Patient-Centered HealthCare : The Dawning of a New Age

This the dawning of the age of Patient Centered Care.  Perhaps this is apparent in primary care and a few other specialties. But what about hospital based specialists and mental health care, euphemistically now named, "Behavioral Health"  Well. what's in a name.?

Psychiatry is the "P" word of health care, much like the C word of cancer. Calling it by another name makes it more comfortable for patients to hear.

When a provider tells a patient, " I am going to refer you to psychiatry" it conjurs up images,  some real, some imagined.  Behavioral health seems to be the term decided by someone in the health herarchy as least frightening to patients.

The problem with the term is that you never know what you are getting in a provider. It is akin to Forrest Gump and his #box of chocolates".  Unless one is seeing a private psychiatrist the road to him is filled with "gatekeekpers" information gatherers and others in the chain of command.

Mental health, behavioral health is not patient-centered. It is shameful.

A scenario.

A patient  has an emergency admission for suicidal ideation, alcohol or drug abuse to a county emergency medical facility.  Once there  he/she is placed in a general  holding area with anywhere from 4 to 10 patients in varying degrees of altered mental state. For some patients, they are placed in isolation as a protective measure. There are no beds in the  unit, only chairs. There is access to a pay phone from which they can call family, or family can reach them. It is a queue with no privacy, patients waiting in line clamoring to call loved ones, acutely anxious with an overriding fear for safety. Patients are there for 72 hours and then must be discharged. It is just an emergency facility for life or safety threatening conditions.

At the end of 72 hours patients are discharged to wherever they may find a home, relatives, friends or even the street.  They can be admitted to an inpatient facility if available.  The ETS is a busy place ,overwhelmed with crisis and limited capacity for holding and patients. There is a wide variety of patients, some psychotic and some with criminal records.  In an effort to control the situation and little means of segregating patients with different levels of behavioral conditions they are indiscriminately placed in one space.

There are no wall placards explaining the process or rights a patient has. In essence all personal freedoms and civil rights are suspended (with good  reason), however it is not open, nor transparent.

The mental health system has been segregated from main stream medicine. The mind-body connection is far more real than a phrase for the 'feel good' niche. Most medical conditons have a connection directly with brain function. Treating one without considering the other leaves a large gap in total health care. Both allopathic physicians and mental health professionalsmust know this. The brain controls the body in ways in which we understand, and in ways that we have not yet delineated. In fact most people do not know we have two brains. One in our head and another in the abdomen. The neural network in the abdomen  has as many neurons and mass as our cerebrum.  And their is a connection,  both humoral and directly by neurons connecting them together.

Obamacare, SCOTUS, King v. Burwell, and Public Opinion

ObamaCareWatch 

The first several weeks of June have begun with controversy from examining the implications of Obamacare.

President Obama's Supreme Court Remarks Set Him Apart
Jess Bravin
The Wall Street Journal, 6/10/15

“‘It’s not unheard of for presidents to take positions on cases before they are decided, but what makes Obama’s remarks stand out is that they are bolder and more extensive than what most presidents have said in the past,’ said Paul Collins, a political scientist at the University of Massachusetts, Amherst.”

The Legality of Executive Action after King v. Burwell

Josh Blackman
The Federalist Society, 6/8/15

The Federalist Society explains that after the Supreme Court rules on King v. Burwell, there are two possible approaches the Department of Health and Human Services (HHS) could take in order to continue the payment of subsidies in some or all of the 34 states using the federal exchanges.

New State Datas Shows the Real Story Behind King v. Burwell
Nina Owcharenko
The Daily Signal, 6/8/15

“Every day there seems to be another article focused on how many individuals might lose their subsidies if the Supreme Court rules in favor of the plaintiffs in the King v. Burwell case. Yet, an even bigger group of individuals harmed by Obamacare has an equally good claim for relief that hasn’t gotten as much attention—the people who, thanks to Obamacare, must pay more for health insurance but who never got subsidies.”

States and Congress Urged to Act if Justices Rule Against Health Law
Robert Pear
The New York Times, 6/10/15

“The Obama administration’s top health care official said Wednesday that if the Supreme Court stopped the payment of health insurance subsidies to millions of Americans, it would be up to Congress and state officials to devise a solution.” 

Obamacare Is Proof That We Need Choices and Affordability
Grace-Marie Turner
The New York Times, Room for Debate, 6/11/15

“The Affordable Care Act has proved the need for health reform, but it also has proved the need for significant changes to the law to reflect Americans’ demand for more choices of more affordable health coverage.” 

Hitting the Wall: When Health Care Costs are No Longer Manageable 

Tevi D. Troy and D. Mark Wilson
American Health Policy Institute, 6/2/15

AHPI’s “Hitting the Wall” study examines the changes coming to both government health insurance programs and employer-sponsored health insurance plans and the challenges that lie ahead.

 

Polling

Taking the Pulse: Public Opinion on King v. Burwell and the ACA

American Enterprise Institute, 6/10/15

"Most Americans have not been paying close attention to King v. Burwell. A majority continue to say that the Affordable Care Act has not had an effect on them or their family, although the proportion that believes it has hurt and, separately, helped has risen. Views of the ACA remain more negative than positive."

Poll Marks a Love/Hate View of the Affordable Care Act 

ABC/Washington Post, 6/8/15

"Overall, just 39 percent support the law, down 10 percentage points in a little more than a year to match the record low from three years ago as the Supreme Court debated the constitutionality of the individual mandate. A majority, 54 percent, opposes Obamacare, a scant 3 points shy of the high in late 2013 after the botched rollout of healthcare.gov"

Thanks to :

Galen Institute
P.O. Box 320010
Alexandria, VA 22320

www.galen.org 

Covered California IG Audit finds Deficits for the Disabled

Audit Finds Accessibility Issues on Covered California Website - California Healthline

For the Affordable Care Act this is a big item.  California is the most populous state in the United States. During the rollout of the Affordable Care Act, California was one of many states which decided to develop their own Health Insurance Exchange, COVERED CALIFORNIA  It arrived with some pros and cons.

State Run Health Insurance Exchanges

Here we are three years later, with additional 'bugs'. and millions of dollars in overrides plus changing key vendors in the journey to affordable care.  It seems programming remote satellites for autonomous crusing through the solar system and landing on asteroids as well as Mars is simple stuff compared to the 'rocket science of health information technology.

Some of the items the IG has discovered include:

Covered California's website is not fully accessible to residents with disabilities, impeding their attempts to purchase health coverage through the state exchange, according to a new state audit, U-T San Diego reports

Covered California Findings

Of the four departments included in the audit, Covered California's website had the most violations of Web accessibility standards. The audit reviewed 57 pages of the exchange's site and found:

• 55 pages with distinct accessibility violations; and
• Seven pages with common accessibility violations.

Overall, the audit found more than 300 critical accessibility violations on the site that made certain content "completely inaccessible to users."

For example, the audit found that individuals with motor disabilities who are unable to use a mouse to navigate the Internet would be unable to complete an application on Covered California's website using a keyboard.

While Covered California tested for accessibility before launching its website, the audit found that the exchange failed to perform regular, automatic tests of the accessibility of later updates to the site.

In addition, while no accessibility complaints have been filed for Covered California's site since June 2013, the audit found that the exchange did not include on its site all of the contact information for complaints that is recommended by state policy. According to the audit, "When departments do not provide multiple forms of contact information, the risk increases that users will be unable to complain about Web accessibility problems they may encounter so that departments can fix those issues."

While some deficits may be due to state web sites built in  functions many computer operating systems or general add-on equipment allow for access by the disabled with low vision and/or motor problems, speech to text and text to speech are readily available as well.

For the visually impaired 

For those with motor or multiple handicaps

For example, the audit found that individuals with motor disabilities who are unable to use a mouse to navigate the Internet would be unable to complete an application on Covered California's website using a keyboard.

While Covered California tested for accessibility before launching its website, the audit found that the exchange failed to perform regular, automatic tests of the accessibility of later updates to the site.

The IG found 'non-events', however this may be due to the content "completely inaccessible to users."

The deficits were not isolate to the Covered California health exchange but were also found in other state web sites.

In addition to Covered California, the audit reviewed the websites for:

• California Community Colleges;
• The California Department of Human Resources; and
• The state Franchise Tax Board.

Of the four departments included in the audit, Covered California's website had the most violations of Web accessibility standards.

I temporarily went back to paper records. And it wasn't so bad.

I temporarily went back to paper records.  And it wasn't so bad.



The real story. Hopefully his database is still intact.  The big question is why this cloud based EMR did not have a mirror which would allow for uninterrupted service.  Another important question for EHR cloud vendors is do they have redundancy in several data warehouses. Fire or other catastrophic events could effect thousands of physicians.  Any physician considering cloud based EHR should insist on this feature.

A refesher look at prior technology. We recomend always keeping some progress notes in the store room.  An alternative to typing in the hand-wriiten notes, just scan them into the EHR when ready. It is ill-advised to use a physicians time to transcribe data. There are many affordable scanners that are also scanning devices:

Hewlett Packard AIO Printer

In the overall scheme of things 20 medical records don't mean anything to the data geeks.

EHRs do afford more legibility and better data retrieval.

The Impact of Aging on the HCFA, HHS, and CMS

Older Americans with five or more chronic conditions incurred an average of $5,300 in prescription drug costs in 2008, compared to $1,230 for those with no chronic conditions. MORE STATISTICS

20 percent of total U.S. population  — The population of Americans age 65 and over in 2030 is projected to be 20 percent of the total U.S. population (72 million), compared to 13 percent in 2010.

SOURCE(S): Federal Interagency Forum On Aging Related Statistics

19.2 years of living after age 65  — Under current mortality conditions, people who survive to age 65 can expect to live an average of 19.2 more years, nearly 5 years longer than people age 65 in 1960.

1.3 years of more living   — Under current mortality conditions, white people who survive to age 65 can expect to live an average of 1.3 years longer than black people.

SOURCE(S): Federal Interagency Forum On Aging Related Statistics

45 percent of beneficiaries live with chronic conditions  — Nearly half (45 percent) of the Medicare population is living with three or more chronic conditions.

SOURCE(S): AARP

JUNE 26, 2012 One in four beneficiaries live below the poverty line  — Nearly one in four Medicare beneficiaries were living below the federal poverty line in 2007. SOURCE(S): AARP UNE 26, 2012 One in six beneficiaries under 65 qualified for Medicare on the basis of permanent disability  — One in six beneficiaries qualified for Medicare coverage in 2011 before turning 65 on the basis of permanent disability. SOURCE(S): AARP 21 percent of federal health care spending  — Federal spending for Medicare made up 21 percent of total expenditures in health care in 2010. SOURCE(S): Congressional Budget Office 80 million people covered by Medicare  — By 2030, 80 million people will be covered by Medicare. SOURCE(S): 2012 Medicare Trustees Report 65 percent in HMO plans  — Sixty-five percent of Medicare Advantage enrollees are in health maintenance organization (HMO) plans, followed by local preferred provider organizations (PPOs) and regional PPOs, 21 percent and 7 percent, respectively. SOURCE(S): Kaiser Family Foundation MAY 31, 2012 17 percent of adults aged 55 to 64 reported having unmet needs or delayed care  — Medicare seniors reported similar rates of unmet needs or delayed care (8%) to adults aged 55 to 64 with private insurance plans (17%). SOURCE(S): Kaiser Family Foundaion 165 provisions in the Affordable Care Act affect Medicare  — The Affordable Care Act contains roughly 165 provisions that affect the Medicare program. SOURCE(S): 2010 Medicare Trustees Report 2015  ANNUAL REPORT OFTHE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS Medicare Fraud Report from the OIG (2012) While Medicare Fraud is widely publicized,  cases were prosecuted in 2012, the OIGs report elaborates further. SUMMARY For the first half of FY 2012, we reported expected recoveries of about $1.2 billion consisting of $483.1 million in audit receivables and $748 million in investigative receivables (which includes $136.6 million in non-HHS investigative receivables resulting from our work in areas such as the States’ shares of Medicaid restitution). We reported exclusions of 1,264 individuals and entities from participation in Federal health care programs; 388 criminal actions against individuals or entities that engaged in crimes against HHS programs; and 164 civil actions, which include false claims and unjust-enrichment lawsuits filed in Federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters. Following are highlights of some of the significant problems, abuses, deficiencies, activities, and investigative outcomes that are included in the Semiannual Report for the first half of FY 2012. Health Care Fraud Prevention About 10 percent of money returned to the Medicare Trust Funds  — About 10 percent of the $20.6 billion obtained from people or organizations that committed Medicare fraud and returned to the Medicare Trust Funds since 1997 was returned in 2011. SOURCE(S): Department of Health and Human Services sent roughly 10.4 percent of GDP spending in 2086, resulting in greater strain on the federal budget, economy and Medicare beneficiaries. SOURCE(S): Medicare Trustees 2012 Report 15 percent of Medicare household budgets  — In 2010, health expenses accounted for nearly 15 percent of household budgets for Medicare beneficiaries, on average – three times more than non-Medicare households. SOURCE(S): Kaiser Family Foundation $78,000 average annual cost  — The annual cost of nursing home care averaged about $78,000 nationwide in 2011. SOURCE(S): Kaiser Family Foundation Graphics

Health Train Express is the Engine pulling or pushing ?

We all know that train engines can pull a train, or push from beind ?  The advantage of pulling the train is that the  engineer can see where he is going and where there might be obstacles on the track, a car, a broken rail, a rock, or any object that could derail  the train.  If the engine is in the rear...it pushes blindly, unless there is an observer in the first car. Perhaps a video monitor would suffice.

The analogy is about health care reform. Although many previoiusly uninsured now are counted as insured, this does not mean that all will receive health care.

The Affordable Care Act sets into play many steps on the journey of health reform. It looks like an all or none plan, destined to jump off the tracks at speed without considering turns or hills or obstacles. Thus far we have seen changes by executive order which have created concerns about the law being changed without congressional approval at the whim of the chief executive.  Most of it was do to poor planning on enrollment methodology, and some due to provider inability to comply in a timely fashion with the law.  None of this increases confidence in the law.

We in our daily work as physicians know all to well the working of our clinic and the work flow. We know  how and why claims are denied, the need for privacy and confidentiality and much more.

We have seen what digital health has done to privacy and confidentiality.

The complexity of our system has increased leading to more possibility for mistakes. The cost of the changes are being ignored in the calculation of savings.

Yes, the main driver of cost is utilization.

Who are the  drivers and sources for health reform ?

1. One can point fingers at state and federal regulators
2. The changes are so complex that it takes an army of consultants, who forever are holding meetings annually just to  assist providers with instructions on compliance. And here are some examples ofv groups and their agenda.

     CAPG               AGENDA 

   AMA This site from the Medicare News Group lists the portions of the ACA which the AMA      supports as well as those the AMA  opposes

FDA labels

In what may be a groundbreaking event, the constitutionality of FDA labels is brought into question, not by what is in the label, but what is left out.

Ethical, Legal & Social Issues
 Discussing off-label uses of drugs with doctors: a constitutional right or sidestepping the United States FDA authority?
  A Dublin based pharmaceutical company - Amarin Pharma, is currently in the process of suing the Food and Drug Administration of the United States for the right to talk about unapproved uses for their products as long as it is an honest depiction of the products capabilities. Even though some lower courts have agreed to this practice, the federal government in the United States have levied huge fines to some companies for talking to patients about off-label use for their medications. AmarinPharma is arguing that it has a right under the First Amendment (free speech) of the constitution of the United States to share certain information about its product with doctors. According to the lawyers for the company this is the first time a manufacturer had pre-emptively sued the agency over the free speech issue, before being accused of any wrongdoing. According to them “If you tell the truth — if you’re not misleading — then the First Amendment protects you when you provide this sort of information,”. But critics point out that this practice sidesteps the authority of the FDA, which is responsible for making sure that only safe and effective drugs reach the marketplace and that the constitution does not guarantee the First Amendment as an absolute right.
For further information 

A Glass of Wine is Equivalent to a Heavy Session on a Cross Trainer

Thoughts for #sciencefriday.



A glass of red wine is the equivalent to an hour at the gym, says new study |

 Drinking red wine could help burn fat, says new study
Research conducted by the University of Alberta in Canada has found that health benefits in resveratrol, a compound found in red wine, are equivalent to those that we get from exercise.

Red wine over a heavy session on the cross-trainer? Now that’s something we can definitely get onboard with.

According to lead researcher, Jason Dyck, these findings will help those unable to exercise as resveratrol was seen to improve physical performance, heart function and muscle strength.

“I think resveratrol could help patient populations who want to exercise but are physically incapable,” he says.

Not Runnning a Hospital

Paul Levy is one of my favorite reads....and he loves alpacas

His most recent post deserves some commentary, and for what it is worth..my history pre-dates his somewhat and all I can observe is that nothing seems to change...at all.

From “Not Running a Hospital (Paul Levy)

More Money coming in through the back door?

Robert Pear at the New York Times offers an excellent summary of findings by the General Accountability Office that the procedure used by the Medicare agency (CMS) to determine the relative weightings for $70 billion physician payments has major flaws.  That CMS weighting is also used by most private insurance companies as the basis for physician payments.  This is a topic that has received coverage over the years, but little has changed.

(A pause here to ask and refer back to a previous post:  When was the last time you heard one of the Triple Aim advocates—inside or outside of CMS--take on this issue, which has a direct result in how much primary care doctors and other cognitive specialists get paid?)

But, there is an important reminder in this story.  Pear notes (with my emphasis added):

“Under federal law, Medicare fees are supposed to reflect the time required to perform a service and the intensity of the work.”

Uh oh.  Let’s consider how the pervasive use of robotic surgery will factor into this calculation.  For example, in the past, most prostatectomies would have been done as open procedures or using a manual laparoscopic approach.

Now, due to a highly successful marketing campaign by Intuitive Surgical and by doctors and hospitals that have showcased their robotic surgery program, the vast majority of these cases are performed robotically.  This has increased the required time in the operating rooms.

The same applies to other procedures in which Intuitive has made and will make inroads—gall bladder removal, hysterectomies, hernia repairs, and so on.

Is this a back-door way for surgeons to receive more money for the same procedures?

POSTED BY PAUL LEVY AT 6/02/2015 11:18:00 AM

Health Train Express’s Response

Commentary on his blog post:

Dr. Levy, this is not an unusual or new problem:

Medical Device companies repeatedly create this type of disruptive innovation, created by an innovative medical bioengineer, and quietly pass along the problem to the MD who becomes the evil-doer.  In this case the increase in time due to the complexity of the surgery requiring significant expense purchasing the equipment retraining and other hidden costs should be adjusted upward.

A literature review from the   American Cancer Society  reveals the following:

“Robotic-assisted laparoscopic radical prostatectomy

A newer approach is to do the laparoscopic surgery using a robotic interface (called the da Vinci system), which is known as robotic-assisted laparoscopic radical prostatectomy (RALRP). The surgeon sits at a panel near the operating table and controls robotic arms to do the operation through several small incisions in the patient’s abdomen.

Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there seems to be little difference between robotic and direct LRP for the patient.

In terms of the side effects men are most concerned about, such as urinary or erection problems (described below), there does not seem to be a difference between robotic-assisted LRP and other approaches to prostatectomy.

For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of LRP is the surgeon’s experience and skill.

If you are thinking about treatment with either type of LRP, it’s important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that either type of LRP is the treatment for you, be sure to find a surgeon with a lot of experience.”

In another specialty such as ophthalmology, cataract removal underwent many changes requiring more expensive equipment, such as phacoemulsifiers, femtosecond lasers, yag lasers and more.  These changes resulted in a shift to an ASC for a  fifteen minute surgery, vs a three day in patient procedure taking one hour.  Medicare slashed the allowed amount from $1300 for the physician fee to about $ 500.00.  The overall change improved outcomes greatly, reduced hospital stay (eliminating it completely in most cases)

One must not forget that the reimbursement includes time for post-operative care, up to 90 days in the case of cataract surgery, which is truly neglected in the case of cataract removal and most likely also LRP or RALRP.

The truth is that CMS is bloated with bureaucracy and needs to be investigated by an inspector general.  We have too many parastic entities feeding off the chaos of CMS , the Affordable Care Act and burgeoning health reform.