The Doctor Is In, but Hundreds of Miles Away
By NINA BERNSTEIN
High in a Manhattan skyscraper near Grand Central Terminal on a recent Tuesday, 80 critically ill patients in intensive care units scattered from Georgia to New Jersey were being monitored, remotely, by a doctor scanning a dozen computer screens.
On one monitor, she scrolled to a report of new symptoms in a 77-year-old patient in High Point, N.C. On another, she summoned a graph of blood pressure readings from a woman struggling with chronic pulmonary disease. Finally the doctor — who is an “intensivist,” or critical care specialist — clicked to a live image of an unconscious 60-year-old man in septic shock in Warner Robins, Ga., and zoomed close enough to check the dial on his ventilator. The setting was correct, she said, reflecting an algorithm designed to improve survival rates and shorten ICU stays.
More than a decade ago, this kind of tele-ICU command center was trumpeted by its creators as the new standard in critical care, a way to save lives and money by stretching the skills of an inadequate pool of intensivists to help oversee more of the country’s sickest patients. Today, with the growth of such systems stalled at about 10 percent of ICU patients nationwide, and wildly contradictory studies about the results, no one can say with authority if, or under what circumstances, tele-ICUs deliver on their promises.
Like many expensive innovations in medicine, from robotic surgery and designer drugs to electronic medical records, tele-ICUs have shown their most stellar results in studies linked to the companies that sell the systems; some hospitals in these studies cite as much as a 40 percent decline in mortality and a tenfold return on investment. In contrast, some independent studies published in the last five years have found no significant effect on survival rate, complications or length of stay, and have found that tele-ICUs brought new budgetary burdens, not payoffs.
Doctor-Owned Hospitals Prosper Under Health Law
By JORDAN RAU
KHN Staff Writer
APR 12, 2013
Doctor-owned hospitals are earning many of the largest bonuses from the federal health law's new quality programs, even as the law halts their growth.
The hospitals, many of which specialize in heart or orthopedic surgeries, have long drawn the ire of federal lawmakers and competitors. They say physicians often direct the best-insured and more lucrative cases to their own facilities, while leaving the most severely ill patients to others.
Some researchers say the doctors' financial interests encourage them to perform more tests and procedures, driving up the cost of care. The health law banned construction or expansion of these hospitals except in unusual circumstances.
But physician-owned hospitals have emerged as among the biggest winners under two programs in the health law. One rewards or penalizes hospitals based on how well they score on quality measures. The other penalizes hospitals where too many patients are readmitted after they leave. There are more than 260 hospitals owned by doctors scattered around 33 states, according toPhysician Hospitals of America, a trade group. They are especially prevalent in Texas, Louisiana, Oklahoma, California and Kansas.
Of 161 physician-owned hospitals eligible to participate in the health law's quality programs, 122 are getting extra money and 39 are losing funds, a Kaiser Health News analysis shows. That's a stark contrast with other hospitals -- 74 percent of which are being penalized.
Exam Time
By KUMIKO MAKIHARA
I got 21 As, three Bs, two Cs and a D on my report card this year. My grades were down from the last time I took the exams. And I was chastised for one section in which I did surprisingly poorly.
“You gained too much weight too quickly,” said the doctor at the clinic in Tokyo. “That might explain why your liver count is high.” Although I still weighed-in at less than average for a person of my height, I had put on two kilograms (4.4 pounds) in the last two years. “Only in Japan would two kilos over two years be called rapid weight gain,” commented my girlfriend from New York City.
This is the world of Japan’s obsessively comprehensive annual physicals. They are popularly called ningen dokku, or human dock, from the likening of the full check-ups to the docking of ships for repairs. About 35 percent of adults undergo such exams or similar cancer screenings each year, according to government statistics. The tests take from a half to several days depending on the number of areas to be analyzed. I skipped the gastrointestinal endoscopy this year because I hate the discomfort of swallowing the tube with camera, but I did undergo the abdominal ultrasound and a CT scan of the chest that were both part of my one-day basic package.
Comprehensive physicals first appeared in Japan in the 1950s, around the time the government began promoting wellness as a definition of good health — as opposed to just a lack of illness. The tests caught on. They are lucrative for doctors who charge outside of health insurance plans for the exams, but often affordable to clients because many employers subsidize them.
Japanese doctors like the hard numbers. Universal health coverage gives people easy access to hospitals, and doctors often see dozens of patients per day. With minimal time for dialogue, testing offers reassuring extra evidence when making diagnoses. Japan has the largest number of MRI units per capita among O.E.C.D. countries. The people are used to being probed from a young age. At primary school in Tokyo, every year my son received a urinalysis, ear, nose and throat and vision exams, a quick dental checkup and an electrocardiogram.
Breast Cancer Drugs Urged for Healthy High-Risk Women
By DENISE GRADY
Should healthy women take drugs to lower their risk of breast cancer?
On Monday, an influential panel of experts said that the answer is yes, but only for certain women who are at increased risk because of breast cancer in the family or a personal history of breast lumps or other problems. Two drugs, tamoxifen and raloxifene, can lower the risk, and may be worth taking even though both can have serious adverse effects like blood clots and strokes, the experts said.
The panel, the United States Preventive Services Task Force, recommended that for healthy women ages 40 to 70, doctors help assess the odds of breast cancer and offer to prescribe one of the drugs for patients whose risk is above average — but only if their chances of developing blood clots and strokes is low.
Because of the adverse effects, the panel also advised that the drugs not be prescribed for women unless they are at increased risk of breast cancer.
“There is evidence of benefit for certain women,” said Dr. Wanda K. Nicholson, a task force member and an associate professor of obstetrics and gynecology at the University of North Carolina School of Medicine in Chapel Hill.
Dr. Nicholson said she recommended the drugs for some of her own higher-risk patients. Some take them; some choose not to.
“The take-home point for women is to have that initial conversation with their provider,” she said.
The task force recommendations are being published in draft form and are open for public comment until May 13. An analysis of research on which the recommendations were based was also being published in Annals of Internal Medicine. The advice matches that given by the task force in 2002 (the group re-evaluates many of its subjects once a decade), though the earlier report stopped short of telling doctors to offer to prescribe the drugs. Members of the group said they relied on a wealth of new data that helped confirm and clarify the risks and benefits of the two drugs, and how they measure up against one another.
Tamoxifen and raloxifene have been recommended for years for women whose odds of developing breast cancer are higher than average. Both drugs block the effects of estrogen, and can lower the risk of the type of breast cancer whose growth is stimulated by the hormone. About 75 percent of breast cancers fall into that category. Tamoxifen is more commonly used to prevent recurrences in women who have already had breast cancer, and raloxifene is most often prescribed to prevent fractures in women with osteoporosis. Tamoxifen can also decrease the risk of fractures.
Doctors may see these drugs as a rare opportunity to lower the risk of cancer, but some women see them as simply trading one risk for another. Many healthy women, even if they are at increased risk, refuse the drugs, asking why they should take pills to lower the odds of a disease they may never get anyway, especially when the drugs can have dangerous or unpleasant side effects.
A Battle Plan to Lose Weight
By CATHERINE SAINT LOUIS
Laura Ward, 41, had always attributed her excess pounds to the drugs she takes for major depression. So Ms. Ward, who is 5-foot-6 and once weighed 220 pounds, didn’t try to slim down or avoid dietary pitfalls like fried chicken.
But in a clinical trial, Ms. Ward managed to lose more than 30 pounds doing low-impact aerobics three times a week. During the 18-month experiment, she was introduced to cauliflower and post-workout soreness for the first time. She and the other participants attended counseling sessions where they practiced refusing junk food and choosing smaller portions. She drank two liters of Diet Dr Pepper daily instead of eight.
Eventually, Ms. Ward, who lives in Baltimore, realized her waistline wasn’t simply a drug side effect. “If it was only the medications, I would have never lost all that weight,” she said.
People with serious mental illnesses, like schizophrenia, bipolar disorder or major depression, are at least 50 percent more likely to be overweight or obese than the general population. They die earlier, too, with the primary cause heart disease.
Yet diet and exercise usually take a back seat to the treatment of their illnesses. The drugs used, like antidepressants and antipsychotics, can increase appetite and weight.
“Treatment contributes to the problem of obesity,” said Dr. Thomas R. Insel, the director of the National Institute of Mental Health. “Not every drug does, but that has made the problem of obesity greater in the last decade.”
It has been a difficult issue for mental health experts. A 2012 review of health promotion programs for those with serious mental illness by Dartmouth researchers concluded that of 24 well-designed studies, most achieved statistically significant weight loss, but very few achieved “clinically significant weight loss.”
Beyond Obamacare
How a single-payer system can save health care in the United States
By Dave Dvorak, M.D., M.P.H.Minnesota Medicine, April 2013
As Minnesota’s physicians, health care leaders and legislators grapple with the complex changes brought by the Affordable Care Act (ACA), many are concerned that even after the law is fully implemented, hundreds of thousands of people will remain uninsured while health care costs continue to spiral.
What if there were a simple, streamlined solution that would guarantee health coverage for every Minnesotan while saving the state billions of dollars? A growing number of Minnesota physicians are endorsing what they consider to be such a solution: single-payer health care. Weary of having to comply with hundreds of different insurance plans’ administrative requirements while their patients are denied needed tests and treatments, these physicians are drawn to the simplicity, cost-effectiveness and truly universal coverage offered by a single-payer system.
Their views were supported by an independent analysis last year demonstrating that with a state-based single-payer system, every Minnesotan could have comprehensive coverage while the state would save billions annually.[1]
A deeply flawed system
The desire for meaningful reform comes in the face of the U.S. health care system’s long-recognized dysfunction. Despite health care accounting for 18 percent of the nation’s economy—twice that of other wealthy democracies—48 million Americans lack health coverage.[2,3] Another 29 million are underinsured, having poor coverage that exposes them to unaffordable out-of-pocket expenses.[4] Health insurance premiums have doubled over the past decade, with the average annual cost for family coverage now exceeding $15,700;[5] and health care costs now account for two-thirds of personal bankruptcy filings in the United States.[6]
At the root of these problems is the fact that we have a fragmented, highly inefficient system. Employed Americans younger than 65 years of age have job- based insurance, if their employer chose to provide it; the elderly and disabled are covered through Medicare; the poor by Medicaid; military veterans through the Veterans Administration; and American Indians through the Indian Health Service. Persons who do not fall into any of those categories must try to purchase individual coverage in the private market, where it is often prohibitively expensive or unobtainable if they have a pre-existing health condition.
Owing largely to this fragmentation and inefficiency, a staggering 31 percent of U.S. health care spending goes toward administrative costs, rather than care itself.[7] Inefficiency exists at both the provider and payer level. To care for their patients and get paid for their work, physicians and hospitals must contend with the intricacies of numerous insurance plans—which tests and procedures they cover, which drugs are on their formularies, which providers are in their network. Meanwhile, private health insurance companies divert a considerable share of the premiums they collect toward advertising and marketing, sales teams, underwriters, lobbyists, executive salaries and shareholder profits. The top five private insurers in the United States paid out $12.2 billion in profits to investors in 2009, a year when nearly 3 million Americans lost their health coverage.[8,9]
The ACA of 2010, known widely as Obamacare, is expected to extend coverage to 32 million more Americans.[10] But it accomplishes this goal primarily by expanding the current fragmented, inefficient system and maintaining the central role of the private insurance industry in providing coverage. As a result, the ACA is expected to do little to rein in health care spending.[11] Furthermore, it will fall far short of achieving universal coverage, as tens of millions of Americans (including 262,000 Minnesotans) will remain uninsured after its full implementation.[1,10]
The solution
The central feature of a single-payer health care system would be one health plan that covers all citizens, regardless of their employment status, age, income or health status. Having a public fund that pays for care would slash administrative inefficiencies and eliminate profit-taking by the private insurance industry.
Under a single-payer system, the way society pays for health care would change, but the market-based health care delivery system would remain. Physicians and hospitals would continue to compete with one another based on service, quality of care and reputation. The chief difference is that they would bill a single entity for their services, rather than numerous insurers.
http://www.pnhp.org/print/news/2013/april/beyond-obamacare
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