The Institute of Medicine put out a report yesterday titled “Retooling for an Aging America: Building the Health Care Workforce.” The report discusses how the aging of the baby-boom generation will create greater needs for health care providers (of all types) who are trained in caring for the elderly with chronic conditions. The report’s recommendations fall into three categories: training, system transformation and financing. Like many reports about health system improvement, their recommendations all make sense – particularly within the context of the three categories. However, like many IOM reports, the writing by Committee process is a bit evident in that, (at least from the Executive Summary), it doesn’t seem to describe a complete plan, nor does it prioritize any of its recommendations – either in terms of funding or which actions should be done first.…
Information Can Change Medical Practice, Patient Behaviors, and Kill Kids
Medical information can change how clinicians treat patients, how patients care for themselves, and how healthcare payers promote or prevent the use of treatments and diagnostic tests. However, this information can act as either a broad sword or a scalpel, and produce good or bad outcomes.
A recent report from a Canadian new service about an article from the Canadian Medical Association Journal describing the outcomes from warning about the use of anti-depressants in children brings this issue down from a general concept to being very specific. This news report stated:
…Two years after Health Canada warned about prescribing anti-depressants to children, the number of children and teens who died by suicide increased 25 per cent after years of steady decline, major new Canadian research shows.
More on the Supply of Primary Care Clinicians
Yesterday, when I wrote about “Ensuring Enough Primary Care Clinicians,” I didn’t realize that public radio station WBUR would be doing a story this week on the same topic. (The WBUR story can be heard/read on their web-site.)
Nor did I know that this was an agenda item for today’s Medicare Payment Advisory Commission (MedPAC) meeting. While the one-page MedPAC briefing summary doesn’t include their draft recommendations, Modern Healthcare reports that they are recommending budget-neutral adjustments to Medicare’s fee schedule to increase payments to physicians who provide primary-care services – including office and home visits, and visits to patients in non-acute facilities.…
Ensuring Enough Primary Care Clinicians
Like many complicated problems in the US healthcare system, setting a goal can be easy, but achieving it can be hard. In recent years there has been a number of proposals for increasing the use of primary care clinicians to help patients with chronic diseases (like diabetes) manage their care and avoid long-term complications – and to presumably lower long-term healthcare spending. For example, the “Patient Centered Medical Home” proposal supported by a dozen organizations, (including companies and family practice and pediatrics associations), doesn’t specifically use the term “primary care,” but it gets to the same result – heightened relationships and communications between patients and a particular clinician or clinic.…
More on Counterfeit Medicines & Safety
My last post contained some perspectives about fake medicines. That same day, the LA times ran an article about California’s long-delayed pedigree requirements for tracking prescription medicines. This law was prompted by the discovery of fake medicines for HIV/AIDS in 2000, and was intended to achieve what the FDA has been trying to implement for many years.
The LA Times article blames the delays in the state’s drug tracking system on the industry – from the manufacturer to the retail pharmacy. I suspect that the real challenge is not in the technical or cost aspects from the manufacturers – who certainly have lots to gain by stopping counterfeits of their products from being sold instead of the real thing, but from the wholesalers and to a lesser extent the pharmacies.…
Safety, Costs and Quality of Medicines
I’ve been trying to figure out how to write something meaningful about the many reports over the last several months about the safety, costs and quality of medicines. I finally concluded that rather than a too lengthy blog post, a series of snapshots would create a good description of the situation – sort of like a slide show rather than a feature film:
Safety of Generic Drugs: A recent LA Times article discussed patients who had adverse reactions when switched from a brand name to a generic medicine. This article includes physicians’ experiences with several types of generic medicines, e.g. for epilepsy, depression, high blood pressure, irregular heart rhythms, and to prevent rejection of organ transplants.…
Culture of Healthcare Organizations
Culture change is one of the core messages of a book I’m working on, so I was interested to see an article about “cultural transformation” in Modern Healthcare by John Mitchell, CEO of Harbor Community Hospital in WA. He notes that there is frequently a disconnect between a hospital leader’s stated goal of wanting to create a great culture and their actions: Retaining a central command and control structure does not empower people, and forcing solutions onto hospital staff who feel uninspired to excel will not produce sustainable improvements. Rather cultural changes leading to improved quality and reduced costs requires the leader to inspire the staff to perform while also empowering them to achieve shared goals.…
Vaccines and Autism – More Mess
There has been a lot reported in the news about the recent payment from the Federal Vaccine Injury Compensation Program for Hannah Poling, a girl who developed autism after being vaccinated. (See New York Times article and a Wall Street Journal blog report about this case.)
Amidst all the debate and news reporting there have been several connected and interesting facts:
- The Federal program that is making the payment to the Poling family doesn’t concede that the payment is in any way an admission of a link between vaccines and autism.
- Since most vaccines no longer contain the mercury containing preservative thimerosal, and yet the rate of new cases of autism hasn’t declined, it would seem that whatever arguments there were for a link between thimerosal and autism should have been settled.
More On Evidence Based Medicine
In a previous post I was somewhat critical of evidence-based medicine (EBM) when it is used to make payment decisions. One of the points I was trying to make is that EBM is not a passing fad. The staying power of EBM was recently reinforced by two recent developments.
First, the Medicare Payment Advisory Commission’s (MedPAC) March 2008 Report to Congress cites their own 2005 report recommending EBM as a touchstone for comparing physicians’ practices as one way to improve quality of care and value for the Medicare program:
…In the March 2005 Report to the Congress, the Commission recommended that CMS measure physicians’ resource use over time and share the results with physicians (MedPAC 2005).
UK NHS Restricting Access to Uncovered Treatments
A very interesting article in yesterday’s New York Times discusses how the National Health Service (NHS) in England is clamping down on patients using both their own money and the NHS services to get treatments for the same condition at the same time. The article primarily discusses the case of a woman with breast cancer where the NHS wouldn’t pay for Avastin, and told her if she paid for it herself, she would have to pay for all her medical treatments for breast cancer.
The article also discusses the complexity and apparent confusion within the medical community and the NHS about how this policy is supposed to be implemented.…
Comparative Effectiveness in Healthcare Session at AAAS Meeting
I attended the annual meeting of the American Association for the Advancement of Science today to hear a session titled “Health Economic Evaluations of Medical Technologies: Is the Cost Worth the Cure?” The topic of this session was really about comparative effectiveness of medical interventions – particularly pharmaceuticals. The panel was a substantial group of physicians and health services researchers/regulators:
- Milton C. Weinstein, Harvard School of Public Health
- Michael F. Drummond, University of York, United Kingdom & NICE (National Institute for Health and Clinical Excellence)
- Jeffrey Kelman, Chief Medical Officer at CMS
- Marc Berger, Eli Lilly
- Tracy A.
Denial of Off-Label Medicines in Medicare Part D
I have been helping the Medicare Rights Center (MRC) with some appeals of Medicare Part D plans denying coverage for off-label uses of FDA approved medicines. These denials are based on a very detailed provision in the 2003 Medicare Modernization Act that the Centers for Medicare and Medicaid Services (CMS) interprets to mean that Part D can only cover FDA approved medicines for off-labeled uses that are listed in at least one of three specific compendia.
I became involved with the MRC’s work on this issue because as a Congressional staff person I had helped write a 1993 law that expanded coverage for cancer treatments under Medicare Part B (that’s “B” as in ball) to specifically include off-label uses listed in the compendia OR supported by articles published in peer reviewed literature.…