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Should Doctors Be Allowed To Self-Refer?

Federal law generally prohibits physicians from referring their own patients to a diagnostic facility in which they have an ownership issue — a practice called “self-referral” — unless the facility is located in their own practice. This exemption exists to allow patients with access to a laboratory test, X-ray, or other imaging test at the same time and place as when patients are seeing their physician for an office visit. Less inconvenience and speeder diagnosis and treatment — what could be wrong with that?

Much, say the critics, if it leads to overutilization and higher costs and doesn’t really represent a convenience to patients. This is the gist of two studies by staff employed by the American College of Radiology, published in the December issue of Health Affairs.

One study analyzes Medicare claims data and concludes that patients aren’t really getting “one-stop-shopping” convenience when their physician refers them to an imaging facility that qualifies for the “in-office” exemption.

“Specifically, same-day imaging was the exception, other than for the most straightforward types of X-rays. Overall, less than one-fourth of imaging other than these types of X-rays was accompanied by a same-day office visit. The fraction for high-tech imaging was even lower — approximately 15 percent.” Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

Healthcare Repeal: How Would It Affect Coverage And Cost?

[Soon] the new GOP-controlled House of Representatives will be voting on and is expected to pass a bill to repeal the Affordable Care Act (ACA) — lock, stock, and barrel. There is virtually no chance the repeal bill will get through the Senate, though, which maintains a narrow Democratic majority, and President Obama would veto it if it did.

But let’s say that the seemingly impossible happened, and the ACA was repealed. What would the impact be on healthcare coverage, costs, and the federal deficit?

In a letter to Speaker John Boehner (R-OH), the Congressional Budget Office (CBO) released its preliminary estimates of the impact of repeal on the deficit, uninsured, and costs of care, and found that it would make the deficit worse, result in more uninsured persons, and higher premiums for many:

— Deficit: repeal of the ACA would increase the deficit by $145 billion from 2012-2019, by another $80 to $90 billion over the 2020-21 period, and by an amount “that is in the broad range of one-half percent of the GDP” in the decade after 2019* — or about a trillion dollars. Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

Doctors, Patients, And “Remote Third Parties”

From the ominously-titled book “New Rules” by Donald Berwick, M.D., and Troyen Brennan M.D.:

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care…is to constrain decentralized individualized decision making.”

Unfortunately, Dr. Berwick’s straightforward formulation of the appropriate role of the individual physician in our reformed healthcare system is not isolated to thinkers of the Progressive persuasion. The notion that most clinical decisions can be usefully made by a centralized authority is attractive even to some conservatives.

For example, a few years ago the noted economist Arnold Kling strongly defended the idea. “My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.”

Now, Kling is no far-left radical, pushing for centralized control of healthcare (and everything else). Indeed, he is now with the Cato Institute, and before that he taught economics at George Mason University. So he has earned his conservative and/or libertarian chops.

And to be fair, he is not really calling here for “remote third parties” to have final authority on what’s best for individual patients. Rather, he thinks patients should make that decision for themselves, weighing the recommendations of data-driven guidelines promulgated by remote experts, against the ego-toss’d recommendations from their all-too-fallible doctors, or, as Kling sarcastically refers to them, their “heroic personal saviors.” (Such sarcasm, regular readers will know, is as abhorrent to DrRich as it probably is to you.) Kling is saying: Trust patients, armed with good evidence-based recommendations handed down from experts, to make the right decisions for themselves. Read more »

*This blog post was originally published at The Covert Rationing Blog*

Another Look At Geographic Variation In Poverty And Healthcare

MedPAC has released another report in which they have tried to explain variation in healthcare utilization among metropolitan statistical areas (MSAs), of which there are approximately 400. MSAs more-or-less correspond to Dartmouth’s 306 hospital referral regions (HRRs), and the conclusions reached by the Dartmouth folks and MedPAC tend to correspond. In commenting about MedPAC’s last report, issued in December 2009, I noted that the major variation was caused by high Medicare expenditures in seven southern states, where patients are poorer and sicker and use much more care.   

In their new report, MedPAC went a step beyond measuring expenditures, which they adjusted for prices and other factors in their last report, to measuring the actual units of service, a far better way to assess the healthcare system. MedPAC’s new findings on the distribution of service use in MSAs are graphed below:

Based on this new approach, MedPAC concluded: “Although service use varies less than spending, the amount of service provided to beneficiaries still varies substantially. Specifically, service use in higher use areas (90th percentile) is 30 percent greater than in lower use areas (10th percentile); the analogous figure for spending is about 55 percent. What policies should be pursued in light of these findings is beyond the scope of this paper, which is meant only to inform policymakers on the nature and extent of regional variation in Medicare service use. However, we do note that at the extremes, there is nearly a two-fold difference between the MSA with the greatest service use and the MSA with the least.” Read more »

*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*

First Report From The Society of Participatory Medicine’s Newly-Appointed Public Policy Committee Chair, David Harlow

In December, the Society for Participatory Medicine’s executive committee appointed health law attorney David Harlow to represent the Society in public policy matters. Regular readers of HealthBlawg::David Harlow’s Health Care Law Blog know what a patient-centered, participatory thinker David is. This is his first report.

David HarlowI am delighted to offer my first report as Public Policy Committee Chair for the Society of Participatory Medicine. I encourage all of you who are not yet Society members to join, and I encourage new and old members to consider volunteering to help with the wide range of public policy issues facing us today.

Over the past couple of months, the Public Policy Committee has gotten its sea legs. We are beginning to add the Society’s voice to the national discourse on patient engagement in a formal manner. As planning for health reform and related initiatives becomes more concrete, it is clear that patient engagement and patient-centeredness are key issues to be considered. For example, it was encouraging to hear Centers for Medicare and Medicaid Services (CMS) Administrator Don Berwick speak about the “Triple Aim” at the Accountable Care Organization (ACO) workshop this fall, and explicitly link the achievement of the triple aim — better care for individuals, better health for populations, and reduced per-capita costs — to patient engagement and empowerment.

There will be many opportunities for the Society to engage with policymakers, payors and provider organizations as this work continues. CMS and its many related organizations, as well as many provider and private sector payor organizations recognize that without maintaining a focus on the patient at the core, health reform and related health IT initiatives cannot be successful. We’ve kicked things off on two fronts — ACOs and Stage 2 Meaningful Use rules. Read more »

*This blog post was originally published at e-Patients.net*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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