Fifteen years ago, protecting patient confidentiality was a simple matter for physicians. Keep your voice down in restaurants and elevators, make sure the door is closed when you speak on the telephone, and guard your patients’ paper medical records like a mother hawk.

Social media has changed that. Two weeks ago, a physician was fired from a Rhode Island hospital and cited for ‘unprofessional conduct’ by the state medical board after she posted information to Facebook that could be used to identify a patient. She did not name the patient, but included information about the patient’s unusual condition that would have allowed unauthorized third parties to identify the patient if they wanted to.

The physician deleted her Facebook account and will attend a CME course to help her get clear on patient-physician confidentiality issues in the age of social media.

This physician is not alone. A recent review by Lagu and colleagues showed that 17% of blogs by health professionals included information that could be used to identify a patient or the patient’s physician. Three blogs contained identifiable pictures.

Nothing in their training or their experiences in the era before social media could prepare physicians for the sudden, profound impact it has had on their practices. These new tools are disrupting decades-old codes of conduct, not to mention the very processes by which care is rendered and providers communicate with patients and their colleagues.

To be clear, I firmly believe that physicians and all health professionals should aggressively adopt social media to enhance the care and support they give to patients. This includes providers who have yet to get in the game. At a minimum, providers are obligated to join the fray because their patients use these sites to find information, seek support and make health decisions for themselves. (more…)

For the first time in 30 years, an expert panel has updated guidelines for the diagnosis of Alzheimer’s disease. The long overdue facelift should favorably impact care for millions and accelerate badly needed research on the disease.

The guidelines were produced by representatives from the National Institute on Aging and the Alzheimer’s Association. They portray Alzheimer’s for the first time as a three-stage disease. In addition to ‘Stage 3,’—the full-blown clinical syndrome that had been described in earlier versions of the guidelines—the new guidelines describe an earlier ‘Stage 2,’ of mild cognitive impairment due to Alzheimer’s, and a ‘Stage 1, or preclinical’ phase of the disease. The latter can only be detected with biochemical marker tests and brain scans.

The guidelines legitimize years’ worth of observations by the family members of Alzheimer’s patients, who recognize in retrospect that Grandpa had a slowly progressive cognitive disorder long before he was diagnosed. The guidelines also reflect progress on the research front, where it has now been established that the disease begins years before patients become symptomatic.

Alzheimer’s patients and their families, and the teetering US health system that supports them, would have been better served by the publication of these guidelines 2-3 years ago.

The science was compelling enough back then, and a 2 to 3 year lead-time on research could have had an enormously positive impact on our economy and our health system. In a report last summer for example, the Alzheimer’s Association concluded that unless disease-modifying treatments are found quickly, the number of Americans with Alzheimer’s disease will jump from 5.1 million to 13.5 million by 2050. The total costs of caring for these folks will have exceeded $20 trillion, in today’s dollars, by then. A lions’ share of these expenses will be borne by government entitlement programs, Medicare and Medicaid.

The New Guidelines Will Improve Care
Meanwhile, several commentators have criticized the new guidelines as confusing and stress-provoking. ‘Why should we rush to tell people they have something we can’t treat?’ is the crux of their argument.

These people have it wrong. Denial is not the way to go with Alzheimer’s. The sooner patients and their families find out they have it or are at risk to develop it, the more time they have to develop care plans that reflect their preferences. Mildly affected individuals get to decide for themselves how to enjoy what may be a limited number of years-worth of relatively unimpaired mental functioning. They also get to decide whether to participate in clinical trials and which ones to participate in. They and their families can access counseling and support groups more quickly, a benefit that can improve the quality of life for everyone involved. Even providers themselves can use the enhanced lead-time to implement a patient support plan that respects the needs of the patient and his family.

Today, full-blown Alzheimer’s affects 5.1 million Americans. In all likelihood, at least that many have mild cognitive impairment due to Alzheimer’s (the new ‘Stage 2′). These are the people that will benefit immediately by the expanded definition.

The New Guidelines Will Improve Research
By formally recognizing that Alzheimer’s is slowly progressive and establishing criteria for each stage of the disease, the guidelines facilitate scientific inquiry into various diagnostic and therapeutic options. They allow patients to be grouped by stage of illness (a breakthrough similar to what tumor staging has done for cancer research). Most importantly, they encourage patients to enter clinical trials at a time in the natural history of their disease when treatment success is more likely. (more…)

US hospitals are not leveraging Facebook to engage patients, improve brand recognition, build communities or just about anything else, a new study finds.

Verasoni Worldwide and Simon Associates conducted the study, which did praise children’s hospitals as pioneers in the use of the popular social networking site.

The study quantified the extent to which hospitals engaged in typical Facebook activities like posting on their walls, using the event function and discussion boards, offering engagement opportunities like games and photo sharing, and providing links to hospital-sponsored blogs and Twitter accounts.

It focused on 120 hospitals of various sizes and types (including academic medical centers, community hospitals and safety net hospitals) in every state. The study took place between December 15, 2010 and January 12, 2011.

Key results from the study include:
Although all hospitals had a presence on Facebook, only 8 (6%) had at least 10,000 fans. More than 50% of the hospitals had less than 1,000 fans. Two of the leaders were Children’s Hospital of Boston (465,073 fans) and Seattle’s Children’s Hospital (15,510 fans).

Only 48 hospitals (40%) posted daily on their walls. Unsurprisingly, these hospitals had more encounters with patients (both current and prospective) and providers. Ninety-six others posted between once per month and twice per week. Once again, children’s hospitals led the way in terms of post frequency.

Just over half (63) the hospitals used Facebook’s event calendar to promote hospital events.

Seventy-six hospitals (63%) had no unsolicited feedback or questions on their pages.

Only 5 hospitals had games, apps, contests or incentives, and a majority of hospitals, 66 (58%), did not allow members to share photos on their Facebook page. Several children’s hospitals allowed parents to post photos of their ‘well’ children, with notes of thanks to hospital staff.

More than 100 hospitals (86%) did not integrate blogs into their Facebook page, and only 10 integrated their Twitter feeds into Facebook.

“While the numbers clearly indicate that patients are on Facebook, it is the job of hospitals to find them, and engage them in a meaningful way. And just because a hospital is on Facebook doesn’t mean that they are building a meaningful Facebook experience for both the hospital and the patient,” Abe Kasbo, a study co-author said in an interview. (more…)

Several years ago, scientists led by Harvard’s Nicholas Christakis showed how happiness and obesity can spread through social networks. The team showed for example, that when certain people gained weight, the chances increased that others in their social network would also gain weight. Similar analyses have mapped-out the impact of social networks on influenza outbreaks and cigarette smoking.

Now, Christakis has teamed-up with Larry Miller to create MedNetworks, a company that uses the same network mapping methods to identify physicians that most strongly influence their colleagues when it comes to prescribing drugs. If their work proves successful, they will surely find plenty of drug makers who will pay for their insights.

The Boston-based start-up relies on medical claims data for its mapping studies. It claims to be able to track growth in the popularity of a new drug within professional circles. It has identified physicians within these circles that appear to influence the prescribing behavior of others, in that after they begin prescribing a newly released drug, colleagues within three degrees of separation from them begin doing the same. “We’ve shown that we can predict adoption of pharmaceuticals among doctors,” Miller said in an interview.

To support its claims, MedNetworks cites a case study on the launch of Merck’s diabetes drug Januvia in the Raleigh-Durham area. In this example, prescribers that had Januvia adopters within one degree of separation in their social network were twice as likely to prescribe the drug as those who did not have Januvia adopters in their network.

As another example, MedNetworks reports that when a generic replacement drug for Pfizer’s blockbuster Lipitor became available, prescribers discontinued Lipitor “in clusters…and social network influence accounted for about 40% of the decline.” (more…)

Spring training 2011 is in full swing. With baseball’s regular season just 2 weeks away, pitchers are lengthening their starts and adding curveballs to the mix. Promising, but lamentably green prospects are being reassigned to Triple A. And word has it that Mariano Rivera is preparing to throw an inning or two, just to be sure his 4-seamer is game-ready before opening day.

People have said that Baseball is Life. That may be stretching it for folks not named Yogi, but surely the game holds lessons for us all…even health policy wonks! Before we highlight the top submissions to this week’s HWR, let’s review some of these lessons:

Lesson 1: People Will Believe Anything
Somewhere this spring, a local sports writer opined that the kid who touched 98 in the 6th inning of a Cactus League game is the next Tim Lincecum, even though he has never recorded a regular-season out above Double A. Another said this year’s Phillies’ rotation will match the prodigious ‘71 Orioles quartet of Cuellar, McNally, Palmer and Dobson. Others claimed that A.J. Burnett will win 20 this year, and that Vlad Guerrero (whose gait is reminiscent of the Tin Man in Wizard of Oz) will steal 20 bases.

And people believe it!

During the epic health reform debate of 2009-2010, Democrats tried to include provisions which authorized payments to physicians for time spent helping Medicare patients prepare living wills. But Sarah Palin claimed those provisions allowed the government to create “death panels,” and John Boehner warned that they would “start us down a treacherous path toward government-encouraged euthanasia.”

People believed that, too!

To this day, an astounding 30% of elderly Americans believe the new health law empowers government panels to make end-of-life decisions for Medicare beneficiaries.

Lesson 2: Sometimes You Get a Do-Over, Sometimes You Don’t
Umpire Jim Joyce robbed Tigers pitcher Armando Galarraga of a perfect game last year when he blew a call on what should have been the last out of the game. Although Joyce later admitted his mistake, there are no do-overs in baseball. The pitcher’s chance to make history was gone forever.

Meanwhile, GOP-appointed Federal District Judge Robert Vinson decided in January that since he found one provision of the Big O’s health law to be unconstitutional, he might as well trash the whole deal. The decision threatened to disrupt planning in 50 states and confused the bejesus out of the American public. But unlike baseball, the US judicial system does permit do-overs…sort of. Two weeks ago, Vinson issued a stay of his own ruling, effectively allowing the law to stand pending an appeal to the Supreme Court.

Galarraga would be immortal if Joyce could have done that!

Go figure. Anyway, the Yankees will rise again in 2011 (believe me!) and finally, thanks to the HWR All-Stars who contributed posts for this week’s edition. Here is the formidable line-up:

The Sluggers (Health Policy)
For his post on the Forbes website, Avik Roy produced a chart showing results from the Health Tracking Study Physician Survey. The chart confirms that physicians refuse to accept Medicaid patients at rates that far exceed those who are covered by Medicare and private insurance. Roy suggests this problem is responsible for poor clinical outcomes seen in Medicaid beneficiaries.

Between innings, Roy should have a beer with Austin Frakt, who pretty much blows-up the premise that Medicaid recipients receive poor quality health care. In a post for the Incidental Economist, Frakt shows that studies used to support the premise reveal an association between Medicaid and individuals with poor health… it’s their poor health, Frakt says, that is driving poor outcomes in this population, not lousy doctors or poorly designed care systems.

Now that President Obama has decided to support Wyden-Brown, disaffected governors and state legislators can craft PPACA alternatives that are more to their liking, writes Joe Paduda over at Managed Care Matters. According to Paduda, if Republicans actually have a better approach to the problems of health care access and cost, they are going to win big in 2012.

For his part, John Goodman predicts that the PPACA will encourage many patients and providers to opt-out of the third-party payer system. Posting on his own Health Policy Blog, Goodman visualizes a major shift toward concierge-type services and the creation of new markets in which providers compete for patients on price, quality and amenities.

Neil Versel is a huge fan of Don Berwick, but he deplores the way President Obama attempted to install the Quality Don as a recess appointment to head CMS in July, 2010. According to Versel, the underhanded nature of the appointment provided fodder for “uninformed ideologues and assorted nut jobs to attack Obama’s healthcare reform efforts.” Versel’s blog is Meaningful HIT News.

Over at BNet Healthcare, Ken Terry observes an accelerating trend in which insurers and providers are partnering to create Accountable Care Organizations. Terry believes the 2 groups actually can cooperate to form such organizations, and cites several recent acquisitions and partnerships which appear to support his position.

Marsha Gold has followed the Medicare Advantage program and its predecessors for years. In her post on the Health Affairs Blog, she summarizes the program and describes how its beneficiaries will be affected by the PPACA.

In a post for his Health Business Blog, David Williams reminds us that many folks want to overturn new rules restricting Flexible Spending Accounts. Williams ups the ante a bit by suggesting that we eliminate FSAs altogether, and get rid of those pesky tax deductions for health insurance while we’re at it.

David Kindig reviews the implications of Wisconsin Governor Scott Walker’s plan to eliminate the state’s $3.6 billion dollar deficit. Kindig argues that some of Walker’s proposed cuts (including reducing Medicaid eligibility) will have serious health implications for people in his state. His post appears at Improving Population Health.

The Lucidicus Project’s Jared Rhoads reacts to presentations he heard at the TEDxDartmouth 2011 conference. After hearing Al Mulley’s familiar argument that our health system needs to adjust more effectively to consumer preferences, Rhoads doesn’t believe we can pull it off.

Reconciling state and federal laws can be difficult, and according to Louise Norris of the Colorado Health Insurance Insider, Health Reimbursement Arrangements (HRAs) are a particularly nettlesome case-in-point in her home state. Her post clarifies the situation, thankfully.

The Starters (Providers)
Roy Poses describes how physicians who are employed by corporations can be pressured to put the corporations’ economic interests ahead of their patients’ interests. Writing for Health Care Renewal, Poses argues that the primary means of corporate control includes restrictive covenants in contracts that have been signed by naive physicians, or signed by physicians under duress.

The PPACA will eventually generate a huge increase in the number of ER visits, according to Amer Kaissi. He argues that better coordination between ER and primary care doctors will be required to address the coming deluge, and offers a roadmap for this effort. Kaissi posts on Healthcare Hacks.

Julie Ferguson of Workers Comp Insider writes that nurses, nurses’ aides and paramedics are facing a rising tide of on-the-job violence. In fact according to Ferguson, only police and correctional officers experience higher rates of on-the-job assaults. Ferguson explores whether this is emblematic of a dysfunctional health system or just a sign of the times.

Liz Borkowski reminds us that while palliative care teams can reduce costs associated with the care of seriously ill hospitalized patients, most people who are eligible for these services don’t receive them. Borkowski, who posts at The Pump Handle, concludes that we have to do more to encourage utilization of these teams.

On The Health Care Blog, Matthew Holt posts an interview with JD Kleinke concerning the latter’s new novel, Catching Babies. Holt describes the book as a “tour de force of health policy and medical soap opera–Health Affairs meets Grey’s Anatomy–wrapped up in the complex world of childbirth.”

The Closers (Quality and Safety)
There is limited evidence to support claims that pay for performance programs improve quality and reduce the costs of health care, according to Jason Shafrin, who posts on The Healthcare Economist. Shafrin reviews Massachusetts’ pioneering P4P program and several other ones that failed to improve care.

Jaan Sidorov laments that a one-size-fits-all approach to health care—characterized by guidelines and decision support—is woefully behind sociotechnical trends that make “mass personalization” possible. Writing for Disease Management Care Blog, Sidorov argues that those who embrace the latter approach (by tailoring treatments based on the health status, preferences and values of individual patients, for example) will win in the marketplace.

At The John A. Hartford Foundation Blog, Chris Langston discusses the problem of overmedicating the elderly. He reviews a study in which 42% of the Indiana Medicaid population who live in nursing homes received at least one “potentially inappropriate medication.” Not surprisingly, these patients had worse health outcomes.

-Seventh Inning Stretch-
Famed HWR Contributor Argues Against a Key Policy Decision:

The Base-Stealers (Health IT)
Many CEOs and CIOs believe that their healthcare IT systems are secure because they “use SSL encryption” or “have a firewall.” That’s not the case, according to The Healthcare IT Guy, Shahid N. Shah. Shah offers a list of questions that executives can use in order to assure their systems really are secure.

Walking through the palatial vendor displays at this year’s HIMSS conference, Anticlue blogger Elyse Nielsen heard surprisingly little buzz about “the cloud.” In her post, Nielsen explains why this was the case, and opines that it won’t be long before the buzz picks-up.

The Slick Fielders (Pharmaceuticals)
Over at Nuts for Healthcare, Jeffrey Seguritan wonders what things would be like if drugs and their makers were forced to endure the same mano-a-mano competition that makes the NCAA basketball tournament such a good watch. Although the FDA does not require comparative trials like this before green-lighting drugs, Seguritan reviews a few such trials that are actually underway.

The Five-Tool Guys (Media)
Lately, health media watchdog Gary Schwitzer has focused on instances in which press releases drive what we call “news” in health care. In a pair of posts on his HealthNewsReview Blog (here and here), Schwitzer warns that when this happens, independently vetted journalism may not have taken place. 

The Stud Prospects (Consumerism)
Employers and health plans continually seek ways to contain health care costs. According to Dave Kerrigan, limiting the size of provider networks is a powerful and potentially beneficial tool in this regard. Kerrigan’s post appears on A Musing Healthcare Blog.

The Rabid Fans
Nobody is immune from DrRich’s sharp-tongued post on The Covert Rationing Blog. DrRich skewers, in no particular order, lying doctors, the right-wing media, the left-wing media, and quite possibly my Aunt Millie as well. We’re not sure what DrRich is for, but we know what he’s against, and it’s just about everything.

“Unions get waivers,” the InsureBlog’s Bob Vineyard exclaims. “Campaign contributors get waivers. Business owners and states get waivers. Why should consumers be left out?” In his post, Vineyard points out that some Michigan Representative wants to give consumers the right to opt out of “Obamacrap.” Obamacrap? Really? Obamacrap?

Whatever. Two weeks from today, Jason Shafrin hosts the Health Wonk Review over at the Healthcare Economist. Good luck Jason, and thanks to the all-stars who contributed to today’s edition!

Most people know that the US is struggling to contain a surging epidemic of obesity, and that the problem is most acute among African-Americans. Whereas about 27% of all adult Americans are obese (defined as having a body mass index of 30 or more), fully 37% of African-American adults are obese, and that number jumps to an appalling 42% among African-American women.

Over the years, public health officials have provided evidence that socioeconomic and cultural factors drive this racial disparity. Now, a new study suggests there is another reason as well: obese African-Americans receive less obesity-related counseling than their white counterparts, and it matters not whether the physicians they see are African-American or white.

To reach these conclusions, Sara Bleich and colleagues from the Johns Hopkins School of Public Health used clinical encounter data from the 2005–2007 National Ambulatory Medical Care Surveys (NAMCS). The sample included 2,231 visits involving African-American and white obese people who were at least 20 years old and who visited family practitioners and internists that were either African-American or white. Asian and Hispanic patients and physicians were excluded from the study because their numbers were too small to permit hypothesis testing.

For each encounter in the study, the scientists determined whether the patient received guidance on weight reduction, diet and nutrition, or exercise from his or her physician.

It turned out that African-American patients received weight-loss counseling about half as often as white patients did, regardless of whether the physician was African-American or white. Worse yet, African-Americans were only about one-third as likely as their white counterparts to receive advice about exercise from their physicians—once again, regardless of the physicians’ race. (more…)

Several key health care bowl games will be played in 2011. Their outcomes will affect the health and well-being of a hundred million Americans and help determine the timing of the nation’s inevitable economic double-dip. They’ll also help health insurance CEOs decide whether to re-decorate their offices with fur or linoleum, and who knows? They may even help Mrs. Farquhar find a PCP.

Before you gamble your hard-earned reimbursement check on the outcomes of these tilts, be sure to consult our handy bettor’s guide for insights and advice! We’re so sure we can help you get rich quick, we’re offering these guaranteed locks to you for free. If you like what you see here and want an even bigger edge, we recommend contacting the experts listed below. 

Florida Citrus Bowl
Republican-appointed Judges vs. Democrat-appointed Judges: My civics class teacher told me that the judicial branch of government was not subject to partisan politics. So how come every time a GOP-appointed judge rules on the Big O’s health reform law the verdict comes out unconstitutional, and every time a Clinton-Obama appointee rules, it’s cool? This is Bush-Gore 2000 all over again. We know how that turned out. GOP Judges to prevail by a hanging chad.

Sugar Bowl
Contrave vs. the FDA: Drug companies have spent billions developing a pill for obesity and have gornisht to show for it. The FDA gonged rimonabant three years ago and trashed Qnexa and Lorcaserin more recently. But in a shocking development last month, FDA scouts said Orexigen’s Contrave was the real deal. Forget that it was minimally effective and had a lousy side-effect profile! The FDA will probably approve it later this month. Over/Under = 10 pounds lost per user. Take the under.

Alamo Bowl
Texas Governor Rick Perry threatened to pull his state out of Medicaid, then backed-off amid catcalls from his advisors and top docs in the state. It also dawned on Perry that he’d lose $15 billion a year in federal matching funds if he pulled out, and that Texans would still be paying federal taxes and thus subsidizing Medicaid programs in other states. Perry to win the Grady Little Manager of the Year Award.

Fiesta Bowl
EMR companies enjoyed soaring profits and stock prices in 2010, but official scorers refused to re-write the record books saying the performance was wind-aided by HITECH. And even though virtually all reputable EMRs have nailed Meaningful Use by now, their systems still look like they were designed by Rube Goldberg on blotter acid. Fifteen yard penalty for unsportsmanlike conduct!

BCS Championship Bowl
The latest chapter in the health reform grudge match between the Pelosis and the Boehners features a new twist now that the latter kicked serious donkey in the midterms. Casual fans can’t figure out if that’s Mitch McConnell or a wax figure of Mitch McConnell on C-SPAN, but it’s not going to matter. Boehners score early and often, and win by 2 touchdowns.

WHAT THE EXPERTS ARE SAYING ABOUT:
The Doctor-Patient Relationship                                                                                                    MariaYang’s terrific new blog, In White Ink contains short character sketches and vignettes drawn from her work as a psychiatrist and from her observations of the world at large. The pieces are insightful, funny and poignant. In a post titled Lucky, Yang describes a person who hears voices and believes she alone can reunite North and South Korea, yet she is surprisingly capable of an occasional astute observation. In Aging, we observe the mannerisms of an elderly man who is befuddled, if not particularly stressed-out by his surroundings. Our pick to click!

Boomers 2011 is a moving, introspective post by John Schumann over at the GlassHospital Blog. Schumann reminds us that this year, the oldest Baby Boomers turn 65 and hence become eligible for Medicare. Then, to illustrate the challenges faced by these folks, Schumann shares a letter he received from a patient. “Ted” is acutely aware of his growing infirmities, and his letter amounts to a lament for times gone by. Thankfully though, a second patient offers Schumann a fresh approach to helping people like Ted. And the approach has nothing to do with prescribing more drugs or ordering more tests.

Health IT
According to Michael Kirsch at MD Whistleblower, electronic medical records (EMRs) are a double-edged sword when it comes to litigation risk. In his post titled “EMRs: Medical Malpractice Shield or Magnet?” Kirsch presents a balanced summary of their risks and benefits in this regard, but in the end Kirsch remains skeptical: “I fear that, at least in the short term, the legal risks for (physicians) exceed legal protections. We need to be vigilant, not only to protect our patients’ health, but also to protect ourselves.”

Quality and Safety
In a post titled, Joint Commission: Anti-Safety in Action, WhiteCoat lambasts the agency for designating suicides in the emergency department as Sentinel Events. Writing for the CallRoom Blog, WhiteCoat calculates that the incidence of suicide in the ED is about one per 25 million visits. As a result, ED staff is more likely to win the lottery than find a patient who will commit suicide. Nevertheless, WhiteCoat writes, staff must now be on the look-out for suicidal patients and document its activities every step of the way.

In The Downside of Understanding, Nick Fogelson marvels at the deluge of new medical knowledge that has become available since he entered practice 10 years ago. But as he points out, the new information is often complex and nuanced. It’s a challenge, he writes, to present this information in a way that patients can understand. The post appears at Academic OB/GYN.

Legal Matters
For Ed Pullen, the ongoing litigation involving Myriad Genetics and a bevy of plaintiffs led by the ACLU has taken-on personal overtones. Myriad holds patents on a pair of genes in which certain mutations confer increased risk of breast and ovarian cancer. As a result, it owns exclusive rights to tests that detect these mutations. In BRCA Gene Patent, Pullen explains why the matter has become personal for him, and why he feels the patents should be invalidated.

Regulation
In a scathing, hilarious post titled, Zippity Zappity, Powerbands and AMI, Sheepish lauds recent actions by regulators against 3 companies engaged in quackery and shonky medicine in Australia. Despite the interventions, Sheepish reports in his blog, Paper Mask, that at least one  company remains in business, and another still operates a web site (albeit from the USA).

Insurance
Over at Colorado Health Insurance Insider, Louise summarizes the recent expansion of her state’s Medicaid program. The successful expansion, she writes, was driven by a “presumptive eligibility” policy in which applicants are automatically enrolled when they first apply. If they are subsequently determined to be ineligible, they are removed from the program at that time.

Social Media
Over at InsureBlog, Henry Stern skewers Oregon Democrat Earl Blumenauer for overlooking a fundamental tenet of life in Internet Age: Never write anything in an email that you wouldn’t want showing up the next day in the New York Times. The Congressman did just that, and sure enough, the next day his top-secret email was reprinted in the Newspaper of Record. To find out what Blumenauer wrote, please see Henry’s post.

Behavioral Health
Eating healthier is a common New Year’s resolution, but most people find it tough to undertake wholesale dietary changes overnight. Recognizing this, Dr. Charles presents a manageable list of unhealthy foods that consumers will, hopefully, cross-off their shopping lists. The post is titled 7 + 3 Foods to Avoid. It can be found in The Examining Room.

Recognizing that many people experience painful flares of their gout during the holidays, Irwin Lim presents a timely, patient-focused review of the affliction on the BJC Health Blog. Lim’s post reminds us that flares can largely be prevented with a combination of reduced alcohol intake, dietary modification, weight loss and urate-lowering medications.

In a post titled, Universal Curative Processes, psychologist Will Meek offers a list of 10 behaviors (ranging from accepting one’s self to engaging in creative activities) that he believes can be used by most people to improve their sense of well-being.

Thanks to everybody who submitted posts to this week’s Grand Rounds! Have a great day and best of luck in the New Year!

Buyer Beware: This Bettor’s Guide Picked the Team in Red

If the Affordable Care Act works like it’s supposed to, 32 million Americans will obtain health insurance for the first time over the course of this decade. Authors of the health reform law expect primary care physicians (PCPs) to care for most of these people. Unfortunately, the nation’s severe and worsening PCP shortage means these expectations are unrealistic.

How big is the PCP manpower problem? The Association of American Medical Colleges estimated we’d be short 45,000 of ‘em by the end of this decade, and that was before the Big O signed the Affordable Care Act into law.

Many studies have linked the dwindling supply of PCPs to long work-hours, administrative hassles and most importantly, a widening income gap between PCPs and specialists.

A recent study by Martin Palmeri and colleagues at Dartmouth has shed light on one aspect of this income gap: the excessive debt burden faced by PCPs in the first years after they complete residency training.  

To quantify the early-career financial situation for PCPs, Palmeri’s group developed a net income and expense model based on data from the 2007 Physician Compensation Survey and several other databases. Their model looked at physician reimbursement, medical student debt, college savings, retirement planning and cost-of-living expenses.

The scientists found that in contrast to specialists, most PCPs do not earn enough in the first 3 to 5 years post-residency to cover expenses.

PCPs who deferred loan payments until after residency averaged $199,159 in debt, the scientists found. To pay this off in 10 years, they had to fork-out monthly payments of $2,261. When their debt repayment was combined with housing costs, retirement savings, children’s college savings and other expenses, PCPs ended-up $801 short each month, assuming their average starting salary was $130,000. This doesn’t even include the costs of entertainment, clothing and travel expenses.

In the researchers’ model, the only way PCPs ended-up with a net positive income in the first 3-5 years after residency was if they had no debt coming out of medical school or exhibited a lifestyle considered by the researchers to be “optimal low cost” (Mad Men reruns on a Saturday night, anyone?).

The sliver of good news in the study was that PCP income did rise quickly during those first few years, but the scientists were unequivocal in their conclusion: the short-term financial realities faced by primary care physicians create strong disincentives to the pursuit of a career in that field.

Palmeri himself is training to be an Oncologist, by the way. His study appears in the November issue of Academic Medicine.

Last week, we highlighted an unintended consequence of the Affordable Care Act: it will dramatically worsen an already gaping mismatch between the demand for and the supply of physician services in the US. Put simply, there aren’t enough white coats out there to care for 32 million Americans who will obtain health insurance coverage for the first time as a result of the new law. It’s not even close.

We also speculated that the recommendations made by the American Association of Medical Colleges to address the burgeoning crisis will not work. The AAMC wants Congress to increase the number of Medicare-funded medical residency training slots—essentially, to increase the pipeline for new physicians. This isn’t a bad idea except that Congress is gridlocked on a good day, bitterly divided on all things health reform, and in no mood to enact spending programs of any sort.

That brings us to an alternative solution, proposed recently by the Institute of Medicine. In a report titled, The Future of Nursing: Leading Change, Advancing Health, the IOM concluded that the best way to meet the coming tidal wave of demand for medical services is through a sweeping expansion in the roles and responsibilities of nurses.

Reasoning that nurses are cheaper and quicker to produce than doctors, the IOM recommended the implementation of incentive programs which would assure that 80% of nurses have a bachelor’s degree within 10 years, and that 10% of such nurses enter advanced degree programs. It recommended further that nurses should assume central roles in redesigned, team-based care systems, and that regulatory and institutional obstacles, including limits on nurses’ scope of practice, should be removed so that advanced practice registered nurses (APRNs, including nurse practitioners) can practice more freely. This includes increasing their power to prescribe drugs.

To support its recommendations, the IOM cited studies describing the experiences of health care organizations that already have expanded the roles and responsibilities of nurses in patient care. The studies show that nursing professionals deliver safe, high-quality primary care and make no more errors than physicians in such settings.

In particular, the IOM reviewed recent efforts by the Department of Veterans Affairs to leverage its nursing labor force as part of a strategy to meet a sudden surge in demand for health services, just as we expect the Affordable Care Act to create on a national level. The Veterans’ Healthcare Eligibility Reform Act of 1996 doubled the number of enrollees in military healthcare programs over an eight year period. To accommodate the anticipated deluge, the VA redesigned its care systems from an old-school, hospital based acute care model to a community based delivery model. Central to the redesign were greatly expanded responsibilities of nurses in the system.

When the non-partisan Congressional Budget Office studied the VA experience, it found that the redesigned system allowed more veterans to receive appropriate care than matched controls in the Medicare program. The new system also cut the annual increase in health expenditures per beneficiary by more than 50%. (more…)

The Affordable Care Act is the most important piece of federal health care legislation since the Social Security Act of 1965 established the Medicare program. It assures that 32 million Americans will have access to health insurance for the first time. But who will care for these people?

Our health care system was plagued by a severe and worsening physician shortage even before the new law took effect. In fact, a 2008 study by the Health Resources and Services Administration projected shortages of 35,000 surgeons and 27,000 medical specialists within 10 years, and that’s not even counting expected shortfalls among primary care practitioners like those in Family Practice and Obstetrics.

Those 32 million newly insured people will create an unprecedented surge in demand for physician services, exacerbating this shortfall by at least 50%, according to a new report by the Association of American Medical Colleges.

The report estimates that by 2015—which is one year after the major provisions of the Affordable Care Act take effect—the US will be short a whopping 63,000 physicians—including both PCPs and specialists. Previous analyses had pegged the shortage at 39,600 physicians.

Nearly half the shortfall, 33,100 to be exact, involves specialists like cardiologists, oncologists and emergency medicine experts. For certain specialties like urology and thoracic surgery, the number of physicians is actually expected to decrease.

The report adds that the shortage will get worse in the following 10 years. For example, by 2020, our nation will be short by 45,000 primary care physicians, and 46,000 few specialists.

The physician shortfall will be exacerbated by demographic trends. The number of Americans who are at least 65 years old (a group known to require more medical care than younger folks) will increase by 36% during the upcoming decade, according to the Census Bureau. The graying of the US population is also expected to mean that nearly a third of today’s practicing physicians will retire within the next 10 years, according to the AAMC report.

The physician shortfall will hurt everyone, but the AAMC projects that the impact will be particularly severe on medically underserved populations where finding a doctor is already quite difficult. The population in question includes nearly 20% of Americans living in inner-city and rural areas where shortages of health professionals are already acute.

Offsetting this trend to some degree is the fact that (provisions in the Affordable Care Act aside) the number of medical school students will increase by about 7,000 graduates per year during the next decade. Unfortunately, according to the AAMC this increase doesn’t keep up with the projected surge in demand for physician services.

What Should We Do?
While team-based approaches like “medical homes” can ameliorate the looming crisis to some degree, few believe they will eliminate it.

Recognizing this, the AAMC recommends that Congress should mandate at least a 15% increase in residency training slots which would add 4,000 physicians per year to the pipeline. This surge is not contemplated by the Affordable Care Act, which in the most optimistic of projections will add approximately 350 physicians per year for the next decade via small primary care grants and the reshuffling of residency programs.

The only way to reach the AAMC’s proposed target of 4,000 new physicians per year, it seems, would be for Congress to overturn a 1997 law that froze Medicare-funded residency positions and increase by at least 15% the number of GME positions funded by Medicare. However with Congress mired in partisan gridlock and public opinion now pretty entrenched against new spending programs, this seems like a long shot at best.

Beyond this, the options are relatively slim and controversial. We either agree to increase the numbers of foreign medical graduates or expand the scope of practice for nurse practitioners so they can help shoulder the burden of an accelerating demand for medical services.

To those who would disagree with these latter solutions, which can work, I ask, “What alternatives do you propose?”