Health Business Blog

May Day for Medicare?

Tomorrow, May 1 may be a big day in the US. First, immigrants intend to “shut down” major cities by not showing up for work. It’s being called “The Great American Boycott” and “A day without an immigrant.” It may be an empowering event for participants and a minor wakeup call for some of the native-born, but I’m guessing it won’t have a major, lasting impact on most people.

Meanwhile, the Medicare Trustees release their annual report of the health of Medicare tomorrow. (That’s the one that generates the annual headlines –usually greeted with a yawn– of when the trust funds are likely to go bust.) But with the Medicare Modernization Act of 2003 came a new requirement –that the trustees make an estimate of the year when general revenues (as opposed to the Medicare portion of FICA) will pay 45 of the cost of Medicare. If the threshold is forecast to be crossed within six years, and if the trustees make this finding two years in a row, the President must make a proposal in his budget so that the 45 percent threshold won’t be reached. There are some technical and philosophical arguments against the 45 percent rule (see this paper, for example) but I think it’s generally a good idea. Medicare is overfunded relative to other Federal programs as it is, and it doesn’t hurt to highlight the fact that it’s largely paid for out of general funds.

It’s quite possible that in tomorrow’s report the Medicare trustees will forecast that the 45 percent threshold is coming within six years. In the near term, that will probably send a bit of a chill through the stocks of companies whose fortunes are tied to Medicare. In the longer term it may dampen the growth rate of Medicare spending.

So how is this tied to the May Day immigrant protests? Well, the easiest way to deal with the 45 percent problem is to encourage younger people to come to the US, work, and pay taxes. That broadens the base on which the Medicare tax is collected, but has virtually no impact on the over-65 population and the disabled –the ones who receive Medicare benefits.

So this is one more argument in favor of immigrants: they are responsible for extending the viability of the Medicare program. And that’s not to minimize the other benefits of a liberal immigration policy, which are many.

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Go West young man! (But don’t count on subsidized health insurance)

California Health Care Foundation analyzed the potential to apply a Massachusetts-style universal coverage model to California. The bottom line: it would be doable, but significantly more expensive. Why?

• Overall, the uninsured rate among the non-elderly is 21% in CA v. 13% in MA and 18% in the US overall
• In CA, 56% of employers provide coverage v. 69% in MA and 63% in the US overall
• Both states have high average incomes, but CA has a higher percentage of low income residents (43% in CA v. 29% in MA v. 39% in the US overall make less than 250% of the Federal Poverty Level)
• Among those making less than 250% of the Federal Poverty Level, 32% of CA residents are uninsured v. 22% in MA and 29% in the US overall

The reason MA can move toward universal coverage is that the state has already done a reasonably good job of seeing that health insurance is widely available. Part of that is demographics, part is policy, part is cultural. Other states may find they need to walk first; they may fall flat on their faces if they try running to keep up with Massachusetts.

Read the executive summary here.

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Put this on your calendar

Lilly Chairman and CEO Sidney Taurel is a straight shooter, telling it like it is about the pharmaceutical industry and what needs to change. He will be interviewed by the Kaiser Family Foundation on May 10 from noon till 1 pm EDT, in a webcast that is open to the public. If you are going to be in Washington, DC that day you can attend if you register ahead of time.

The conversation will touch on Taurel’Â’s views on key issues affecting health care and the drug industry, such as the Pharmaceutical Research and Manufacturers of America’Â’s voluntary guidelines for direct-to-consumer drug advertisements; the drug development and approval process; the early impact of Medicare’Â’s prescription drug benefit; and state and national efforts to expand access to health coverage.

Click here for more information on the webcast.

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Here’s how we’ll know when hospital safety and quality programs are working

If you’ve ever accompanied a friend or relative during a hospitalization, you know the patient is lucky to emerge with his or her life, even if they went in with something relatively minor. Lots of little things go wrong, or not quite right –wrong or skipped or mis-timed medication, medical staff not washing their hands, wrong food delivered and so forth. It’s almost always a harrowing experience as far as I can tell.

But lots of patients don’t have someone from the outside to look after them, and many patients experience delirium in the hospital, making it even harder for them to fend for themselves. See A practical program for preventing delirium in hospitalized elderly patients.

Delirium is a marker of poor hospital care for older people: it is associated with serious complications; it often goes unrecognized by physicians and nurses; and its occurrence is integrally linked with processes of hospital care, such as overuse of medications and iatrogenic events.

The estimated occurrence rates of delirium range from 14% to 56% during the course of hospitalization.

Hospital mortality rates of patients with delirium range from about 10% to 65%, more than twice as high as for matched controls. Thus, delirium has a case fatality rate as high as that of acute myocardial infarction or sepsis.

Rate of delirium and mortality rate of delirious patients are probably good metrics to track in evaluating a hospital’s overall safety and quality record.

Thanks to Mickey.

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More therapies for rare diseases

The Washington Post reports:

People often criticize the brand-name drug industry for its focus on blockbuster drugs that can be sold to millions of people with common problems. What people may not have noticed is that drug companies have become increasingly successful in discovering and winning approval for medications that treat rare, or “orphan,” diseases.

The focus on rare diseases is certainly welcome; with new decision support tools –and no doubt support from industry– a higher percentage of people with rare diseases will be diagnosed. It’s good that effective treatments will be available for them.

However, implicit in the Post article is that pharmaceutical companies are turning away from high-selling “blockbuster” drugs to smaller, niche markets. Yet as the biotech companies have demonstrated, drugs for orphan diseases (like Cerezyme for Gaucher Disease) can be blockbusters in their own right, with annual sales in the high hundred millions or even reaching a billion dollars. At some point soon payers are going to find a way to ratchet down prices, which may limit the number of new drugs that ride the orphan/blockbuster gravy train.

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Safe cell

San Francisco is using text messages to communicate with young people about safe sex practices. Users can simply send the text message “sexinfo” and receive a reply with choices of question categories.

“Most youth get their information from their friends. … They’re winging it, trying to figure it out for themselves.” Michelle Irving, a peer educator at the health department, said that many teens do not visit clinics and are “afraid to ask questions,” but with the text messaging service “[t]hey don’t have to talk to someone if they think they’re pregnant or their condom broke”

From Kaiser Family Foundation’s Daily HIV/AIDS report.

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Guaranteed issue

There’s a good post on A Healthy Blog that includes a discussion on Guaranteed Issue in Massachusetts. That’s the rule that means insurers have to accept all applicants, regardless of health status. Massachusetts also has community rating, which means premiums don’t vary based on health status –only age and zip code.

Guaranteed issue and community rating are attacked by critics as left-wing ideas, which drive up costs and interfere with the market. But in my own experience, these rules actually promote entrepreneurial activity (a capitalistic pursuit, last I checked.) As I commented on A Healthy Blog:

When I left my job at a big firm 5 years ago to strike out on my own, I was worried about getting and keeping health insurance. Turns out that’s not a problem in Massachusetts due to guaranteed issue.

In the years since I left, I’ve counseled numerous would-be entrepreneurs. They are all worried about whether they’ll be able to get health insurance once they are on their own, and they are all relieved when they hear about how we do things in Massachusetts.

How many potential entrepreneurs in non-guaranteed issue states are deterred by worries about health insurance availability?

Guaranteed issue doesn’t address affordability of premiums, but having a successful entrepreneurial venture does.

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Open access scheduling starts to ease wait times

The Flint Journal reports that some physicians are turning to “open access” scheduling to improve service levels. Rather than filling up all or almost all of their schedules weeks in advance, physicians leave a meaningful share of slots (1/3 is the number cited in the article) open for same-day appointments.

“It improves the flow of the office because we’re doing today’s work today,” said Patty George, business manager at [a] three-physician practice. “The goal is not to put people off.”

Physician offices have tended to fill their schedules in advance, because it appears to give them more control –after all, maybe no one will show up if slots are left open till the last minute. But most offices actually have a fairly predictable flow of patients –for example, more patients call for same-day appointments on Mondays than Wednesdays– and doctors can adjust their schedules accordingly.

Patients who make appointments long in advance are more likely to be no-shows; in some cases the problem will have resolved itself, in others the patients may have simply forgotten or gone somewhere more convenient.

Speaking of convenience, one reason physicians are starting to embrace open access is that they are justifiably concerned that patients will begin to turn to in-store MinuteClinics and the like that are beginning to pop up at major retailers. Retailers know a lot about convenience and customer service and will set a standard for service levels that will influence physician practice.

For the moment, open access is just a way to catch up with best practices that have been around for a long while. My doctor has had a version of it for years. But more can be done, including allowing the patient to book his/her own appointment electronically –with the physician setting permission levels for different patients– electronic appointment reminders, and same-day notices indicating that the physician is running later (or early?) As consumers pay more for their own care, might physicians turn to other airline-type yield management practices such as lower fees for off-peak appointments?

You’ll know things have gone too far when your doctor starts to require a Saturday night stayover.

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Grand Rounds 2:31

Welcome to the 83rd edition of Grand Rounds, hosted here at the Health business blog! I noticed at least a couple of changes since I hosted #40 almost a year ago. First, the pre-Rounds writeup on Medscape (thanks Nick) and second, the sheer number of submissions.

Now, let’s get started…

Editor’s picks (aka Dave’s Faves)

“I hope they clean those things between uses.” A ChronicBabe wearing a Holter monitor invites her boyfriend over for sexcapades.

“Isn’t that the same guy I saw leaving ChronicBabe’s apartment?” Dr. Charles scores an invitation to visit his patient’s homebrew lab to monitor beer-induced atrial fibrillation. “Hey, Doc, do I really have to wear that Holter again tonight?”

“What did the deaf nurse say to the patient who forgot to wear her hearing aids?” Find out at Healthy Policy.

“Don’t take my word for it,” when you can ask AJ, who can recall the details of every day of her life back to 1980. (Over my med body!)

“I thought doctors were gods,” but Orac Knows that many are stupid enough to fall for Intelligent Design.

“If you’re looking for a fun-filled evening at your house, call Dr. Charles.” But if you’re in labor, Neonatal Doc recommends going to the hospital instead.

“Can we have your liver (once you’re done using it)?” That depends. It’s Organ Donor Awareness Month and donorcycle wants us to ponder ways to alleviate the organ shortage. Should we have presumed consent for donation? Should organs be restricted to those who’ve agreed to donate their own organs?

BEST OF THE REST

Workplace

When the bird flu arrives, how many health care workers will fly the coop? (Healthcare.wurk.net)

If you want to summon the Evil Spirits That Watch Over the Emergency Department (ESWOEDSs), just say something innocuous. (Doc Around The Clock)

It takes dedication to go to work when bullets are whizzing around the neighborhood. (Digital Doorway)

This harasser needs to calm down and stop yelling at Barbados Butterfly, otherwise Tim’s (Medic of One) mugger might have to be sent in his direction.

Doctor/patient relationship

Have you heard about those annoying patients? The ones that are always late, are seeking drugs and so on? PegSpot has. Meanwhile a (formerly) Difficult Patient provides insight into why some patients behave as they do.

Dr. Flea continues to fight a losing battle to keep kids out of the ER and away from unneeded IV rehydration. In this episode the NEJM, NIH and GSK have crushed him like a bug with a new use for Zofran.

HealthyConcerns heads to the doctor for her annual exam and (almost) enjoys it.

GruntDoc reviews a book about a doctor who journeys from Chicago to the mountains of Nepal and concludes that it’s pretty good.

Inked Caduceus will be a great doctor if they’ll just stop lecturing her about mitosis and meiosis and let her watch BALL, a one-man show about a man’s battle with testicular cancer.

Treatments

A disgruntled youth is featured in Tony Plant’s post about Fish vs. Drugs for Children and Criminals. Keep him away from me please.

Diabetes Mine is holding her breath, hoping for the success of MannKind’s inhaled insulin in clinical trials. Among other things, the inhaler is a lot more socially acceptable than the Exubera bong.

Keep smiling, bloggers! Fixin’ Healthcare reports a new mood checker program is keeping an eye on us.

MiniMed’s combined insulin pump/glucose monitor is the closest thing yet to an artificial pancreas. (Straight from the Doc)

It’s not just for killing aliens anymore. Virtual Reality shows potential in the treatment of Post Traumatic Stress Disorder. (Anxiety, Addiction and Depression Treatments)

InsureBlog worries about Advair.

Pinworm: it ain’t a pretty picture. (Inky Circus)

Practical advice

Tired of Twilight Zone meetings (and after all who isn’t)? MSSPNexus Blog will help you avoid them.

Graduating nurses, here are a few things Emergiblog wants you to know as you head out into the world.

In case Google doesn’t already have enough on you to ruin your life, Clinical Cases and Images reports that some patients are using Google Calendar to keep track of their medical conditions. No thanks.

Health education

Good news courtesy of the Homely Scientist. Mercury fillings are probably not killing us.

There are a lot of myths about stress. Dr. Serani dispels six of them.

A new study examines the impact of nature vs. nurture on the development of obesity. Bottom line, according to Aetiology: diet and exercise is still your best bet.

Wandering Visitor notes that working in a popcorn factory can damage your lungs. (The butter flavoring is the culprit.)

Diabetes and heart disease are a bad combination in Malaysia and elsewhere. The heart of the matter helps us understand why.

The Biotech Weblog and The Cheerful Oncologist are advocates for the Mediterranean Diet. Oncologist boils it down for us: “STOP EATING JUNK FOOD, YOU FATTIES!” Such tact.

Avoid this one if you can. Inside Surgery tells us about Neuroleptic Malignant Syndrome.

DiseaseProof wants to get you up to speed on prostate cancer, aka breast cancer for men.

Inhalant abuse is a problem in the Philippines and the US, too. (Parallel Universes)

Love and hope

Dream Mom shares a stirring story of her special needs Dear Son and provides information about ARX testing.

The Mote in the Light reminds us that health care professionals may be hardened to death but aren’t immune from grief.

Tales from the Womb describes the emotional impact on caregivers of a badly ill child.

Testing the Cultural Divide concludes that medical shows are so popular because medicine is romantic.

Milliner’s Dream shares a story of her family and their feet.

Wonky stuff

California Medicine Man wonders whether NEJM published a pilot study of pre-hypertension treatment to please people in high places.

The Blog That Ate Manhattan would rather see study results released in peer-reviewed journals rather than the general media.

Why is Allan Hubbard running around the country blaming the health care crisis on lack of pricing transparency by providers? Could it be because the Administration has a rather superficial and dogmatic view of health reform? Matthew Holt lays it all out for you.

If you still think Allan Hubbard is on to something, The Doctor is In explains the maze of medical coding.

Hospice Blog is determined to get the $625 that Blue Cross has been withholding.

When is a patient too ill or old for medicine? Kevin, MD’s readers have some thoughts on the matter.

Pay for performance (P4P) sounds like a reasonable concept to Treat Me With Respect, except that the current P4P systems are really pay for keeping costs down.

KidneyNotes is shocked that acute renal failure is no longer a surefire indication for hospital admission.

Hippocrates seeks your feedback for a talk he is preparing on the role of blogs in consumer driven health care.

Can’t we all just get along? Hospital Impact would like to see clinical and financial managers collaborate.

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That’s it for this edition! Next week’s host is Polite Dissent.

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Rare and common at the same time

One of the big problems in medicine is patients with rare diseases who go from doctor to doctor in search of a diagnosis, being misdiagnosed or not diagnosed along the way, receiving treatments that are useless or harmful, and meanwhile suffering or even succumbing. It must be costly from the payer standpoint as well. An individual doctor may never see a specific rare disease even in many years of practice, and may not even know what symptoms to look for.

I have a hunch that when we look back 20 years from now, one of the major benefits of the transformation of health care from paper to electronic will be that patients with rare diseases are diagnosed much more promptly and accurately. I don’t have a lot of data to support that contention, but I’m working on it. Here’s something from the European Commission:

It is estimated that between 5 000 and 8 000 distinct rare diseases exist today, affecting between 6% and 8% of the population in total – in other words, between 27 and 36 million people in the European Union.

Rare diseases are defined as those with a prevalence below 1 in 2000, which amounts to 228,000 persons in the EU. It’s almost identical to the US definition of an orphan disease.

So how will electronic records help? The main way is by coupling the electronic record with clinical decision support tools that are specifically focused on rare diseases. They can analyze data from the patient record to provide differential diagnoses and suggest what data to collect in order to narrow the differential. Tools like this can help generalists and can even surpass their creators by drawing inferences that are too complex to juggle in one’s head. The parallel from the industrial world is the reduction or elimination of rework. A small first-pass defect rate can drive up costs considerably by causing rework. It’s much the same here except we are dealing with people, not widgets!

My favorite, early example of such a tool is SimulConsult (which I’ve mentioned before). It’s run by pediatric neurologist Mickey Segal and is available free of charge to physicians. Check it out.

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