A study in The New England Journal of Medicine found:
”{E}early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times.”
Cambridge Management Group has recently been heavily involved in the coordinated-care project in Oregon, which has been seen as a model for improving population health nationwide while controlling costs, especially of Medicaid.
By SHEFALI LUTHRA, for Kaiser Health News
Though medically unnecessary tests and procedures are often blamed for the nation’s high healthcare costs, patients’ requests for such superfluous treatments may not be what triggers them, suggests a study published today in the JAMA Oncology.
Conventional wisdom suggests that doctors often give unnecessary treatments because patients demand them. Some estimate this care account for a third of the $2.8 trillion spent annually.
But the survey, which tracked 60 Philadelphia-based clinicians’ interactions with about 3,600 cancer patients, found that patients asked for a particular treatment in only 8.7 percent of those exchanges. Of those requests, doctors considered only 11.4 percent to be for inappropriate or unnecessary care.
Those findings, the paper’s authors write, indicate that patient demands are likely not the impetus for unnecessary procedures. That might suggest doctors provide extraneous treatments for other reasons, though the authors didn’t speculate on what those could be.
“There just aren’t many patients’ demands or requests for unnecessary tests and treatments, and when there are, doctors comply with very few of them,” said Ezekiel Emanuel, one of the authors and chair of the University of Pennsylvania’s Department of Medical Ethics and Health Policy.
It’s not entirely clear whether the findings from this study, which focused on oncologists and cancer patients, can be generalized to medicine at large. Though cancer seems like a fitting condition to study due to its “extremely high stakes and very expensive treatments,” it is possible other specialties, such as primary care, actually elicit a lot more patient-requested procedures, said Emanuel, who also is a former White House health policy adviser.
He recommended other researchers conduct similar studies investigating other specialties in cities other than Philadelphia to see whether those results echo this study’s conclusions. When it comes to patient requests, “if you don’t see them in oncology, it’s kind of unlikely you’re going to see them a lot of other places, like cardiology or rheumatology or surgery,” he added.
The authors may be correct that patients in general don’t seek unnecessary treatment, said Jason Doctor, an associate professor at the University of Southern California’s School of Pharmacy, who was not involved in the study. “But they need to test it in a broader, more general clinical setting,” such as outpatient facilities, he said.
It would make sense to expect similar results in other specialties, said Katherine Kahn, a professor of medicine at the University of California at Los Angeles and a senior scientist at the RAND Corp., which researches health costs, among other subjects. Still, Kahn, who is not affiliated with the study, cautioned against using the results to make a definitive statement about what drives health costs.
The study indicates that patient requests can be a valuable part of practicing medicine, she said, highlighting needs doctors otherwise might not notice. “Patients often have information about their symptoms or their values or their priorities that clinicians might not know,” Kahn said.
But it takes a bit of a jump, she added, to go from establishing that idea to answering questions around “overuse and costs associated with overuse in the United States.”
That’s especially true in this study, she said, because doctors were the ones who determined and reported what wasn’t an appropriate request – and that potential bias or perspective makes it hard to know how often wasteful or unnecessary procedures actually took place.
Even so, Emanuel said, it still highlights a larger point.
Anecdotally, “It’s doctors who say, ‘we had a lot of patients ask for inappropriate tests and treatments.” By quantifying how often doctors actually think this happens – and by noting that, in practice, doctors rarely indicate this is the case – the findings suggests patient demands aren’t the source of wasteful procedures, he said.
“There’s always this question about provision of inappropriate treatment: Is it driven by patient demand or provider supply, and what’s the best way to address the problem?” Doctor said. “People should study this through – then we can understand whether we should do supply-side intervention or demand-side interventions to reduce inappropriate treatment.”
By PHIL GALEWITZ, for Kaiser Health News
WEST PALM BEACH, Fla. — MDVIP, the nation’s largest concierge-medicine practice, has seen meteoric growth since it was founded 15 years ago promising “exceptional care” and quick access to doctors in exchange for a $1,500 annual membership fee.
But it took a big hit Tuesday, when a Palm Beach County, Fla., jury returned an $8.5 million malpractice verdict against the company, which has nearly 800 affiliated physicians in 41 states. It was the first malpractice verdict against MDVIP, and is believed to be the first against any concierge management firm. The companies offer such perks as same-day appointments and more personalized care with contracted doctors in return for a retainer.
The jury found MDVIP was liable for the negligence of one of its physicians, who was sued for misdiagnosing the cause of a patient’s leg pain, leading to its amputation. The jury also found the firm had falsely advertised its exceptional doctors and patient care.
Industry experts say the ruling is significant because it shows concierge companies can be held liable for the care provided by their contracted doctors. The companies typically argue they do not actually provide care but merely act as brokers between doctors and patients.
“This pierces that veil…and shows these companies have a legal risk that everyone assumed did not exist,” said Tom Blue, chief strategy officer of the American Academy of Private Physicians, a trade group of concierge doctors.
MDVIP argued it was not responsible for the actions of a physician with whom it had contracted. MDVIP physicians are not directly employed by the company; the physicians pay the firm a per-patient fee for services such as marketing, branding, and other support.
The doctor, Charles Metzger Jr., settled with the plaintiff’s family before the trial.
MDVIP representatives declined to be interviewed, but they indicated they would appeal the verdict. In a statement, the company said it and Metzger acted appropriately.
Karen Terry, one of the plaintiff’s attorneys, said the verdict will push MDVIP and similar companies to scrutinize doctors more carefully before they affiliate with them because they may be liable for the doctors’ actions.
Such companies will also be more cautious about advertising that they offer better care. “You can’t make promises you can’t keep,” Terry said. “This verdict is going to have a huge impact on MDVIP.”
Harry Nelson, a Los Angeles healthcare attorney, agreed the verdict will change how companies market their doctors. “A lot of people will be taking notice of this verdict…It’s a shocking decision,” he said. “The result of this decision is going to be more caution from the concierge medicine companies in terms of their claims of providing superior care.”
But Roberta Greenspan, founder of Specialdocs Consultants, a concierge medicine consulting firm in Chicago, was skeptical of the decision’s significance.
“This singular verdict will not have a major long-term effect on the industry,” she said. “The industry has evolved from a fad years ago to one that has gained tremendous respect.”
An estimated 6,000 doctors nationally have moved to concierge-style practices in the past 15 years, with the figure doubling just in the past five, according to the concierge trade group. Patients who see concierge doctors typically pay an annual fee, in addition to their insurance coverage, in return for gaining easier access to doctors and more personalized care.
The lawsuit against MDVIP was brought by the widower of the late Joan Beber of Boca Raton, who had sought medical attention for leg pain. Despite what plaintiff’s lawyers described as the progressive worsening of her condition, she was repeatedly misdiagnosed by Metzger and other MDVIP-affiliated staff. She was referred to orthopedists who they contended did not get her medical records or learn of her worsening symptoms. The information, they argued, might have led to the discovery of a serious circulation problem that eventually required above-the-knee amputation of her leg.
Beber died of leukemia four years after her leg was amputated in 2008.
Dr. Matthew Priddy, president of the concierge trade group, said the verdict will “give national companies pause if they are on the hook” for their physicians’ care.
Still, Priddy said the industry’s track record is good. While concierge physicians are not immune from malpractice suits, they are less likely to face them because they spend more time with patients than most doctors, he said. They typically limit their patients to a few hundred a year – 600 is the limit for MDVIP doctors — compared to a few thousand for an average practice. They are able to do that because the retainer fees make up for lost revenue.
One thing we think we know about the Republicans is that they take a dim view of waste, fraud and abuse. So how come the U.S. House of Representatives, in Republican hands, has voted 56 times to repeal or cripple the Affordable Care Act, better known as Obamacare?
They’ve put forth this extraordinary effort despite an explicit veto threat from President Obama. Their repeated effort reminds one of Onan in the Bible, which politely says he spilled his seed on the ground.
It’s a waste of the legislative calendar and the talents of the House members. It’s a fraud because it gives the impression that the House is doing the people’s business when it is holding a protracted political rally. It’s an abuse of those who need healthcare because it introduces uncertainty into the system for providers, from the insurers to the home-care visitors.
It’s symptomatic of the political hooliganism which has taken over our politics, where there is little to choose between the protagonists.
Republican groups think that Obama is the doer of all evil in the nation — especially to the economy — and the world. Daily their Democratic counterparts gush vitriol against all the potential Republican presidential candidates, only pausing for an aside about the wickedness of Fox News.
Their common accusation is middle-class job woes. They’re on to something about jobs, but not the way the debate on jobs is being framed.
The political view of jobs is more jobs of the kind that we once thought of as normal and inevitable. But the nature of work is changing rapidly, and it cries out for analysis.
The model of the corporation that employs a worker at reasonable wages that rise every year, toward a defined-benefit pension, is over. Today’s businesses are moving toward a model of employment at will; the job equivalent of the just-in-time supply chain.
While more of us are becoming, in fact, self-employed, the structure of law and practice hasn’t been modified to accommodate the worker who may never know reliable, full-time employment.
The middle-class job market is being commoditized, as the pay-per-hour labor market includes everything from construction to network administration. Sports Illustrated — synonymous with great photography — has just fired all six of its staff photographers. Don’t worry, the great plays will still be recorded and the Swimsuit Issue will still titillate, but the pictures will be taken by freelancers and amateurs.
Two forces are changing the nature of work. First, the reality that has devastated manufacturing: U.S. workers are in competition with the global labor pool, and business will always take low-cost option. If unemployment goes up in China, that will be felt in the U.S. workplace. Second is the march of technology; its disruptive impact is the new normal. Accelerated change is here to stay.
All is not gloom. The trick is to let the old go — particularly difficult for Democrats — and to let the new in. There will be new entrepreneurs; more small, nimble businesses; and whole new directions of endeavor, from gastro-tourism to cottage-industry manufacturing, utilizing 3D printing. Individuals will be free in a new way.
Government needs to think about this and devise a new infrastructure that recognizes that the nature of work is changing. The emerging new economy should have simplified taxes and Social Security payments for the self-employed; portable, affordable healthcare; and universal catastrophe insurance, so that those who are not under an employer umbrella can benefit from the equivalent of workers’ compensation. The self-employed, rightly, fear the day they can’t work.
Rugged individualism has a new face. The political class needs to look and see the new workplace.
Llewellyn King (lking@kingpublishing.com), an occasional contributor, is executive producer and host of “White House Chronicle” on PBS.
Using such data as information from ”the patient’s medical records and specifics of the surgery itself such as patient vital signs during the operation, the University of Iowa can predict which patients are likely to face the biggest risk of infection. Before those patients leave the operation room, doctors can create a plan to reduce that risk whether that’s altering medication or using different techniques in treating the wound,” the newspaper reported.
Do report cards on the performance of healthcare institutions really improve healthcare?
A study this month in the Journal of the American Medical Association comparing surgical outcomes among U.S. hospitals that publicly reported their mortality and morbidity data, versus those that didn’t, found comparable levels of progress in both groups.
In HealthAffairs, Ronald Kuerbitz and Benjamin Kornitzer discuss how to develop a sustainable network for the polychronically ill. They say that subsystems with the following attributes should be developed:
The Connecticut Hospital Association proposes that state phase out the levy over the next five years, asserting that it costs the Nutmeg State’s hospitals more than $250 million every year.
