Melanoma

Melanoma: The most dangerous form of skin cancer, a malignancy of the melanocyte, the cell that produces pigment in the skin. Melanoma is most common in people with fair skin, but can occur in people with all skin colors. Most melanomas present as a dark, mole-like spot that spreads and, unlike a mole, has an irregular border. The tendency toward melanoma may be inherited, and the risk increases with overexposure to the sun and sunburn.

Melanoma is classified into four clinical types which are called:

• acral-lentiginous melanoma,
• lentigo maligna melanoma,
• nodular melanoma, and
• superficial spreading melanoma.

Fair-skinned people and people with a family history of melanoma should always use a high-SPF sunscreen when outdoors. Everyone who has concern about an unusual mole-like spot should see their doctor. Detected early, melanoma is almost always treatable. Undetected, melanoma can spread rapidly and be fatal.

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
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Hernia

Hernia: A general term referring to a protrusion of a tissue through the wall of the cavity in which it is normally contained. Also known as rupture.

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Lyme disease

Lyme disease: An inflammatory disease that is caused by the bacterium Borrelia burgdorferi, which is transmitted to humans by the deer tick. The first sign of Lyme disease is a red, circular, expanding rash, usually radiating from the tick bite, followed by flu-like symptoms and joint pains. After the B. burgdorferi has entered the bloodstream, it can infect and inflame many different types of tissues, eventually causing many diverse symptoms. Lyme disease is medically divided into three phases: early localized disease with skin inflammation; early disseminated disease with heart and nervous system involvement, including palsies and meningitis; and late disease, featuring motor and sensory nerve damage and brain inflammation and arthritis. Within hours to weeks of the tick bite, an expanding ring of unraised redness develops, with an outer ring of brighter redness and a central area of clearing, giving it the appearance of a bull's-eye. The redness of the skin is often accompanied by generalized fatigue, muscle and joint stiffness, swollen glands, and headache. Early treatment with antibiotics is the best strategy for preventing major problems due to Lyme disease. Further prevention of Lyme disease involves avoiding areas where ticks are common, wearing protective clothing and lotion, and immediately removing any ticks from the body. Interestingly, Lyme disease only became apparent in 1975, when mothers of a group of children who lived near each other in Lyme, Connecticut, made researchers aware that their children were all diagnosed with rheumatoid arthritis. This unusual grouping of illness that appeared to be rheumatoid eventually led researchers to the identification of the bacterial cause of Lyme disease in 1982.

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Drug Shows Promise Against Advanced Lung Cancer

Drug Shows Promise Against Advanced Lung Cancer

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Developing Standards ‘Of, By, And For’ Older Adults: Reflections On Patricia Gabow’s Narrative Matters Essay

Imagine three people: a healthy 30-year-old, a 60-year-old with high blood pressure, diabetes and arthritis, and a 90-year-old who is frail and has dementia advanced to the point where her speech often doesn’t make sense.

If I lined them up, any doctor could instantly tell me which was which.

Ditto if each broke a bone and I showed the physicians only their x-rays.

And if I asked the clinicians to predict each patient’s risk of complications and adverse events based on nothing more than the few words above, they would again rapidly and reliably make accurate assessments.

Yet, for the most part, our health system lumps these three people into a single “adult” category, an approach that flies in the face of anatomy, physiology, pharmacodynamics, risk stratification, and a whole lot more, including common sense, population trends, ethics, economics, and epidemiology.

As CEO and chief medical officer of a large safety net health system, Patricia Gabow, author of the powerful Narrative Matters essay in the May 2015 issue of Health Affairs, introduced evidence-based standard care pathways, computerized order entry and order sets, and Toyota’s “Lean” principles, which led to marked improvements in quality of care and health outcomes in patient populations for whom health disparities have been longstanding challenges. Such methods are now being adopted across the country and incentivized by the Affordable Care Act.

Then her mother, a nonagenarian with frailty and advanced dementia, injured herself in a fall. Gabow realized she didn’t want her mother to receive standard care. She successfully advocated for care better suited to their situation, and her mother was soon released from her surgeon’s care and lived the remaining two months of her life in relative comfort.

Since the vast majority of Americans lack Gabow’s training, clout, and connections, the only way to ensure all older Americans get similar high quality care is to create standards and policies that acknowledge what we all already know: older adults differ from younger adults in ways that matter.

Precedents In Medicine And Health Policy

I began medical school in 1988. At that time, we learned to care for a single patient: the 70-kilogram man. He was healthy until given the diseases we had to diagnose and treat, and it went without saying that he was neither young nor old, and Caucasian. This educational scenario paralleled clinical research where subjects were also male, white, and middle-aged. The reasoning behind this approach was that women were obviously different than men, and blacks different than whites, so adding in these complications polluted the science.

While clean study samples worked well in laboratory settings, they proved counterproductive in medical education, research, and care. Excluding large segments of the population from standards because of their differences, and then applying those standards to them despite their differences, often resulted in poor care and outcomes. The civil rights and feminist movements of the 1960s and 1970s led to investigations of the impact of this approach on care and outcomes in the 1980s and brought new educational strategies and federal research policies in the 1990s.

Interestingly, this was not the first time medicine acknowledged that differences matter. In the 1800s, hospitals—first in Europe and then in the United States—were founded for the exclusive care of children. We still have pediatric hospitals and clinicians today. We understand that children differ from adults: they require different doses of medications, respond differently to some treatments, have conditions unique to their age group, and have additional developmental, social, and family needs that significantly impact their care and outcomes.

The same is true of older adults. Now it’s time to apply the same logic to their care as we already apply to the care of children, women, and minorities.

An Action Plan for Health Policy

Transforming health care to better serve older patients must begin with the development and application of standards of care that consider age-related changes in physiology and risk, patients’ health status—based on co-morbidities, functional abilities or disability, and overall prognosis—as well as life priorities. In this approach, age is necessary but not sufficient to determine good care; the care that will benefit an 82-year-old who exercises daily, travels, and volunteers may not help, and might harm, a 73-year-old with significant heart disease who is wheelchair bound and dependent from a stroke.

Policy makers can take three key steps to move American medicine away from its failed one-size-fits-all approach for adult care. First, they must require care pathways and outcome metrics “of, by, and for” older adults when certifying health systems and hospitals. Second, medical education oversight bodies such as the Liaison Committee on Medical Education and Accreditation Council for Graduate Medical Education must begin requiring training in the care of older adults analogous to the training these bodies already require in the care of children and women. Third, the National Institutes of Health and other funders must add older adults to the categories of subjects to be included in trials, or justify their exclusion, just as they have done for women, children, and minorities.

Standards For Life’s Third Act

Patricia Gabow’s experience with her mother gives us clues into some of what these new standards might look like:

1. They would focus more on the person and their health, and less on the affected organ or disease process. Gabow’s mother’s dementia meant that a c-spine collar and IV would have caused agitation that would have led to distress and possibly more harm to her body than that already sustained in the fall.
2. They would skip tests that would not change the treatment plan. Gabow explains that her mother’s head trauma notwithstanding, there was no head CT finding on which their family would act.
3. They would prioritize care that maximized wellbeing and independence. While Gabow’s mother initially balked at having the cut on her forearm sutured, a local anesthetic enabled the wound to be closed so it would be more comfortable and easier to care for going forward.
4. They would base all diagnostic and treatment decisions on the patient’s goals of care and support the family in doing the same. Gabow had to advocate against the system and many of its providers for care in keeping with her mother’s wishes and happiness, a situation that added to Gabow’s stress and anxiety.
5. They would consider not only the pros and cons of acute management but the downstream risks and benefits of treatments. When a “simple fix” of her mother’s hip fracture was recommended, Gabow alone seems to have imagined the future in which the hip was repaired but her mother was terrified in a foreign setting, strapped down, and subject to invasive attentions she didn’t want, all of which would “seem like torture to her.”

By creating a care pathway appropriate to her mother’s frailty, dementia, goals, and values, Patricia Gabow not only saved her mother’s life (perhaps literally, and certainly figuratively), she also saved our health system approximately $156,000. It was a win-win, but older adults shouldn’t need to have raised a physician-CEO to get that standard of care.

Fear-based Medicine: Using Scare Tactics in the Clinical Encounter

By NAMRATHA KANDULA, MD and MATTHEW WYNIA, MD

How often do doctors say something like this to patients?  “It’s really important for you to do this; if you don’t you might … have a stroke, go blind, lose a leg, die or (insert a scary outcome here).”  There are no solid data to answer this question, though patients report that conversations containing such direct threats are common in clinical encounters. The more important question is, do scare tactics work?

Fear-based messages in clinical encounters

Health communication experts call these types of messages fear-based appeals. Fear appeals create an emotional reaction to some “threat” of disease, disability or death, which in turn, is thought to motivate behavior change. Doctors may use fear-based messages when counseling patients about chronic disease self-management or prevention, especially when faced with a patient we believe to be unmotivated or non-adherent.  In such situations, using fear as a tool is appealing because it is easy, doesn’t take much time and we know intuitively that fear can be a powerful motivator.   Yet despite decades of research on the subject, there is no consensus on whether or how fear can be used effectively to motivate long-term behavior change.

Research supporting the effectiveness of fear appeals is generally from public health campaigns, where frightening facts or images can quickly capture the audience’s attention.  This makes sense when a message sender is competing for audience attention among many billboards, advertisements and other messages. But it rarely makes sense when a doctor is alone in an exam room with a patient. For many patients, the 15 minutes they have with their doctor will be the 15 most important minutes of their day.

More important, research suggests that appeals to fear can cause harm.  For example, in a study of patients with type 2 diabetes, patients recognized when their doctors were using scare tactics to motivate compliance, but many said such threats resulted in increased feelings of anxiety, incompetence and negativity towards their physician.

Why threatening patients rarely works

The reason threatening patients with bad outcomes often fails to persuade patients to change behavior lies in the powerful 2-way interdependency of fear and self-efficacy in prompting action. A recent meta-analysis of studies on fear-based messaging found that threatening information only sparks behavior change when self-efficacy is high, and self-efficacy is only correlated with behavior change when the individual perceives himself to be susceptible to a threat.  Moreover, in the absence of strong levels of self-efficacy, raising fear levels can lead to maladaptive responses such as shutting down, feeling overwhelmed or denial.  For clinicians this means that although fear-based messages can quickly increase a patient’s sense of being threatened, which may be a necessary predicate for behavior change, this fear must be matched with success in raising the patient’s sense of self-efficacy or it could backfire.  The problem is that increasing self-efficacy is a laborious process.

Several communication methods work to increase patient self-efficacy, but none are quick or easy to implement.  For instance,randomized controlled trials of motivational interviewing (MI) in primary care suggest that MI can increase self-efficacy and help patients achieve goals related to weight loss, blood pressure and outcomes related to substance use; but effective MI requires multiple counseling sessions and multidisciplinary teamwork.

There is also a robust evidence base behind self-determination theory (SDT), which leverages 3 psychological mechanisms related to self-efficacy to help individuals achieve long-term behavior change: autonomy (feeling internally motivated and not coerced into the recommended action), competence (feeling competent to act and to problem-solve), and relatedness (feeling connected to others). Studies of SDT-based interventions have shown positive effects on various health behaviors, such as smoking cessation, weight loss maintenance and physical activity.  But the effective clinical use of SDT, like using MI, requires both time and teamwork and is challenging to implement in the real world of health care practice.

Can fear-based messages be used effectively?

Knowing this, is there ever an appropriate approach to the use of fear appeals during the clinic encounter?  Consider, as an example, patients at high risk of developing diabetes. Will telling patients they have prediabetes and using the threat of developing diabetes and its potential consequences (i.e. kidney failure, losing a limb) stoke unproductive fear? Or could it be beneficial because the fear of developing diabetes motivates patients to change their lifestyles?

Many patients with prediabetes have described feeling fear, anxiety and uncertainty when first diagnosed. Fear and anxiety are also heightened when patients have witnessed a family member suffer the downstream consequences of diabetes, and these feelings are further intensified by the fact that few patients are confident they can make healthy lifestyle changes to reduce the threat of diabetes and its consequences.  So, being diagnosed with prediabetes dramatically increases the perceived threat of diabetes, indeed some patients perceive it as inevitable, but self-efficacy is also generally low.

What should the physician do?  A statement like, “You have prediabetes; if you don’t lose weight, you are going to develop diabetes which could lead to other more serious problems, like heart attacks or kidney failure” is likely to grab the patient’s attention but fail to motivate weight loss – it might even backfire, leading to resignation, denial or hopelessness. Evidence-based diabetes preventionprograms that help patients increase self-efficacy and chances of weight loss exist, using techniques derived from MI and SDT; but these programs takes months to complete and are typically offered outside the doctor’s office, in community-based organizations such as the YMCA. A more effective approach might be to say, “Having prediabetes means you are at high risk for developing diabetes, but there are thing you can do to avoid or prevent it –like losing weight, eating healthier and being more physically active. If you are interested, I’m going to give you a referral to a program that can help you prevent diabetes.”  Then provide the patient with a direct referral to a diabetes prevention program or other evidence-based lifestyle program.

Perhaps in an ideal world, the physician would deliver a comprehensive MI and SDT-based intervention herself – usually many weeks of intensive work with modest reimbursement at best–but for most of us this is not realistic. Still, physicians play critical roles by helping patients understand their risk, supporting the patient’s autonomy, and by staying connected to and supportive of the patient through the behavior change process.

In sum, evidence suggests that fear appeals have limited utility in the clinical encounter, and that any appeal to fear must be coupled with communication strategies that increase motivation, autonomy and competence in patients.  Using fear as part of an effective motivation strategy for patient behavior change requires a long-term, team-based approach, often extending beyond the doctor’s office.

Namratha Kandula, MD, MPH leads the Improving Health Outcomes Project at the American Medical Association. Matthew Wynia, MD is an Assistant Professor of Medicine at Northwestern University.

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How Paid Family Leave Would Have Made Life Easier For One Family

In this year’s State of the Union address, President Obama brought some much-needed attention to the topic of family leave. In the months since, he and some of his allies in Congress have been championing the “Healthy Families Act,” which establishes guidelines providing that all employees receive up to seven days of paid leave. This paid time away can fall under the category of “sick leave,” but the leave could alternatively be spent caring for a chronically ill loved one.

In 2006-2007, I had the privilege of following the health care story of Thor Lem and his family. I was in the midst of producing my documentary film “American Heart,” which looks at health care through the eyes of three refugees living in the U.S., each of them combating both chronic and emergent health problems.

Thus, what became the final year of Lem’s life unfolded, in part, in front of our cameras. During that time, it became clear that Lem’s family was in some ways a very typical American family, striving to make ends meet and meanwhile managing the day-to-day struggles of seeking health care for aging members of the family.

End-of-Life Care

When we first meet Thor Lem in the film, he has recently been diagnosed with liver cancer, and his long-term prognosis is not good. Lem approaches this news with understandable apprehension. During one particularly heart-breaking exchange, we hear Lem ask his primary care physician, Dr. Patricia Walker, to give him “more hope.”

With the help of an interpreter, Dr. Walker gently reminds Lem that his treatment is palliative in nature, meaning they will treat his cancer to manage pain and symptoms, and to extend his life, but there is little chance his cancer can be cured.

We learn that Lem is a refugee hailing from Cambodia, where he endured the Killing Fields and the tumultuous rule of Pol Pot. He’s been in the United States for many years, and has built a life and raised a family in St. Paul, Minnesota. He is 74 years old.

Lem and his family receive their primary care at HealthPartners Center for International Health, a clinic in St. Paul that attracts a diverse patient population composed almost entirely of immigrants and refugees from the surrounding neighborhoods. The clinic prides itself on serving these patients with compassion and flexibility, making accommodations for the cultural differences, language barriers, and economic struggles that arise when your waiting room is a global village.

It was this global village and its inhabitants that first captured my imagination. Dr. Walker and her colleagues had pointed out that every patient that walked through their doors had a fascinating story to tell. At first, I wasn’t sure if I would be bearing witness to the failings of the health care system or, conversely, creating a virtual guidebook to battling health care inequities. In the end, thanks to the compassion and dedication on display at the clinic, it was closer to the latter.

Family Caregiving

Still, not every story can reach a happy ending. When situations like Lem’s crop up, providers at even the best-equipped and best-intentioned health care facilities can start to feel powerless. Dr. Walker points out that Lem is missing appointments — it’s a transportation issue, but it’s also something more.

With his health failing, Lem relies heavily on his adult son Thei War. Thei has a family of his own, and not only does Thei look out for his dad and provide for his own young children, but he also cares for his mother, who is likewise chronically ill.

In addition to caring for his multi-generational family, Thei works hard—really hard—to hold down his manufacturing job. He works the night shift, arriving home every morning just in time to drive his kids to school.

Lem feels that he needs his son Thei with him at the appointments. It’s not surprising. Many senior citizens count on their younger family members to help them navigate the health care system, and in my years observing and documenting various immigrant communities seeking care, this phenomenon seems even more prevalent in immigrant families.

It’s not uncommon for a large, extended family of refugees or immigrants to rely on one member of their family to serve as their health care “navigator.” This young adult is often more comfortable with the English language, more acclimated to American culture, and more confident when it comes to negotiating the systems that permeate modern American life.

But Thei can’t do it all, and some commitments inevitably fall through the cracks. Dr. Walker laments one particular occasion when Lem was a no-show for a scheduled scan of his heart, and as a result he was unable to receive his next chemotherapy treatment. Lem’s health deteriorated from there.

Thei is clearly engaged in his father’s health care, and he displays heartfelt concern about his father’s wellbeing, so it’s not for a lack of caring. When asked, Thei seems exasperated by his own hectic schedule, pointing out that he is often faced with a difficult choice: get your children to school or get your parents to their many medical appointments.

Dr. Walker shows great sympathy, and she is in awe of Thei and all he accomplishes on two or three hours of sleep. Ultimately, in Dr. Walker’s words, Lem “is not getting best care” because of the pressures put on Thei by his complicated work-life balance. After some ups and downs, Lem died in the hospital on December 27, 2007.

Next Steps For Family Leave

So what if, during these crucial final months of Thor Lem’s life, Thei had been given access to a guaranteed seven days of paid leave? Currently, there is no such requirement on the books at the federal level. The Family and Medical Leave Act does protect certain employees from losing their job when a family illness requires them to take unpaid time off. But for families like Thei’s, giving up one week of income can be a big blow.

The second generation “navigator” can only do so much to ensure their family is well cared for. In this and other ways, Thei’s dilemma is emblematic of the struggles many refugee families face. But I suspect many Americans will relate to the central problem that vexed Thei. When every paycheck matters, when pressures of all kinds can have profound effects on a family’s health, feeling like you can count on your livelihood, and that your employer is on your side, can make a big difference.

When President Obama shined a light on this issue in January, it had the hallmarks of a Democratic initiative that would face an uphill battle getting through the Republican-controlled House and Senate. But, in March, a filibuster-proof majority in the Senate voted for a non-binding budget amendment that hints at bipartisan support for something akin to the Healthy Families Act.

So there are signs of potential progress on this front during Obama’s final twenty months in office. But it will require a strong push from engaged communities to see that legislation moves forward.

Pulmonary embolism

Pulmonary embolism: Sudden closure of a pulmonary artery or one of its branches, caused by a blood-borne clot or foreign material that plugs the vessel.

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
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Project ECHO GEMH: Disruptive Technology For Geriatric Mental Health

New York State is a leader on many health fronts, whether it be antismoking, obesity reduction, or insurance coverage. But our state is also a leader in another area: we are among the states with the greatest shortages in physician supply. According to the Healthcare Association of New York State, the deficits are especially large in rural areas, which lack both primary care physicians and specialists. This situation hits particularly hard in rural communities since primary care doctors may be their only source of health services, including those for mental health.

The prevalence of mental illness is not much different in rural and urban areas, but the lack of access to and availability of mental health services are particular challenges in rural areas.

According to the American Association of Family Practitioners, although mental health professionals are a key component to a patient’s total health, patients are more inclined to disclose signs of mental illnesses to primary care doctors. Yet, primary care physicians can be inadequately equipped to manage patients with behavioral health issues and have little access to back-up resources. For example, 93 percent of primary care physicians describe their problematic access to and communication with mental health specialists (in particular geriatric psychiatrists) as impediments to effective care for patients with dementia. As a result, primary care doctors may hesitate to diagnose and treat older adults in need of mental health care since this is not their area of expertise.

Exacerbating this problem is the following scenario: It is estimated that from 2000 to 2030, New York State’s older adult population will double, and the number of senior citizens with mental illness and dementia will grow dramatically. According to the New York State Office of Mental Health, the number of adults age sixty-five years or older will rise from 2.5 million to almost 4 million. The number of older adults with mental illnesses, including dementia, in the state will climb from 495,000 to 772,000. The costs associated with inadequate mental health and dementia care are profound. In 2013, the estimated cost of health care in New York State for all patients with dementia was $742 million.

Recognizing the impact of this “Silver Tsunami,” in 2014, the New York State Health Foundation awarded a $344,484 grant to the University of Rochester Medical Center to launch the Extension for Community Healthcare Outcomes in Geriatric Mental Health (Project ECHO GEMH) model to enhance primary care capacity to provide geriatric mental health services in rural and underserved communities of New York State.

Project ECHO, which originated at the University of New Mexico, is an innovative model of health care education and delivery that substantially improves the treatment of chronic and complex diseases for rural and underserved populations. Initially designed for patients with hepatitis C, Project ECHO has attained impressive results and has been adapted to numerous additional conditions including cancer, chronic pain, substance use, women’s health, diabetes, and HIV/AIDS.

In general, the ECHO model uses web-based videoconferencing to create “virtual grand rounds.” It connects specialists located at academic medical centers to rural primary care physicians. Through biweekly videoconferencing, didactic presentations, and case-based learning, specialists help primary care physicians develop expertise in a specific field, which they can then apply to patients at their clinic. As a result, primary care doctors deliver best-practice care to their patients, and the need to refer them to specialists is reduced.

With Project ECHO GEMH, the University of Rochester Medical Center will serve as an academic “hub” and will connect a team of its geriatric mental health specialists from medicine, nursing, social work, psychology, and pharmacy to “spokes” made up of primary care sites and individual providers. The only technology required on the part of the participating spoke site is access to the Internet and any device with a camera—a laptop, a webcam, a tablet, or even a cell phone. Led by Yeates Conwell and Michael J. Hasselberg, the project at this medical center will operate two-hour, biweekly TeleECHO clinics, which offer case-based educational experiences for community providers.

Given the projections of increased numbers of older adults and older adults with mental illnesses in New York State, and the long wait times to see specialists, the University of Rochester Medical Center is experiencing a high demand from primary care physicians. As of this writing, twenty-nine sites throughout rural upstate New York have expressed interest in participating in the pilot. If this trajectory continues, we will meet our goal of 175 rural primary care providers trained to provide better care for late-life mental disorders and dementia. Through Project ECHO GEMH, the expectation is that the quality of the care that the primary care doctors deliver will improve, costs of care will be reduced, and provider satisfaction will be high.

When Sanjeev Arora, the founder of Project ECHO, gave a presentation to the University of Rochester Medical Center and other stakeholders in Rochester, New York, he espoused the simplicity of the model. But, as with any “disruptive innovation,” there were some unanticipated challenges in the beginning of this New York project. For example, ensuring the compatibility of telecommunication systems for the sites required more work than originally envisioned. But in the end, none of the challenges were insurmountable, and the lessons learned from the experience have proven to be invaluable for work going forward.

Since the launch of ECHO GEMH there have been two important developments that may accelerate interest in the model. The first is the New York Department of Health’s Delivery System Reform Incentive Payment program’s specific encouragement to use the Project ECHO model (for various conditions) in its “Expand Usage of Telemedicine in Underserved Areas to Provide Access to Otherwise Scarce Services” application instructions.

The second is Gov. Andrew Cuomo’s (D) recent signing into law of legislation that requires insurers, including New York State’s Medicaid program, to cover telehealth services. It’s still too early to gauge the impact of these two developments, but at the very least, it highlights the momentum Project ECHO and other telehealth models are experiencing throughout New York State.

Other Health Affairs GrantWatch content about Project ECHO:

“Project ECHO Is Awarded $6.4 Million Grant For Diabetes And Endocrinology Care To New Mexico Underserved,” by Tracy Gnadinger, July 23, 2014.

“A Workforce That Can Do More: Project ECHO At Ten Years Brings Behavioral Health Care To Underserved Areas,” by John Lumpkin of the Robert Wood Johnson Foundation, July 8, 2013.

Health Affairs article on Project ECHO:

“Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care,” by Sanjeev Arora and coauthors, June 2011 issue. (free abstract)

Another Health Affairs GrantWatch blog post by Brian Byrd:

“Improving The Accuracy Of Wikipedia’s Medical Information,” December 9, 2014.

Diabetes Drug Metformin May Lower Glaucoma Risk

Study found people with highest dose were 25 percent less likely to develop eye condition

Non-Profit IDNs: Where’s Da Beef?

By GREGG MASTERS

I have followed this narrative for quite some time albeit inside the industry contained debate of whether so-called ‘non-profit’ [501(c)3] hospitals or their parent systems (really more aptly characterized as “tax exempt”) actually earn this financial advantage via material ‘returns’ to the communities they serve.

As can be expected you have the party line of the American Hospital Association (AHA) a trade group of predominantly non-profit members vs. that of it’s for-profit brethren The Federation of American Hospitals (FAH). You can guess which side of the argument each of them favor.

Now thanks to a recently published landmark study ‘Integrated Delivery Networks: In Search of Benefits and Market Effects’ by Healthcare Futurist Jeff Goldsmith, PhD et al, of the 501(c)3 cast of characters in the related but more often than not distinctly different ‘IDN culture’ we extend that line of inquiry into what has been a somewhat conversational ‘safe harbor of sorts’ – not any longer?

The Executive Summary notes both the rationale and basis to study the market ‘incident to’ a more focused pricing (via asset concentrations) power line of inquiry:

In January 2014, the National Academy of Social Insurance commissioned a study of the performance of Integrated Delivery Networks (IDNs), incident to its Study Panel on Pricing Power in Health Care Markets. The premise of this analysis was that any examination of the role that hospitals play in health care cost growth is complicated by the fact that in most large markets, the significant hospitals are part of larger, multi-divisional health enterprises. In these markets, hospitals may be part of horizontally integrated hospital systems operating multiple hospitals; vertically integrated health services networks that include physicians, post-acute services and/or health plans; or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums) like Kaiser Permanente. The latter two models are collectively labeled IDNs.

IDNs have very different stated purposes than mere collections of hospitals: to coordinate care across the continuum of health services and to manage population health. IDN advocates claim that these complex enterprises yield both societal benefits and performance advantages over less integrated competitors. The purpose of this analysis is to evaluate the evidence to support these claims.

And now for the less than surprising but wholly unacceptable answer albeit modestly caveatted by the limits of publically available information:

Despite more than 30 years of public policy advocacy on behalf of IDN formation, there is scant evidence in the literature either of measurable societal benefits from IDNs or of any comparative advantage accruing to providers themselves from forming IDNs. We have similarly found no such evidence in our analysis of 15 IDNs. Serious data limitations hamper anyone attempting to evaluate IDN performance based on publicly disclosed information. IDN financial disclosures obscure the operating performance of their hospitals and physician groups.

There does not appear to be a relationship between hospital market concentration and IDN operating profit [emphasis mine]. However, if the performance of the IDN’s flagship hospital is any indicator of overall systemic efficiency, the IDNs’ flagship hospital services appear to be more expensive, both on a cost-per-case and on a total-cost-of-care basis, than the services of its most significant in-market competitor.

This runs counter to the theoretical claim of IDN operating efficiency. Further, the flagship facilities of IDNs operating health plans or having significant capitated revenues are more expensive per case (Medicare case-mix adjusted) than their in-market competitors.

The authors would have greater confidence in these findings if they covered not only multiple years of information but also multiple institutions in the IDN portfolio (e.g. its suburban or rural hospitals, etc.). Further, the central question of whether IDNs have abused their market power in metropolitan markets can only be answered by examining actual service-specific payments to their hospitals by local health plans and by determining the profits generated by their hospital portfolio.

I am struck by the reaction or better yet absence of a reaction in public discourse let alone in health wonk or big data evangelists circles particularly at time when there’s been so much mis-direction and battle fatigue surrounding the endless debate/efforts at repeal of the Affordable Care Act.

Such a profound observation and ‘counter intuitive’ result (i.e., ‘hey, there may not be a there, there insight’) based on frequent accolades and ‘innovation’ recognition extended to such trophy name plates as Kaiser Permanente, Geisinger Health, InterMountain Health and so little public debate (see complete list) causes me to question whether we’re paying attention to what matters?

How can we intelligently debate, discern and buildout the qualities and characteristics of financing and delivery system platform efficacy and business model innovation that delivers on the triple aim and lays a solid foundation for a sustainable healthcare economy if we do not understand their root DNA and the results (“community benefit”) they ostensibly generate?

Anyone?

What Is Tummy Time and How Does It Help My Baby?

Tummy time helps your baby develop. Use these tips to do it safely and make it fun.

New Meds OK’d for Hard-to-Treat IBS With Diarrhea

The FDA has approved two new prescription medications to treat irritable bowel syndrome with diarrhea, or IBS-D. It’s the latest step in a years-long struggle to find safe and effective treatments for the condition.

Proactive Psychiatric Consultation For Hospitalized Patients, A Plan for the Future

The Yale Behavioral Intervention Team (BIT) is a proactive, multi-disciplinary psychiatric consultation service for all internal medicine inpatients at Yale-New Haven Hospital. The goal of the team, which includes nurses, social workers, and psychiatrists, is to shift from a “reactive” to a “proactive” paradigm of psychiatric consultations on hospital inpatient medical floors.

The team screens for, identifies, and removes/mitigates behavioral barriers to the effective receipt of health care among hospitalized medical patients, especially among those with co-occurring mental illness and/or substance abuse. To facilitate delivery of timely, effective inpatient medical care, the BIT collaborates closely with the medical team through formal and informal advice, co-management of behavioral issues, education of medical, nursing, and social work staff, and direct care of complex behaviorally disordered patients. The team also assists the primary medical treatment team as needed with transitions to the next level of care involving behavioral health services.

Standard “Reactive” Psychiatric Consultation Challenges

We implemented this change in our psychiatric consultation service paradigm because the standard “reactive” psychiatric consultation paradigm was not as effective as all the stakeholders wanted and needed. The Behavioral Intervention Team was created to address the following challenges to the hospital’s provision of care to medical patients with co-occurring psychiatric (also known as “mental” or “behavioral” health) or substance abuse issues:

1. Psychiatric problems have become a significant barrier to the delivery of efficient, high quality medical care, largely due to increased numbers of co-occurring psychiatric diagnoses, stigma, and lack of training and education among medical staff for handling psychiatric problems.
2. Psychiatric consultation requests were often too late to alter a full-blown crisis or were requested for issues that were trivial or inappropriate.
3. Psychiatric consultations were usually provided to the physicians in writing and had an air of formality that did not support the give and take of supportive education among peers.
4. Mental health clinicians were not reaching the people who spent the most time with the patients, namely the nurses.
5. Post-hospitalization transitions in care for mental health services were frequently poorly managed by the primary medical team without input from the psychiatric consultation team.
6. Health care workers without training in mental health care were increasingly experiencing distress and demoralization when they had to take care of psychiatric patients, thereby reducing their job satisfaction and work effectiveness.

Overall, the traditional, physician-focused psychiatric consultation service model is reactive and too slow to capture the fast-moving, complex elements of mental illness, creating havoc in a general medical ward. We needed a change.

Table 1 summarizes and compares some of the qualities of a proactive and reactive consultation service in psychiatry.

Table 1

The Experiment’s Beginning

We began by testing the hypothesis that patients could be screened rapidly and effectively at admission for psychiatric service needs and early “proactive” consultation. We asked whether such a system actually had an advantage over a “reactive” consultation.

For six weeks, we embedded a psychiatrist into the admissions process of a medical unit with a high rate of psychiatric co-morbidity. We focused our efforts on patients with co-morbid mental health and substance abuse disorders whose conditions, we believed, were hindering (or threatening to hinder) the provision of inpatient medical care. A psychiatrist went to the test unit every morning, screened all patients proactively, and usually provided consultation on the identified patients on the first or second day of their medical admission.

This six-week experiment produced surprising results. The length of stay for all admitted patients in the test unit for six months prior to our experiment was roughly four days, with a 9 percent consultation rate. During the proactive phase of the experiment, the consultation rate increased to 22 percent, and the length of stay decreased by almost 25 percent.

When the proactive phase stopped, and the test unit returned to the prior reactive approach, the consultation rate dropped to 13 percent and the length of stay increased to almost four days, as it was before the experiment. This single case study provided evidence of a potential cause and effect relationship between a proactive consultation model and reduced length of stay in medical services at Yale-New Haven Hospital.

Based on the successful results of this experiment, and with the support of the hospital administration, we created the Behavioral Intervention Team (BIT), a multi-disciplinary, proactive consultation, education, and management approach to address the behavioral service needs of medical inpatients. The BIT took on consultations and, when appropriate, co-management of complex psychiatric patients, educated the staff, and helped manage extra nursing care when additional supervision was necessary for specific patients. The BIT also managed the relationship with the insurance company when a required psychiatric bed was not immediately available.

To implement the BIT program, we assigned a half-time consulting psychiatrist, a full-time mental health clinical nurse specialist, and a full-time psychiatric social worker whom together covered roughly 75 inpatients on three medical units. In a subsequent 11-month study with a “before and after” design, the target medical units had a consultation rate of about 15 percent and reduced the length of stay by 0.65 days among medical patients with a psychiatric intervention. In addition, there was a 0.3 day length of stay reduction for all admitted patients in the medical units compared to the two years prior to implementation of the BIT model on the same units.

We believe this overall reduction in length of stay may be a function of the “curbside” effect of informal, non-billable consultations by the BIT, thereby improving the work efficiency of the medical personnel generally (i.e., nurses and doctors were consequently less burdened by unfamiliar aspects of care of psychiatric co-morbidities). The results of this work, authored by Sledge, Gueorguieva, Desan, Bozzo, Dorset, and Lee, are in press and are due to be published during 2015 in the journal, Psychotherapy and Psychosomatics. The ranges of conditions that were formally consulted upon are noted in Table 2.

Table 2

BIT’s Today

In the current and third iteration of the program, the BIT is on all eight general medical units at our York Street Campus, covering roughly 192 patients. There are two teams comprising between them 1.75 full-time equivalent (FTE) psychiatrists, two advanced-practice registered nurses (APRNs), and three social workers with a clinical nurse specialist who administers the teams.

In addition, there is robust weekend coverage of a social worker, a resident (24 hour coverage), and an attending psychiatrist who provides multidisciplinary, partially pro-active psychiatric consultations for the entire hospital (approximately 960 beds). The current BIT also helps manage the costly utilization of constant companions assigned to patients with acute behavioral issues (e.g., runaway patients and suicide precautions).

Today, the BIT screens daily for possible and active behavioral problems (e.g., substance abuse, mood and psychotic disorders, agitation, etc.) among all medical patients upon admission to the general medical services of the Yale-New Haven Hospital York Street Campus. Screening is based on review of admission notes from the electronic medical records and on patient’s interaction with the admitting nursing staff. This activity is carried out early in the morning by the APRNs or the social workers.

Upon identification of one or more active behavioral issues that could interfere with the delivery of effective, efficient inpatient medical service, a BIT clinician (APRN or physician) provides a formal psychiatric assessment and ongoing follow-up during the hospitalization. The BIT is designed to identify and treat/manage active behavioral problems at the earliest possible time during the hospitalization. As a result, decisions about which patients will receive formal assessment are made in a huddle at mid-morning. By focusing on early recognition, the BIT seeks to mitigate the effects of patients’ mental or substance abuse disorders on their physical recovery.

Concurrent with the clinical evaluation, the consulting BIT members educate their corresponding discipline personnel (physician to physician, nurse to nurse, and social worker to social worker) of the medical team on the salient clinical aspects of acute and chronic medical management of the particular patient. In addition, by embedding a mental health care provider in the inpatient medical setting, there is extensive “curbside” advice and informal collaboration among the BIT team and the primary medical team members for all patients with behavioral health problems, including those who would not otherwise receive care without formal psychiatric consultation. We consider this “curbsiding” a form of proactive, just-in-time education.

The BIT blends well with other hospital-based programs that attempt to manage length of stay and re-admission rates. Also, the presence of an effective and partially proactive BIT service on the weekend has had a substantial impact on the patient flow for the rest of the week. There are no longer long patient lists on Mondays and Fridays, and more patients are able to be discharged on the weekend and not forced to wait for “psychiatric clearance.”

Outcomes

We rigorously evaluate and measure outcomes. While we focus on reducing length of stay, we do not view such reduction as the main goal but rather as a proxy for the efficiency and effectiveness of the model. Reduced length of stay also pays for the intervention. Our ultimate goal is to improve the care of psychiatrically co-morbid medical patients in the hospital. The presence of an active mental illness diagnosis adds on average (depending on the setting) between 0.8 and 1.2 days to the length of stay in our settings. We seek to reduce this added burden to zero.

A commonly noted challenge of the BIT model is that it requires an extensive outlay for personnel costs that exceeds direct revenue generated by the heightened psychiatric clinical service. However, through cost-saving and revenue enhancement opportunities, we have demonstrated a return on investment ranging from break-even to four-to-one for every dollar spent.

The success of the BIT depends on a prospective payment system that rewards efficiency and reduction of expensive inpatient services. The power and effectiveness of the BIT model lies in mitigating and reducing the disruptive influence of mental illness on the daily clinical milieu of the medical staff and patients as well as reduction of prolonged and unnecessary hospitalization.

Our work has spawned other proactive, collaborative behavior-focused programs at Yale-New Haven Hospital, including a Sickle Cell Disease program. Recognizing the impact of behavioral health problems on the prolonged length of stay for Sickle Cell patients, the hospital developed an interdisciplinary “medical home” approach involving psychiatry, hematology, social work, and nursing.

Looking Ahead

In the future we aim to improve the effectiveness of the BIT program by developing standardized screening methods that can be more easily disseminated systematically and taught to others. We also want to explore the early introduction of active, specific mental illness treatments as needed, which can be a means of integrating general health and mental health services more effectively.

For example, a depressed patient might be able to start a course of medications while still in the hospital. The BIT of the future should also address the post-hospital outpatient phase. We believe this integration would improve the care of our patients by bridging the gap between the hospital and downstream treatment programs.

We intend to expand BIT throughout the Yale New Haven Hospital System and to implement new versions of BIT for specialized programs such as cardiovascular services and our cancer center. Patients with cardiovascular disease typically have short hospitalizations, so we will focus on proactive delivery of mental health services (particularly for depression and anxiety) and integration of their cardiac and mental health care in a rehabilitation program. Such a focus on transitions to cardiac rehabilitation will reduce subsequent re-admissions.

With cancer patients, we will focus on the acute distress of initial diagnosis along with neuropsychological changes and disruption of cancer treatments in the aftercare due to behavioral issues. We will integrate oncology and mental health services and, when needed, palliative care services. With cardiac illnesses, we will probably focus primarily on problems of depression, distress, and delirium, as these seem to be the most common disruptive diagnoses.

We believe that this method of providing proactive inpatient psychiatric consultation to hospitalized medical and surgical patients will prove to be a sustainable and perhaps even necessary paradigm shift in order to fully meet the triple aims of health care reform.

How to Recognize ADHD Symptoms at Every Age

Learn how to recognize ADHD symptoms in children, teens, and adults. WebMD tells you how.

The Latest Health Wonk Review

Last week, Julie Ferguson put up the latest Health Wonk Review at Workers’ Comp Insider. Julie offers a smorgasbord of great posts, including Preeti Malani’s Health Affairs Blog post on the intersection of politics and HIV in Indiana.

If you haven’t done so already, check out Steve Anderson’s Grumpy Cat Wonk Review edition, at the medicareresources.org blog, which preceded Julie’s pre-Memorial Day edition. And watch for next week’s Review, which will be hosted on June 4 by Louise Norris at Colorado Health Insurance Insider.

Creative Minds: Building a Better Electronic Health Record

By Dr. FRANCIS COLLINS

Is 5 too few and 40 too many? That’s one of many questions that researcher David Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.

Chan became interested in this topic when he was a resident at Brigham and Women’s Hospital in Boston, where he experienced the challenges of seeing many patients and keeping up with a deluge of health information in a primary-care setting. He had to write prescriptions, schedule lab tests, manage chronic conditions, and follow up on suggested lifestyle changes, such as weight loss and smoking cessation. In many instances, he says electronic reminders eased his burden and facilitated his efforts to provide high quality care to patients.

Still, Chan was troubled by the lack of quantitative evidence

that electronic reminders actually enable healthcare providers to provide better patient care, as well as by anecdotal evidence that too many electronic reminders may actually have a detrimental effect on care. Indeed, getting a better handle on the efficacy of electronic reminders is crucial as the US healthcare system continues its transition from paper to electronic health records. It’s been estimated that eight in 10 office-based physicians and six in 10 hospitals now use some type of EHR system, and that number continues to grow [1].

Now an assistant professor at Stanford School of Medicine, Palo Alto, CA and a physician-scientist with Veterans Affairs (VA) Palo Alto Health Care, Chan recently received an NIH Early Independence Award to explore the impact of EHR electronic reminders on the quality of primary care. His research will focus on the Veterans Health Administration (VHA), the country’s largest healthcare delivery system serving about 9 million enrollees at 150 hospitals and 819 community-based outpatient clinics. Because the VHA was among the first healthcare systems to adopt EHRs, it will provide Chan with an excellent window into the real-world experiences of doctors, nurses, and other healthcare professionals accustomed to working with electronic reminders.

Preliminary research by Chan shows that, depending upon the VHA facility, the same type of healthcare provider caring for the same type of patient may have to process as few as 5 or as many as 40 electronic reminders relating to preventive care and disease management. Building upon this work, Chan will study in greater detail how electronic reminders vary not only in number, but in topic breadth, complexity, and comprehensibility. Most importantly, he will analyze the impact of all of these factors upon the productivity and efficiency of healthcare professionals and the quality of care received by patients.

Such work is part of a much larger, ongoing NIH effort to generate the evidence base needed to guide the design, use, and evaluation of an ever-expanding array of health information technologies. For example, the recently announced Precision Medicine Initiative will enable volunteer participants to partner with researchers to develop creative new approaches for the gathering, use, and sharing of genomic, health, and lifestyle information via EHRs, mobile health devices, social media, and other electronic information platforms.

Reference:

[1] Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Furukawa MF, King J, Patel V, Hsiao CJ, Adler-Milstein J, Jha AK. Health Aff. 2014 Sep;33(9):1672-1679.

Links:

David Chan (Stanford School of Medicine, Palo Alto, CA)
NIH Director’s Early Independence Award Program
VA Palo Alto Health Care System
Precision Medicine Initiative (NIH)
HealthIT.gov (US Department of Health and Human Services)

Francis S. Collins, M.D., Ph.D., was officially sworn in on Monday, August 17, 2009 as the 16th director of the National Institutes of Health (NIH). Dr. Collins was nominated by President Barack Obama on July 8, and was unanimously confirmed by the U.S. Senate on August 7.

Narrative Matters: On Our Reading List

Editor’s Note: “Narrative Matters: On Our Reading List” is a monthly roundup where we share some of the most compelling health care narratives driving the news and conversation in recent weeks.

The One In 40,000

Parents think their children are one in a million, but Liz Savage knows what it means to have your child be the statistical anomaly. One in 40,000 measles, mumps, and rubella (MMR)-vaccinated patients will be affected with immune thrombocytopenia purpura.

Her son, whom she refers to as “Oscar” in her story for Slate, “My Son, the Statistic,” was hospitalized with low platelet counts, as his body adversely reacted to the immunization. Oscar recovered, and despite the stress of the ordeal, Savage says she’d still vaccinate him again.

“I had to weigh my fear of ITP [immune thrombocytopenia purpura] against a lifetime of worrying that he could contract measles anytime we went on vacation, to the park, or to the grocery store.”

The measles vaccine, she points out, has reduced the number of measles cases by 99 percent. “The anti-vaccine movement spreads a misguided belief that expertise is overrated,” she writes. “[Experts] aren’t perfect, and neither are vaccines. But together they are saving countless lives every day.”

Mental Illness, The Silent Killer

Doris A. Fuller didn’t see the symptoms of mental illness when her daughter Natalie was a junior in college. “I had no frame of reference to recognize them,” she writes in her essay for The Washington Post, “My Daughter, Who Lost Her Battle with Mental Illness, is Still the Bravest Person I Know.”

Onset of mental illness peaks between the ages of 18 and 25, but she attributed Natalie’s erratic behavior to jet lag and typical college drama. But after a diagnosis of severe bipolar disorder with psychosis, Natalie embarked on a six-year journey of treatment and, when she refused medication, relapse.

“Each time she … relapsed, she plunged into a longer free fall, hitting the ground harder, recovering more slowly and returning to a lower plateau,” Fuller wrote. Natalie ended her life in March, a few weeks before she would have turned 29.

Amidst her grief, Fuller was contacted by a postdoctoral fellow at Johns Hopkins, who wrote that: “Natalie will help our society to move forward. She is helping us to look at mental illness with the respect, the compassion and the dignity it deserves.”

Doctor, Motivate Thyself

Scott Berman doesn’t practice medicine anymore, but he misses it every day, even as he acknowledges there has been a shift in the ways physicians voice their dissatisfaction with the profession: griping versus whining. “Griping” he characterizes as voicing common complaints without any intention of quitting. “Whiners,” by contrast, are looking for a way out of their predicament.

In his essay “Gripers and Whiners” for the Journal of the American Medical Association, Berman recommends that doctors become stronger activists for patient care.

“It is time for us to stop whining that someone else, the hospital administrator, the insurance company, the nursing staff…is at fault. We need to find the fortitude to just say, ‘we’re mad as hell and we’re not going to take it anymore.’”

Berman includes his father’s story of staying overnight in a hospital holding unit without medications or food. The nursing shortage and the physician who “chewed out” the one available nurse were both complicit in bad care, Berman writes. Doctors need high moral standards, he concludes, and a willingness to go the distance for every patient.

The “Person” In “Personalized Medicine”

“No one paid much attention to her pain,” Jerald Winakur writes of a 91-year-old woman who fell in her garage, in his opinion piece in The Washington Post, “We Need To Take Better Care of Our Elderly.”

The woman, who is later revealed to be Winakur’s mother, triggered her emergency alarm necklace, and then spent the following days in the hospital, with a series of doctors and nurses rotating in and out of her room, as her sons stood by, encouraging her to eat.

“No one asked her about her advance directive,’” Winakur writes. “No one came to give the old woman a bed bath for more than a week. No one repositioned her. No one came in the middle of the night to put a hand on her forehead or to ask ‘Are you able to sleep?’”

The nurses said they had once performed such tasks, but no longer have time. Winakur, whose work has appeared in Narrative Matters previously, believes our entire health care system must change how it treats the elderly and redefine truly “personalized care” for patients.

“The skillful application of compassion and empathy it takes to do this work will—in the end—benefit us all,” Winakur concludes.

End-Of-Life Paperwork

Advance directives may not be sufficient for a patient to receive their specific health care requests when the time comes, Jessica Nutik Zitter writes in, “The Right Paperwork for Your End-of-Life Wishes,” published on The New York Times’ Opinionator blog.

Zitter recounts the story of a patient in the intensive care unit, hooked up to a ventilator as his daughters come running, waiving his advance directive in the air and insisting their father be taken off all machines.

‘“He made us promise,’” they said. Advance directives vary by state, however, and their purpose is “to chart the broad strokes, to delineate the guiding principles,” Zitter writes.

A better option for specific end-of-life requests is a Physician Orders for Life-Sustaining Treatment, or Polst form, which details specifications for the use of certain treatments, such as breathing machines, when full recovery is unlikely. After a conversation with the patient’s daughters, Zitter took the patient off the ventilator and sent him home on hospice, “to be with his family for the precious time he had left.”

Rehab Gone Awry

In a harrowing tale about the unregulated aspects of drug and alcohol rehabilitation units, John Hill tells the story of Ryan Rogers, a 28-year-old seeking treatment for alcoholism who died at the Bay Recovery treatment center. “The Rehab Racket: The Way We Treat Addiction is a Costly, Dangerous Mess,” in the May/June issue of Mother Jones, reveals that due to a lack of national standards, the state-by-state regulation of treatment facilities means that many places are in desperate need of oversight and lack evidence- or science-based approaches to treating patients.

Many patients seeking treatment cannot find availability or cannot afford the often-astronomical prices. Many health insurers do not cover the cost, though the author notes that the Affordable Care Act has started to change that. Bay Recovery’s executive director, Jerry Rand, had his medical license suspended several times and had been placed on probation for “gross negligence and incompetent treatment” of a patient, yet had been allowed to stay in business.

Rogers died in rehab from acute respiratory disease, likely linked to the combination of prescribed medications he had been taking. Bay Recovery was closed down, but without increased access and affordability of quality care centers, many addicts, like Rogers, will struggle to find a solution.

In Case You Missed It

In this month’s Narrative Matters’ essay, Patricia Gabow, a physician and former CEO of Denver Health, writes about her desire to deviate from standards of care to provide care better suited to her 94-year-old mother with dementia after she sustains a fall.

In “The Fall: Aligning The Best Care With Standards of Care At the End of Life,” Gabow finds that the standards of care she had spent so much of her career championing no longer seemed to fit the bill when it came to her mother’s wishes.

Gabow suggests that “we can better align the standards of care with the best care, especially at the end of life.”

Cholera

Cholera: An infectious disease characterized by intense vomiting and profuse watery diarrhea and that rapidly leads to dehydration and often death. Cholera is caused by infection with the bacteria Vibrio cholerae, which may be transmitted via infected fecal matter, food, or water. With modern sanitation, cholera is no longer as common as it once was, but epidemics still occur whenever people must live in crowded and unsanitary conditions, such as in refugee camps. The disease is treated with intravenous fluids and with antibiotics. Cholera has also been known as Asian cholera, due to its one-time prevalence in that area of the world.

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
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For Kids Who Stutter, Rhythm Perception May Be Key

Expert says study emphasizes brain differences in those with speech problem

Health Affairs Web First: Are Marketplace Enrollees Sicker Than Those With Employer-Sponsored Insurance?

To date little is known about the health status of the 7.3 million Americans who signed up for health insurance through either federal- or state-run exchanges created by the Affordable Care Act (ACA). One effective way to gain information is to examine their use of prescription drugs.

A new study, being released by Health Affairs as a Web First, compared prescription data from January to September of 2014 of more than one million Marketplace enrollees. The study reviewed the characteristics and medication use of early enrollees (October 1, 2013 through February 28, 2014) and those enrolling later (between March 1 and May 31, 2014), and compared those findings with a sample of some one million Americans enrolled in employer-sponsored health coverage.

There were three key findings, which have implications for understanding the impact of the ACA. According to the study, those who signed up earlier were on average four years older and used more medication than later enrollees. Additionally, the authors found that prescription drug spending among Marketplace enrollees as a whole was lower than in the comparison group: $72 versus $93 per month during the nine-month study period. Finally, Marketplace enrollees were nearly four times more likely to use HIV medications and had 36 percent higher out-of-pocket expenses for specialty medications than did the comparison group.

Data for the study were gathered from Express Scripts, Inc., the largest pharmacy benefit manager in the United States, to compare the characteristics and medication use of more than one million Marketplace enrollees with a matched sample in employer-sponsored insurance plans.

“Our descriptive analysis, which showed lower medication use among Marketplace enrollees relative to a comparison group with employer-sponsored coverage, suggest that the ACA Marketplaces did not experience adverse selection in their first year,” conclude the authors.

“However, we cannot necessarily rule out adverse selection…[because] some of the differences in usage between Marketplace and comparison group enrollees may be attributable to the extended time it can take previously uninsured Marketplace enrollees to obtain care and have unrecognized conditions diagnosed and treated.”

This study, by Julie Donohue, Eros Papademetriou, Rochelle Henderson, Sharon Glave Frazee, Christine Eibner, Andrew Mulcahy, Ateev Mehrotra, Shivum Bharill, Can Cui, Bradley Stein, and Walid Gellad, will also appear in the June issue of Health Affairs. It was supported through a contract from Express Scripts, Inc. to the RAND Corporation.

Donohue is affiliated with the University of Pittsburgh; Papademetriou is with the Eliassen Group in New Jersey; Henderson is affiliated with Express Scripts in St. Louis, Missouri; Glave Frazee is with the Pharmacy Benefits Management Institute in Plano, Texas; Eibner, Mulcahy, Stein, and Gellad are affiliated with the RAND Corporation; Mehrotra is with Harvard Medical School; Brahill is an undergraduate at the University of Michigan, in Ann Arbor; and Cui is a doctoral candidate at the University of Texas at Austin.

Health Affairs Web First: Early Marketplace Enrollees Were Older And Used More Medication Than Later Enrollees; Marketplaces Pooled Risk

To date little is known about the health status of the 7.3 million Americans who signed up for health insurance through either federal- or state-run exchanges created by the Affordable Care Act (ACA). One effective way to gain information is to examine their use of prescription drugs.

A new study, being released by Health Affairs as a Web First, compared prescription data from January to September of 2014 of more than one million Marketplace enrollees. The study reviewed the characteristics and medication use of early enrollees (October 1, 2013 through February 28, 2014) and those enrolling later (between March 1 and May 31, 2014), and compared those findings with a sample of some one million Americans enrolled in employer-sponsored health coverage.

There were three key findings, which have implications for understanding the impact of the ACA. According to the study, those who signed up earlier were on average four years older and used more medication than later enrollees. Additionally, the authors found that prescription drug spending among Marketplace enrollees as a whole was lower than in the comparison group: $72 versus $93 per month during the nine-month study period. Finally, Marketplace enrollees were nearly four times more likely to use HIV medications and had 36 percent higher out-of-pocket expenses for specialty medications than did the comparison group.

Data for the study were gathered from Express Scripts, Inc., the largest pharmacy benefit manager in the United States, to compare the characteristics and medication use of more than one million Marketplace enrollees with a matched sample in employer-sponsored insurance plans.

“Our descriptive analysis, which showed lower medication use among Marketplace enrollees relative to a comparison group with employer-sponsored coverage, suggest that the ACA Marketplaces did not experience adverse selection in their first year,” conclude the authors.

“However, we cannot necessarily rule out adverse selection…[because] some of the differences in usage between Marketplace and comparison group enrollees may be attributable to the extended time it can take previously uninsured Marketplace enrollees to obtain care and have unrecognized conditions diagnosed and treated.”

This study, by Julie Donohue, Eros Papademetriou, Rochelle Henderson, Sharon Glave Frazee, Christine Eibner, Andrew Mulcahy, Ateev Mehrotra, Shivum Bharill, Can Cui, Bradley Stein, and Walid Gellad, will also appear in the June issue of Health Affairs. It was supported through a contract from Express Scripts, Inc. to the RAND Corporation.

Donohue is affiliated with the University of Pittsburgh; Papademetriou is with the Eliassen Group in New Jersey; Henderson is affiliated with Express Scripts in St. Louis, Missouri; Glave Frazee is with the Pharmacy Benefits Management Institute in Plano, Texas; Eibner, Mulcahy, Stein, and Gellad are affiliated with the RAND Corporation; Mehrotra is with Harvard Medical School; Brahill is an undergraduate at the University of Michigan, in Ann Arbor; and Cui is a doctoral candidate at the University of Texas at Austin.

White Matter Damage in Brain May Help Spot Early Alzheimer's

Study finds widespread changes using specialized MRI

Competitive Harm From State Licensing Boards: First North Carolina Dentists, Now Texas Physicians

What should be a new era of medical board governance has begun with what looks more like a finger to the eye of the U.S. Supreme Court. On May 22, a federal district judge in Austin, Texas heard arguments to determine whether a rule adopted earlier in the month by the Texas Medical Board should take effect on June 3. No decision on a temporary restraining order has yet been issued, but the hearing offered a preview of litigation likely to arise under federal antitrust law as it was recently clarified by the nine justices.

In February 2015, the Supreme Court decided North Carolina State Board of Dental Examiners v. Federal Trade Commission, a case involving “cease and desist letters” sent to non-dentist teeth whitening businesses. By a 6-3 vote, the Court subjected professional licensing boards with a majority of members from the regulated profession to antitrust lawsuits unless they are “actively supervised” by the state itself.

The dispute in Austin pre-dates the Supreme Court’s ruling. For several years, the Texas Medical Board has been in litigation with Teladoc, a Dallas-based company that contracts with licensed Texas physicians to provide telephonic consultations to patients in the state. Teladoc physicians sometimes prescribe medications during those sessions, a practice that the Texas Medical Board has attempted to eliminate by an increasingly stringent set of interpretations and amendments to its longstanding Rule 190.8, which quite reasonably prohibits prescribing unless a physician-patient relationship has been established.

Each of these actions was challenged by Teladoc under state administrative law, including the Board’s adoption in January of an “emergency rule” that was stayed by the courts for lack of a demonstrated emergency. To settle the issue, the Board amended the Rule at its May meeting to require an in-person physical examination by the physician or presentation of the patient to the physician by another health professional using a high-resolution video connection. Because 12 of the Board’s 19 members are licensed physicians, and the Board’s action is not “actively supervised,” the new Rule 190.8 fits squarely within North Carolina State Board and is subject to review under the federal antitrust laws.

At the hearing, however, the fact that the Teladoc litigation had morphed from administrative law to antitrust law was lost on the Texas Medical Board’s lawyers. Based on the case it presented, the Attorney General’s office seemed unclear on the concept of competition being unlawfully hindered by licensing board action. The Assistant Attorney General arguing on behalf of the Board brushed aside Teladoc’s challenge on the ground that “practitioners are always looking for new avenues of attack on regulation,” and even claimed it was “kind of a distortion to be talking ‘business’” — entirely missing the point that established practitioners were being accused of abusing their regulatory privileges to insulate their existing business models from competition.

Indeed, the language of competition seemed alien to the Board’s attorney, even though the Attorney General’s office employs an expert cadre of antitrust litigators in other matters. He spoke mainly in terms familiar to the profession, such as “standard of care” and “medically necessary,” and offered his own impromptu opinions on what can happen if physicians aren’t forced to take every precaution. More worrisomely, he cited state Medicaid coverage rules as validating the Board’s restrictions on private physician practice (they don’t), and argued that a medical restraint of trade cannot be “unreasonable” and therefore prohibited by the Sherman Act unless no reasonable physician would support it (it can).

Whether or not the judge issues a preliminary injunction in the Teladoc case, similar challenges to state licensing board action are likely to proliferate. The Supreme Court understood this when it decided North Carolina State Board, and the Texas Medical Board’s apparent obliviousness to competition proves that the Court made the right call and that antitrust oversight is needed.

Looking Forward

Over the next months to years, we can expect several important questions to be raised and debated in antitrust litigation involving state licensing boards. Are all rules at risk, or only those that demonstrably favor the interests of the active market participants who control the board? Drawing on the Supreme Court’s 1999 ruling in the California Dental Association case, must a plaintiff prove a complete case under the “rule of reason” or may a court condemn a licensing board’s practice after only a “quick look”? What procompetitive benefits may be asserted in defense of a challenged rule beyond the established profession’s views regarding quality or safety? Can “consumer confidence” from the existence of comprehensive professional regulation be considered a procompetitive benefit, even if that regulation appears excessive or unjustified?

As more private plaintiffs sue state licensing boards under the federal antitrust laws, other novel issues will arise. To his credit, the Texas Assistant Attorney General identified some of these in his presentation. Does state sovereign immunity under the 11^th Amendment to the Constitution constrain or prohibit suits for injunctions or damages involving bona fide state agencies that the federal antitrust laws now treat as private parties? (Teladoc sued the Board as a whole, and also sued each of the Board members who voted in favor of the new rule both as individuals and in their official capacities.) How will plaintiffs prove “antitrust injury” when action is being taken by a licensing board rather than by entities with whom the plaintiff is doing or wants to do business? Will these legal hurdles be easier to surmount when a board has adopted a blanket rule involving many potential competitors, as opposed to taking disciplinary action against a single competitor?

Most importantly, how should states “actively supervise” professional licensing boards in order to protect them and their members from repeated suit? Should states provide for direct legislative or executive branch review and validation of formal board action on a regular basis? Might states work together to develop a uniform state law setting forth supervisory “best practices” that each state could adopt after modification to suit its individual circumstances and philosophies? Should Congress intervene, as it did in the late 1980’s after the Supreme Court ruled that hospital medical staffs were not immune from antitrust liability?

In the near term, federal courts hearing antitrust challenges will be asking state licensing boards some unfamiliar and uncomfortable questions about the evidence supporting their professional judgments. Licensing boards are often loath to interfere with the judgment of their mainstream licensees. Texas Rule 190.8, for example, did not specify exactly how a physician-patient relationship must be established until Teladoc’s practices became known, and the Board still inexplicably allows “on-call” physicians covering for patients’ regular physicians to prescribe medication after a phone call. As the judge in Austin observed, there has to be “something more than ‘we’re doctors, trust us.’”

Only the Texas Medical Board knows why it adopted this particular rule at this particular time. It seems doubtful that preventing competition was its major goal. On the other hand, the rule doesn’t seem necessary to protect patients either. Like many legal disputes, the years-long battle between Teladoc and the Board probably has a lot to do with strong personalities and entrenched positions. But in a health care system desperately in need of access, efficiency, and innovation, how it plays out will matter to us all.

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A Shout Out For Our Sponsors: Health Catalyst

By MATTHEW HOLT

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