Monday, June 27, 2011

Physician Briefing Paper Number 1

We have published our first Physician Briefing Paper. Click the title line to link to our library.

Obama Administration Mystery Shoppers

If there is anything most health policy wonks and politicians agree on, it is the shortage of primary care physicians, a shortage that may get worse.

So now the Obama administration is setting out to prove what we already know, and likely to create a public relations attack on primary care physicians.

The administration has hired a research firm to employ mystery phone shoppers to call primary care offices with two versions of a script, one a insured patient script and the other a government funded patient script.

The purpose is to measure wait times for new appointments, and to look for discrimination against government-funded patients, particularly Medicaid patients.

The biggest burden will fall on front desk personnel, who are always too busy (I never asked an employee to do what I wouldn't, so I have worked the receptionist chair - gasp).

All this to prove what we already know. ????

Tuesday, June 21, 2011

ACO Update

Accountable Care Organizations are the heart-and-soul of Obamacare quality and cost control initiatives. All is not healthy.

Ready – Fire – Aim

When the Center for Medicare and Medicare Innovation (CMMI) released the draft regulations for Medicare ACOs on March 31, 2011 the reaction was brutal. CMMI was publicly beaten like a rented mule, even by enthusiastic supporters of the ACO concept.

Criticisms included: 1) the rules are too complex 2) start-up costs will be much higher than CMMI estimates 3) the probably of achieving savings to share is small and 4) the time lines are too short.

The Empire Strikes Back

In May CMMI burst forth with two new models in an attempt to quiet critics (unlikely) and to improve participation.

Advanced Payment ACO

AP-ACOs are designed to share ACO shavings before the savings are created, in effect, an advance for start-up capital. No one has told us yet what happens if the AP-ACO never generates any savings.

Pioneer Model ACOs

CMMI is hoping large physician groups already involved in the Medicare physician group practice demonstration program will start ACOs before the 1/1/2012 start-up date.

CMMI jeopardizes this initiative out of the gate by setting a ridiculous deadline. The deadline has now been extended a slightly less ridiculous deadline of August 19th.

The Pioneer Model is more flexible than the original Medicare SSP-ACO model, and has rules for both regular and “rural” ACOs, but is practically restricted to existing integrated delivery systems capable of moving very, very quickly.

Physicians Move to Integrate

Story in the Washington Post.. (c) Washington Post Co., 2011

Wednesday, June 15, 2011

Pharm Supply Chain Meltdown

The pharmacy supply chain for many critical medications is melting down, with resulting shortages.

Why? The potential list so far:

1) ultra-cheap generics are no longer profitable to produce
2) an international supply chain does not work smoothly all the time
3) consolidation in the pharmaceuticals industry
4) hyper-regulation from the FDA since 2006 has disrupted the chain with little gain in safety

The hyper-regulation problem, involving both real safety issues and of course increases in paperwork is likely the biggest problem. The biggest problems seem to be in injectibles, including certain cancer and anesthesia drugs, which are being rationed if they can be found at all. Rationing and substitution seem to be the only short term solutions.

Sunday, June 5, 2011

Non-compliant patients - what to do?

Ask physicians and nurses about their biggest clinical problems and non-compliant patients will likely be near the top of the list.

And why should we care? Because non-compliant patients are huge cost drivers.

Ezekiel Emanuel (MD, PhD, NIH) estimates that one-third of U.S. health care costs are driven by diabetes, and we know a lot about controlling diabetes, but it is very dependent on the patient being compliant with diet and medications. We don't do so well on this. Ask a nurse.

Is there something about Americans that make us less compliant than we should be? Is our consumer culture a bad place to promote health? Is there not enough information? Are we stressed into non-compliance?

Whatever the reason, it is very costly for all of us.