The Fallen Souffle Economy and the Health Care Bubble

Jeff Goldsmith

First posted 8/10/11 on The Health Care Blog

It is increasingly clear that the United States’ economic troubles are far from over.

The stock market plunge that began in earnest last week reflects the market’s belief that we’re not going to recover fully from the recession that began in 2007. As a Wall Street Journal commentator said mid-Monday’s plunge: “The market is pricing in a double dip recession”. In reality, the 2007 recession (caused initially by $150 a barrel oil) never really ended.

Past remedies for recession basically involved nearly free money and Keynesian pump priming to stimulate demand with either borrowed or freshly printed money. The most recent (bipartisan) stimulus effort, nearly a trillion worth of extended Bush tax cuts, unemployment extensions, payroll tax cuts, etc. which Congress and the Obama Administration negotiated in December, seems to have disappeared into thin air, producing a whopping 0.8% economic growth in the first half of 2011 and a July unemployment rate of 9.2%. This Economist analysis argues that the political system has exhausted its remedies for our economic problems.

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Why Medical Specialists Should Want to End the Reign of the RUC

Paul M. Fischer, MD

The old doctors know. The practice of medicine has changed in a very basic way over the last 20 years. Physician relationships have lost their civility and have been replaced by a level of tension that takes the fun out of collegial interactions. I remember my first year of family medicine as the only doctor in Weeping Water, Nebraska. My personal medical community had gone from an entire medical school campus with limitless lectures and many physicians to share in “interesting cases” to an occasional phone call with a consultant in Omaha. These contacts became my primary source for medical education and updates for Weeping Water’s health care. The phone calls were collegial, respectful, and focused on what was best for my patients.

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What Really Happens on a Hospital Night Shift

Research and design by Nursing Schools Site

Alternatives To Scrapping 510(k)

Merrell Goozner

First posted 8/11/11 on Gooz News

The Institute of Medicine report on medical device regulation released two weeks ago called for scrapping the 510(k) process that allows for market entry of new devices if they’re shown to be “substantially equivalent” to already marketed devices. In a Perspective in today’s New England Journal of Medicine, committee members David R. Challoner, M.D. of the University of Florida and William W. Vodra, J.D., an attorney at Arnold & Porter, reiterated the reasoning of the report:

Today, we have a system in which a new moderate-risk device can enter the market because it is substantially equivalent to another device that may have been cleared for marketing 2 years ago because its manufacturer showed that it was substantially equivalent to yet another device cleared in 2003, and so on, all the way back to a device that was being marketed when the law was enacted in 1976. But that original device might never have been assessed for safety or effectiveness, nor perhaps would any subsequent ones in the family tree. . . We decided that the 510(k) process cannot be transformed into a premarketing evaluation of safety and effectiveness as long as the standard for clearance is substantial equivalence to a previously cleared device.

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MHA Does CLABSI Right!

Paul Levy

First posted 8/13/11 on Not Running A Hospital

Here’s a great step forward by the Massachusetts Hospital Association, a public presentation of current data on the rate of central line associated bloodstream infections among its participating members. Here’s the current chart:

Let’s talk about what’s good about this. First, the data are quite current, just a few months old. Next, the monthly figures, which are subject to minor variations, are smoothed out with a three-month moving average, so you can see the trend. Third, there are no punches pulled. When the rate goes up, they say it.

Since each hospital knows it own rate, it can easily compare its progress to others in the state. N0t for the sake of trying to attract more patients or for other kinds of marketing, but to act as a form of creative tension within the organization to do better. Now, that’s the right kind of competition.

Paul Levy is a former large hospital CEO in Boston. He now writes as an advocate for patient centered care and efficient management of health care services.

Low Back Pain: Is Relief In Sight?

By Dov Michaeli

First posted 8/8/11 on The Doctor Weighs In

For people of a certain age low back pain is a fact of daily life. Why, of all people, should our venerable seniors suffer from this affliction? The short answer is disk degeneration. The longer answer requires a longer explanation. So bear with me and I’ll walk you through it.

The intervertebral disk

This structure is a marvel of engineering. Now don’t get me wrong, I am not implying that an all knowing intelligent engineer designed it. What is marvelous about it is that an evolutionary process of trial and error lasting many millions years made us, and all vertebrates, well…vertebrates. And probably as important, it allowed us to walk upright, although we had to pay a penalty for the privilege. More on that later.

The picture below shows the basic structure of a disk.

The center of the disk, called nucleus pulposus, is made up of cartilage material, which has the consistency of a gel; imagine a water-filled sponge. If you apply pressure on the sponge from above, what would keep the water from running off to the sides?

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Community Health Centers: Local Economic Engines and Cost-Effective Primary Care Providers

Jane Sarasohn-Kahn

First posted 8/09/11 on Health Populi

As the recession drags on and millions of people in the U.S. lack health insurance, there’s a community resource that extends primary care to them that’s not in a doctor’s office: it’s in Community Health Centers (CHCs). There are over 8,000 CHCs throughout the U.S., and 20 million people use them as medical homes — providing 25% of all primary care visits for low-income people in America.

At the same time, there are 60 million people in the U.S. who do not have access to primary care due to the maldistribution and shortage of primary care providers (PCPs). Access Endangered: Profiles of the Medically Disenfranchised, a report published by the National Association of Community Health Centers, details the growing challenge of filling the gap between the limited supply of PCPs and growing demand for their services.

The most convenient place for medically disenfranchised people to gain access to primary care is in the most expensive, if accessible, health provider setting: the closest emergency room.

The fact is that funding for Community Health Centers is scaling back, due to Congress’s recent reduction in the Health Centers Program midway through FY2011. This action, combined with the fiscal fact that other funding sources at the state and federal levels are threatened due to the economy and debt discussion, endangers CHC patients’ access to health care.

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Twenty-Four Seven

Bradley Flansbaum

First posted 8/07/11 on The Hospitalist Leader

Two recent articles, one from The New York Times, the other from The Hospitalist,initiated some 24/7 staffing issue rumination on my behalf. It stems originally from a recent op-ed by Lucian Leape:

“Given the accrediting council’s reluctance to act, the federal government needs to get tougher. If we are serious about curbing the tide of injuries stemming from medical errors, Medicare should make its funding of graduate medical education contingent on hospitals’ limiting work hours. We can’t afford to wait another 40 years.”

How do the aforementioned pieces resonate with the above quote?

The NYT article, well written, examines pediatric training, errors that stem from doctor “fatigue,” and the root causes behind these errors—presumably due to burdensome hours and the legacy of educational norms of decades past. The author, chief of pediatric cardiology at UMass Medical School, cites the evidence before and after implementation of trainee work hour restrictions in 2003 (not overwhelmingly positive incidentally), and concludes that it may not be the stretch worked—although this is a factor, but how information is communicated doc to doc, and shift to shift. This is not news to hospitalists.

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With Big Pharma on Campus, Who Will Look After the Public Interest?

Alison Bass

First posted 8/3/11 on Alison Bass

Medicare and social services for vulnerable Americans are not the only programs on the chopping block with Washington’s deal to raise the debt ceiling and cut trillions of dollars in government spending. Looming ahead may be deep cuts in funding for medical and science research, and that raises the specter of growing collaboration between academic centers and industry, including pharmaceutical and medical device companies.

Even before the debt deal was reached, partnerships between Big Pharma and universities have been on the rise, according to an article in the current issue of Chronicle of Higher Education. The article, Big Pharma Finds a Home on Campus, details this growing collaboration and the “many new ethical and practice questions” it raises, including the increasing potential for conflicts of interest.

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Politics in Service of Public Health

Kenneth Lin

First published 8/1/11 on Common Sense Family Doctor

Below is the text of a proposed resolution that will be submitted by the District of Columbia Academy of Family Physicians to next month’s Congress of Delegates of the American Academy of Family Physicians in Orlando, Florida.

WHEREAS family physicians rely on current, unbiased sources of evidence-based guidelines to select appropriate screening tests and counseling services for their patients;

WHEREAS the primary source of evidence-based prevention guidelines for family physicians is the federally-sponsored U.S. Preventive Services Task Force (USPSTF), whose recommendation statements commonly serve as the basis for AAFP clinical policies on preventive services;

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For Rotator Cuff Injuries –Try Yoga

Dov Michaeli

First posted 8/3/11 on The Doctor Weighs In

To Elizabeth, a trainer’s trainer.

My favorite thing to do in the morning is not having a cup of coffee or reading the newspaper (this usually depresses me or sends me into a rage) –it is exercising. Sounds pretty ascetic, requiring military discipline. But no, it actually isn’t; you should try it. Start slow, either with a 30- minute walk outdoors or on a treadmill. I used to run in the morning, but since I screwed up my back I switched to the elliptical. Either exercise is aerobic and beneficial. Your heart will thank you, your stiff lower back will loosen up and your still somnolent brain will wake up to the torrent of oxygenated blood courtesy of your pumping heart. Having finished the aerobic part, I usually stretch to further loosen up my lower back and then move on to resistance exercises, such as push-ups, pull-ups, and weight lifting.

And therein lies a big problem. Doing the resistance exercises, especially the weight lifting, somehow caused frequent episodes of shoulder pain. Initially I thought I could “blast through” the pain. Mistake!!! Pain is a signal that your body is sending: stop! Something is going wrong. Acute pain can be due a stretched tendon or a muscle spasm. If you stop and let the injured area rest, things will come back to normal very quickly. But if you ignore that signal and continue exercising –chronic inflammation sets in. Not only is the pain more severe, it takes weeks and sometimes months to resolve.

One of the most frequent injuries of resistance exercises is the rotator cuff syndrome. The rotator cuff is a group of 4 muscles that attach to the shaft and head of the humerus (the bone of the upper arm) which participate in lifting the arm above the head.

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Get Ready for Big Changes in Provider Reimbursement

Joe Paduda

First posted 8/2/11 on Managed Care Matters

Get ready for big changes in provider reimbursement

Now that the debt limit deal is done, the hard stuff starts. While there’s been a lot of focus on the Pentagon budget and lack of revenue increases, the real heavy lifting will come when the super-committee convenes to figure out how to save the next $1.2 trillion. And their focus will be on Medicare, Medicaid, and provider reimbursement.

Because that’s where the ‘super-committee’ is going to have to find a big chunk of the additional savings required by the deal.

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IOM Calls For Overhaul of Device Regulation

Merrill Goozner

First posted 7/29/11 on Gooz News

The Institute of Medicine committee that’s been reviewing medical device regulation for the past two years called this morning for a sweeping overhaul of Food and Drug Administration rules that allow some implanted devices to enter the market without adequate safety and effectiveness testing. The process — known as 510(k) — provides for minimal testing of devices if they are deemed “substantially equivalent” to a device that is already on the market.

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The Debt Deal: There Will Be Blood on the Floor on November 23rd

Robert Laszewski

First posted 8/1/11 on Health Policy and Marketplace Review

The debt deal is finally done. But it really isn’t an agreement on what cuts will be made, just the process that will be used to make them.

The real work is left to the Congressional appropriators for the first $917 billion and for a super-committee of Congress for the second $1.2 trillion to $1.5 trillion in ten-year cuts.

That second tranche is where health care will make its contribution. The super-committee has to make its decisions by November 23rd and, as a practical matter, the Congress can only accept what the super-committee decides or face the consequences of the automatic $1.2 trillion fallback cuts.

When it comes to health care and the super-committee, all federal health care spending is on the table—–Medicare, Medicaid, the new law, benefits, and provider payments.

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Dov Michaeli

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Robert Laszewski

The debt deal is finally done. But it really isn’t an agreement on what cuts will be made, just the process that will be used to make them.

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