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February 15,
2010 |
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IN THIS ISSUE
Editor's Column: Physicians And The Law Of
Intended Consequences
Sen. George Examines Key Issues With WCMSSM
Delegate Body
WSU, DMC Agree On Long-term Deal
Henry Ford Study Tests Using Progesterone To Treat
Brain Injuries
Oakwood Patients Can Use Computers In Waiting
Rooms
WSU People In The News
Feds Pledge Almost $1 Billion For Health Care IT,
Michigan To Benefit
Social Security Awards Nearly $20 Million In
Contracts For EMR
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Editor's Column: Physicians And The
Law Of Intended Consequences
By JOSEPH WEISS, MD
The New Year brings patients with new health care plans. In my
practice and likely in others as well, the most marked difference
between past health care insurance and 2010 plans is the huge
deductible in the new plans. I see a number of patients with
deductible amounts as high as $5,000 with a 10 percent co-pay on all
prescriptions when the deductible is met, and no payment for office
visits.
This increase in deductibles and the concomitant loss of
office coverage is creating a change in my physician-patient
relationship. With some patients I spend more time at the bargaining
table than in the examining room. Patients with high deductibles
want to negotiate visits, laboratory work and medication in the same
manner as buying a rug from a vender at an open-air bazaar.
The patient with the high deductible wants to spend as
little as possible on care and views me, the physician, as trying to
extract as much profit as possible from the scheduled appointment.
This change in relationship brings the following
consequences.
First, I find myself bargaining for care rather than
prescribing it. Second, because I must accommodate the patient if I
want to continue a connection with that patient, I must respond to
his view. And third, I must accommodate because the patient makes
the good point that less cost doesn’t necessarily mean less care.
Let me illustrate: I treated a patient, M.M., who had
rheumatoid arthritis, with a combination of methyltrexate and Enbrel;
I obtained laboratory tests monthly. With his $5,000 deductible he
had to pay out of pocket both the medication, ($1300/month), the
office visit and the laboratory tests. Initially, he argued over the
laboratory testing pointing out that his results had remained stable
over the last six months. We worked out an arrangement that I would
rotate what tests I ordered each month. Instead of 6 tests he could
have two. Then he bargained for office visits: he would come
in-person every 3 months so I could see for myself if his joints
remained free of swelling, but the other months he would go to a
draw station for the laboratory work and save the expense of an
office visit.
I have lengthened intervals between office visits, modified
laboratory testing orders and re-arranged medical regimens with a
number of patients because their increased out-of-pocket expenses
caused them to challenge my approach to their care.
These experiences taught me that at times, I had developed a
pattern of care, that when scrutinized could be criticized as not
necessary for that patient. Also, if I wanted a patient to listen to
me, I better be prepared to listen to him. Compromising and
negotiating is not only for politicians. A patient’s compliance
depends on both his respect for your orders, and in his belief that
you are working with his needs. I had to accept that using the large
deductible to control the cost of care is a successful way to bring
physicians into the strategy. And finally, I had to know when and
how to tell the patient that cutting his cost of care was not in his
best interest.
Each physician will need to work out an approach of when to
accommodate and when to resist a change in his role. For guidance,
do not look to the Ethics of the Fathers, your malpractice carrier,
or management consultant. The decisions of how to cut cost and not
compromise care will be yours alone.
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Sen. George Examines
Key Issues With WCMSSM Delegate Body
By PAUL NATINSKY
Sen. Tom George, MD, spent some time at the Feb. 10 WCMSSM Delegate
Body Meeting sharing his views on health care. George, an
anesthesiologist from West Michigan, did not put the audience to
sleep. Rather, he gave members a preview of what he would do if he
is elected governor in November.
“We must change
the behavior of our patients,” he said in outlining his approach
making health care more efficient and less costly. “This is one of
the keys to turning Michigan around, getting a better return on our
investment (in health care dollars).
His second
priority is streamlining government at all levels. George bemoaned
the multi-layered and expensive structure of government that he said
includes dated concepts like townships (parceled areas of land that
overlay the state like a grid and exist, archaically as precursors
to modern cities and villages). He said many costly government
features were incorporated in the most recent revision of the state
constitution, almost 50 years ago when Michigan was a “rich state.”
On more specific,
and health-care-focused levels, George, an ally of physicians
against last year’s physician tax proposal, said that spending more
state money on health care to draw down more federal dollars is not
the answer to that part of our state’s budget problems. He said we
have to learn to be more efficient and change behaviors to get
better results. More money is not the answer.
“The premise is
that if we put more money in, the feds will match it. That’s a
failed system for a poor state. It’s a death spiral. We need to
negotiate those social programs that are open-ended,” he said.
Philosophically,
George doesn’t like ratcheting up spending without seeing results.
He favors a “block-grant” approach, in which innovative programs
that produce positive health outcomes get money directly from the
federal government.
The physician tax
would have added a 3 percent surcharge to physician services. The
surcharge would have been used to obtain federal matching funds and
physicians would be granted a higher reimbursement rate from
Medicaid.
The state Senate
shot down the proposal last year, but Gov. Granholm reincarnated it
in her State Of The State speech last month. Rumor has it several
major health systems are now on board with the plan, which might
sway the Senate this time.
George also
addressed his ongoing efforts regarding individual market insurance
reform, the so-called “IMR Bills.” The issue began last year, when
Blue Cross and Blue Shield of Michigan and friendly legislators in
the Michigan House pushed through a series of bills. The legislation
would have ended the Blues’ responsibility as an “insurer of last
resort”—which forces the company to write policies for all
comers—but retained the Blues’ favorable tax treatment. The
legislation also would have allowed BCBSM to do business more like
commercial insurers, scrapping its obligation to ignore age and
other factors when establishing premiums. BCBSM’s rationale for the
legislation was that it was losing a dangerous amount of money in
the individual market, where people who don’t have policies through
their employers buy insurance. As the economy continues to skid and
leaves an increasing number of people without insurance and/or work,
the Blues assert that the problem is worsening.
The bills went
through the House very quickly with substantial debate beginning in
Sen. George’s Health Policy Committee.
The legislation
died last session, but the issue continues to march forward. George
and House Health Policy Chair, Rep. Marc Corriveau, are working
toward a solution that George said likely would be unveiled toward
the end of February. Details are not yet clear, but a scheme that
would relieve the Blues of their part of their tax burden in favor
of a proportional plan tabbing all state insurers to take a share of
high-risk patients is in the mix. In the trade-off, BCBSM would be
assessed for a the portion of the high-risk market they no longer
insure, with the money going toward a federal matching fund to bring
in more Medicaid dollars; a move George said would obviate the need
for a physician tax. The Blues might also get some relief on the
rate setting end, allowing them greater flexibility, and other
concessions, said George.
The Delegate Body
Meeting stop was another on the long chain of statewide stops Sen.
George is making in his quest for the governor’s office. It’s a long
road for a wide-open field of candidates with no clear favorite from
either party.
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WSU, DMC Agree On
Long-term Deal
The Wayne State
University School of Medicine and the Detroit Medical Center Feb. 10
signed new contracts that provide stability to clinical and
educational programs, according to a statement appearing on the WSU
and DMC websites. The contracts replace an agreement signed in
November 2006 that was scheduled to expire in June.
The deal includes
a long-term teaching agreement between the two organizations for the
education of medical students. The five-year contract is
automatically renewable.
An agreement
transfers sole sponsorship of 50 residency training programs to the
DMC, as opposed to the previous co-sponsorship by Wayne State and
the DMC. Sole sponsorship is the current national model and is
expected to create several educational and administrative
efficiencies. Wayne State School of Medicine faculty members will
have a teaching contract for the residency programs.
The DMC and Wayne
State also signed a three-year clinical services contract for the
ten Wayne State University Physician Group practices that provide
patient care and administrative services in the DMC’s eight
hospitals. Those practices include internal medicine, neurology,
neurosurgery, obstetrics and gynecology, ophthalmology, pathology,
psychiatry, physical medicine and rehabilitation, radiation/oncology
and surgery.
The contracts are
the culmination of months of negotiations.
“I’m proud of the
commitment that the DMC and Wayne State are making together,” said
Valerie Parisi, MD, MPH, MBA, interim dean of the WSU School of
Medicine. “These agreements provide great stability for Wayne State
students, residents and faculty, as well as patients of the DMC.”
“This contract
not only cements the future of what has been a more than 100-year
partnership between the DMC and Wayne State,” said Mike Duggan, CEO
and president of the DMC, “it is a testament to the unwavering
commitment of both of our organizations to the city of Detroit,
training our nation’s future physicians and caring for people most
in need.”
“To the
residents, this agreement represents a renewal and stabilization of
a great partnership. This partnership has served well both the
training of resident physicians and its community at large. Those of
us who have personally benefited are excited to see that future
residents will continue to have this terrific training opportunity,”
said Resident Council President Mark Hoeprich, MD, a current
fifth-year neurosurgery resident.
As part of the
agreement, Wayne State will receive a reduction in its compensation
from the DMC over the next three years. This is due in part to the
evolving DMC-Wayne State relationship in which both entities have
forged additional relationships with other clinical and academic
institutions.
“This evolution
of our partnership allows us to continue providing educational
opportunities and clinical services that are critical to Detroit,”
said WSU President Jay Noren, MD. “While it is reduced from where it
once was, it is still a very important and constructive
relationship. It is also consistent with the strategic direction of
both DMC and Wayne State to expand their respective networks of
clinical partnerships with other institutions to ensure stability in
all aspects of medical education, research and patient care. ”
“These are very
difficult economic times, so in negotiations we tried to put
ourselves in the other organization’s shoes,” Dean Parisi said. “In
the end, the compromises we made allow both entities to focus on our
shared mission of serving vulnerable populations and preparing the
next generation of physicians.”
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Henry Ford Tests
Using Progesterone To Treat Brain Injuries
Henry Ford
Hospital will evaluate the effectiveness of using the hormone
progesterone to treat traumatic brain injuries without first
obtaining patients' informed consent as part of a national research
study.
During emergency
conditions federal regulations allow research to be performed
without the informed consent of patients who are unconscious at the
time. As soon as family members are available or the patients awaken
their consent is sought to continue their participation in the
study.
Called ProTECT,
the study aims to determine if progesterone can decrease the
disability and death associated with TBI, the leading cause of death
and disability in children and adults under age 44, according to the
Brain Trauma Foundation. Multiple animal studies have demonstrated
that progesterone may decrease brain damage caused by a traumatic
brain injury.
Progesterone is a
naturally occurring hormone that regulates ovulation and
menstruation in females. It is also present in small amounts in the
brain and helps regulate normal brain function in men and women.
A traumatic brain
injury, or TBI, is a blow or jolt to the head that disrupts brain
function. An estimated 1.4 million people suffer a traumatic brain
injury every year, and 50,000 die from it. Most of these injuries
are caused by motor vehicle accidents, physical assaults and falls.
TBI is also considered the signature wound of soldiers injured
during the Iraq war.
The double-blind
study will evaluate patients who suffer moderate to severe traumatic
brain injuries and are taken to Henry Ford, DMC Detroit Receiving,
DMC Sinai Grace and Beaumont, Royal Oak hospitals within four hours
of the injury to be considered for the study. Enrolled patients will
be randomly given either progesterone intravenously or a placebo, a
fake version of the study drug.
The study is
funded by the National Institute of Neurological Diseases and Stroke
and involves 17 hospitals across the country.
Henry Ford's
Institutional Review Board, Wayne State University's Human
Investigation Committee and Beaumont's Human Investigation Committee
will review and monitor the study.
For more
information, visit
www.detroitprotect.org
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Oakwood Patients Can Use Computers In
Waiting Rooms
Oakwood Hospital
& Medical Center (OHMC) has launched a program designed to help
visitors stay connected to their lives outside of the hospital. The
“In-Touch” program allows visitors in the public waiting rooms the
ability to use loaner laptops provided by the hospital. OHMC is the
only hospital in Michigan to institute the “In-Touch” program.
“As loved ones
undergo surgery, visitors’ lives continue,” said Ioan Duca,
Director, Service Excellence & Volunteer Services, OHMC. “It became
apparent that busy lifestyles and demanding schedules make it
necessary for our visitors to stay connected at a moment’s notice.
That is why Oakwood, the first to offer a program such as this, is
very pleased to offer wireless internet service along with laptops
to anyone while they are waiting.”
The “In-Touch”
project originated with the Guest Relations and Employee Relations
divisions of OHMC, who then partnered with Nancy Gorski, Community
Health Volunteer Services Representative, and her team to
successfully execute the program.
The loaner
laptops, lent out for an hour at a time, enable visitors who are
waiting long hours to connect family and friends via a built in web
camera. Visitors are also able to check email, surf the web and read
the news. The laptops also allow visitors to plug in their flash
drives enabling them to work on any projects they have set aside
while at the hospital.
“I think this a
great idea,” said visitor Cynthia Raymond. “It helps pass the time
and you can finish up any work that you may be worried about falling
behind in.”
The program
currently includes six laptops with hopes to acquire four more. By
the end of the year, the “In-Touch” program is hoped to be included
in the remaining Oakwood hospitals: Oakwood Annapolis Hospital in
Wayne, Oakwood Southshore Medical Center in Trenton and Oakwood
Heritage Hospital in Taylor.
“These laptops
are definitely an advantage for visitors and family,” said visitor
Mark Pogorzelski. “People can connect to family and friends that are
not in the hospital and keep them updated. It allows visitors to
feel more comfortable and waiting becomes less stressful especially
since they have so many other things on their minds.”
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WSU People In The
News
McCarty Cancer
Foundation Awards Grant To Dr. Zonder
The McCarty Cancer Foundation has presented a $25,000 grant to
Jeffrey Zonder, MD, of the Wayne State University Physician Group.
The award
supports Dr. Zonder’s multi-center clinical research projects,
coordinated by the Multiple Myeloma Research Program at Karmanos
Cancer Center. Since 2005, the program has received approximately
$232,000 from the McCarty Cancer Foundation. McCarty Cancer
Foundation funds were instrumental in providing seed money for the
program, which has become one of the most active clinical programs
of its kind in the Midwest. That funding also has allowed the
program to secure federal grant monies and pharmaceutical contracts.
Student Groups
Bring Emmy-Nominated Native American Doc To SOM
Three student organizations have combined efforts to bring a Native
American physician to the Wayne State University School of Medicine
to present his Emmy-nominated documentary focusing on the health
problems affecting the nation’s native peoples.
Arne Vainio, MD,
will speak and present his film, “Walking Into the Unknown,” at 6
p.m. March 15, in the Margherio Family Conference Center. His
appearance was funded and organized by the Wayne State University
School of Medicine’s chapters of the American Medical Student
Association, the Rural Medicine Interest Group and the Family
Medicine Interest Group.
Dr. Vainio is a
Family Medicine physician who practices on the Fond du Lac
Reservation in northern Minnesota. His film traces the personal
journey of a middle-aged American Indian physician – himself -- as
he becomes a patient. Frustrated by his patients who avoided health
screenings, Dr. Vainio filmed his own journey through the health
care system as he experienced medical screenings and procedures,
from the routine drawing of a blood sample to a prostate exam and
colonoscopy. The film addresses the major health problems affecting
Native American people and aims to show men that they need not fear
preventive health screenings.
Dr. Vainio has
received the National Indian Health Service Director’s Award, the
National Diabetes Physicians Recognition Award and the Minnesota
Medical Foundation’s Early Distinguished Career Award. His film was
nominated for an Emmy in 2009.
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Feds Pledge Almost
$1 Billion For Health Care IT, Michigan To Benefit
Health and Human
Services Secretary Kathleen Sebelius and Labor Secretary Hilda Solis
Feb. 12 announced a total of nearly $1 billion in Recovery Act
awards to help health care providers advance the adoption and
meaningful use of health information technology (IT) and train
workers for the health care jobs of the future. The awards will help
make health IT available to over 100,000 hospitals and primary care
physicians by 2014 and train thousands of people for careers in
health care and information technology. This Recovery Act investment
will help grow the emerging health IT industry which is expected to
support tens of thousands of jobs ranging from nurses and pharmacy
techs to IT technicians and trainers.
In Michigan, two
groups will receive grants: State Designated entity-Michigan
Department of Health,$14,993,085 and Regional Extension
Center-Altarum Institute, Michigan $19,619,990.
The over $750
million in HHS grant awards Secretary Sebelius announced today are
part of a federal initiative to build capacity to enable widespread
meaningful use of health IT. This assistance at the state and
regional level will facilitate health care providers' efforts to
adopt and use electronic health records (EHRs) in a meaningful
manner that has the potential to improve the quality and efficiency
of health care for all Americans. Of the over $750 million
investment, $386 million will go to 40 states and qualified State
Designated Entities (SDEs) to facilitate health information exchange
(HIE) at the state level, while $375 million will go to an initial
32 non-profit organizations to support the development of regional
extension centers (RECs) that will aid health professionals as they
work to implement and use health information technology - with
additional HIE and REC awards to be announced in the near future.
RECs are expected to provide outreach and support services to at
least 100,000 primary care providers and hospitals within two years.
The more than
$225 million in DOL grant awards Secretary Solis announced will be
used to train 15,000 people in job skills needed to access careers
in health care, IT and other high growth fields. Through existing
partnerships with local employers, the recipients of these grants
have already identified roughly 10,000 job openings for skilled
workers that likely will become available in the next two years in
areas like nursing, pharmacy technology and information technology.
The grants will fund 55 separate training programs in 30 states to
help train people for secure, well-paid health jobs and meet the
growing employment demand for health workers. Employment services
will be available via the Department of Labor's local One Stop
Career Centers, and training will be offered at community colleges
and other local education providers.
The HHS and DOL
awards are part of an overall $100 billion investment in science,
innovation and technology the Administration is making through the
Recovery Act to spur domestic job creation in growing industries and
lay a long-term foundation for economic growth. In addition to the
10,000 jobs the DOL grantees expect to fill with freshly trained
workers, the health IT extension centers are expected to hire over
3,000 technology workers nationwide in the months ahead. Overall,
the Administration investments in health IT and training will help
significantly expand an emerging industry expected to support tens
of thousands of secure, well-paid jobs nationwide.
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Social Security
Awards Nearly $20 Million In Contracts For EMR
Michael J. Astrue,
Commissioner of Social Security, today announced that 15 healthcare
providers and networks have received $17.4 million in contract
awards to provide electronic medical records to the agency. These
electronic medical records, which will be sent through the
Nationwide Health Information Network (NHIN), will significantly
shorten the time it takes to make a disability decision and will
improve the speed, accuracy, and efficiency of the disability
program.
“Using health
information technology will improve our disability programs and
provide better service to the public,” Commissioner Astrue said.
“We’ve seen a significant increase in disability applications. To
process them, the agency sends more than 15 million requests
annually for medical records to healthcare providers. This largely
paper-bound workload is generally the most time-consuming part of
the disability decision process. The use of health IT will
dramatically improve the speed, accuracy, and efficiency of this
process, reducing the cost of making a disability decision for both
the medical community and the American taxpayer.”
The contract
awards are funded through the American Recovery and Reinvestment
Act. They will require awardees, with a patient’s authorization, to
send Social Security electronic medical records through the NHIN.
The NHIN, a safe and secure method for receiving access to
electronic medical records over the Internet, is an initiative of
the Department of Health and Human Services supported by multiple
government agencies and private sector entities.
For the last
year, Social Security has been successfully testing health IT to
obtain electronic medical records. Disability applications processed
with electronic medical records from the test sites in Massachusetts
and Virginia have significantly reduced processing times. Some
decisions are now made in days, instead of weeks or months. Social
Security expects to receive more than 3.3 million applications in
fiscal year (FY) 2010, a 27 percent increase over FY 2008.
Contracts were
awarded to the following organizations:
1. Cal RHIO, San
Francisco, CA - $1,625,000
2. CareSpark,
Kingsport, TN - $1,363,000
3. Center for
Healthy Communities, Wright State University, Healthlink,
Dayton, OH -
$999,000
4. Central
Virginia Health Network/MedVirginia, Richmond, VA - $1,139,000
5. Community
Health Information Collaborative (CHIC), Duluth, MN - $977,000
6. Douglas County
Individual Practice Association, Roseburg, OR - $502,000
7. EHR Doctors
Inc., Pompano Beach, FL - $1,000,000
8. HealthBridge,
Cincinnati, OH - $1,400,000
9. Lovelace
Clinic Foundation (LCF), Albuquerque, NM - $1,083,000
10. Marshfield
Clinic Research Foundation, Marshfield, WI - $998,000
11. Memorial
Hospital Foundation & Memorial Hospital of Gulfport Foundation,
Inc.,
Gulfport, MS -
$1,100,000
12. Oregon
Community Health Information Network (OCHIN), Portland, OR -
$284,000
13. Regenstrief
Institute, Inc, Indianapolis, IN - $350,000
14. Science
Applications International Corporation (SAIC), Reston, VA -
$1,587,000
15.
Southeastern Michigan Health Association, Detroit, MI - $2,988,000
More information
on Social Security’s use of health IT is available at
www.socialsecurity.gov/hit.
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