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Health Policy

Affordable, High-Quality Health Care

4,000 patients in the Seattle area buy their primary care directly from a group of three clinics called Qliance Medical Group, as noted in this Bloomberg Businessweek article. In exchange for monthly fees between $50 and $130—depending on age—Qliance patients can see their doctors as often as they want.

After 10 years of running his own small practice, founder Garrison Bliss opened the first Qliance clinic in Seattle in 2007, which he envisioned as the start of a national network. Now his three clinics have eight doctors and two nurse practitioners. None handles more than 800 patients.

  • The model eliminates the cost of collecting money from insurers, which Qliance says can eat up $16 of a $60 payment for an office visit, or more than a quarter of a practice’s revenue.
  • Qliance doctors’ income isn’t tied to the number of procedures they do, so they see fewer patients and spend more time with them.
  • Patients’ monthly fees cover preventive care, basic tests, advice, treatment for chronic conditions, and simple emergency procedures such as stitches and X-rays.
  • Patients still have to pay for prescriptions, specialists, and hospital expenses. Most have insurance to cover at least some of those costs.
  • According to the company, Qliance patients make fewer trips to hospitals and specialists because of the more attentive primary care and incur 22 percent less in medical costs annually than average.
  • Qliance has raised $13.5 million from the likes of Jeff Bezos and Michael Dell to bring its brand of affordable, high-quality primary care to cities across the country.

Bliss believes the model could help reduce health-care costs nationwide: “We see this as an enormous, almost unlimited marketplace,” he says. Read more…

Most violent job in Washington? Nurse’s aide

The most violent job in Washington state isn’t being a police officer or a security guard. It’s working as a nurse’s aide.

Seattle public radio station KUOW-FM made that finding as part of an investigative series on workplace safety airing this week, as noted in this Seattle Times article. The station found that violence strikes health care workers in Washington at six times the state average, and frontline caregivers in emergency rooms and psychiatric wards get assaulted even more than that.

The single most violent workplace in the state is at Western State Hospital, where criminal defendants are taken when they are found incompetent to stand trial. Workers at psychiatric hospitals are assaulted on the job more often than anybody else – 60 times more than the average worker in Washington state.

How many is that? James Robinson, president of the union for many workers at Western State Hospital, says there were 313 assaults there last year – a drop of nearly 30 percent in assaults per patient-care hour, though union officials also note that many incidents go unreported because of the time required to fill out paperwork about assaults.

Nan Yragui, a psychologist with the Department of Labor and Industries, studies workplace violence. She said budget cuts to the health-care safety net have made emergency rooms nationwide more violence-prone.

“When patients can’t get services they need, they end up going to the emergency department,” she said. “So more of the severely mentally ill are going to the emergency department and then that makes that group of nurses more at risk because they’re getting more exposure.” Read more…

Breast Cancer & Avastin Approval

This is fascinating New York Times article that underscores a number of challenges:

While drug use should be based upon data, interest groups and patients are trying to influence public policy and drug approval in a heart-wrenching set of personal appeals.

The FDA has a mandate to respond to data. In this situation they appeared to hurry approval and study the data later. Such study did not support the approval for this application of a very expensive drug. The cost of this and other treatments is predominantly not paid for by the patient or their family but rather by taxpayers and employers and employees who fund private insurance, Medicare, Medicaid, the Veterans Administration – the major payers for health care.

Should we collectively pay for the wishes of hopes of others when quality data does not appear to support such expenditure? And how much of the price of such medications and other treatments is influenced by the disconnect between the payer and the consumer? How many treatments of questionable value would be deferred if individuals felt the impact personally, and how would prices differ paid for by the consumer/patient rather than someone else?

The moral hazard dilemma of insurance if evident in stories like this: Originally intended to help people afford unexpected expenses due to significant health matters, health insurance has evolved or devolved into payment for normal expenses like eyeglasses, routine physicals, contraception and the like. Health inflation is markedly impacted by the market disconnect between buyer and payer, and legislation has forced payment of questionable services and professionals in many jurisdictions. Whether this was envisioned when insurance became common is not clear, but it certainly is what we now have. Read more…

Potato Chips Go To Waist

New research completed through the Harvard School of Public Health and published in the New England Journal of Medicine indicates that eating more potato chips and French fries is likely to lead to a bigger weight gain over the years than the weight change associated with eating more of other foods, as noted in this Wall Street Journal article.

The Harvard researchers looked at three separate long-term studies covering 120,877 women and men who weren’t obese and who were healthy when the studies began. (They were mostly white, educated and in the U.S.)

The study stands out because it quantifies how much weight a person is likely to gain or lose over four years based on one additional daily serving of a range of specific foods. Eating more potatoes correlated with a gain of 1.28 pounds, with French fries in particular associated with a 3.35-pound gain.

Marion Nestle, New York University professor of nutrition and public health, expressed surprise that potato products were linked with more weight gain than desserts like cake, cookies and doughnuts, which contribute the most calories to the American diet, other research shows. She says she suspects people who eat potato chips and fries also tend to eat too much in general, making these foods markers for a diet leading to weight gain.

Read more…

Louisville Confronts Obesity

The city of Louisville, Kentucky, is stepping up efforts to fight obesity, as noted in this New York Times article. More than six in 10 people in metro Louisville are considered “seriously overweight” and Kentucky ranks seventh in the nation for obesity. The rates continued to rise through 2008, while the percentage of the population reporting any physical activity outside of work fell despite public campaigns advocating more walking and biking.

More recent developments underscore the tug of war over food and weight:

  • On one hand, Kentucky Fried Chicken has announced plans for its first non-fried menu while offering leaflets listing the calorie, fat and salt content of its entire line (as required by the new federal health act).
  • On the other hand, its corporate parent, Yum Brands, was quietly lobbying the state government to turn Kentucky into one of the few states that allow the use of food stamps in its restaurants, which include Pizza Hut and Taco Bell.

The city’s efforts to combat obesity, how and where it is spending money to fight it are instructive at a time when federal dollars are becoming more scarce and budgets are pinched. Cities are increasingly vying for nonprofit and government financing now available as concerns about the obesity epidemic have been underscored by Michelle Obama and others.

“For businesses, a healthy work force is more productive and less costly, so it became a competitiveness issue,” Jerry Abramson, the former mayor who began the Mayor’s Healthy Hometown Movement, said. “Every city was offering tax incentives, every city was offering real estate deals but not every city had the weight problem we do.”

In reference to a grant Louisville received from the Robert Wood Johnson Foundation to help the city’s efforts, Mary Lou Northern, senior adviser to Louisville’s current mayor, Greg Fischer, noted: “The grant made us think about the problem differently, that it’s not just about smart growth, it’s not just about transportation, it’s not just about parks or better nutrition, it’s about all of those things and more.” Read more…

Panel urges crackdown on excessive MRIs

As noted in this Seattle Times article, an influential independent congressional advisory group is urging lawmakers to crack down on doctors who order too many MRIs for seniors, setting off a battle with physicians and patient groups that argue that Medicare beneficiaries might suffer significant delays in treatment.

The recommendation by the Medicare Payment Advisory Commission, or MedPAC, would require some physicians who order a lot of MRIs, CT scans, nuclear-medicine studies and other imaging tests to obtain pre-approval from Medicare.

In its latest report, sent to Congress this week, MedPAC takes aim at doctors who order these tests inappropriately and concludes that Medicare costs for such tests are surging partly because physicians are buying their own high-tech equipment. When they can perform diagnostic tests in their offices, they pocket the profits.

How much do imaging costs impact Medicare? Imaging is one of the fastest-growing Medicare costs, rising from $6.5 billion to $11.7 billion from 2000 to 2009, according to federal figures. Industry groups say the use of imaging services declined from 2008 to 2009, but MedPAC disputes that data and counters that usage is on the rise. While a 1989 law prohibited physicians from referring patients to testing centers in which they had financial interests, it didn’t stop them from performing tests in their offices.

As a side note to this article, MCN does not own any X-ray or imaging facilities and must approve such studies when performed by consultants. Imaging and X-rays are needed in fewer than 5% of orthopedic and related IMEs performed by MCN. If you find that a particular IME physician or provider orders studies at a higher rate, questions are warranted. Does the provider have a financial interest in testing facilities or equipment and is the study truly necessary to render a credible report?

Read more…

Falling Behind: Life expectancy in US Counties

The University of Washington’s Institute for Health Metrics and Evaluation (IHME), as reported in this Seattle Times article (somewhat ominously titled “How long will you live? Depends on the county”), released a study today which has collected county-by-county life-span data for 20 years, comparing it to national averages as well as to other nations.

The numbers revealed gaps everywhere — between counties, between black and white residents, and between men and women.

The study (itself somewhat ominously titled)  “Falling Behind: Life expectancy in US Counties from 2000 to 2007 in an International Context” — found life expectancies in most American counties failing to keep up with gains in the 10 longest-living nations.

“We are finally able to answer the question of how the US fares in comparison to its peers globally,” said Dr. Christopher Murray, IHME Director and one of the paper’s co-authors. “Despite the fact that the US spends more per capita than any other nation on health, eight out of every 10 counties are not keeping pace in terms of health outcomes. That’s a staggering statistic.”

Some interesting points from the IHME’s website :

  • When compared to the international frontier [the ten nations with the longest life expectancies worldwide] for life expectancy, US counties range from being 16 calendar years ahead to more than 50 behind for women. For men the range is from 15 calendar years ahead to more than 50 calendar years behind. This means that some counties have a life expectancy today that nations with the best health outcomes had in 1957.
  • The researchers suggest that the relatively low life expectancies in the US cannot be explained by the size of the nation, racial diversity, or economics.
  • Instead, the authors point to high rates of obesity, tobacco use, and other preventable risk factors for an early death as the leading drivers of the gap between the US and other nations.
  • Change in life expectancy is so uneven that within some states there is now a decade difference between the counties with the longest lives and those with the shortest.
  • The authors propose that state and local policymakers use the life expectancy data and the county comparisons to tailor strategies that will fit the dynamics of their communities. This resonates with local policymakers, such as Dr. David Fleming, Director of Public Health – Seattle & King County. “It’s not the health care system that’s having the biggest impact on health; it’s the community,” Dr. Fleming said. “The average person in the US spends one hour annually in a physician’s office unless they are really sick. So until we start moving our interventions out into the communities where people live, we are not going to get ahead of these problems.”

Read more of the Seattle Times article or at the IHME’s site…

As Physicians’ Jobs Change, So Do Their Politics

At MCNtalk, we try to stay away from political discussion,  but we thought this article in the New York Times was interesting as it highlights some potential shifts in the medical profession. Specifically, “Doctors are changing. They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.”

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states. And why is this important?

  • As the article notes, that change could have a profound effect on the nation’s health care debate.
  • Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.

Read more…

Under an Arizona Plan, Smokers and Obese Would Pay Fee for Medicaid

Arizona, like many others states, says it is no longer able to adequately finance its Medicaid program. As part of a plan to cut costs, the state has proposed imposing a $50 fee on childless adults on Medicaid who are either obese or who smoke.

In Arizona, almost half of all Medicaid recipients smoke; while the number of obese people is unclear, about one-in-four Arizonans is overweight, according to the Centers for Disease Control and Prevention. The state’s plan must ultimately be approved by the federal government. Monica Coury, spokeswoman for Arizona’s Medicaid program, discusses in this New York Times “Asked and Answered” piece.

As Ms. Coury notes, “We’ve talked about $50 once a year. We haven’t done the math, but it’s not about how much we would collect. It is totally about testing the efficacy of this strategy. Obesity is costing us billions in health care costs, so our thought is ‘let’s test some of these strategies.’”  Read more… 

When Doctors Are Called to the Rescue in Midflight

Ever wonder what happens when there’s a medical emergency mid-flight? According to this article in the New York Times, the answer to that question will vary quite a bit depending not just on who’s on the flight (“Is there a doctor in the house?) but on what’s actually in the plane’s emergency medical kit varies a great deal.

The F.A.A. requires that flight attendants undergo CPR training and that all United States airlines carry emergency medical kits and automated external defibrillators, but there’s no standard as to what’s in the kits nor how frequently they’re stocked.

Since the earliest days of commercial aviation, airlines have coped with medical emergencies in flight by calling on physicians who happen to be passengers. And as more people travel by air, the number of emergencies has risen accordingly.

“Passenger health is becoming more and more of an issue, because of increased life expectancy and more people flying with pre-existing conditions,” said Dr. Paulo Alves, a vice president at MedAire, a company that provides crew members with medical advice from physicians on the ground.

MedAire, which advises more than 60 airlines around the world, managed about 19,000 in-flight medical cases for commercial airlines in 2010. Although few were life-threatening, 442 were serious enough to require diverting the plane — and 94 people died onboard.

The numbers reflect a fraction of the actual number of in-flight emergencies. The Federal Aviation Administration does not track in-flight medical episodes, and airlines are not required to report them.

Airborne calls for medical assistance pose a singular challenge for physicians, who find themselves suddenly caring for a stranger whose history they don’t know, often with a problem well outside their specialty, in a setting with limited equipment but no shortage of onlookers scrutinizing their every move.

The lack of standardization was criticized in a recent article in The Journal of the American Medical Association. The paper argued not only that the medical kits should be standardized, down to the number of latex gloves, but also that a method for reporting incidents should be consistent among all airlines.

“Aviation is held up as this paragon of safety, yet here’s this nasty thing that happens with no standard for reporting,” said one of the article’s authors, Dr. Melissa Mattison, associate director of hospital medicine at Beth Israel Deaconess Medical Center in Boston. “We know more about animals that die on airplanes than we do about people.”

Despite the pressures, the haphazard nature of the work, the lack of compensation and the risks, physicians continue to reach up and answer the call. In a world of insurance forms, rushed office visits and ubiquitous technology, many count such emergency calls among the purest expressions of their Hippocratic oath.

“You feel good about trying to help someone, and that’s the most important thing,” said Dr. Ingrid Katz, an infectious disease specialist at Brigham and Women’s Hospital in Boston. “But don’t expect anything. It’s solely for the benefit of the person in need.” Read more…