Friday, October 25, 2013

Nanomedicine - A Key Component to the Future of Medicine

Nanotechnology is making fast advances in medicine. I have written about it before here and in "The Future of Medicine - Megatrends in Healthcare." A nanometer is one billionth of a meter. New science and technology based on the nanometer refers to the ability to manipulate individual atoms and molecules to build machines on a scale of nanometers or to create materials and structures from the bottom up with novel properties.Nanotechnology, according to the National Science Foundation, could change the way almost everything is designed and made, from automobile tires to vaccines to objects not yet imagined. The concept is to prepare "smart objects" that can invade small spaces and target specific parts of the body. Some researchers expect nanoscience to have a profound impact on the way medicine is practiced.
Here is a an infogram that gives a nice overview, compliments of  its originator, Marcela De Vivo and her sponsor Associates Degree in Nursing.

Monday, October 14, 2013

Have You Had Your Colonoscopy Yet? –A Ludicrous Colonoscopy Rule and the ACA

“An ounce of prevention” we all know is good medicine. An example is colonoscopy. It was time for mine so after some lengthy procrastination I called and set up an appointment which I soon found a perfectly good reason to postpone for a few weeks. A common occurrence. The government wants me (and you) to not procrastinate, at least not because of the cost. The Affordable Care Act (ACA or Obamacare) makes an effort to get more people to get preventive care screening by requiring that there be no deductibles or co-pays for defined screening and prevention services. Sounds good. But,  in this Part 8 of my Medicare series, there may be a catch, as I soon learned.
The concept and purpose of colonoscopy is to find a polyp and remove it before it turns into cancer. Colon cancers arise from polyps. Polyps are common but only a minority of polyps progress to cancer. But if removed they obviously cannot become colon cancer. Colon cancer is the third most common cancer in men and women in the USA with about 150,000 new cases per year, behind only lung, breast and prostate cancers. And it causes about 50,000 deaths per year. Prevention obviously makes sense.
On my appointed day I arrived at 8:25am having had clear liquids for 24 hours and the effects of a very strong purgative. I was pleased that part was now over. The receptionist seemed like she already had a long day but was nevertheless efficient. By 8:35 I was in a cubicle getting into my procedure gown. Thelma – a wonderful nurse and nurse administrator who had come out of retirement for the intellectual stimulation of working with people – reviewed my pre-completed history and kept up a patter while another nurse deftly inserted an IV. The senior anesthesiologist came by and then the gastroenterologist, Dr Kester Crosse. I was whisked off to the procedure room, slipped off to sleep and awoke back in the cubicle. Dr Crosse came by to say that the procedure went smoothly, that he found a polyp which looked benign and that he had removed it. The pathology report would be back in few days. Another cheery nurse chatted with me and my wife for about fifteen minutes; her medical purpose was to be sure I did not aspirate before fully regaining alertness. When she was satisfied that I was really awake and alert she let me get up and get dressed. We walked out at 9:32am. Most everyone at Digestive Diseases Associates had been friendly, all had been competent and all had done their job effectively. Very efficient and satisfying to me.
The Medicare and Medigap statement came in a few weeks. Dr Crosse had billed $964. Medicare reduced this to $327.61 as per its formula. In other words, Medicare says a colonoscopy is worth about $328 and it paid its portion of that amount or $262. The doctor is not allowed to “balance bill” me for the rest of what he had originally charged. In order to participate with Medicare he, by contract, has to accept the price Medicare determines. Since Medicare generally pays about 75% of covered services, the bill next went to my Medigap provider (Carefirst Blue Cross/BlueShield in my case.) They did not pay the remainder stating correctly that I have a high deductible policy. So the doctor’s office sent me a bill for the $65.57. I paid it. But what about the new Medicare rule in the ACA/Obamacare that there are to be no co-pays or deductibles for such preventive services?
A check of the  web site stated that colonoscopy was covered by the ACA and that   “If your doctor finds polyps inside your colon during testing, these growths can be removed before they become cancer.”
I decided to call the doctor’s billing office to check. After the clerk talked to her supervisor she called back to say that I was correct that there was to be no deductible if it was a simple “screening” colonoscopy. But since the doctor had found and removed a polyp it became a therapeutic procedure. Medicare and Medigap (and apparently commercial insurers as well for those under 65) do not recognize this as a preventive screening procedure under the ACA guidelines. Hence I was on the hook for the remaining $65.52. By chance I was at a breakfast shortly after with a senior person at Blue Cross who confirmed that, yes, this was the rule. I also received a facility charge (nurses, procedure room, equipment, cleaning, etc.) of $695; Medicare reduced that to $391. This left a Medigap portion of $78.15 but again it was my responsibility to pay. Finally were the anesthesiologist s’ bills totaling $975. Medicare reduced that to $150, paid $65 leaving me with a bill of $66. So altogether it cost me just under $250 to have the colonoscopy and the peace of mind that all is in order. Not a bad value.
Admittedly $250 was not a huge amount of money but it strikes me as strange, to say the least, for Medicare rules to say that, since Dr Crosse removed a polyp while doing the colonoscopy, then it was no longer a preventive/screening procedure.
As an aside, I happen to be a big believer in high deductibles. I think that Medicare should be totally changed so that everyone (except the financially challenged) should be required to have a high deductible. That would engage patients into more dialogue with their physicians and lead to better quality at lower cost. I have posted and written an op-ed in the Washington Times about this concept.
But that is not what Congress set into law in the ACA, i.e., Medicare recipients would not pay deductibles for specified preventive screening, including colonoscopy. The whole point and purpose of the colonoscopy is to look for polyps and to remove them if found. It makes little common sense to claim that polyp removal changes the procedure from screening to therapy and therefore not eligible for the no deductible rule. Admittedly, my argument can be challenged. For example, a screening test for cholesterol would have no deductible but the drug treatment for high cholesterol would of course be another matter. Similarly, if a mammography detects probable breast cancer, the subsequent treatment would not be covered with no deductible. But in the colonoscopy example, the procedure is underway, the doctor finds a polyp and, as part of the process, removes it. Maybe there should be a separate bill just for the polyp removal part and a deductible for that portion. The facility charge would be the same except for sending the specimen off to pathology and I doubt the anesthesia was any longer or more complicated as a result of the polyp removal.  So most of the deductibles would be eliminated as per Congressional intent.
I wonder what our elected representatives really intended – or maybe they never really thought about the details.

Wednesday, October 9, 2013

A “Grand Bargain” To Improve Quality and Decrease Medicare Costs

There are just a few key reasons why Medicare has become inordinately expensive. There is no end in sight for cost escalation. But there are some obvious solutions and they all begin with chronic illnesses.

Chronic illness – diabetes, heart failure, cancer, chronic lung disease, etc. – are increasing at exponential rates; are caused largely by lifestyle behaviors; and consume 70-85% of all claims paid. Medicare enrollees tend to have chronic illnesses; 85% have at least one and 50% have three or more and many are taking 5-7 prescription medications. Any attempt to control costs must begin with chronic illnesses. 

Is there a good solution to the Medicare cost rise issue? Are there approaches that could be instituted now that would have an immediate impact on improving quality of care and thereby reduce costs? There are and could be the basis of a “grand bargain.” Here are five workable suggestions. 

1) The first recommendation is to recognize that one is never too old to benefit from sound preventive measures. Most chronic illnesses are related to excess calorie consumption, lack of exercise, chronic stress and tobacco. And aging leads to impaired mobility, vision, hearing, dentition and cognition. So Medicare should strengthen the wellness, health and preventive programs with specific funding to PCPs to engage in detailed, in depth preventive care. The new annual preventative care session built into the Affordable Care Act (ACA/Obamacare) is a good start in this direction but it must be augmented since a single yearly session is not sufficient to deal with the serious lifestyle issues leading to and exacerbating these chronic illnesses. This will improve health now and substantially bring down costs in the longer term.

2) The second recommendation is to recognize that older individuals with multiple chronic illnesses on multiple prescription medications who may have visual, hearing, mobility and cognitive impairments cannot be effectively diagnosed and treated in short time periods. There must be time – to listen, think, prevent and treat. This means adequate reimbursement per visit to spend the time required. And it means Medicare must pay the PCP sufficiently and specifically to provide chronic illness care coordination. This must be done in a way that is a quid pro quo – higher reimbursements but only in return for the care the patient needs and deserves. This will markedly improve quality, substantially reduce costs and do so immediately. It means the PCP must substantially reduce his or her case load from today’s 2000 plus to no more than 1000 (and preferably substantially less) so as to have the time required for each patient. (Many believe that it best to convert from a fee for service to a fixed reimbursement system, capitation system or a salaried approach. That is probably a good idea but only if the system grants the PCP the critical needed time per patient, i.e., assignment of a limited number of patients or a large enough payment per year per patient so as to keep the total number of patients under care low enough to give the time needed.)

3) The third recommendation is that Medicare should reconsider its approach to hospital care alternatives. For example, today a patient becomes eligible for nursing home care only if he has been hospitalized for three or more days. Costs could be dramatically reduced if a patient could be sent directly to a well-qualified nursing home by his PCP who certifies in writing as to appropriateness. Similar consideration should be given to home antibiotic administration and other home care alternatives which mean better quality and lesser costs. 

4) The fourth recommendation, somewhat of an alternative of the second, begins with the realization that primary care is generally not expensive. Indeed when Medicare originated, it was the patient’s responsibility to pay for primary care and should be again. Medicare should institute high deductibles with the opportunity for a health savings account (HSA) to pay for primary care with tax advantaged dollars. Patients begin to ask questions and challenge recommendations when they are paying for primary care directly. They can request more time per visit and pay for it through their HSA. Both have the result that the care quality goes up and the overall cost to Medicare goes way down because the patient gets the time needed by the PCP to give good care, avoid excess testing and avoid the reflex to refer to the specialist unless really appropriate. The patient-doctor relationship is corrected to being a direct contractual relationship leading to better care at much lower cost. Most studies suggest that the deductible needs to be high enough to be meaningful, often about $1000 or more. This could be reduced for those of lesser means. Given the importance of preventive care, that might be excluded and continued to be paid for by Medicare. High deductibles will be politically difficult. But high deductibles are available thought the private plans for Medigap and for the Part D prescription drug policies so the precedent is there. This would lead to a much more responsible use of the entire system with better care and much reduced costs.  

Meanwhile, many PCPs are switching to a direct pay system where they no longer accept Medicare and either expect to be paid per visit by the patient or be paid a flat annual amount (retainer). Medicare is losing these physicians now who are providing better care but at a cost to the patient. Better that Medicare reexamines its policies and adapts now. 

5) The fifth recommendation relates to end of life care. Americans believe in individualism and the right to whatever care is available, damn the expenses. And physicians are trained to treat death as an obstacle to be surmounted rather than to be accepted as ultimately inevitable. This plays out eventually towards the end of life where “one last” drug, procedure, etc. is proposed or requested or both. Generally this occurs because the physician has not engaged in a constructive, honest and empathetic conversation with the patient well ahead of time and ongoing. This is fundamentally irresponsible use of the medical care system by both patient and doctor. Much better is reasoned, empathetic discussion between patient (and family) and the doctor followed by humane, compassionate active support and emotional care – in other words, death with dignity. End of life discussions are not only logical but humane. And it must be stressed that this recommendation has nothing to do with so called “death panels” or some nefarious means of rationing care. 

Each of these recommendations incorporates a balancing of rights and responsibilities. The first offers the enrollee added wellness and preventive services but it must come with the responsibility to use them effectively. The second grants the PCP added revenue per patient but only for the commitment to take the needed time with patients and of offering extensive preventive services and chronic illness care coordination. This of course means limiting the total number of patients under care per PCP. The third grants a new approach to paying for alternative care but only provided that it is certified as appropriate. The fourth places the responsibility for first dollar coverage on the patient/enrollee but with it must come a right to a better doctor-patient contractual relationship – one that the patient can void if the response is not adequate for the dollars expended. And the fifth recommendation places a responsibility on patient and doctor alike to have in depth and rational discussions regarding end of life options and needs while expecting Medicare to pay not only for the discussion time but also for the option selected. 

These five recommendations could have a major impact on Medicare expenditures, beginning immediately. The real benefit of course is that these recommendations will improve health care quality while leading to more satisfaction by patient and doctor alike. It would be a valuable “Grand Bargain.”

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).