Bipartisan support for measures to increase research, improve care.
This article was first published on Wednesday, January 8, 202 in MedPage Today.
By Joyce Frieden,News Editor, MedPage Today January 08, 2020
WASHINGTON -- The House Energy & Commerce Health Subcommittee hearing on Wednesday sounded a lot like an Obama campaign rally, with "Yes we can" as the overarching theme.
"It's safe to say that this is a bill that will [make it] through the subcommittee and full committee process and hopefully to our colleagues in the Senate," member Michael Doyle (D-Pa.) said of one of the bills under discussion.
"This bill's going to move; it has to," subcommittee chairman Anna Eshoo (D-Calif.) said of another bill. "It will make all the difference in the world not only for patients but also for the dollars attached to it, it's common sense."
"We will fix it," ranking member Michael Burgess, MD (R-Texas), said of a provision in a third bill that a fellow Republican was complaining about.
The subcommittee was discussing a smorgasbord of seven different health bills, with topics ranging from paying for immunosuppressive drugs for kidney transplant patients to encouraging more research into the causes of sudden unexpected infant death (SUID) and unexpected deaths of children.
Subcommittee members were visibly moved during testimony on the latter bill, known as the "Scarlett's Sunshine on Sudden Unexpected Death Act," by Stephanie Zarecky, whose daughter Scarlett died in her sleep of unknown causes at 16 months. "We read the parenting books and followed all safe sleep guidelines ... yet we still lost our healthy, thriving, precious baby girl," Zarecky said. "It is an unimaginable tragedy no parent should have to live with, and there are thousands of us who do it every day." (CDC statistics put the annual total at about 3,600 per year.)
The bill would require CDC to revise the Sudden Unexplained Infant Death Investigation Reporting Form to include doll re-enactments and scene investigation information on sleep-related deaths of children under the age of 5; it also would authorize CDC to make grants toward improving completion of death scene investigations for sudden unexplained deaths of children and infants. The bill also authorizes grants through the Health Services and Resources Administration to develop and deploy support services for families who have had a child die of unexplained causes, something that Zarecky said was desperately needed.
"Having someone who could make a phone call to the medical examiner's office ... I can't tell you how impossible even dialing that phone number is at times ... Having that support not only from an emotional standpoint but logistical are things you don't think of when you've lost a child," she said. Also, "bereavement support for families is critical ... I don't know where I'd be today if I didn't have the support of other families who've walked this journey before me."
Rep. Joe Kennedy (D-Mass.) said he had a constituent who wrote about how he had lost his child under similar circumstances; he later met with the man in person. "[It was hard] listening to that young dad try to make sense out of what happened, to wrestle with the stigma associated with the loss of a child and the judgment that came down on him and his wife for the perception of having done something wrong and not being able to point to anything," he said. "It highlights the obvious need to do everything we can to make sure this doesn't happen again ... and that families get answers."
Members on both sides of the aisle also were sympathetic to H.R. 2468, the School-Based Allergies and Asthma Management Program Act. That bill would give grant preference to states requiring the presence of a school nurse during school operating hours; a school-based allergies and asthma program, including a way of identifying students with allergies and asthma; and an individual action plan for each one of those students.
Rep. H. Morgan Griffith (R-Va.) supported the bill. "When I was 5 years I got in trouble because I threw a cookie across the room" after a teaching aide tried several times to give it to him. "I had a wheat allergy and I knew I couldn't eat that cookie."
Kenneth Mendez, president and CEO of the Asthma and Allergy Foundation of America, who testified in favor of the bill, noted that "Food allergy bullying happens in classrooms that we really ought to be aware of," and also spoke in favor of increasing diversity in clinical trials for allergy and asthma treatments.
There was similar enthusiasm for H.R. 5534, the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act. Currently, for patients with end-stage renal disease who are covered by Medicare, the government pays for the transplants but only provides coverage for immunosuppressive drugs that prevent rejection for 36 months, even though such treatment normally extends far longer. This bill would remove that 36-month limit. Transplant patients who go off their immunosuppressive drugs -- which typically cost around $2,000 annually -- because they can't afford them once the coverage runs out often lose the graft and have to resume dialysis and then join the transplant wait list a second time.
Loss of a kidney graft "is a bad deal when it happens to someone," Burgess said. "They were on the waiting list, waited a long time, and got a match ... [These drugs are] not a big expense [for Medicare]; this is relatively manageable and yet but for that small investment, these patients go into something from which they cannot recover without another surgery."
"Across the country, well over 70% of programs can talk about at least one patient who lost their organ due to insufficient coverage," testified Matthew Cooper, MD, director of kidney and pancreas transplantation at MedStar Georgetown Transplant Institute here. "It costs about $86,000 a year for dialysis," while a kidney transplant, after the initial upfront $100,000 cost, requires only about $2,000 a year for immunosuppressive drugs."
"This legislation can potentially save kidneys, save lives, and potentially save Medicare money. Let's bring this across the finish line; it's time to put an exclamation point on this."
Prior authorization (PA) requirements usually succeed in reducing use of certain procedures, but the evidence on whether patients are harmed as a result is not so clear, according to a report funded by the National Institute for Health Care Reform, a nonprofit founded by the "Big Three" U.S. automakers and their principal labor union, the United Auto Workers.
"The research generally shows [that PA] reduced use of the targeted care, sometimes with offsetting increased use of preferred treatments," wrote co-authors Ani Turner, Samantha Clark, and George Miller of the Altarum Institute's Center for Value in Health Care. "Evidence also shows reduced spending on the targeted care, although this does not always translate into lower overall health care spending. Positive outcomes have been shown under PA programs for diagnostic imaging, where high rates of use and cost were reduced, and opioid prescribing, where rates of subsequent opioid abuse and overdose were reduced."
The authors conducted their study via an analysis of peer-reviewed literature on prior authorization, as well as "gray literature" including reports by the Medicare Payment Advisory Commission, the Government Accountability Office, and the American Medical Association (AMA). The authors also interviewed insurance and pharmaceutical industry experts.
Cost Estimates for Doctors Vary Widely
Regarding the cost of PA, "Estimates of the cost burden to physician practices vary considerably, from $80,000 annually per physician to between $2,200 and $3,400 annually per physician (2010 dollars)," the authors wrote. "We find the direct cost of PA likely to be closer to the lower-end estimates, which were focused specifically on PA interactions with insurers and were based on staff time requirements recorded in real time, rather than on requirements estimated by providers from memory."
"The American Medical Association has done surveys annually and puts out numbers related to PA from those surveys, and the study that's quoted a fair amount puts the [annual] cost at $80,000 per physician, but that study looks at interactions between physicians and insurance companies more broadly -- maybe a lot is PA but it's not clear it's entirely so," Turner said in a phone interview.
"Other studies had numbers of less than $10,000 per physician -- those were doing tracking of actual time spent in practices relating specifically to PA. That's why we concluded that while there is a wide range, based on the methodology and rigorousness of the studies, the true cost is likely to be at the lower end of those estimates -- in thousands rather than tens of thousands, but it varies based on whether or not the physician is able to do things electronically, and how many insurers the physicians are dealing with, because the requests and method of submitting requests vary."
Furthermore, "some studies show that when physicians groups get together and do centralized activity on PA, that can be a more efficient way of doing it ... So there's not one answer, even on the cost side," Turner said. "It also depends on whether insurers support electronic submission."
Not Going Anywhere
"It's clear to us that PA is not going anywhere in the near future," she added. "If anything, it seems to be increasing, but hopefully it's becoming more automated and more standardized ... and hopefully there's a pull on providers and insurers toward streamlining and automating the process so it is less of a burden."
Turner said she understands that physicians have concerns about the PA process. "While I'm sympathetic with the fear of having the insurer looking over your shoulder, there is the issue of low-value care, of fraud and abuse, and of good treatment of resources," she said. "When physicians are surveyed, a very high percentage believe that patients are negatively impacted by PA, and I don't discount their views on that, but we're looking for what the evidence says, and certainly the evidence says people get less care, and less care that's found to be inappropriate."
For example, prescription drugs have a lot of prior authorization associated with them, especially if they're prescribed off-label. "In the meantime the patient decides to say, 'Forget it; it's not worth the hassle,' so care is delayed and sometimes abandoned altogether," said Turner. "The question is, does that negatively affect their health in the long run, and that's less clear." The only area where some evidence outcomes are harmed is in psychiatry, she added. "Patient adherence can be very difficult if someone has a condition like schizophrenia -- making sure they stay on their medications and constantly adjusting doses can be challenging. So when there are interruptions due to PA, there is evidence in the literature that can interrupt care for people with mental health conditions, and that does put outcomes at risk."
Increasing Use in Public Programs
PA's use, while common among commercial insurers, has until recently been limited in public programs like Medicare and Medicaid. However, the investigators noted, "recent demonstration programs and the growing role of managed care organizations in delivering care to Medicare and Medicaid enrollees are expanding the use of PA for the publicly insured ... In recent years, [federal law] was amended to allow PA to be tested and evaluated under Medicare fee-for-service for several categories of care, including repetitive, scheduled, non-emergency ambulance transport, non-emergent hyperbaric oxygen, home health care, and power mobility devices. Stemming from these demonstrations, systemwide PA requirements have been implemented for power mobility devices; CMS maintains a Required Prior Authorization List of specific requirements."
One way that's been suggested to make PA less of a burden is to "gold card" certain providers whose PA requests are always approved, and exempt them from PA requirements. However, one insurance industry representative "made the point that it's not as straightforward as you might think to implement gold carding," said Turner. For instance, "You may have providers within the same practice who do things differently, and it may be difficult to distinguish one doctor from another and just give a gold card to one physician."
In addition, "the systems in place [from the payer side] aren't always easy to configure to allow a waiver of the requirements," she said. "And sometimes the physician may have a high approval rate for particular types of services but not for others, so it's difficult to say they get a pass on all their PA requests. But in principle it makes a lot of sense to not have to go through that hassle if the vast majority of time someone is approved."
Turner noted that "some insurers may say they'll sunset their PA requirements if they find that across all of their providers, the vast majority of PA requests are approved. So it's desirable for insurers to track and regularly update requirements and eliminate them if they're not really serving a useful purpose. That's another way the burden could be reduced."
As institutions struggle to find solutions, some women are taking matters into their own hands.
This article was first published on Sunday. January 5, 2020 in MedPage Today.
By Shannon Firth, Washington Correspondent, MedPage Today
In February 2019, MedPage Today launched a#MeToo Medicine series, which examined how entrenched hierarchies and a climate of intimidation, retaliation, and fear discourage targets from reporting sexual harassment. In this follow-up, we take a new look at the situation.
Institutionally, at least, 2019 saw the problem being taken seriously:
On March 1, more than 50 women launched the TIME'S UP Healthcare movement to foster the development of "more balanced, diverse, and accountable leadership" while at the same time responding to workplace discrimination, harassment, and abuse, and promoting "equitable and safe cultures."
In May, the National Institutes of Health Advisory Committee to the Director Working Group on Changing Culture to End Sexual Harassment held a "listening session" to explore the ways individuals are "adversely affected" by sexual harassment.
Also in June, the Association of American Medical Colleges (AAMC) held a Leadership Forumthat explored institutional barriers that prevent alleged harassers from being adequately investigated and disciplined as well as the difficulty of enacting a broad and sweeping cultural change.
In November, the National Academies of Science, Engineering, and Medicine (NASEM) held an Action Collaborative on preventing sexual harassment in higher education, which highlighted new initiatives focused on reducing power differentials that allow harassment to persist, and ways academic institutions can foster support for targets and block perpetrators of harassment from transferring positions -- i.e., ending the "pass the harasser"phenomenon.
Medical journals also gave voice to individuals' grievances. Last month, the Journal of General Internal Medicine published an essay by University of Michigan medical student Anitha Menon in which she described being peppered with questions about her age, marital status, and where she was from by a middle-age male patient complaining of a testicular bulge. The patient then turned to her attending and asked, "So where can I get myself one of these pretty assistants?"
"To my dismay," wrote Menon in December, "the attending -- without missing a beat -- replied, 'Well, they send them to us every month – they're medical students.'"
Holding back tears of anger and frustration, Menon completed the exam. "To this day, I wish I had not," she wrote.
She recalled other examples of harassment, from a patient repeatedly asking for her phone number, to an attending telling an operating room nurse to leave a patient's nipples visible, "because he 'had a fetish.'"
"[S]exual harassment, especially in the form of gender harassment, is rarely about sex -- it is about power," Menon wrote. "It reinforces a gender hierarchy that has become normative and serves to remind women that we are seen as objects, not physicians."
Most harassment wouldn't qualify as criminal behavior, but the daily microaggressions that target experience can have "terrible consequences for women in academic medicine," said Reshma Jagsi, MD, DPhil, deputy chair of the Department of Radiation Oncology and director of the Center for Bioethics and Social Sciences at the University of Michigan Medical School, in an AAMC press release on the Leadership Forum.
The ripple effects of these inappropriate behaviors include lost productivity, physical and emotional distress, depression, and women choosing to leave an institution or leave the profession altogether, Jagsi said in the release.
Nearly a quarter-century ago, Canadian researchers reported that among female physicians and trainees who had experienced sexual harassment, waning interest in their studies and "intrusive memories" were common, and one in three considered quitting medicine.
Engaging Leadership, Bystanders
"There are already rules in place about not harassing people, not discriminating based on gender or race, and so the question is ... how do you make the culture change so that those rules are enforced?" asked Janis Orlowski, MD, AAMC's chief healthcare officer.
"And the answer is that you don't tolerate it," she told MedPage Today.
The whole community has to be educated about this shift and a clear signal sent by the leadership, so that if an incident does occur, the school has to deal with it appropriately, "so that people know the school means business," Orlowski said.
Timothy Johnson, MD, professor of obstetrics and gynecology and of women's studies at the University of Michigan -- and a co-author of NASEM's landmark 2018 report on sexual harassment-- said the first step is defining the problem.
"And I think that's what the National Academies report did," he said.
"I think, more and more, we're asking ... senior faculty to say something, so that if a patient says to a medical student, 'Hey, you're too cute to be a medical student' ... it's up to the attending to say, 'Hey, that's not appropriate language.'"
Clinicians, historically, have been taught "that we have to love our patients and they have to love us [but] ... sometimes you just have to say, 'Excuse me. I understand you're sick ... but this behavior's not appropriate.'"
Similarly, an attending has to be able to interject if a chief resident "says something obnoxious," or vice versa, Johnson added.
But culture change takes time.
"Changing culture doesn't occur just by changing a rule or enforcing a rule," Orlowski said, adding that "we're talking about a 10-year horizon" to work and keep up the pressure.
Raising Awareness, Learning to Intervene
Creating this kind of culture shift takes work and requires "more than just watching a video," Johnson said.
But role-playing, and working through potential scenarios of harassment face-to-face, can be very effective, he noted.
Doctors don't intrinsically know how to take a patient's history. It's learned and practiced, he said.
Johnson said that early in his career as a gynecologist, "it was very uncomfortable for me to say things like, 'Do you have sex with men or women or both?'"
"I mean that didn't roll off my tongue the first hundred times I said it."
Similarly clinicians aren't going to wake up one day and magically know the right words to say to intervene when they see harassment.
"You have to ... give people the words and make them comfortable saying the words and internalizing the words," Johnson said.
At the AAMC's June forum, participants had a chance to participate in bystander training, where they were taught both direct and indirect intervention tactics. Direct interventions included asking the harasser to stop or telling a supervisor, while more indirect strategies included telling a student she's late for class or having a clinician paged.
Roberta Gebhard, DO, president-elect of the American Medical Women's Association (AMWA) and a member of the TIME'S UP Healthcare advisory board as well as the AMA's Women Physician Section, agreed with Johnson that face-to-face training far exceeds online programs.
She also noted that such training is particularly powerful if the CEO of an organization or the dean of a medical college participates.
"There are not a lot of bad actors, but there are a lot of bystanders that can be educated on how to be allies," Gebhard said.
Harassment -- A Learned Behavior
"People are not born perpetrators; they learn this over the course of a career," said Kristina Larsen, JD, who has worked in university administration and employment law for 20 years, and who was one of the panelists at the NASEM Action Collaborative on sexual harassment prevention.
A frequent pattern in medicine, Gebhard told MedPage Today, is that a person who's accused of harassment may make a lateral move to another institution mid-investigation, or even be transferred to a higher position. The harasser escapes blame and then puts students and faculty at his new institution at risk.
The strategy is so common it has a name: "Pass the harasser."
And one reason harassers continue this pattern of behavior is that nondisclosure agreements at some academic institutions or hospitals require that certain information about an academic's behavior be kept confidential.
"And what we have to do is for someone who is disciplined or who is known to be a harasser, we can't let them move forward without that information being given to the next institution," Orlowski said.
If a university or institution of higher learning really wants to address sexual harassment, it needs to include an individual's conduct as one of the factors it weighs during its promotion and tenure process, Larsen said.
She noted that in nearly every sexual harassment case she's been involved in, at no point in that individual's career did the person receive "meaningful consequences for any conduct."
Because of this "zero-to-60" paradigm in compliance, academics receive either no feedback or they're pinned with a formal accusation or investigation -- and "this is really not good for anyone," either victim or perpetrator, Larsen said.
"In the past people were able to harass, but if they did good research or ... they were good educators or they were great surgeons, they were allowed to move forward in their professional career," Orlowski noted. "What happens now, or what should happen now, is even if you do all those other things well, but you're a known harasser your career should not continue to flourish."
Larsen said the more comprehensive evaluation isn't simply about the individual being evaluated, it's about everyone else who's affected by promotion and tenure decisions. "[H]aving people see that the university is willing to defend this [process] because it's the right thing thing to do will send such a powerful message, she said -- particularly to graduate students aiming to join university faculties themselves one day."
The authorization includes language allowing the university to have access to documents typically considered confidential, such as separation agreements or forms where an individual agreed to a particular sanction.
This approach is "[m]aking it clear to our hiring committees that these things matter in the evaluation of a candidate," O'Rourke said.
'Whisper Campaigns'
While programs aimed at weeding out harassers before they become tenured professors unfold -- the University of Wisconsin is testing a similar model -- some women have taken it upon themselves to warn others of known perpetrators.
In private Facebook groups, "whisper campaigns" warn women about individual harassers at different institutions, Gebhard said. Many of the groups allow members to post anonymously through the group's administrator, to protect that individual's identity, Gebhard wrote in a follow-up email.
One closed Facebook group has more than 70,000 female physician members.
Women can also share stories about which institutions -- medical schools, residency programs, and hospitals -- are failing women and which ones treat women equitably, Gebhard said.
As a member of one closed Facebook group and the founder of AMWA's Gender Equity Task Force, Gebhard wrote a letter to one institution letting the leadership know that a "bad actor" was being transferred there, "that he was trouble and that we'd be monitoring his behavior."
As for other channels for reporting inappropriate behavior, the University of Michigan now has at the top of its homepage a button for reporting sexual misconduct, Johnson noted.
Both the Accreditation Council on Graduate Medical Education, which provides accreditation for residencies and fellowships, and the Liaison Council on Medical Education, which decides whether medical education programs meet established standards, serve as more formal watchdogs for residents and students, according to Gebhard.
Both organizations can survey students and intervene if problems of sexual harassment occur, as a matter of student safety, Gebhard said.
Any action by these bodies would require the students to disclose problems with sexual harassment, but "since this could ultimately result in the closing of their program, it's not always in their best interest," Gebhard said in an email. She said at least one residency has been shuttered for not providing a safe, equitable workplace.
Reducing Power Imbalances
One key recommendation of the 2018 NASEM report was to reduce the power differentials between harassers and potential targets.
"[E]nvironments where people are isolated because of significant differences in power are more likely to foster and sustain sexual harassment," the document stated, also noting that the more power a harasser has over a target the greater the negative consequences the target endures.
One of the strategies for diffusing such power differentials in medicine and in academia is to promote multiple mentorships, explained Maria Lund Dahlberg, co-editor of another NASEM report, "The Science of Effective Mentoring in STEMM."
The model can be as simple as a triad with two mentors to a mentee, or two mentees to a mentor. In the latter model, often there's a kind of "vicarious learning" among the mentees who may be at different stages in their career.
If an individual establishes trust in a multiple mentorship model and that trust is broken with one individual, there is still at least one other individual to provide the psychosocial support and guidance "to process the loss of that relationship" and ideas on ways to move forward.
Another way to enhance mentoring relationships is to establish mentoring agreements as a way of explicitly stating what each person expects to get out of the relationship -- "they can help steer the relationship back on track, should it get derailed," Lund Dahlberg said.
When mentor-mentee pairs are selected by the Gilliam Fellowship at the Howard Hughes Medical Institute (HHMI) for funding, mentors are required to attend a year-long culturally aware mentor training program, explained Sonia Zárate, PhD, HHMI's program officer for Science Education, in an email.
Applicants to the program are also required to outline a "conflict resolution plan" as part of a broader mentoring plan.
"By having to reflect on what they would do, the expectation is that they will be able to manage situations in real-time before they escalate," Zárate said.
Barriers Remain
Given privacy concerns and the threat of retaliation, advocates for change told MedPage Today that in some cases the best option for an individual target, usually a woman, is to leave her program or employer.
This frustrates Lauren Powell, currently director of health equity for the Virginia Department of Health, who will become TIME'S UP Healthcare's executive director later this month. She spoke with MedPage Today over the phone with a press representative also on the line.
"Placing the blame or the onus on a survivor to find somewhere else to work or, in some cases, find a totally different career, is completely unacceptable to me because that completely absolves us of looking at the system that created these conditions," she said.
One of the goals of TIME'S UP Healthcare is to create policy change, including making it easier to report problems and enforce consequences, she said.
Additionally, the TIME'S UP Legal Defense Fund provides financial and legal assistance to women who experience sexual harassment.
Nearly 4,000 individuals have reached out to the fund, which has provided financial and/or public relations support (but not legal services) for 250 cases including five paramedics in Chicago and for a nursing student in North Carolina.
"But," said Powell, "it's not lost on me that there has to be more discussion about ... what to do [about] retaliation and how to move organizations away from making it so hard to come forward to just tell the truth."
Big drop in scripts after interventions in Texas program.
This article was first published on Thursday, January 2, 2019 in MedPage Today.
By Diana Swift, Contributing Writer
Interventions to reduce the use of proton pump inhibitors (PPIs) -- both overall and inappropriate -- resulted in a significant decrease over a year, researchers reported.
They found that in 2017, before the start of the de-escalation initiative in the Harris Health System in Harris County, Texas, 66,261 unique PPI prescriptions -- equating to 3,990,790 pills -- were dispensed across the network's 16 pharmacies. In the year after implementation of the program in January 2018, the number of unique scripts fell to 55,322, a 16.5% decrease (P<0.0001) equating to 3,194,651 pills dispensed and a decrease of 19.9% (P<0.0001).
In their prescription review, Derek Lin, MD, and colleagues at Baylor College of Medicine in Houston found that of 80 PPI prescriptions dispensed pre-intervention in the last quarter of 2017, a total of 56 (70%) were inappropriately prescribed, either by indication or duration. Post-intervention, 162 of 308 (52%) prescriptions were inappropriately prescribed (P=0.005).
That increase has raised concerns about appropriate indications, duration of use, adverse effects, and unnecessary costs for patients and the health system. "Arguably the most debated of these concerns by the public at large seems to be the reported adverse consequences associated with chronic PPI therapy as documented in several observational studies, including increased enteric infections and micronutrient deficiencies," Lin and co-authors wrote.
For example, a recent French study found prolonged PPI use to be correlated with a greater risk of viral gastroenteritis, with those researchers calling for monitoring of long-term PPI users. In terms of inappropriate prescription, a survey based on simulation research revealed that most doctors continue to prescribe PPIs for patients with the least need to prevent bleeding while stopping treatment in those most likely to have fatal upper gastrointestinal (GI) bleeds.
Asked for his perspective, Jacob E. Kurlander, MD, MS, of Michigan Medicine in Ann Arbor, who was not involved in the research, called the study important, and said it does seem that clinicians are using PPIs more cautiously, although underuse for conditions other than acid reflux has been a longstanding problem.
"While PPI for acid reflux can be considered low-value treatment with little benefit for some patients, our research has shown that only a minority of high-risk patients who really need these agents to prevent upper GI bleeding are prescribed them," Kurlander said.
He added that PPI cessation should always be considered in the context of the possible unintended consequences of inappropriate withdrawal, such as increased medical visits and gastroenterologist referrals for upper GI symptoms and more endoscopies.
Study Details
For the current study, clinicians in the Harris Health System, which had 1.9 million outpatient visits in 2017, received instruction on the appropriate use of PPIs. This included information on appropriate indications, duration, and reported adverse effects outlined during primary-care grand rounds and through system-wide emails. Baylor internal and family medicine residents received additional small-group teaching at noontime conferences.
To reduce the risk of rebound acid hypersecretion and improve patient compliance with PPI cessation, a tapering algorithm was implemented as a global order in the electronic medical record system. This order prescribed a PPI every other day for 2 weeks followed by a PPI every 4 days for 2 additional weeks before discontinuation.
In their assessment, Lin and co-researchers reviewed all 80 patient charts from September to December 2017 showing a previous dispensed PPI. In 2018, after implementation, all 308 charts with a dispensed PPI were analyzed for the full calendar year. Pre-intervention, of the 80 prescriptions analyzed, 56 were categorized as inappropriately prescribed (70%) either by indication or duration. Post-intervention, 162 of 308 prescriptions were inappropriately prescribed (52%, P=0.005).
In other project findings, 66 anonymous surveys conducted in pharmacy staff indicated that 49% of the time staff members were counseling patients on the potential risks of PPIs, and 58% were providing instructional handouts for patients with each script. These included instructions on discussing PPI discontinuation with the providers, if desired.
To see whether patients or providers were initiating discussions on de-escalation, 17 attending physicians and 55 resident physicians were also surveyed. Almost two-thirds of providers (63%) said they believed that addressing inappropriate PPI use was of intermediate or high priority during office visits. The actual decision to discontinue PPI therapy was deemed to be provider-initiated most of the time (80%), jointly initiated sometimes (17%), and rarely initiated by patients (3%).
Such tapering initiatives have worked elsewhere, the team noted. For example, one quality-improvement projectat the Omaha Veterans Affairs resident continuity clinic successfully reduced inappropriate long-term PPI usage, defined as more than a year, by 17% within 2.5 months of the start of the intervention.
Once inappropriate PPI use has been identified, having a comprehensive discussion about de-escalation is critical, Lin and co-authors stressed. They noted that a reviewpublished in 2017 found that most patients (70%) were willing to discuss de-escalation and about 40% were willing to reduce or discontinue if so advised by their physicians.
Patient surveillance remains important, Lin and colleagues added. "We advise clinic follow-up within a month after beginning de-escalation to monitor the patient's symptoms and elicit general feedback."
They added that clinician education is also essential, and the prime movers of de-escalation, ambulatory primary-care givers, need to be especially well informed. "Having providers study the indications and durations for PPI use, as outlined by multiple gastroenterology organizations, would be useful to supplement baseline competency," and future efforts should focus on continued provider education and patient surveillance, the team concluded.
Lin and co-authors reported having no conflicts of interest.
Kurlander reported having no conflicts of interest.
Fewer infants colonized when parents underwent cleaning procedure.
This story was first published on Monday, December 30 in MedPage Today.
By Molly Walker, Associate Editor.
Half as many infants in the neonatal intensive care unit (NICU) became colonized with the same strain of Staphylococcus aureus as their parents when the latter underwent decolonization procedures in a randomized, placebo-controlled trial.
Rates of colonization with parents' S. aureus strain within 90 days of randomization were 14.6% in the intervention group versus 28.7% in the placebo group, reported Aaron Milstone, MD, of Johns Hopkins University in Baltimore, and colleagues.
That translated to a hazard ratio of 0.43 (95.2% CI 0.16-0.79, P=0.03), the authors wrote in a preliminary communication in JAMA.
Milstone and colleagues noted that while S. aureus is a leading cause of healthcare-associated infections among NICUs, many infection prevention strategies are generally focused on healthcare workers and the hospital environment, but that "postnatal transmission from mother to infant is common in the first few months of life."
Researchers hypothesized that if they treated S. aureus-colonized parents, with intranasal mupirocin, an antibiotic ointment designed to treat skin infections, and chlorhexidine gluconate antisepsis, a skin cleaner, it would ultimately reduce S. aureus in infants.
The Treating Parents to Reduce Neonatal Transmission of Staphylococcus aureus (TREAT PARENTS) trial enrolled eligible infants and their parents in two tertiary care NICUs from November 2014 to December 2018. Criteria for eligible infants included that they had cultured positive for S. aureus, had at least a 5-day stay, and had at least one parent who tested positive for S. aureus at screening.
Parents in the intervention group received antibiotic ointment and cloths with medicated skin cleaner, and parents in the control group received placebo ointment and cloths with non-medicated skin cleaner. They were instructed to apply the ointment twice daily in their nostrils and use the packaged cloths to clean their arms, legs, chest, neck, back, and perineum for 5 days.
The primary outcome was neonatal acquisition of an S. aureus strain concordant with the strain their parents were colonized with in baseline screening.
There were 208 infants in the analytic sample. A little over half were boys, three-quarters were singleton births, their mean birth weight was 1,985 g, and mean parent age was 31. With 18 infants lost to follow-up, 190 were included in the analysis, Milstone and colleagues said: 89 in the intervention group and 101 in the placebo group.
Fewer infants in the intervention group acquired any S. aureus colonization within 90 days of randomization versus the control group (33.7% vs 45.5%, respectively), similarly reflected when calculated as a hazard ratio (HR 0.57, 95% bias-corrected and accelerated CI 0.31-0.88). Infants in the intervention group were also linked with a lower risk of S. aureus colonization by NICU discharge and a lower risk of acquiring S. aureus colonization within 4 weeks, the authors said.
There were 26 adverse events reported by study parents, and nearly all were either mild skin irritation or nasal congestion.
Limitations to the data included that this trial enrolled in centers with "comprehensive S. aureus surveillance and decolonization programs," which could limit its generalizability, and that the definition of true adherence to the intervention may have been overestimated true adherence.
An accompanying editorial by Philip Zachariah, MD, of Columbia University Irving Medical Center, and Lisa Saiman, MD, of NewYork-Presbyterian Hospital, praised the study as "bold and innovative," and said that it "offers a novel and promising strategy to address a highly relevant, often intractable, clinical problem."
But they also listed some caveats, including that the study was not powered to detect differences in infections or mortality between groups. The editorialists noted potential issues with scalability of the results, given that the study not only took 4 years to complete, but that 93% of screened infants did not fulfill inclusion criteria.
"Cost-effectiveness will also need to be determined," Zachariah and Saiman wrote. "While the number needed to treat (NNT) to prevent S. aureus colonization may be acceptable, the much higher NNT to prevent S. aureus infection necessitates additional data derived from a much larger sample size before widespread adoption of parental decolonization could be considered."
But ultimately, the editorialists said that the future of parent screening programs such as this will be dependent "on multicenter studies that demonstrate reductions in invasive infections."
This study was supported by the Agency for Healthcare Research and Quality.
Milstone disclosed support from the CDC, the NIH, Sage Products Inc, and Becton Dickinson.
Other co-authors disclosed support from Novartis, Theravance, Basilea, the NIH, Singulex Inc, Curetis Inc, Accelerate Inc, GenMark, Pattern Diagnostics, and Becton Dickinson.
Plaintiffs in a federal lawsuit involving maintenance of certification (MOC) requirements officially filed a notice of appeal in Philadelphia Monday following a district judge's September decision to dismiss the suit.
Prompting the Kenney v. American Board of Internal Medicine (ABIM) lawsuit, lead plaintiff Gerard Kenney, MD, and Glen Dela Cruz Manalo, MD, declined to continue participating in the board's MOC program, a decision which affected their employment; Alexa Joshua, MD, did not pass the MOC examination, resulting in her being barred from providing inpatient care to her patients, according to the lawsuit; and Katherine Murray-Leisure, MD, failed one MOC examination and had some of her practice privileges revoked for a year, until she re-took the exam and passed it.
The physicians argued that ABIM violated antitrust laws by tying initial board certification to its MOC program; the Sherman Antitrust Act does not allow a business to tie the purchase of one product to the purchase of another as a way of maintaining monopoly power. But Judge Robert Kelly of the U.S. District Court for the Eastern District of Pennsylvania declined to go along and, on Sept. 26, granted ABIM's motion to dismiss the lawsuit.
"We disagree with Plaintiffs and find that ABIM's initial certification and MOC products are part of a single product and do not occupy distinct markets," Kelly wrote. "Not only are we unconvinced by Plaintiffs' arguments, we find that Plaintiffs' entire framing of the ABIM certification to be flawed. In essence, Plaintiffs are arguing that, in order to purchase ABIM's initial certification, internists are forced to purchase MOC products as well. However, this is not the case. As Plaintiffs state in their Amended Complaint, Kenney, Joshua, Manalo, and Murray were all able to purchase ABIM's initial certification without also buying MOC programs."
Kelly also dismissed another claim by the doctors. "Plaintiffs assert ABIM waged a 'successful campaign' to deceive the public that MOC 'benefits physicians, patients, and the public and constitutes self-regulation by internists,'" he noted. "In turn, this has allegedly led hospitals, insurance companies, and other such medical providers to more frequently require internists to purchase and maintain ABIM certification as a condition for employment or reduced medical malpractice insurance premiums."
"Plaintiffs believe this must be deceptive because there is 'no evidence of an actual causal relationship between MOC and any beneficial impact on physicians, patients, or the public.' However, in support, Plaintiffs merely put forth several public marketing materials from ABIM. There is no claim that ABIM actually deceived or coerced any hospital into requiring its internists to be ABIM-certified."
Similar Suit Against Radiology Board
Last month, a similar lawsuit against the American Board of Radiology also had an unfavorable outcome for the plaintiff. In that case, known as Siva v. American Board of Radiology (ABR), Sadhish Siva, MD, a radiologist in Murfreesboro, Tennessee, made the same claim as in the ABIM case, that the ABR had "tied" its initial certification and MOC products. (Like ABIM, the ABR started with lifetime initial certification, but added an MOC requirement in 2002.)
But again, the court was unconvinced. "Ultimately ABR sells only one product: certification of radiologists as having 'acquired the requisite standard of knowledge, skill, and understanding essential' to the practice of medicine in their particular specialty or subspecialty," wrote Judge Jorge Alonso of the U.S. District Court for the Northern District of Illinois on Nov. 19, in granting ABR's motion to dismiss. "This was once a one-stage process, and it is now a multi-stage process, but it does not follow that the certification process consists of separate products; now as ever, there is only one product."
Judge Alonso cited the Kenney v. ABIM ruling in his own decision. "This case is all but identical, and the Court agrees with the reasoning in Kenney," he wrote. "As in Kenney, the fact that the MOC component was only added relatively recently does not make it a separate product. Almost every product can be viewed as a package of component products: a pair of shoes, for example, as a package consisting of a left shoe and a right shoe; a man's three-piece suit as a package consisting of a jacket, vest, and pants; a belt as a package consisting of a buckle and a strap. As shown by the last of these examples, it is possible to describe a product as a package of components even if the components are physically integrated at the point of sale to the consumer."
Cases Are Not Over Yet
Westby Fisher, MD, a bitter opponent of MOC programs, expressed his feelings in a recent blog post about the Kenney case. "Initially, I must say I was surprised by Judge Kelly's ruling, but not shocked," Fisher wrote. "We have encountered significant naiveté with non-physician legislators when attempting to pass anti-MOC legislation at the state legislative level. Most non-physicians do not have a clue what ABIM Board Certification and MOC are, let alone their history and current relationship to obtaining and maintaining physician hospital credentials and insurance payments."
Fisher, whose anti-MOC organization Practicing Physicians of America is providing the plaintiffs with funds for their cases through a GoFundMe campaign, told MedPage Today that both judges offered plaintiffs an opportunity to amend their complaints, adding that court records indicate that Siva is planning to file an amended complaint by Jan. 10, 2020.
Because many hospitals and insurers require doctors to maintain board certification in order to be part of hospital staffs or insurance networks, "the Plaintiffs in this case were free to decide that they did not need to purchase MOC just as they are free to decide to stop breathing," Fisher wrote. "How long could the Plaintiff internists earn a living and work as internists if they cannot hold hospital privileges or receive insurance payments unless they purchase MOC? ... I look forward to seeing where the next chapter of this ongoing legal battle takes us in the weeks and months ahead."
Lots of analysis needed to figure out whether to sign up, they say.
This article was first published on Sunday, December 29, 2019 in MedPage Today.
By Joyce Frieden, News Editor.
Last April, MedPage Todaycovered the announcement of a new Medicare physician reimbursement program, Primary Care First, aimed at getting primary care doctors to change from fee-for-service billing to monthly payments based on their patient populations. In this follow-up feature, we look at what has happened since the program was first announced.
WASHINGTON -- With great fanfare, the Centers for Medicare & Medicaid Services (CMS) announced its new proposed Primary Care First (PCF) reimbursement models for Medicare on April 22, heralding them as good ways to help primary care providers get paid for all the work they do in addition to seeing patients. So what has happened since the initial rollout?
Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, in Pittsburgh, who in May laid out a list of changes that he thought would improve the models, is not impressed with what he has seen so far. "CMMI [Center for Medicare & Medicaid Innovation] made a couple of small changes to Primary Care First that were positive, but they didn't solve any of the problems that I described in the piece I wrote in the spring," Miller said in an email to MedPage Today earlier this month. "Moreover, it's not clear why it took 6 months to make those small changes, and that delay has ended up delaying the start of the entire program for a year."
For instance, he said, "I wasn't able to say very much about the 'Seriously Ill Population' (SIP) component of Primary Care First, because CMMI had provided very few details about that component. The RFA [Request For Applications to participate] has a lot of detail, and it is very troublesome." One issue is that the proposed payments under SIP, while much higher than what CMS would pay for other patients in PCF, "are far below what it costs to deliver palliative care to patients," Miller said. Although it costs an estimated $400 per month, on average, to cover the costs of palliative care, "CMMI is proposing to pay only $275 per month, i.e., only two-thirds of the cost."
Doc Groups Urge Caution
PCF, which will be tested in 26 regions through a demonstration project, has two models, both of which would let primary care clinicians move away from fee-for-service and allow them to stop worrying about up-and-down Medicare revenue, according to CMS. The agency will pay monthly population-based payments along with a simple flat fee for primary care visits. "Primary Care First will focus on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments," the agency explains on its website.
With a Jan. 22, 2020 deadline looming for physician practices to apply for the demonstration project, physician groups seem to be urging caution. The American Medical Association (AMA) acknowledged that some of the changes made since the initial rollout -- such as increasing the lowest monthly per-patient payment rate from $24 to $28 -- were "important improvements," but added that "each practice will have to determine whether the payment rates will be adequate to support the care delivery requirements of the model."
"That determination depends on what risk group the practice is in, what new investments they will need to make to be able to successfully participate, whether the PCF payments are sufficient to support the delivery of high-quality care for their patients, and the likelihood that the practice will be able to earn more within the PCF model than it would by staying in the fee-for-service system. The answer is not the same for everyone, so it would be helpful if CMS could provide revenue calculators and similar tools to help practices better evaluate the specific impact of PCF participation on their practice," the association said in a statement emailed to MedPage Today.
'Very, Very Complicated'
Gary LeRoy, MD, president of the American Academy of Family Physicians (AAFP), said in a phone interview that figuring out whether to apply for the PCF program "is really very, very complicated. That's what concerns many of our members, especially our solo and rural practitioners, to try to get their heads wrapped around all the nuances of the system."
The models "are attractive to our members in the fact they're acknowledging the value of primary care ... even though when we look at overall spending on primary care in our country, it's somewhere in the area of 6% of the total expenditures on healthcare," said LeRoy, a family physician in Dayton, Ohio. "It really needs to be 12% or more in order to improve healthcare outcomes ... There's obvious interest in it, but some elements of the model do not really increase spending much beyond the current fee-for-service model we have in place, so I think that's why they're proceeding with caution."
LeRoy added, "personally I don't know any practices that have expressed to me that they're going to meet the January deadline to sign up. AAFP is urging practices to evaluate their current practice delivery ... and how their payment structure is currently situated, to see if they can even risk any of the downside risk," which can be as high as 10% under the models. "If I have a practice really on the margin right now, I can't risk another 10%." The association offers a checklistto help practices figure out whether they should apply for the PCF program.
Outside Help Needed
The Medical Group Management Association (MGMA), which represents physician practices, said that some of its members have enlisted outside help to figure out whether or not to apply. "That leads to an overarching concern with CMS and implementation of these models -- there is not sufficient data or resources provided by the administration," said Mollie Gelburd, JD, the MGMA's associate director of government affairs, in a phone interview. "I've heard from MGMA members that they've turned to private entities or private companies providing resources to try to fill that gap. Doing that type of financial modeling and analytics necessary to evaluate whether participation is a good idea might be difficult for some groups."
As to the model itself, Gelburd mentioned one concerning issue for the association. "In the first year [of participation], the performance adjustment is based entirely on the acute hospitalization measure and doesn't include any quality or patient-centric measures." That could be a problem for a practice with a small patient population "if you have a patient that gets into a car accident, or a patient that has a severe disease that wasn't diagnosed before now, that could affect your performance adjustment."
Practices also need to make sure they have a big enough attributed population to be able to receive adequate income from the models' prospective monthly payments, she said. "You only collect a per-beneficiary-per-month payment for patients attributed to your practice based on past historical visits, or if the patient chooses to voluntarily align with the practice. To make the [required] clinical changes and operational changes worthwhile, the practice would want to have a robust attributed patient population."
CMS itself did not answer MedPage Today's question about whether the agency had received many applications for the demonstration program. "CMS is excited about implementing the Primary Care First Model Options that will transform primary care to deliver better value for patients throughout the healthcare system," a CMS spokesperson said in an email. "The agency continues to hold webinars and office hours with potential participants that address a variety of topics, including key model concepts -- such as program eligibility requirements, the payment methodology, model overlap, the SIP payment model option, and practice applications. CMS anticipates announcing practice and payer participants in Spring 2020."
Severe obesity also projected to be more common, affecting nearly 25% of the population in 25 states.
This article was first published on Wednesday, December 18, 2019 in MedPage Today.
By Jeff Minerd, Contributing Writer
Ten years from now, nearly half of U.S. adults will be obese if current trends continue, researchers predict, noting that almost one-quarter will be severely obese, and the epidemic will hit some states even harder.
By 2030, 48.9% of adults nationwide will be obese, defined as having a body mass index (BMI) of 30 to 35 (95% CI 47.7%-50.1%). The prevalence of obesity will be more than 50% in 29 states, and it will not be less than 35% in any state, noted Zachary Ward, MPH, of the Harvard T.H. Chan School of Public Health in Boston, and colleagues.
Also by 2030, 24.2% of adults will be severely obese, with a BMI of 35 or greater (95% CI 22.9%-25.5%). The prevalence of severe obesity will be higher than 25% in 25 states, Ward's group said in their study online in the New England Journal of Medicine.
The estimates, based on national survey data, corrected for self-reporting bias also indicated that severe obesity is likely to become the most common BMI category among women (27.6%), non-Hispanic blacks (31.7%), and low-income adults (31.7%) by 2030.
"The high projected prevalence of severe obesity among low-income adults and the high medical costs of severe obesity have substantial implications for future health care costs, especially as states expand access to obesity-related services for adult Medicaid beneficiaries," Ward and co-authors wrote.
"Although severe obesity was once a rare condition, our findings suggest that it will soon be the most common BMI category in the patient populations of many health care providers. Given that health professionals are often poorly prepared to treat obesity, this impending burden of severe obesity and associated medical complications has implications for medical practice and education," the researchers stated.
A state-by-state analysis found that obesity prevalence will reach 58% in Alabama, Arkansas, Mississippi, and Oklahoma. States projected to have the lowest prevalence of obesity by 2030 include California (41%), Colorado (38%), and Hawaii (41%). The District of Columbia was projected to have the lowest prevalence of all, at 35%.
The predictions are likely to be accurate because they are based on data from more than six million adults who participated in the Behavioral Risk Factor Surveillance System Survey in 1993-1994 and 1999-2016, the researchers said. Although survey participants self-reported their height and weight, the team corrected for potential self-reporting bias using data from more than 57,000 adults whose height and weight were actually measured in the National Health and Nutrition Examination Survey (NHANES).
"By adjusting the entire distribution of reported BMI to be consistent with measured BMI in NHANES, we adjusted for self-reporting bias while preserving the relative position of each person's BMI," the researchers explained. "Specifically, we estimated the difference between participant-reported BMI and measured BMI according to quantile and then fit cubic splines to smoothly estimate self-reporting bias across the entire BMI distribution. Each person's BMI was then adjusted for this bias given his or her BMI quantile."
June Stevens, PhD, of the University of North Carolina at Chapel Hill and a spokesperson for The Obesity Society, said the potential public health implications of the study "are, in a word, devastating. The projection that nearly one in four adults will have severe obesity in 2030 is particularly distressing," she wrote in an email to MedPage Today. "Severe obesity is associated with much more disability, disease, and death than moderate obesity. The high rates of severe obesity will impact our country's medical costs and productivity, and potentially our national defense."
Stevens, who was not involved in the study, said that while the projections are glum, they are based on the assumption that increases in obesity prevalence will continue at the same rates as they have in past years. That assumption need not hold, however, she said. With work, the trend can be changed.
"Obesity is a difficult disease to prevent and treat, and there is no magic bullet," she said. "It is understandable that some members of the public are frustrated with the current therapies, but they indeed do work if implemented. There is a lot we as a nation could do to better apply current approaches, and to discover new approaches. We need to do both. Prevention and treatment of obesity should be a national and personal priority."
Ward's group acknowledged that the assumption that current trends will continue is a chief limitation of the work. "Although our predictive validity checks from 2010 through 2016 help build confidence in our approach, projections through 2030 involve a much longer period, so the uncertainty around our projections may be larger than estimated," they said.
Experts at a House hearing take sides on a single-payer system.
This article was first published on Wednesday, December 11, 2019 in MedPage Today.
By Shannon Firth, Washington Correspondent.
WASHINGTON -- Expert witnesses at a House Energy & Commerce subcommittee hearing Tuesday offered the pros and cons of single-payer healthcare systems.
"Every day, nurses witness the failure of our current health system," said Jean Ross, RN, president of National Nurses United. She reported that one patient arrived in the emergency department (ED) in a "hypertensive crisis" at risk of an "imminent stroke." The patient reported that he took his blood pressure medication every other day, instead of daily, because of its cost.
She also shared that her grandson, Evan, had been sick as an infant. Her daughter was worried she would not be able to afford the co-pay, Ross said, so she covered the cost. If Ross had not done that, her grandson may have never received care, she added. In the ED, Evan was diagnosed with encephalitis, a condition that can cause permanent brain damage and even be fatal, she said.
Without care, Evan would have "been in severe trouble," Ross said. "Single-payer 'Medicare for All' is the only way we can guarantee healthcare, while also reducing the amount of money we spend on healthcare overall," she said.
But others disagreed, pointing out that a single-payer system would lead to "serious trade-offs," including the potential for rationed care.
Universal Coverage?
In the U.S. today, 30 million people are uninsured and 44 million others are considered under-insured. Despite paying more than other countries for healthcare, the U.S. ranks lower than many developed countries on health indicators including average life expectancy, maternal mortality, infant mortality, and death from preventable diseases, Ross said.
"Under 'Medicare for All,' we will transform our profit-driven ... insurance system into a healthcare system, one that prioritizes patient care," she said. Ross explained that because insurance carriers will no longer have a say in treatment options, doctors and nurses will provide care based on their professional judgment, and patient outcomes will improve.
She urged all members of Congress to support Rep. Pramila Jayapal's (D-Wash.) "Medicare for All Act of 2019." It is the only bill that would provide healthcare to everyone in the country "regardless of their ability to pay," Ross noted.
Jayapal's proposal was one of many bills designed to expand access to healthcare. Rep. Rosa DeLauro (D-Conn.), Rep. Antonio Delgado (D-N.Y.), Rep. Brian Higgins (D- N.Y.), and Rep. Tom Malinowski (D-N.J.) also put forth proposals at the hearing.
The "Medicare for All Act of 2019" would eliminate copays, deductibles, and out-of-pocket expenses, as well as employer-sponsored insurance. It would also offer additional benefits over current Medicare plans including dental, vision, and hearing (the bill was the subject of a separate House hearing in May).
DeLauro's bill would maintain access to "high quality" employer-sponsored health plans, if employers choose to offer them, and would automatically shift everyone enrolled in the Affordable Care Act (ACA) exchanges, Medicaid, or the Children's Health Insurance Program (CHIP) into the proposed "Medicare for America" program.
Higgins' bill would allow people, ages 50-64, to buy into the Medicare program. Malinowski's bill would allow first responders, including law enforcement officers, firefighters, and those providing emergency medical services (ages 50-64) who are "separated from service due to retirement or disability" to buy into the Medicare program. Delgado's bill would create a public option for anyone who is uninsured or "unhappy" with their current health plan.
'To What End?'
Doug Holtz-Eakin, PhD, president of the American Action Forum, a conservative think tank here, described universal coverage as "a very important goal" and Jayapal's bill as "a truly sweeping reform."
He differentiated it from other single-payer plans that don't ban private insurance, don't eliminate the role of the states or regents, nor do they eliminate co-pays or other incentives for encouraging efficient utilization of care.
"This is like nothing else that has ever been proposed," Holtz-Eakin said, but cautioned that it would have "serious trade-offs."
For instance, the lower rates of reimbursement that could be imposed under such a plan -- at or near Medicare rates -- would "inevitably deteriorate" the quality of hospital care. In extreme cases, some hospitals might close, which obviously undermines the goal of increasing access to care, he stated.
Holtz-Eakin estimated a "ballpark" $30 trillion price-tag over a decade for 'Medicare for All.' If financed in the usual manner for Medicare, it would require a 21 percentage point increase in the payroll tax, according to research from the Heritage Foundation, leaving two-thirds of American households "worse-off" financially.
"And to what end?" he said.
Half of the roughly 30 million people who are uninsured now are eligible for public programs such as plans on the ACA exchanges, Medicaid program, or CHIP, Holtz-Eakin said. Others have rejected the offer of employer-sponsored insurance, he claimed.
After the hearing, Holtz-Eakin told MedPage Today that 4.7 million people could enroll in a "zero-premium bronze plan" on the ACA exchanges and "simply don't do it," according to a study from the Kaiser Family Foundation.
The only people who would likely benefit from a single-payer plan would be the 2.5 million "relatively low-income" individuals living in states that didn't expand Medicaid. "Is it worth overturning the enormous heterogeneity and rich complexity of the U.S. healthcare system for 2.5 million individuals?" Holtz-Eakin said.
He also said he did not support more "targeted" approaches, such as Higgins' Medicare buy-in, saying it would only cover about 500,000 people even with $180 billion of additional money.
'Only the Poor...'
Another criticism of a single-payer system is that it would lead to restrictions in access to care.
Scott Atlas, MD, senior fellow at the Hoover Institution, another conservative think tank, said that cancer drugs are far less available in single payer countries like Canada and Britain. He also cited wait times of 8 months for brain surgery in Canada.
Half of all residents of England who earn more than 50,000 pounds buy private insurance, Atlas said.
He claimed that "only the poor and lower-middle class are stuck with nationalized, single payer healthcare, because only they ... cannot afford to circumvent the system."
But Ross rejected Atlas' comments about rationed care, saying that there's "self-rationing now." She told MedPage Today that those with high co-pays or high deductibles often don't seek care even when they need it.
As for the concern that 'Medicare for All' would lead to two tracks of care -- one for the wealthy and another for the poor -- Ross said that is already happening now under the current system.
The current healthcare system "is for the wealthy ... and statistics show that," she said. "The more money you make, the better access you have to healthcare, the better you do ... We want to fix that. Nurses want everyone to get the same quality care across the country."
She stressed that 'Medicare for All' "is not socialism ... [and] the delivery of care is just what you're used to. It would be private, but it would be publicly funded."
As for upending the healthcare system Ross argued that the government already funds at least two-thirds of the healthcare system; all that's needed is to redirect the remaining one-third back into the government.
"It's not taking apart the system. It's building on what we've already got," she said.
Regarding the cost of single payer plans, she said it was "disingenuous" for witnesses to underscore that point, without also noting the potential savings.
"We can't afford the system that we have now." Ross said.
This article was first published on Tuesday, November 26, 2019 inMedPage Today.
By Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today
At least 15 physicians have been fired from Edward-Elmhurst Health as the suburban Chicago-based health system moves to cut costs, sources told MedPage Today.
The doctors, who worked across its seven "Immediate Care" or urgent care sites, will be replaced by advanced practice nurses, according to an email sent by hospital leadership that was shared with MedPage Today. The physicians were informed late last week that they would be terminated as of April 1, 2020.
A physician who spoke on the condition of anonymity said the doctors were "broadsided" by the news. While they harbored some concerns that a few of the slower urgent care sites might be turned over to non-physician clinicians, they weren't expecting so many of the sites to be impacted and for such a large number of doctors to be let go.
In their email, hospital system CEO Mary Lou Mastro, MS, RN, and Chief Medical Officers Robert Payton, MD, and Daniel Sullivan, MD, pointed to patient cost concerns as the reason for eliminating the jobs: "Patients have made it very clear that they want less costly care and convenient access for lower-acuity issues (sore throats, rashes, earaches), which are the vast majority of cases we treat in our Immediate Cares."
"Beginning in the spring of 2020, we will move to a delivery model in which care is provided by Advanced Practice Nurses (APNs) at select Immediate Care locations," they wrote.
Leadership also stated in the email that they are "working closely with these physicians to assist them with finding alternative positions within Edward-Elmhurst Health or outside our system," but doctors noted that they face a saturated Chicago healthcare market and they're likely to have to relocate.
When asked to confirm the layoffs, Keith Hartenberger, a spokesperson for Edward-Elmhurst Health, said in a statement: "We continue to assess our care delivery models in the interest of providing cost-effective care to our patients. We shared with physicians that we have plans to change the model next year at some outpatient sites and are working with anyone affected to find alternative placement."
The move is becoming a more familiar one as some health systems try to save money by relying more heavily on non-physician clinicians.
Last year, 27 pediatricians at a chain of clinics in the Dallas area lost their jobs and were replaced by nurse practitioners -- even though the chain subsequently changed its name to MD Kids Pediatrics.
Rebekah Bernard, MD, wrote in Medical Economics that she spoke with three of the pediatricians who were fired: "They told me that they and their physician colleagues were completely shocked by the sudden firing. 'We thought we were going to retire from this place,' one told me."
Also in 2018, Charlotte, North Carolina-based Atrium Health ended a nearly 40-year contract with a 100-member physician group, signing up instead with Scope Anesthesia, which says it's dedicated to forming partnerships with certified registered nurse anesthetists. Atrium said it too was looking to reduce patient costs.
"This trend of shuttering hospital departments and firing physicians to save money is dangerous and short-sighted," Bernard wrote.
Purvi Parikh, MD, of NYU Langone Health in New York City, and a board member of Physicians for Patient Protection, which advocates against other healthcare providers replacing doctors, said that although non-physician clinicians "are vital members of the healthcare team, they are not trained to be substitutes of physicians and as a result diagnoses are missed and improper treatments and tests [are] prescribed."
Parikh said patients "have the right to choose a facility that is physician-only or one with physician-led care. In Chicago, luckily there are other options among competitors."
