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Friday, August 27, 2010

Effects of health care reform on small medical practices

It is clear from the content of the healthcare reform that the Obama administration wishes doctors to join large organizations which they believe can deliver more efficient care and which will be better able to translate the financial incentives and payment strategies envisioned by the legislation into actual delivery strategies to make things more efficient. Unfortunately such "efficiency" does not necessarily translate into better care. What you can expect to disappear as medical care transitions into large organizations: 1) small intimate practices 2) continuity with one doctor, 3) involvement of the doctor in routine care, 4) your ability to pick the best person to do each part of an episode of care, even if the doctors belong to different organizations. This has to do with the payment mechanism which will be adopted of bundling payments for an episode of care. This means only one organization will be able to deliver the care for the entire episode. For example, if you have a heart attack and require bypass surgery, the organization which admits you for the heart attack will be paid a lump sum for the entire episode of care, and you will not be able to choose a better surgeon in a different center.

While am in favor of health care reform including increasing coverage and preventing insurance companies from cherry-picking the lowest risk patients, I am very much against the type of payment bundling that is being promoted by the Center for Medicare and Medicaid Services and the health care reform legislation. Nothing in this type of bundling promotes high quality care. Just like the prospective payment system for hospital care, this type of payment promotes efficiency and reduced service during an episode of care. Quality measures are imperfect and tend to be very slow to incorporate and reflect new innovations and technology.

Pharmaceutical company and medical device company interests will continue to promote the use of unnecessary expensive technology. On the other hand, we are now likely to see powerful healthcare industry interests promote the underuse of needed care across the spectrum of medical care for each episode of care just as they have promoted decreased use of services during a hospitalization. But now there will be nowhere for the patient/consumer to go and no time or place at which the person CAN obtain the needed service. As with the passage of prospective payment for hospital care in the 1980s, there will be little or no incentive to provide high quality of care. The quality indicators used to date for performance bonuses for physicians (which in the future will go to the large organizations which employ these physicians) are generally inadequate and and reflect little of what makes care truly high quality.

We are now down to 25% of doctors in small practices. Healthcare reform as it is currently constituted will reduce that even further. I find this very sad. As someone who has devoted my entire career to improving medical care, often working in hospitals against the perverse financial incentives of the prospective payment system, and as someone who now works as a consultant helping people find good medical care, I am keenly aware of how these new payment strategies of bundling for episodes of care will reduce consumers' ability to choose good doctors.

Thursday, August 19, 2010

new ovarian cancer screening test being studied

There's a new screening blood test for ovarian cancer whose results have been reported in an early small study to be unbelievably accurate. I'll be watching with interest to see how the larger ongoing study in 500 women pans out. But 100% accuracy even in a small number (under 100) women is an unbelievably good result and has piqued my interest.

Wednesday, August 18, 2010

Contact sports

For years, the AMA has been against boxing because of the brain injury known as "boxer's encephalopathy" (popularly known as being "punch drunk") which so often results from it. Football is also known to cause a lot of head injury and encephalopathy. A recent study by Boston University researchers dissecting the brains of 12 athletes again notes the frequency of degeneration in the brain in areas characteristic of ALS or Lou Gehrig's disease as a result of sports-related and combat-related head injury.

This prompted the New York Times to say that "maybe Lou Gehrig didn't have Lou Gehrig's disease", prompting others in the blogosphere to say "huh?" But the point the Times was making was that since Lou Gehrig had a lot of sports-related head injury, perhaps this was the cause, whereas by definition for ALS, the cause has been unknown.

Bottom line: Boxing, football, and military combat are dangerous. While the latter may be unavoidable, the first two are not, so avoid them and help your children avoid them. Our entertainment is not a good reason to sacrifice their future health.

Risks of Antacid Drugs such as Zantac and Prilosec

Some of you have asked about The New York Times article today highlighting that today many elderly people continue to take drugs that reduce stomach acid, like Zantac (an antihistamine) and Prilosec (a proton pump inhibitor), for years and years and that this may not be a good idea. Often people are first prescribed these drugs for questionable or no specific reasons (for example, see study here this study. These drugs have side effects including increased infections (both pneumonia and gastrointestinal infections) and osteoporosis (because of reduced calcium absorption).

Bottom line: If you are not taking antacid drugs for known ulcers or bad symptoms of acid reflux (which can cause pneumonia as well if really bad!), then stop them. If you are taking them for a real indication such as ulcer disease or bad acid reflux disease, then work with your doctor to see if you still need them.
These drugs have risks and the risks must be weighed against the benefits for you.

Tuesday, August 17, 2010

Emergency contraception

Emergency contraception - Make sure the late teenagers and college students in your family know about ulipristal, marketed under the trade name of Ella, an emergency contraceptive recently approved by the FDA, which will be available by prescription and protects against pregnancy for 5 days after intercourse. Also make sure they know about Plan B One Step and Next Choice, (see Mayo Clinic discussion here) which are already available over the counter and protect against pregnancy if taken within 3 days of intercourse. While I agree that abstaining from unprotected intercourse outside of a committed relationship in which the desire and intent to have a child has been articulated by both parties, the reality is that such unprotected intercourse occurs frequently despite the stated intent of young women not to accede to such requests.

Given these hormonal realities in which young men and women ignore the reproductive consequences of their actions, please educate your children about these available ways of preventing an unwanted pregnancy. While there are side effects, on average the benefit of averting an unwanted pregnancy exceeds the harm of nausea, vomiting, or some abdominal cramping or discomfort in some individuals.

Monday, August 16, 2010

Statins - Do they Work to Prevent Heart Attacks in Healthy People?

Drug manufacturers have convinced the American public that everyone with high cholesterol or diabetes should take statins to lower it and prevent heart attacks and strokes. This week a lot of publicity has emphasized how little we actually know about the effectiveness of doing so. More at this link