Latest Drugwonks' Blog
This is an abomination, especially if a super-majority is needed to kill it.
Article published Jun 28, 2009
Doctor shortage proves painful to state
By BRENT CURTIS Staff Writer
Much of the state is short on primary care providers at a time when the nation as a whole is searching the same pool of doctors.
Since the start of the year, Rutland County, for example, has lost three primary care doctors and three more are over age 60 and planning to retire within the next few years, said Rutland Regional Medical Center President Thomas Huebner.
"We have the biggest shortage of primary care doctors in the state," Huebner said, pointing to a 2008 state Department of Health report that indicated that all but a tiny portion of the county faced a "severe need" for primary care physicians.
And that study was conducted before the departure of three primary care doctors earlier this year.
The loss of those doctors is more than just an inconvenience for their patients. With the demand for primary care in Rutland County exceeding the supply – which Huebner said is short by about four doctors – patients are forced to wait longer to see doctors who are overburdened. Also, many doctors in the region aren't accepting new Medicare or Medicaid patients – most physicians can only accept so many state-insured patients due to low government reimbursement rates – which compels many patients to put off doctor visits until their needs are acute and they end up in the hospital.
It's a fallback practice for those who can't find primary care doctors that Huebner and other health care professionals say ends up costing hospitals, insurance companies and ultimately those paying for insurance more.
And the primary care problem hardly is unique to Rutland or to Vermont for that matter.
Elsewhere in the state and nation, primary care physicians are in short supply.
Dr. Ted Epperly, president of the American Academy of Family physicians, said the United States is about 15,000 primary care doctors short of demand — a 30 percent shortfall across the board for all 50 states.
If current trends persist, the AAFP predicts the deficit will grow to 40,000 over the next 10 years.
That estimate is no surprise given that only 17 percent of U.S. medical school graduates in 2008 expressed a preference for family medicine. The AAFP said the small percentage of primary care-minded graduates represented an "all-time low" among emerging students.
Even in Vermont, where the University of Vermont prides itself on ranking in the top 5 percent of all medical schools for primary care, access to family medicine is spotty.
In addition to Rutland County, large swaths of the Northeast Kingdom along with large portions of Grand Isle, Franklin, Lamoille, Addison, Orange, Washington and Windham counties were labeled "severe need" areas by the Department of Health. Many other areas of the state were listed as "limited need" areas.
In fact, the only sizeable areas with adequate supplies of primary care, according to the most recent state study that compares full-time equivalent hours with regional populations, were portions of Chittenden, northernmost Orleans, southern Addison, much of Windsor, central Windham and most of Bennington counties.
The reasons for the doctor shortage, which has been gradually worsening over the years, are well documented. Much of the problem boils down to money. Medical students who opt to specialize rather than enter primary care practices stand to make significantly more because specific procedures earn higher reimbursements than generalized care and diagnoses. For medical students leaving school with debt loads often topping $150,000, the decision to enter primary care practice often means a degree of financial hardship, according to survey-based research conducted in Vermont and nationwide.
Those same surveys show that primary care physicians tend to work longer hours than specialized doctors and must juggle larger caseloads with the reams of paperwork that accompany most procedures in modern medicine.
In Rutland, Huebner said those symptoms are particularly acute due to high ratios of Medicaid and Medicare patients in the community. Reimbursements from the two government programs are well below the cost of medical procedures.
Vermont can be a tough place to recruit new doctors who can often find higher wages in other states, according to the Vermont Medical Society.
"What Vermont has going for it is quality of life," said Paul Harrington, executive vice president of VMS. "Nothing trumps a desire to be here because there are other places where doctors do earn more."
On top of that, Harrington said Vermont has a higher ratio of Medicaid patients and an ever increasing number of Medicare patients due to a graying population.
The pay scale puts Vermont at a disadvantage when it comes to recruiting new doctors – and it makes keeping them here a challenge, as well.
Since the primary care shortage is a national problem, other states constantly are trying to lure doctors away from Vermont.
To keep physicians here, hospitals around the state utilize their own recruiters who not only try to bring doctors to their facilities but work toward a balance of doctors in private practice in the surrounding communities as well.
Hospitals have an interest in the medical community beyond their own walls because a shortage of primary care doctors means more patients arriving in the emergency room suffering from ailments that a family physician could have detected and dealt with at a less acute and less expensive stage.
"We're all in this together," said Donna Izor, vice president of physician services at Central Vermont Medical Center.
Izor, and other recruiters around the state, offer incentives such as electronic medical records, startup loans and hospitallist services – hospital employed doctors who oversee a primary care physician's patients during hospital stays – to ease the financial, paperwork and time burden that family physicians shoulder.
But all acknowledge that the real answer to the problem lies at the state and federal level, where Medicaid and Medicare reimbursement levels are set – and all too often are cut.
During the last legislative session, budget realities prompted legislators to cut Medicaid reimbursements by 2 percent.
In the Legislature's defense, Rep. Steve Maier, D-Middlebury, said legislators exempted a number of procedures common to primary care physicians from those cuts and he said the Legislature increased Medicaid reimbursements for some primary care procedures.
"We know there's a shortage and we know that quality primary care saves money for the system in the long term," said Maier, who is chairman of the House Health Care Committee.
The Vermont medical community is also looking at changing the way that primary care is delivered. Through a blueprint model originally developed to handle chronic care for patients, three pilot programs are underway in Burlington, Bennington and St. Albans that will provide a small supplemental sum for each primary care provider in the pilot. More importantly, the blueprint pilot establishes a team approach that would surround primary care doctors with physician assistants and specialists, who the pilot's drafters hope will assist family physicians and relieve some of their time and caseload burden.
Huebner said he is seeking to make Rutland the fourth pilot site for the blueprint.
In the meantime, the RRMC president said he's looking ahead to the opening of a federally qualified health care center at 69 Allen St. later this summer.
The center, which will serve as a satellite for the main FQHC center in Castleton, is starting small with just a single doctor, but Huebner said he has applied for funding to expand the practice by building a center on land owned by the hospital.
There are eight other FQHC centers in the state – the one in Springfield is the newest – and 34 satellite offices. The centers' greatest asset is something of a commentary on the underlying problem confronting other primary care doctors – they are paid a much higher reimbursement for Medicaid and Medicare patients.
The FQHC facilities operating in the state cover a majority of the state's 14 counties.
But independent U.S. Sen. Bernard Sanders, who has advocated for additional centers for years, said he won't be satisfied until two more centers are added in Addison and Bennington counties.
Sanders said this week that he has had recent success expanding the FQHC program, which will create 126 new health centers nationwide this year.
"We have 60 million people out there with no doctor of their own," he said. "What we need to do and work on is making sure that every person in the nation has access to a doctor."
Harvard Teaching Hospitals Cap Outside Pay
The owner of two research hospitals affiliated with the Harvard Medical School has imposed restrictions on outside pay for two dozen senior officials who also sit on the boards of pharmaceutical or biotechnology companies. The limits come in the wake of growing criticism of the ties between industry and academia.
Medical experts say they believe the conflict-of-interest rules at the institution, Partners HealthCare, go further than those of any other academic medical center in restricting outside pay from drug companies. The rules, which became effective on Friday, impose limits specifically on outside directors who guide some of the nation’s biggest companies.
http://www.nytimes.com/2010/01/03/health/research/03hospital.html?pagewanted=printWill someone please explain to me what the downside of such ties are as long as all relationships are transparent and the research conducted is done so at arms length? Should academia receive no industry support of any kind?
However, it's okay for business professors who criticize pharma ties to academia to disgorge huge consulting fees from said corporations...
"Thomas Donaldson, a professor of business ethics at the Wharton School of the University of Pennsylvania, said: “It strikes me as a breath of fresh air in a room that’s getting progressively more stale. I hope this will set a standard for others — hospitals, medical schools.”
Professor Donaldson, who advises large companies on corporate governance, said dual roles in a hospital and at a drug maker were “dicey at best” because a director’s duty is to look out for the corporation’s financial interests.
The irony or hypocrisy is not even noted because, well, only pharma dough is evil. Meanwhile, I have obtained a photo of the new Partners RNAi antibodies facility... paid for from medical students actvitivy fees
As we flip the calendar to a new year, it’s time again for our drugwonks.com annual Golden Clipboard Awards.
Why a golden clipboard? Well, commenting on the current state of 21st century bioinformatics, CDER chief Dr. Janet Woodcock quipped that, "Today the major tool of modern medicine seems to the clipboard."
In the past, we’ve given out awards to those who impede (unwittingly or otherwise) the advance of medical progress. For 2009, in the spirit of non-partisanship, we hand out honors based on those who helped move the needle towards real healthcare reform in a more positive direction.
Herewith our 2009 honorees …
Honorable Mention: The FDA for telling Senator Dorgan et al. to park their idea for drug importation in a tamper proof location.
Honorable Mention: Richard "Buzz" Cooper of the Leonard David School of Public Health at University of Pennsylvania and Gary Puckrein of the National Minority Quality Forum for respectfully challenging the outdated Dartmouth methodology and forcing policymakers to examine the impact of poverty,
behavior and severity of illness on differences in health expenditures. Equally dead is not a
Honorable Mention: Representatives Mike Rogers (R) and Anna Eshoo (D) for working together to promote a safe and savvy pathway for follow-on biologics.
Honorable Mention: Billy Tauzin for cutting “the deal” that protects the Non-Interference Clause, thus preventing a slippery slide towards broader government price controls for pharmaceuticals. Price controls = choice controls.
The Bronze Clipboard: We are pleased to award the 2009 Bronze Clipboard to Paul Offit for bravely and publicly standing up to those (including CBS News) who slandered him and threatened the lives of his children for simply saying vaccines have benefits far outweighing the risks.
The Silver Clipboard: And the winner is NIH Director Francis Collins for telling it like it is about comparative effectiveness when he points out that it ignores individual differences that we know exist at the clinical and genetic level.
And the 2009 Golden Clipboard winner is … DRUMROLL PLEASE …
The Golden Clipboard Winner for 2009 is FDA Commissioner Peggy Hamburg for saying “yes” to science and personalized medicine and “no” to political interference at the Food & Drug Administration. She calls it like she sees it and that’s just the attitude required to help the FDA advance the public health by being both regulator and colleague to the industries the agency oversees. It’s a tightrope to be sure – but Dr. Hamburg has the requisite smarts and finesse.
And so, Golden Clipboards awarded, let us march forward together into 2010 with high hopes and in a spirit of cooperation to advance the public health.
(But we’re keeping our athletic supporters on just in case.)
Happy New Year.
This end-of-year revelation comes after my wife’s emergency appendectomy. Here’s the briefest chronology:
2AM: Horrible stomach pain and other relevant symptoms.
5:45AM: 911 call
5:50AM: EMTs arrive
6:00AM: Arrive at emergency room
6:07AM: Wife in emergency room bed
6:15AM: Nurse takes blood
6:20AM: Initial physician consultation
6:25AM: Wife on saline and anti-nausea drip
7:00AM: Wife gets some morphine
7:00AM – 11:00: Wife rests comfortably waiting for CT scan
11:00AM: CT scan (One machine was out of service, hence the long wait.)
11:10AM: Resident confirms diagnosis of appendicitis
11:15: Initial consultation with surgery resident
1:00PM: Surgery prep
2:00PM: Surgery
3:30PM: Recovery Room
5:00PM: Admitted to empty room
9:30AM (the following day): Released
To use a pain intensity scale analogy – the entire experience was only “moderately painful.”
Which brings me back to the plural of anecdote being reality. As a good resident of the 21st century, I used Facebook to let my friends and family know about my wife’s condition. The Americans were all appropriately sympathetic. The Europeans were mostly amazed. Amazed that we didn’t wait hours for an emergency room bed. Amazed that we saw a doctor in fewer than 5-8 hours. Amazed that we weren’t told to go home and come back at a later date (since her white blood cell count was only slightly elevated and the appendix wasn’t in danger of bursting) and not amazed but astounded that the surgery was done immediately. That there was actually a room available and that it was vacant – at a large urban hospital – they couldn’t even fathom.
Here is one verbatim comment from one continental comrade:
“I waited three days in London to see a GP and 20 hours at ER for an "exploratory op." It burst and I nearly died (to say nothing of the two life-threatening incidents whilst I was being "cared" for). But hey! The public option is better than letting people choose, right?”
So, while the plural of anecdote isn’t data – it is reality. And, in the immortal words of George Santayana, “Those who do not learn from history are doomed to repeat it.”
Speaking of General Santayana, here’s one of his less famous observations – keenly apropos of the current debate on American healthcare reform, “Fanaticism consists in redoubling your efforts when you have forgotten your aim.”
And the occasional anecdote goes a long way to reminding us of that, um, reality.
“The Food and Drug Administration is developing guidelines that will set tougher scientific standards for data from tests on humans that makers of medical devices submit when seeking approval of their products, a top agency official said.
Dr. Jeffrey Shuren, the acting director of the Center for Devices and Radiological Health, said in a telephone interview on Monday that the F.D.A. most likely will soon urge device makers to take steps like using more sharply defined targets to measure the success of clinical trials. The agency may also urge producers to more closely follow patients enrolled in such trials to determine whether the targets are met, he added.
The F.D.A.-sponsored study found that more than 40 percent of the studies used to approve cardiovascular devices had lacked high-quality data about either the treatment or safety goals of the study. In addition, that study also found that about 25 percent of trials had failed to adequately follow the outcomes of a sufficient number of patients, a level the review defined as 90 percent or more of patients initially enrolled in a trial.”
The full New York Times story can be found here.
According to a new report just issued by the Center for Technology and Aging, medical optimization (“med-ops”) via information technology is an important element to improving medication-related errors and improving medication adherence among older adults.
The report says "widespread use" of technology aimed at this population could save thousands of lives and billions of dollars.
"More widespread use of technologies that reduce the cost and burden of medication-related illness among older adults is urgently needed," said David Lindeman, the center's director.
The Institute of Medicine reports that more than 2 million serious adverse drug events and about 100,000 deaths occur annually due to medication use problems. The New England Healthcare Institute estimates that $290 billion in healthcare expenditures could be avoided if medication adherence were improved.
"Medication non-adherence is responsible for up to 33 percent to 69 percent of medication-related hospital admissions and 23 percent of all nursing home admissions," said Lindeman. "As Congress debates ways to improve our healthcare system and lower costs, it will be critical to put in place incentives that encourage providers to accelerate the use of available 'med-op' technologies."
The report addresses three areas of opportunity for medication optimization: reconciliation, adherence and monitoring. It describes the technologies being used or under development within the three areas along with an assessment of their pros, cons, market stage and economics.
Some of the technologies described include:
* Medication kiosks, such as those piloted at the Veterans Health Administration;
* Walgreen's online medication history tool for consumers;
* Cognitive assessment tests like the Mini-Mental State Exam (MMSE);
* "Rex," a talking pill bottle designed by Pittsbugh-based MedivoxRx that assists visually or cognitively impaired patients;
* The Med-eMonitor System, a portable electronic medication-dispensing device from Rockville, Md.-based InforMedix;
* Mobile phone apps with medication management, reporting and trending features; and
* Wireless point-of-care testing devices to monitor medication use.
According to the report, of the 3 billion medication prescriptions issued each year in the United States, 12 percent are never picked up by the patient and 40 percent are not taken correctly.
"And yet, effective tools and technologies already exist to greatly reduce these problems," said Lindeman. "Ultimately, medication optimization technologies can lead to significant improvements in the cost and quality of care for older adults."
Number of words devoted to such concepts in both the House and Senate health reform bills? Zero.
The best that can be said about this cynical exploitation of people and families in hospice settings is that at least there is no Death Panel making coverage decisions. The cut is across the board, one size fits all and designed not to save lives or save Medicare as Senator Reid claims, but to win the support of specific Senators and special interests. Connecticut’s Chris Dodd gets a hospital, New York and Florida get to keep Medicare Advantage, a program that allows poor seniors to get additional services (like hospice) without paying more premiums while millions of other seniors will be tossed from the program. (They will be able, once again, to buy expensive supplemental insurance from AARP, which coincidentally supported the health care bill.) There are very special Medicaid payments for Ben Nelson’s Nebraska, which already gets more dollars per person and a higher federal share of payments than the programs average.
Liberals excuse this behavior by claiming it is the one-time cost of getting a deal done that benefits the nation as a whole. However, such horsetrading – cutting benefits to free up cash for universal healthcare is a central feature of both the House and Senate bills and of government run systems in general.
Healthcare policy and deal making is already a big business.
It is easier to get cuts by force than through regulatory “reform.”
And, when it comes to health care, there seems to be nothing but wild cards. From “the deal” that Billy Tauzin cut with the White House to the future of follow-on biologics, from the “doc fix” to clinical effectiveness, from closing the doughnut hole to paving a pathway for follow-on biologics, there are enough issues in play to offer at least a dozen plausible scenarios. They’re all interesting and important. But some (in a very Orwellian sense) are more important than others.
The most important is the future of innovation.
For the rest of the story, see here.
Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.
