Health Reform Challenges and Prospects

February 19, 2009 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing, Federal Healthcare Reform, Politics / No Comments

The prospect for Federal health reform legislation remains high because of the growing need, Democratic control of Congress, and a lower barrier to major actions because of the economic situation. However, opposing these positive factors are the apparent unraveling of broad coalitions supporting fundamental health reform, and lower expectations for bipartisanship in Congress.

Growing conflicts within health reform coalitions was reported in Tuesday’s Chicago Tribune, (and discussed on the HealthBeatBlog), but this dis-cohesion was very predictable when it came time to talk specifics. Unfortunately, the prospects for bipartisan action on health reform also seem to have faded sooner than one would have hoped. …

Controlling Health Care Costs and Improving Quality with Effective Care Coordination

February 16, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety / 2 Comments

A study published by in the New England Journal of Medicine last week examining the effects of 15 different Medicare care coordination demonstrations received wide coverage by the general media. Unfortunately, much of this focused on the study’s overall finding that these programs didn’t reduce hospitalizations or Medicare spending. For example, the AP story’s headline, “Study finds bid to cut Medicare costs failed,” was used by many papers such as the Washington Times.

However, the actual study had much more complex, important, and useful findings, and the paper’s authors from Mathematica, (which Medicare contracted to do the analysis from this project), deserve a lot of credit for extracting meaningful information from this project.…

Communicating Health Quality Measures

February 15, 2009 / Michael D. Miller MD / Delivery of Healthcare, Information & Communications, Miscellaneous, Quality of Care & Safety / 2 Comments

Educating patients, (a.k.a. “consumers”), to make the “best” health care choices has been a fundamental principle in some health reforms schools, including those advocating for more high-deductible health plans. While this concept makes sense in economic theories, it also requires belief that patients can and will make good use of the information available to them – particularly when they are ill.

Another fundamental necessity for making such consumer-directed healthcare work to improve quality and lower costs is that the information provided to people is meaningful and accurate. A study published in the November/December 2008 issue of Health Affairs illustrates the complexity of providing accurate information.…

Osteoporosis – Increasing Rates and New Treatments

February 10, 2009 / Michael D. Miller MD / Delivery of Healthcare, Innovation / No Comments

A press release from the NIH yesterday announced a new discovery about the biology of bone remodeling that may lead to a new way to treat osteoporosis. The study, (published in Nature), described how a compound found in the blood helps control the development of bone destroying cells called osteoclasts. (Osteoclasts break down bone while osteoblasts build new bone – The balance between these two cell types determines whether bone density and strength stays the same, increases or decreases.)

Lead for New Treatments for Osteoporosis
The effects of this compound, (sphingosine-1-phosphate), on osteoclasts may lead to the development of new treatments for osteoposorisis since the existing treatments have focused on the activity of more mature osteoclasts and osteoblasts. …

Chronic Wellness Promotion v. Chronic Disease Management in Medical Homes

February 9, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety / 2 Comments

One of the hottest health reform topics is Medical Homes: Medicare has Demonstration Project starting this year, several states have implemented, (or are implementing), medical home related initiatives, the Center for Studying Health System Change (CSHSC) released a great white paper titled “Making Medical Homes Work,” and the New York Times just had a story about how IBM is teaming up with United Healthcare to promote Medical Homes for their 11,000 employees and dependents in Arizona.

Definition of Medical Homes
One of the controversies in Medical Homes is the definition. CSHSC and many others use the definition developed by 4 national medical societies which combines aspects of preexisting primary care and chronic care models with the goal of creating a primary care “home” that can more effectively address the needs of patients with chronic conditions.…

Advancements in Understanding Head Trauma and Preventing Long-Term Problems

January 28, 2009 / Michael D. Miller MD / Delivery of Healthcare, Public Health, Quality of Care & Safety / 1 Comment

When I was training to become an orthopedic surgeon, one of the senior physicians said that the two best learning sources for orthopedic surgeons were football and war. Over the past year I’ve been talking with friends and colleagues about another connection between war and football – how minor repetitive head trauma has long-term serious consequences.

It has become clear with the increasing reports about the neurological, cognitive and personality problems military personnel have experiences after repeated minor concussive events, (often from being inside vehicles hit by IEDs), that this is a real and serious situation. While the VA health system has taken steps to understand the consequences of repetitive minor head trauma and work to provide appropriate diagnostic and treatment methods, I have been telling people that this new understanding of neuro-trauma will have implications for football.…

Health Reform and the Economy: 4 Spheres to Consider

January 25, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Health System Reform / 2 Comments

Many people and pundits have opined on the effects that the economic downturn will have for the likelihood of health reform: On the Federal level, how much money will be available for expanding insurance coverage, and how much money will be included in the “stimulus package” – and for what? And in the States, how much will be cut from Medicaid programs and government employees’ benefits? In addition, there have been news stories about the economic downturn leading to loss of insurance coverage secondary to job-loss, as well as people forgoing direct medical care, healthy activities, and wellness behaviors.

These points illustrate how the multiple parts of our health care “system” interconnect, (particularly financing effecting delivery), and everything existing within the overall economic environment. …

Quality of Care in Medical Practices – Size Does Matter

January 19, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 6 Comments

The Journal of General Internal Medicine published a study last month that looked at primary care medical practices in Massachusetts to see how well they were able to provide the quality improving capabilities of Patient-Centered Medical Homes. These structural capabilities represent process measures that assess the quality of care in medical practices. However, these same measures could also help patients select their own primary care physicians.

Study Finds Larger Practices Have More Quality Related Capabilities
Not surprisingly the study found that larger practices, (and to a lesser extent those affiliated with larger networks of practices), provided more capabilities to improve the quality of patient care.…

Health Reform – Achieving Universal Coverage

January 5, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Health System Reform, Medicaid, Public Health / 5 Comments

During the holidays the Obama Health Transition Team urged people to organize discussions about health care in their homes and communities – and then to report back. Reading about these discussions – including the one that Secretary Designee Tom Daschle attended in Indiana – made me think about what things are going to be needed to make health reform actually work.

My end-of-year reflections and ruminations led me to conclude that one of the most challenging parts of health reform will be to actually get more people enrolled in whatever expanded coverage plans are developed and implemented. Enrollment barriers are not new, but they are frequently not highlighted because they may present great political and fiscal risks.…

Transparency in Non-Profit Organizations

December 22, 2008 / Michael D. Miller MD / Delivery of Healthcare, Public Health / 1 Comment

The ongoing series of financial failures and scandals have made me more interested in financial transparency for non-profit organizations – which economic theory states are really supported by everyone because their donations are tax deductible which reduces total tax revenues. My thinking about the finances of non-profits has also been piqued because of an accounting class I’ve been taking, as well as by my last post about transparency in health reform legislation.

One recent example of non-profit organizations increasing their transparency is colleges and universities issuing press releases and sending letters to alumni about how the economic downturn has effected their endowment, and what steps they are taking to be more fiscally conservative – such as freezing hiring or delaying construction projects.…

Making Physicians Better, and Making Better Physicians

December 10, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Public Health, Quality of Care & Safety / 5 Comments

A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions. The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

Ask permission to enter the room; wait for an answer
Introduce yourself; show your ID badge
Shake hands
Sit down.

…

Healthcare Consumerism, Deductibles and Copayments, and HSAs — More from HUMANA

December 4, 2008 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing / 1 Comment

Humana’s “educational” YouTube video series expanded this week with three new videos that range from benign, to strangely confusing, to something else.

1.
The first video, “Deductibles and Coinsurances,” does a reasonable job of explaining the different ways people can pay their share of healthcare costs after the monthly premium, i.e. what is a copay, and how a deductible is applied. The one area where they could have been clearer is explaining that a co-pays and coinsurance both are the portion that a patient pays for healthcare services, but that a co-pay is a fixed dollar amount, while coinsurance is a percentage of the costs of the service, i.e.…

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