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While nostalgic irony may have been vanquished, regular irony is still making headlines. Natural medicine advocate and AIDS denier Gary Null is recovering after a manufacturing snafu caused him to overdose on Vitamin D. The author, along with half a dozen consumers, had been ingesting a batch of his Ultimate Power Fail Meal, accidentally laced with 1,000 times the correct dose of Vitamin D when he began experiencing bleeding “within his feet.” Also: severe kidney damage. Null is suing the manufacturer, Triarco Industries for $10 million. According to Discovery News:

Null and his customers would likely not have been poisoned if his products were held to the same standards and regulations that real drugs are subjected to—and which Null and others in the “alt med” industry have long rejected.

There's a joke about “taste of his own medicine” in there somewhere.

News outlets report on issues affecting physician practices: Kaiser Health News, in partnership with The Fresh York Times, explores what medical students are taught about health attention costs: “Doctors in training have traditionally been insulated from data about the cost of the tests and treatments they order for patients - in circumstance, for decades, the subject was virtually taboo when professors and trainees discussed treatment decisions during hospital rounds. …
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Bold changes are needed in how the United States delivers and pays for primary care if the key goals of national health reform are to be achieved, according to the May issue of Health Affairs. This thematic issue of the journal, released today at a National Press Club briefing, examines the crisis facing the U.S. primary care system as well as promising solutions for reinventing primary care. Building a state-of-the-art primary care system, the issue concludes, is critical to achieving better health care, better value for the dollars spent, and expanded access for the tens of millions of Americans who will gain insurance coverage over the next few years.

The United States faces a well-known shortage of primary care providers, but recruiting more physicians, nurse practitioners, physician assistants, and others is only a part of what’s needed. As Mark W. Friedberg and colleagues at the RAND Corporation suggest, the entire system needs to shift toward a primary care orientation to improve health outcomes. The “horribly broken” primary care system that we have now is plagued by underinvestment and misaligned incentives, says Susan Dentzer, Health Affairs’ editor-in-chief. Dentzer says health reform offers the opportunity to reinvent primary care and rapidly move it into the twenty-first century. “Primary care is maddeningly stuck in a bygone era. Practitioners are typically paid only for in-person ‘visits’ when e-mail consultations and telemedicine could readily handle many patient complaints,” she writes.

The May issue of Health Affairs is funded by the United Health Foundation, California HealthCare Foundation, CVS Caremark, ABIM Foundation, and American Academy of Physician Assistants.

Primary Care – Where We Are and How Far We’ve Come

Several studies in this issue review the state of primary care in the United States and reflect on the lessons that history – and a tradition of reinvention – offer about reform:

An overview of the current landscape of U.S. primary care from Thomas Bodenheimer of the University of California, San Francisco, and Hoangmai H. Pham of the Center for Studying Health System Change quantifies anticipated workforce shortages in primary care, highlights the geographic maldistribution problem, and offers short- and long-term solutions to improving access.
It is currently difficult to recruit physicians to primary care, due in large part to the considerable pay gap between specialists and primary care physicians. A study by Bryan T. Vaughn and colleagues at Duke University underscores the challenge of overcoming that gap, noting that a primary care physician could earn $3 million less over a career than a cardiologist – a disparity that significantly influences the career choices of medical students.
Primary care was born out of tension with other forms of medical care, and the same external forces that shaped past systemic transformation will do so again, observes Joel D. Howell of the University of Michigan. “The question is not, ‘Will primary care be reinvented?’ but rather, ‘How?’” he says.
A look back at trends in medical practice redesign over the last four decades can offer lessons for how to implement new models of care, such as the medical home. Charles M. Kilo of the Oregon Health and Science University and John H. Wasson of the Dartmouth Medical School emphasize that the medical home model is not yet tested by time, and that periodic evaluation of its progress during implementation will be important.

Medical Homes: Delivering Better Care for Less

Recent health reform legislation handed the U.S. Department of Health and Human Services the authority to test out the patient-centered medical home. Several studies examine this model, widely regarded as the most promising one for reforming primary care delivery:

To succeed, the patient-centered medical home must have four essential elements, say Daniel Fields, a law student at Harvard University , Elizabeth Leshen, a student at the Massachusetts Institute of Technology, and Kavita Patel, formerly of the White House Office of Public Engagement. These elements are: dedicated care managers to direct patient care, tools to manage performance and track outcomes, payment incentives to lower cost, and round-the-clock medical advice.
Paul Grundy of IBM, Senator Kay R. Hagan (D-N.C.), Jennie Chin Hansen, the outgoing president of AARP, and Kevin Grumbach of the University of California, San Francisco, make the case for primary care reform for private purchasers, government, consumers, and clinicians. They argue that broad stakeholder support will be critical for primary care reform to succeed.
Robert Reid of Group Health Research Institute and colleagues share results from a medical home model developed by the Seattle-based Group Health Cooperative. A study comparing more than 7,000 patients at the medical home with more than 200,000 non-medical home patients showed that access to a medical home led to 29 percent fewer visits to the emergency room and 6 percent fewer hospitalizations.
There is no single best way of paying for care in medical homes as of yet, but Katie Merrell of the Center for Health Research and Policy and Robert A Berenson of the Urban Institute detail promising paymentmethods, including an approach that features both fee-for-service and capitation or fixed payment for all services.
Medical homes must overcome some key challenges to be successful, including finding ways to fund the early start-up phase, according to a study by Bruce E. Landon of the Harvard Medical School and colleagues.

Primary Care Reform Relies on Teamwork, Management Skills

Reforms of the primary care system almost certainly will demand new models of care, including the creation of primary care teams and expanded roles for nonphysicians like nurse practitioners and physician assistants. New studies suggest that such team-centered care represents a fundamental shift in delivery, one that has the capacity to handle more patients yet still deliver high-quality care.

Most physicians lack the skills to manage teams and coordinate care under the new models of primary care. Richard M.J. Bohmer of the Harvard Business School says that medical schools and residency programs must start training physicians to be managers if reform efforts are to succeed.
The United States will face a shortage of 46,000 physicians by the year 2025. Mary D. Naylor of the University of Pennsylvania and Ellen T. Kurtzman of George Washington University argue that registered nurses should be tapped to fill that void since nurses already provide hands-on bedside care in a variety of settings and are well equipped to deliver certain kinds of primary care. Joanne M. Pohl of the University of Michigan and her colleagues argue that while physicians are pushing for bigger salaries and a lead role in managing new models of care, nurse practitioners are already highly skilled at managing teams. The authors call for lifting state restrictions that prevent nurses from practicing to the extent that their training and licenses warrant.
Physician assistants could bolster the workforce in the primary care field, but only if a pay gap between those who work in primary care and those who work in medical and surgical specialties is addressed, according to Perri A. Morgan of the Duke University Medical Center and Roderick S. Hooker of the University of North Texas Health Sciences Center and the Department of Veterans Affairs in Dallas. Their new analysis shows that the number of physician assistants in specialty fields has been growing rapidly, probably because of higher pay in these fields.
Pharmacists must be members of any team providing primary care, according to Marie Smith of the University of Connecticut and her colleagues. Pharmacists often catch medication mistakes made by other members of the primary care team, mistakes that can lead to costly medical complications, the authors say.
Stephen C. Shannon of the American Association of Colleges of Osteopathic Medicine and colleagues point out that a loan forgiveness program might get more osteopathic physicians to pick careers in primary care.

Practice Profiles: E-Referrals, Core Teams Provide Better Quality

This issue of Health Affairs includes a series of Practice Profiles, case studies of promising approaches to delivering primary care across the country. Highlights:

Christine A. Sinsky of the Medical Associates Clinic and Health Plans and colleagues paired physicians with nurses into core teams that delivered primary care in a novel way. Nurses focused on prevention of chronic conditions, and physicians spent more time treating or managing health problems. The authors found that such teams often provided better, more coordinated care.
In 1991, Quad/Graphics, a large, Wisconsin-based printing firm, started QuadMed, an in-house health care provider focusing on prevention and wellness. Its continuing success, writes QuadMed’s president, Raymond Zastrow, and colleagues is due to the integration of benefit design and a focus on patient-centered, prevention-oriented primary care, delivered on site.
Access to specialist care is a common barrier for safety net clinics trying to deliver high quality care to the poor. To overcome this barrier, Alice Hm Chen at San Francisco General Hospital and colleagues developed an electronic referral system that reduced wait times for nonurgent visits for the poor and uninsured by up to 90 percent during a six-month period.
Seattle’s Qliance Medical Group is a direct primary care practice. Patients pay a modest age-adjusted monthly fee for unrestricted, comprehensive care, with access to providers 24/7. This direct care medical home offers longer patient visits, minimizing referrals to specialists and hospitals, for which patients must purchase separate insurance coverage. Qliance’s CEO, William N. Wu, and colleagues report that in its first two years of operation, the practice’s patient base has grown to almost 3,000 patients, with no provider turnover.
Barbara S. Fischer at the Department of Public Health in Chicago and colleagues implemented an electronic system to request and track specialist or diagnostic testing for uninsured and Medicaid patients. Wait times dropped from an average of three months to 5.5 days.

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Add comment Tagged: doctor, Health, healthcare พฤษภาคม 5, 2010

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Every so often, a new media report warns us of the potential dangers of cell phone use. But while it’s frightening to think that health problems lurk within our favorite communication device, these media bulletins don’t lead to a mass rejection of the cell phone. Perhaps that’s because so much is still unknown about the long-term effects of cell phone use.

A new study following 250,000 European mobile phone users for at least two decades aims to determine whether links truly exist between cell phones and health problems. The study’s co-principal investigator, Dr. Mireille Toledano, a senior lecturer in epidemiology at Imperial College London’s School of Public Health, answered my questions last week.

How will the study work?

In the [United Kingdom], participants will be sent an invitation pack via their mobile phone network operator. If they are interested, will go online to http://www.ukcosmos.org/ and complete the consent form and online questionnaire. It takes about 30 to 45 minutes. With their permission, we will monitor their health for the next 20 to 30 years via linkage with national health records and storage of information on secure databases at Imperial College London.

You’re investigating possible links between cell phones and health problems. Which health problems are you considering?

The study will be monitoring a large range of health outcomes, including brain cancers, salivary gland cancers, skin cancers, leukemia, cerebrovascular disease (stroke) and neurodegenerative disease [such as] Alzheimer’s, Parkinson’s and multiple sclerosis.

Is there any evidence to suggest that cell phone use is connected to those health problems?

The balance of evidence to date is reassuring that mobile phone use for less than 10 years does not cause cancer. However, uncertainties remain with regard to longer-term use. Mobile phones are still a relatively new technology and most people haven’t been using them for much more than 10 years. Also, some diseases take many years to develop and there hasn’t been a sufficient observation period for potential disease development since the time that most people first started using their phones. In addition, most research to date has been based on recall of past mobile phone usage and this lends itself to inaccurate reporting and the possibility for recall bias which makes it difficult to interpret study findings. Finally, studies to date have been focusing on brain tumors only, but nowadays people don’t only use their phones by making voice calls and putting their phone to their head.

For all these reasons, there are a number of uncertainties and gaps in our current scientific knowledge about a new widespread technology. The will address these gaps by looking at long-term mobile phone use, potential long-term health effects, prospectively collecting information on mobile phone use so as to avoid any recall biases and a range of different health outcomes.

What’s your goal?

To monitor the health of a large number of mobile phones users across Europe for the next 20 to 30 years and hopefully exclude any links between mobile phone use and possible health effects over the long term.

Why is this research so important to you?

This is an important international initiative because there is currently scientific uncertainty about a relatively new and widespread technology that is part of everyday life for most of us. To address this uncertainty, the most responsible step society can take for the sake of current mobile phone users and for future generations is due diligence by beginning to monitor the health of a large number of mobile phones users over a long period of time. In this way, the study will build up a valuable picture as to whether or not there are any links between mobile phone use and possible health effects over the long term.

Image: Mireille Toledano

Colby Hall says:
May 3, 2010 at 8:35 pm
Its disingenuous to quote what he said?

no Colby, it’s not, but like Norbit said before you replied, it is disingenuous to quote ANYONE when you fail to put the quote in proper perspective. bloomberg said it as just an example but you failed to tell the reader that and used his quote just for linkbate. i saw this video earlier and i just had a feeling you guys would take that bait and guess what…you did. you’re quickly turning into politico for dummies and that’s saying a lot. congrats?

example: colby said he likes diet coke.

my article: colby hall is for the death of bamboo because he likes diet coke.

see how hard that was colby? hell, i probably just gave you a writing tip.

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Health Article: Bad for wellness May Be Good for health

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Time running out for Medicaid overhaul

By Jim Saunders
4/23/2010 © Health News Florida
With the annual legislative session ending next Friday, Florida lawmakers could be running out of time to pass a major overhaul of the Medicaid system.

"The days dwindle down to a precious few,'' Senate Health Regulation Chairman Don Gaetz, R-Niceville, said Thursday evening. "I think that's a line from a song.''

House and Senate leaders have relatively little time to negotiate a deal and build support on an issue as complex as the $19 billion Medicaid program.
Also, Gov. Charlie Crist said this week he has "concerns" about a sweeping House proposal, fueling fears he would veto major changes in Medicaid.

Gaetz and Senate President Jeff Atwater, R-North Palm Beach, both described the House proposal, which includes enrolling Medicaid recipients statewide in managed-care plans, as "bold.'' But the proposal is substantially different from a Senate bill that would expand a pilot managed-care program.

"It’s late in session and we’re looking to see what we can do," Atwater told the News Service of Florida on Thursday. "I don’t consider it (the House proposal) dead. I think it’s that bold of an idea … it’s what we need to do. (But) I don’t know if all the elements are right at this moment."

The House approved its proposal Monday, and Gaetz said he wishes the Senate would have seen it much earlier in the session. He said getting the proposal in early- or mid-March would have allowed time to thoroughly review it.

"It took me two nights just to read the (House) bills and read the briefing book,'' Gaetz said.

Pointing to the program's costs and problems such as widespread fraud, House and Senate leaders have said repeatedly during the session that they want to make major changes in Medicaid. Both chambers also have moved toward a solution of requiring Medicaid recipients to enroll in managed-care plans, such as health-maintenance organizations.

But details of the House and Senate approaches differ. The House proposal would gradually require almost all Medicaid recipients — including groups such as seniors and people with developmental disabilities — to enroll in managed-care plans over five years.

The Senate earlier in the session approved a narrower proposal to expand a pilot program that requires managed care for Medicaid recipients in five counties. That proposal would expand the pilot to 19 additional counties, including metro areas such as Miami, Orlando, Tampa and St. Petersburg.

"The good news is there's a commonality of philosophy,'' Winter Park Republican Dean Cannon, a House leader on the issue, said this week. "There's sort of a difference in the mechanics.''

Gaetz said lawmakers could deal with the Medicaid issue in several ways. That includes setting aside the House proposal and studying it in the coming months; modifying the House proposal; modifying the Senate proposal; or passing the House proposal — which he described as the "full monty.''

House and Senate officials met Tuesday to discuss the House proposal, but Gaetz said additional meetings had not been scheduled. Also, he said the governor's office had rebuffed efforts by the Senate to meet about the issue.

"We asked twice, and we were told the governor's staff was not having any more meetings about legislative issues,'' Gaetz said.

Crist spokesman Sterling Ivey said the governor's staff did not decline to meet with Senate officials but responded that it was reviewing the Medicaid proposals. In an e-mail message, he described the potential Medicaid overhaul as a "a very large and complex bill, and we continue to review both the House and Senate versions.''

But Karen Woodall, a longtime social-services lobbyist who opposes proposals to expand Medicaid managed care, said she hopes lawmakers don't pass an overhaul bill. Medicaid provides health care to about 2.7 million Floridians.

"There doesn't need to be a rush,'' Woodall said. "This is too important and affects too many lives to do this hurriedly.''

Capital Bureau Chief Jim Saunders can be reached at 850-228-0963 or by e-mail at jim.saunders@healthnewsflorida.org.

We've been seeing a lot of stories about people who say they're healthy and shouldn't be forced to waste the money on health insurance. For example, a recent story in The New York Times talks about a man who earns about $25,000 and never bought health insurance and doesn't think he needs it. He doesn't want to spend money on something he calls a “maybe” — maybe I'll get sick.

So what happens to these people who decide to forgo insurance in 2014? They may or may not have to pay a tax penalty. But for someone making just $25,000 a year, if he can't find a policy that is no more than 8% of his income or about $167 per month, there would be no tax penalty.

The mandate doesn't require people to buy insurance if the lowest cost option exceeds 8% of one's income. People with incomes below the tax filing threshold also are exempt from the penalty. That threshold for people under 65 was $9,350 for singles and $18,700 in 2009 for couples, and is adjusted each year by the IRS.
Tax penalties for someone in 2014 who does not buy insurance, but is not exempt from the mandate, are $95 or 1% of taxable income. That jumps to $325 or 2% of taxable income in 2015 and $695 or 2.5% of taxable income in 2016. After that, the penalty will be increased annually by the cost-of-living adjustment. Why the mandate? There needs to be a large enough pool of people buying insurance to offset the costs of the insurance companies for covering people with pre-existing conditions.

Let's assume people decide they'll pay the penalty rather than buy health insurance — what will that mean when they seek health care in an emergency? “The health care system will function as it does now,” says Sara Collins, vice president for the Affordable Health Insurance Program at the Commonwealth Fund. “There will continue to be a safety net. You'll still be able to go to an emergency room for emergency care.”

For non-emergency care, $11 billion is slated in the bill for community health centers, Collins explains. So people without insurance will be able to use those centers for non-emergency care, but they'll still have to pay the bill. Charges, even today, at community health centers are usually set on a sliding scale based on income.

“People won't be able to call to sign up for insurance while they're in an ambulance being rushed to the hospital,” explains Aaron Albright, who is on the staff of the House Committee on Education and Labor. While the regulations still need to be written, he expects that the individual and small business exchanges for buying health insurance will have open enrollment periods each year, as is true today with most employer insurance policies. If you don't buy insurance during the open enrollment period, you'll likely have to wait until the next year.

Collins also expects there will be provisions for people to buy in between open enrollment periods for change of life events, such as a marriage, divorce or adoption of a child. As in group insurance today, specific change of life events do allow the purchase of health insurance between open enrollment periods.

Collins explains that about 60% of the uninsured earn less than 200% of the federal poverty level ($29,140 for a couple and $44,100 for a family of four). So most of them will be eligible for either premium assistance or expanded Medicaid provisions. She's carefully watched what happened in Massachusetts after its mandate and says the program has been successful in encouraging “a lot healthy individuals to buy insurance” to build a large enough insurance pool to offset the costs of those with pre-existing conditions. Massachusetts is a good test case for what will likely happen to the health insurance marketplace in 2014.

But there will still be uninsured. Undocumented immigrants will not be eligible for any government help. Another big group that she thinks will fall through the cracks are people who are newly eligible for Medicaid, but don't realize they can apply for the help. She thinks these two groups will make up about one-third of the 23 million who will still be uninsured after the new law takes effect in 2014. Other uninsured will still find that even with the government help, health insurance is unaffordable for them.

The key will be to get the word out about the new eligibility rules for Medicaid, as well as the premium help that will be available under the new bill. You may be eligible for refundable and advanceable premium tax credits to help buy heath insurance through the exchanges. These credits will limit your premium contributions to the costs of buying health insurance. The government will pay the rest through tax credits.

Here's how the tax credits will be calculated:

If you earn up to 133% of the federal poverty level (FPL), the cost of health insurance will be capped at 2% of your income. The rest will be paid using tax credits.
If you earn up to 133-150% of FPL, your health insurance costs will be capped at 3% to 4% of income.
If you earn up to 150%-200% of FPL, your health insurance costs will be capped at 4% to 6.3% of income.
If you earn up to 200-250% of FPL, your health insurance costs will be capped at 6.3% to 8.05% of income.
If you earn up to 250-300% of FPL, your health insurance costs will be capped at 8.05% to 9.5% of income.
If you earn up to 300-400% of FPL, your health insurance costs will be capped at 9.5% of income.

Any premium costs above your income would mean you are eligible for refundable or advanceable premium tax credits. With advanceable premium tax credits, you won't even have to lay out the money to pay the premiums and wait for a tax credit.

Lita Epstein has written more than 25 books including The Complete Idiot's Guide to Social Security and Medicare and The Pocket Idiot's Guide to Medicare Part D.

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Medical Article: Good for wellness May Be Good for health

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I congratulate President Obama and the Democrats on their historic health reform achievement.

Will this bill be able to win approval as it runs the parliamentary gauntlet? Is it an act of political suicide that will become manifest in November? Will it bankrupt the country because of lack of cost controls?

Regardless of where one stands, the bill is a political act of vast ambition and colossal risk.

Now may be a good time to pick winners and losers of health reform.

Winners

• Drug companies, which backed Democratic efforts and will have 32 million more new customers, financed by government.

• Hospitals, which heretofore have had to accept non-paying patients and now will have patients paying money-losing Medicaid rates.

• The uninsured, with the possible exception of the young and healthy who now buy insurance or be penalized by the IRS by failing to comply with the individual mandate.

• Those with pre-existing illnesses, those whose payments were capped by insurance companies, those who had to pay full costs of preventive care or high deductibles, and children who will now be covered by their parents’ insurance policies until their 26th birthday.

Losers

• The biggest loser is likely to be private insurance companies, which will be heavily regulated, restricted from raising rates, obligated to accept all comers, unable to rescind coverage , and the target of higher taxes.

• Middle-class taxpayers and patients, who, if Massachusetts with its universal coverage can be used as an example, can expect higher taxes because of lack of cost controls, higher premiums as health plans pass through their increased expense, more limited access to doctors because of primary care shortages, and longer waiting lines to see a physician.

• Medicare recipients, who among other things, will see about $500 billion cuts in benefits, higher fees, reduction in Medicare Advantage plans, and more controls over what tests and procedures doctors can order.

• The states, many already on the verge of bankruptcy because of high Medicaid costs. and Medicaid providers, physicians, pharmacists, and others, who cannot continue losing money based on low reimbursements. State attorney generals in nine states, are taking actions by mounting efforts to declare the bill unconstitutional.

Doctors

The results will be mixed.

Negative

• The practice load of 32 million more uninsured entering the system, coupled with the influx of new Medicare recipients, will strain the capacity of already overloaded practices.

• Low Medicare rates, and even lower Medicaid rates, will tax the ability of practices to survive economically.

• The doctor shortage, particularly of primary care physicians, now estimated at 50,000, will be exacerbated, partly because more doctors will decline to accept new Medicare and Medicaid patients.

• The bill does not address the problems that concern physicians the most – tort reform and the sustainable growth rate formula, which calls for an annual reduction in Medicare physician fees — this year 21% — and which is always reversed.

• The creation of an independent payment advisory board, free from Congressional oversight, is regarded as a negative, because it can make arbitrary decisions.

Positive

• Medicaid rates are likely to be increased to Medicare rates for primary care physicians . This will be plus for primary care doctors and will tilt the table towards primary care over specialists,

• Another plus is a “modest increase” in funding for training programs.

• The American Medical Association, the American College of Physicians, and family practice and pediatric associations have supported the Obama administration’s position on reform. The members of these organizations and physicians in general support expansion of insurance coverage for the uninsured.

I predict this bill will be the start of a long and bitter debate on how to fund generous federal health benefits – coverage for pre-existing illnesses, free preventive care, guaranteed comprehensive health plans, mandated benefits with no caps, and subsidies for 32 million uninsured — up to $88.000 per family.

As history has shown with Medicare and Medicaid, costs will surely far exceed projections. As a nation, we shall have to grapple with the economic consequences of the universal coverage moral imperative.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

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