Change the System! But How?
Employment-based healthcare accounts for 63% of the direct or indirect coverage of non-Medicare-eligible Americans. That form of coverage has been in place in the United States since the end of World War II, when it was used as an extra incentive as companies competed for skilled workers in a rapidly-rebounding economy. Now think tanks, politicians and lots of other learned people are looking for ways to switch away from a plan that seems to be pricing many out of the market. Ideas aplenty are being presented. Solutions are, at best, evasive.
For example…a recent conference of world-class economists tracked the growth of job-based healthcare plans in the United States and in effect said “something has to give”. So professors from top-grade schools such as the U. of Pennsylvania, Stamford and Princeton matched wits and complaints with representatives from the Brookings Institution and GE’s Global Healthcare…and came up with all that’s wrong, but no real way to right the wrongs.
They complained that employment-based healthcare was both unfair and simply not sustainable in our global economy. Point made was that the average company, small to giant, simply isn’t in the business of evaluating or managing healthcare services, especially those provided by a third-party. That it has led to “distortions” in the labor market, often influencing why people select a particular job or stay with it long past the time they want to move on. That it leads many companies to hire non-covered part-timers rather than offering additional full- time jobs. That often leads companies to sign on with less-costly insurers rather than giving best possible coverage to employees.
Their major suggestion was a system built on core groups of multi-specialty medical practices rather than around health insurers, better use of IT (of course!) and performance rewards to practitioners. But all agreed that not one of the suggestions more than “touched the edges” and certainly did not eliminate the current, costly and cumbersome system of effective employee-based health insurance.
Meanwhile eighteen state legislatures have introduced bills that would result in a “Medicare-for-all” system which effectively would copy the plans that are stumbling in Europe. Admittedly most of these proposals don’t have much of a chance; but there are pockets of interest.
California seems to be taking the matter quite seriously, in part because the legislators apparently are soft-peddling the fact that some heavy mix of additional payroll, personal income and luxury taxes will be needed to pay the bill. At the same time, there is a positive thought: an outside consultant claims such a changeover will save California $340 billion in healthcare costs in ten years. Apparently no hard figures were presented, though.
Oregon voters defeated a state-controlled healthcare system in 2002; the issue is set to appear again on their 2008 ballot. Passage is not anticipated.
A Kaiser Foundation poll taken early this year found that 55% of Americans want the system to remain as is; 37% voted for change to a single-payer system. Ohio doctors and union officials are gathering signatures to get a single-payer system on the ballot in 2006. Meanwhile the AMA has come out against single-payer, saying it would stifle the development of new medical technology and increase the waits for patient care, citing the rapidly-growing healthcare system problems of present-day Canada as an example.
So the talk goes on, solutions seem almost impossible and the number of uninsured has now climbed to 45 million, plus 16 million Americans currently listed as “under-insured”. In New Jersey, totals are just over one million uninsured, with 178,000 of them under the age of 18.
Rx4NJ & the Big Bus
During this past summer, these “call letters” have been much in view as a can’t-be-missed charter bus has traveled along the roads and into the fun sites of New Jersey with a message of health and hope for people in need. Rx4NJ offers information and guidance from the HealthCare Institute, a less-than-a-year-old association of pharmaceutical and hi-tech related companies operating in the state. The group has dedicated itself to guiding more in-state eligible adults and their children along a path to the wide variety of free or almost-free “miracle” medicines offered by various pharmaceutical companies; medicines these individuals need but cannot afford to purchase at across-the-counter cost.
According to the Institute there are about 350 “patient-assistance” programs currently available; too few people are aware of the offers, their number and scope. The Institute selected the Big Bus as a loud-and-clear way to dramatically increase this awareness within our state.
The Big Bus is more than a giant-sized moveable sign that rolled up to beaches, ball games and parks during the two vacation months…making its point in a bold-type message painted on its sides. “Can’t Afford Your Prescriptions? Help is now a click or a call away. Rx4NJ”. Everyone was welcomed inside, where knowledgeable Rx4NJ representatives equipped with pamphlets and computer access were ready to offer basic processing service. Though the final acceptance in a program requires the approval of the individual pharmaceutical company involved, general qualification of a person’s apparent eligibility was almost always established by their answers to just ten questions which cover a patient’s (or parent’s) income, household size and prescription drug insurance status.
But the Institute was busy enough even before the Big Bus was put on this past summer’s road. It had previously received over 90,000 inquiries on its website (www.Rx4NJ. org) and on its help phoneline (1-888-Rx-for-NJ). Almost three quarters of those inquiries were processed and matched with at least one drug company’s “prescription-connection”.
Marginal note…overall, about five million Americans-in-need participated in drug-assistance programs last year.
Backlash A-Building!
As we mentioned almost-in-passing in late spring, direct-to-patient advertising of prescription drugs has risen close to fivefold in just a few years in the face of complaints by consumer groups and various government agencies; but those serious Congressional restraints, often referred to, rarely reached actionable stage.
Now there seems to be a serious mood change. Currently, there are a number of bills before Congress that could impose severe limits on direct-to-consumer advertising for prescription drugs. Several bills would actually limit or eliminate the companies’ tax-deducting right to treat these ads as legitimate “marketing expenses”. Another bill would create an office within the FDA that would more-carefully monitor, on an ongoing basis, information of very real possible side effects often just marginally mentioned in these ads. Many legislators cited the life-threatening problems of Vioxx, which was finally discontinued, as well as the too-frankly explicit ads for a product such as Levitra, as reason for new legislation. All this in anticipation of the new generation of sleep aids that is just starting to come to market.
On their own, the FDA has petitioned Congress for blanket authority to dictate label changes to the pharmaceutical companies. At present, the FDA has to “negotiate” with the company for what the agency feels is an important -- and timely -- consumer-warning change of label.
In addition, several positive inroads were recently announced. On their own, Bristol-Myers Squibb ruled their new drugs will not be promoted directly to patients for one year after their introduction, apparently allowing sufficient time to double-check a product’s possible effects. Also…the AMA has initiated an in-depth study of direct-to-consumer pharmaceutical ads.
At the same time, the industry association PhARMA recently sent a set of voluntary ad guidelines to all members, suggesting that companies have “discussions” with doctors before new products go into full consumer-ad mode. Almost immediately thereafter, that “suggestion” was amplified by PhARMA’s further announcement that they are opening an Advertising Accountability Office, which will monitor complaints and forward them to the individual companies. A PhARMA-backed independent review panel is promised to be in place by year’s end.
State-of-the-Art-IT
This is the first of a new series which has been added to the monthly edition of “On the Record”; hopefully to better acquaint you with the cutting edge of our world, that is changing, literally at our fingertips.
EMscribe Dx is an automatic coding solution that scans documents containing medical phrases and then matches them to appropriate ICD-9-CM diagnostic codes. Its innovators present it as the only automated solution specifically designed for hospital coding requirements, covering all clinical disciplines and subspecialties.
In addition, the system’s developers say it understands rigid “doctor talk” plus the occasional colloquial terms and slang that sometimes find their way into some clinical dictation. Overall promise is that, with EMscribe Dx, hospitals or independent services providers can assure better accuracy…and do it at lower total cost.
The system is still in its early stages; it is reportedly being
tested at a major New Jersey hospital.
Is it Worth the Savings?
Best estimate is that Medicaid -- which currently serves more than 50 million lowest-income Americans -- will cost close to $330 billion this year; roughly half supplied by the Feds and half by the states. Increasingly the cash-strapped states are deciding to take advantage of the small co-pays they are permitted to charge patients in order to lessen what many complain is a back-breaking financial burden; others are petitioning the federal government to expand the amounts the state’s can charge patients.
At the same time, Congress is attempting to reduce overall Medicaid by $10 billion over the next five years.
According to rules that have been in effect since 1982, states are permitted to charge small co-pays, with exceptions for children, pregnant women and people that are institutionalized. Usually these charges are extremely low, but Oregon decided to try an aggressive approach two years ago, charging monthly premiums of $6 to $20 for couples, plus $5 for each doctor’s visit and $50 for an ER incident.
The use of the program has dropped by more than 50% since then, with half of the drop attributed to the higher fees, which many people apparently found unaffordable. Now Oregon legislators wonder what is happening to the roughly 20,000 residents no longer getting their illnesses cared for. And how that will affect the health of the rest of the state’s residents.
Attacking the Shortage
All but shouting “We need more healthcare workers in general and RNs in particular”, an amalgam of hospitals, colleges and charitable groups in northern Virginia hopefully has pledged to spend over $24 million towards an innovative four-year drive to get more people interested in healthcare work in general and nursing in particular. Enlarging and modernizing present teaching facilities. Reaching out to other fields. Developing methods that will streamline and automate RN workloads. Creating a friendly, possible on-the-job atmosphere.
The alliance goes under the name of NoVa HealthFORCE and is currently chaired by the president of a local community college.
Impressive grants have been promised from local hospitals and at least one managed care company. Major funding though depends on area members of Congress, who hope to produce $19 million for both increasing training facilities at the colleges and enlarging the number and amount of financial aid to potential students. Key element is a “back to school” program that will accelerate specific healthcare-related training for college graduates with degrees in other fields. This latter has proved quite workable in a number of areas and especially at several colleges in New Jersey.
Helping Healthcare's Least-Served
The world’s richest man has made a number of headlines in the past several years passing out grants to individuals and groups that present potentially-powerful solutions to the health challenges facing people in the world’s poorest countries. Recently a total of $437 million in new grants were announced, presented to the innovators of 43 projects that were found to offer the greatest potential.
This “Grand Challenges” competition was announced in 2003 and drew 1,500 proposals from 70 countries. Winners included both groups of noted scientists and others of less renown. Most-original thinking and the potential to make it happen were the judges’ guideposts in the selection process.
Priority targets were generally designated when the competition was announced, with vaccines and innovative vaccine delivery systems high on the foundation’s wish list. Stated specific goals illustrate the type of people the foundation wants to help.
Included...vaccines that don’t require refrigeration, vaccines that can be given without a needle, vaccines that provide necessary immunity with a single dose and are safe for newborns. Innovative ways to attack devastating diseases such as hepatitis and TB when they are dormant, therefore destroying them before they can attack. And any testing device that can be used in villages without electricity.
The William and Melinda Gates Foundation is only a few years old, but has previously presented grants of close to $2 billion targeted towards new and imaginative ways to deliver some measure of healthcare to those most in need.
Those receiving grants were given quite a personal incentive, too…the right to patent anything they invent or develop, with the single stipulation that their invention or innovation is offered to poor countries at as close to “no-cost” as possible.
Creating IT of the Future
General Electric Healthcare is in the initial stages of developing an Electronic Medical Administration Record system that will be put in operation at giant Intermountain Health Care. The total program should take ten years to become fully operational at IHC’s 21 hospitals, plus their 100 clinics and physician practices in Utah and Idaho.
This apparently is the first stage in a giant $100 million joint effort that also plans to develop electronic medical records systems and electronic prescription technology that will be broadly marketed by GE after IHC’s needs are met.
GE plans to have a basic EMAR system in production at one or more of IHC’s hospitals by the end of next year. But GE technicians will apparently go to work almost immediately on an advanced “second stage” model designed to meet the exact workflow habits and needs of the hospital’s doctors and nurses. The future really begins here for both GE and IHC!
Heart of this second-stage system will be a handheld device which will include bar-code technology with specific and personalized detailed individual patient information; all this designed to eliminate every possible opportunity for drug medication error. The first of these units is expected to at work in the latter part of 2007.
IHC, little-known on the east coast, is a community-owned nonprofit healthcare organization based in Salt Lake City. One healthcare research-rating organization has named it the nation’s leading integrated health network for the past four years.
Prop 78 vs. Prop 79
Another down-to-the-wire California special election will be held on November 8. Two financial-support drug propositions will be competing against each other. But with a typical California twist, voters can endorse either one or both…leaving the possibility that both opposing options could pass. If that happens, the one with the most votes wins. (Unless a talked about last-minute compromise also gets on the ballot; then there will be three choices.)
Proposition 78, supported by PhARMA, would allow pharmaceutical companies to voluntarily participate in a plan that offers drug discounts to uninsured residents earning up to three times the poverty level ($58,000 for a family of four). A number of states -- including California -- have similar bills on the books or in-work; most currently restrict these discounts to seniors and the disabled.
Proposition 79, supported by consumer groups , would offer prescription drug discounts to uninsured individuals and families making up to four times the poverty level ($75,000 for a family of four). It would penalize non-participating drug companies from participating in the state’s $4 billion Medicaid program….and it seems would permit residents to sue them for “illegal profiteering”! An early statewide poll showed that 65% of potential voters favored Prop 78 & 55% favored Prop 79.
Medical Minutia
The “old wives’ tale” that eating carrots improves your eyesight apparently has sound basis in fact.
It’s all about beta carotene, an element in vitamin A, which in turn is essential to good vision. A Johns Hopkins study at the end of the 20th century tested 30,000 women in South Asia, where rice is a staple, carrot-consumption is near zero and night blindness is quite common. One group received a vitamin A tablet over an extended period, the others received a placebo. Those taking vitamin A registered 67% fewer cases of night blindness than the placebo-takers.
However, additional studies seemed to show that increased intake of vitamin A could not reverse poor vision or slow its age-related natural decline.
Coding Tips
Coding for Diabetes in Pregnancy. Diabetes in pregnancy can cause a considerable risk to the mother as well as the unborn baby if it remains untreated. Diabetes may be chronic in nature, or the patient may develop gestational diabetes, which is determined by an abnormal glucose tolerance test during pregnancy. Like chronic diabetes, it necessitates treatment with oral medication, insulin, or a combination of both to sustain adequate blood sugar levels. Gestational diabetes requires only code 648.8x, Abnormal glucose tolerance test, while diabetes mellitus in pregnancy requires code 648.0x, Diabetes mellitus complicating pregnancy, and, per coding guidelines, a second code from category 250, Diabetes mellitus, to identify the type of diabetes. Additional codes are assigned for any diabetic complications. Code V58.67, Long-term (current) use of insulin, should also be assigned if the gestational diabetes or diabetes mellitus is being treated with insulin.
For example, a 28-year old was admitted for term delivery of a healthy baby. The patient has chronic type II diabetes with mild polyneuropathy, and takes insulin twice per day. Correct diagnoses codes are 648.01, 250.60, 357.2, and V58.67, & V27.0.
Transcription Tips
Abbreviations used in dictation which could be dangerous or detrimental to healthcare or which could be confusing to a non-medical reader need to be addressed by the medical transcriptionist and expanded or edited for clarity and accuracy. Of course, if the abbreviation is unclear to the transcriptionist, typing verbatim or leaving a blank is the best course.
Current guidelines for dangerous abbreviations include “q.d.” which should be changed to “daily” and “cc” which should be changed to “ml” or “mL.” Other examples:
Dictated: The patient complains of pain which radiates from the CVA to the upper quadrant, present prior to the CVA.
EDIT: The patient complains of pain which radiates from the costovertebral angle to the upper quadrant, present prior to the cerebrovascular accident.
Dictated: The patient was DC’d from the antibiotic just prior to DC.
EDIT: The patient was discontinued from the antibiotic just prior to discharge.
Auditing the News
The head of a major research firm that has closely followed the growth of IT in physician’s offices for over 30 years recently forecast that physician-office EMR use will grow 30% a year for the next five years. This after a series of interviews with doctors, software vendors and consultants.
Texas-based Vinson Hudson forecast EMR growth to $4 billion a year by 2009; it is currently running about $1 billion a year. Maximum levels of growth is anticipated for the largest practices, with smaller groups lagging due to financial restraints.
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GlaxoSmithKline is apparently convinced that high-intensity vaccines loom large in the fight against disease. If all goes as planned, it will soon acquire Seattle-based Corixa, a biotech company it has worked closely with in the potential development of a vaccine targeted against cervical cancer.
Key element in these planned vaccines is Corixa’s MPL, which seems able to improve patients’ immune response and thereby reduce the need to receive booster shots. All in the future, though.
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Want to lose a bit of weight the easy way? Laugh a lot. Scientists at a European conference have concluded that a hearty laugh -- or at least fifteen minutes of giggling -- can burn off the calories gained in a medium-sized square of chocolate.
Measurements were made quite scientifically, too...by recording how much oxygen volunteers inhaled and how much carbon dioxide they exhaled, all of which measures rate-of-energy.
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Health Canada, which among its broad range of duties includes the country’s FDA-type oversight, has issued a ruling that the manufacturers of all statins -- Lipitor, Crestor, Zocor. Pravachol and others -- must attach both a warning and a description of possible risk to each product sold.
Health Canada originally downplayed possible health problems related to statins, but now says it wants to err on the side of caution since so many Canadians use them on a regular basis.
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The Louisville Courier-Journal recently published an 8-page insert reporting that Kentucky was a healthcare disaster, with a death rate 18% above the national average. Major blame was placed on smoking, poor eating habits and obesity. The state’s many economically-depressed rural areas were also cited as a major part of the problem.
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In a deeply-divided Congress, “odd couples” seem to be uniting in the newest attempt to make real healthcare reform possible. Senator Hillary Clinton and former Speaker Newt Gingrich are working together -- and sometimes even sharing a stage -- to accelerate the introduction of healthcare IT. Senators Orrin Hatch (R) and Ron Wyden (D) are sponsoring a series of grass-roots discussions to hopefully develop workable ideas and real reform. New Jersey’s Congressman Bob Mendez(D) and Ohio’s Debbie Pryce (R)sponsored a small but breakthrough bill that gives financial support to a “patient navigator” program which will direct the less-affluent towards better healthcare.
A lot of credit is also being given to retired Senator John Breaux (D), a “certified consensus-builder” who has decided to devote his retirement years to finding common Congressional ground for meaningful healthcare reform.
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Cost of generic drugs is holding steady, up less than 2% in the early months of the years. Generics accounted for 56% of prescriptions in 2004 against 49% in 2000.
Generics are increasingly being produced by the major pharmaceutical companies. At the turn of the millennium, a brand name coming off-patent was supplemented by an in-house generic version of the drug about 25% of the time. Best current estimate is that this now happens almost 100% of the time! Making generics secondary, but important, money-makers.
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A trend that started twenty years ago is apparently accelerating, as newly-minted doctors increasingly choose highly-specialized fields for their residencies, leaving many internal medicine and family practice positions to international students.
According to the American College of Physicians, 72% of these positions were filled by American-school grads in 1985; now it is down to 56%. General forecast is that we are rapidly heading for an oversupply of specialists and a scarcity of generalists.
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An American Cancer Society psychologist and a Columbia U. psychiatrist recently delivered a report concluding that 30% of the caregivers of terminally-ill family members suffer from clinical depression. Females, people under 55 and those culturally conditioned not to ask for help are the most susceptible. Guilt and shame surprisingly are key elements in the latter problems leading to failure to reach out and take greater advantage of the various support systems.
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