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I’d previously gotten some bad information on when meaningful use stage 1 would be applied and when meaningful use stage 2 would go into affect. In fact, I put it out there as a reason why providers should show meaningful use of a certified EHR in 2011 and not wait until 2012.

Read More: http://www.emrandhipaa.com/emr-and-hipaa/2010/12/03/years-for-meaningful-use-stage-1-correction/

Below, Kent Bottles, M.D. reflects on the difference between “slow medicine” and what he calls “UCLA medicine.” (For the full post, see “Kent Bottles’ Private Views” )

“I have been thinking about the difference between slow medicine and UCLA medicine. It has made me realize how complex and difficult it is to transform American health care so that we lower per-capita cost and increase the quality of our lives. And yet we must achieve these two goals.

“Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother: Embracing ‘Slow Medicine,’ The Compassionate Approach to Caring for Your Aging Loved Ones. Slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care.

“McCullough describes slow medicine as ‘care that is more measured and reflective, and that actually stands back from rushed, in-hospital interventions and slows down to balance thoughtfully the separate, multiple and complex issues of late life.’ Shared decision-making, community and family involvement, and sophisticated knowledge of the American health care system are some of the slow medicine practices that sharply contrast with UCLA medicine.

“UCLA medicine is the status quo where the hospital is the center of the medical universe; where care is often uncoordinated and hurried, and where cure is the only acceptable outcome for both patient and physician. I call it UCLA medicine because the CEO of that well-regarded medical center was quoted in a New York Times Sunday Magazine article as saying, ‘If you come into this hospital, we’re not going to let you die.’   This is a statement that puzzles me as an old time anatomic pathologist.”

I would add that I find the UCLA CEO’s statement more than puzzling; I find it frightening.

I can’t help but think of the doctor who explained: “Once you’re in the hospital, you’re in ‘the system.’”  I imagine a prison door closing behind me. I am now in a place where people no longer ask me what I want.  Instead, they tell me:  “This is what we’re going to do.”

Of course, Bottles goes on to acknowledge that “there are times (serious acute illness correctly diagnosed where there is an evidence-based treatment that has a good chance of success) when I hope I am treated in UCLA’s ICU or operating room by UCLA specialists. However, there are also times as I get older that I hope I end up living in the Kendal-at-Hanover retirement community cared for by a wise and experienced geriatrician like Dennis McCullough and the community’s nurse practitioner; I want my providers to take things slowly and listen to what I want out of life.”

Read More: http://www.healthbeatblog.com/2010/12/slow-medicine.html

In a nation where ‘no child left behind’ has been a mantra, it’s clear that in the U.S., many children are left behind when it comes to health. UNICEF’s Report Card #9 is out from the Innocenti Research Centre, providing the league table for child well-being in the world’s 24 richest countries.

In health inequality — that is, the gap between kids who have ‘average’ well-being in the U.S. and those who fall below – the U.S. ranks #22 among the 24 wealthiest nations in the world. While an educated guess might put U.S. kids’ health inequality below Switzerland, Norway, and Denmark, the sad surprise in the data are that U.S. children fall well behind places like the Czech Republic, Poland and Slovakia. The chart summarizes the rankings for the 24 OECD countries studied by UNICEF. Only Italy and Hungary’s children have greater “bottom-end inequality” (a UNICEF term) than American kids.

UNICEF found that the countries with the highest median levels of health — the Netherlands, Austria and Portugal — also have the lowest levels of health inequality.

“Whether in health, in education, or in material well-being, some children will always fall behind the average,” the report recognizes. ”The critical question is — how far behind? Is there a point beyond which falling behind is not inevitable but policy susceptible, not unavoidable but unacceptable, not inequality but inequity?”

 UNICEF based data on child well-being based on data from a World Health Organization survey, Health Behaviour in School-aged Children among children 11, 13 and 15. Young people were asked how often in the previous six months they had experienced the following problems: headache, stomach ache, feeling low, feeling irritable, feeling bad tempered, feeling nervous, having difficulty getting to sleep, and, feeling dizzy.

Health Populi’s Hot Points:   Inequality in health is driven by socioeconomic status. In Closing the Gap in a Generation, WHO observes that, ” Increasingly the nature of the health problems rich and poor countries have to solve are converging. The development of a society, rich or poor, are judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health.”

In the U.S., the gap between health-rich and health-poor is widening. From East LA to Detroit, Bangor, Maine to New Orleans, health inequities and disparities can look like those between the south side of Chicago and Nairobi or Dharavi, India.’

Health policies that address unequal health for children (and older people too) have as much to do with income security, job security, safe water and healthy and accessible food supplies. Good health comes from vaccines and basic medicines, surely; but also from the ability to read, secure and hold a decent job, and get a good education.

When children fall behind in education and economic standing, they ultimately lose in health. The longer-term consequences morph from teenage pregnancies and alcohol and drug dependence, to behavioral difficulties and welfare dependence.

Read More: http://healthpopuli.com/2010/12/03/kids-in-america-have-unequal-health-compared-to-most-of-the-worlds-rich-nations/

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As mentioned before (Accountable care shouldn’t equal consolidation) a very likely outcome of the evolution toward Accountable Care Organizations is consolidation under hospital-centric health systems. Hospitals are the ones with sufficient capital, infrastructure and scale to position themselves for the new environment. When they assemble the rest of the pieces they will be in a formidable position. That may be good news for hospitals, but it’s not particularly encouraging for most physicians, patients, health plans or taxpayers. That’s because such ACOs are likely to be expensive, bureaucratic and powerful.

Medical societies recognize where things are headed and are trying to devise approaches that will preserve physician autonomy and independence. In this case their views are well-aligned with the public interest and I hope they prevail. The American Medical Association (AMA) has been most vocal on this topic. Here’s what AMA president Cecil B. Wilson MD has to say about it in Healthcare IT News:

“The physician-led ACO model injects competition into the market by eliminating the need for consolidation under a hospital system,” said Wilson. “Competition fosters innovation, which ultimately helps patients receive efficient high-quality care. Care coordination is vital, and physicians can work together with a healthcare team to keep patients healthy and out of the hospital while maintaining independent medical practices. CMS should adopt policies that facilitate physician-led ACOs and do not inadvertently bias participation in favor of large health systems and hospitals.”

“Our goal is to ensure that new models of care benefit patients, and for this to happen physicians must be able to successfully participate in and lead ACOs,” Wilson said.

I think there’s a reasonable chance that physician led efforts will prevail long term, once the high cost of hospital-led ACOs is better understood. In my opinion it would be better to help physicians get out ahead now rather than have society learn its lesson the hard way.

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Read More: http://diseasemanagementcareblog.blogspot.com/2010/12/disease-management-ie-population-health.html

Combine a procedure for treatment of a obesity, a high prevalence condition, with a large patient population seemingly as dedicated to fast food  as it is to fast solutions to the resulting condition, and further combine it in a country with the highest percent of GDP spent on healthcare and it becomes clear that the demand for bariatric surgery and its related device and drug markets is highest in the U.S.

Below, drawn from Metabolic/Bariatric Surgery Worldwide 2008. Obesity Surgery, 2009 (Dec;19(12):1605-11) is illustrated the global share of bariatric surgeries by country.

Source: Metabolic/Bariatric Surgery Worldwide 2008. Obesity Surgery, 2009 (Dec;19(12):1605-11) and MedMarket Diligence, LLC, report #S835.

In descending order, the number of annual bariatric surgeries by country is USA/Canada, Brazil, France, Mexico, Australia/New Zealand, Belgium/Luxembourg, Spain, United Kingdom, Italy, Netherlands, Sweden, Greece, Israel, Argentina, Germany, Denmark, Austria, Chile, Egypt, Norway, Portugal, Venezuela, India, Czech Republic, Switzerland, Romania, Poland, Russia, Peru, Turkey, South Africa, Hungary, Ukraine, Japan, and Serbia.

Read More: http://feedproxy.google.com/~r/AdvancedMedicalTechnologies/~3/bDJ9KMUOWbk/

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1. Submit a single comment at the bottom of this blog post (starting on Dec 1) with the following information: 
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Remember all the excitement about resveratrol, the red wine extract that some hoped would be proven as a wonder drug for cancer and other ailments? Quackwatch (Resveratrol: Don’t Buy the Hype) had the substance pegged as a loser as early as 1999, but that didn’t stop GlaxoSmithKline (GSK) from paying $720 million for Sirtris Pharmaceuticals, the Massachusetts company developing resveratrol, two years ago. As you may have heard, GSK has just shut down development after data showed the drug did little good and posed a danger to the kidneys.

Big pharma is running scared now because they need to replace their aging portfolio with new drugs, so it’s understandable that they need to take risks on unproven drugs. Still, you can bet whoever led the charge for Sirtris at GSK is feeling a little sheepish right now. It would have been much better for him (her?) if it took longer for the drug to fail. Sirtris founder Christoph Westphal put some serious cash in his pocket when the deal was done. He’s now running GSK’s venture fund and has definitely had the last laugh. Read my Myth of the Innocent Drug Company for more on his perspective.

This background may help explain why Merck just bought SmartCells, another Massachusetts firm, for $500 million. The company has a cool sounding, patented approach for insulin development, but it’s apparently years away from even entering a clinical development program. That seems like it should make the company worth a lot less, but actually from the perspective of the Merck business development person, it may make it worth more. After all there’s little chance SmartCells will fail and be written off for at least five years. By that time the deal maker will have been promoted and/or moved on to another company. No one will be able to pin the failure on this person.

The deal does include some milestone payments, which have not been publicly disclosed. Still it’s a safe bet that there’s a goodly amount of cash upfront.

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Today, “The National Commission on Fiscal Responsibility and Reform” a bi-partisan group that President Barack Obama appointed earlier this year, released the final version of a report recommending ways to rein in the budget deficit.  I’m not going to try cover all of the Commission’s proposals in this post, but I think it’s important to compare how the Accountable Care Act reins in Medicare spending to the Commission’s more Draconian approach.

The commission takes aim at healthcare for seniors by hiking co-pays and deductibles for Medicare patients without considering what patients can afford. Under these proposals, many middle-class Medicare beneficiaries will not be able to afford health care. Those who are sickest would suffer most. The report then blindly freezes and ultimately cuts Medicare payments to all physicians--ignoring the fact that, today, some are underpaid for essential services.  Finally, it calls for reinstating the dreaded sustainable growth rate (SGR) formula as a benchmark for reducing reimbursements to physicians, beginning in 2015.

Friday, the 18-member panel will vote on the plan. If 14 members of the group say “yea,” it will go to Congress for its consideration.  

 How the Fiscal Commission Would Reduce Medicare Payments to Doctors: The commission’s co-chairs, Alan Simpson and Erskine Bowles, released an outline of the report on November 10 which called for "modest reductions" in Medicare reimbursement for physicians, but did not specify an amount. Today's full-fledged report unveils the numbers.

Over the short term, the Commission would freeze Medicare payments to doctors through 2013, and then trim payments by 1% in 2014. The Group also “directs the Centers for Medicare and Medicaid Services (CMS) to develop an improved physician payment formula that encourages care coordination across multiple providers and settings and pays doctors based on quality instead of quantity of services.” http://www.kaiserhealthnews.org/Stories/2010/December/02/fiscal-commission-medicare-recommendations-document.aspx

The Affordable Care Act (ACA) already calls for pilot projects that would pay doctors for value in the form of better outcomes rather than rewarding them for volume through fee-for-service payments.  The ACA also gives the Secretary of HHS the power to roll out successful pilots nationwide, without needing to go through Congress. (In the past, Congressional lobbyists have blocked expanding programs that would reduce spending.)

But the Commission goes one step further: “In order to maintain pressure to establish a new system and limit the costs of physician payments,” the proposal would reinstate the much hated “Sustainable Growth Rate” SGR formula in 2015 (using 2014 spending as the base year) “until CMS develops a revised physician payment system.”

The SGR formula, which was devised in the late nineties, requires that if increases in Medicare’s total payments to physicians exceed GDP growth by a certain amount in a given year, reimbursements must be sliced the next year. When Congress approved the formula, GDP growth was much higher than it is today. But by 2003, economic growth had fallen to a point that the formula kicked in, calling for across-the-board reductions in Medicare’s payments to doctors.

Knowing that some Medicare doctors are underpaid--and fearing that they might stop seeing Medicare patients if they could not cover their costs-- Congress was unwilling to lower fees for all services.  Instead, each year it kicked the can down the road, postponing the day of reckoning.

The Medicare Payment Advisory Commission (MedPAC) has recommended ditching the SGR.  And liberals in Congress have voted to repeal it, but fiscal conservatives have blocked repeal. So each year, the SGR cuts are debated, and each year, Congress has been able to muster only enough votes to postpone slashing Medicare payments. Meanwhile, virtually everyone in Washington understands that the SGR formula will never be implemented.  It has become a political tool that those who oppose health care reform use to frighten doctors that under “Obamacare” their incomes will fall. In fact, when President Obama took office he did not include the SGR savings in his budget.

Nevertheless, the deferred cuts have accumulated, and the SGR formula now directs Congress to whack all Medicare reimbursements to physicians by 25% % next year.  Everyone realizes that this is unthinkable. If asked to take such a hit, many doctors would stop taking Medicare patients.

Let me be clear: the Fiscal Commission does not propose lowering payments by 25% . It would “re-set” the formula making 2014 the baseline, but going forward, physicians would be subject to across-the-board reductions in payments for all services.

By contrast, the Affordable Care Act recognizes that while some doctors are over-paid for certain services, others are underpaid. Taking an axe to all reimbursements is a crude solution. Instead, the ACA calls for adjusting payments with a scalpel, giving the Secretary of HHS the authority to reduce payments for particular services that are overvalued, while lifting reimbursements for services that are undervalued. In addition the law calls for a 10% hike in pay for primary care physicians and other doctors who provide primary care, effective January 1, 2011.

Finally, if Medicare spending is growing significantly faster than consumer prices (using the Consumer Price Index plus 1% as a benchmark) the Independent Payment Advisory Board (IPAB) is charged with reducing Medicare spending--without cutting benefits or raising co-pays and deductibles. It’s likely that this would mean trimming fees for some tests and treatments.  (Congress could override IPAB”s recommendations only if it could realize equal savings, again without reducing benefits or increasing cost-sharing. Otherwise, IPAB’s proposals automatically become law.)

Shifting the Burden to Seniors:The Commission aims to raise $110 billion by requiring seniors to pay for the first $550 of visits to doctors and hospitals. In other words, Medicare would not reimburse for patients for any doctors’ bills or hospital bills until the patient had shelled out $550 of his own money. 

In addition, the Commission would keep a 20% co-pay on spending above the $550 deductible--with no cap on total out of pocket costs until the beneficiary has spent $7,500 out-of-pocket

This would no doubt lower Medicare spending; many seniors would have a hard time scraping together $7,500, and so would put off needed medical care. To make sure that even the sickest Medicare patients cut back on healthcare,  the report prohibits private Medigap plans (designed  to fill some of the holes in Medicare) from covering the first $500 of an enrollee’s cost-sharing liabilities and limits coverage to 50 percent of the next $5,000 in Medicare cost-sharing.

The Commission ignores the fact that median income among seniors is $18,000 a year. That includes Social Security, pensions, dividends, capital gains--every penny that comes into the household. In other words, half of Americans over 65 live on less than $18,000 a year.  “Middle-class” seniors (those on the third step of a five-step income ladder) are making do with roughly $15,000 to $21,000 a year. In many parts of the country, this means that they are barely getting by.  If they spent $7,500 out-of-pocket in co-pays, medical care would be eating up as much as 50% of their income.

By contrast, the Accountable Care Act eliminates co-pays for preventive care recommended by the U.S. Preventive Services Task Force. The goal is to reduce Medicare spending and improve the quality of care by encouraging seniors --many of whom suffer from two or three chronic diseases-- to receive preventive care before they land in a hospital.  If they visit a doctor, also will receive counseling on how they can help manage their chronic diseases. In 2011, the ACA  also provides  a 50% discount on covered brand name drugs if a senior hits the prescription drug “donut hole” and covers a free annual wellness visit.

Late this afternoon, it didn’t look likely that the report will garner the needed 14 votes. Even if it did, these recommendations would not make it through the House. Nevertheless, the Commission’s proposals are important because they offer a revealing snapshot of what Congressional conservatives would like to do. . .  

Read More: http://www.healthbeatblog.com/2010/12/comparing-the-fiscal-commissions-proposals-to-the-accountable-care-act.html

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I posted here yesterday on Practice Fusion‘s survey on consumers’ views of remote health monitoring, discussing a key finding that older Americans are less keen on the idea than younger people. The company sent me more detailed survey data which I’ve dug into, and discovered a counter-intuitive finding worth exploring: “Influential” people appear less interested in remote health monitoring than the mainstream American.

Who are these “Influentials?” GfK Roper, who conducted the study on behalf of Practice Fusion, bases this consumer segment on an index built on political and social activities engaged in over the past year: writing a letter to the editor or a politician, writing an article, working on a political campaign, being an officer in a civil organization, or being a member in an association that seeks to influence public policy. Respondents who have done at least four of these activities are part of the Influentials — whom GfK equates to “thought leaders” in the community. Statistically, for market research wonks among the readership here, the Influentials made up about 20% of the unweighted sample, and about 16% of the weighted sample.

On nearly every parameter in the survey, fewer Influentials say they are interested (net = somewhat plus very interested) in aspects of remote health monitoring. Specifically:

• 50.3% of Influentials agree that remote health monitoring between doctor and patient would improve their health, compared with 56.1% of the overall U.S. adult population
• 39.7% of Influentials with chronic conditions would be interested in using devices at home such as digital blood pressure monitors, glucometers, and scales that would automatically relay personal health data from the device to the doctor’s office, vs. 45.4% of the general population with chronic conditions
• 43.3% of Influentials with chronic conditions would be interested in using home medical devices that would trigger alerts for their doctor when their health condition significantly changed, versus 56.6% of the general population with chronic conditions
• 47.8% of Influentials with chronic conditions agree that this kind of communication (i.e., remote health monitoring) would improve their health, compared with 61.9% of the overall U.S. adult population with chronic conditions.

Health Populi’s Hot Points:   What factors could contribute to socially/politically active health citizens having slightly lower interest in and placing lower value on remote health applications?  Slightly fewer of the Influentials have been diagnosed with a chronic condition: 24% versus 25.2%. So having a chronic disease doesn’t appear to be a variable here. Responses to the various questions based on income are also variable and there’s nothing conclusive in the survey which demonstrates that people with higher incomes value remote health monitoring any more or less than people of lower socioeconomic status.

Gender, however, does play out differently across the different survey questions, and in statistically significant ways. For example, the automatic relay of personal health data from a medical device is more attractive to men who have chronic conditions than to women; so is the ability for doctors to be alerted regarding patients’ changing conditions.

The answer to the question posed in this post’s title remains a conundrum. This survey was based on an “N” of 1,000, so the statistical confidence level on the total sample passes scrutiny. However, given the relatively small proportion of Influentials who have been diagnosed with chronic conditions in the weighted sample — numbering a scant 38 people in the weighted sample. Perhaps the numbers for this sub-segment are questionable on that basis.

Nonetheless, in the overall sample, there’s statistical significance that the Influentials overall seem less interested in remote health monitoring in late 2010.

Read More: http://healthpopuli.com/2010/12/02/are-influentials-less-keen-on-connecting-health-practice-fusion-says-yes/

Many reasons can contribute to a company’s success in the market, but it is hard to underestimate the significance in medical technology of having a very strong foundation in intellectual property.

Out of forty one new international patents listed today at the World Intellectual Property Organization with the word “medical” in the abstract, ten of them are Medtronic’s.  Take my word for it that this is typical of Medtronic week in and week out.  The company stays at the forefront of development, securing positions in advanced medical technology markets.

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