E-DMN - November 3, 2008

November 3, 2008

Editor's Column: Wall Street To Our Main Street
Response To: 'What Is The Real Patient Centered Medical Home'
Stem Cell Debate Proves Lively
AMA Urges Docs To Push Insurers For Accurate Claims
Rapid HIV Testing Boosts Diagnosis, Screening
WSUSOM Study Might Lead To Advanced Treatment For MS
DMC Neurologist Addresses Largest International Cardiology Meeting
Henry Ford Physician Honored

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Editor's Column: Wall Street To Our Main Street
What the Wall Street Crash Means to Us at 3031 West Grand Blvd

By JOSEPH WEISS, MD
No doubt, events on Wall Street since August have meant a loss for most of us of our personal wealth, but the impact on the medical community will be felt for years.

First is the effect on personal philanthropy. Medical research for innovative ideas depends on individuals donating personal funds. New approaches to disease and devices need to show proof of concept before obtaining National Institute of Medicine funds. Private funds allow a researcher to work on unproven or unorthodox concepts, but the uncertainty now is more with obtaining the money than with proving the concept. Like bank credit, the private donor’s will to give and funds to offer have dried up. The loss in original ideas, research talent and new drugs will add up to an enormous amount.

Second is the decrease we can expect in government programs to further health care. The great debt that government is accruing because of the bailout will necessitate cutbacks in state and federal health services. The National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) will be fortunate if funding is kept at a level comparable to prior years; new initiatives and smaller grants have little hope of receiving funds.

Third is the inflation to come when the enormous amount of dollars the U. S. Treasury is now pouring into circulation combines with the inevitable return of credit and lending. Prices will rise, increasing the cost of health care. In turn, the public will point at us as being wasteful and unscrupulous. The truth will be that a vastly increased amount of dollars will be bidding for a steady, or possibly decreasing, supply of medical services.

The Wall Street bail out will do more damage than raising the national debt. The cost of medical care and progress forgone will be beyond reckoning.

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Response To: 'What Is The Real Patient Centered Medical Home'

Editor’s Note: The following is a response to a column published Oct. 27 by DMN Editor Joseph Weiss, MD, that is critical of the patient centered medical home concept. It is authored by Angelo Patsalis, MD, President, Michigan Academy of Family Physicians.

By ANGELO PATSALIS, MD
Joseph J. Weiss, MD, recently wrote an article entitled, “What Is The Real Patient Centered Medical Home?” and while Dr. Weiss raises some legitimate questions, some clarifications need to be made.

In March 2007, all of the major national primary care organizations – the AAFP, the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) – agreed on joint principles for the PCMH detailed in a three-page document. The document outlines principles for patients to receive continuous, comprehensive and coordinated care from their own personal, physician-led health care team. The patient centered medical home is the vehicle to obtain this vision by facilitating the relationship between patients and their physicians. Patients will receive enhanced access through open scheduling, expanded hours and new options for communications, such as telephone consultation or e-mail correspondence. Physicians will be better equipped to care for their patients by adopting chronic disease registries and health information technology like electronic medical records and e-prescribing.

The cost of clinical systems redesign to achieve patient-centric care is a financial hurdle for many primary care physicians; but this is mainly due to the history of the undervalued and under-compensated role of primary care. Under the current transactional fee-for-service model, physicians must see a specific volume of patients in order to make enough simply to pay their office costs. As a result, time with patients is severely limited and physicians are forced to treat only the acute manifestations of illness while the underlying chronic conditions are ignored. The PCMH was designed to remove the time constraints between patients and their physician so that patient needs can be met.

As the PCMH pilot projects are implemented around the country, insurers and policy makers are slowly recognizing the benefits. The results have shown a per-member-per-month payment allows primary care physicians to spend more time with their patients coordinating other specialist care and counseling patients on how to manage their chronic diseases, which studies show are a major driver for health care. Many patients are afflicted by multiple chronic diseases and the problem will only continue to grow as our population ages. In 2007, $1.8 trillion, or 78 percent of the $2.3 trillion spent on US health care was attributed to chronic diseases. By 2016, it is estimated health care spending will be more than $4 trillion.

Despite our astronomical spending, the federal Centers for Disease Control and Prevention (CDC) still estimates that one out of 10 Americans, or 25 million people, are living with chronic disease. Conditions like heart disease, cancer, asthma, diabetes and others account for 70 percent of all deaths in the United States, which is 1.7 million a year. Clearly, we are paying for health care that does not meet the needs of the majority of our patients. So, while transforming practices to the PCMH model may be costly, insurers and policy makers are beginning to make the investment. The cost of inaction will be extraordinarily greater, not just in dollars, but more importantly, in terms of patients’ health.

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Stem Cell Debate Proves Lively

The Wayne State University School of Medicine hosted a lively debate on Proposal 2, which seeks to amend the state constitution to permit research on embryonic stem cells in the state. Voters will decide the ballot issue Nov. 4.

Two Republicans squared off over the proposal during the Oct. 30 forum, hosted by WSU President Jay Noren, MD, Dean Robert M. Mentzer Jr., MD, and the School of Medicine.

Former U.S. Rep. Joe Schwarz, MD, made the case for the proposal, while state Sen. Tom George, MD, who chairs the Senate Health Policy Committee, opposed the language in the current proposal.

Detroit Free Press editorial page editor Ron Dzwonkowski served as moderator.

“We wanted the forum to offer both perspectives about the proposal,” said Dean Mentzer. “This is an important issue, a hotly debated one, and the School of Medicine felt it valuable to offer this forum.”

Dr. Schwarz noted that Michigan is one of only five states restricting embryonic stem cell research. While President George Bush has twice vetoed legislation that would fund an expansion of embryonic stem cell research, Dr. Schwarz said, presidential candidates Barack Obama and John McCain have endorsed pending legislation that will be one of the first bills placed before the new president.

“It will pass,” Dr. Schwarz said. “I don’t want Michigan to be left out of the game.”

While adult stem cell research – the only type now allowed under existing Michigan law – offers possibilities, Dr. Schwarz said, embryonic stem cell research offers many more possibilities for future cures, and researchers and residents would be remiss not to explore them.

The state Legislature, Dr. Schwarz said, will eventually develop oversight rules and guidelines for embryonic stem cell research.

Sen. George praised Wayne State University for inviting the opposing view to be heard, noting that other universities had not done so during their forums.

While not saying he opposed embryonic stem cell research, Sen. George contended that the language in Proposal 2 is “fatally flawed,” and should be defeated. He said state residents who support embryonic stem cell research should still find reason to reject this specific proposal.

Sen. George pointed to the phase “for any research,” indicating that is too broad a license to allow researchers without oversight. He also objected to amending the state constitution to allow such research, claiming Proposal 2 would prevent legislative regulation of the industry.

“We regulate hospitals, hair stylists and soon tattoo artists,” he said. The language, as proposed, would create “an industry that wants a special shield,” he added.

President Noren, while noting that his position prevents him from speaking for or against Proposal 2, said he favors embryonic stem cell research. He also said that if voters approve the language, he would expect WSU researchers to press him to fund embryonic stem cell research, and he would seek ways to provide that funding.

Jeffrey Loeb, MD, PhD, associate professor in the Department of Neurology and associate director of the Center for Molecular Medicine and Genetics at the School of Medicine, seemed to sum up the feelings of the many researchers in the audience who favor lifting state restrictions on embryonic stem cell research.

“Those embryos not implanted during in-vitro fertilization would be lost,” Dr. Loeb said. “Shouldn’t we use those embryos to save lives? To save somebody’s life, that’s why we went into medicine, and if this can save a life, that’s pro-life.”

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AMA Urges Docs To Push Insurers For Accurate Claims

As part of its national campaign to save the health system billions of dollars by improving the accuracy and efficiency of medical claims processing, the American Medical Association (AMA) Oct. 29 announced it has selected November for the first national Heal that Claim Month.

Many physician practices often experience an increase in claim denials from health insurers during the last quarter of the year, making November an ideal time to appeal inappropriately underpaid and denied claims. An estimated 90 percent of claim denials are preventable and 67 percent of denials are recoverable, according to the Advisory Board Company, a Washington-based research organization. Based on those estimates, physicians collectively lose billions of dollars a year of revenue to health insurers.

"The AMA is encouraging both physicians and insurers to take steps to prevent claim denials and improve the efficiency of billing and collections during Heal that Claim Month," said William Dolan, MD, AMA board member. "Insurers should pay claims accurately the first time, and comply fully with federal standards for electronic transactions to make claims processing as easy and transparent as possible. Physicians can also play a role in ensuring accurate payments by reviewing their claims process, double-checking claims results and appealing any irregular insurer payments."

To help physicians participate in Heal that Claim Month, the AMA is offering tools to physicians for cutting through the ambiguity and bureaucracy of processing claims with health insurers. The AMA's easy-to-use online resources can help physicians and their administrate staff create a systematic approach to claims management and offer instructions on preparing claims, tracking claims and appealing claims when necessary. The tools are available to all physicians at no charge through the AMA's Practice Management Center.

"The AMA's Practice Management Center can help physicians focus on caring for their patients, instead of battling health insurers over delayed, denied or shortchanged payments for their services," said Dr. Dolan. "Studies suggest that physicians divert 14 percent of their revenue to a costly fight for fair reimbursement. The AMA is committed curing the ailing claims process and helping physicians reduce the cost of submitting claims to 1 percent of revenue."

The Practice Management Center's library of education materials includes the following practical tools:

· Prepare That Claim is designed to help physician practices review their claims-management process. It includes sample workflows for patient registration, clinical documentation, patient check-out, coding, billing and collection. It also includes sample forms to help physicians work efficiently and effectively in preparing, submitting and collecting claims.

· Follow That Claim is a look at how health plans process claims, both electronic and paper. It includes flow charts and tables detailing how plans typically handle their internal and external claims processing, adjudications and payments. This information can help physicians better understand and comply with health plan policies, thereby assisting in receiving timely and complete payment.

· Appeal That Claim offers charts, tips and advice for setting up an internal claims-auditing system, which is key to knowing what claims should be appealed. The booklet helps physicians and staff reduce their administrative burden, yet gain greater awareness of how and when to appeal an underpaid, delayed or inappropriately denied claim.

These tools also include interactive user-friendly tools and resources, such as template appeal letters and printable checklists and logs that help physicians simplify their claims management revenue cycle. To access the AMA's Practice Management Center, and any of the educational tools associated with Heal that Claim Month, please visit the AMA Web site.

Heal that Claim Month is part of the AMA's ongoing Heal the Claims Process campaign, which launched last June with the unveiling of the AMA's first National Health Insurer Report Card, an objective comparison of the nation's largest health insurers and their claims processing performance. The findings of the National Health Insurer Report Card are available on the AMA Web site.

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Rapid HIV Screening Boosts Diagnosis, Screening

One in every 50 people screened for a suspected sexually transmitted infection (STI) in the Emergency Department at Henry Ford Hospital was found to be infected with HIV using a rapid blood sample screening test.

Henry Ford researchers hope their study heightens awareness and directs more focus on implementing future prevention strategies in the HIV/AIDS epidemic. They say testing in the ED could diagnose new HIV infections, expand the reach of screening, and help get patients into counseling and treatment programs.

The study comes on the heels of a report by the federal Centers for Disease Control and Prevention that showed an estimated 56,300 HIV infections occurred in the United States in 2006, up by more than 16,000 from a previous estimate earlier this year. The CDC said the difference was due to the use of a more precise method of technology for estimating HIV incidence. The report was published in the Aug. 5 edition of the Journal of the American Medical Association.

The CDC noted that while the new estimate did not represent an actual increase in new infections, it showed that the HIV epidemic is worse than previously known. An estimated 275,000 U.S. adults were living with undiagnosed HIV infection in 2006.

“This sobering news should underscore a need to look at new ways of expanding the reach of HIV testing,” says Indira Brar, MD, an Infectious Disease specialist at Henry Ford and lead author of the study.

“We know that people are more likely to modify risk behaviors and less likely to transmit or acquire infection if they know whether they are HIV positive or not. By offering more testing resources, as our study reflected, we can boost ways to diagnose infections and accelerate progress in reducing the HIV epidemic.”

The study will be presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) and the Infectious Diseases Society of America (IDSA) Oct 25-28 in Washington DC.

Hoping to increase efforts to better track HIV/AIDS prevalence and incidence, the CDC is working with states to implement a national system for estimating HIV incidence based on direct measurement of new HIV infections, closing a previous loophole for tracking the epidemic. The agency also says the new system, when available, will provide the “clearest picture to date” of HIV infections in the country. The new system, the CDC says, will allow better target prevention and measure progress in high-risk populations.

HIV prevalence, defined as people living with HIV/AIDS, increased from 2003-06 nationally, while HIV incidence, defined as new HIV infections, remained stable.

According to the Henry Ford study, patients who sought treatment for a STI in Henry Ford’s Emergency Department from 2004-08 were screened for HIV using a rapid antibody test. The test, administered with a finger-stick for a blood sample, provides results for HIV infection in 20 minutes.

Of the 2,575 patients tested for a STI, 56 were newly diagnosed with HIV, the virus that causes AIDS, and a majority of them also tested positive for gonorrhea, chlamydia or syphilis. Patients received counseling with their results, and were given access to follow-up care within three days.

According to national and state figures, the rate of new HIV infection among African Americans is eight times that of other ethnic groups. In the Henry Ford study, 90 percent of the new diagnoses occurred in African Americans and 75 percent were in men.

The Henry Ford study also found that 55 percent of the ER patients were infected through high-risk heterosexual sex and 35 percent were infected through male-to-male sex, in contrast to 2006 Michigan and national figures in which nearly half of all people diagnosed with HIV in the United States in 2006 were infected through male-to-male sexual contact.

The study was funded by the Michigan Department of Community Health and Detroit Department of Health and Wellness Promotion.

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WSUSOM Study Might Lead To Advanced Treatment For MS

A Wayne State University School of Medicine professor’s research on a new drug that may dramatically advance the treatment of Multiple Sclerosis was published in the New England Journal of Medicine this month.

The article, “Alemtuzumab vs. Interferon Beta-1a in Early Multiple Sclerosis,” was published Oct. 22, and describes the findings of a multi-center study to determine the effectiveness of alemtuzumab in treating MS. Omar Khan, MD, served as principal investigator on the study for the School of Medicine. Dr. Khan is professor of Neurology and director of the Multiple Sclerosis Clinical Research Center and Image Analysis Laboratory for the Wayne State University School of Medicine. He also serves as director of the MS Clinic for Harper University Hospital.

“This phase II study very convincingly showed that treatment with alemtuzumab, a monoclonal antibody directed against the CD52 molecule expressed on lymphocytes and monocytes, is more effective than high-dose, high-frequency interferon-beta 1a, which is one of the FDA-approved therapies for MS,” Dr. Khan said. “The efficacy data, including clinical and MRI outcomes demonstrated with alemtuzumab treatment, are by far the best with respect to any MS therapy to date. Ongoing phase III trials will confirm these impressive data and perhaps redefine platform first-line therapy for MS in the future.”

Dr. Khan noted that equally important is the question regarding the safety of alemtuzumab. Researchers have to determine the price patients will pay if the drug effectively knocks out CD52 expressing immune system cells and induces long-term immunosuppression. That question, he said, will be better addressed by two large ongoing phase III trials at the School of Medicine’s MS Center and several other sites in the United States.

“Achieving a therapeutic equipoise by balancing efficacy with safety will be the mainstay of the next generation of highly effective designer drugs for the treatment of MS,” he said.

Despite the initial side effects, “the bar of efficacy has unequivocally been lifted much higher by alemtuzumab,” Dr. Khan said.

The phase 2 study detailed in the New England Journal of Medicine article involved a randomized, blinded trial of 334 patients with previously untreated early relapsing–remitting multiple sclerosis. The patients received either subcutaneous interferon beta-1a three times per week or annual intravenous cycles of alemtuzumab for 36 months. Alemtuzumab, Dr. Khan noted, significantly reduced the rate of sustained accumulation of disability compared to treatment with interferon beta-1a.

The researchers concluded that in patients with early relapsing–remitting multiple sclerosis, alemtuzumab was “more effective than interferon beta-1a, but was associated with autoimmunity” that in its most serious level manifested as immune thrombocytopenic purpura, a bleeding condition in which the blood doesn’t clot as it should.

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DMC Neurologist Addresses Largest International Cardiology Meeting

Seemant Chaturvedi, MD, professor of Neurology at the Wayne State University School of Medicine and director of the WSU-DMC Stroke Program, was a featured speaker at the world’s largest interventional cardiology meeting.

Dr. Chaturvedi presented “Medical therapy for asymptomatic carotid stenosis” at the Oct. 13 meeting of Transcatheter Cardiovascular Therapeutics in Washington, DC.

He also was recently appointed to a national committee for the American Stroke Association, which will publish guidelines on “Prevention of a First Stroke,” including how to best modify risk factors for stroke such as cholesterol, diabetes, carotid stenosis and hypertension.

Dr. Chaturvedi, a Fellow of the American Academy of Neurology, saw his research on elderly people who take cholesterol-lowering drugs after a stroke or mini-stroke lowering their risk of having another stroke just as much as younger people in the same situation published in the Sept. 3 online issue of Neurology, the medical journal of the American Academy of Neurology.

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Henry Ford Physician Honored

Jan Rival, MD, a senior staff internist at Henry Ford Hospital, received the annual Fred W. Whitehouse Distinguished Service Award.

To be honored with the award, a physician with the Henry Ford Medical Group must have exemplary clinical practice and/or clinical research; contribute significantly to teaching; earn a national reputation in his field; represent distinguished principles of professionalism; and provide service on medical group committees.

The award is named after Dr. Whitehouse, a longtime physician at Henry Ford Hospital who is nationally recognized for his substantial contributions to the understanding of diabetes.

Dr. Rival has held such positions as:

• Governor of the Michigan Chapter of the American College of Physicians (ACP). The college is the largest society of internists in the world, with more than 90,000 members and 76 chapters. The Michigan Chapter is one of the most active associations nationally, with about 4,000 members.

• President of the Henry Ford Medical Association. The association was established in 1950 as an alumni organization to foster professional and social relationships for current and former medical and research staff and those who have trained at Henry Ford Hospital. There are currently more than 6,500 members.

In addition, Michigan Chapter of ACP has bestowed on Dr. Rival the Lifetime Achievement Award and the Laureate Award - both for his years of contributions to the College.

Dr. Rival earned a medical degree from Komenski University in Bratislava, Czechoslovakia. He completed a fellowship in cardiology at Philadelphia General Hospitals and Wayne State University School of Medicine. He is a fellow of the American College of Cardiology.

He is board-certified in Internal Medicine and earned the outstanding teacher award at Henry Ford Hospital in 1993-94.

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