Cooperating for better care.

Robert Whitcomb

Author Archives

The perils of ‘gray-zone medicine’

 

This article in The New England Journal of Medicine looks at “gray-zone medicine” — in which medical evidence fails to offer clear guidance for physicians’ treatment decisions.

The authors challenge “the misguided perspective that healthcare is a binary world in which interventions are either effective or ineffective, appropriate or inappropriate.”

They cite the risk for overuse of treatments in gray areas of diagnosis that may not work or might even do harm.

 


Another bid to kill a Medicare-cost curb

 

Here’s a perfect example of  how, despite Americans’ complaints about their having the world’s highest healthcare costs, special healthcare  economic interests do everything they can to keep those costs high.

Congressional Republicans are pushing to repeal the Independent Payment Advisory Board (IPAB), whose job is to give Congress recommendations on how to slow the growth of Medicare spending if it tops certain thresholds.

Medscape reports that the Affordable Care Act’s language “makes it hard for Congress not to enact IPAB proposals, and if lawmakers fail to do so, the U.S. Department of Health and Human Services is required to implement them.”

Some conservatives even call the IPAB a “death panel,” although, as Medscape notes, the law prohibits the board from proposing anything that “would ration healthcare or restrict benefits.”

IPAB backers say the board is a way to offset the power of industry lobbyists in Congress (actually, legislators and lobbyists are often effectively the same creatures) to stop efforts to control Medicare spending.

Organized medicine strenuously opposes the IPAB because they fear that it will tend to reduce physicians’ incomes, which are  by far the highest  in the world.

 


Tougher for patients to be in the right place

 

Abigail Zuger writes in The New York Times:

“It is increasingly critical for patients to be sick in the right place, and increasingly difficult for them to do so. As the great plates of medical care heave and split in cash-based tectonics, the options are multiplying in confusing plenty.

“There used to be the doctor’s office and the hospital. Now we have street corner wellness centers and urgent care centers, free-standing emergency rooms with no hospital attached, chain pharmacies with occasional doctors attached, and nursing practices with no doctors attached.

“We have hospitals that have merged and split and merged again into configurations that put all the cardiologists uptown, all the neurosurgeons downtown, and all the pediatricians somewhere that keeps changing.

“Accordingly, we spend a lot of time and energy getting people to where they need to be, launching them according to condition, severity and, always, insurance….”


Happy (for industry) hospital-admission numbers

 

Sterne Agee/CRT analyst Brian Wright writes:
“We view 1Q15 results as an important milestone for hospital shares showing generally better-than-expected admission admission levels on a current quarter and two-year stacked basis. While comparisons become more challenging as the year progresses, our positive thesis on the hospital industry is not a function of second derivative growth calculations, but one of absolute admission levels. We view improved adjusted admissions outlooks as sustainable, especially given increased capital expenditure plans and organic growth commentary from the companies.”


Fla. governor pitches idea for safety-net hospitals

 

Florida Gov. Scott has suggested to the state’s hospital executives that they share some of their  total of $3.7 billion in profits to help the state “transition” from depending on federal funding for the state’s Low Income Pool for safety-net hospitals.

He told The Miami Herald:

“This would be similar to how large market baseball teams share revenues with small market baseball teams.”

The state has received $1 billion-$2 billion a year from the federal government to support its LIP program to aid the state’s safety-net hospitals.

The  idea comes as lawmakers stalemate  on how to fund growing healthcare costs in Florida, whose government has refused to expand Medicaid under the Affordable Care Act. That refusal has led to threatening sounds from Washington about continued LIP support.

 


When physicians became ‘providers’

 

Philip Caper, M.D., bemoans what he sees as the takeover of U.S. healthcare by “businessmen wealth-seekers.” His recent essay in the Bangor (Maine) Daily News says, among other things:

“This shift in emphasis from patient care to money profoundly has affected the practice of medicine and resulted in the clash of cultures within healthcare. As increasing numbers of ‘providers’ — formerly ‘doctors’— become employees of large healthcare corporations — formerly community hospitals — we have come under increasing pressure to diagnose profitable diseases and order profitable tests and procedures without enough regard to the benefits or harm accruing to patients. Hospital ‘CEOs’— formerly ‘administrators’ — trained in the ethics and practices of business rather than healthcare are incentivized to configure their ‘product lines’ — formerly ‘services’— to produce the largest ‘profits’— formerly ‘margins.’

“Those of us in the healthcare ‘business’ — formerly ‘profession’— have been slow to react to this hijacking of our healthcare calling. Patients, despite sensing something is deeply wrong, feel helpless to push back. That now seems to be changing.”

 


Cuban a ‘lunkhead’ about health

How data-worshipper and billionaire entrepreneur Mark Cuban’s remarks touting excessive healthcare testing show him a “lunkhead” about healthcare.

 


Baltimore lessons in public health

 

This JAMA article inspired by the recent Baltimore riots looks at the public-health strengths and weaknesses of the city and by implication those of other cities with such wide divisions in public health and widening racial and socio-economic inequality.

 

 

 


A way to lubricate patient flow

The American Journal of Medical Quality describes the Patient Flow Management Center (PFMC) at the three-hospital, 935-bed Thomas Jefferson University Hospitals system, in Philadelphia. The center improved rates of emergency department (ED) walkouts, ED and post-anesthesia care unit (PACU) boarding, ambulance diversion, and average elapsed time from ED door to hospital bed.

“This is about taking non-value-added steps out of the process and getting rid of the ‘silos’ of bed management,” said lead author Paris B. Lovett, M.D.,  emergency-medicine specialist at Jefferson. “Lots of hospitals suffer from poor patient flow. The problem is the hospital itself being very full—with a mismatch of demand and supply that impacts a lot of areas. We were having all of these problems [at Jefferson].”

The PFMC, with an open floor plan and 18 pods, lets the hospital system  integrate services that, in other hospitals, typically do not share management or reporting relationships and are not in a shared workspace, including, Medscape summarizes:

  • Environmental services for cleaning rooms.
  • Within-facility patient transport.
  • Around-the-clock bed management by a patient flow clinical supervisor who is a critical care nurse.
  • Dispatch for local ambulance services and for advanced life support air and ground transport.
  • Transfer center for coordinating transfer of patients from other facilities.
  • A single technology platform for all of these functions.

 


Telemedicine parity laws slowly spread

MedPage Today reports that 24 states and Washington, D.C.,  have enacted “parity laws requiring comparable coverage of and reimbursement for services delivered via telemedicine as is available for in-person services, by state-approved private insurance plans, state employee medical plans, and Medicaid.”

That’s up three states from last September.

“Health insurers in states still lacking parity laws are feeling the pressure, according to a major South Carolina healthcare provider….”

“Ninety percent of the private insurance [in South Carolina] is Blue Cross Blue Shield,”  pediatrician James McElligott,  M.D., medical director for telehealth at the Medical University of South Carolina (MUSC) Health, told MedPage Today. “‘They have each year taken baby steps [in telemedicine reimbursement]. [That’s] the main reason we are not going for parity legislation.”‘

“Telemedicine reimbursement is ‘not as good as we need, but we’re working with Blue Cross Blue Shield so that would cover the vast majority of the state,’ McElligott says. ”Insurers in states still lacking parity laws hope to avoid passage of such laws by responding to demands for greater coverage of telemedicine….”

“Medicare reimbursement of telemedicine services, the only category not covered by the ATA survey, remains a more daunting challenge to states with a particular kind of geography, such as South Carolina. In that state, ’44 out of 46 counties are rural by our definitions, but not by [Medicare’s],’ McElligott says. “It’s almost as if telehealth is only acceptable if you’re North Dakota, where you have these huge distances.”‘

 


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