One month after MinuteClinic struck a heady deal to link EMRs with the Cleveland Clinic and one week before the US government announced a health emergency due to Swine flu, the CVS Caremark subsidiary announced it planned to shutter 16% of its locations during spring and summer, normally the off-season for colds and flu.
Industry experts claimed that poor business performance during these periods represented “a structural flaw” in the retail clinic business model, and predicted a gloomy future for all but those with storefronts in close proximity to, or otherwise affiliated with hospitals and physician groups.
That’s because provider-associated retail clinics have large enough catchment populations to sustain themselves year-round, or at least offset lower off-season traffic with business at other venues and facilities.
MinuteClinic’s decision risks nullifying the very image of convenience that drives success in the first place, according to Tom Charland, CEO of Merchant Medicine, a consultancy specializing in retail clinics.
“You can’t preach convenience and consistency out of one side of your mouth and then have it sort of up in the air as to whether that clinic is open or not,” Charland told AMedNews.
With over 500 stores, MinuteClinic is the largest retail clinic chain in the US. It’s not clear whether other clinic chains will follow suit, or how the Swine flu scare might shuffle the deck.
The retail clinic business is not for the faint of heart.
On average, it takes 3 years before outlets turn a profit, and many fold before then.
CheckUps for example, closed 23 of its Wal-Mart housed clinics in January 2008, and last summer SmartCare shuttered 15 venues which had also been housed in Wal-Mart.
Nearly 25% of Americans live at least an hour from an Emergency Department that’s equipped to save lives in the event of a heart attack, stroke, bacterial bloodstream infection or major trauma.
To reach this conclusion, Brendan Carr and colleagues from the University of Pennsylvania School of Medicine queried the National Emergency Department Inventories–USA to identify the location and visit volume for all EDs in the country.
They estimated driving distances, driving speeds and population density, and measured ED access as the total population that could reach any particular ED within specified time intervals.
The scientists determined that 71% of Americans can access an ED within 30 minutes, and 98% can do so within an hour. But many of these facilities can’t handle the life-threatening stuff. Only high volume EDs are staffed, trained and equipped to do that.
In Montana for example, just 8% of the population resides within an hour of an ED that sees at least 3 patients per hour.
“Whether you are bleeding to death from an injury, having a heart attack or a stroke, the common denominator is time,” lead author Brendan Carr told BurrillReport.
The assistant professor of Emergency Medicine and Epidemiology added “in life-threatening emergencies, we must rely upon the system to deliver us to the care that we need.”
“If we knew what services were provided where, we could design a system that would do that everywhere in the country.”
The scientists suggest EMTs should be empowered to bypass the closest hospital in lieu of facilities better equipped to handle appropriately sick patients, ED facilities at rural hospitals should be beefed up, and incentives should be offered for physicians to practice in remote locations.
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.
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 GoozNewsapplauds 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.
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
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.
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
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.
As a result of their remarkable 3-year effort, Massachusetts lawmakers increased by 430,000 the number of people with health insurance in the state.
That leaves only 2.6% of Bay Staters uninsured, which is one-sixth the national average and by far the lowest rate in the nation.
Not only that, the legislators, working in synchrony with then Governor Mitt Romney, enacted the law faster than a Harvard Club Eight.
They pulled off the coup by deferring for another day the matter of controlling health care cost escalations which everyone knew would accompany the move.
That other day is here.
Massachusetts will spend $600 million more in 2009 on health insurance than it did in 2006, a 42% bump.
So Governor Deval Patrick has decided to completely overhaul the process by which the state’s insurers reimburse providers.
His proposal emphasizes prevention and chronic disease management in lieu of the current system, which pays fee for service.
If he pulls it off, the achievement would be every bit as audacious as the universal coverage plan itself.
Massachusetts after all, boasts more physicians per capita than any other state, and its vaunted academic medical centers have cut sweet deals with insurers.
Patrick recently chided the latter. “Frankly,” he told the New York Times, “it’s hard for the average consumer to understand how some of these companies can have the margins they do and the annual increases in premiums that they do.”
Patrick’s persuasive powers have worked, at least temporarily. Insurers who want in on the state’s subsidized insurance program submitted bids for 2009 that were so low, officials reported they can keep premiums flat this year.
But policy experts argue that to truly control cost escalations, government needs to cap budgets and yes, ration care.
“Really controlling costs requires just stopping spending,” Brandeis health policy expert Stuart Altman told the Times.
In January, the Hawaii Medical Service Association began offering Internet-based “house calls” in which physicians communicate with patients using streaming video, text chat or phone.
HMSA-covered patients pay $10 for a 10-minute exchange but anyone can get the same 10 minutes in heaven for $45.
Boston-based American Well is choreographing that show, and now other companies have entered the market.
SwiftMD offers services in the New York-New Jersey area and TelaDoc is giving it a go in Dallas.
They have to be careful though since physicians’ licenses to practice medicine are good only for the issuing state.
And the scope of practice matter is dicey for the new tool, so the companies are going slowly.
SwiftMD for example lists on its site the ailments in its wheelhouse: allergies, colds and flu, rashes, things like that.
The very young and very old are not eligible, nor are those with pregnancy-related issues or serious mental health issues like psychoses.
Big Apple resident Leah Light received a subscription to SwiftMD as a gift from her mom.
Light takes prescription meds for an anxiety disorder.
She recently used the service to refill her prescription.
The online visit lasted 55 minutes and cost $55 with a discount.
Last time she did things the old fashioned way. The doctor visit was time-consuming and set back the uninsured graduate student $260.
“I feel reassured (that) if I need to talk to a doctor, I can without having to blow my food budget for a month,” Light told the Journal. “It makes me feel a lot better.”
With the dentist shortage nearing crisis proportions in Maine, 2 of the state’s primary care residencies have begun to train physicians how to do simple dental procedures like lancing abscesses and pulling teeth.
The Pine Tree state has 4 times more physicians than dentists and that means there’s only one dentist for every 2,300 people.
The national average is a dentist per 1,600 people.
“Doctors typically say, ‘say aah,’ take a look at the back of the throat and are done,” William Alto told the New York Times. Alto is a physician at the Maine Dartmouth Family Practice Residency in Fairfield, home to one of Maine’s dental clinics for medical residents.
Maine is a largely rural state and dental school grads are even less prone to opt for such practice settings than their med school brethren. It doesn’t help that the state has no dental schools; the closest ones are in Boston, an hours’ drive with a tailwind from the state’s southernmost point.
Since Maine’s dental training programs began in 2005, 2/3 of residents graduating from these particular programs have set up shop in rural or remote areas.
“I see dental complaints all the time,” Andrew Fletcher confirmed for the Times. Fletcher learned some dentistry during his medical residency and now works up near the Canadian border.
“It’s mostly Medicaid patients who don’t have money to see dentists,” he added.
The Maine Dental Association supports the program but would rather recruit real dentists to the state. Said executive director Frances Miliano, “medical residents are only going to be doing this in dire circumstances. It’s not a total solution by any means.”
The American Cancer Society has reported yet again that African-Americans are more likely to develop and die from cancer than all other groups.
Cancer mortality in black men and women is 33% and 16% higher than in whites respectively, and these yawning gaps haven’t closed a bit since at least 1981, according to Ahmedin Jemal, a co-author of the report.
A key reason for the disparity is that whites tend to get diagnosed at an earlier stage in the disease, when chances for a cure are higher.
But it’s also true that blacks are less likely to receive high-quality treatment, Peter Bach told USAToday.
The Sloan-Kettering oncologist had shown in 2004 that physicians treating black cancer patients were less likely to be cancer specialists and to have access to the latest diagnostic imaging facilities.
Blacks also tend to have lower educational levels, and that makes a big difference regardless of race. In the ACS study, cancer mortality for people with a high school education or less was twice as high as that for people who attended college.
And if that’s not enough, blacks tend to exercise less and are more likely to be obese than whites. These are both major risk factors for cancer. And they receive fewer colonoscopies and other cancer screening tests, and on and on and on.
“This study shows a real disparity in mortality between the haves and the have-nots in this country,” Jemal concluded.
In 2005, Wal-Mart employees had to work 2 years before qualifying for the company health plan, which most considered to be an expensive joke, anyway.
Then, an activist group publicized a confidential company memo saying that health expenses could be cut by not hiring sick people.
This was going down just when towns were protesting store openings, unions were underwriting nasty campaigns, teachers were telling students to take their back-to-school business elsewhere and the company’s stock price was languishing.
But the world’s largest company has made great strides since then.
First, Wal-Mart cut the wait to enroll in the health plan to one year for part-timers and 6 months for full-timers. That made 50,000 more employees eligible in one year.
Then it expanded the menu of insurance coverage options and extended to some employees a credit of up to $500 to offset any health-related expense.
Next, it extended its popular $4 generic drug plan from the 350 drugs available to consumers to greater than 2,000 for employees.
The retailer subsequently cut a preferred-provider deal with Mayo Clinic of all places to cover transplant services for its employees.
The company’s latest foray, Life with Baby, targets premature birth rates among Wal-Mart employees, which are twice the national average.
Expecting moms get paired with a nurse who advises them on diet, smoking, stress reduction and the like. Lactation counseling and vaccination programs are available to moms after that.
“Wow, it was really good. It helped me so much,” Cristina Majano told the Washington Post. The 23-year-old new mom works for Wal-Mart in Virginia.
Nowadays, only 5.5% of Wal-Mart employees lack health insurance. That’s much lower than the national rate, which is 18%.
Hurricane Katrina was hell on Charity Hospital, but things haven’t improved much since the day it left patients stranded in sweltering, unsanitary conditions with no power and vanishing supplies of water, food and medicine.
Charity was the place where caregivers stored bodies in hallways because the morgue was flooded, and made horrible decisions about patients for whom they could not comfort, let alone care for properly.
It’s been 3 ½ years since Katrina and now the ghost of Charity stands in silence, surrounded by a chain-link fence and barbed wire, boarded up like a set for a B-grade horror movie.
Until the storm, the 70-year old facility had been the go-to place for the city’s poor and uninsured. It was the only Level One trauma center in town and by far the most important site for training new physicians.
But plans to replace the gigantic structure and restore these services are dead in the water. The hang-up according to USA Today, is money.
Louisiana requested $492 million in disaster aid from the federal government. It wants to pick up the balance on a $1.2 billion downtown medical center.
But FEMA contends Charity was neglected and in disrepair before the storm. Disaster aid doesn’t cover that, so it countered $150 million, or $51 million more than what it calculated were the costs of storm-related damage.
Nothing’s going to happen until the stand-off is settled, according to LSU’s general counsel Raymond Lamonica. The dispute is likely headed to court.
Meanwhile, the state is focusing on site-designs and buying land for a new Charity. “That’s going to take a couple of years,” Lamonica said. “Hopefully by then we’ll have our money.”
Pizaazz encourages the posting of comments that are pertinent to issues raised in our posts. The appearance of a comment on Pizaazz does not imply that we agree with or endorse it.
We do not accept comments containing profanity, spam, unapproved advertising, or unreasonably hateful statements.
Subscribe Feed (RSS)
One month after MinuteClinic struck a heady deal to link EMRs with the Cleveland Clinic and one week before the US government announced a health emergency due to Swine flu, the CVS Caremark subsidiary announced it planned to shutter 16% of its locations during spring and summer, normally the off-season for colds and flu.
The retail clinic business is not for the faint of heart.
To reach this conclusion, Brendan Carr and colleagues from the University of Pennsylvania School of Medicine queried the National Emergency Department Inventories–USA to identify the location and visit volume for all EDs in the country.
The assistant professor of Emergency Medicine and Epidemiology added “in life-threatening emergencies, we must rely upon the system to deliver us to the care that we need.”
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 
And ironically, technology–which helped undermine house calls 50 years ago–now assures that physician home visits are more productive than ever.
Normal carousels just spin ’round and ’round and don’t get you anywhere, but ours is different.
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.
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.
Jaan Sidorov at 
At 
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.
Not only that, the legislators, working in synchrony with then Governor Mitt Romney, enacted the law faster than a Harvard Club Eight.
So Governor Deval Patrick has decided to completely overhaul the process by which the state’s insurers reimburse providers.
Patrick recently chided the latter. “Frankly,” he told the New York Times, “it’s hard for the average consumer to understand how some of these companies can have the margins they do and the annual increases in premiums that they do.”
SwiftMD offers services in the New York-New Jersey area and TelaDoc is giving it a go in Dallas.
They have to be careful though since physicians’ licenses to practice medicine are good only for the issuing state.
Big Apple resident Leah Light received a subscription to SwiftMD as a gift from her mom.
The Pine Tree state has 4 times more physicians than dentists and that means there’s only one dentist for every 2,300 people.
A key reason for the disparity is that whites tend to get diagnosed at an earlier stage in the disease, when chances for a cure are higher.
In 2005, Wal-Mart employees had to work 2 years before qualifying for the company health plan, which most considered to be an expensive joke, anyway.
Charity was the place where caregivers stored bodies in hallways because the morgue was flooded, and made horrible decisions about patients for whom they could not comfort, let alone care for properly.
Nothing’s going to happen until the stand-off is settled, according to LSU’s general counsel Raymond Lamonica. The dispute is likely headed to court.
