Quis custodiet ipsos custodes?

by Kim Bellard, February 1, 2011

Don’t worry if your Latin is as rusty as mine; I’ll provide a translation of the title a little later on in case its meaning has not become clear by then.

The New York Times recently got a lot of attention for their story about older physicians, reporting that one-third of U.S. physicians are over 65, and that proportion was expected to rise as baby boomer docs increasingly begin to hit 65.  The Times pointed out that, while many of these older physicians provide excellent care, there are not strong mechanisms in place to assure continued competence of the aging physicians, and, in fact, many older physicians are “grandfathered” (pun unintended, one hopes) from efforts intended to help demonstrate physicians’ continued expertise, like tougher board certification standards.  They contrast the situation for physicians with that of pilots, who not only face mandatory retirement at age 65 but also are required to begin periodic physical and mental tests at the tender young age of forty. 

With all due respect to the Times, the issue is not age (and, by the way, their estimate of one-third of physicians over 65 appears overstated – as best I can tell, one third of physicians are 55 and older, but slightly less than twenty percent are currently over 65).  The issue is competence and demonstration of that competence, regardless of age. 

In 2009 Sidney Wolfe and Kate Resnevic of Public Citizen analyzed data from the Federation of State Medical Boards (FSMB), and found that disciplinary rates per 1000 physicians ranged from .95 in Minnesota to 6.54 in Alaska, with the overall U.S. average at 2.92.  According to their analysis, that latter number has actually been dropping in recent years, over 20% lower than the peak in 2004.  Maybe physicians are getting better, and maybe the doctors are that much worse in Alaska (or in Kentucky or Ohio, the next highest states), but one has to worry about how well problems are being reported. 

Indeed, last year Catherine DesRoches and her colleagues published an article that reported survey results about physicians’ attitudes towards peer reporting.  Only 64% felt a professional obligation to report fellow physicians who were significantly impaired or otherwise incompetent to practice.  Seventeen percent of the surveyed physicians had direct personal knowledge of a physician colleague who was incompetent to practice, although only 67% of those admitted they actually reported that colleague.

The disciplinary actions and the survey results don’t measure quite the same thing, but one has to worry that there is too big a gap between 17% of physicians knowing an incompetent colleague and yet, on average, only 0.3% of physicians with disciplinary actions.   Even if the latter number was the “right” number, the variation of the disciplinary rates between states would still be troubling.

Economist Mark Perry, of the University of Michigan and a visiting scholar at the American Enterprise Institute, has some strong views about the medical profession.  Not pulling any punches, he likens the medical profession to a cartel (see, for example, this blog entry).  He contrasts the number of law schools versus medical schools over the past 100 years.  The former has grown sharply (much to many people’s dismay!), while the latter has dropped even in the face of predictions of looming physician shortages due to population growth and aging of the population (all those baby boomers hitting 65!).  The number of schools is perhaps not the best measure, but the number of students graduating from medical school each year has not changed substantially over the past 30 years (something some blame on federal policies on residency training funding).  The number of physicians per 1000 residents has been increasing over the past several decades, but this is due in large part due to importing physicians from other countries rather than graduating more in the U.S.  Despite this increase, the U.S. still ranks well below the OECD average for practicing physicians per 1000 population.  We just pay physicians much more than other countries (as reported by the Congressional Research Service and others.  But that’s a topic for another blog.

It has always been difficult for consumers to get information on physician performance.  Sites such as Healthgrades or WebMD have some information on physicians, but to date they have still been largely demographic in nature.  The FSMB allows consumers to get some information on individual physician disciplinary actions, at $9.95 per result.  Some specialty associations are developing quality measures aimed at consumer reporting, as are NCQA and others.  Various health plans have been trying to publish data on physician quality, although not without controversy.  Most recently, Medicare launched its Physician Compare site, as it had done some time ago with Hospital Compare; the launch has its critics (see Michael Millenson’s view).  All of this is good – and none of it is enough.

The medical profession takes great pride in its work, and since the medical school scandals of the early 20^th century has fiercely kept control over medical training and oversight.  In medieval days guilds served the purpose of ensuring that trade secrets and practices in specific areas stayed within the members of those guilds.  Both the legal and the medical professions retain many characteristics of those guilds, including having de facto monopolies for their field of expertise.   Whether that is good or bad can be debated, as could how much of a monopoly either actually enjoys, but as consumers we should be able to expect demonstration of that expertise, not just have to take it on faith.   And we should be able to assume that the profession will do a good job of policing its own members and standards.

As can be inferred from my prior blog entries, I am a big believer in the importance of transparency of information and of consumers’ right to get – and obligation to use – information on the services they may receive and the practitioners from whom they may receive them.  We need our health care professionals focusing on improving the quality of care, which already is neither as high nor as uniform as it should be (see, for example, my previous entry “Gambling on Health Care”).  We shouldn’t also need to wonder if the medical profession is properly ensuring that their brethren are adhering to the adage in the Hippocratic oath -- “first, do no harm.” 

Sad to say, one only has to pick up a newspaper to realize these concerns are very real.  It certainly wasn’t the sole responsibility of local physicians to report or of the state Board of Medicine to put a stop to the recently discovered events at the abortion clinic in Philadelphia – some physicians did try, and the city and Health Departments also didn’t do their parts -- but the local medical community and the Board both evidently had some knowledge of the horrors and must bear some of the blame for not doing more to protect those patients.  Who was watching out for them?

About that title.  It has been more decades than I care to admit since I took Latin, but fortunately Wikipedia helped me find the right quotation.  For those of you similarly not fluent, it means “Who will watch the watchers?”  

Impact and Implications of Comparative Effectiveness Research

by William DeMarco, November 2, 2010

MCOL asked me to respond to the following questions for their Thought Leaders publication: What will be the impact and implications of Comparative Effectiveness Research on U.S. health care delivery, in the short-term, and in the long-term? How dependent is CER, going forward, on federal policy and funding?

My abbreviated response is included in the current issue of Thought Leaders, but I wanted to provide a more complete response below.

Comparative effectiveness research is somewhat of a newcomer to healthcare.
Borne out of early practice variation studies at Dartmouth and other universities that reported surprising gaps in the delivery of care at the physician level, the CER takes this one step further to explain not just what the variance is but what the norm should be as a best practice.

These evidence based norms and practice guidelines are intended to give us a starting point to what we have been missing and that is ambulatory care comparators and a full disclosure of what are the best practices for a specific diagnosis for a specific population of patients with similar co morbidities and health status.

For decades we have seen hospital data on costs and length of stay being produced as DRGs and admissions data were available and understandable to many of us as a common unit of measurement and cost. Payers saw this as a large bottom line expense not realizing that the reason people were admitted was not because the hospital made that decision rather the doctors made the decision to admit based upon what they thought was a diagnosis that warranted such and action.

As we begin to look for root cause as to why the doctor thought this admission should occur we see again variation in practice style, training and capability come into play. The patient variation suddenly becomes key to understanding the physician logic and we start to see a move towards patient and population management which the CER process is trying to address.

Now we should have the ability with millions of records and billions of dollars invested in CER by HHS to discover just what is an appropriate admission for a specific diagnosis and begin to track this through impatient and outpatient treatment which is an imperative for a better understanding of how best to handle chronically ill populations as well as some of the less critically ill who need to be treated BEFORE they move to stage three or four cancer.

We have always asked about how lower back pain should be treated for the 70 year old versus the 50 year old, we have always wondered whether the mammogram should be done annually at 40 or 50 or is to tied to whether or not the patient has a predisposition and family history.

These are worth studying in terms of screening and are also worth building available database to see what works because much to the surprise of the public not all patients are treated the same because not all doctors are trained the same. Once can see a pattern of care in the medical notes and billing for a patient with hypertension yet 5 other doctors in the same group may treat this hypertension differently. Who is right and what is the best guideline to follow is.

In addition these guidelines change as we move from the discoveries and technologies of health care. CAT scans are useful but are they as useful for some illnesses as a MRI or would a simple x-ray do?

Most patients still ask for antibiotic for a cold yet truthful doctors will say it’s a virus and you have to ride it out... we can see how a national registry would enable our medical training and treatment expectations to come together over time to rid the system of wasteful tests and spending and assure both doctor and patient the results are predictable based upon good scientific population studies.

However we can also see the negative side of the argument.

In England and other countries we have seen the rise of the QUALY measurement that is used to determine wethere4 a patient really is a candidate for a specific procedure.

In several situations the QUALY dictates whether the man or women with stage 4 cancer gets treatment, whether the baby with an incurable disease is treated at all.

QUALY is the measurement of cost versus treatment for many countries and with CER we could see this occur here in the US as Harvard and other universities begin to but a VALUE on a human life.

The QUALY can be used to make some of the treatment decisions and also can place a number on ones forehead for underwriting just like a FICA score does for credit and loans.

Several states have banned using clinical effectiveness and similar means to be used to withhold issuing policies for GROUPS but as we see a move towards more individual policies with newly promised insurance exchanges and the like we see a potential for QUAYS being used to justify higher premiums or cancellation of insurance policies when the score does not justify expenditures of funds for saving or even extending a life represents a potential risk to an insurance and healthcare system that is already under funded.

One can see that in the hands of some insurers this methodology could be brutally unforgiving. In the hands of government one can see they like the idea of numbers and distancing themselves from patients just setting in motion a number and backing into a Medicare or Medicaid budget.

This Kevorkian factor represents all that most of us in health care and the health plan business are against but represents both am moral and ethical battles to fight to police one another and make sure we are not letting statistics dictate the value of a human life.
Rather we would like to see a more fruitful transition of using CER to build upon health and prevention. To determine what in a person’s lifestyle could be changed to avoid diabetes and heart problems, what could be done in an exercise routine to strengthen a back injury without needing formal rehab?

So what can health plans do? As the CER begins collecting data we see the opportunity for health plans to collaborate on a regional basis to also pool de-identified data to determine unique care patterns in their area that can be addressed or diagnosis that can be mentored to determine an outbreak of disease or unseal pattern in treatment protocols during different times of the year.

Lack of Iodine in the water in Detroit affecting thyroids, sinusitis conditions in Seattle affecting respiratory illnesses, allergies in droves in an urban population that uses antibacterial soap extensively could all tie to an unusual outcome unless treated,

Moreover these local models would have a national comparator baseline to look at but also contribute to local CER research that could help streamline care and diagnosis precision but most certainly would, be a way to obtain even further ROI on data collection process at the Health plan, ACO or similar integrated system.

This moves health plans data away from the typical claims warehouse into a life-science role that could also be shared with Pharma for testing and data sharing as well as scientific studies by local and regional medical schools to look at systemic variation in population health.

Health plans are already doing this in some cities such as ICSI in Minnesota and similar efforts are being headed by employers in Las Vegas and St Louis to try and come up with a value comparison of outcomes to be shared with all health plans in developing and monitoring their individual P4P and global payment reforms.

CER offers wonderful tools and more discussion of its application by the scientific community can help us really understand what works and what works best in short term and long term treatment.

If the research should go the other direction of assigning dollar amounts to QUALYS and reduction of services to those who need hope the most we will see a rapid de-funding of the program and a very loud outcry from the scientific and religious communities.

Health reform arguments have already surfaced this debate between the use of CER as a practice guideline builder versus a potential rationale to limit care. Health Plans have it in their power to build local and regional warehouses for clinical and scientific research always sharing such research with a national clearinghouse such as CER.

Scary Stuff

by Kim Bellard, October 25, 2010

Two studies were released in the past week that are appropriate harbingers of Halloween.  The Centers for Disease Control announced that one in three adult Americans will have diabetes by 2050.  Earlier in the week, researcher Philip F. Stahel, M.D. and his colleagues published a study in the Annuals of Surgery detailing the disturbing number of wrong site or even wrong patient surgeries.

I’m not sure which study scares me more.

The CDC projections suggest a sharp increase from the current one in ten prevalence of adult diabetes.  An aging population, an increase of minority populations most at risk of developing diabetes, and persons with diabetes living longer are cited as key reasons for the increase.  Diabetes rates have already more than doubled over the last thirty years, and are closely tied to higher health expenditures and adverse health effects on impacted individuals.  Even if actual rates end up only half as bad as the CDC fears, it would still be a train wreck for health care in America.

Dr. Stehel’s study found 27,370 adverse events from January 2002 through June 2008, using a database of 6,000 physicians in Colorado.  These adverse events included 25 wrong patient and 107 wrong site operations, and came despite widely adopted universal protocols developed by the Joint Commission that were intended to avoid such mistakes.  “These happen much more frequent than we think,” Dr. Stehel says. “This is just the tip of the iceberg.” 

Diabetes, of course, can be often controlled through proper diet and exercise.  Its increase has often been tied to the similarly large increases in obesity in America – nearly 34% of adults are now considered obese, double the percentage thirty years ago, while childhood obesity rates have tripled during the same period; 17% of children are now obese.  Increased availability of fast food and lack of adequate exercise are commonly cited as reasons for the increase in obesity.  While many persons with diabetes are often unaware of having it, obesity is harder to not be aware of.  It’s not that people don’t know that they should eat better, get more exercise, and keep control of their weight; it just seems that fewer people are willing to make the necessary efforts to do so. 

Similarly, the universal protocols are supposed to ensure “never events” such as surgery on the wrong patient don’t happen, but “never events” reflect more of a goal than an achieved outcome.  The researchers note that the blame for the mistakes fall across the medical profession.  Dr. Stehel says doctors should take more personal responsibility for their errors.  

For both problems, we don’t need magic bullets; we need the appropriate parties taking responsibility for themselves.  Unfortunately, that is not as easy as it sounds.  No one wants to develop diabetes, and no physician wants to operate in the wrong site/patient.  Yet here we are.

It does seem that somehow personal accountability in health care is getting lost.  Patients too often abdicate their own decision-making for their physician’s judgment and treatment, and physicians often don’t have adequate mechanisms to admit, track and improve on their errors.  Physicians should be able to expect that patients are doing their best to maintain and improve their own health, and patients should be able to expect that physicians are doing the right thing at the right time for the right reasons.  One would have to be something of an optimist to believe that either of those behaviors are always the case. 

Halloween is all about mock scares, with children trick-or-treating in cute costumes (while receiving lots of candy that probably help drive up those childhood obesity rates!).  These studies reveal real boogeymen, things that should frighten us and cause us all to act.  These aren’t the first unsettling revelations about how poorly our health system works at times, despite its high costs.  How many more of these scary stories do we need to see before we get serious about improving it?

Hospital Mortality at Five Star versus One Star Facilities

by Clive Riddle, October 22, 2010

HealthGrades, which touts itself as the “leading independent healthcare ratings organization” has just released a study of patient outcomes at U.S. hospitals, stratified by their ratings, that found “patients at 5-star rated hospitals had a 72% lower risk of dying when compared with patients at 1-star-rated hospitals.”

Other well known ratings and ranking of U.S. hospitals include the U.S. News and World Report rankings of U.S. Best Hospitals, which is based on AHA data in part. Consumer Reports also offers hospital ratings based on results from CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems survey, known as HCAHPS, and CMS directly offers Hospital Compare at Medicare.gov, also providing HCAHPS results.

The Thirteenth Annual HealthGrades Hospital Quality calculated that if all hospitals performed at the level of their 5-star rated hospitals, 232,442 Medicare lives could potentially have been saved from 2007-2009 (the study period.) The study analyzed mortality and complication rates using 40 million hospitalization records obtained from CMS.

The study found overall hospital mortality rates declined by 7.98% from 2007 to 2009. Of the 17 mortality-based diagnoses and procedures analyzed, two experienced increased mortality rates – gastrointestinal surgeries (+8.76%) and coronary intervention procedures (+9.26%). HealthGrades rated individual hospitals with a 1-star (below average), 3-star (average) or 5-star (outperformed national average) rating in each of 26 procedures and diagnoses, from bypass surgery to total knee replacements.

Other findings released from the study included:

• The highest unadjusted mortality rates are among sepsis, respiratory failure, and gastrointestinal surgeries and procedures (20.59%, 19.45%, 10.29%, respectively).
• The most improvement in unadjusted mortality was seen in chronic obstructive pulmonary disease (18.73%), bowel obstruction (14.72%), heart attack (13.68%), and stroke (13.50%).
• Approximately 55.91% (129,949) of the potentially preventable deaths were associated with just four diagnoses: sepsis (48,809); pneumonia (29,017); respiratory failure (26,361); and heart failure (25,762).
• On average, one in nine patients developed a hospital-acquired condition, across the nine procedures evaluated for inhospital complications, from 2007 to 2009.

On average, a typical patient would have a 80.40% lower risk of developing one or more inhospital complications by going to a 5-star rated hospital compared to a 1-star and a 63.64% lower risk of developing one or more inhospital complications by going to a 5-star compared to the U.S. hospital average.

The State of Health Care Quality 2010

By Clive Riddle, October 15, 2010

NCQA has released their annual quality report:  The State of Health Care Quality 2010: Reform, The Quality Agenda and Resource Use.  The 162 page report provides their annual analysis of quality measures and data from over 1,000 health plans that represent 118 million U.S. members.

This year’s report addresses the concept of Relative Resource Use (RRU): which “indicates how intensively health plans use health care resources (such as physician visits and hospital stays), compared with other plans in the same region, serving similar members. When used alongside quality measures, RRU makes it possible to talk about quality and cost simultaneously. Given the definition of value as the intersection of health plans’ spending (resource use) and their results, RRU reveals the value that plans offer.” NCQA analysis found that “many plans that deliver below-average quality use above-average levels of resources. More care is not always linked to better results.”

Another significant issue raised in the report was that commercial plan 2009 childhood vaccination rates dropped almost four percentage points. NCQA speculates that “a possible cause of this drop is commercial plan parents may refuse vaccines for their children based on the unproven, but increasingly popular, notion that vaccines cause autism. Celebrity activists are outspoken advocates of this view. Interestingly, we see vaccination rates in Medicaid – the program serving the poor – continuing to steadily improve. “  NCQA President Margaret O’Kane tells us “The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation. All of us in health care need to work together to get better information to the public.”

The report also measures the state of the states, indicating the top ten and bottom ten states for quality, based on four measures for ranking

1. Comprehensive Diabetes Care (ten indicators)
2. Controlling High Blood Pressure (one indicator)
3. Persistence of Beta Blockers After a Heart Attack
4. Cholesterol Management for Patients with Cardiovascular Conditions (two indicators)

States included in the Top Ten, based on mean of rates: CA, IA, MA, MN, ND, NH, OR, SD, VT, WU

States included in the Bottom Ten, based on mean of rates: AK, AL, AR, DE, LA, MS, NC, OK, SC, TN

NCQA/Consumer Reports 2010 HMO Rankings

By Clive Riddle, October 7, 2010

NCQA has released its rankings of HMO and Point of Service plans around the nation for 2010, via Consumer Reports.

According to NCQA, themeasures and methodology used to rank plans did not change from 2009. Details on the methodology and guidelines are listed at http://www.ncqa.org/rankings .

Below are the top ten ranked private plans (excluding Medicaid and Medicare plans). You will note that regional and non-profit plans (vs. national for-profit) and integrated plans are well-represented.

NCQA 2010 National Ranking of HMOs: Top Ten Private Plans

1. Harvard Pilgrim Health Care (MA, ME)
2. Tufts Associated Health Maintenance Organization (MA, RI)
3. Harvard Pilgrim Health Care of New England (NH)
4. Capital Health Plan (FL)
5. Geisinger Health Plan (PA)
6. Grand Valley Health Plan (MI)
7. Group Health Cooperative of South Central Wisconsin (WI)
8. Fallon Community Health Plan (MA)
9. Kaiser Foundation Health Plan of Colorado (CO)
10. Health New England (MA)

Source: Consumer Reports: The 2010 rankings of HMOs from the National Committee on Quality Assurance

Source URL: http://www.consumerreports.org/health/insurance/best-health-insurance-privateRatings-1.htm

Notes: Private plans exclude Medicaid and Medicare.  This year, the NCQA ranked 227 HMOs and point-of-service plans with a total enrollment of about 42 million. Not all HMOs are on the list; some do not submit data to the NCQA, or submit insufficient data, and others decline to make it public.

The Difference a Year Makes: H1N1 Adieu

By Clive Riddle, August 13, 2010 

The CDC Situation from their H1N1 Swine Flu web site: “The U.S. Public Health Emergency for 2009 H1N1 Influenza expired on June 23, 2010. On August 10, 2010, the World Health Organization (WHO) International Health Regulations (IHR) Emergency Committee declared an end to the 2009 H1N1 pandemic globally…..Internationally, 2009 H1N1 viruses and seasonal influenza viruses are co-circulating in many parts of the world.  It is likely that the 2009 H1N1 virus will continue to spread for years to come, like a regular seasonal influenza virus.”

WHO reported this week that “in the majority of countries, out-of-season 2009 H1N1 outbreaks are no longer being observed, and the intensity of 2009 H1N1 influenza virus transmission is lower than that reported during 2009 and early 2010.

CDC reports that as in years past, beginning in October, 2010, they will provide weekly reports of influenza surveillance information throughout the season with the publication of FluView available at www.cdc.gov/flu/weekly

So how should we behave in a post pandemic world? WHO recommends that surveillance and vaccination during the post-pandemic period include:

• monitoring for unusual events, such as clusters of severe respiratory illness or death;
• investigating severe or unusual cases, clusters or outbreaks to facilitate rapid identification of important changes in the epidemiology or severity of influenza;
• maintaining routine surveillance, including for influenza-like illness and cases of severe acute respiratory infections;
• continuing to use routine channels of data transmission, such as FluID, FluNet, and EUROFlu, to transmit data from the routine surveillance of respiratory disease;
• monitoring the H1N1 2009 virus for important genetic, antigenic or functional changes, such as antiviral drug sensitivity;
• WHO strongly recommends vaccination of high-risk individuals in countries where influenza vaccines are available.

Change in VBAC Guidelines

by Clive Riddle, July 22, 2010

The American College of Obstetricians and Gynecologists have just issued new guidelines for a vaginal birth after cesarean (VBAC).  Doctor Richard Waldman, president of The College tells us, "the current cesarean rate is undeniably high and absolutely concerns us as ob-gyns. These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

Doctor Waldman adds, “Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC." The VBAC rate has dropped dramatically during the past 15 years, due to “restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.”

What has changed? The College guidelines now state women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a trial of labor after cesarean (TOLAC).Proactive counseling is being emphasized, whereby “physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans.” They state that women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center. The new guidelines, Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is available in the August 2010 issue of Obstetrics & Gynecology.

Here’s three statistical items supplied by the College:

• U.S. Cesarean delivery rate: 5% in 1970; 31% in 2007.
• U.S. VBAC rate:  5% in 1985; 28% in 1996, 8.5% in  2006
• Risk of uterine rupture during a TOLAC: —between 0.5% and 0.9%

Much Ado about Peer Review

By Clive Riddle, July 14, 2010

JAMA’s current issue features the article: Physicians' Perceptions, Preparedness for reporting, and Experiences Related to Impaired and Incompetent Colleagues, by Catherine M. DesRoches, DrPH et.al. [JAMA. 2010;304(2):187-193. doi:10.1001/jama.2010.921]. The article presents survey results regarding physician peer monitoring and reporting, which nationally polled “2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded.”

The survey asked "In the last three years, have you had direct, personal knowledge of a physician who was impaired or incompetent to practice medicine in your hospital, group, or practice?" The study found that:

• 64% agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.
• 69% said they were prepared to effectively deal with and report impaired colleagues in their medical practice
• 36% do not feel obligated by professional commitment to report such physicians
• 17% had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice.
• Of the 17% with this knowledge, 67% reported this colleague to the relevant authority.
• Physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.
• Pediatricians and family practice physicians were the least likely to say they felt prepared to deal such colleagues; anesthesiologist and psychologists apparently felt most prepared
• Most cited reasons for taking no action was (1) belief that someone else was taking care of the problem (19%) belief that nothing would happen as a result of the report (15%) and fear of retribution (12%)

The study concluded that “physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report” " Matthew Wynia, director of the AMA Institute for Ethics, comments that “I don't think there's any excuse for less than 100 percent of physicians holding true to these ideals." A free JAMA podcast by JAMA’s editor in chief discussing the survey as part of commentary on the current issue is available for download.

Headlines regarding the article accentuate the minority percentage of physicians who do not report:

Los Angeles Times:  Study shows doctors often eschew watchdog role

CBS News:  Many Docs Don't Blow Whistle On Colleagues

The Washington Post:  Do doctors rat on each other?

This is certainly not the first study to address the issue of physician peer review. Some recent examples include California’s legislatively mandated study, which was released by sub-contractor Lumetra as the Comprehensive Study of Peer Review in California: Final Report, July 31, 2008 which found it was “apparent is that the present peer review system is broken for various reasons and is in need of a major fix”; from Public Citizen-  Hospitals Drop the Ball on Physician Oversight , released May 27, 2009 which concluded a “lack of detection and widespread under-reporting to the National Practitioner Data Bank raise serious questions about hospital peer review.” Modern Physician magazine, in their June 8, 2009 issue ran a lengthy article discussing the debate about the Public Citizen report .

Here’s a few observations for consideration on this issue:

• Regulated peer review focuses on the hospital setting, and is built on a 20^th century model in which a greater degree of care was delivered in a hospital setting. Physician behavior and actions outside the hospital setting are typically under-addressed by state or federal regulations
• Physicians, excel as they do as a profession, are still human, and subject to similar mindsets, pressures and workplace issues as other professions. Who really thinks any other profession subject to peer review would have better reporting outcomes?
• Accountability for professional competence in any profession is much stronger when there is an organization structure that the professional is employed by, or financially belongs to. Organization accountability can be an even stronger continuous force for some than regulatory or even ethical accountability.  Thus large medical groups, medical schools, VA, group health plans and other such entities tend to have less of a problem in this area than open medical staffs. Note the survey findings that “physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.” As younger physicians have a greater tendency to practice in larger medical groups and organizations, this issue should experience improvement over time.

Health Plan Coverage of H1N1 Virus Administration Varies

by Clive Riddle, September 17, 2009

Earlier this week, the FDA announced approval of four vaccines against the H1N1 virus. As we await the expected spread of the H1N1 virus this fall, health plans around the country are announcing their policy regarding coverage. Of course, the H1N1 vaccine itself is being covered by the government, once it becomes available. So the coverage issue is with respect to payment to providers for their administration of the shot.

Is it a no-brainer that health plans will provide coverage for administration of the H1N1 virus? It is as long as their specific plan of benefits cover immunizations. But typically, health plans offer a wide menu of benefit plans, including some that do not provide immunization coverage.

However, some health plans have announced they will take the extra step to provide administration coverage for all their members, even those whose benefit plans do not offer immunization coverage. Such health plans are taking the public health policy approach that by removing barriers to the vaccine, they are doing their part to reduce the potential spread of the virus, which should provide the indirect benefit of reduced overall incidence and corresponding cost of treatment for their member population as well.

A survey of recent health plan coverage announcements indicates health plans uniformly will cover H1N1 administration costs for member benefit plans that cover immunizations, but are split on providing H1N1 administration coverage when their benefit plans do not cover vaccines.

Those who will provide administration coverage to all members include:

• CIGNA has just stated they will provide coverage of H1N1 vaccine administration for all insured members without application of any deductible or copay requirement.

• United Health Group has announced they will on a corporate-wide basis provide coverage of H1N1 vaccine administration even for members whose benefit plans exclude immunization coverage.    

• Likewise, Independence Blue Cross in Pennsylvania issued a release that they will provide coverage of H1N1 vaccine administration including for members whose benefit plans exclude immunization coverage

•  Blue Cross Blue Shield of Arizona issued a statement that they will provide coverage of H1N1 vaccine administration including for all members

• Blue Cross and Blue Shield of Florida also will provide coverage of H1N1 vaccine administration including for members whose benefit plans exclude immunization coverage. BCBS Florida also announced its operational continuity preparedness plans in case of a significant disruption due to pandemic influenza.

Those who will limit administration coverage to members with vaccine coverage benefits include:

• WellPoint some time ago announced they will provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

• Aetna sent notices to providers that they will provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

•  Wellmark Blue Cross and Blue Shield in Iowa and South Dakota issued a statement they provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

• Blue Cross and Blue Shield of Nebraska also announced they will provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

The AAFP news yesterday published a story providing details on how physicians should code and bill major health plans and Medicare  for H1N1 administration fees. Interestingly, there is not a standard approach for coding by the health plans. The administration fee cannot exceed the regional Medicare vaccine administration fee.

H1N1 Flu: Key Info, Web Resources and News Headlines

by Clive Riddle, July 29, 2009

So the health care community has been warned for some time to brace for a surge in swine flu this fall. As August approaches, what’s the latest? The following is a summary compiled of some key information, key web resources, and recent news headline:

- KEY INFORMATION –

CDC provides this summary in their latest situation update: “On June 11, 2009, the World Health Organization (WHO) signaled that a global pandemic of novel influenza A (H1N1) was underway by raising the worldwide pandemic alert level to Phase 6. This action was a reflection of the spread of the new H1N1 virus, not the severity of illness caused by the virus. At the time, more than 70 countries had reported cases of novel influenza A (H1N1) infection and there were ongoing community level outbreaks of novel H1N1 in multiple parts of the world.  Since the WHO declaration of a pandemic, the new H1N1 virus has continued to spread, with the number of countries reporting cases of novel H1N1 nearly doubling. The Southern Hemisphere’s regular influenza season has begun and countries there are reporting that the new H1N1 virus is spreading and causing illness along with regular seasonal influenza viruses. In the United States, significant novel H1N1 illness has continued into the summer, with localized and in some cases intense outbreaks occurring. The United States continues to report the largest number of novel H1N1 cases of any country worldwide, however, most people who have become ill have recovered without requiring medical treatment.”

According to the CDC Novel H1N1 Flu Situation Update as of July 24, 2009, the U.S. has experienced 43,771 cases involving 302 deaths. The top five states by number of cases are:  

1. Wisconsin 6222 cases; 6 deaths
2. Texas 5151 cases; 27 deaths
3. Illinois 3404 cases; 17 deaths
4. California 3161 cases; 52 deaths
5. Florida 2915 cases;  23 deaths

For the week of July 12 -18 the CDC reported that:

· Widespread influenza activity was reported by seven states (California, Delaware, Georgia, Hawaii, Maine, Maryland, and New Jersey).

· Regional influenza activity was reported by Puerto Rico and 13 states (Arizona, Arkansas, Connecticut, Florida, Nevada, New York, North Carolina, Pennsylvania, Rhode Island, South Carolina, Virginia, Washington, and West Virginia).

· Local influenza activity was reported by the District of Columbia and 13 states (Alaska, Illinois, Massachusetts, Michigan, Minnesota, New Hampshire, New Mexico, Oklahoma, Oregon, Tennessee, Texas, Utah, and Wisconsin).

· Sporadic activity was reported by 17 states (Alabama, Colorado, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Dakota, Ohio, South Dakota, Vermont, and Wyoming).

The World Health Organization’s (WHO) latest update, as of July 24, 2009, states “in most countries the majority of pandemic (H1N1) 2009 cases are still occurring in younger people, with the median age reported to be 12 to 17 years (based on data from Canada, Chile, Japan, UK and the United States of America). Some reports suggest that persons requiring hospitalization and patients with fatal illness may be slightly older.... The development of new candidate vaccine viruses by the WHO network is continuing to improve yields (currently 25% to 50 % of the normal yields for seasonal influenza for some manufacturers). WHO will be able to revise its estimate of pandemic vaccine supply once it has the new yield information. Other important information will also be provided by results of ongoing and soon-to be-initiated vaccine clinical trials. These trials will give a better idea of the number of doses required for a person to be immunized, as well as of the quantity on active principle (antigen) needed in each vaccine dose. Manufacturers are expected to have vaccines for use around September. A number of companies are working on the pandemic vaccine production and have different timelines.”

- WEB RESOURCES -

Pandemic (H1N1) 2009

World Health Organization

Key Facts About Swine Influenza

Centers for Disease Control and Prevention

Novel H1N1 Flu (Swine Flu) and You

Centers for Disease Control and Prevention

 Novel H1N1 Flu Situation Update

Centers for Disease Control and Prevention

Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts

Centers for Disease Control and Prevention

H1N1 Influenza A (Swine Flu) Alert Center

Medscape

- NEWS HEADLINES -

H1N1 Flu Spreads to Remote Corners of the World

Reuters Health Information, July 28, 2009

Pregnancy Likely to Be Swine Flu Shot Priority

Associated Press via Google, July 28, 2009

H1N1 Flu Shots Ready in Months, Winter a Risk: WHO

Reuters Health Information, July 27, 2009

China Presses Quarantine Against Flu

New York Times, July 27, 2009

Swine flu could hit up to 40% in U.S. this year and next without vaccine

Associated Press via USA TODAY, July 26, 2009

US: 160M doses of swine flu vaccine due in Oct.

AP via GoogleNews, July 23, 2009

First Trials of Swine Flu Vaccine Begin in Australia

Bloomberg News, July 22, 2009

Grants to States and Territories, July 2009

HHS Press Release, July 10, 2009

Misdirection Can Be Fatal

by Laurie Gelb, March 17, 2009

ETHEX has initiated a retail-level recall of tablets found after the fact to have been manufactured in non-cGMP conditions. A Blues plan finally sent out a one-page masterpiece of misdirection, one that I'm confident was replicated similarly nationwide, to patients for whom one of the affected scripts was reimbursed. Unfortunately, in this case, misdirection could potentially be fatal, so a communication like this is worth delving into.

First, the letter is dated February 2009, though received in March. ETHEX PR is dated Jan. 28, so there's been a communication delay.

The salutation, despite the fact that these letters are obviously databased from PBM records, is the time-honored "Dear Valued Member." So what would cue a member that this letter, unlike several others received this quarter, should actually be read? The outer envelope holds no clue, either.

The sentence announcing the recall is in bold. That seems scary and necessitating action, doesn't it? But no.

We read that these prescriptions were no longer processed by the PBM as of January 30. If I were comparing this with recalls for cars or food, that would mean that I should take it back and get something fixed or refunded, yes?

Not here. Of course, use of the word "recall" isn't the plan's doing, but there remains the responsibility to explain it.

About halfway down the page, we read "...it is recommended that you continue to take them [the medications] in accordance with your prescriptions, as the risk of suddenly stopping needed medications may increase your risk for side effects."

Side effects -- not quite the term that most clinicians would characterize as the risk of suddenly d/c'ing nitrates or beta blockers. So this letter is presuming that the patient knows why s/he is on each medication (and remember, each of these is listed only under its full generic name). Alas, if the good ship Argo...and since the letter lists each of the recalled tabs, without specifying which one(s) were filled for the patient, it would be easy to skim this long, complex list and not see the connection. Another form letter gone astray, one might think.

But let's say the patient does recognize one of these meds. She should be thinking that she should do nothing, right? Side effects and all that. But the very next sentence advises: "Your physician is in the best position to help you slowly discontinue use of the medication..."

Wait a second. So the member is supposed to "discontinue?" That sounds like "stop?" But that logic fails when there's no mention of getting a replacement supply, because, of course, the letter is not really recommending that anyone d/c her meds. It's just saying that if you wanted to, you should let your doc in. In fact, it's not saying anything at all, but merely palming patients off on the Ethex customer service number or the MedWatch URL.

The closing: "Thank you for your attention to this matter," once again suggests that you should do something, but by this time, we're immune to confusion (and conclusions). Time to cue up the David Bowie song, "Changes."

This letter mentions five different organizations by name: the plan, its PBM, its pharmacy "consultant," ETHEX and the FDA. However, nowhere does the letter explain any of their responsibilities, roles, accountability or possible usefulness in sorting out any of the letter's contents.

Some of the recalled tabs may be over-generous with the active ingredients. Nowhere in this letter does this fact appear. What to do about refills when shortages for some of the compounds in question have been news for months is nowhere addressed (some patients have been switched over to immediate release vs. extended release metoprolol, for example). Even if the PBM is fully stocked, that reassurance is not made. Nor are terms like cGMP explained. Nor is it identified which drug(s) on the list may apply to the patient (we call it a mail merge with a form field). A single-spaced missive that fills a page, this letter raises more questions than it answers, yet it hints delicately at clinical implications.

When you read polls about distrust, mistrust and misunderstanding of the health insurance industry, remember this letter. A patient who is on a recalled med, based on the PBM's data, is sent a letter in a 8.5 x 11" envelope, signed by a PharmD. There's bold face type and mention of the FDA. It seems serious and worth reading, (well, if you get past the first sentence regarding "changes to prescription drugs in the marketplace"). But, in the end, it's not only unhelpful, it's anxiety-producing or a sedative, depending on which sentences one reads. The tone is cold, formal, impenetrable and replete with jargon. Health plan as robot? We are here.

What would the LA Times think and write about a physician who sent this letter? A hospital? What would you think? Need a plan somehow avoid any visible role in medication management beyond formulary access? The plan will certainly assume a broader role when it comes to hospitalization, surgery, medical devices, etc. and patients know this very well.

So to the Blues plan and your sisters and brothers: After the next recall, if you can't acknowledge the facts for whatever reason (and remember, there's more than one general counsel in the sea), please send your members somewhere that offers actual answers. For example, see the simple language about this recall at the Facts & Comparisons Web site: http://www.factsandcomparisons.com/News/ArticlePage.aspx?id=8294. Ironically, this para is written for HCPs, but is simpler than many of your letters to members.

And next time, don't delay. Spring for a mail merge that produces a personalized salutation and short name rx info. A member with a condition serious enough to justify a drug that you're paying for deserves personhood, not to mention the fact that you might want to converse with that person in the future. Names of drugs and people are a good start. Run your next effort by some real patients, please, and if you can't come to grips with the fact that these are sick people, you might want to think about finding a vertical with lower stakes.

Thank you for your attention to this matter.