health plan website
Called health plan directly
Health plan newsletter
Hospital newsletter
Newsletter at doctor’s office
TV or radio programs
Hospital website
Called hospital directly
Online support group
A health resources center or library
Consumer Reports
You Tube
CMS Hospital Compare website
Blog or microblog
Mayo Clinic website
Centers for Disease Control
Social media
HealthGrades website
National Institutes of Health
Independent hospital or physician quality ratings organization
Podcast or Webcast

Media for Health Education

The Most Prevalent Queries relating to health care are:

In Rank Order from most common to least common

Articles on health and wellness
Preventive health information
Answers related to a specific health concern for you/family/friend
Lifestyle advice for everyday use
Health care reform and how it will impact you and family
Clinical information about specific health conditions
Health care articles and information personalized to your own health status
Health care articles and information personalized to the health status of someone you care for
How to prepare for Medicare
Support and advice for managing health-related costs
Accountable Care Organizations
Have not read about any of these topics

Further specific details are available as a download from Krames Staywell

 

Technorati Tags: medical home,patient centric,online,patient portals,health web health care information,webmd,patientslikeme,mayoclinic,nih,healthgrades,fda

SCOTUS Decision will be Critical to Economy

 

Either way the decision goes enormous changes will occur in the U.S. economy. As the Patient Care and Affordability Act plays out reality is effecting hospitals, doctors, insurers, Medicare and Medicaid.  This does not even factor the secondary consequences upon employers, large and small.

Several major goals of “Obama Care” have been initiated:

1. The implementation of “no prior illness can be reason for denying coverage

2. Minors will be eligible for insurance in their family’s insurance policy until the age of 25.

Looming on the horizon in August 2012 (three months from now) is the ruling that insurance companies must limit their administrative costs to a specified amount. Many companies thus far have failed to accomplish this, and face a  $ 1.5 billion dollar rebate in August

According to the Kaiser Family Foundation:

:Marylanders will receive $37.7 million from four insurance providers, according to the report. Kaiser did not name the insurers, but said the average rebate for Marylanders will be $293.50..”

The rebates will be paid by August of this year by insurers who are not following the provision that says insurers offering coverage to individuals and small businesses must devote at least 80 percent of their premium income on health care claims and "quality improvement" activities. Large group plans must spend at least 85 percent.

The rule went into effect in 2011 and this will be the first year rebates are paid. Full implementation of health care reform is slated for 2014. But their is uncertainty as the U.S. Supreme Court debates key parts of the law.

American Health Insurance Plans criticized the provision in the following statement:

“The new medical loss ratio requirement (MLR) does nothing to address the real driver of premium increases: the underlying cost of medical care.  Given the inherently unpredictable nature of health care costs, it is not surprising that some health plans expect to pay rebates to consumers in certain markets. However, the coverage disruptions and other unintended consequences of imposing a new arbitrary federal cap on health plan administrative costs are likely to outweigh any benefit these rebates will provide to consumers.  Moreover, the taxes, benefit mandates, and other regulations included in the health care reform law will cause premium increases that far exceed the value of prospective rebates.  For example, a technical analysis by Oliver Wyman estimates that the new health insurance tax included in the ACA “will increase premiums in the insured market on average by 1.9 percent to 2.3 percent in 2014,” and by 2023 “will increase premiums 2.8 percent to 3.7 percent.”

One thing is certain, we need to turn down the rhetoric.  The issues go far beyond partisan politics. Either issue…the Economy  and/or Health Reform are symbiotic and dependent upon each other. Politicians are failing to address this connection to their constituents, and so are health care experts.

A recent survey by Krames Staywell shows the economy is of concern to 42% of those polled, and to health 27% see it as a primary concern.

Health care reform advocacy group Health Care for America Now said the rebates are a victory for consumers.

"For far too long, health insurance companies have been ripping off consumers, and Obama care finally put a stop to that," the group said in a statement. "The rebate money will come to consumers from insurance companies that spent too little on medical care and too much on profit, red tape and bloated CEO pay."

What’s your opinion?  Repeal Obama care completely?  Have SCOTUS remand the law to Congress with Constitutional Guidelines? Just throw out the Individual Mandates?

What should be done with the changes already enacted?

In the next several weeks take a look at Health Train Express’ new presence at Google Plus and here at G + MD

 

Technorati Tags: Obamacare,scotus,health care for america now,ahip,kaiser family foundation

Keep Your Head Down, Shut Up and Forge Ahead

 

A blog colleague of mine who writes “Dr J’s House Calls” who I am certain would not mind my telling you her non-stage name is Mary Johnson M.D. while I explain her life since medical school.  While this is not the worst case scenario I have stumbled upon, it is a heart-breaking story of how things do not always turn out for the best.

I won’t go into a lot of detail here, for the story is told nobly if a bit one sided I do not doubt for a minute what she tells is the absolute truth about Randolph Hospital

There’s something about ‘Mary” as the movie title says.  Mary has INTEGRITY and she stands by her story, never  blinking, nor questioning her role in playing into the hands of dirty politics, good old boy networking and the power of money.

If you are a young physician or medical student thinking of taking on scholarships/loans to be forgiven for time spent in National Health Service, according to Mary Johnson consider the alternatives. Military Service, Loans not based upon indentured servitude, and perhaps even not going into a medical career at all.

I have been reading her “stuff” since 2005  when we were both much younger.

Her stories are as fresh today as they were when she wrote them in 2005. At first I determined it was all “cut and paste”. then decided she needed to be medicated for a fixation, or obsessive compulsive disorder.  I am sure many thought the same.

However I am not dismissive of anyone in so much pain. I also thought she enjoyed the pain and playing the role of ‘victim’. It played out in a sado-masochistic sort of way.  But I was wrong once again. 

Mary simply broadcasts a warning to all young, altruistic, inexperienced physicians being led to slaughter (and not even getting the bar of soap (stone) by hospitals, other physicians (who should know better, or who sold out a long time ago) and now it will be Obama Care.

That brings us up to today and her latest post of Dr. J’s House Calls.

Admittedly it is a long read, but it can be summarized quickly reading her first post and this most recent one.   I sum it up….”There’s Something About Mary”

After reading about  Dr. J’s tribulations I now understand much more about John Edwards.

Mike Wallace may be turning over in his grave.

And as for Mary Johnson…..I still love you.

 

Technorati Tags: Mike Wallace,Dr J's Housecalls,Randolph Hospital,Mary Johnson MD

Digital Health Space MyVeHU and G + MD

 

Digital Health Space is a new Google Plus Page. It features breaking medical news, social media information for health professionals. It also provides links to medical meetings, social media users in health and related information.

This week Digital Health Space introduces MyVeHU Campus. MyVeHU Campus provides an online tutorial and reference for learning about Electronic Medical Record Systems.

Watch for G + MD Hangouts where interviews and broadcasts will be hosted and streamed “On Air” via YouTube “live”. Circle G + MD to receive the schedule and Scheduled Guests.

Content of G + MD will be moderated.

Health Care Social Media #hcsm  are encouraged to apply and participate as “EXPERTS” in their field. Categories may include but are not limited to: Health Care and Social Media , My Favorite Social Media Platform(s), Why and How I use Social Media, The Future of Social Media in Health Care, What's New in Social Media This Week? Primary Care, What's in it For Me? Opinions on Health Reform, Do You Know what Health 2.0 is? Can You Market your Medical Business using Social Media?

Additional Topics: To Be Announced.

I hope you will participate. Bring me your ideas.

Gary Levin MD

 

Technorati Tags: MyVeHU,G+MD,Digital health space,hcsm,on air hangout,health care social media,YouTube Live

Down the Rabbit Hole “Alice in Wonderland”

 

 

Most physicians when questioned about PPACA are truly ambivalent about the law and whether the fact that it may very well  be unconstitutional.

However they do not want reform to fail completely, nor undo more than two years of preparation, not only through publicly funded efforts, but the private hospital preparations and hard cold assets poured into HIT, health reform, ACOs and other organizational imperatives.

In fact if PPACA is overturned or throttled by the constitutional issues much of the changes will not be wasted at all. Some experts state they fail to see ROIs for HIT and other reform proposition.  However as Yogi Berra once said, “It ain’t over until its’ over”.  The time elapsed is still very short when compared to the life of Medicare and medical practice in America.

The Supreme Court is at a difficult juncture.  Their decision will ultimately effect our health non-system in whichever direction they decide.

One of the few groups willing to address the subject was the American Medical Association. In a statement, the AMA's president-elect, Jeremy Lazarus, says, "With the countless hours of work already done to implement this new law, it is hard to imagine the full impact of it disappearing."

Reading the Federal Register on health care issues is a daunting task, as are the determinations set for in the regulations.

It will require some serious “reverse engineering”  in any case no matter what SCOTUS decides to ‘throw out’

"I think it's more akin to Alice in Wonderland," it has been said. "That we're going down the rabbit hole and nobody really knows what it's going to look like inside."

But in the next few months, they may find out.

Here are some who offer their “wisdom”

Some might opine, “It’s as good as any”

Rabbit
Oh my ears and whiskers, how late it's getting!

Alice's Adventures in Wonderland:
Either the well was very deep, or she fell very slowly, for she had plenty of time as she went down to look about her and to wonder what was going to happen next.

Lewis Carroll Quotes
If you don't know where you are going, any road will take you there.

Alice's Adventures in Wonderland:

Alice: But it's no use going back to yesterday, because I was a different person then.

Through the Looking Glass:

The Queen: Now, here, you see, it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!

 

Technorati Tags: affordable care act,scotus,hit,health reform,aco,ppaca,medicare,alice in wonderland,lewis carroll,american medical association

Primary Care and How it can Cut the Cost of Renal Failure

 

Telemedicine Can Cut Health Care Costs by 90%

by Vijay Govindarajan

Vijay Govindarajan is the Earl C. Daum 1924 Professor of International Business at the Tuck School of Business at Dartmouth. He is coauthor of Reverse Innovation (HBR Press, April 2012).

The title for the post is a bold one. It is a vague, sweeping declaration, certainly one we would all like to believe, an it grabs one’s attention to see how the conclusion has been derived by Dr Govindarajan.

If you've not yet heard of telemedicine or think that it's not a great  way to deliver quality health care, you may want to read this. Telemedicine, made possible by the availability of mobile networks, is revolutionizing health care. But not in the U.S.

You have to look to India, where telemedicine is already widely used in the delivery of health care — and is saving lives even in the most rural corners of the country. Nephrologists have developed a system that allows for peritoneal dialysis at home in  lieu of the more expensive hemodialysis with expensive devices in dialysis centers or in hospital. At home PD requires no vascular access ports, pumps or technical personnel. It can be accomplished by a trained patient with minimal if any supervision.

Dialysis Center                          At Home Peritoneal Dialysis

The major barrier in the acceptance of PD is concern that patients won't have proper access to a doctor — especially in geographically dispersed countries such as the United States. As a result, less than one in twelve ESRD patients are treated with PD. The net result? It costs over $170,000 to treat patients with ESRD in the U.S., using the more expensive HD.  HD requires a network of redundant hemodialysis centers scattered within travelling distance for a procedure necessary several times a week.

It doesn't have to be this way. The "distance" between the patient and the PD unit can be overcome, at a dramatically low cost, by efficient use of the internet, mobile phones, and a strong home visit protocol. To quote Dr. Nayak: "Our success can easily be replicated in the U.S. Conservatively, even if 15% of ESRD patients choose PD over HD, cost savings for Medicare and Medicaid will run into many millions of dollars every year."

After signing into the (secure) hospital website, patients and caregivers are directed to a personalized home page from which they can use the site to enter and share information. Health complaints made by patients receive immediate response. Remote monitoring is augmented by a home visit protocol that ensures that each PD patient's progress is followed up by a well-trained clinical coordinator (CC) on a regular basis. The CCs are trained to follow a set protocol and are equipped with a standardized checklist for a step-by-step assessment of patient well-being during each visit. All this information, together with a brief summary of the patient's most current laboratory results, is conveyed to the nephrologist by SMS from the patient's home. The CC is instructed to wait until the nephrologist responds (usually within 15 minutes), and then to counsel the patient accordingly. CCs also assess and advise patients on nutrition, psycho-social well-being, and physical fitness and rehabilitation levels.

Dr. K. S. Nayak, Chief Nephrologist at the Lazarus Hospital in Hyderabad, India, and his team are able to treat ESRD patients using PD, supported by  mobile phone short messaging service (SMS), inexpensive digital cameras, and the internet to address patient accessibility issues.

The hospital retrospectively analyzed 115 rural patients who had started PD using this remote monitoring technology. Amazingly, rural patients performed well on PD and had significantly better survival rates than did their urban counterparts.

What is the primary driver of this system-wide inefficiency and cost? Most health care providers would agree that it is physician "mindset:" higher physician reimbursement for HD than PD, and concerns about accessibility in a geographically vast country contribute to historically low use of PD in the U.S.

Author comments:  Gary M. Levin MD

In this now Patient-Centric health model in the U.S. a driving force for P.D. should be patient demands for quality of life issues and cost.

Primary care physicians should encourage nephrologists to make peritoneal dialysis a predominant form of dialysis if indicated.  In the coming changes in reimbursement not based on procedures, this may become a reality.  Most patients on ESRD (end stage renal disease) programs are already funded by a separate Medicare administrative system. Prior authorization for HD may become a routine to select HD in lieu of HD.

The "distance" between the patient and the PD unit can be overcome, at a dramatically low cost, by efficient use of the internet, mobile phones, and a strong home visit protocol.

To quote Dr. Nayak: "Our success can easily be replicated in the U.S.

Ref:  Health 2.0 News

 

Technorati Tags: dialysis,hemodialysis,peritoneal dialysis,telemedicine,reimbursements,primary care,nephrologist,dialysis center,Vijay Govindarajan center,esrd,medicare,medicaid,india dialysis

Brave New World

 

Author: G. M. Levin M.D., Attribution to the American Medical Association, AMED news

 

More details are forthcoming regarding ACO establishment and leadership. One of the key announcements is that 27 of the leaders of ACOs will be physician leaders. AMA Medical News announced that “Thousands of physicians will be among those coordinating patient care in the 27 accountable care organizations that were chosen in April to participate in the new Medicare shared savings payment model.”

Organized medicine was pleased to see that 21 of the 27 ACOs would be physician-run. The American Medical Association also noted that five of the approved groups will participate under an advance payment model, which provides up-front funding from Medicare to cover the costs of establishing the infrastructure needed to coordinate patient care. Advance payments make it possible for smaller groups of doctors to participate in the program in a leadership role, said AMA President Peter W. Carmel, MD. More than 50 organizations have applied for the advance payment option beginning July 1.

So far, CMS has received more than 150 applications seeking approval to participate in the second phase of the program, and the agency will announce the groups that qualify in July. Another round of applicants will be approved in January 2013.

The newest organizations to be chosen, which involve more than 10,000 physicians, have agreed to coordinate care for nearly 375,000 Medicare beneficiaries, the agency said during an April 10 briefing with reporters.

Safeguards are being put in place to insure equality with physician leadership and control

Plymouth Bay Medical Associates, Jordan Physician Associates and a number of specialty physicians from Jordan Hospital joined to form Jordan Community ACO in Plymouth, Mass. Physicians in the network will coordinate care for more than 6,000 Medicare patients.

The Vitruvian Man,  Leonardo Davinci, circa 1478 (Wikipedia)

The ACO is structured so that physicians and the hospital have an equal say in how the organization will operate and share in any savings. The pool of doctors, who mostly are primary care physicians, and the hospital each have one vote, and a majority is needed to move forward. That effectively means decisions must be unanimous or both sides continue negotiating.

This is unchartered ground so far, and the ACO will be looking for Medicare patients to be active rather than passive participants in the care model. “Patient education is paramount for any project to work,” Dr. Johnson said.

Accountable care organizations that provide higher-quality care and cut costs can earn bonuses from Medicare. Groups will be evaluated by their performance on 33 quality measures, their use of preventive health services and whether they improve care for at-risk patients. The 27 ACOs participating in the systemwide shared savings program as of April 1 will be joined by additional members in July.

But beneficiaries still retain the right to choose physicians outside an ACO.

 

Physician-led ACOs

• Accountable Care Coalition of Caldwell County, Lenoir, N.C.
• Accountable Care Coalition of Coastal Georgia, Ormond, Fla.
• Accountable Care Coalition of Eastern North Carolina, New Bern, N.C.
• Accountable Care Coalition of Greater Athens, Ga.
• Accountable Care Coalition of Mount Kisco, N.Y.
• Accountable Care Coalition of the Mississippi Gulf Coast, Clearwater, Fla.
• Accountable Care Coalition of the North Country, Canton, N.Y.
• Accountable Care Coalition of Southeast Wisconsin, Milwaukee.
• Accountable Care Coalition of Texas, Houston
• AppleCare Medical ACO, Buena Park, Calif.
• Chinese Community Accountable Care Organization, New York.
• Coastal Carolina Quality Care, New Bern, N.C.*
• Crystal Run Healthcare, Middletown, N.Y.
• Florida Physicians Trust, Winter Park, Fla.
• Jackson Purchase Medical Associates, Paducah, Ky.*
• Optimus Healthcare Partners, Summit, N.J.
• Physicians of Cape Cod ACO, Hyannis, Mass.
• Premier ACO Physician Network, Lakewood, Calif.
• Primary Partners, Clermont, Fla.*
• RGV ACO Health Providers, Donna, Texas*
• West Florida ACO, Trinity, Fla.

Nonphysician-led ACOs

• AHS ACO, Morristown, N.J.
• Arizona Connected Care, Tucson, Ariz.
• CIPA Western New York IPA, doing business as Catholic Medical Partners, Buffalo, N.Y.
• Hackensack Physician-Hospital Alliance ACO, Hackensack, N.J.
• Jordan Community ACO, Plymouth, Mass.
• North Country ACO, Littleton, N.H.*

 

*  These ACOs are receiving advance Medicare implementation funding.

Source: “First Accountable Care Organizations under the Medicare Shared Savings Program,” Centers for Medicare & Medicaid Services, April (cms.gov/apps/media/press/factsheet.asp)