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Hospital Performance Improved But Are Measurements Accurate? September 17, 2011

Posted by jomaxx in : health care news, health care reform, health reform, Hospitals, medicine, patient care, Physicians, Public Health , add a comment

Is performance or reputation more important?

Does reputation equate to performance?

Are the data being measured of real patient care value?

A new report released by the Joint Commission on Accreditation of Hospitals (JCAH) suggests that on a variety of fronts hospitals are doing a better job of patient care. They looked specifically at five areas of care: heart attack, heart failure, pneumonia, surgical, children’s asthma.  The report shows that in terms of several quality measures, such as administering antibiotics in a timely manner to surgical or ICU patient, giving aspirin to heart attack patients on admission to the ER and the like, overall hospitals have improved in last couple of years.

The new report identifies 405 hospitals out of over 3,000 (14%) accredited by the JCAH.   Those selected had to achieve a compliance score of at least 95% in one or more of the five key areas monitored during this review.  Some hospitals achieved these scores in only one category, others in two, three or more.  The complete list has been published.

Of note is the finding that none of the 17 medical centers listed by U.S. News & World Report on its “Best Hospitals Honor Roll” this year are on the Joint Commission’s list of 405 hospitals that received at least a 95% composite score for compliance with treatment standards. About one-third of a hospital’s score in the U.S. News methodology is also based on its reputation as gauged by a survey of physicians.

The findings bring into question how deserving these institutions are of their reputations.  Still other measures of quality are out there including Medicare’s Hospital Compare site which lists among other things, mortality and morbidity rates for hospitals based on Medicare data.

It should also be noted that many hospitals that did not make this list still scored very highly and only missed the list by a few percentage points.  In fact it could well be that the difference in some cases was not performance at all, but simply lack of detailed documentation, which is really all JCAH and Medicare can go by in their respective data compilations.

The entire “science” of medical comparative outcomes is still really in it’s infancy, with many confounding factors needing to be considered and analyzed to achieve a true picture of outcomes and valid comparisons between facilities and treatments.  Still, it is clear that with increasing data collection, better analytical evaluation can be undertaken and a more informed patient and provider population will result.

Report Finds Improved Performance by Hospitals – http://is.gd/STHqr4

2010 Top Performers on Key Quality Measures – http://is.gd/YK09jV

Hospital Compare – http://is.gd/QfMaQ9

Health Insurers Charged with Increasing Anti-Competitive Behavior November 25, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance, health insurance reform, Hospitals, Insurance, patient care, Physicians, politics, Public Health, Tax Policy , add a comment

Justice Department Sues Blue Cross of Michigan

Recently, a case involving Blue Cross Blue Shield of Michigan (BCBSM) has received attention in the press (USA Today, Detroit Free Press, Kaiser Health News).  The case involves alleged attempts by Blue Cross of Michigan to inhibit competition in the health insurance marketplace.  Specifically, the case in question focuses on TheraMatrix, a physical therapy provider.  They apparently were able to carve out coverage contracts with major employers such as automakers for physical therapy services.  That brought about a host of reactions from BCBSM and local hospitals aligned with Michigan’s dominant health insurance carrier. 1,2,3,4,5,6

This case highlights among other issues, most favored nation (MFN) status in contracts offered by BCBSM to potential participating hospitals.  These types of clauses in health insurance contracts are under attack in general, and specifically in this case, are the subject of a legal action brought by the United States Justice Department as well as the State of Michigan against BCBSM. 6,7

Additionally, it has been reported that insurers nationally have been hoarding huge reserves of cash, far in excess of actuarially required amounts to meet future demands.  The reasons for this are not clear, but one can of course speculate that this excess cash is being invested to increase profits for health insurers. 8

It has been argued that one of the best ways to deal with health insurers in the private market is to view them in the same light as a utility.  That would allow them to be regulated not just in terms of their solvency and adequacy of reserves, but also in terms of their rate structure in relation to those issues and their overall profitability.  It is clear that regulated utilities still make money, earn profits and yield returns for their investors.  The same would be true of regulated health insurers. 9

Elsewhere in the nation, Blue Cross Blue Shield of Louisiana (BCBSLA), that states largest insurer, and East Jefferson General Hospital (EJGH) in the New Orleans market have been engaged in a war of words following failed negotiations over a new contract.  BCBSLA argues that EJGH wanted higher payments for services than other local hospitals.  EJGH argues that BCBSLA is building excess reserves while cutting services and raising premiums.  The two sides ended their contract last month leaving many locals without access to one of the areas major hospitals. 10,11,12

The issues raised by the recent news regarding anti-competitive behavior, excess cash and profits, along with continuing rate increases all point to a market which has run amuck.  Free markets are generally best, however, when vital services are at stake, necessary regulation must be implemented.  The fact that in many states, one or two major health insurers hold sway over the majority of the market raises classic anti-trust questions. 13,14

Currently, the health reform bill fashioned by Congress that was passed along partisan lines last December, does not resolve these issues.  In fact, in many ways, in complicates them.  Still the bill fails to address issues of rate structure, premium increases, profitability, and anti-trust issues, which are of major concern when discussing health insurance reform.

Removal of anti-trust exemptions, along with the ability of health insurers to sell across state lines would be major steps toward improving access to affordable private coverage.  However, this can only come to pass if there is proper exercise of regulatory control over health insurance rates as outlined above.  Only these reforms will secure both the private health insurance market and the needed changes the citizenry deserves. 15

  1. Did Blues bully cost-saving firm in Michigan?
  2. Case against Blue Cross shows difficulty of cutting health costs
  3. BCBS Of Michigan Alleged To Have Crushed Pilot Physical Therapy Program It Saw As Competition
  4. TheraMatrix
  5. Blue Cross Blue Shield of Michigan
  6. Feds accuse Mich. Blue Cross of anti-competitive contracts
  7. UNITED STATES OF AMERICA and the STATE OF MICHIGAN, Plaintiffs, v. BLUE CROSS BLUE SHIELD OF MICHIGAN, a Michigan nonprofit healthcare corporation, Defendant (Case 2:10-cv-14155-DPH -MKM Document 1 Filed 10/18/10)
  8. Consumer group: Insurers kept surplus while hiking premiums
  9. Details on “the plan”
  10. East Jefferson General Hospital seeks arbiter in dispute with insurer
  11. East Jefferson General Hospital
  12. Blue Cross Blue Shield of Louisiana
  13. Healthcare Sector Comes Under Increased Government Antitrust Scrutiny
  14. Are Insurance Companies Still Exempt From Antitrust Laws?
  15. Health Insurers Charged with Increasing Anti-Competitive Behavior

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Waivers from Health Reform Law? Is the plan flawed? October 12, 2010

Posted by Obi Jo in : health care reform, health insurance reform, health reform, medicine, politics , add a comment

Waivers from Obamacare fast-tracked by HHS

McDonald’s, the United Federation of Teachers (with 351,000 members!) and others got a break this past week.  Quietly and without fanfare, the federal government granted them, and other high-profile companies and organizations waivers allowing them to opt out of a key mandate in the new health care law. The United Agricultural Benefit Trust (a California coop offering coverage to farm workers) was allowed to exempt 17,347 people. San Diego-based Jack in the Box’s waiver is for 1,130 workers, while McDonald’s asked to excuse 115,000. The waivers being granted at this time are for one year.  They have been granted to at least 30 major employers, insurers and unions, representing over 1 million employees.  These waivers will allow those companies and unions to maintain coverage which is minimal and far below the new laws requirements. In the case of McDonald’s, and other employers, many of their plans are designed to offer some coverage to the many thousands of part-time workers they employ. The largest waiver was for the aforementioned United Federation of Teachers Welfare Fund in New York, whose mini-med plan has 351,000 enrollees. Other waivers were approved for CIGNA Healthcare (265,000 enrollees), Aetna Inc. (209,423 enrollees) and BCS Insurance Group (115,000 enrollees)

Administration officials have defended these actions as a protection for lower wage workers who desire coverage by trying to avoid the creation of a new group of of uninsured Americans before other options are available.  However, it is the massive health bill which has actually created this problem. Obama administration officials have tried to soften stepped up resistance to implementation of the new health bill by allowing these exemptions. In addition to complaints from unions, insurers and companies about the new laws current levels of benefits, a number of leading insurers, including WellPoint, Aetna and Cigna, have also objected to rules requiring them to cover  children who are seriously ill.  They have warned that they will simply stop selling new policies in some states because the rules do not protect them from having to cover too many sick children. In some states we are aware of insurers offering so called “family coverage” but not insuring children at all to get around the new requirements.  In some cases they are limited or eliminating the term family coverage all together.

Officials in Washington and policy consultants have countered that implementation and transition would always be considered the hardest part of the health plan.  Many predict that more and more companies will petition the government to delay, weaken or repeal various regulations.  Some feel that this will continue until the law is fully implemented in 2014.  However, many others are equally skeptical.

President Obama’s hand picked director of the Office of Health Reform, Nancy-Ann DeParle, has openly admitted that concessions given to companies and insurers are attempts to avoid people losing coverage before the full law goes into effect.  She has argued that it is a “balancing act” and that the President is hoping to create a smooth pathway to get to 2014.

White House officials are struggling with implementation of the widely unpopular health reform law in the run up to the mid-term elections. Regulations are gradually being rolled out, with many more to be issued over the years to come. If past history is any guide, a Congressional bill that totals over 2,400 pages is likely to generate two to three times that many pages in new regulations.  The real threat of companies dropping their coverage due to the new law has evolved into this falls most problematic political issue.

Officials indicate that to date all but one waiver has been granted.  It is also unknown just how many waivers are pending at Health and Human Services (HHS). Since the waivers presently only extend for one year, many believe that employers will continue to seek renewals, as well as new or similar waivers as future limits and provisions of the health bill come into effect.  The health care reform law sets minimum annual limits on health expenses at $750,000 effective after September 23, 2010. This amount rises to $1.25 million September 23, 2011, to $2 million September 23, 2012 through January 1, 2014. In 2014, annual limits will be banned except for a few cases.

Lobbyists are very interested in securing waivers for clients.  They have not been surprised that the administration chose not to publicize them.  Some lobbyists have opined that the administration has been happy to keep these waivers low key. Others have commented that they too would have kept these hidden out of fear that other companies would hop on the waiver bandwagon.  The premise of the administration, said one lobbyist, that it can set a reform package, then impose expensive mandates, and expect it to be followed is totally invalidated by the waiver process.

Again, with elections coming up November 2nd, the timing could not be worse for the White House or Congressional Democrats. The major political issue here is that the President, Speaker Pelosi and Majority Leader Reid all promised that no person would lose the health coverage they have. It turns out this is not the case since here, one month before the election, some 1 million workers have been faced with loss of the coverage they had – that is unless the waivers were granted.

A recent survey (Mercer, LLC NY, NY) found the annual benefit provided by most mini-med plans (for those employers with at least 20,000 employees) was $10,000 in 2009.  Only 7% of all employers with 500 or more employees offer any kind of mini-med plans. Proposals in the health care reform law would allow low-wage employees to qualify for government-subsidized coverage that will be available from insurers offering coverage through new state insurance exchanges starting in 2014, supposedly reducing the need for mini-med plans.  Of course this assumes the plan is implemented as envisioned.  It also adds credence to critics who warned that many employers would simply drop coverage all together forcing many into the government controlled exchanges.  Of course, for some on the left, this is music to their ears, for as more persons are added to government controlled health insurance it moves the nation one step closer to their goal of single payer, government run health care . . . fully socialized medicine by any definition . . . obi jo and jomaxx

Obama Administration Grants Health Care Waivers to Big Companies, Unions – http://www.foxnews.com/politics/2010/10/08/obama-administration-grants-health-care-waivers-big-companies-unions

Waivers Aim at Talk of Dropping Health Coverage – http://www.nytimes.com/2010/10/07/business/07insure.html

Obama grapples with implementing unpopular health law before Nov. – http://thehill.com/blogs/healthwatch/health-reform-implementation/123305-obama-grapples-with-implementing-unpopular-health-law-weeks-before-election

White House defends waivers from new health law – http://www.wral.com/business/story/8417118/

McDonald’s, 29 other firms get health care coverage waivers – http://www.usatoday.com/money/industries/health/2010-10-07-healthlaw07_ST_N.htm

A third of employers may be penalized for health coverage deemed ‘unaffordable’ – http://www.mercer.com/summary.htm?idContent=1378875

HHS swiftly OKs waivers for ‘mini-med’ sponsors – http://www.businessinsurance.com/article/20101010/ISSUE01/310109971#

White House defends waivers from new health law – http://srnnews.townhall.com/news/Health/2010/10/07/white_house_defends_waivers_from_new_health_law

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Adult Vaccinations: Neglected Preventative Medicine September 29, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance reform, health reform, Medicare, medicine, Pharmaceuticals, Physicians, Public Health, women , add a comment

The CDC believes that far too few adults are maintaining vaccinations or getting vaccinated at all. C.D.C. recommends that ALL people 19 and older receive immunizations against as many as 14 infectious diseases, while remembering that not all adults require every vaccine. Most of the time, adults rarely think about getting shots unless they are injured or plan travel to an undeveloped country.

For example, this year alone, over 11,000 cases of whooping cough (pertussis) have been reported nationwide. Infections are near record levels in California and 9 infants have died. No doubt some of these young children had not received all of their vaccinations.  Still, it is firmly believed that some of those deaths could have been prevented if more adults had also been immunized.

CDC studies currently show that only 7% of Americans over age 60 have received the herpes zoster vaccine to prevent shingles.  Shingles is a painful nerve infection which can become a chronic pain issue and cause debilitation. The widely publicized vaccine against the two types of human papilloma virus that cause 70% of all cervical cancers has to date only been received by an estimated 11% of young women.

More concerning is data from a study by the National Foundation for Infectious Diseases conducted in 2007 which showed that 40% responded that if they had been vaccinated as a child they no longer needed any other vaccinations.  Even worse is that some 18% said that vaccines were not necessary for adults at all.

One aspect of the new health care law should be of some help in removing barriers that may be keeping adults away from vaccinations.  The new health plan mandates that group and individual health plans along with Medicare provide preventive health services, including immunizations recommended by the C.D.C., at no charge. For insured persons, that will mean no co-payments, co-insurance or deductibles. However, that is not the entire story. If your insurance is through a group or individual health plan, your plan must be new, or have been substantively changed, in order for the new requirements to apply. Also, some of the CDC recommendations, those which are most recent, will not be covered initially.

From the standpoint of disease prevention, vaccines are cheap.  One trip to the emergency room due to a significant case of the flu or pneumonia can generate bills totally in the thousands of dollars. Flu shots are almost always to be found for about $20 and for many individuals, are often found at no charge.  Pneumonia vaccines cost around $70 to $80 versus potentially much more if you get pneumonia.

Many local pharmacies, including most of the large chain pharmacies offer vaccinations.  Some even have so-called “retail clinics” and administer a wide range of vaccines.  The most well known include CVS MinuteClinics and Walgreens Take Care Clinics. A wide range of vaccines can be obtained at these pharmacies.  Prices vary but some examples include: hepatitis A ($110-$120) and B ($100-$110), meningitis ($140-$150), pneumonia ($70-$80) and DPT (diphtheria, pertussis and tetanus ($80-$90). There are literally thousands of pharmacies nationwide offering these services, with many open daily.  Usually appointments are not necessary nor are prescriptions.  Some larger chains even offer travel vaccines with specified lists for defined areas of travel. In all states, pharmacists are licensed to give flu shots after taking some basic courses.  Many states allow pharmacists to administer a full range of vaccines as well.

This raises the question, why can’t I get these shots from my doctor? In many cases you can, but increasingly, the cost of vaccines are not covered for physicians at a rate commensurate with what they must pay.  Also, administration costs are barely if at all covered by many insurers.  Recently, flu shots were available at the local family doctor here, but were not “advertised” and given only if established patients asked.  This was actually done as a courtesy. So it would appear that vaccines have made the jump to the public health arena completely.  This is good news overall, as the broader the range of persons vaccinated against communicable disease, the better for all, regardless of age. This is especially true in an age where inter-continental and international travel occur thousands of times daily . . . jomaxx and obi jo

Cost and Lack of Awareness Hamper Adult Vaccination Efforts – http://www.nytimes.com/2010/09/25/health/25patient.html?_r=1&emc=tnt&tntemail0=y

Saving Lives:Integrating Vaccines for Adults into Routine Care – http://www.nfid.org/pdf/publications/adultimmcta.pdf

Grantee Immunization Websites – http://www.cdc.gov/vaccines/spec-grps/prog-mgrs/grantee-imz-websites.htm

Vaccinations for Adults:You’re NEVER too old to get immunized! – http://www.immunize.org/catg.d/p4030.pdf

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Communications Technology Speeding ER Care Delivery August 20, 2010

Posted by Obi Jo in : E Health, EHR (electronic health records), health care news, health care reform, health reform, Hospitals, medicine, Nursing, patient care, Physicians, Public Health , add a comment

Despite the many difficulties and costs involved in the gradual movement of medical records systems to fully digital mode, it appears that where implemented, digital data systems are making quite a difference.   A new study shows that patients treated at hospital emergency rooms that use all-digital-records systems are more likely to have shorter stays than at hospitals with paper or basic digital-records systems. The study was based on data from the 2006 National Hospital Ambulatory Medical Care Survey.  It found that people spent 22.4% less time and were treated 13.1% more quickly at hospitals with complete electronic health-records systems compared with other hospitals. It also found that hospitals with basic computerized records were less efficient than other hospitals. Emergency-room wait times at those semi digital hospitals were 47.3% longer for patients with an urgent or semi-urgent matter. Of course, training of medical staff, physicians and nurses, is critical to both acceptance and overall ease of use of any system implemented.

Another trend just gaining ground is the use of “apps” for various mobile phones and PDA’s as well as computer web site updates related to emergency room access and wait times.  A suburban Boston hospital has introduced a new way for patients to avoid long emergency room waits — texting.  MetroWest Medical Center located outside of Boston in Framingham, launched the state’s first texting program that allows potential patients to find out ER wait times before making the trip to the hospital. The hospital began the service last week in hopes of building its market share and improving ER performance — and by extension, patient satisfaction. Since that time, people have sent in more than 450 text requests from their cell phones for wait times at the medical center’s emergency rooms at Framingham Union Hospital and Leonard Morse in Natick. Average wait times as of yesterday afternoon were 24 minutes and 6 minutes, respectively. The medical center measures wait times from when patients check in to when they see a doctor. Ochsner Clinic, based in New Orleans, with affiliated throughout southeast Louisiana has also moved to the use of “apps” as well a maintaining a real time online report of wait times at the ERs in their various medical facilities.

Of course, in a real life and death emergency, it is hard to imagine anyone using any of these services since a call to 911 or an immediate trip to the hospital would seem more prudent.  For less than life threatening emergencies, however, this would seem to be common sense concept, to reduce waiting and its associated frustration and tension which affects both care givers and patients.  Health information technology and the use of newer applications that were not originally designed for health care (texting, mobile downloads, web based monitoring) will make the difference going forward.  Real health reform will come from true innovation in technology and subsequent adaptation with service based innovations as well . . . obi jo and jomaxx

Texting, On-Line Updates Assist Patients Seeking Timely ER Care – http://www.associatedcontent.com/article/5708630/texting_online_updates_assist_patients.html

Digital hospital records tied to higher efficiency – http://www.azcentral.com/arizonarepublic/business/articles/2010/08/20/20100820digital-hospital-records-more-efficient.html

Hospital starts texting service for ER wait times – http://www.boston.com/news/health/blog/2010/08/hospital_starts.html

CURRENT EMERGENCY ROOM WAIT TIMES – http://www.ochsner.org/emergency

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AMA: Health Insurers, Make Your Physician Rating Measures Public! July 20, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance, health insurance access, health insurance reform, Insurance, insurance access, Insurance Profits, Medicare, medicine, Patents, patient care, Physicians, Public Health , add a comment

Doctors are openly criticizing  growing efforts by health plans and health insurers to direct patients toward certain physicians based on perceived cost or quality, arguing that the rankings may be unreliable and unfair. In response to new evidence that patients are receiving inaccurate physician profiles from health insurers, the American Medical Association (AMA) delivered letters today to the nation’s largest health insurance companies asking for immediate action to improve the accuracy, reliability and transparency of physician ratings.

The AMA sent letters to 45 health insurance companies nationwide asking them to verify that their physician rating programs are accurate by allowing outside experts to analyze them.  Forty-seven (47) state medical societies also signed the letters. The AMA is concerned that health plans are not providing customers with accurate information when they rate physicians based on cost and quality. Physician ratings have grown in popularity as insurers seek to provide more information to members and employers to evaluate the quality and cost of services. The AMA cites a March study by the RAND Corp. published in the New England Journal of Medicine that indicated physician ratings by health insurers can be wrong up to two-thirds of the time for some groups of physicians.  In that study the final conclusion was that current methods for profiling physicians with respect to costs of services may produce misleading results.

Patients should always be able to trust that insurers are providing accurate and reliable information on physicians,” said AMA President Cecil Wilson in a statement. Robert Zirkelbach, spokesman for America’s Health Insurance Plans said that insurers are working closely with providers to develop these measures. “This is an ongoing process that is continually improving.”    That comment however, begs the question of just who is it that is making up the measures?   Who has input?  Are physicians and others involved in an open process, or is this a closed door endeavor.  Health plans after all, are funding agents, taking in premiums and making payment for services.  They keep the margin – which goes up if doctors have fewer visits, order less tests and do fewer procedures.  So, is ” quality” really being measured by most health insurers, or in the end, is it overall cost to the health insurer that rules the day?

Having said all that, we know that the primary rating measure for insurer is cost – read, what they have pay out to providers (doctors, hospitals, labs, etc.).  Yes, they look at other things such as certification, specialization, office hours, convenience for patients, locations and the like.  But in the end, they look and profile based on visits, tests and procedures.   Health plans quantify these measures via the CPT coding system and they then look at overall costs.  In the end, the most “cost efficient” doctors (read cheapest), are for the most part who are found on select panels.  This process reached a peak with the failed HMO craze of the 80’s and early 90’s.  More and more, open panels have become the norm.  However, in light of a likely squeeze on health insurance profits, health plans are looking to resurrect many of these programs to limit physician panels and therefore limit access of their subscribers.  The end result will be to reduce costs – as well as increase health plan profits.

Measurement of physician and surgeon “quality” in the end, is exceedingly difficult, beyond the most obvious of measures such as overall mortality and morbidity associated with interventions performed by an individual physician.  We applaud the AMA and other medical societies for publicly calling out health plans and health insurers.  They should and MUST make their profiling measures public so that they can be independently reviewed for accuracy, veracity and reliability.  Also, physicians need to know what they are being judged on by these payers, and patients must have confidence that these ratings and rankings are of some real value . . . jomaxx and obi jo

AMA and State Medical Societies Call on Insurers to Publicly Document the Accuracy of Physician Cost Profiling – http://www.ama-assn.org/ama/pub/news/news/physician-cost-profiling.shtml

AMA presses insurers on doc-rating programs – http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100719/NEWS/307199967

Doctors Slam Insurers Over Their Rankings – http://online.wsj.com/article/SB10001424052748704720004575377523886401684.html

Physician Cost Profiling — Reliability and Risk of Misclassification – http://content.nejm.org/cgi/content/short/362/11/1014

AMA wants Humana, others to consider quality more in ranking doctors – http://www.courier-journal.com/article/20100719/BUSINESS/7190349/1003/rss03

AMA battles insurers over doctor ratings – http://www.startribune.com/lifestyle/health/98797709.html?elr=KArksD:aDyaEP:kD:aUt:aDyaEP:kD:aUiD3aPc:_Yyc:aU7DYaGEP7vDEh7P:DiUs

Medical Groups Criticize Insurers on Rating Doctors – http://prescriptions.blogs.nytimes.com/2010/07/19/medical-groups-criticize-insurers-on-rating-doctors/

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QUICK POST: Birth Rate in US Fell in 2008 July 12, 2010

Posted by Obi Jo in : health care news, medicine, politics, Public Health, women , add a comment

Both the number and rate of U.S. births fell in 2008, according to   recent data — a change partly attributable to uncertainty about the economy. The decline was seen in nearly all age groups, from teens 15 and up through women in their 30s, reported researchers from the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. The birth rate rose only in women 40 and older.

An estimated 4,251,095 births occurred in 2008, down nearly 2% from the 4,317,119 in 2007 — the highest number ever registered in the USA. The “crude birth rate,” or the number of births per 1,000 total population, also fell 2% between 2007 and 2008.

Other highlights of the CDC’s preliminary 2008 births report include:

•The U.S. teen birth rate dropped 2% after rising in both 2006 and 2007. A decline in teen pregnancies had been a public health success story, but when the rate began to rise, some observers wondered whether teens had grown tired of prevention messages.
•The preterm, or premature, birth rate dropped 3% to 12.3% of all births. The decline occurred mainly in late preterm births, those that at 34 to 36 weeks gestation.
•The C-section rate rose for the 12th straight year to an all-time high of 32.3%. Still, the pace of the increase has slowed in the last few years.

So the economy does influence reproduction . . . something we all suspected . . . jomaxx

CDC: U.S. birth rate falls, but not among moms 40 and up – http://www.usatoday.com/news/health/2010-04-06-birth-rate_N.htm

U.S. birthrate drops 2 percent in 2008 – http://www.washingtonpost.com/wp-dyn/content/article/2010/04/06/AR2010040600758.html

Overall Birth Rates are Down, But Up for Older Women – http://www.latimes.com/news/health/boostershots

Rise in teen birth rate may have been ‘blip’ – http://www.cnn.com/2010/HEALTH/04/06/teen.births.cdc

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Recurring SGR Mess: Medicare Doctor Payment Formula Flawed June 30, 2010

Posted by Obi Jo in : health care news, health reform, Hospitals, Insurance, Medicare, medicine, patient care, Physicians, politics, Public Health, Tax Policy , add a comment

Congress passes ‘doc fix’ bill to stave off cuts

This past week, the House passed legislation to reverse a steep pay cut for Medicare doctors that began on June 1st. The temporary “doc-fix”, as it is called, staved off the 21% cut until December and provides a 2.2% pay increase for doctors who treat Medicare patients.  The Senate had passed the bill unanimously the previous week, but House Democrats sat on the proposal in order to pressure Senate budget hawks to back an extension of unemployment benefits and $15 billion for state Medicaid programs. When it became clear that the tax package would fail in the Senate, however, House Democrats finally — and reluctantly — brought the stand-alone doc-fix bill to the floor.

The American Medical Association (AMA) has for years urged Congress to repeal the formula that updates Medicare’s physician payments — a formula that most health experts agree is flawed. To no avail.  “Delaying the problem is not a solution,” AMA President Cecil Wilson said in a statement. “It doesn’t solve the Medicare mess Congress has created with a long series of short-term Medicare patches over the last decade — including four to avert the 2010 cut alone.”

Sadly, the political quagmire created by the SGR legislation can be seen in this latest round of action and inaction.  The SGR system does not work, yet Congress seems unable to muster the courage to fix it. The SGR (sustainable growth rate) concept was introduced in 1997.  It was designed to be a  target rate for growth in Medicare Part B spending for physician and non-physician practitioner (nurses, physical therapists, physician assistants, etc.) services. The SGR system is a key element upon which payment updates are established each year for physicians and other health providers.

This payment dynamic was designed to bring actual spending in-line with allowable spending over time.  It tied increases in volume of services per Medicare beneficiary to growth in the GDP (gross domestic product).  Adjustments can be made for changes in law and regulation, yet, these adjustments have not  reflected increased services resulting from technological advances and expansion of Medicare benefits (cancer screenings, diabetes management, etc.).  This flawed process has resulted in annual payment cuts that have continually been worsened by Congressional actions to stop the cuts, while failing to every adjust the target, leading to ever larger payments cuts being postponed to the next year.

When Congress enacted this law the target was set with 1996 as the base year. Payment updates for each subsequent year are determined by comparing cumulative actual expenditures to cumulative target expenditures in the prior year. Thus, the 2009 payment update was set by comparing actual expenditures from 1996-2008 to targeted expenditures from 1996-2008. If spending exceeds the SGR target, then physician payment updates will be less than the increase in the inflationary cost of providing a service.  Another major flaw is the inclusion of drugs administered in a physician’s office and laboratory tests (actual products), and physician services (set by the fee schedule). Payment updates however, only apply to physician services (fee schedule) – not drugs or lab tests. In January 2002, this formula resulted in a 5.4% cut.  During the intervening time payment rates fell further and further behind inflation in medical practice costs.

Let’s look at the history of these actions by Congress year by year since 2002

Congressional Interventions to Stop SGR Cuts
Year Scheduled – Rate – Congressional Action
2002 -5.4% cut None
2003 -4.4% cut -1.6% increase
2004 -4.5% cut -1.5% increase
2005 -3.3% cut -1.5% increase
2006 -4.4% cut -Freeze at 2005 level
2007 -5% cut -Freeze at 2005 level
2008 -10.1% cut -0.5% increase
2009 -15% cut -1.1% increase
2010 -21% cut

Congress has seemingly been blind to the fact that physicians have no control over a number of demographic facts of life which affect costs such as:

  • The overall increase in population in the US (estimated to exceed 310 million when the 2010 census comes in)  meaning more patients and more medical expenses
  • The expansion in the number of elderly, soon to be made much worse by the 75  million baby boomers turning 65 between 2011 and 2029 again, meaning more patients and more expenses
  • Revolutionary new medical technologies and pharmaceuticals, most of which are initially expensive, but which advance disease management and survival, many of which can and should be available within a doctor’s office, but whose costs are placed on the ledger of doctor costs, when they in fact are not
  • General inflation in the economy and the medical economy in particular
  • Failure of any general relief by government on the medical malpractice front
  • Increased mandates from federal rule makers on physicians (HIPPA, CLIA, OSHA, etc.

Some, mostly in the halls of academia, have argued that physicians have not met their targets to control spending because of their unwillingness to “limit spending” and “abide by recognized standards of care”.  We have noted in past commentaries that physicians do have a great deal of impact on overall health spending by the use of their pen, but despite that fact, the momentum of the changes occurring is far beyond the control of doctors. The outlined items above are at odds with any suggestion that physician are somehow at “fault” for continuing rises in health spending and renders those opinions to the contrary null and void.

Drugs Should Not Be In the SGR Calculation
Drugs administered by physicians in their offices offer many advantages.  First is the convenience to patients in not having to go to an outpatient center of similar to receive either an IM (intramuscular) or IV (intravenous) injection.  Second, in many if not most cases, the patients receiving these medications are ill with cancer or similar serious conditions so the ability to see their physician and receive a treatment is the same office setting offers greatly reduced stress for already stressed patients.

Physician do receive modest payments for the actual administration of drugs, but the cost of the drug itself is included in the spending that is used to calculate the SGR. Drug administration is a true physician service and should be included.  The drug product is, on the other hand, is an item that a medical practice must purchase in advance, is NOT a  physician service and should NOT be included.  In the case of cancer medications, these drug costs can be very high and adding them to the SGR inflates the rise in physician services artificially.  Why? Because doctors have NO control over Part B drug costs.  So, as drug costs increase, physicians get penalized under SGR rules.

Spending for physician-administered drugs has grown at higher rates than spending for all other physician services. This cost has increased over the past few years from $1.8 billion to $9.1 billion. This fact alone has significantly contributed to the spread between target and actual spending and large projected reductions in future physician payment rates.

The average annual growth in Medicare spending on drugs included in the SGR was 22% compared with 6% for all services (including drugs) included in the SGR, from the first quarter 1997 through  first quarter 2005.

Growth in Proportion of SGR Spending Consumed by Drug and Lab Costs:
1996: Drugs – 4%    Lab – 9%     Fee Schedule – 88%
2007: Drugs – 10%  Lab – 8%    Fee Schedule – 82%
2019: Drugs – 15%  Lab – 13%   Fee Schedule – 73%

Members in current and past Congresses from both parties have joined the physician community in advocating for retroactive removal of drugs from the physician payment system through administrative authority. Despite this, no President (neither Bush nor Obama) has taken any action.  Clearly, it cannot be realistic to finance the cost of life-saving drugs through cuts in payments to physicians. Physician payment cuts only serve to further reduce access to the very drugs that these policies are intended to make more accessible.  Removing drugs from SGR calculation would be a major step toward preserving access to these important drugs and other critical physicians’ services .  At the present time, the Administration’s proposed physician payment schedule for 2010 does indeed retroactively remove drugs from the SGR formula. Estimates are that the cost of eliminating the SGR debt burden and providing a payment freeze DECREASED by $122 billion over 10 years. As a result, the cost of eliminating the debt burden and freezing current payment rates has fallen from $285 billion over 10 years, to $163 billion over 10 years.

Getting to Permanent Reform

Recent Medicare legislation has provided temporary relief from SGR cuts.  Yet, the budgetary crisis is made worse by moving the cuts to the next year. This artificially has increased the severity of cuts and raised the cost of enacting a permanent solution. A key step toward a permanent reform and repeal of SGR is to rebase by setting the baseline to present spending rather than 1996 rates. Budget baselines provide policymakers with a forecast of projected spending and taxpayer obligations. Using the 1996 baseline paints a false picture of actual Medicare spending. Technology, Medicare coverage and benefits, and medical practice costs have changed significantly since 1996 and the SGR fails to recognize those changes. Congress itself, has essentially said the baseline of 1996 is wrong, by acting six times since 2003 to temporarily stop Medicare physician payment cuts. This action has created a large SGR debt burden that is impossible to eliminate if kept on the current path of “kicking the can down the road” to the next year. Congress, by temporarily stopping SGR cuts by moving cuts to future years has created an enormous debt that has no hope of being paid off  – that is unless the SGR debt burden is eliminated and the physician payment system is rebased. The longer Congress delays action, the more expensive SGR reform has become.

Any Rebasing of SGR Must  Not Be Subject to PAYGO budget rules

The SGR formula for January 1, 2010, required a 21.5% cut. Over the next few years these cuts will pass 40%.  If not stopped these cuts will limit patient access as doctors will limit Medicare patients, or outright eliminate Medicare patients from their practices. Physician practices, even large one, are still small businesses.  As such, they simply cannot these losses. No small business could survive with steep cuts year after year. Delaying action will only cause cuts to grow and a solution will become even more expensive. Congress must also enact a PAYGO exemption  (from the current budget rules which dictate that all spending must be paid for).  Without this action, it may well be impossible due to the to replace the SGR with a new Medicare physician payment system. The Administration’s proposal to remove drugs from the SGR formula MUST be coupled with a legislative PAYGO exemption in order for the SGR debt burden to be eliminated – removing drugs from the formula alone will not move us toward a permanent solution of the SGR problem.Regardless of political ideology, physicians are the foundation of our health care system. Actions such as are outlined here would help to support physicians and allow Medicare to fulfill its promise of high quality, cost-effective health care to seniors and disabled persons.  This is especially of concern as Medicare begins enrolling the first wave of baby boomers in 2011 (enrollment is expected to increase from 44 million in 2011 to 50 million by 2016).

Projected SGR cuts exacerbate the ongoing physician shortage.  Rebasing and repeal of the SGR will favorably affect the future supply of physicians. The Council on Graduate Medical Education predicts we will face a shortage of 85,000 physicians by 2020. The Association of American Medical Colleges (AAMC) reported in November, 2008, that there will be a shortage of at least 124,000 physicians by 2025 across all specialties. Adopting a new baseline means billions of dollars each year that are spent providing a temporary SGR fix would be available for other important health reforms.

Since many other payers tie their rates to Medicare including military members, their families, and retirees in TRICARE, retired Federal employees, and those enrolled in state Medicaid programs, rebasing and repeal of the SGR provides stability to patients covered by these programs.  It would also a great help to physicians dealing with private payers, who also, across the board, look to Medicare rates as a base for their fee schedules.  A permanent SGR fix would bolster our economy by helping sustain the jobs of some 3 million individuals employed by physicians and related businesses affected by the Medicare physician payment cuts.  Physicians and patients deserve better than this continuing series of eleventh-hour temporary SGR fixes which Congress seems to be wedded to.  As with all of our current problems, bold action is needed by Congress, instead of piecemeal attempts to avoid political fallout . . . obi jo and jomaxx

House passes ‘doc fix’ bill to stave off cuts – http://thehill.com/blogs/healthwatch/medicare/105453-house-approves-six-month-doc-fix

‘Doc fix’ calms physicians — for now – http://www.chicoer.com/ci_15383737?source=most_viewed

Congressional Dems push ‘doc fix’ – http://www.politico.com/news/stories/0510/37579.html

Short-Term Medicare ‘Doc Fix’ Approved – Cuts are stalled for six months, but critics say temporary patches undermine physician practices – http://www.aarp.org/health/doctors-hospitals/info-06-2010/_shortterm_medicare_doc_fix_approved.html

Medicare (United States) – http://en.wikipedia.org/wiki/Medicare_%28United_States%29

SGR Patch Bill Signed -http://new.mgmanv.org/component/content/article/56-sgr-patch-bill-signed.html?date=2010-07-01

New Health Policy Brief: Medicare Physician Payment – http://healthaffairs.org/blog/2010/06/28/new-health-policy-brief-medicare-physician-payment/

Paying Physicians For Medicare Services – http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=18

Medicare Physician Payment System SGR Reform Fact Sheet – http://www.aad.org/gov/documents/SgrFactHsrCenter.pdf

Physicians, Congress, and Medicare Fees – http://www.allacademic.com/meta/p_mla_apa_research_citation/2/8/1/0/8/p281083_index.html

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Interns not to work more than 16 hours June 24, 2010

Posted by Obi Jo in : health care news, health care reform, health reform, Hospitals, medicine, Patents, patient care, Physicians, Public Health , add a comment

But what if I am sick?

What if shift change is in the middle of a major surgery?

How can expanded health access be accommodated?

The American Council for Graduate Medical Education (ACGME) is issuing new guidelines for the amount of time interns and residents may work at one stretch.  The new guidelines prescribe no more than 16 hours straight for interns and no more than 24 hours straight for more senior residents.  In each case, a transition time of 4 hours is to be allowed in order to hand over patient care from one doctor to another.  The ACGME acknowledges that there is no data to support concerns for trainees beyond the first year (internship) but does site data suggesting that after 24 hours judgment becomes impaired and medical errors are prone to increase.

We certainly applaud any advocacy for patient safety and agree with outlining guidelines for physicians in training.  However, the fact of the matter is that we have only marginally increased the number of physicians being trained overall in the United States over the past two decades.  Additionally, we have minimally expanded, or not expanded at all, the number of resident positions, especially among medical and surgical specialties over the same period of time.  The Association of American Medical Colleges (AAMC), which oversees medical education in the US, embarked on a review of manpower and launched an enrollment expansion to increase the number of graduates by some 30% by 2015.   That is the good news.  The bad news is that they are about 20 years too late.

Unfortunately, a perfect storm of events is conspiring to exacerbate the physician shortage and its effects.

  • First is the too long delayed expansion of medical school enrollment, which has made no sense, since the US “imports” physicians via the ECFMG portal (Educational Commission for Foreign Medical Graduates) to the tune of nearly 10,000 per year since 1992. In a nation of over 300 million, this makes no sense at all.  America, the melting pot of the world, has ample diversity from which to select all the physicians we need.
  • Second, the aging of the medical profession as a whole with the attendant attrition brought on by death and retirement.  For example, within medical education institutions themselves the average medical faculty age was 41.7 in 1967, 44.7 in 1987, and 48.5 in 2007. The percentage of all faculty over 55 years old was 9% in 1967, 19% in 1987, and 29% in 2007. Over these decades, the average age of first-time assistant professors pursuing research increased from 33.6 to 39.3 years old. The average age of all first-time faculty, regardless of entering rank, increased from 35.3 in 1987 to 37.8 years old in 2007.
  • Third, the increasingly hostile reimbursement environment compounding the already hostile liability situation creating impetus for senior physicians to reduce work hours, restrict complex cases, reduce overall case loads and take early retirement. Many, many physicians who are in the prime of their careers (age 50-60) are seriously considering opting out of medical practice altogether.
  • Fourth, the expansion of health insurance coverage that is in progress under recently passed legislation will lead to major overcrowding of doctors offices, clinics and hospitals. Like it or not, physicians are human, and they will vote with their feet if the medical practice environment becomes too burdensome.

In the end, the true practice of medicine does not lend itself to strict hours, punch cards or time clocks. However, it would seem that the educational, health policy and reimbursement structure are being attuned to “force” physicians, beginning at the earliest point in their training, into an employee mindset.  This concept fits nicely with the administrative needs of a federally run system, which is the goal of this administration, many in Congress and among a large number within the profession as well.  In the end, the private practice of medicine, as we have known it, will likely be preserved only in boutique manner with those being able to afford a real personal physician, being able to access one. The rest will have to queue up and wait while the doctor changes shifts, so that he/she can be sure to get enough sleep . . . jomaxx and obi jo

New Rx for Young Doctors: Shorter Work Day – http://online.wsj.com/article/SB10001424052748703900004575325130511028968.html?mod=WSJ_hps_sections_news

The New Recommendations on Duty Hours from the ACGME Task Force – http://content.nejm.org/cgi/content/full/NEJMsb1005800

ACGME TASK FORCE ON QUALITY CARE AND PROFESSIONALISM: PROCESS FOR DEVELOPING RECOMMENDATIONS ON NEW SUPERVISION
AND RESIDENT DUTY HOUR STANDARDS Executive Summary – http://acgme-2010standards.org/pdf/Executive_Summary.pdf

Projections of Future Medical School Enrollment – http://www.aamc.org/data/aib/aibissues/aibvol9_no3.pdf

The Aging of Full-time U.S. Medical School Faculty: 1967-2007 – http://www.aamc.org/data/aib/aibissues/aibvol9_no4.pdf

Coming to America — International Medical Graduates in the United States – http://content.nejm.org/cgi/content/extract/350/24/2435

Educational Commission for Foreign Medical Graduates – http://www.ecfmg.org/

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Mental Health Reform Just a Taste of Battles Ahead May 10, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance, health insurance access, health insurance denial, health insurance reform, health reform, Insurance, medicine, Mental Health, patient care, pre existing conditions, Public Health , add a comment

Major controversy is now in play over new rules issued by the Obama administration related to enforcement of a 2008 law requiring equal insurance coverage for the treatment of mental and physical illnesses. Both health insurers and major employers are lobbying the White House to delay and rework the rules on what is termed “mental health parity.” These groups supported the 2008 law, but now say the rules go far beyond the intent of Congress.  They argue that the new rules would severely damage and hamper their cost-control techniques while raising out-of-pocket costs for some patients. Patient advocate groups support the rules, saying they will eliminate many forms of insurance discrimination against people with mental illness. The rules are also supported by the American Medical Association, the American Psychiatric Association and House Democrats.

Mental disorders are very common in the US and worldwide.Some 26+% of Americans ages 18 and older or about one in four adults, suffer from a diagnosable mental disorder in a given year.Using the 2004 U.S. Census residential population estimate for ages 18 and older, this translates to 57.7 million people.  Based on the expected increase in population we will see when the 2010 census is complete, we can safely assume that the number of affected Americans is well in excess of 60 million.Even though mental disorders are widespread in the population, a much smaller proportion — about 6%, or 1 in 17 — suffer from a serious mental illness.Mental disorders are the leading cause of disability in the U.S. and Canada for ages 15-44.  Many people suffer from more than one mental disorder at a given time. Nearly half (45%) of those with any mental disorder meet criteria for 2 or more disorders, with severity strongly related to co-morbidity.

One area which has insurers particularly upset is the provision that requires them to maintain a single deductible for all medical and mental health services combined.  Currently many if not most have separate benefit packages for mental health care with separate deductible levels.  This change would be a significant one based on current industry practice. Health insurers argue that many mental health patients will face higher out-of-pocket costs because the combined deductible will almost surely be higher than the current one for mental health services alone.  That argument may be somewhat bogus, since many health plans limit mental health benefits overall.

Suffice it to say that mental health conditions are a major source of not only morbidity and illness, but lost work and wages for the nation. The failure of our system to adequately address these illnesses in the same manner as physical illness has been lamented for decades.  In fact, in may well be a gross injustice to refer to mental health problems and “physical illness” as if the two were separate entities, unrelated and without connection.  In fact, we now know that many forms of mental illness are in fact physical, based on brain chemistry and other factors which alter the brains response to stimuli and the environment.  Thus, mental illness is in fact, a physical ailment with real consequences that effect not only outward behavior and inner peace of mind, but also bodily functions and body maintenance.

We feel that insurers can make mental health parity work within the confines of their traditional policy structures, including single deductibles and uniform co-pay rules for ALL medical care, regardless of identity.  Just as their is no distinction between coverage of cardiac conditions and urological conditions, there should be no distinction for coverage of mental health conditions (psychiatric and psychological).  Real health reform means addressing real needs and mental health coverage, allowing for appropriate access to professional care is an unmet need.  The time has come for mental health coverage parity.  Health insurers need to adjust to this reality . . . obi jo and jomaxx

Fight Erupts Over Rules Issued for ‘Mental Health Parity’ Insurance Law – http://www.nytimes.com/2010/05/10/health/policy/10health.html?emc=tnt&tntemail0=y

The Devil is in the Details on Mental Health Parity Law – http://blogs.wsj.com/health/2010/05/10/the-devil-is-in-the-details-on-mental-health-parity-law/

Obama Administration Issues Rules Requiring Parity in Treatment of Mental, Substance Use Disorders – http://www.hhs.gov/news/press/2010pres/01/20100129a.html

The Mental Health Parity and Addiction Equity Act – http://www.cms.gov/HealthInsReformforConsume/04_TheMentalHealthParityAct.asp

45 CFR Part 146 Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; Final Rule –
http://edocket.access.gpo.gov/2010/pdf/2010-2167.pdf

Fact Sheet: The Mental Health Parity Act – http://www.dol.gov/ebsa/newsroom/fsmhparity.html

The Impact of Mental Illness on Society – http://www.nimh.nih.gov/health/topics/statistics/index.shtml

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