House Democratic leaders worked furiously on Thursday to secure the final votes for weekend approval of a sweeping healthcare overhaul as President Obama threw his weight behind the lobbying effort and Republicans dug in against the health plan. Democratic vote counters said they did not yet have the necessary 218 confirmed supporters. But they said they were confident they would exceed that total in time for a landmark vote set for Saturday on the $1.1 trillion, 10-year health plan that many Democrats have sought for years. Readying for the first floor test of legislation months in the making, top Democrats appealed to undecided lawmakers while trying to quell resistance from Hispanic House members worried the measure was too punitive regarding illegal immigrants and anti-abortion lawmakers who fear that public money could be funneled toward abortions.
Many doctors are performing unnecessary Pap smears, ignoring guidelines issued by major medical organizations and adding to healthcare costs, a survey of physicians has found. Of 1,212 primary care doctors who responded to a survey about cervical cancer screening, only about one-fifth described practices that were consistently in line with the latest recommendations from groups including the American Cancer Society and the United States Preventive Services Task Force, the study found. Most had overused cervical cancer screening. A vast majority said they would recommend annual Pap smears for at least three years for an 18-year-old woman, who had recently become sexually active, which is consistent with the recommendations of major medical groups. But many of the doctors said they would also recommend the screening for a 35-year-old woman whose cervix had been removed, but who had no history of cancer; testing in that situation would be inconsistent with guidelines.
New York City health officials have distributed small amounts of the swine flu vaccine to some major New York companies, including Wall Street banks like Goldman Sachs and Citigroup, even as shortages continue. Citigroup has received 1,200 doses, more than half of what it requested, health officials said, and in late October, Goldman received 200 of the 5,400 doses it asked for. By contrast, Memorial Sloan-Kettering Cancer Center received 200 of the 27,400 doses that it requested for its workers, according to the New York City Department of Health and Mental Hygiene. Jessica Scaperotti, a health department spokeswoman, said the priority was to get the vaccine to pediatricians, obstetricians, gynecologists, community health centers, and public and private hospitals. Private companies that have asked for the vaccine are also eligible to receive it, as long as it is distributed to people who are considered at risk. Citigroup and Goldman Sachs said they had administered the vaccine to pregnant women and employees with serious health conditions.
Now that the White House has declared swine flu a national emergency, and with the H1N1 vaccine in short supply, many Web sites have been peddling swine flu nostrums. The Food and Drug Administration has identified 140 different dubious products sold online and has sent letters to 75 manufacturers. It is violation of federal law to market products that claim to prevent or treat H1N1 and that have not been approved by the FDA. The agency has gone after sellers of gloves, inhalers, masks, shampoos, herbal extracts, air fresheners, and an array of vitamins that make claims about fighting swine flu. Some of the Web sites were fly-by-night operations that have since closed down.
Chanting "Kill the bill," thousands of conservatives rallied at the Capitol on Thursday against the Democrats' healthcare overhaul plan, labeling it a government takeover of the nation's medical system. The protest attracted many of the so-called Tea Party demonstrators angry with increased spending and an expanded government role under the Obama administration. Their signs ranged from the harsh, "Waterboard Congress," to an echo of the rallying cry at August town halls with lawmakers, "Vote no to government-run health care." One protester carried a placard reading, "Bury Obamacare with Kennedy," a reference to Sen. Edward Kennedy, D-Mass., who died of brain cancer this past summer.
Dallas County health officials spent Thursday figuring out how to get people with insurance more 2009 H1N1 flu vaccine, even as they continued to vaccinate the uninsured. Almost 3,100 people received vaccine during the second day of the county's first large-scale walk-in vaccination clinic, bringing the two-day total to about 6,700. But plans announced by Texas officials on Wednesday may send thousands of doses a week to the county health department. And large clinics like the one this week that basically closed the department to anything but swine flu vaccinations just aren't practical very often, county health department director Zachary Thompson said.
The Federal Trade Commission is investigating some of CVS Caremark Corp.'s business practices, the company said Thursday. The drugstore chain and pharmacy benefits manager did not disclose the details of the "nonpublic investigation," but said it has not violated any antitrust laws. CVS suggested the FTC inquiry is connected to complaints made by the Change to Win coalition of labor unions. Change to Win has said CVS Caremark's size and buying power is bad for consumers, and accused CVS of a stocking expired products and violating patients' privacy, among other issues.
The American Medical Association has endorsed a House healthcare reform (H.R. 3962), but has also called on Congress to pass a separate bill (H.R. 3961) that eliminates the sustainable growth rate formula in Medicare that will mandate a 21% cut in reimbursements this January.
"These two bills were introduced together, and they need to be passed together. Both are essential to achieving meaningful health system reform this year," AMA President J. James Rohack, MD, told reporters during a midday media teleconference.
H.R. 3962, The Affordable Health Care for America Act, is the sweeping healthcare reform bill that emerged from three separate House committees. The bill would expand healthcare insurance to more than 96% of the population, and key features include a public health insurance option made available through a health insurance exchange.
"H.R. 3962 is not the perfect bill, and we will continue to advocate for changes, but it goes a long way toward expanding access to high-quality affordable health coverage for all Americans, and it would make the system better for patients and physicians," Rohack said today. "This is not the last step but the next step toward health system reform."
Rohack says H.R. 3962 is consistent with AMA "principles of pluralism, freedom of choice, freedom of physician practice, and universal access."
Rohack also called on Congress to pass H.R. 3961, the Medicare Physician Payment Reform Act of 2009, to permanently repeal the SGR.
"In less than 60 days, Medicare physician payments are scheduled to be cut by 21%, with more cuts in years to come," Rohack said. "Annual patches have temporarily averted widespread access problems, but they have also grown the size of the problem and the cost of reform.
A similar bill was defeated in the Senate last month, but Rohack said that will not deter the AMA's efforts on the House bill.
"The House action is going to reestablish momentum on repeal of the payment formula," he said. "When the Senate took this up some people did not want to vote because of the deficit. But in reality they could have fixed this problem three years ago for less than $50 billion. Now it's over $250 billion and will only grow continued temporary patches are used. We believe this is fulfilling an existing obligation, and that is the reason why we strong believe the House recognizes this and will pass this bill."
Los Angeles-based rapper Dr. Dre may have some competition in the rap game—at least when it comes to educating kids on the H1N1 flu. And this competition comes from an actual doctor.
Mache Seibel, MD, a.k.a. "DocRock," uses music to educate on health issues, and has released more than 100 songs and 12 CDs. His goal, Seibel says, is to increase health literacy through entertainment.
Seibel's latest effort is the H1N1 Rap, which offers five Centers for Disease Control and Prevention-endorsed steps to avoid contracting H1N1 flu. Working alongside health insurer Cigna, a video was produced to accompany the song that is available for viewing on YouTube.
"My goal is to really improve health literacy by making information fun and easy to remember, and I do that with original songs," says Seibel, who is a board-certified physician who teaches at the University of Massachusetts Medical School. "My goal with the H1N1 pandemic was to make as many people as I could aware in an as easy and fun way as possible.
In H1N1 Rap, Seibel kicks the rhymes:
I'm DocRock teaching 5 steps to you
To avoid H1N1 flu
One: Get a flu shot, at clinics or school
It only takes a minute; it's my number 1 rule
Two: Use your elbow when you cough or sneeze
Or sneeze into a tissue and throw it out please
Three: Wash your hands 20 seconds or more
Or use a sanitizer that you buy at the store
Four: Keep a distance from people who are sick
Two steps away usually does the trick
Five: Keep your fingers out your eyes, mouth and nose
'Cause that's the places H1N1 goes
To learn more about the 5 steps above
Go to www.flu.gov
Seibel says he chose rap to educate children on H1N1 because it is one of the most widely accepted music genres.
"It also allows you to put a lot of words together in a short time—you can express a lot of key points," Seibel says. "We had five points to make in about 30 seconds, and the best way to do that is to speak it in a more direct way."
Songwriting is a skill that Seibel has had "for as long as he can remember," and has used songs to educate children of all ages on health issues, including preschoolers (The Potty Train), adolescents on anger control (Stay Cool), and high schoolers on teenage pregnancy (I Didn't Think About Thinking).
The songs are available on Seibel's Web site, HealthRock.com, and schools across the country use the songs to educate young people on health issues.
"Music is incredibly effective way to get people's attention, and once you get their attention, you have the potential to improve their retention," Seibel says.
Seibel says that when writing the H1N1 rap, as he does with all of his compositions, he is very careful they are accurate factually, as well as entertaining.
"That's why its very good to have a doctor doing it—you not only have a fact checker as the creator, but you also have the sensitivity and nuance to how to communicate to people in a way that deals with sensitivity and appropriateness," Seibel says.
And Seibel might have some competition when it comes to "rapping" about H1N1 education. In September, New York family physician John D. Clarke, MD, won the 2009 H1N1 PSA Contest sponsored by the U.S. Department of Health and Human Services. Clarke's rap won a contest that was part of the federal government's effort to spread the word on how to avoid both the seasonal flu and H1N1.
But as Seibel says, there are 90 million adults who are "health illiterate," and anybody who educates people on health in an easily-remembered way should be encouraged.
"The perspective is that if you can sing about something, then you can talk about it," Seibel says. "And then once you can talk about it, you can affect behavior—that's the premise behind this."
When you think of improving quality, you may think it involves something new—new ways of evaluating data, new methods to pay for care, or new applications of information technology. But it also can mean looking at something old—and seeing if it can have an impact as well—such as encouraging the idea of provider home care visits, especially for the senior population.
While great interest has been emerging over the concept of the patient-centered medical home in both the healthcare and political communities, it may be time to look at care in the patient's home as a way to provide quality care.
Back in 1930, house calls accounted for 40% of the encounters between physicians and patients. However, by 1980, that rate dropped to less than 1%. But that has been changing: in 1995, 1.5 million home visits were paid for by Medicare, and by 2007, those visits increased by nearly 2.2 million. Approximately 4,000 of the nation's physicians, plus nurses and physician assistants, are making home visits part of their practice, according to the American Academy of Home Care Physicians.
And greater changes could be ahead if healthcare reform legislation is approved on Capitol Hill. Incorporated into the House bill (HR 3962) and the Senate Finance Committee bill (S 1796) is a provision called the "Independence at Home Medical Practice Demonstration Program" that would test a "payment incentive and service delivery model" staffed by physicians and nurse practitioners on home based primary care teams.
So why this kind of model? As Peter Boling, MD, the head of general medicine at Virginia Commonwealth University Medical Center in Richmond, tells it, there usually is just enough payment in the current Medicare fee-for-service payment formula to cover short, uncomplicated home-based care visits to patients.
However, "It's not enough to support the really complex case management that actually saves [Medicare] money," said Boling, who speaks from 25 years of experience providing home-based care to Richmond-area residents. "It's hard to grow as a business model."
"We see ourselves saving lots of money for the Medicare program because if the programs are designed the way ours are, we end up keeping people from having to go into the hospital," said Boling, who works with his hospital-supported primary care program that includes several physicians and nurses who make approximately 2,500 to 3,000 home-based calls per year.
Home-based care "ultimately saves the Medicare program money and it makes the patients less sick and more happy—which is also a good thing," he said.
The home-based program described in the bill is a type of "gain-sharing arrangement" in which the main elements of the Medicare program—such as the hospital, physician, and drug coverage—remain the same.
However, for individuals who enroll in a special program called Independence at Home, if the amount of money spent on them was less than what Medicare expected to spend, then the savings would be given to the provider or organization that was providing the healthcare. The Independence at Home amendments, which were actual bills before being incorporated into the reform bills, has attracted strong bipartisan support in both congressional chambers.
Having home-based care available presents many advantages to older and vulnerable patients, Boling said. In particular, patients can receive medical assistance in a few hours rather than a few days, and the care is less disruptive to their day-to-day lives," he said. "We're here to help them manage."
"And the quality of service would be better because we would actually know what was going on with them. We'd see all those pill bottles that they have or we would see the reality of their house . . . Do they have to go up stairs? Do they need some additional equipment?" he said.
There are "all sorts of things that you know right away when you go into somebody's house that you don't always know when somebody's in the artificial environment of the clinic," he said.
And the advantages are there for Medicare, too, such as the reduced hospital readmissions or "incident admissions" to hospitals and emergency rooms. "We've intercepted a certain percentage of hospitalizations before they even happen," Boling said.
And what about the likelihood that home-based programs eventually do expand—posing competition to his group practice? He said that would be a "good problem to have—as opposed to being the only game in town. [We would no longer] have a waiting list of people actually dying before they come into the program, which is what happens now."
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