What if the Placebo Effect isn’t a trick? NY Times

The NY Times has a fascinating article on the latest research into the Placebo Effect. The Times does a good job of outlining the history of the Effect, including the beginning of modern science’s interest in it, with none other than Benjamin Franklin in the mix. The latest research helps paint a picture that if correct, could help us understand the interconnection between faith healing, eastern medicine, therapeutic touch, and western medicine. It also holds out the possibility of even making our drugs more effective. Read on…

 

Why Doctors Hate their Computers – New Yorker

Atul Gawande is one of the best writers today, writing on the subject of healthcare, end of life issues and modern medicine in general. You likely have heard him on NPR. Finally, he tackles the aggravation and lost promise of  electronic medical record systems (EMR).

EMRs have been viewed as a panacea by the medical community, primarily by politicians and government administrators lured by the promises of centralized control of medicine with rising costs of patient care, along with lawyers who are seeking to minimize risk of lawsuits. Add to that  hospital administrators, many of whom have never had to fill in a screen of medical data in their lives.

From the medical practitioners I’ve talked to about EMRs they are frustrated with the level of work they have had to do to keep up and the difficulty of finding useful information in the systems. Some patients have lost their lives due to EMRs, as specialized practitioners enter data that is not easily found, and when a patient is admitted to an ER room, often these instructions are lost to the ER techs. Or, to be more precise, they can’t take the time to find them in the mountains of screens. Yes, because of EMRs patients that otherwise may have lived are dead. Gawande alludes to this issue in his article.

Once, physicians could dictate and have the dictation sent to India overnight for translation. They’d have it the next morning. Or they wrote notes that were good enough and ended up in charts where they could be found quickly.

We are now in the worse of all worlds. EMRs are not automated enough to actually save practitioners time. Because of the use of EMRs, the expectations that medical providers can do the work faster and better mean that funding agencies drive providers to work faster and see more patients. A PA I know would spend two hours after seeing over 25 patients a day, before finishing the work of  filling out her EMR records. She was not reimbursed for this effort and she said it affected her home life as well. It’s a story I’m hearing from many practitioners.  At some point in the future dictation will be perfected and finding data that’s critical to patient care in an emergency will be easy to do. Until then, providers will continue to burn out and leave the system, just at a time when we need them more than ever.

We encounter, in Gawande’s article, an administrator who claims that the EMRs are not for the doctors but for the patients. While it’s true that patients use these systems a lot, (myself included) the results that most of us get are simply lab results and some easy to understand notes from our providers. That someone would think that the patient is the focus of all of this is misguided and shows a lack of understanding of systems.  The patient could just have easily have been given this information without the vast back end systems that affect every moment of provider time.  Think I’m wrong? It’s the backbone of every app you run on your smart phones. They are small and customer/consumer focused. We create these systems all the time. Requirements? Just listen to the customer. No need for thousands of hours of input meetings and lawyers.

It’s time to demand better EMR systems, focused on the needs of the providers and patients, not the hospital administrators, the lawyers, government and private insurers and the like. It can be done.

With all that said, Gawande’s article is the best thing I’ve read yet that gives a clear lay of the land of the frustration that physicians are feeling about EMRs. Take a read.

https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers/amp

 

 

 

Trump Administration Slashes Medicare/Medicaid Payments. Local Hospital Is Targeted

The Peninsula Daily News (PDN) is reporting that the Trump Administration, against the wishes of hundreds of letters and testimony against it, is slashing Medicare and Medicaid reimbursal rates to clinics more than 250ft away from a central hospital. The new rule is called the “CY (for Calendar Year) 2019 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System”

The rule announcement from July is found at

https://www.cms.gov/newsroom/press-releases/cms-empowers-patients-and-ensures-site-neutral-payment-proposed-rule

and the October 30th update is found here:

https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-hospital-outpatient-and-ambulatory-surgical-center-policy-and-payment-changes

The goal of the proposed rule was to eliminate patient clinic visits to hospital clinics that charge more than non hospital clinics. The Center for Medicare and Medicaid Services (CMS) claims in it’s press release that, “Currently, CMS often pays more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.” They offer no proof to that claim.

The most affected facility for this on the Olympic Peninsula is Olympic Medical Center’s (OMC) offsite clinics in Sequim. Ironically the clinics serve a population that voted for President Trump in the last election and they will, if this rule is not overturned via legislation, be the most effected by it. The chart at the link below shows how various precincts voted in 2016.

https://www.nytimes.com/interactive/2018/upshot/election-2016-voting-precinct-maps.html#8.27/47.920/-122.715

The PDN is reporting that payments may be slashed up to 60%, which would apparently make these clinics financially nonviable. Medicare and Medicaid payments today are so lean that many physicians do not take new Medicaid/Medicare patients because they cannot survive on the reimbursal rates.

The outcome of this will be that seniors and the poor will have to travel further for medical care, and that some hospitals, like OMC may be forced to close their remote facilities and possibly even put their main hospitals in financial jeopardy. Hospital closings in the last decade in rural areas have reached new highs, leading to rural areas often being the most under-served areas for healthcare in the country. Forbes magazine, in 2017, had an article that researched the issue and found that “Approximately 2300 rural hospitals are in the United States. Of those, 81 have closed since 2010.” Forbes went on to show how President Trump’s proposed healthcare cuts were putting “673…at risk of closing”. The full story from Forbes is available at https://www.forbes.com/sites/bisnow/2017/07/26/obamacare-repeal-could-cripple-rural-hospitals-and-lead-to-more-closures/#6dbd6b4f42b8

It is not known how this will affect Jefferson Healthcare (JHC) as they have kept their clinics within the required 250 yard rule. They have worked around the issue by setting up their clinics in Quilcene and Port Ludlow in a different legal framework. They claim that they will be less affected.

There have been rumors from healthcare providers that other standalone clinics may be affected, those not attached to a hospital. We will track those as we hear from the community. Your comments and insights are welcome to be sent to albergstein@gmail.com

What is happening is an ongoing push to centralize healthcare in urban centers and reduce the costs. While healthcare costs are rising, much of these costs are centered in the last years of life. Our insistence on providing all out high cost medical support to terminally ill patients, for example, rather than focusing on expanded hospice care has led to a heavy weighing of costs to end of life medical intervention. From personal experience, I can say that in some locales there seems to not be honest dialogue between patient and provider about the likelihood of a successful outcome, leading to the patient not knowing that they are essentially terminally ill and wanting to continue, under the providers suggestions, with expensive treatment that will only likely extend life a few months.

Medical providers are also, due to litigation costs, often insisting on far more tests than necessary, driving up costs. There is no easy route out of that issue, as patient expectations are not often aligned with actual healthcare scenarios and outcomes. The inability to also properly judge physician history and ratings also make it hard for patients to know when some providers have a history of malpractice.

But the slashing of medicaid and medicare costs to OMC and other hospitals like it, is a cynical ploy by the Trump Administration and Congress to do a stealth attack on these services, one which was highlighted in an article last month.

Larry Kudlow, the director of the Trump White House’s National Economic Council, recently said he wants to take aim at “entitlements” as early as “next year.” A few months earlier, House Speaker Paul Ryan (R-Wis.) said he wants to see policymakers bring the budget closer to balance by cutting “entitlements.” Rep. Steve Stivers (R-Ohio), who currently chairs the National Republican Congressional Committee, made the same argument in August.

And now Senate Majority Leader Mitch McConnell is making the identical pitch.

http://www.msnbc.com/rachel-maddow-show/mcconnell-eyes-cuts-medicare-social-security-address-deficit

This all comes after slashing taxes to the wealthiest Americans and corporations earlier in the year.

It is worth remembering that this administration and previous ones have spent approx. $170M a day for 16 years funding the war in Afghanistan. We have the money to fund Medicare and Medicaid at appropriate levels. It’s all about priorities.

Just last month, our legislators from both Clallam and Jefferson counties, including some of our county and hospital commissioners and executives, traveled to Washington D.C. and met with numerous staffers, both at the White House and Congress. Some of them, such as Republican Congresswoman Jamie Herrera Butler, was not in Washington and sent out a staffer who knew nothing of the issues.

It remains to be seen if our legislators can fix this problem in Congress next year. If you want to help ensure it gets done, vote Democratic on Tuesday November 6th. Putting Democrats at least in charge of the House will allow a real debate and bipartisan approach on how this all proceeds. Representative Kilmer, who is up for re-election, along with other Democratic Representatives have been fighting hard to protect rural hospitals. These politicians are not perfect. None of them will agree with all of us all the time. That’s just not how this representative democracy works. But these Democratic politicians in our district have a track record and to elect more Republicans and expect a different outcome seems unrealistic.

Otherwise these kind of cuts are going to continue to come at us, with the outcome being far worse healthcare options for all of us, no matter who you voted for in this election. This is not “making America great again.”

The final rule will appear in the November 13, 2015 Federal Register and can be downloaded from the Federal Register at: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.

 

Open Enrollment: Seven insurers offering plans for 2018

Open enrollment for 2019 coverage will run from November 1, 2018 to December 15, 2018.

Source: https://www.healthinsurance.org/washington-state-health-insurance-exchange/

All counties will have 2019 exchange coverage, but 14 (up from 9 this year) will have only one insurer; average proposed rate increase is more than 19 percent

Washington marketplace highlights and updates

Source: https://www.healthinsurance.org/washington-state-health-insurance-exchange/
Follow us: @EyeOnInsurance on Twitter | healthinsurance.org on Facebook

 

Rare polio like disease cases growing in WA – Seattle Times

What is causing AFM? This is bizarre disease is increasing in the number of cases, and apparently is happening in Washington State.

Hayden Werdal was born “perfectly healthy.” He caught a nasty cold at age 14, and now, four years later, he’s considered a paraplegic and needs a ventilator. Werdal, of Bremerton, has a rare and mysterious illness that’s left Washington families reeling. AFM is spiking, with 127 confirmed or reported cases nationwide this year, including eight in Washington. – Seattle Times

Just today, another case in Yakima:

http://newstalkkit.com/possible-acute-flaccid-myelitis-case-in-yakima-county/

While this is emerging, Trump has cut the budget at the Center for Disease Control. According to Politifact:

Among other changes, Trump’s budget would cut $138 million from the program dedicated to chronic disease prevention and health promotion, cut $59.9 million from programs studying “emerging and zoonotic infectious diseases,” and $46 million from a program called “Racial and Ethnic Approaches to Community Health.” A zoonotic disease is a disease that can be transmitted from animals to people.

Remember this as you decide who to vote for. A vote for Republicans is a vote to continue cutting the one agency that might help find a cause for this emerging illness.

Flu shot time. And a story to prove why.

Flu shots are cheap and available. Time to one. Here’s a story of someone who didn’t get the shot and the outcome of a bad case of flu. We have been very lucky that we have not seen another outbreak of a virus as bad as the 1918 Spanish Influenza. My grandmother started her nursing career with that outbreak and it colored the rest of her life. Here’s a story,  similar to ones she told me growing up.

Last Year, The Flu Put Him In A Coma. This Year He’s Getting The Shot

 

 

 

On Doctor Burnout – NY Times

The NY Times magazine has a good short article on a subject that many of my friends in the medical profession talk about, burnout. The reasons documented in the story mirror their concerns, electronic medical records being among the most irritating. Many doctors and their support teams of Physician Assistants, Nurse Practitioners and others spend vast amounts of time before or after seeing patients documenting their work. It is a demoralizing let down for people who have spent years becoming highly specialized providers of care. It used to be that many physicians could dictate their notes, then send them via modem to India for overnight translation. No longer. Read about that issue and others.