Dr. George Taler makes house calls!

The Washington Hospital Center-based physician belongs to an intrepid tribe of providers that are reviving a lost art one tongue-depressor at a time. 

Back in the 1930s, 40% of all encounters with physicians occurred in the home, but that number dropped to 10% by 1950, and 1% by 1980, according to Helen Kao and colleagues whose article appears in Clinics in Geriatric Medicine.

Patients preferred to visit hospitals and clinics, which were perceived to be modern wonders, jam-packed with gee-whiz diagnostic tools and treatments that became the sine qua non of medicine in the second half of the century.

Or, as Kao’s team put it, “house calls became old fashioned.”

Financial incentives also drove the migration. Physicians who opted for lucrative, technology-driven specialties found themselves tethered to the facility-based machines, while PCPs deduced that they could triple visit counts by having patients come to them rather than the other way around. 

Then, about a decade ago Medicare began facilitating payment to physicians who made home visits to the elderly and chronically ill, and sweetened their reimbursement pot by 50%.

Since then, physician home visits have risen from 1.5 million to 2.2 million.

“There is growing interest,” Constance Row told the Washington Post. The executive director of the American Academy of Home Care Physicians added it’s a “win-win situation for everyone. It is one of those things that patients, their families and caregivers want and also something that (could) save money.”

And ironically, technology–which helped undermine house calls 50 years ago–now assures that physician home visits are more productive than ever.

Nowadays, physicians carry laptops, electronic medical records, portable EKG machines, and ultrasound machines right into the bedroom.

Playing fast action video games, including first-person shooter games can boost ones’ ability to perceive subtle differences in shades of gray.

Contrast sensitivity like this is the primary factor that determines how well a person can see.

Daphne Bavelier and colleagues at the University of Rochester and the Eye Institute at Tel Aviv University probably had no problem rounding up 22 young adult volunteers for her study of these matters.

After assessing the participants’ visual contrast sensitivity, the scientists randomized them into 2 groups and asked them to play assigned video games for 50 hours during a 9 week intervention.

The test group played 2 action video games, “Unreal Tournament 2004″ and “Call of Duty 2.” Controls played “The Sims 2″ which was visually complex, but had a slower pace and did not require precise, visually guided aiming activity.

After the volunteers had skipped the light fandango and turned cartwheels ‘cross the floor for 9 weeks, action game players were found to have improved by 43% their ability to discern between shades of pale. There was no change in the Sims group.

 “Normally, improving contrast sensitivity means getting glasses or eye surgery—somehow changing the optics of the eye,” Bavelier told BurrillReport. “But we’ve found that action video games train the brain to process the existing visual information more efficiently.”

The improvements held true for 2 years after the “training” had ended. The write-up is in Nature Neuroscience.
 
The scientists’ findings extended Bavelier’s earlier research showing that action video games reduce visual crowding and increase visual attention.

They concluded that action video game training may complement standard eye-correction techniques by teaching the visual cortex to better use the information it receives.

Scouting video on the Big O confirms he doesn’t just lean left politically.

Interestingly though, 5 of the last 7 presidents have been left-handed including Ford, Reagan, Bush the semi-reasonable, Clinton and Obama. Only Carter and Bush II went right.

That seems odd given that only 10% of humans are lefties, but it’s probably just a statistical fluke.

Even if it wasn’t, no one knows whether or how left-handedness impacts factors that drive electoral success like political skill, smarts, charisma, appearance, insider connections, and wealth. 

And before lefties start popping their collars, they’d be well to remember they’re at increased risk of accidental death not to mention a possibly increased risk for some psychiatric diseases. 

It’s not clear why some people become left-handed, although genes are clearly involved. About one-quarter of the sons of left-handed parents are left-handed, whereas only 10% of boys who have right-handed parents end up as southpaws.

But genes aren’t the whole story since 20% of identical twins have different handedness.

Non genetic effects on handedness can be demonstrated in chickens, in whom brain lateralization is driven by light penetrating the shell during incubation.

In most chick embryos, the right eye is exposed to light. These chickens end up being more adept at identifying food and prey with their right eye, and are better able to detect predators and potential mates with their left eye.

If the eggs are incubated in darkness however, the resulting adults don’t lateralize this way.

When scientists reported that sun-splashed vacations stimulate nevi development in kids and that nevi counts predict lifetime skin cancer risk, some figured maybe caving is the way to go for a solar-free, wholesome family interlude.

But that’s not going to work now that federal officials have warned people to stay out of caves from New Hampshire to West Virginia, where up to half a million bats have died from White Nose syndrome.

The Fish and Wildlife Service issued the unprecedented request after raising the possibility that humans were unwittingly spreading the fungal infection when they explored multiple caves.

The disease does not appear to affect people, so this is strictly a Save the Bats deal.

The bizarre bat condition is named for the granular fungal eruptions that appear on the schnozzles and wings of hibernating bats.

Somehow the fungus causes afflicted bats to deplete their winter fat stores prematurely and they die in their sleep.
 
Scientists worry that a massive bat die-off could trigger an insect population bomb which could damage apple, wheat and a dozen other crops.

The proposed voluntary moratorium on caving would cover states adjacent to affected areas, so the affected swath actually stretches from Maine to North Carolina and Virginia to Ohio.

Recreational cavers were bewildered by the scope of the ban.

“The ramifications are mind-boggling. I guess we’re all just trying figure out what to do,” Peter Youngbaer, the White Nose syndrome liaison for the National Speleological Society told the New York Times.

Just 2 years ago, Big Pharma fielded 102,000 sales reps. That number has already dropped to 92,000 and it’s headed to 75,000 by 2012, according to Chris Wright, a principal at ZS Associates.

That’ll save $3.6 billion for the beleaguered pharmaceutical companies, who are dealing with desiccated drug pipelines, patent expirations on blockbusters, blood thirsty politicians, and populist rages against the industry…and that’s before breakfast.

Decisions to make the cutbacks haven’t been that difficult since sales force effectiveness is way down.

Nowadays, only 37% of the drug reps who visit medical practices get to place products in the sample cabinet, and a measly 20% speak directly to a physician, according to TNS Healthcare.

About 25% of physicians belong to a practice that bans the reps altogether, and that was before new regs prohibited them from distributing tchotchkes!

“The old sales model is broken now, and who knows how it will look in the future,” Peter Nalen told AmedNews.

The president of Compass Healthcare Communications added “what’s happening is that pharmaceutical companies are realizing there are other ways to reach the doctor instead of banging on the door of the doctor who just doesn’t want to talk.”

Ari Silver-Isenstadt persuaded his Baltimore pediatrics practice partners to adopt a “no soliciting” policy for drug reps. “More than half of us doctors still just have a feeding frenzy of reps in our offices,” he told AmedNews.

“We should be ashamed of ourselves for allowing such an intertwining of our patients’ best interests with the convenience and niceties of drug reps.”

But Ken Johnson, a senior VP for the Pharmaceutical Research and Manufacturers of America disagrees.

“Interactions between physicians and pharmaceutical company representatives benefit patient care through the exchange of information about new medicines, new uses of medicines, the latest clinical data, appropriate dosing and emerging safety issues,” he insisted.

Last year, officials working for the Dalai Lama in India asked cybercrime experts to come have a look at their computers, which they suspected had been infected by malware.

Yessiree concluded the specialists, but that was just the tip of the iceberg.

The cybersleuths uncovered a global electronic spying operation that had infiltrated 1,295 computers and ripped off documents from government and private offices in 103 countries.

Computers in several embassies, foreign ministries and the Dalai Lama’s Tibetan exile centers in several countries were hit. US government systems were not violated, so far as is known.

According to a report released by Greg Walton and colleagues at the University of Toronto, the spy system, dubbed GhostNet, was controlled by computers based largely in China.

GhostNet remains operational, invading a dozen new computers per week, according to the report.

Its malware can activate video- and audio-recording functions in infected computers, so the thieves can see and hear what’s going on in the room housing the infected hardware. 

And GhostNet has impacted world events, at least a bit. For example, shortly after the Dalai Lama’s office sent an email invitation to a foreign diplomat, the Chinese government called the diplomat to discourage the visit.

Yet the researchers cautioned against concluding China’s government was directly responsible for the shenanigans.

“We’re careful about (ascribing blame), knowing the nuance of what happens in subterranean realms,” Ronald Deibert told the New York Times.

“This could well be the CIA or the Russians. It’s a murky realm we’re lifting the lid on,” added the associate professor of political science at the University of Toronto.

Meanwhile, a spokesman from the Chinese Consulate in New York scoffed at insinuations his government was involved. “These are old stories and they are nonsense,” Wenqi Gao told the Times. “The Chinese government is opposed to and strictly forbids cybercrime.”

Valencia, California- based MannKind has submitted a New Drug Application to the FDA to market AFRESA, an inhaled insulin product for the treatment of adults with diabetes mellitus. 
 
MannKind’s actions come in the aftermath of a spectacular flame-out by Exubera, Pfizer’s inhaled insulin product that was once touted as a blockbuster but ended up being pulled from the market in 2007 after physicians rejected it as too costly and no better than injectible insulin. 

“If you have low impact needles and very good regimens that work in my clinic or my hospital, why should I change what I do?” Michael Schulman, an editor with ChangeWave Research told BurrillReport at the time.
 
Exubera was also saddled with safety concerns. Some worried the stuff diminished lung function. Then, about a year ago Pfizer alerted physicians that 6 of 4,740 Exubera users developed lung cancer. All had been cigarette smokers, but the fat lady sang after that.
 
MannKind has addressed the safety concerns with data showing that AFRESA doesn’t accumulate in pulmonary tissue as did its predecessor, and that it doesn’t affect lung function.

And MannKind intends to pitch AFRESA as having physiologic effects that mimic endogenously released insulin more closely than its injectible counterparts.  
 
AFRESA has a more rapid onset of action and is cleared more quickly than any other exogenously administered insulin.

It achieves peak effect 12-14 minutes after inhalation. If it’s taken at the right time, that pattern matches almost exactly the effects of endogenously released insulin release in response to a meal.
 
MannKind has begun discussions with potential distribution partners.

“There’s a lot of interest,” MannKind VP Matthew Pfeffer told Burrill. “The world changes when you have positive phase III data and you have filed an NDA.”

23.6 million people in the US and 246 million people worldwide have diabetes.

With apologies to GE, Disney and the 8 US citizens who remain optimistic about prospects for our health care system.

Welcome to the US Health Care Carousel of Progress!

Normal carousels just spin ’round and ’round and don’t get you anywhere, but ours is different.

The Health Care Carousel makes progress every year.

And progress isn’t simply moving forward, it’s working together and dreaming and assuring better health care for all.

Progress is the whiz-BANG of an MRI machine in use for the evaluation of a 22 year old with a headache. It’s the drug-induced smile on the face of a woman that became depressed after losing her home to foreclosure.

Progress is the rhythmic lub-dupp of a heart beating normally following a transplant for preventable cardiac disease. It’s the sound of an uninsured child wheezing in a crowded emergency room.

Why, you can hardly imagine all the amazing gadgets they’ve got in ERs nowadays!

Remember the sixties when folks got their exercise doing the Twist? Well, today we keep our cholesterol down with pills!

And our food safety system has never been better.

Our generation may be the first in 300 years to experience a decrease in life expectancy, but think how much worse it would be without $10,000 cancer drugs and blood thinners that prevent complications from hardware we’ve inserted into people’s bodies.

It’s never been easier to find a PCP, and would you believe it? They’re building our city’s 17th PET scanner right where that run-down urban health clinic used to be.

You should hear physicians rave about how those newfangled EMRs save them time.

And progress even has a smell! It’s the smell of money lining the pockets of a hundred-thousand physicians that have been bought off by Big Pharma.

With all these marvels, it’s hard to believe things could get better than they are right now. But as you join us for a spin around our Carousel of Progress, you’ll surely agree. Anything’s possible.

Ethics
In a referenced essay titled, Transparency in the Pharmaceutical Industry, Brain Blogger’s Jennifer Gibson describes how the impending passage of the Physician Payments Sunshine Act has motivated Big Pharma to disclose financial relationships with physicians. She warns there may be adverse consequences from this otherwise laudable development: some physicians will be discouraged from forging socially beneficial collaborations with the private sector.

Last week, the FDA’s Psychopharmacologic Drug Advisory Committee unanimously rejected AstraZeneca’s application to market its atypical anti-psychotic drug Seroquel for generalized anxiety disorder and major depression.

Merrill Goozner at GoozNews applauds the decision, but wonders whether the agency may have left itself open to charges of bias by seating a patient representative on the panel who had lost a son to cardiac arrest while taking the drug. 

Health Care Renewal contributor Roy Poses has reviewed an unseemly side show to the Madoff scandal. The antagonist is Ezra Merkin, a hedge fund director charged with fraud for misrepresenting his investment strategies.

Merkin and Madoff had served on the board of Yeshiva University, which lost $110 million to the Ponzi scheme. Their unholy alliance leads Poses to consider possible negative consequences of having too many financial types on the boards of academic institutions.

Insurance
In the latest chapter of her neverending odyssey to navigate Big Insurance and the health care system generally, Colorado Health Insurance Insider’s Louise Norris describes what happened when her husband needed knee surgery. The savvy couple planned for every contingency, yet still they encountered a system failure in the form of an out of network charge.

Jaan Sidorov at Disease Management Care Blog has proposed a frightening, unintended consequence of health care reform which is that private health insurers might, like AIG, become too big to fail.

Sidorov thinks creation of a new public insurer will prompt a wave of consolidation in Big Insurance, and the remaining behemoths will seek cover in the form of regulatory oversight from the Feds.

Over at The Health Care Blog, Brian Klepper has contributed a wide-ranging historical perspective on efforts by Big Insurance to control health care cost escalation.

After characterizing utilization review and PCP gatekeeper systems as well-intentioned but poorly executed efforts, he proposes that tricked-out workplace-based clinics (“onsite clinics”) may be a solution, and cites facilities on the premises of Cigna as shining examples.

He concludes however, that the proof will be in the pudding. After all, everyone thought UR and gatekeepers were good ideas, too.

There’s a great, big, beautiful tomorrow,
Shining at the end of every day

There’s a great, big, beautiful tomorrow
And tomorrow’s just a dream away

Man has a dream and that’s the start
He follows his dream with mind and heart

When it becomes a reality
It’s a dream come true for you and me

Access, Cost Escalation
InsureBlog’s Bob Vineyard reviews interim results from Massachusetts’ much publicized universal health care plan, which many believe should be a model for national health care reform.  The plan has left at least 200,000 state residents uninsured while utterly failing to rein in costs. And to make it right Vineyard warns, Bay state lawmakers are either going to have to squeeze providers even more or (gasp!) ration care.

At Managed Care Matters, Joe Paduda has posted a dispassionate, fact-based treatise designed to calm the knee-jerk anxiety that normally surrounds concepts like universal health care and rationing.

He points out for example that Big Insurance already engages in rationing through pre-certification processes, provider agreements and so forth.

He then dismantles the claim that universal health care leads to longer waiting times for care. Paduda concludes that if we manage to institute such programs, “access will go up and waiting times may well go down.”

Amid a fusillade of jabs and an occasional uppercut to the jaws of the Big O and his admirers, JD Bell reveals over at It Takes Work that Howard Dean has launched a web site to promote his own vision for health care reform.

According to Bell, Dean is concerned the Big O is waffling on his campaign promises, and wants nothing more for the American people than what Obama promised them prior to November 4.

Writing for Workers’ Comp Insider, Jon Coppelmen observes that employers’ most effective tools for managing comp losses vanish after they lay off employees. The trust, indeed the entire relationship between employer and former employee, is lost. This leaves claims adjusters, who are typically overworked and not properly incented, to manage workers’ compensation costs.

With unemployment approaching historical levels, Copplemen’s antidote, three proactive steps employers can take to manage the regrettable situation, is timely indeed.

Quality and Safety
A recent NEJM article on the cost and quality implications of readmissions has prompted Maggie Mahar to review the subject over at Health Beat. Mahar summarizes the views of White House budget director Peter Orszag and others on the matter, and then offers several home-grown suggestions about how to tackle the problem.

Mahar explores for example, the concept of bundling payments to hospitals and physicians who are responsible for care immediately following discharge, and directing special attention towards states in which the readmission problem is particularly severe.

Novo Nordisk had been prepared to discuss cardiovascular complications at last week’s FDA advisory panel meeting regarding liraglutide, its new diabetes drug, but instead the drug’s association with rare tumors of the thyroid drove the discussion.

Jeffrey Seguritan at Nuts for Healthcare summarizes the surprising development then expands into an informative discussion of the efficacy with which drug trials assess cancer risk.

There’s a great, big, beautiful tomorrow,
Shining at the end of every day

There’s a great, big, beautiful tomorrow
And tomorrow’s just a dream away

Man has a dream and that’s the start
He follows his dream with mind and heart

When it becomes a reality
It’s a dream come true for you and me

Legal
HealthBlawg’s David Harlow is generally supportive of the deal struck by CVS and Google, in which prescription data from the retail pharmacy giant can now be directly imported into Google Health, the search giant’s personal health record. On balance Harlow says, the gains in patient safety and quality outweigh the increased risk of breaches in patient confidentiality, at least for people who have not recently given birth to octuplets or are named Britney Spears.

Health IT
When a healthcare journalist came down with a touch of bronchitis, he blew off the last vendor meeting at HIMSS and went to the doctor.

His encounter underscored a yawning gap between today’s reality of spotty EMR adoption and a future-state of nirvana that has been promised by so many. 

The real-life story appears at Niel Versel’s Healthcare IT Blog.

We hope Neil feels better, by the way.

At the Health Business Blog, David Williams has posted a transcript of his interview with Wayne Guerra, the co-founder and chief medical officer of Healthagen, the maker of a way-cool iPhone application known as iTriage.

In the interview, Guerra explains how his mobile triage and health information tool can be used, the types of people most likely to benefit from it, and how he hopes to monetize the idea.

The Healthcare IT Guy invited Paul Nuschke, a software design expert at the IT consultancy Electronic Link to comment on the subject of EMR usability. Nuschke asserts there are three keys: the EMR should be easy to learn, efficient, and prevent errors automatically.

Nuschke appends a series of baffling screen shots which make it laughably clear that some of the mainstream players in the space aren’t quite there yet.

Policy
Over at the Healthcare Economist, Jason Shafrin asks, “Why have disability rates decreased?” To answer the question, Shafrin reviews a scholarly piece from the National Bureau of Economic Research. He notes that the apparently heartening trend has occurred despite an increasing burden of illness in the general population. The beneficial trends, he concludes, are attributable primarily to non-medical advances like “internet shopping, amplifying devices for phones and street ramps” rather than health care-specific interventions.

Damn, we thought we had something there for a moment.

Actual US Health Care Carousel of Progress:

Warfarin has ruled the roost for decades as the oral drug of choice for preventing venous thromboembolism. Now, there’s a new kid on the block and it has a chance to get real big.

Last week, an FDA advisory panel voted 15-2 to recommend that the agency approve rivaroxaban for short-term prophylaxis against VTE in patients that have undergone hip or knee replacement surgery.

Typically, the FDA follows the recommendations of its advisory panels.

Rivaroxaban is the result of a JV involving Bayer and Johnson & Johnson.

Industry experts believe that rivaroxaban could generate $200 million in sales for the orthopedic use, but the real prize lies with a large population of patients who take warfarin chronically for stroke prevention and sundry cardiac indications.

“This is Act 1 of a multiact play,” Rick Wise, a Leerink Swann analyst told the New York Times.

UBS Securities analyst Bruce Nudell estimated for example that rivaroxaban could generate $6 billion in annual revenue by completely supplanting the generically-available warfarn, unlikely though that may be.

Physicians and patients alike have chafed for decades at the nuisance factor associated with taking warfarin. The drug requires frequent blood tests to assure proper dosing and has this annoying tendency to cause bleeding and death.

Problem is, the new kid might not be much better in this regard. Trials comparing it with enoxaparin, an injectible anticoagulant, showed it to be better at reducing blood clots but saddled with nearly twice the incidence of major bleeding events.

That’s why panelist Sanjay Kaul voted against approving the new kid. “I saw a risk-benefit ratio which was a washout,” the Cedars Sinai cardiologist told the Times.

Seattle Semi-Pro Wrestling has entertained bar patrons in the Pacific Northwest for 6 years with its lampoons of World Wrestling Entertainment.

The cast includes Ronald McFondle, a raunchy rendition of a the iconic hamburger peddler who finishes off opponents with a lewd gesture and a vainglorious fellow named Deevious Silvertongue who looks like a cross between David Bowie and Liberace.

The characters grapple on foam padded stages, or at least they did until the Washington State  Department of Licensing classified the show as “sports entertainment,” meaning the SSP had to post a $10,000 bond, hire medical personnel to monitor events, and buy a regulation wrestling ring.

The SSP, which has no money to speak of, plans to appeal the ruling but has halted matches in the meantime.

“It’s a bunch of grown men and women in costumes pretending to be professional wrestlers,” David Osgood, the league’s lawyer told the Wall Street Journal. “It is to wrestling as ‘West Side Story’ is to actual gang relations.”

To which department spokesperson Christine Anthony countered that pro wrestling “is just as much theater as these guys claim to be.” The department considers the WWE to be sports entertainment and requires it to have a license to perform in the state.

The smackdown was prompted by a fallout involving the league and The Banana, one of its characters. Apparently, Paul Richards, who played The Banana, left the league upon hearing of plans to sideline his character.

The league had named Lucas Keyes to be The Second Banana, a sidekick to The Banana, and planned to have The Second Banana betray and then defeat The Banana.

Richards stormed off rather than lose his status as the top banana, according to the Journal.

That might have been the end of it, but then Richards found out that SSP members were ridiculing him behind his back, so he notified the licensing department that he believed SSP was violating the law.

In his appeal, Osgood will argue the ruling threatens everything from jello wrestlers to actors engaging in a sword fight in “Hamlet.”

“We’re in ‘Looney Tunes’ territory here,” he told the Journal.