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Friday, August 17, 2012

Health Care Reform Articles - August 20, 2012

Journal editorial: Pay-for-performance a faulty policy in medicine

By Chelsea Conaboy, Globe Staff
Programs that reward doctors and hospitals for hitting certain quality targets are being rolled out in Massachusetts and across the country. A major focus of the health care law signed by Governor Deval Patrick last week is that doctors should be paid for keeping patients healthy, rather than for the volume of tests or treatments they order. Yet, several recent publications question whether pay-for-performance systems actually lead to better care for patients.
The programs are meant to push doctors to think about a patient’s overall care and to consistently do things that are thought to improve health outcomes, such as give appropriate counseling to people with heart conditions or timely antibiotic treatment to people with pneumonia.



LePage’s special session would address state’s debt to hospitals

AUGUSTA, Maine — If Gov. Paul LePage ultimately calls lawmakers back to the capitol this fall for a special legislative session, it will be to deal with the more than $150 million the state owes its hospitals, a Maine Hospital Association official confirmed Friday afternoon.
Steven Michaud, the association’s president, said Maine Hospital Association officials have discussed a number of concepts with LePage’s office related to the state paying back hospitals for services they provided to patients under the Medicaid program, but for which they haven’t been paid. Michaud said the discussions about a special session had to do with addressing that debt.
“I do know that the whole issue of paying the hospital debt was behind this whole thing,” he said. “How they’re going to do all of that and what proposals they have to do it, I’ve never seen anything.”
Maine’s hospitals are owed about $460 million for treating patients under the state’s Medicaid program, which provides insurance to low-income residents. To repay the debt, Michaud said, the state would have to come up with about a third of the money — about $153 million — and the federal government would kick in the rest.


Testing What We Think We Know


By H. GILBERT WELCH


Hanover, N.H.
BY 1990, many doctors were recommending hormone replacement therapy to healthy middle-aged women and P.S.A. screening for prostate cancer to older men. Both interventions had become standard medical practice.
But in 2002, a randomized trial showed that preventive hormone replacement caused more problems (more heart disease and breast cancer) than it solved (fewer hip fractures and colon cancer). Then, in 2009, trials showed that P.S.A. screening led to many unnecessary surgeries and had a dubious effect on prostate cancer deaths.
How would you have felt — after over a decade of following your doctor’s advice — to learn that high-quality randomized trials of these standard practices had only just been completed? And that they showed that both did more harm than good? Justifiably furious, I’d say. Because these practices affected millions of Americans, they are locked in a tight competition for the greatest medical error on record.
The problem goes far beyond these two. The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway. Our annual per capita health care expenditure is now over $8,000. Many countries pay half that — and enjoy similar, often better, outcomes. Isn’t it time to learn which practices, in fact, improve our health, and which ones don’t?
To find out, we need more medical research. But not just any kind of medical research. Medical research is dominated by research on the new: new tests, new treatments, new disorders and new fads. But above all, it’s about new markets.

Truth and Lies About Medicare



Republican attacks on President Obama’s plans for Medicare are growing more heated and inaccurate by the day. Both Mitt Romney and Paul Ryan made statements last week implying that the Affordable Care Act would eviscerate Medicare when in fact the law should shore up the program’s finances.
Both men have also twisted themselves into knots to distance themselves from previous positions, so that voters can no longer believe anything they say. Last week, both insisted that they would save Medicare by pumping a huge amount of money into the program, a bizarre turnaround for supposed fiscal conservatives out to rein in federal spending.
The likelihood that they would stand by that irresponsible pledge after the election is close to zero. And the likelihood that they would be better able than Democrats to preserve Medicare for the future (through a risky voucher system that may not work well for many beneficiaries) is not much better. THE ALLEGED “RAID ON MEDICARE” A Republican attack ad says that the reform law has “cut” $716 billion from Medicare, with the money used to expand coverage to low-
income people who are currently uninsured. “So now the money you paid for your guaranteed health care is going to a massive new government program that’s not for you,” the ad warns.
What the Republicans fail to say is that the budget resolutions crafted by Paul Ryan and approved by the Republican-controlled House retained virtually the same cut in Medicare.
In reality, the $716 billion is not a “cut” in benefits but rather the savings in costs that the Congressional Budget Office projects over the next decade from wholly reasonable provisions in the reform law.

How Much Can Patients Learn in a 15-Minute Doctor Visit?

By PAULINE W. CHEN, M.D.
Built more like a former professional basketball player than an elementary schoolteacher nearing retirement, the patient dropped a bagful of prescription medications on the table in the examining room and fell back into a chair. He couldn't remember what most of them were for.
Several weeks earlier, he had seen a new doctor who'd prescribed several new drugs and spent much of the visit reciting a list of advice - lose weight, exercise more, stop smoking, eat more fruits and vegetables. Before he even arrived home, he realized he couldn't recall any of the details of what the doctor had said.
"I felt like I was in a Charlie Brown cartoon," he said, recounting the visit with a laugh. "All I can remember the doctor saying was, 'Waw, waw-waw, waw-waw.' "
This patient is far from alone in his difficulty absorbing a fire hose of advice. Thanks to some dazzling advances in preventive medicine and public health, doctors in almost every specialty of medicine now have a panoply of proven preventive recommendations to keep their patients from getting sick. And as the number of validated interventions has grown, so has the pressure on doctors to remind their patients of all the now-standard advice in the course of a 15-minute office visit.
Faced with an impossible task, some physicians have thrown up their hands and chosen to focus on only a couple of topics at each visit. Others have resorted to handing out typed lists of the recommendations for patients to read at home. But an increasing number of doctors, under mounting pressures from insurance companies and others to prove that they are delivering quality care, are simply scrambling to cover as many of the wellness recommendations as they can, piling on the dos and don'ts in what a colleague of mine once referred to as "the grand information dump."
In no other specialty is the problem as acute as in pediatrics, as two papers published this week in the journal Pediatrics underline. For children's doctors, the preventive pearls, which have been amassed in a hefty 648-page official guide titled "Bright Futures," include recommendations on using of car seats, wearing bicycle helmets, limiting television, eating more fruits and vegetables, cutting back on consumption of fruit juice and setting hot-water heaters at no more than 120 degrees Fahrenheit.
If acted upon, all of these recommendations can prevent myriad injuries, even deaths, in children. But it's a humongous "if." Currently there is very little proofthat simply telling patients and their families to do something, much less cramming all the recommendations into a 15-minute visit, will result in any behavioral changes at all.

St. Jude Is Told to Study a Defect in Heart Devices


By 


The Food and Drug Administration ordered St. Jude Medical on Thursday to conduct additional studies on patients implanted with heart-device components that were recalled last year and that have been linked to as many as 20 deaths. It also recommended that patients receive X-rays or other imaging to check for problems with their devices.
The Riata lead, which St. Jude stopped selling in 2010, is a wire that connects a defibrillator to a patient’s heart. Internal wires in the lead have been shown to break through the protective outer coating and cause unintended shocks in some patients. Defective leads may also prevent the defibrillator from working when needed by the patient. Defibrillators deliver a jolt of electricity to interrupt a potentially fatal heart rhythm.
Problems with the Riata leads have dogged the company since late last year. It sent an alert to doctors at that time about the exposed wires and said it would study the issue. Since then, doctors have scrambled to understand the scope of the problem and how best to address failing leads in patients, because removal of the components can also be dangerous. In March, a prominent researcher published a study claiming the Riata lead played a role in some 20 deaths, a contention the company disputed.
About 128,000 patients worldwide still use the Riata lead, according to the company.
On Thursday, the F.D.A. recommended that patients’ doctors check for abnormalities in the insulation around the leads, noting that previous studies showed that X-rays and other imaging had uncovered problems. But it cautioned against routinely removing the leads, a warning that St. Jude underscored on Thursday.
“It is important to note that in published studies, the majority of leads with externalized conductors have continued to function properly,” the company said in a statement. It said that it would continue to work with the F.D.A. “to understand the ongoing performance of our leads and whether additional studies need to be initiated.”

Both Campaigns Seize Role of Medicare Defender


By  and 


THE VILLAGES, Fla. — After several days in which he mentioned only generalities on the campaign trail, Representative Paul D. Ryan sought on Saturday to play offense on Medicare, attacking in detail President Obama’s health care plan, seizing an issue that has the potential to be one of Mr. Ryan’s biggest liabilities in joining the Republican presidential ticket.
Mr. Ryan, who has proposed a controversial voucher program for Medicare, accused Mr. Obama of being the bigger threat because of savings wrung from the growth of spending in the program contained in the president’s health care overhaul of 2010.
He said a board of “15 unelected bureaucrats” would decide what should be cut, and that “one out of six of our hospitals and our nursing homes will go out of business.”
“The president raids $716 billion from the Medicare program to pay for the Obamacare program,” Mr. Ryan said, to boos from a crowd of more than 1,000 seniors in this vast retirement community.
Left unsaid was that his own budget plan passed by the House in March includes the same $716 billion in savings, to be used to reduce the deficit.
Having Mr. Ryan take the Medicare fight to Florida, a crucial battleground state that Mr. Obama won in 2008, represented an effort by Mitt Romney’s campaign to turn what many strategists predicted would be the ticket’s Achilles’ heel — Mr. Ryan’s detailed and aggressive budget cuts — into an asset.
With his 78-year-old mother looking on, Mr. Ryan, 42, wove a story of generational obligation to personalize the long-term threat to Medicare’s solvency. He described how he and his mother, Betty Ryan Douglas, were the primary caregivers for a grandmother with Alzheimer’s disease who moved into their Wisconsin house when he was a teenager.

Romney, Ryan blast Obama’s health care law in N.H. visit

GOFFSTOWN, N.H. – Mitt Romney and Paul Ryan, coming here to the state with one of the oldest median ages, on Monday morning criticized President Obama for his health care law and said the Republican ticket would be more likely to put Medicare on sounder financial footing.
“Medicare should not be a piggybank for Obamacare!” Ryan said.
It was their first unscripted event since Ryan was named the vice president candidate nine days ago, with a town hall meeting where voters could ask questions. But little went awry, and most of the event was carefully choreographed by the Romney campaign.

False piety and the Medicare debate

By , Published: August 19

Deficit hawks are worried that the Medicare debate in the presidential campaign will make it impossible to reach a post-election deal to balance the budget. At the same time, much of the punditry focuses on how mean and nasty this campaign is.
Those who are anxious about the deficit should relax. This campaign could actually pave the way for a sensible budget deal. And those who bemoan the rock-’em-sock-’em campaign should stop wringing their hands and get about the business of calling out falsehoods and identifying misleading assertions.
On the budget, the fear is that because President Obama is attacking Paul Ryan’s fiscal road map and because Mitt Romney is responding by assailing the Medicare savings in Obama’s Affordable Care Act, Congress will be scared away from reducing the government’s health-care costs. In this view, the campaign will poison the well for future budget talks.
Nothing could be further from the truth. The fact is we cannot have honest budget negotiations until we resolve one big question: Will new revenue — yes, higher taxes — be part of a budget deal or not? The election will settle where the country stands on this proposition.
Despite the fantasies of the trickle-down supply-siders, there is no path to a balanced budget without tax increases. Obama openly supports a tax increase. Romney and Ryan not only oppose higher taxes but also claim they can cut taxes and balance the budget — eventually. If they win, we can look forward to more tax cuts compounding the red ink. Isn’t this what should really concern the deficit hawks?

Why Ryan might be right about Medicare

By , Published: August 19

Overlooked in the furor surrounding Paul Ryan’s Medicare proposal — a plan, it should be recalled, that wouldn’t start until 2023 and even then would affect only new beneficiaries — is a just-published study in The Journal of the American Medical Association (JAMA) suggesting that, well, Ryan might be right. The study finds that a voucher-type system might noticeably reduce costs compared to “traditional” fee-for-service Medicare. Three Harvard economists did the study, including one prominent supporter of President Obama’s health-care overhaul.
The study compared the costs of traditional Medicare with Medicare Advantage, a voucher-like program that now enrolls about 25 percent of beneficiaries. Medicare Advantage has cost less for identical coverage. From 2006 to 2009, the gap averaged 11 percent between traditional Medicare and voucher plans that, under the proposal by Ryan and Sen. Ron Wyden (D-Ore.), would serve as a price “benchmark.”
The central issue here is whether the runaway costs of the health sector, comprising nearly one-fifth of the economy, can be controlled without eroding medical quality. Almost everyone agrees that the delivery system — the amalgam of hospitals, clinics, doctors and nurses — should be reorganized to lower costs and eliminate unneeded care. The question is how.
One group favors market-like mechanisms. Consumers would receive vouchers, either payments or tax credits, to buy coverage. The theory: as people shop for low-cost and high-quality plans, competition forces the delivery system to restructure. Hospitals, doctors, insurers create more efficient networks with more coordinated care than today’s fee-for-service system. By contrast, fee-for-service reimburses doctors and hospitals for services they perform; this encourages unneeded tests and procedures.
The JAMA study doesn’t surprise advocates of this “consumer driven” health care. “Medicare fee-for-service is an inefficient way to deliver care,” says James Capretta, associate director of the Office of Management and Budget from 2001 to 2004. “It’s an engine for volume-driven spending.” Cost savings under a full-fledged voucher system would be much larger, he argues, because Medicare Advantage’s modest size has created only “muted competition.”
http://www.washingtonpost.com/opinions/robert-samuelson-why-ryan-might-be-right-about-medicare/2012/08/19/3e6005c0-e88e-11e1-936a-b801f1abab19_print.html


Mercy Hospital may be sold to Mass. chain

Posted: 2:19 PM
Updated: 2:52 PM 

PORTLAND — Mercy Health System of Maine took the first step toward selling itself to Massachusetts hospital chain Steward Health Care System LLC, by signing a non-binding letter of intent.
Terms of the potential deal were not disclosed. Mercy, which has 140 beds, said its intention is to remain a Catholic hospital. The sale, if completed, will be the first acquisition of a full-service Maine hospital by a for-profit health care company.
"The Mercy board of directors has taken a bold and transformative step which benefits the communities of the greater Portland region now and into the future," Mercy President and Chief Executive Eileen Skinner said in a statement. "Steward’s commitment to our employees, patients, medical staff, mission, and vision of community-focused care, made them Mercy’s first choice for partnership.”




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