E-DMN - October 26, 2009

October 26, 2009

Editor's Column: Looking Ahead
Beaumont Lecture: Robotic Prostate Surgery
Novel Influenza H1N1 Vaccination Program
BCBSM Outlook Dropped From Stable To Negative
Health Care Bills Could Leave Millions Uninsured
Senate Bill Now Likely To Feature 'Public Option'
Letter: SGR Backfires; AMA Takes Errant Path
2009 Children's Holiday Party Contributors

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Editor's Column: Looking Ahead

By JOSEPH WEISS, MD
If physicians were queried on what is the most difficult problem in health care, likely they would reply: “The cost of care.” In the controversy of private vs. public insurance, the winner will achieve a bitter victory. The strategies needed to hold down costs will antagonize physicians who see themselves as being denied reimbursements; will outrage patients who consider themselves denied medications and treatments rightfully theirs; and antagonize employers who will see the cost of employee health premiums increase by double-digit percentages yearly.

As health care now runs in this country, there exists no way to stop this upward spiral of expense and inequity.

A report in the Sept. 1, 2009 issue of the Annals of Internal Medicine is of particular interest, as it brings up another approach to providing medical care for Americans. The article, Comparing Costs and Quality of Care at Retail Clinics With That of Other Medical Settings for 3 Common Illnesses (pp 321-328), found that care in retail clinics, manned by nurse practitioners, operating under guidelines set by computer algorithms, provided equal care to that given by emergency rooms and physician offices, and did so at two-thirds the costs of the other two facilities.

A companion article, The Geographic Distribution, Ownership, Prices and Scope of Practice at Retail Clinics (pp 314-320), from a different group, corroborated the cost savings of the retail clinic and pointed out that at this time, nearly 30 percent of the country’s urban population is within a 30-minute or less drive to a retail medical clinic.

The retail clinics represent a model of changes coming to the medical community as the country organizes to contain expense.

First, in the future a great deal of basic medical care will come from auxiliary health personnel, such as nurses, nurse practitioners, physician assistants and medical assistants. They will be aided by computer programs directing them on what they can do and when to refer to physicians. The basic practitioners will be salaried employees of a medical group supervising their work.

Second, physicians will no longer have the choice of independent vs. group or institutional practice. All doctors will be in groups, though many will work out of small offices. Physicians will work for a salary with bonus payments determined by their umbrella organization, likely along the lines of today’s Independent Physician Association (IPA). The IPA will provide local leadership and the size of the group will be such as to allow decisions for the group to come from decisions by the group.

For physicians, the Patient Registry, expanded from its roll in the Patient Centered Medical Home, will become the tool for evaluating their work. In particular, The Registry will provide benchmark data and allow comparisons between physicians as a basis for bonuses.

These momentous changes in the delivery of medical care are hardly imaginable now. However, the present ever-rising cost of medical care is even less conceivable. This other approach awaits; the ways and tools to this change are available. The only element lacking is the will. The spiraling cost of care shall, in time, overcome the inertia of custom and consistency. What now seems visionary will become inevitable.

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Beaumont Lecture: Robotic Prostate Surgery

By PAUL NATINSKY
“We aimed for the heart and we hit the prostate,” said 2009 Beaumont Lecturer Mani Menon, MD, about his experiences using robotic surgery to perform prostatectomy.

Dr. Menon is the Rajendra and Padma Vattikuti Distinguished Chair in Oncology; Director of the Vattikuti Urology Institute and Henry Ford Health System, and Clinical Professor of Urology, Case School of Medicine and New York University.

He described his experience using robotic surgery techniques, in which a physician uses a screen relaying information from tiny cameras to manipulate remote hand controls connected to robot arms carrying miniature instruments. “The surgeon makes moves in virtual reality,” said Dr. Menon. The result, he said, is “kinder and gentler” prostate surgeries.

An audience of more than 100 physicians gathered over lunch in Troy Oct. 23 at the MSMS Annual Scientific Meeting to hear Dr. Manon’s presentation.

Henry Ford Health System has been using the brand-named da Vinci Robot for prostate surgeries since the early 2000s. Dr. Menon said the surgeries are done using a series of small incisions through which the robot arms enter the body, rather than creating a large incision. This technique leaves intact nerve bundles that are involved in continence and sexual performance. The robot prostate surgeries at Henry Ford, of which Dr. Menon has performed more than 1,500, have produced significantly fewer continence and sexual performance complications than traditional surgeries, according to Dr. Menon’s data.

Recent reports have indicated higher complication rates for robotic prostate surgeries, but Dr. Menon said that is in part because of the rapid spread of the machines throughout the country and, particularly, far too little training for physicians who use them.

“The robots metastasized before the cancer did,” said Dr. Menon. He said Henry Ford has an extensive training program and a pool of physicians who are dedicated to performing surgeries with the da Vinci robot; measures which he said are responsible for Henry Ford’s good numbers on complications.

The da Vinci robot was originally designed to operate on a beating heart, said Dr. Menon. But its use became widespread for prostate surgeries. At Henry Ford it is used in 90 percent of prostate surgeries and all major urologic surgery. Dr. Manon said the fastest new growth area for the machine is in gynecology.

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Novel Influenza H1N1 Vaccination Program

Editor’s Note: The following is a letter from the Wayne County Health Department requesting physician assistance in vaccinating against seasonal flu and the H1N1 virus, as vaccine becomes available. We have linked a PDF of the letter and relevant form. Click here to access and print. The letter is dated Sept. 18, 2009.

By TALAT DANISH, MD
Medical Director, Wayne County Department of Public Health
As the anticipated release of the Novel Influenza A-H1N1 vaccine approaches, we want to provided your practice with valuable information to assist in ordering and receiving H1N1 vaccine for your practice. Due to the projected demand for the H1N1 vaccine, the CDC has advised that providers begin seasonal influenza vaccinations as soon as possible. Most providers should already be receiving shipments of their seasonal influenza vaccine.

Target populations as identified by the CDC to receive the initial doses of the 2009 Influenza A-H1N1 vaccine are:

Pregnant women
Household contacts and caregivers of children younger than 6 months of age
Health care and emergency medical services personnel
Children and adults between the ages of 6 months and 24 years
Persons 25 through 64 years of age who are at higher risk of complications from the 2009 Influenza A-H1N1 because of chronic health disorders or compromised immune systems

In order to successfully immunize these target populations, the Wayne County Department of Public Health (WCDPH) invites all Wayne County health care providers to vaccinate these targeted groups. H1N1 provider enrollment and vaccine ordering will be facilitated by WCDPH. The order will be faxed to WCDPH and sent on to the Michigan Department of Community Health (MDCH) for processing. The order will be shipped directly from McKesson to the approved medical provider’s office. Any small orders (fewer than 100 doses) will be processed and picked up directly from WCDPH.

In addition, you will be required to complete and sign the vaccine provider agreement enrollment form for the Novel Influenza H1N1 Vaccination Program. The form is linked (see Editor’s Note) to this letter. Please print, complete and sign the form and fax it to (313) 967-1223 for processing. In addition, the form can we accessed from the website www.michigan.gov/flu , click on the “Novel H1N1 Influenza” tab; then click on the “clinicians” tab; then click on “Information for Providers Interested in Providing H1N1 Vaccine”; and, finally, click under item #2, the “MDCH 2009 Influenza A (H1N1) Monovalent Vaccine Provider Agreement.”

If you have any questions, please do no hesitate to contact the Wayne County IAP coordinator, Kay Fradeneck at (734) 727-7068.

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BCBSM Outlook Dropped From Stable To Negative

Crain’s Detroit Business Reported the A.M. Best Co., an Oldwick, N.J.-based credit rating agency, revised the outlook to negative from stable for Blue Cross Blue Shield of Michigan as the company continues to experience mounting losses in the individual health insurance market.

However, A.M. Best affirmed the financial strength rating of “A-” and issuer credit rating of “a-” for Blue Cross and its affiliated Blue Care Network, the company’s HMO.

According to Crain’s the negative outlook has been caused by declining capitalization at the Blues from losses in the individual market (insurance that is bought by individuals rather than by companies for employees) and decrease in investment income.

The Blues told Crain’s the outlook change is “independent verification” that the company needs the state Legislature to make changes in regulations affecting the individual insurance market.

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Health Care Bills Could Leave Millions Uninsured

The cost of health insurance could hinder President Obama's goal of achieving universal coverage.

"The high cost of health insurance premiums would continue to put coverage out of reach for millions even if Congress approves legislation President Obama says is intended to ensure 'that every American has affordable health care,'" USA Today reports. "The number of people who remain uninsured will depend on how House and Senate leaders reconcile separate versions of health care legislation to arrive at a final bill. The factors include the size of government subsidies to help low-income families pay for insurance and the scope of penalties that would be charged for those who don't buy a plan." According to a Congressional Budget Office analysis, 17 million Americans would remain uninsured under the Senate Finance Committee's 10-year, $829 billion health care bill," including many "families who earn too much to qualify for Medicaid but not enough to pay for insurance. Others who could remain uninsured under the Finance Committee bill include people who choose to pay a proposed $750-a-year fine rather than buy coverage and those who are eligible for Medicaid but don't enroll" (Fritze, 10/26).

The Washington Post reports that "the question of whether people will follow a government order that they carry health insurance -- an issue that will help determine whether universal health care is a success or costly failure -- will depend on more than the penalty they would pay for refusing, many economists say. This, they say, is the lesson of behavioral economics, a school of thought that holds that people do not necessarily make decisions out of well-reasoned self-interest. It is an approach that has gained a powerful foothold in the Obama White House."

Behavioral economists say that "compliance will depend not only on the penalties and cost of coverage, but also on the ease of signing up for coverage and whether people can be persuaded that it is a widely accepted social norm. They point to the large number of eligible people who fail to take advantage of Medicaid, food stamps and Pell grants as a sign that perceived inconvenience can keep people from taking steps in their economic interest" (MacGillis, 10/26).

This information was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery. © Henry J. Kaiser Family Foundation. All rights reserved.

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Senate Bill Now Likely To Feature 'Public Option'

Senate Health Bill Could Come This Week, 'Compromise' Public Option Now Seems Likely

Senate Democrats will need to move quickly if they want to pass some version of health overhaul legislation by the end of the year.

The Associated Press: With "time growing short," Senate Democratic leaders "still face key decisions..." In the Senate, that "means deciding whether legislation will give the government a role in the marketplace at all, and if so, what rights individual states would have in deciding whether to participate." The Senate is weighing its final choices as negotiators work to merge the bills from Senate Finance and from Health, Education, Labor and Pensions Committees. The latest talks have focused around getting rid of any mandate on businesses to provide health insurance for their employees (Espo, 10/26).

The Wall Street Journal reports that the Senate's finalized health bill could be ready as soon as early this week, when the leaders will submit the bill to the Congressional Budget Office for scoring. Senate Majority Leader Harry Reid "spent the weekend shoring up support for the bill from Democrats in the chamber. But some key moderate Democrats signaled Sunday that they remain uneasy about main planks of the legislation." Although some details could change, the "broad outlines are becoming more clear" (Adamy and Hitt, 10/26).

Politico reports that Sen. Chuck Schumer also believes 60 votes are within sight. But "Senate Minority Leader Mitch McConnell said that Democrats still have work to do in rallying support within their ranks, pointing to last week’s overwhelming vote to strike down a so-called doc fix to Medicare physician reimbursement that would have added nearly $250 billion to the deficit. A group of Democrats crossed party lines on the vote" (Isenstadt, 10/25).

The New York Times: "Several Democratic senators voiced optimism on Sunday that Congress would pass a health care bill containing at least the germ of a government-run insurance program. Their expectations were grudgingly seconded by Senator John McCain, the Republican presidential candidate in 2008. 'I think the Democrats have the votes, and in the House, Blue Dogs bark but never bite,' Mr. McCain said on CBS’s 'Face the Nation,' using the nickname for conservative Democrats."

Democrats who said they see a public plan passing include Sens. Claire McCaskill, of Missouri; Chuck Schumer, of New York; and Russ Feingold, of Wisconsin. Sen. Ben Nelson, D-Neb., said he was willing to look at the proposal if the Senate allows states to opt out of that part of the plan (Berger, 10/25).

CNNMoney: "Senate Majority Leader Harry Reid, D-Nev., is poised to proceed with plans to introduce a Senate health care bill with a public health insurance option that would allow states to opt out, a senior aide to Reid told CNN on Sunday. The aide, who did not want to be quoted by name when talking about private deliberations, said a final decision would be made Monday. Reid is likely to make the move without having firm commitments of support from 60 senators, the number needed to break a filibuster, according to the aide" (Bash, 10/26).

Bloomberg: "The Senate is considering a version of the public option that would have to negotiate rates with providers, as private insurers do, likely resulting in higher reimbursements. There are other compromises, including (Maine Republican Sen. Olympia) Snowe’s plan to trigger a public option if there isn’t enough affordable insurance on the market" (Jensen and Litvan, 10/26).

Reuters has a rundown of the different proposals for a public plan in both the Senate and the House including the opt out plan, the trigger plan, a "robust" plan offered in the House, one with negotiated rates and one that would instead set up non-profit cooperatives (Smith, 10/25).

Politico reports that Democrats are trying to make the benefits start by 2010 to sell the plan to the public: "With Republicans expected to make next year a referendum on health care reform, Democrats are quietly lobbying to push up the effective dates on popular programs, so they'll have something to run on in the congressional midterms. Democrats are anxious to mix the good with the bad since some of the pain would be phased in early, including more than $100 billion in industry fees that critics say could be passed on to consumers." Billions in new taxes in the plans will already come due in 2010 (Budoff Brown, 10/25).

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Letter: SGR Backfires; AMA Takes Errant Path

Editor’s Note: The following is a letter from Dr. Susan Adelman regarding a bill from Michigan Sen. Debbie Stabenow to fix the Sustainable Growth Rate formula, which is used by Medicare to set physician fees each year, and is considered by most physicians to result in inadequate payment rates. Her opinion turned out to prescient, as several Democrats voted against the measure and it was criticized by some as an attempt to buy off physicians to gain support for health care reform.

Editor: In fact Debbie Stabenow's bill, however favorably physicians may regard it, is a way to get the costs of fixing the SGR out of the large health care reform bill, so that the costs of the health care reform bill will not include the cost of fixing the flawed SGR. This is part of a larger effort to fool the public into thinking that the cost of health care reform is lower than it actually is. This strategy was already voted down in the Senate by those who understood it all too well.

Moreover, the AMA, according to what I have read, misled the Senate into thinking that the votes were there for the bill. This is over and above the mistake the AMA has already made in supporting the proposed health care reform on the basis of false promises that Medicare payments will be sweetened.

The efforts by Don Palmisano MD, Past President of the AMA, to tell the nation the truth about the proposed health care reform are the most honest in the country. He is on all the major media, and he is promulgating the actual AMA policy that we developed over the years and that the AMA now is disregarding in order to be at the table in this current debate.

-- Susan Adelman, MD

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2009 Children's Holiday Party Contributors

The following is a list of contributors to the WCMS Foundation’s 24^th Annual Holiday Party for underprivileged children. This year’s event is Dec. 5 at the New Detroit Science Center. For more information, or to contribute, call (313) 874-1360 or visit www.wcmssm.org

Robert G. Borchak, M.D.

Patricia A. Kolowich, MD

Joan & Bob Allaben

Advanced Family Health Care

Marcie Treadwell & Gregory Goyert

Dr. Michael Sandler

Tom & Nancy Coles

William G. Nutting, MD

Dr. & Mrs. Edmund M. Barbour

Dr. Philip C. Hessburg

Ron & Diane Strickler

Joseph Mark Tuthill, MD

Deloris Ann Berrien-Jones, MD

Vincent C. Yu, M.D.

Andrew J. Mitchell, MD

Robert Brent, MD

William Knapp, MD

Nancy Goll

Elizabeth Edmond, MD

Benjamin Ramos, MD

Peter Cracchiolo

Robert Borchak, MD

Julian Alvarez, MD

Beth Ann Brooks, MD

Dr. & Mrs. Sajal Choudhury

William L. and Betty G. Knapp

Drs. Safwan Halabi & Razan Asbahi

Joe Weiss & Marilyn Shapiro

Dr. & Mrs. George C. Hill

Neela Sripathi

Homer M. Smathers, MD

Sidney Baskin, MD

John C. Somogyi, MD

Charla Blacker, MD

Todd R. Williams, MD

Iris and Fred Whitehouse

Joseph M. Beals, MD

Stephanie Flom, MD

Dr. & Mrs. Mark F. Pezda

Eudoro Coello, MD

Christopher W. Hughes, MD & Debra J. Hughes

Claus Petermann, MD

Richard D. Cieslak, MD

Daniel S. Moore

Drs. Peter & Alice Watson

Drs. Rachel and Brian Silver

Kathleen Yaremchuk, MD

Anne-Mare' Ice, MD

John M. Malone, MD

Anne Nachazel, MD

Eastside Surgical Specialists

Paul Mazzara, MD

Dr. Richard Pollard

Michael G. Taylor, MD, FACS

Drs. Kenneth & Deborah Granke

Aaron Lupovitch, MD

Keith P. Bartold, MD

Rev. William and Dr. Mary Logan

Scott Monson, MD

Arthur J. Frazier, MD

M. Natacha Umlauf, MD

Phyllis A. Vallee, MD

Michael Schaldenbrand, MD

Heidi R. Gunderson, DO

Paul J. Sullivan, MD

S.V. Mahadevan, MD

Indu & Bala Pai

Chris and Janet Bush

Eve M. VanEgmond, MD

Taufiek Alhadi, DO

Gwendolyn H. Parker, MD

Dr. Ray and Mrs. Marcia Littleton

Drs. Daniel & Margarita Morris

Dr. & Mrs. Laurence E. Stawick

Dr. & Mrs. John Calwell

S. Rao Talla, MD

Ghaus M. Malik, MD

Eastlake Pediatrics PC

Vernon F. Strand, MD and Jane P. Strand

Martin H. Daitch, MD

John Kurtz, MD

Dr. & Mrs. Dan Michael

Mohammed Arsiwala, MD

Livonia Urgent Care

Margaret Dowling, MD

Dr. S. Maitra

George Mogill, MD

Dr. MaryJean Schenk & David Fry

Dr. Grace Engler & Ms. Anna Fedor

Dr. & Mrs. Donald M. Ditmars Jr.

James A. Rowley, MD

Sion Soleymani, MD

Madjid Mesgarzadeh, MD

Dr. & Mrs. Allan Dobzyniak

Helene C. Dombrowski, MD

Drs. Lalitha and Babu R. Vemuri

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