Real Health Reform in Massachusetts

July 29, 2009 / Michael D. Miller MD / Delivery of Healthcare, Federal Healthcare Reform, Health System Reform, Quality of Care & Safety, State-Level Healthcare Reform / 5 Comments

The Massachusetts Special Commission on Payment Reform recently issued its recommendations for shifting the state’s health care system from Fee-For-Service (FFS) to Global Payments over a 5 year period. The Special Commission’s report lays out a good case for making this change, describing why it needs to be adopted by all payers, (although each payer would still pay different rates, they would all use the same fundamental global payment structure), and some of the challenges for successfully navigating a 5 year transition period from the current mostly FFS system to one dominated by global payments.

The report summarizes its recommendations into 9 areas:

The development of Accountable Care Organizations (ACOs).

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Diabetes Updates – New Diagnostics, Increasing Rates, and Implications for Health Reform, CER, etc.

June 17, 2009 / Michael D. Miller MD / Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Health System Reform, Information & Communications, Quality of Care & Safety / 1 Comment

Changes in the diagnosis and treatment of diabetes is a great example for understanding how healthcare delivery constantly evolves based upon new discoveries. And the history of these changes may help illuminate some thinking about health reform and the development and use of comparative effectiveness research (CER).

First, a little background on diabetes.

Diabetes Background
Diabetes mellitus (or “sugar diabetes”) occurs when the body has problems regulating the level of sugar (specifically glucose) in the blood. This can be because the body’s pancreas doesn’t produce enough insulin, or for some reason the person’s organs become resistant to the actions of the insulin that is present – or sometimes both occur simultaneously. …

People in Health Reform & Transformation

May 20, 2009 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 1 Comment

The importance of the “people factor” in improving the quality and efficiency of healthcare is well understood by experts in health information technology (HIT) and healthcare delivery transformation. In estimating the time and cost for implementing new technologies or processes, they appreciate how behavior change and technology adoption are very time consuming and expensive – factors that are often glossed over in policy discussions.

David Brooks’ recent Op-Ed in the New York Times about the personality traits of CEOs leading successful companies sheds some light on the people factors in health reform. Contrary to a lot of the common wisdom about the importance of good personal connections with coworkers for success in the corporate world, Brooks cites information that the most important factors for successful CEOs are “execution and organizational skills.…

Communicating with Clinicians to Improve Quality

May 8, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications, Quality of Care & Safety / 2 Comments

At a recent public forum on improving quality and value in healthcare, an audience member asked how can patients know if the treatment or diagnostic test their clinician is recommending is really the best thing for them. This reminded me that the Agency for Healthcare Research and Policy (AHRQ), recently ppublished a two page tip sheet to help patients talk to their doctors and a web-page that helps people create a set of questions customized for their individual healthcare needs and situations.

While these are obviously useful tools, I realized that emphasizing patient-clinician communications is now more important than ever because of the growing trend toward “consumer directed healthcare” and “patient empowerment.” …

Improving Cancer Care in Medicare

May 5, 2009 / Michael D. Miller MD / Access to Healthcare, Comparative Effectiveness, Delivery of Healthcare, Innovation, Politics, Quality of Care & Safety, Therapeutic Substitution & Interchange / 1 Comment

This week’s AMA News includes an article about how cancer care for Medicare beneficiaries has improved because of a provision in last year’s Medicare Improvements for Patients and Providers Act (MIPPA). The provision of interest clarified that Medicare Part D plans need to pay for off label uses of medicines to treat cancer when there is supportive evidence in the peer-review literature. This changes became effective January 1st, and for at least one patient, it has improved their care. (See the Medicare Rights Center’s press release about the coverage appeal they won for a client because of the new law.)

However, as I noted in an interview with the American Medical News ReachMD Radio-XM 160, (See MP3 audio file below), because the change only applies to cancer treatments, patients with other serious and life threatening illnesses may still find their treatment options limited. …

Investment for Health Reform – Escaping the Valley of Death

April 30, 2009 / Michael D. Miller MD / Comparative Effectiveness, Health System Reform, Innovation, Quality of Care & Safety / 3 Comments

The debate about health reform has mostly focused on expanding insurance coverage and controlling costs. However, successfully improving the US healthcare system will require some long-term quality improving investments.

The stimulus bill (ARRA) included two such investments. The $1.1 Billion for Comparative Effectiveness Research has been widely discussed because it is important, and a very large percentage increase in the Federal Government’s spending in this area. But the ARRA bill also included $10 Billion to increase NIH’s funding.

The significance of the increased NIH funding is twofold: First, it will provide expansion of biomedical research related jobs. And second, it will help the NIH increase the work it does in translational research, which should help biomedical research build a better bridge over what the Parkinson’s Action Network and others have labelled the “Valley of Death.”…

Quality, Checklists, Patient Education, the TV Show ER, and Comparative Effectiveness

March 16, 2009 / Michael D. Miller MD / Delivery of Healthcare, Quality of Care & Safety / 2 Comments

In case you missed it last week, amidst all the returning stars for one of the final episodes of the TV show ER, there was a dramatic Operating Room scene where Dr. Benton (played by Eric Lasalle) is “observing” the kidney transplant of Dr. John Carter (played by Noah Wyle), because as we see, the transplant surgeon is a very coarse and roughshod individual. The significance of the scene is that as the surgery is about to begin, Dr. Benton pulls out his pre-surgical checklist and browbeats the transplant surgeon into going through it – during which the nurses note their concern that they don’t have reperfusion solution in the OR, so they go and get some as the surgery starts. …

Transparency & Accountability for Physicians in Health Reform

March 12, 2009 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety / No Comments

Yesterday I had the opportunity to give Medical Grand Rounds at Caritas Carney Hospital in Boston on the topic of “Health Reform 2009 and Beyond.” Rather than compare and contrast various national health reform proposals, I reviewed the major forces and trends that are reforming healthcare, and explained how they would likely impact different stakeholder groups – particularly physicians.

I started by discussing the major trends in cost, access and quality – noting how the first two are easier to quantify and that the debate over access to healthcare services versus insurance coverage has been resolved in favor of health insurance coverage, because only having access to free clinics and emergency rooms doesn’t enable people to get the type of healthcare that they really need. …

Controlling Health Care Costs and Improving Quality with Effective Care Coordination

February 16, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety / 2 Comments

A study published by in the New England Journal of Medicine last week examining the effects of 15 different Medicare care coordination demonstrations received wide coverage by the general media. Unfortunately, much of this focused on the study’s overall finding that these programs didn’t reduce hospitalizations or Medicare spending. For example, the AP story’s headline, “Study finds bid to cut Medicare costs failed,” was used by many papers such as the Washington Times.

However, the actual study had much more complex, important, and useful findings, and the paper’s authors from Mathematica, (which Medicare contracted to do the analysis from this project), deserve a lot of credit for extracting meaningful information from this project.…

Communicating Health Quality Measures

February 15, 2009 / Michael D. Miller MD / Delivery of Healthcare, Information & Communications, Miscellaneous, Quality of Care & Safety / 2 Comments

Educating patients, (a.k.a. “consumers”), to make the “best” health care choices has been a fundamental principle in some health reforms schools, including those advocating for more high-deductible health plans. While this concept makes sense in economic theories, it also requires belief that patients can and will make good use of the information available to them – particularly when they are ill.

Another fundamental necessity for making such consumer-directed healthcare work to improve quality and lower costs is that the information provided to people is meaningful and accurate. A study published in the November/December 2008 issue of Health Affairs illustrates the complexity of providing accurate information.…

Chronic Wellness Promotion v. Chronic Disease Management in Medical Homes

February 9, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety / 2 Comments

One of the hottest health reform topics is Medical Homes: Medicare has Demonstration Project starting this year, several states have implemented, (or are implementing), medical home related initiatives, the Center for Studying Health System Change (CSHSC) released a great white paper titled “Making Medical Homes Work,” and the New York Times just had a story about how IBM is teaming up with United Healthcare to promote Medical Homes for their 11,000 employees and dependents in Arizona.

Definition of Medical Homes
One of the controversies in Medical Homes is the definition. CSHSC and many others use the definition developed by 4 national medical societies which combines aspects of preexisting primary care and chronic care models with the goal of creating a primary care “home” that can more effectively address the needs of patients with chronic conditions.…

Advancements in Understanding Head Trauma and Preventing Long-Term Problems

January 28, 2009 / Michael D. Miller MD / Delivery of Healthcare, Public Health, Quality of Care & Safety / 1 Comment

When I was training to become an orthopedic surgeon, one of the senior physicians said that the two best learning sources for orthopedic surgeons were football and war. Over the past year I’ve been talking with friends and colleagues about another connection between war and football – how minor repetitive head trauma has long-term serious consequences.

It has become clear with the increasing reports about the neurological, cognitive and personality problems military personnel have experiences after repeated minor concussive events, (often from being inside vehicles hit by IEDs), that this is a real and serious situation. While the VA health system has taken steps to understand the consequences of repetitive minor head trauma and work to provide appropriate diagnostic and treatment methods, I have been telling people that this new understanding of neuro-trauma will have implications for football.…

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