The Drawn-Out Medical Degree
By Denise Grady
Should medical education be shorter?
The answer is yes, at least according to administrators at many of America’s leading medical schools. The idea may conjure up images of clueless residents Googling symptoms on their smartphones at the patient’s bedside, but advocates insist that time spent in school can be trimmed without shortchanging education or compromising quality of care. And they say there are compelling reasons to speed up the process: to reduce the crushing debt many face by eliminating a year’s tuition and allowing doctors to start careers, and earn money, earlier.
The traditional four-year medical curriculum — two years of academic study and two years on the wards — is based on recommendations made in 1910 in a study called the Flexner Report and, many educators say, it’s time to rethink the program.
A recent, unpublished survey of 120 medical schools, conducted by the New York University School of Medicine, found that 30 percent were considering or already planning to start three-year programs, according to Dr. Steven B. Abramson, the senior vice president and vice dean for education, faculty and academic affairs. N.Y.U. enrolled its first three-year medical students a year ago. A handful of other pioneers include the medical schools at Mercer University in Savannah, Ga.; Texas Tech in Lubbock; the University of California, Davis; and Lake Erie College of Osteopathic Medicine.
The American Medical Association is among those urging changes in the way doctors are taught. Last year, it awarded $11 million to medical schools to spur innovative approaches. One emphasis is competency-based programs, in which students’ pace is determined by how well they perform a task, not by the number of years spent in school. Such programs in other fields have shortened the education process by about 20 percent, said Dr. Susan E. Skochelak, the association’s group vice president for medical education.
The Physician Assistant Will See You
By Barbara Moran
Flora Traub is a 37-year-old mother of three with a master’s in public policy from Harvard’s John F. Kennedy School of Government. But after years as a policy analyst, she found herself reflecting on her undergraduate premedical studies and the happy year she spent in AmeriCorps Community HealthCorps after college. She decided she wanted a new career, in medicine, but not as a doctor.
“I wouldn’t dream of medical school,” said Ms. Traub, who entered Boston University’s physician assistant training program this year. “Seven years of training and residency? I don’t want that much time away from my kids.” Another reason: “Doctors just seem to be running all the time, all day long.”
Think of it. No M.C.A.T., no residency, two years of professional school and you’re out making $100,000 a year. And like nurse practitionersand other “physician extenders,” P.A.s now carry out many duties once handled by doctors: They perform physical exams, diagnose illnesses, assist in surgery, order lab tests and prescribe medication.
Pay the Maine nursing homes, but don’t forget the fight to keep seniors independent
osted Aug. 01, 2014, at 2:01 p.m.
The emphasis in recent weeks on directing additional funds to Maine’s nursing homes highlights a disconnect between where policymakers such as Gov. Paul LePage are focusing their attention and what older adults in Maine actually want.
By and large — and this isn’t surprising — older adults in Maine want to remain in their own homes as long as possible as they age.
AARP Maine recently commissioned a poll of 2,000 Maine residents age 50 and older to gauge the issues and concerns they’re thinking about as they make their voting decisions this fall. Eighty percent of respondents — four out of five — said it’s extremely or very important that they remain at home as they age.
That desire informs a number of policy preferences for the voters AARP surveyed. Three-quarters of those polled said elected officials should make funding for services that help them stay at home — home health care and transportation, for example — a high priority.
Nearly 80 percent of voters 50 and older, according to the poll, are likely to vote for a candidate who devotes attention to ensuring older Maine residents can afford to remain in their homes as they age. And those polled by AARP are civically engaged: Ninety-three percent said they voted either in all elections or most.
Meanwhile, Maine has a nursing home funding situation that needs to be fixed, and the attention paid to the plight of nursing homes by LePage and Republican legislative leaders has intensified the discussion to an all-consuming crisis level.
Nursing homes play a critical role in our society in ensuring the health and safety of some of the state’s oldest residents with limited ability to take care of themselves. Maine’s nursing homes will remain a critical part of Maine’s long-term care system.
But there’s already been a shift away from nursing home care, both in Maine and nationally. In the 1990s, Maine had about 10,000 nursing home beds across the state. Today, the number is about 7,000. And nationally, the number of nursing homes fell 5.3 percent between 2002 and 2011, according to the federal Center for Medicare and Medicaid Services. Occupancy rates slipped in that time, even with fewer homes.
In Maine, much of the shift away from nursing homes occurred in the 1990s as the state set stricter nursing home admission standards, and more older adults transitioned to assisted living facilities that provide a less intensive level of care. But states also are using more of their Medicaid funds to pay for long-term care services delivered at home. In 1995, states spent 20 percent of their Medicaid long-term care funds on home- and community-based services, according to the Kaiser Family Foundation. By 2011, that percentage had risen to 45 percent.
Delivering long-term care services at home isn’t just popular among older residents, it’s more cost-effective for the taxpayers who are often footing the bill through Medicaid. According to AARP, the cost of a year of nursing home care in Maine amounts to 303 percent of the median household income for someone 65 or older compared with 96 percent for home-based care.
Maine and other states have been making progress in delivering more long-term care at home, but more needs to be done. As the state ages even more, older residents will need to have viable care options that allow them to stay at home and delay the need for nursing home care.
High Cure Rate, but Huge Cost, for Hepatitis C Pill
Critics Raise Concerns About Sovaldi
A new drug for the liver disease hepatitis C
is scaring people. Not because the drug is dangerous — it’s generally
heralded as a genuine medical breakthrough — but because it costs $1,000
a pill and about $84,000 for a typical person’s total treatment.
A
Washington advocacy effort has sprung up overnight, largely devoted to
objecting to the cost of this one medication, Sovaldi. Members of
Congress have started a joint investigation into how its maker, Gilead Sciences, settled on its price.
“Clearly, $1,000 a pill strikes people as completely unreasonable,” said John Rother, president of the National Coalition on Health Care, an advocacy group that has been raising an outcry about the drug’s price as “unsustainable.” Gilead “stepped in it when they decided to go for that cost per pill, because people can’t imagine why that could be justified.”
But maybe we are looking at the costs of Sovaldi in the wrong way. One reason it is causing such angst among insurers and state Medicaid officials is that treatment costs are coming all at once.
First
of all, there is pent-up demand. There are a lot of people with
hepatitis C — an estimated 3.2 million in the United States — many of
whom have been waiting for a good treatment. Second, unlike drugs for
most chronic diseases, like diabetes or H.I.V./AIDS, for which treatment continues over many years, Sovaldi can cure most patients’ hepatitis
in just a few weeks, with the bill soon to follow. The lifetime cost of
treating someone with an H.I.V. infection is around $380,000, according
to estimates from the federal Centers for Disease Control and Prevention, but the annual bill is much smaller.
Think about AIDS treatment as paying a mortgage. Sovaldi is like buying a house with cash.
The United States health insurance
system works better for costs that are spread out and predictable.
People change insurance frequently, discouraging insurers from making a
big investment now that might pay off later. That does not mean that our
health care system is not expensive — it is — but we are more used to
costs that pile up slowly over time. Expensive one-time treatments like
Sovaldi can be a shock to the system.
Hepatitis
C slowly destroys the liver. Over decades, many infected people will
end up with liver damage and complications, including joint pain and kidney disease, while a smaller number will get cirrhosis or liver cancer,
and a tiny fraction will end up needing liver transplants. People used
to get the virus from blood transfusions; now, it is contracted mostly
by intravenous drug users who share needles.
Until
now, doctors would mostly treat hepatitis C patients’ symptoms. Some
drugs attacked the virus itself, but they did not work very well. And
most had side effects, including fever, depression and anemia, that about half the patients were not healthy enough to tolerate.
Those
drugs were also expensive — the most effective drug cocktail before
Sovaldi cost about $70,000 — but because few patients chose them, the
price tag did not cause a big reaction. Sovaldi is different. Patients
want this drug, with its high success rate and smaller list of side
effects. That means a big financial
“With
a product like Sovaldi, it’s a new price to the system,” said Gregg H.
Alton, Gilead’s executive vice president for corporate and medical
affairs. He said the company priced the drug to be competitive with
existing therapies, adding, “It’s a new cost they weren’t paying for
before.”
The
accounting firm PricewaterhouseCoopers estimated that this single drug
could bump up employer insurance premiums by half a percentage point
next year. Researchers at the Kaiser Family Foundation, a health care research group, estimate that it could increase premiums for Medicare’s drug benefit program by 3 to 8 percent next year, even if only a fraction of eligible seniors were to seek the treatment.
Insurer-sponsored
studies are estimating even higher costs. Express Scripts, a company
that manages drug benefits for insurers, prepared a worst-case situation:
It said that states alone could be on the hook for up to $55 billion if
every Medicaid patient or state prisoner with the disease was treated.
“We
think a perfect storm is arising out there,” said Dr. Steve Miller, a
senior vice president and the chief medical officer at Express Scripts,
who helped prepare its estimates.
Newly Insured by Health Law, Millions Face a Learning Curve
PHILADELPHIA
— Advocates of the Affordable Care Act, focused until now on persuading
people to buy health insurance, have moved to a crucial new phase:
making sure the eight million Americans who did so understand their often complicated policies and use them properly.
The
political stakes are high, as support for the health care law will
hinge at least partly on whether people have good experiences with their
new coverage. Advocates of the law also say teaching the newly insured
how to be smart health care consumers could advance the law’s central
goal of keeping costs down, such as by discouraging emergency room
visits, while still improving care.
For
those reasons, hospitals, clinics, insurers and health advocacy groups
around the country are organizing education efforts, aimed particularly
at lower-income people who might not have had insurance in years, if
ever. The Centers for Medicare and Medicaid Services has jumped in, too, with a project called “From Coverage to Care,”
which provides educational materials to community groups and medical
providers who are trying to teach health and insurance literacy.
Investigators Warn of Possible Perils in Fall With Health Site
By ROBERT PEAR
WASHINGTON
— The federal health insurance marketplace, a centerpiece of President
Obama’s health care overhaul, still suffers from serious problems,
raising questions about whether it will be ready to enroll millions more
people this fall, federal investigators said Wednesday.
The
investigators, from the Government Accountability Office, an
independent arm of Congress, said that the marketplace and its website, HealthCare.gov, were over budget and behind schedule because of “new and changing requirements” imposed by administration officials.
In
testimony prepared for a House hearing on Thursday, William T. Woods, a
senior official at the auditing agency, warned of “significant risks”
in the next open enrollment period, which begins Nov. 15.
His
comments were striking because the White House has said that the
problems were mostly solved with the help of a new team of professionals
led now by Sylvia Mathews Burwell, the secretary of Health and Human
Services.
In January, Mr. Woods said, the Centers for Medicare and Medicaid Services,
which runs the federal marketplace, awarded a contract valued at $91
million to Accenture Federal Services to continue work on the project.
But, he said, costs have ballooned to more than $175 million, and the
marketplace is still unable to perform essential functions needed to pay
insurers and update information on consumers.
There
have been other unanticipated increases. From September 2011 to
February of this year, the auditors said, the estimated costs for
developing the federal insurance marketplace rose to $209 million, from
an initial commitment of $56 million, and the cost of a data hub linking
federal and state agencies nearly tripled, to $85 million.
The
administration “launched HealthCare.gov without verification that it
met performance requirements,” Mr. Woods said, and federal officials did
not have a “quality assurance surveillance plan” to monitor the work of
contractors like CGI Federal, which had the main responsibility for
building the marketplace, or exchange.
Despite
close supervision by the White House, “there was confusion about who
had the authority to approve contractor requests to expend funds for
additional work,” Mr. Woods said. In 40 instances, he said, the staff
members of the federal exchange “inappropriately authorized contractors
to expend funds, totaling over $30 million.”
The
balky, often dysfunctional federal exchange frustrated millions of
consumers after it opened on Oct. 1. The White House led an emergency
repair effort, and eight million people eventually signed up by
mid-April.
Work to Bolster Health Website Is Raising Cost, Officials Say
By ROBERT PEAR
WASHINGTON
— Obama administration officials said Thursday that the cost of the
federal health insurance exchange was growing because they were
assigning new work to contractors in an effort to prevent a repetition
of the problems that crippled HealthCare.gov last fall.
Andrew M. Slavitt, the No. 2 official at the Centers for Medicare and Medicaid Services, told Congress that the agency was changing requirements for its contracts to expand the scope of work that must be done.
Mr.
Slavitt said that the administration was making improvements in the
federal exchange, but that the second round of open enrollment, starting
in November, would not be perfect. “There will certainly be bumps,” he testified at a House hearing.
The
Government Accountability Office, an investigative arm of Congress,
said that through March of this year the administration had made formal
commitments to spend $840 million on the federal exchange, or
marketplace.
In
January, the administration brought in a new company, Accenture Federal
Services, to lead work on the exchange, which was then in the middle of
its first open-enrollment period. The one-year contract with Accenture
was initially valued at $91 million. The accountability office said that
“new requirements and other enhancements” had increased the cost of
this contract to $175 million as of June 5.
Accenture said Thursday that another “task order” had increased the total to $190 million.
The D.O. Is In Now
Osteopathic Schools Turn Out Nearly a Quarter of All Med School Grads
The
old Blumstein’s department store sits across 125th Street from the
legendary Apollo Theater. It’s something of a Harlem landmark, where
“don’t buy where you can’t work” protests led to the hiring of
African-Americans as the first salesclerks in 1934 and where the Rev.
Dr. Martin Luther King Jr. was stabbed by a mentally unstable woman
during a book signing in 1958. Now a row of colorful clothing and
jewelry stores lines the ground floor. But the rest of the building has
been gutted and fitted with lecture halls, classrooms, laboratories and a
library to house the Touro College of Osteopathic Medicine.
Harlem
is a fitting location for Touro’s new medical school. Many osteopathic
schools have an added mission: to dispatch doctors to poorer
neighborhoods and towns most in need of medical care.
“The island of Manhattan has lots of doctors, but not here in Harlem,” said Dr. Robert B. Goldberg, dean of the college, which taught its first class in 2007.
Inside,
Touro seems indistinguishable from a conventional medical school — what
doctors of osteopathic medicine, or D.O.s, call allopathic, a term that
some M.D.s aren’t much fond of. A walk through the corridors finds
students practicing skills on mannequins hard-wired with faulty hearts.
They dissect cadavers. They bend over lab tables, working with
professors on their research. And, unlike their allopathic counterparts,
they spend roughly five hours a week being instructed in the
century-old techniques of osteopathic medicine, manipulating the spine,
muscles and bones in diagnosis and treatment.
In
one classroom, several students lay flat on examining tables while
classmates, under the guidance of Dr. Mary Banihashem, worked over their
necks. She reminded them to use the patient’s eyes as a reference point
in judging alignment as they assess neck motion, “We’re looking for any
tenderness” in neck muscles, she said.
Gabrielle
Rozenberg, in her second year at Touro, remembers the Ur-moment that
would lead her to this somewhat unconventional path in medicine. Growing
up on Long Island, she suffered from chronic ear infections. Her doctor
recommended surgery. But before committing to an invasive procedure,
her parents took her to a D.O. — a physician whose skills are comparable
to those of an M.D. In several visits, he performed some twists and
turns of her neck and head, and within days the infection cleared up.
“The infection happened because of fluid in the ear,” she explained,
“and the manipulations opened up the ear canal.” The infection didn’t
come back.
Ms. Rozenberg began thinking about one day becoming a doctor of osteopathic medicine herself.
Many
are drawn to the field for this more personal, hands-on approach and
its emphasis on community medicine and preventive care. There are
pragmatic reasons as well. Medical schools are failing to keep pace with
the patient population, and competition for careers in medicine is
growing fiercer. More students see osteopathy as a sensible alternative
to conventional medical school, a way to get a medical education with
M.C.A.T. scores that may not make the cut for traditional medical
schools. According to the American Association of Colleges of Osteopathic Medicine, students entering osteopathic schools last year scored, on average, 27, compared to 31 for M.D. matriculants. Incoming M.D. students average a 3.69 grade-point average, versus 3.5 for D.O. matriculants.
Yet
it should be noted: Getting into osteopathic school is still
excruciatingly tough. Last fall, almost 16,500 students applied for some
6,400 spots. Touro this year received 6,000 applications for 270
first-year seats for the Manhattan school and a new campus opening this
summer in Middletown, N.Y. (The average M.C.A.T. score for students
entering this fall was just a point below the M.D. average.)
The
boom in osteopathy is striking. In 1980, there were just 14 schools
across the country and 4,940 students. Now there are 30 schools,
including state universities in New Jersey, Ohio, Oklahoma, Texas, West
Virginia and Michigan, offering instruction at 40 different locations to
more than 23,000 students. Today, osteopathic schools turn out about 22
percent of the nation’s medical school graduates.
A Health Trade-Off That’s Here to Stay: Lower Cost, Limited Choice
By
changing the rules, the Affordable Care Act pushed health insurers
toward a new strategy: limiting the choice of doctors and hospitals
they’ll pay for. That move helped insurance companies keep premiums low
despite all the new restrictions, but they’re inspiring resistance.
Plans
sold this year in the new health insurance marketplaces were much more
likely than previous ones to include what insurers call tailored or
narrow networks. According to an analysis from the consulting firm McKinsey & Company, some 48 percent of plans offered in the most popular category included such features.
“Plans
have fewer tools available to them to offer lower-cost coverage options
than before, so they’re using these tools to do so,” said Brendan Buck,
a spokesman for America’s Health Insurance Plans,
an industry trade group. That’s because the Affordable Care Act
outlawed a lot of the old options. Insurance companies can’t exclude
sick customers. They all have to cover a defined set of basic health
benefits. There’s a cap on how much they can ask patients to pay each
year out of pocket, and rules about what percentage of average costs
they must cover to sell their plans in a certain category.
McKinsey
defined a “narrow network” plan as one that included less than 70
percent of the doctors and hospitals in a given metropolitan area,
though some plans they surveyed covered less than 30 percent of local
providers. The plans save money by allowing insurers to avoid hospitals
and doctors that charge high prices.
Insurers
can offer favored hospitals lots of guaranteed patients in exchange for
lower prices, or can simply squeeze out hospitals that won’t negotiate
on rates. That means that, in some markets, expensive, popular specialty
hospitals aren’t covered. In some extra-narrow plans, only one big
health system gets covered. Over all, the strategy has lowered premiums
by 5 to 20 percent, according to an industry-funded study from the actuarial firm Milliman.
The
concept is not new to health insurance, which suggests that many people
may turn out to like the trade-off between low premiums and a smaller
selection of providers. Traditional H.M.O.s, like Kaiser Permanente in
California and Group Health Cooperative in Washington, have long
attracted patients despite their lack of flexibility. And seniors are increasingly choosing private Medicare Advantage plans,
which tend to have limited networks, but lower premiums and some extra
benefits, over traditional Medicare, which covers every willing
provider.
Do you really need that medical test or treatment?
By LISA ZAMOSKy
For some time there has been a nationwide effort to cut back on unnecessary medical tests, over-prescribed drugs and surgery that doesn't end up helping people feel better.
But old habits die hard.
Dr. Emma Trejo knows that only too well. As an internist practicing in the South Bay city of Lawndale, she says patients frequently come to her office with their minds set on what medical services they want.
And sometimes, the doctor says, it doesn't matter that her experience tells her there's a better way to treat what ails them.
"Oftentimes, the patient is already convinced.... They come with their list and that's all they want from you," she says. From these patients, she says she often hears: "I don't need you to tell me if I need the treatment or not."
What patients often don't consider is that all medical tests and treatments come with some risk.
Over-treatment is also needlessly expensive. It's estimated to cost upward of $226 billion in wasted healthcare in the U.S. each year, according to a 2012 study published in the Journal of the American Medical Assn.
A national campaign called Choosing Wisely is pressing for better doctor-patient communication as an important way to avoid unnecessary treatments of all kinds. It is an initiative of the American Board of Internal Medicine and it has much to say about all this.
Its website at http://www.choosingwisely.org is packed with information for patients and doctors that may amaze you.
No comments:
Post a Comment