More on the Supply of Primary Care Clinicians

April 9, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Medicare, Politics / No Comments

Yesterday, when I wrote about “Ensuring Enough Primary Care Clinicians,” I didn’t realize that public radio station WBUR would be doing a story this week on the same topic. (The WBUR story can be heard/read on their web-site.)

Nor did I know that this was an agenda item for today’s Medicare Payment Advisory Commission (MedPAC) meeting. While the one-page MedPAC briefing summary doesn’t include their draft recommendations, Modern Healthcare reports that they are recommending budget-neutral adjustments to Medicare’s fee schedule to increase payments to physicians who provide primary-care services – including office and home visits, and visits to patients in non-acute facilities.…

Ensuring Enough Primary Care Clinicians

April 8, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Politics / 3 Comments

Like many complicated problems in the US healthcare system, setting a goal can be easy, but achieving it can be hard. In recent years there has been a number of proposals for increasing the use of primary care clinicians to help patients with chronic diseases (like diabetes) manage their care and avoid long-term complications – and to presumably lower long-term healthcare spending. For example, the “Patient Centered Medical Home” proposal supported by a dozen organizations, (including companies and family practice and pediatrics associations), doesn’t specifically use the term “primary care,” but it gets to the same result – heightened relationships and communications between patients and a particular clinician or clinic.…

Canada’s Proposal for Subsequent Entry Biologics

April 1, 2008 / Michael D. Miller MD / Economics & Financing, FDA, Patents & IP, Politics, Quality of Care & Safety, Therapeutic Substitution & Interchange / No Comments

After writing about Follow-On Biologics in a recent posting, I saw a notice about Health Canada’s proposal for how they would approve biologic products that are similar to already approved biologics whose patents have expired. They call these products Subsequent Entry Biologics (SEBs), and the proposal is open for public comment from March 14, 2008 until April 16, 2008.

While the draft guidance is lengthy, it does strike an overall well-balanced tone:

“SEBs are not ‘generic biologics'”
Approval of an SEB does not mean it can automatically be substituted for the original biologic that it is “similar” to
Comparative studies will be required to generate data showing similarity to the original biologic in terms of quality, safety and efficacy

In many ways, the draft guidance is similar (no pun intended) to the process the US FDA used to approve some generic drugs prior to the 1984 Hatch-Waxman Drug Price Competition and Patent Term Restoration Act.…

Ben Franklin’s Virtues and the Pennsylvania Primary

April 1, 2008 / Michael D. Miller MD / Health Policy and Communications Blog, Nutrition, Politics / No Comments

While reading a Ben Franklin biography (“The First American,” by H. W. Brands), I was struck by a list of 13 virtues he wrote while in his mid-20s to guide his life:

1. Temperance. Eat not to dullness. Drink not to elevation.
2. Silence. Speak not but what may benefit others or yourself. Avoid trifling conversation.
3. Order. Let all your things have their places. Let each part of your business have its time.
4. Resolution. Resolve to perform what you ought. Perform without fail what you resolve.
5. Frugality. Make no expense but to do good to others or yourself: i.e.,…

More on Counterfeit Medicines & Safety

March 27, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, FDA, Information & Communications, Public Health, Quality of Care & Safety / No Comments

My last post contained some perspectives about fake medicines. That same day, the LA times ran an article about California’s long-delayed pedigree requirements for tracking prescription medicines. This law was prompted by the discovery of fake medicines for HIV/AIDS in 2000, and was intended to achieve what the FDA has been trying to implement for many years.

The LA Times article blames the delays in the state’s drug tracking system on the industry – from the manufacturer to the retail pharmacy. I suspect that the real challenge is not in the technical or cost aspects from the manufacturers – who certainly have lots to gain by stopping counterfeits of their products from being sold instead of the real thing, but from the wholesalers and to a lesser extent the pharmacies.…

Safety, Costs and Quality of Medicines

March 25, 2008 / Michael D. Miller MD / Delivery of Healthcare, FDA, Politics, Public Health, Quality of Care & Safety, Therapeutic Substitution & Interchange / 1 Comment

I’ve been trying to figure out how to write something meaningful about the many reports over the last several months about the safety, costs and quality of medicines. I finally concluded that rather than a too lengthy blog post, a series of snapshots would create a good description of the situation – sort of like a slide show rather than a feature film:

Safety of Generic Drugs: A recent LA Times article discussed patients who had adverse reactions when switched from a brand name to a generic medicine. This article includes physicians’ experiences with several types of generic medicines, e.g. for epilepsy, depression, high blood pressure, irregular heart rhythms, and to prevent rejection of organ transplants.…

Trans Fat Shocker

March 21, 2008 / Michael D. Miller MD / Nutrition, Public Health, Quality of Care & Safety / 2 Comments

A couple of days a week I work out of shared office space in Cambridge, MA that is part of a multi-floor incubator/start-up facility. One of the benefits in the office is the food stocked in the kitchens – including lots of healthy things, like fresh fruits, nuts, dried fruit, bagels, etc….. Now not all the food is purely healthy…. They have sodas and M&Ms, etc. But today I did a double-take, when I saw that the Drakes Apple FruitPies had 8 grams of Trans Fats per serving.

For those of you not familiar with Trans Fats, they are chemically created by taking naturally occurring oils and heating them in the presence of a metal catalyst (like nickel or platinum) to add extra hydrogens to the oil.…

Culture of Healthcare Organizations

March 17, 2008 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety / No Comments

Culture change is one of the core messages of a book I’m working on, so I was interested to see an article about “cultural transformation” in Modern Healthcare by John Mitchell, CEO of Harbor Community Hospital in WA. He notes that there is frequently a disconnect between a hospital leader’s stated goal of wanting to create a great culture and their actions: Retaining a central command and control structure does not empower people, and forcing solutions onto hospital staff who feel uninspired to excel will not produce sustainable improvements. Rather cultural changes leading to improved quality and reduced costs requires the leader to inspire the staff to perform while also empowering them to achieve shared goals.…

Boston University Biolab Update

March 15, 2008 / Michael D. Miller MD / Information & Communications, Innovation, Public Health / No Comments

I don’t mean to keep harping on the BU biolab situation, but yesterday’s Boston Globe had a concise perspective on the situation. In that article, the attorney who sued to block the facility summarized the whole situation with the quote, “They should have taken the time before they spent a dime of the taxpayers’ money.” [In the context of the article, she clearly means that no money should have been spent on the building until the community’s safety concerns had been answered.]

I certainly agree. The facility will most likely be worthwhile and will do important work related to serious diseases and possible bioterrorism agents, but in rushing to build and open it, the result is that it is costing more and actually take longer to complete because of the need to address the community’s concerns.…

Principles for Health Reform & EBM

March 13, 2008 / Michael D. Miller MD / Comparative Effectiveness, Economics & Financing, Health System Reform, Politics, Private-Employer Based Health Insurance / No Comments

The National Federation of Independent Businesses (NFIB), just launched their health reform campaign called Solutions Start Here. Their 10 small business principles for healthcare reform includes:

Evidence-based:
The healthcare system must encourage consumers and providers to accumulate evidence and to use that evidence to improve health. Appropriate treatment choices and better wellness and preventive care should be key outcomes.

Current information and decision systems make it difficult to accumulate, interpret and use evidence affecting treatment decisions. One result is overspending on treatments and underspending on prevention. Decision-makers must understand the impact of their decisions on both costs and outcomes. Such an understanding must be based on solid clinical and economic evidence.

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Vaccines and Autism – More Mess

March 11, 2008 / Michael D. Miller MD / Delivery of Healthcare, Innovation, Politics, Public Health, Quality of Care & Safety / No Comments

There has been a lot reported in the news about the recent payment from the Federal Vaccine Injury Compensation Program for Hannah Poling, a girl who developed autism after being vaccinated. (See New York Times article and a Wall Street Journal blog report about this case.)

Amidst all the debate and news reporting there have been several connected and interesting facts:

The Federal program that is making the payment to the Poling family doesn’t concede that the payment is in any way an admission of a link between vaccines and autism.
Since most vaccines no longer contain the mercury containing preservative thimerosal, and yet the rate of new cases of autism hasn’t declined, it would seem that whatever arguments there were for a link between thimerosal and autism should have been settled.

…

More On Evidence Based Medicine

March 6, 2008 / Michael D. Miller MD / Access to Healthcare, Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Medicare, Quality of Care & Safety / 1 Comment

In a previous post I was somewhat critical of evidence-based medicine (EBM) when it is used to make payment decisions. One of the points I was trying to make is that EBM is not a passing fad. The staying power of EBM was recently reinforced by two recent developments.

First, the Medicare Payment Advisory Commission’s (MedPAC) March 2008 Report to Congress cites their own 2005 report recommending EBM as a touchstone for comparing physicians’ practices as one way to improve quality of care and value for the Medicare program:

In the March 2005 Report to the Congress, the Commission recommended that CMS measure physicians’ resource use over time and share the results with physicians (MedPAC 2005).

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