A Florida agency will monitor Miami Children's Hospital in the wake of a county report blaming a common-yet-deadly bacteria for the deaths of two infants in the hospital's neonatal intensive care unit. The Florida Agency for Health Care Administration will follow the hospital's compliance with recommendations by the Miami-Dade Health Department to improve its water supply, where 23 strains of the Pseudumonas aeruginosa were found by health investigators.
The Massachusetts healthcare law requires residents to have insurance that meets minimum standards, but regulators are discovering many employers' plans test the limits by exploiting loopholes in the rules. Regulators said that reviews of scores of health plans show many cap the benefits insurers pay each year on prescription drug coverage, exclude maternity coverage for dependents, or place an annual overall dollar limit on benefits. As Congress debates an overhaul of the nation's healthcare system that would borrow heavily from the Massachusetts blueprint, any flaws in the state's system are likely to become part of the discussion, said healthcare policy specialists.
The nation's deep recession is helping to alleviate the decade-long nursing shortage, as workers who had left the field are returning. Nearly a quarter-million nurses entered the work force in 2007-08, an 18% surge that was the largest two-year increase in at least three decades, according to a study. Many nurses who had left the field have re-entered the work force to compensate for a spouse's lost income or health benefits, the study said.
Mobile devices, doctor review sites, and blogs are changing the way millions of health consumers find and share find health information, according to a new survey released by the Pew Research Center's Internet & American Life Project and the California HealthCare Foundation. Nearly 60% of respondents said they have consulted blog comments, hospital reviews and doctor reviews, listened to podcasts about healthcare and signed up to receive updates about health or medical issues. And 20% have posted comments, reviews, photos, audio or video online related to healthcare.
While lawmakers agree that a bigger government role in disease prevention is needed to fix the healthcare system, such efforts have had little success in reducing illness or costs. "It is not going to cut costs," said Louise Russell, a research professor in the Institute for Health at Rutgers University who has studied the issue. "We already do a lot more prevention than other countries. We are not healthier." The findings don't question the benefits of a healthy lifestyle, the problem is that when testing becomes too widespread, or heavy investments are made in monitoring people with chronic diseases, the rewards often fail to match the costs.
A survey by the Pew Internet and American Life Project reports that 61% of Americans go online for health information, and the majority of them have turned to user-generated health information. But a scan through peer-reviewed journals reveals only a handful of articles, and no evidence-based guidelines, to guide doctors on the use of social media, says New York Times columnist Pauline W. Chen, MD. It is unclear whether the online engagement "adds to or detracts from a patient-doctor relationship, and clinicians are unsure about what constitutes good standards of care and professional responsibility on these platforms," Chen says.
The World Health Organization has declared the seven-week-old outbreak of the novel H1N1 influenza virus a pandemic. The announcement essentially warns the WHO's 194 member nations to get ready for the new flu strain, which is likely to infect as much as one-third of the population in the first wave and return in later waves that may be more severe. The declaration does not by itself initiate any particular action, nor does it predict the pandemic's ultimate severity, which is likely to vary between regions, ages, ethnic groups, and economic strata.
Doctors in 14 urbanized California counties applauded bills introduced Thursday by Rep. Sam Farr and Dianne Feinstein that would revise the rules that underpay physicians for treating Medicare patients by redefining their practices as more expensive and urban, instead of rural.
Instead of paying doctors based on an algorithm called the Geographic Practice Cost Index or GPCI, Medicare fees would be based on costs according to the Metropolitan Statistical Index, which is updated annually and is a more accurate recognition of expenses in urban environments.
That's the way hospitals are paid now, the California congressman says, so it only makes sense to pay doctors that way too. "It's fairer, it's smarter, and it's certainly more accurate," Farr says.
Farr expects the bill will be rolled into a health reform package, along with Feinstein's companion bill on the Senate side. Asked if the bill could disappear in the scramble of numerous reform efforts, Farr says he doesn't think so. "Everybody has agreed it's a problem that needs fixing. And that's half the battle."
In the absence of any formula correction, physicians have been declining to take more Medicare patients, leaving those who remain committed to care for older patients more frustrated and more frantic. In some parts of the state, the last doctor in certain specialties now declines to take Medicare patients, requiring people over 65 to travel long distances to cities in other counties.
Counties in Georgia, Minnesota, Ohio, and Virginia have disparities in physician payments because of the issue as well. But for now, Farr says, the remedy is just for California. "The complaint has arisen in California where the voices were the loudest," Farr says.
But he adds corrective change could eventually come there as well.
"This is a national pilot. But we want to hook this star on the train that's going to the end destination. In the past, we haven't had a major medical bill to hang on to," he says.
The problem has been documented for several years by the Medicare Payment Advisory Commission, the Urban Institute, and a private consulting firm, Acumen LLC.&
California Medical Association leaders say they are thrilled that corrective action is now possible.
"This is a welcome breakthrough on a problem that has reduced access to care for years," said CMA President Dev A. GnanaDev, MD. "As costs have risen in places like Santa Cruz, Monterey, and San Benito counties, Medicare reimbursements have not kept up, and that has resulted in fewer doctors being able to serve those patients. This legislation provides a fix without punishing other counties."
According to Farr's bill, more than half of the current physician payment localities include counties within them with a "large payment difference (that is, a payment difference of 5% or more) between the General Accounting Office's measure of physicians' costs and Medicare's geographic adjustment for the area."
"All these objective studies have recommended changes to the locality system to correct the payment discrepancies."
The new payment structure would take effect with Medicare physician services furnished after Jan. 1, 2010.
The exact amounts of the annual payment increase are not known, but in 2005 dollars, the 14 counties would receive about $50 million, $17 million of which would go to San Diego County. Physicians in Monterey and Sonoma counties would receive $5.2 million each; Sacramento, $4.7 million; Santa Barbara, $4.1 million; Santa Cruz, $3.8 million; Marin, $3.2 million; Riverside, $1.8 million; and San Bernardino, $1.2 million. The remainder would go to Placer, El Dorado, San Benito, San Luis Obispo, and Yolo Counties.
"Doctors in San Diego and 13 other California have been waiting seven years for this change, to continue providing access to quality of care," says Ted Mazer, a CMA trustee and San Diego otolaryngologist. "Hopefully, Congress will act appropriately and the president will sign this bill."
The disparities are the issue in a long-standing legal complaint that asks for more than a billion in retroactive Medicare payments for physicians in seven California counties. The physicians' attorney, Dario DeGhetaldi, says that his claim is waiting on a decision from an appellate court and is so far unaffected by the new bill.
Although the payment disparities have been an issue for eight years, physicians in underpaid counties were having difficulty being heard, in part because other counties worried they would be penalized with reduced fees. This bill will not do that, and will require a larger appropriation, Farr says.
Another problem in getting the formula changed is that it is complex. "It's never been well understood in Washington. It's esoteric."
He credited the California Medical Association for bringing all counties together "to the winners and losers together to essentially come up with an agreement that there were inequities that needed to be corrected," he says.
The concept of "comparative effectiveness research" has been mentioned so many times during the Senate Finance Committee's healthcare reform deliberations in recent months that members suggested that they think of a less controversial—and even easier—name.
"But whatever we call it, one thing is certain: we need to address the very real concerns that this research might be used to 'ration' healthcare," Baucus said. "People talk about cost effectiveness versus clinical effectiveness. People talk about whether the research can be used to make coverage decisions. These concerns boil down to one underlying issue: rationing."
Comparative effectiveness research—or the process of looking at the relative strength and weaknesses of various medical interventions—has emerged as a "great transformative issue" in the healthcare debate, Baucus said. "It is serious and needs to be addressed with integrity."
So can we get around the "R" word when it comes to comparative effectiveness research? Well, possibly. In trying to meet the issue head on, Baucus suggested three main ideas that will have to be up front and center when discussing and using comparative effectiveness research in order to get acceptance of the idea among the public. They are:
Make sure the research is patient-focused, taking into consideration patients' preferences for how they want the treatments to work. Patients should be actively involved in setting the research priorities along with designing the research studies. The studies must be relevant to patients. "In short, patients must be at the center of the questions about medical care that we want answered," Baucus said.
Next, all practicing physicians need to be at the table—and not just research physicians, but those who use and prescribe medical care everyday. They know what questions to ask. They can be key to making the research meaningful for decisions they make with patients, Baucus noted.
Third, create safeguards when it comes to the use in federal healthcare programs. Medicare and Medicaid should not be allowed to create automatic links to any single study. These programs need to be open, transparent, and thorough in how they use patient-centered research. Nothing should be done behind closed doors without public input.
So far, that's off to a good start. But to give more structure to comparative effectiveness research, more might be needed, such as giving a physical presence to the concept.
Baucus and Sen. Kent Conrad (D-ND) reintroduced a bill this month that would create a nonprofit corporation—called the Patient-Centered Outcomes Research Institute. The goal of the institute—which would be established as a private, nonprofit group—would be to review and generate scientific evidence and new data on treatments and best clinical outcomes related to diseases, disorders, and other conditions.
The senators had introduced similar legislation in the previous Congress. But the new measure would require the Centers for Medicare and Medicaid Services to meet specific requirements before using research, including comparative effectiveness research studies, in making coverage decisions.
Comparative effectiveness research will likely play an important role during the healthcare reform debate—and many years after that. So no matter whether it is called "CER" or "Fred" or any other name, the term needs to be carefully defined for this generation, and the ones that follow, to avoid the presence of that "R" word.
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Patients in Rhode Island will soon have a choice regarding whether they will allow their protected health information shared through a statewide health information exchange. The exchange will also allow their providers access to lab data and medication history.
The HIE—termed currentcare—is a secure electronic network created with a $5 million federal grant that the Rhode Island Department of Health received in September 2004 when Rhode Island was chosen as one of six states to receive funds from the Agency for Healthcare Research and Quality. Rhode Island subcontracted with the Rhode Island Quality Institute to provide governance for the initiative, the first phase of which is set to go live in the fall.
The exchange of electronic health information is at the forefront of health leaders' minds these days, particularly because the American Recovery and Reinvestment Act earmarks $300 million specifically for these types of developments. HIEs—the mobilization of healthcare information electronically across organizations or within a region, community or state—is one way of sharing data in this way.
"I think the government is really clear on how important the health information exchange component is to achieving our goal of safer, higher quality, and more efficient care," says Laura Adams, president of CEO of the Rhode Island Quality Institute, adding that currentcare plans to tap into the funds that would support a more robust capability for data exchange into and out of electronic medical records.
"Our plan is to interface all providers and sources of clinical data, such as labs, pharmacies, radiology centers, and hospitals into the system soon and as well as bring in data from physician's offices," Adams says. "Our funders have said we need to exchange data in and out of EMRs sooner rather than anticipated, so we're applying for the available stimulus funding. If we're able to get stimulus money, we can certainly ramp this up and shorten our timeline considerably."
currentcare is a Web-based application that allows physicians to sign in, be authenticated, and access laboratory information from three different labs in the state as well as information about medication history from retail pharmacies statewide. Provided the HIE receives stimulus funds, providers will have the ability to pull information out of the exchange and download it into their EMRs rather than having to read information through a Web viewer, Adams says.
Physician offices don't need an EMR to participate in the HIE, Adams says. "EMRs aren't interoperating with each other. It would involve numerous, expensive connections. Instead, they operate with a center into which all of the data flows versus everyone having to connect with everyone else."
In an effort to ensure the privacy and security of the PHI exchanged through the HIE, Rhode Island passed the Rhode Island Health Information Exchange Act of 2008 that took effect March 1, 2009. The legislation includes numerous explicit consumer safeguards, clear language that participation in the HIE is voluntary, strict penalties for misuse of the system, and created an HIE Advisory Commission that will make recommendations to the Rhode Island Department of Health regarding the use of confidential PHI used in the exchange.
Patients not only choose whether to participate in currentcare, but they also control which providers have access to the information as well as in what scenarios (i.e., emergency versus routine versus both) providers can access that information.
The Rhode Island Quality Institute recently started efforts to educate and enroll consumers in currentcare, which now has 2,300 members. Adams says it will continue to grow. "We think this will save lives. We think it's much more efficient that the current paper-based system, and that it reduces complications and the chances that people experience a medical error."
