Vol. 100 November 1, 2013 Paranoia and Other Scary Bits

November 1, 2013

Cheney cartoon

“Just because you’re paranoid doesn’t mean they aren’t out to get you.”
– Joseph Heller, Catch 22

Even the powerful can get paranoid
Former Vice President Dick Cheney recently said during a “60 Minute” interview that he had his cardiologist turn off the wireless function in his implanted pacemaker “in case a terrorist tried to send his heart a fatal shock.” Years later, he saw that scenario played out in an “Homeland” episode. (1) We knew that his DC residency was pixellated in the Google satellite view. We wondered if he was on the NASA phone surveillance list, but then we remembered that he ordered that.

Sometimes “They” are right
Surveys of over a million people nationwide revealed that Northeast people were described as “irritable, impulsive, and quarrelsome”. Ever drive in Boston? Midwest and Deep South people were considered “conventional, friendly, sociable, compliant, and emotionally stable”, while the West weighed in as “creative and relaxed, reserved, and perhaps somewhat distant.” Well, California IS distant from Boston and New York. (2)

“Whenever physicians are talking about quality, they are talking about money”
From 2005 to 2010 the urology practices that owned a new radiation technology (IMRT) for treatment of prostatic cancer used IMRT twice as much as urologists who did not own the machine so had to refer patients to others for IMRT. Treatment of prostatic cancer with IMRT cost about $31,000 as compared to about $16,000 for surgery or implantation of radioactive seeds. (3)

“I can’t find a primary care physician!”
In 2006 the Association of American Medical Colleges (AAMC), fearing a future doctor shortage, recommended a 30% increase in medical school slots. That goal may be reached by 2016. BUT, there has been no federal support for increased residency training slots. The AAMC states that there is currently a 15,000 shortage of residency training slots. Medicare funding of Graduate Medical Education (GME) is the major support of residency training, and it was reduced by $11 billion during the ACA debates. It is unlikely to be restored during the 2014 budget debates.  “Physician shortages may become more apparent as the ACA’s coverage expansion takes hold.” (4)

“Not another new flu?!”
Chinese health officials announced in March that a “novel” influenza A virus (H7N9) had infected 132 people and that 37 of them had died. BUT, there has been no evidence of human-to-human transmission and very few of the 20,000 Chinese with flu-like illness actually showed infection with H7N9.  A new element in the tracking of the virus was the recognition of huge spikes in tweets containing the word “H7N9” in both Chinese and English. “Digital Disease Surveillance” is the new term.

Why does a state refuse federal money via Obamacare to subsidize its Medicaid program ?
The New England Journal of Medicine says there are 33 such states, and John Stewart says there are 26. These states are declining to set up health insurance marketplaces (“exchanges”) under Obamacare (ACA) and have acquiesced to the federal government to do so. As a result these states will NOT receive the ACA federal subsidy (up to 100%) of their Medicaid costs for the next three years. John Stewart’s incredulous search for a common denominator of why these states would “bite off their nose to spite their face” came up with only one, a Republican governor and/or a Republican-controlled legislature. (5)

“Umpires are always ruling against my team!”
A study of a million pitches in or near the strike zone, but not swung on, revealed that umpires are less likely to call close ones against batters who are catchers. Presumably due to the rapport that the two develop over long hours of being in close proximity.  Also, the strike zone for the next pitch when the count is no balls and two strikes is apparently 26% smaller than the strike zone when the count is 3 balls and no strikes.(6)

There is no free lunch…or free drugs.
Coupons for free prescription drugs were available in 2011 for nearly 400 brand-name drugs or about 11% of all brand-name prescriptions. 75% of the coupons were for drugs treating chronic conditions (those needing six months or more of treatment), and 58% of those brand-name drugs had lower-cost alternative drugs available. By the time the brand-name coupons expire or run out, the pharmaceutical companies seem to hope that the patient has developed a loyalty for it or resists a change to a lower cost equivalent because of its perceived effectiveness.(7)

“I could be killed by lightning playing golf in the rain.”
Who would think otherwise with all those golfers out there swinging metal golf clubs under big antenna-like umbrellas in the rain? It turns out that anglers, campers, and boaters account for more of the 152 fatal lightning strikes over the past seven years than golfers.  About half of the anglers and boaters were struck while seeking safety. The others were clueless and presumably victims of a “bolt from the blue.”

Fear of terrorism
Polls taken in Boston after the Marathon bombings indicate that more people think that “such attacks are likelier, but fewer live in dread of them.”…”In the United States since 9/11 Islamic terrorism has resulted in the deaths of 37 people. During that same period, ten thousand times that many have been killed by guns wielded by their countrymen or themselves.” (8)

“Will my baby’s flat head harm the brain?”
The American Academy of Pediatrics 1992 recommendation to reduce sudden infant death (SIDS) by having the infant sleep on his/her back has worked. The incidence of SIDS has dropped by 50%, but referrals to subspecialty clinics for plagiocephaly (flat head) have increased.  In a recent study of four Canadian communities 47% of 440 infants had observable plagiocephaly (a flat side of the head). Most were mild and needed no treatment, but the mothers probably stayed worried until time and normal activity rounded things out. (9)

References:
1. Boston Globe, 10/26/2013, report from interview on “60 Minutes”
2. Boston Globe, 10/27/13, report from Journal of Personality and Social Psychology
3. NEJM, 369;17,  October 24, 2013
4. NEJM, 369;4,  July 25, 2013
5. NEJM, 369;13, September 26, 2013
6. Boston Globe, 7/122/13, report from “Social Pressure at the Plate: Inequality, Aversion, Status, and Mere Exposure”
7. NEJM 369;13,  September 26, 2013
8. The New Yorker, May 20, 2013, p. 36
9. Pediatrics 2013 Aug; 132:298


Vol. 65 April 15, 2012 First ACOs Appear with a Whimper, Not a Bang.

April 15, 2012

Medicare just released the names of the first Accountable Care Organizations (ACO), a major innovation of the Affordable Care Act (ObamaCare). ACOs apply to and are approved by the federal government as participants in the Medicare Shared Savings Program :

“All ACOs that succeed in providing high quality care – as measured by performance on 33 quality measures relating to care coordination and patient safety, use of appropriate preventive health services, improved care for at-risk populations, and the patient experience of care – while reducing the costs of care – may share in the savings to Medicare.”

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 In the world of health care providers there has been much consternation, gnashing of teeth (maybe other body parts too), and exuberant, expert speculations about what an ACO was going to look like and by what means  the ACO program was going to “revolutionize American medicine” as promised by Washington.

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 The first 27 ACO’s are surprisingly underwhelming. None of them have been developed by the “big boys” with name recognition in the medical marketplace, unless you happen to live in Caldwell County, North Carolina, coastal Georgia, or Hackensack NJ . Half are small physician-led organizations. Less than half appear to involve hospitals. All totaled they cover less than 1% of Medicare patients. Only two of the twenty-seven are willing to take limited risk of losing money (“going over budget”) in return for the potential of sharing in more savings (“providing care under budget”).

Medicare beneficiaries (patients) will continue to be able to see ANY provider and unless the provider boasts about it or otherwise publicize it, the patient may not know that his or her physician is a member of an ACO. In my local community the physicians organization took out a full-page ad in Sunday’s paper to “congratulate” themselves on being selected as an ACO. This particular physicians organization has had a contentious business relationship with the local hospitals for ten years, plans to cover only the minimum of 5,000 Medicare patients, and finds itself in competition with a recently spawned physician-hospital organization.

Another physicians organization formed just this year in a neighboring county plans to cover 6000 Medicare patients and does not involve its community hospital. The hospital itself is in a fierce, cost-cutting competition with a larger hospital up the road  just 15 miles closer to the academic medical centers who are courting it for a merger.

Both situations illustrate how complicated the medical/political/economic environment is for these initial ACOs.

Is this meager initial blossoming of ACOs due to bureaucratic complexity and uncertainty,

(“In conjunction with the final rule, the Department of Health and Human Services Office of Inspector General, the Department of Justice, the Federal Trade Commission, and the Internal Revenue Service issued separate notices addressing a variety of legal issues as they applied to the Shared Savings Program.  These included the interaction of the Shared Savings Program with the federal anti-kickback, physician self-referral, civil monetary penalty (the fraud and abuse laws) and antitrust laws, as well as the Internal Revenue Code regarding the tax implications for nonprofit entities seeking to participate in ACOs.  The final rule, the notice of the Advance Payment ACO Model, and the regulatory guidance on fraud and abuse were published in the Nov. 2, 2011 Federal Register.”)

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 OR does it herald the appearance of an actual “new model of lean and mean care organization led by entrepreneurial physicians”,

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 OR is it just one more step in our historically incremental evolution towards a system of universal health care?

Maybe the next 150 ACOs to be announced in July 2012 will give us more of a clue.

Stay tuned.


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