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20 comments published for 16 articles.

Articles			Comments
	Web Exclusives: The Role Of PBMs In Implementing The Medicare Prescription Drug Benefit Atlas ( 28 October 2004 ) [Abstract] [PDF]		Innovator Of Prescription Drug Benefits: Correction Sydney Aronson   ( 26 October 2009 ) Read every Comment to this article
	Web Exclusives: Evidence Of An Emerging Digital Divide Among Hospitals That Care For The Poor Jha et al. ( November/December 2009 ) [Abstract] [Full text] [PDF]		Percentage Of Hospitals Vs. Percentage Of Beds Glenn P. Tobin   ( 12 November 2009 ) Read every Comment to this article
	Web Exclusives: Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults Wilper et al. ( November/December 2009 ) [Abstract] [Full text] [PDF]		Retired Health Professionals Meet Urgent Need Frederic G. Jones   ( 26 October 2009 ) Read every Comment to this article
	Web Exclusives: Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients Baras and Baker ( November/December 2009 ) [Abstract] [Full text] [PDF]		Appropriateness Criteria and Current Data Provide Correct Perspective James H. Thrall, MD   ( 23 October 2009 ) Read every Comment to this article
	Web Exclusives: Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City Elbel et al. ( November/December 2009 ) [Abstract] [Full text] [PDF]		NYC Fight Against Obesity Andrea V. Fore   ( 9 October 2009 ) Read every Comment to this article
	Web Exclusives: Zoning For Health? The Year-Old Ban On New Fast-Food Restaurants In South LA Sturm and Cohen ( November/December 2009 ) [Abstract] [Full text] [PDF]		Innovative Policies Need Time To Work Larry Cohen   ( 23 October 2009 ) Read every Comment to this article
	Web Exclusives: Global Drug Discovery: Europe Is Ahead Light ( September/October 2009 ) [Abstract] [Full text] [PDF]		Light Paints Distored Picture of U.S. Pharmaceutical R&D Efforts Lori M. Reilly, et al.   ( 25 September 2009 ) Read every Comment to this article
	Web Exclusives: Access, Cost, And Financing: Achieving An Ethical Health Reform Daniels et al. ( September/October 2009 ) [Abstract] [Full text] [PDF]		Housing And Access To Health Care Mustafa Zeedan Younis   ( 21 September 2009 ) Read every Comment to this article
	Web Exclusives: The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals McCord et al. ( September/October 2009 ) [Abstract] [Full text] [PDF]		Do We Need More Red Flags? James I. Koola   ( 15 October 2009 ) Re: Do We Need More Red Flags? Colin McCord   ( 20 October 2009 ) More Questions Than Answers Bruno F. Sunguya   ( 22 October 2009 ) Read every Comment to this article
	Web Exclusives: Developing A Policy For Second-Generation Antipsychotic Drugs Rosenheck and Sernyak ( September/October 2009 ) [Abstract] [Full text] [PDF]		Leave Weighing Of Risk To Patients And Providers Tami L. Mark   ( 21 September 2009 ) Read every Comment to this article
	Overview: Income, Insurance, And Technology: Why Does Health Spending Outpace Economic Growth? Smith et al. ( September/October 2009 ) [Abstract] [Full text] [PDF]		Missing The Forest For The Trees John E Hornbeak   ( 21 September 2009 ) Insurance & Technology: The Authors Respond Sheila D. Smith, et al.   ( 22 September 2009 ) Role Of Markets: The Authors Respond Sheila D. Smith, et al.   ( 25 September 2009 ) Read every Comment to this article
	Web Exclusives: Health Spending Projections Through 2018: Recession Effects Add Uncertainty To The Outlook Sisko et al. ( March/April 2009 ) [Abstract] [Full text] [PDF]		Defining 'Program Administration' In Spending Data E. Barry Solomon   ( 20 October 2009 ) Read every Comment to this article
	Personal Health Records: Information Gap: Can Health Insurer Personal Health Records Meet Patients’ And Physicians’ Needs? Grossman et al. ( March/April 2009 ) [Abstract] [Full text] [PDF]		My Opinion On Personal Health Records Mary E. Bender   ( 12 November 2009 ) Read every Comment to this article
	Web Exclusives: Establishing And Refining Hurricane Response Systems For Long-Term Care Facilities Hyer et al. ( September/October 2006 ) [Abstract] [Full text] [PDF]		Long-Term Care Facility Plans Elaine Davey   ( 20 October 2009 ) Read every Comment to this article
	Mission Vs. Market: The Cost-Shift Payment ‘Hydraulic’: Foundation, History, And Implications Dobson et al. ( January/February 2006 ) [Abstract] [Full text] [PDF]		Re: Why Private Payers Accept Cost Shifting Gerald Gruber   ( 22 October 2009 ) Read every Comment to this article
	Health Tracking: The Effect Of Physician-Owned Surgicenters On Hospital Outpatient Surgery Lynk and Longley ( July/August 2002 ) [Abstract] [Full text] [PDF]		What About Hospitals? James Breit   ( 12 November 2009 ) Read every Comment to this article

Web Exclusives: The Role Of PBMs In Implementing The Medicare Prescription Drug Benefit Atlas ( 28 October 2004 ) [Abstract] [PDF] The Role Of PBMs In Implementing The Medicare Prescription Drug Benefit Innovator Of Prescription Drug Benefits: Correction 26 October 2009 Sydney Aronson, Retired Send comment to journal: Re: Innovator Of Prescription Drug Benefits: Correction saronson{at}fea.net Sydney Aronson This article includes the following: "Prescription drug cards. In the 1960s companies emerged to offer add-on prescription drug benefits to private health insurance plans—most notably, those for unionized workers. Card holders could fill prescriptions at participating pharmacies for nominal copayments. Pharmaceutical Card System (PCS) is commonly identified as the innovator of this concept." In fact, the first company that conceived and implemented this procedure was Paid Prescriptions, which was incorporated on August 11, 1963 in California as California Pharmaceutical Services, Inc., a nonprofit corporation sponsored by the California Pharmaceutical Association. I was the president of that corporation. The name of the plan offered was Paid Prescriptions and the corporate name was subsequently changed to Paid Prescriptions, Inc. PCS was formed later by an employee of Paid Prescriptions in Phoenix, Arizona, where Paid Prescriptions, Inc. had its data processing facility. Paid Prescriptions was initially an insurer which assumed the risk for reimbursing covered prescriptions to participating pharmacies. This arrangement was challenged by the Antitrust Division of the Justice Department, and Paid Prescriptions changed its role to that of administration only for insurers and other providers of prescription drug plans. It also eventually changed its nonprofit status to a for profit-status as Paid Prescriptions Inc. Eventually the company was sold to Bergen Brunswig in 1970 which subsequently sold it to Computer Sciences Corporation. It finally was acquired by Merck. I left the company as an officer and director in 1970 with a consultant agreement. I am currently retired. The concept was placing an Addressograph machine in each participating pharmacy nationwide using the procedure found in gas stations at that time where oil companies provided customers with a plastic card which was swiped in the individual gas station on the Addressograph machine and submitted by the gas station for a single payment for a group of claims. The uniform procedure allowed automated processing by then IBM computer facilities. The first national contract for Paid Prescriptions was with John Hancock Insurance Company for the hourly employes of Ford Motor Company for the prescription drug benefit negotiated by the UAW in 1964. Paid Prescriptions cooperated with others at that time to help establish an industry as a result of its experience with the antitrust issues. As the entity that conceived and implemented the first such third-party payer for prescription drug claims, it is important that its historical role be accurate as all of the current companies and related activities started here.

Web Exclusives: Evidence Of An Emerging Digital Divide Among Hospitals That Care For The Poor Jha et al. ( November/December 2009 ) [Abstract] [Full text] [PDF] Evidence Of An Emerging Digital Divide Among Hospitals That Care For The Poor Percentage Of Hospitals Vs. Percentage Of Beds 12 November 2009 Glenn P. Tobin, Consultant Self-employed Send comment to journal: Re: Percentage Of Hospitals Vs. Percentage Of Beds glennptobin{at}gmail.com Glenn P. Tobin The article calculated the percentage of hospitals with various types of clinical functionalities and, in aggregate, whether comprehensive or basic EHRs were in place. My hypothesis, after working for many years in the health care IT industry, would be that the skew of functionalities would be driven primarily by size of insitution (larger institutions have implemented more). This would match with the software purchase experience from the last decade (larger institutions generally purchased software and began implementations earlier than smaller insitutions). Can your data be cut to prove or disprove this hypothesis? My assertion would be that the percent of hospital beds covered by a comprehensive or basic EHR is much higer than the comparable percent of hospitals. And from a population health perspective, the percent of beds is highly relevant to the number of individuals who will be cared for with comprehensive or basic EHRs. Although I recognize that your survey only captured 60+ percent of the hospitals, this very substantial survey could be used to extrapolate to a different and important question.

Web Exclusives: Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults Wilper et al. ( November/December 2009 ) [Abstract] [Full text] [PDF] Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S.... Retired Health Professionals Meet Urgent Need 26 October 2009 Frederic G. Jones, Physician Transylvania County Free Clinic Send comment to journal: Re: Retired Health Professionals Meet Urgent Need twitty{at}citcom.net Frederic G. Jones What about retired physicians and other health care professionals? All of the suggestions to improve primary care are medium to long term and perhaps successful strategies. A more immediate solution is to utilize the large numbers of “retired” physicians and other health care professionals. Many stand currently competent and willing to provide excellent medical care to our underserved populations. Moreover, many have actually chosen to retire into the areas of physician shortage. Nonetheless, many barriers are placed in their utilization, not the least of which are state medical boards reluctant to grant any type of license. This barrier seems to apply to many practitioners, trained and licensed in another state, who have expressed a willingness to care for the underserved patients of their new state of residence. Fortunately, a number have overcome these barriers and in the settings of free clinics provide top-notch care. These experienced clinicians are quite prudent and efficient in their ordering and practice patterns, further preserving expensive resources. These doctors, nurses, dentists, and other healthcare professionals could be mobilized into a structured organization that could add dramatically and immediately to meet the health care needs of the uninsured and others in our population without ready access. These professionals could be recruited into existing practices, community health centers, and free clinics or into the rapidly increasing numbers of retail clinics. Many of these activities are funded by faith-based and charitable donations and the “sweat equity" of thousands of participating “retired” health care professionals. Some of the greatest impact could be for the management of patients with chronic medical conditions. The future benefits of such care have a predicable benefit for the health and costs. These and other chronic medical conditions are managed quite well in the free clinic settings with very selective specialty referral. In other words, provide care now or pay many dollars in the future for the neglect. For that population, evidence-based protocols are available that could assure best practices. I am in my 26th year of serving the indigent in a free clinic setting. Along with a superb nurse practitioner (certified diabetes educator), 3 retired RNs, and a pharmacist, we strive to provide evidence-based medical care. In my instance, this is in a metabolic clinic, serving adults with diabetes, and its associated conditions: hypertension, obesity, and dyslipidemia. According to the latest guidelines, we attempt to optimize blood sugar and A1c. However, lifestyle management is particularly difficult in this patient population, with limited economic options. Nonetheless, we strive to control the other risk factors and are quite successful in controlling blood pressure and lipids, and tobacco usage. Newer studies suggest that this approach may improve outcomes as well as intensive treatment to optimize blood sugars. Moreover, it can often be attained in patients with 3 generic medications, costing $12 per patient per month, plus low-dose aspirin. We have a community pharmacy that can provide some of these medications, and then some can turn to Wal-Mart, Walgreens, and others. In some 40% of type 2 diabetes cases, the patient will require insulin. We should consider adding insulin to Metformin for a modest additional cost. There are excellent algorithms for insulin management permitting the clinician to provide comprehensive care in a single setting. Insulin may confer benefits in addition to glucose lowering that promote remission and prevention of complications. Many of us are committed to the concept of prevention of disease, and I believe our participation would be well served by this approach. In this era of incentivizing participants, many of the retired health care professionals would welcome a tax credit based on volunteer hours provided. Furthermore, this would encourage them to comply with the various obstacles often placed by state licensing boards. Why do we continue to waste this opportunity and enormous resource for our nation’s patients in need? I am an AMA and ACC member, retired from active cardiology practice in the fee-for-service arena. However, I continue to care about the heath care of our nation’s population!

Web Exclusives: Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients Baras and Baker ( November/December 2009 ) [Abstract] [Full text] [PDF] Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients Appropriateness Criteria and Current Data Provide Correct Perspective 23 October 2009 James H. Thrall, MD, Chairman American College of Radiology Send comment to journal: Re: Appropriateness Criteria and Current Data Provide Correct Perspective jthrall{at}partners.org James H. Thrall, MD This article used obsolete data, made unsupported recommendations, and highlighted an issue that can largely be addressed by tools already freely available to physicians. This study used data from 1998-2005, which are not reflective of today’s medical landscape. Medicare imaging utilization growth for 2006-2007 was only 2 percent. MRI volume actually went down in 2008. From 2006-2008, imaging growth, particularly MRI, was at or below that of other physician services. Given this low growth rate, the study’s outdated statistics, and that the study did not address whether the added MRI use or the additional surgery associated with each scanner was inappropriate, how does this study “contribute to the debate over how to restrain growth of health care spending?” Appropriate use of MRI can be addressed by wider adoption of existing ACR Appropriateness Criteria and point-of-entry ordering systems based on appropriateness criteria, such as the 2010 Medicare pilot project mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Recommendations regarding health care reform need to be based on what is actually happening in America today. Medical imaging exams have been directly linked to greater life expectancy, declines in cancer mortality rates, and are generally less expensive than the invasive procedures they replace. Utilization growth is in line with or below that of other physician services. That is the current state of imaging and is the context in which all policy discussions regarding these life saving services should start.

Web Exclusives: Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City Elbel et al. ( November/December 2009 ) [Abstract] [Full text] [PDF] Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People... NYC Fight Against Obesity 9 October 2009 Andrea V. Fore, Medical Director LGA Send comment to journal: Re: NYC Fight Against Obesity avfore{at}hotmail.com Andrea V. Fore New York City has certainly missed the boat in the fight against obesity in low-income neighborhoods. How can we, as informed and responsible health care providers, be surprised by the results of this study? Given all of the challenges, health, economic, social and otherwise, faced by people struggling at or near the poverty line, using calorie labeling to combat obesity is like using a toothpick to spear an elephant. In fact, the elephant in the room is that the fatty foods served by the fast food chains are cheap, accessible, and filling. When you have just a few dollars to spend on a meal, you choose what leaves you feeling full for as long as possible. Healthy foods such as fresh fruits and vegetables are expensive. And many neighborhoods do not have decent grocery stores. Even so, a piece of fruit can cost close to a dollar and only qualifies as a snack, not a meal. "Five a day," the target suggested by the food pyramid, is about five hard-earned bucks. In Maryland, the WIC program allocates a mere $8.00 a month to "pregnant and mostly breast-feeding women" for vegetables and fruit. That's about two bags of oranges, which might last four days if you're lucky. What about the other 27 days of the month? How can we, on the one hand, say that we're advocating for healthy, balanced diets and, on the other hand, do very little to support these expensive choices? It doesn't add up.

Web Exclusives: Zoning For Health? The Year-Old Ban On New Fast-Food Restaurants In South LA Sturm and Cohen ( November/December 2009 ) [Abstract] [Full text] [PDF] Zoning For Health? The Year-Old Ban On New Fast-Food Restaurants In South LA Innovative Policies Need Time To Work 23 October 2009 Larry Cohen, Executive Director Prevention Institute Send comment to journal: Re: Innovative Policies Need Time To Work sana{at}preventioninstitute.org Larry Cohen Sturm and Cohen argue that the premise for South Los Angeles’ groundbreaking fast food moratorium was “questionable.” As a public health advocate with nearly four decades of experience, I could not disagree more. For starters, the moratorium was never intended as the sole solution but rather as one part of a comprehensive strategy to create a healthier food environment and change eating norms. Second, the moratorium galvanized an entire community and helped to strengthen the voice of youth and community advocates; it brought attention to a community whose needs had been overlooked far too long. As we consider innovative approaches to ensuring that all communities have access to healthy and affordable food, let’s not forget the lessons of tobacco. When I worked on the nation’s first multicity tobacco control policies in Contra Costa County, California, we faced fierce opposition. Critics quickly argued that creating smoke-free areas would not have any effect on smoking rates, and at first they were right. But these initial policies not only built momentum for more comprehensive policies, they also began shifting smoking norms. And these new norms have led to incredible declines in smoking rates. The fast food moratoriums of today are just as innovative as the initial tobacco control policies were in the eighties; similarly, more time is needed before their full impact can be realized. In the meantime, let’s not be too quick to dismiss their role alongside the policies Sturm and Cohen do support, including menu labeling and taxes and fees on soda.

Web Exclusives: Global Drug Discovery: Europe Is Ahead Light ( September/October 2009 ) [Abstract] [Full text] [PDF] Global Drug Discovery: Europe Is Ahead Light Paints Distored Picture of U.S. Pharmaceutical R&D Efforts 25 September 2009 Lori M. Reilly, Vice President PhRMA, Richard I. Smith Send comment to journal: Re: Light Paints Distored Picture of U.S. Pharmaceutical R&D Efforts lreilly{at}phrma.org Lori M. Reilly, et al. Donald Light inaccurately argues that recently Europe has been more productive than the U.S. in biopharmaceutical R&D and ignores the significant innovations achieved in recent years. Light designates a drug’s origin by the location of the innovator company’s headquarters, which is not dispositive of where a drug is developed. For example, numerous EU-headquartered companies have moved large R&D operations to the U.S. To counteract this trend the European Commission recently launched the Innovative Medicine Initiative, stating that “Europe’s pharmaceutical research and development basis has gradually eroded, with new leading-edge technology research units being increasingly transferred out of Europe, mainly to the United States and recently also to Asia.” This is evident in the National Academies finding that the U.S. “supports by far the single largest biotechnology industry.” Moreover, while Light counts only a drug’s first approval, postapproval research for new indications is a central route to advancing patient care. Calfee has noted the fallacy of ignoring post-approval R&D when evaluating innovation; recent research shows that 47% of biologics receive at least one post-approval indication. Finally, in arguing that new drugs provide few benefits, Light ignores dramatic outcome improvements linked to medicines across many conditions. For instance, heart failure and heart attack deaths fell by nearly half between 1999 and 2005 thanks in part to increased medicine use. A Health Affairs article reporting major advances against heart disease noted that targets identified by the pharmaceutical industry “have led to striking, remarkable, and repeated achievement.” Further, the Congressional Budget Office reported in 2006 that “rapid increases . . . in drug-related R&D spending have been accompanied by major therapeutic gains.” Ignoring the centrality of U.S.R&D to biopharmaceutical advances could lead to policies that undermine both medical advances and the economic potential that life sciences hold for the U.S.

Web Exclusives: Access, Cost, And Financing: Achieving An Ethical Health Reform Daniels et al. ( September/October 2009 ) [Abstract] [Full text] [PDF] Access, Cost, And Financing: Achieving An Ethical Health Reform Housing And Access To Health Care 21 September 2009 Mustafa Zeedan Younis, Professor Jackson State University Send comment to journal: Re: Housing And Access To Health Care younis99{at}gmail.com Mustafa Zeedan Younis The moral and ethical issues for health care reform are an understandable but insufficient argument. Universal health care would be successful if we solve the ethical issues of the homeless and unemployment. Any universal health care system will fail because many of the unemployed will become homeless. The homeless will lack a healthy environment and healthy way of life. Which is really the most pressing moral issue facing the country -- homelessness, unemployment, or universal health care? We are sure that universal health care will be ranked lower than unemployment!

Web Exclusives: The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals McCord et al. ( September/October 2009 ) [Abstract] [Full text] [PDF] The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian... Do We Need More Red Flags? 15 October 2009 James I. Koola, MD MPH, Public Health Specialist Afya Research Africa, Karatu-Arusha, Tanzania Send comment to journal: Re: Do We Need More Red Flags? jignas{at}jhsph.edu James I. Koola I would like to pose a few questions and urge a response from the authors of this article. I should point out that I am a Tanzanian physician and public health specialist with both formal and informal knowledge about the health system of my country. There has been and always will be a conflict of interest between Assistant Medical Officers (AMOs) and Medical Officers (MOs). Speaking from a public health point of view and being a supporter of universal coverage, AMOs have a role to play in providing health care to the majority of Tanzanians. This paper will likely be grasped by policymakers and used as evidence that more AMOs need to be trained, as they have the same kind of service outputs as MOs, as explained and echoed by this article. However, as we would like to adopt the results and believe that they reflect what is happening on the ground, can the authors explain how a total of 1,134 complicated deliveries discussed in this review are broken down to 945 performed by AMOs, 313 by MOs, and 21 by both AMOs and MOs but for this paper classified as for MOs? The addition of this breakdown totals 1,279 -- way above 1,134 identified as complicated deliveries. Throughout the exhibits, while comparing different measures of quality of care, the number of procedures done by AMOs has remained very consistent (approximately 940), but surprisingly the number of procedures performed by MOs has been approximately 140, which is 42% of the initial number of 334. It is acknowledged that there can be missing information as a result of weak record-keeping in developing countries, but lacking 60% of the records for MOs procedures and having almost 100% of AMOs procedures raises eyebrows. Unless more explanation is provided for such obvious disparities and mathematical errors, I think the scientific and policy-making community should take the conclusions of the paper with a pinch of salt. The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian... Re: Do We Need More Red Flags? 20 October 2009 Colin McCord Send comment to journal: Re: Re: Do We Need More Red Flags? cwm1{at}columbia.edu Colin McCord Dr. Koola has correctly identified a typographical error in the text of our artcle, cited above. In the "Data and Methods" section, we wrote: There were 1,134 obstetrical cases with complications — 821 admitted to government hospitals and 313 to mission hospitals. Of these patients,1,087 required a major operation — 945 of them done by an assistant medical officer and 313 done by a medical officer. The number of operations done by a medical officer was not 313, but 145. Because of missing data, 3 of the 145 were excluded from the calculation in one table, and 2 in the others. These correct numbers were used in all the calculations, and the error was not repeated in the text, so we do not see a reason to alter our conclusions, but we apologize for the error. The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian... More Questions Than Answers 22 October 2009 Bruno F. Sunguya, MD, MHSc candidate University of Tokyo, Japan Send comment to journal: Re: More Questions Than Answers sunguya{at}gmail.com Bruno F. Sunguya I am also interested in this paper, and indeed the results and the conclusion. This might be the first of its kind to be conducted in Tanzania, in trying to address the health care worker shortage in developing countries, yet it leaves many loose ends untied, and still has some pitfalls which if not properly addressed may mislead policymakers. The unexplained loss of (170) 54% of the representative sample population just on the MO side without alteration of the AMO representative sample clearly raises eyebrows, so is the inconsistent use of the remaining MOs numbers in several tables remaining controversial. If their data were not found, why then include them in the total study population from the beginning? This could be one of the causes of bias in this study. Although the reason why the number of MOs in the representative sample remains low compared to the AMOs in this study can be analyzed, better results could be obtained by trying to reduce the wide disproportion between the two groups, which can also result in study bias. In the study data and methods, the authors clearly mentioned that the study was conducted between January and May. However, I could not find the sampling method that was used. Since this was designed to be a comparative study, bias in selection of cases could lead to bias in the results and to a result the investigator intended or would like to find. Concluding that in Tanzania the shortage of staff capable of doing emergency obstetrical surgery is not a limiting factor, while you have mentioned the met need is only 30% (meaning that about two-thirds of women needing care don’t get it), sounds like more political than scientific reasoning. In Tanzania, there is a very serious shortage of health care workers of all cadres, the worst in the region. The patient-to-physician ratio is more than 30,000. How then can you conclude that it is not a limiting factor towards better care?

Web Exclusives: Developing A Policy For Second-Generation Antipsychotic Drugs Rosenheck and Sernyak ( September/October 2009 ) [Abstract] [Full text] [PDF] Developing A Policy For Second-Generation Antipsychotic Drugs Leave Weighing Of Risk To Patients And Providers 21 September 2009 Tami L. Mark, Director, Analytic Strategies Thomson Reuters Send comment to journal: Re: Leave Weighing Of Risk To Patients And Providers Tami.Mark{at}thomsonreuters.com Tami L. Mark Rosenheck and Sernyak argue that given the evidence that second-generation antipsychotics (SGAs) are expensive and may not be more efficacious than first-generation antipsychotics (FGAs), policies such as step therapy that encourage more use of FGAs prior to use of more expensive SGAs should be implemented more widely. We believe that this advice is misguided and that it downplays a primary reason that SGAs offer advantages over FGAs: the reduced risk of tardive dyskinesia (TD). Tardive dyskensia is an extremely disfiguring side effect that involves involuntary movements, typically around the face, such as grimacing, tongue protrusion, lip smacking, puckering, and rapid eye movements, which can be permanent. As Rosenheck and Sernyak indicate, recent reviews of the evidence suggests a higher risk of TD with FGAs than SGAs. In contrast, some SGAs are associated with a higher risk of weight gain, high cholesterol, and diabetes -- conditions that may be reversed with diet and exercise. The fact that patients who critically need antipsychotic medications must face the potential for any of these risks indicates how imperfect the current treatment approaches are. However, creating policies that force patients to take the risk of TD over the risk of metabolic side effects in the name of cost savings is unfair and fails to recognize that risk preferences and risk profiles vary across patients. Although the CATIE trial found equal efficacy with most SGAs and FGAs, it did not address TD because patients at high risk for TD were excluded from the FGA arm. Our analysis of MarketScan claims data indicates that there has been no increase in FGA use relative to SGAs following the CATIE trial. It seems that patients and physicians have already decided that the risk of TD is not worth the cost savings. Even in Great Britain, which commonly restricts costly medications that offer no advantages over cheaper medications, NICE practice guidelines state that the choice of antipsychotics should be “made by the service user and healthcare professional together.” Every antipsychotic is unique in its side effects, and the decision of how to weigh the serious risks of different treatment alternatives should be left to patients and their physicians.

Overview: Income, Insurance, And Technology: Why Does Health Spending Outpace Economic Growth? Smith et al. ( September/October 2009 ) [Abstract] [Full text] [PDF] Income, Insurance, And Technology: Why Does Health Spending Outpace Economic Growth? Missing The Forest For The Trees 21 September 2009 John E Hornbeak, Executive in Residence, Graduate Program in Healthcare Administration Trinity University, San Antonio, Texas Send comment to journal: Re: Missing The Forest For The Trees jhbeak{at}sbcglobal.net John E Hornbeak This study is very well done and comports to economic theory quite well. Reducing the "technology" cause as an excuse for cost inflation is a welcome and positive step. My criticism is that the authors did not distinguish between technology and the overuse of technology. Supply-induced overuse and preference-induced overuse, as explained by Wennberg at Dartmouth, are huge cost drivers! They represent gargantuan waste. Please indulge the elaboration below: 1. Supply-induced overuse: Defined as care delivered by specialists and in hospitals that, frankly, should have never been undertaken, where risks to the patient outweigh any potential benefit. The intensity of care for supply-sensitive services is driven by the subliminal influence of available resources on clinical decision making. (Supply of services, enabled by insurance, creates its own demand.) Supply-sensitive care refers to services where the supply of a specific resource (e.g., the number of specialists per capita) has a major influence on utilization rates. Physician visits, hospitalizations, stays in intensive care units, and imaging services are all examples of care where the local supply is the dominant influence on the frequency of use. Variations in supply-sensitive care are huge and enabled by a payment system that ensures that existing capacity remains fully deployed. The variation is not only huge among different geographic areas but also within the same region or city (from one hospital and its doctors to another). Unfortunately, very few conditions correspond to the model where demand is dictated by the incidence of disease rather than the supply of resources. In all, Wennberg reports that, conservatively, supply-induced overuse accounts for 14% of all care delivered in the United States. So the first step is to “cut that out.” Don’t deliver care that has no benefit. 2. Preference-induced overuse: Wennberg identifies 10 elective surgical conditions; top of the list is orthopedists doing mechanical low back pain surgery (e.g., spinal fusions). It turns out that if patients are given a fair choice about these procedures, the use rate drops by 40 to 60%. That is, if we use formal, validated methods for decision quality -- in the patient’s best interest. 3. Together, supply- and preference-induced overuse account for about 80% of all hospital-associated Medicare spending. Effective care, on the other hand, shows very little variation but is consistently underutilized. The "culture of money" that drives the overuse was brilliantly illustrated by Atul Gawande's June article in the New Yorker. I am interested in the authors' assessment of the above. Thank you. Income, Insurance, And Technology: Why Does Health Spending Outpace Economic Growth? Insurance & Technology: The Authors Respond 22 September 2009 Sheila D. Smith, Economist CMS, Joseph P.Newhouse and Mark Freeland Send comment to journal: Re: Insurance & Technology: The Authors Respond ssmith2{at}cms.hhs.gov Sheila D. Smith, et al. John Hornbeak raises a point that is relevant to the interpretation of our results; both theory and empirical evidence suggest that medical technology is likely to be applied inefficiently at the margin. The culprit is moral hazard -- insurance pays most or all of the bill for innovative techniques and procedures -- and still most often on a fee-for-service basis. However, it is the combination of the continuous stream of new medical technologies with the incentives for overuse (dynamic moral hazard) that is the critical issue for the contribution to growth in health spending. The Dartmouth Atlas work has long pointed to inefficiency in the level of health spending. Geographic variation in the treatment of specific medical conditions is large, and continues to be significant after controlling for the effects of income, race, health, local prices, gender, and age of the population. The robust conclusion of this body of research is that more intensive patterns of medical treatment are not associated with improved health outcomes. The potential for the overuse of new technologies to add to health spending growth (rising level of inefficient spending over time) is also widely acknowledged. To the extent that this effect occurs -- it is probably even more pernicious from the perspective of health policy. However, from the perspective of evaluating the relative importance of the factors driving health spending growth, we cannot identify how much of the contribution of technology is associated with overuse -- even within a ballpark range. If the effect of all medical innovation on health spending is a net positive over time (which is generally agreed), no one wants to throw the baby out with the bathwater. Neither is there great agreement on the appropriate means to distinguish between the two. Income, Insurance, And Technology: Why Does Health Spending Outpace Economic Growth? Role Of Markets: The Authors Respond 25 September 2009 Sheila D. Smith, Economist CMS, Joseph P.Newhouse and Mark Freeland Send comment to journal: Re: Role Of Markets: The Authors Respond ssmith2{at}cms.hhs.gov Sheila D. Smith, et al. I believe that Dr. Younis' principal point is that the intermediation of employers and public payers on behalf of consumers in the purchase of health insurance blunts the incentive for cost-reducing innovation in the delivery of health care. While this point certainly applies in theory, it is critical to recognize that markets for health insurance are subject to market failures that vastly complicate the problem. In particular, the potential for adverse selection and high administrative costs that hamper current markets for individually purchased insurance coverage will also preclude a functioning market at a more aggregate level -- unless the issues of pooling and coverage mandates are resolved. Can a market for insurance function? Certainly. However, this would require that we set in place a good bit of careful infrastructure, along the general lines proposed by Alain Enthoven and others for a system of managed competition.

Web Exclusives: Health Spending Projections Through 2018: Recession Effects Add Uncertainty To The Outlook Sisko et al. ( March/April 2009 ) [Abstract] [Full text] [PDF] Health Spending Projections Through 2018: Recession Effects Add Uncertainty To The... Defining 'Program Administration' In Spending Data 20 October 2009 E. Barry Solomon, Retired Send comment to journal: Re: Defining 'Program Administration' In Spending Data solomonbarry1{at}comcast.net E. Barry Solomon In Exhibit 2 (and others) "National Health Expediture Amounts, and Annual Percent Change by Types of Expenditure: Calendar Years 2003-2018" Line Item: "Program Administration and Net Cost of Private Health Insurance" Net cost of private health insurance is self-explanatory, but I'd like to know how, or have you direct me to a site where, "program administration" is precisely defined. I'd also like to know the breakdown between the two components.

Personal Health Records: Information Gap: Can Health Insurer Personal Health Records Meet Patients’ And Physicians’ Needs? Grossman et al. ( March/April 2009 ) [Abstract] [Full text] [PDF] Information Gap: Can Health Insurer Personal Health Records Meet Patients’ And Physicians’... My Opinion On Personal Health Records 12 November 2009 Mary E. Bender, Consultant/EHR Former Employee, Wm. Beaumont Hospital Send comment to journal: Re: My Opinion On Personal Health Records maryforhealth{at}live.com Mary E. Bender I have around 28 years' experience in the health information technology field (medical records). As we know, hospitals or hospitalization are a source of fear and apprehension for any patient. I started out at the University of Michigan in the School of Nursing. I studied for the health information technology degree in the 1990s. Even though the medical records degree has most likely been around since the 1970s, with my particular experience, my conclusion is that this particular aspect (not calling it a field) of hospitalization is not moving forward in any big way at all. In some aspects it is moving backward, in my opinion. To me the personal health record is a beneficial thing, because it is giving the patient more control over his or her records and might even lead to making different and/or better health care choices.

Web Exclusives: Establishing And Refining Hurricane Response Systems For Long-Term Care Facilities Hyer et al. ( September/October 2006 ) [Abstract] [Full text] [PDF] Establishing And Refining Hurricane Response Systems For Long-Term Care Facilities Long-Term Care Facility Plans 20 October 2009 Elaine Davey, Director Counter Disaster Unit Sydney West Area Health Service, Australia Send comment to journal: Re: Long-Term Care Facility Plans elaine_davey{at}wsahs.nsw.gov.au Elaine Davey Have there been improvements made since 2006 in disaster plans, long-term accommodation for evacuated nursing home residents, etc.? I would be very interested to know how far you have come.

Mission Vs. Market: The Cost-Shift Payment ‘Hydraulic’: Foundation, History, And Implications Dobson et al. ( January/February 2006 ) [Abstract] [Full text] [PDF] The Cost-Shift Payment ‘Hydraulic’: Foundation, History, And Implications Re: Why Private Payers Accept Cost Shifting 22 October 2009 Gerald Gruber, Retired Private Financial Management Send comment to journal: Re: Re: Why Private Payers Accept Cost Shifting g-gruber-11{at}alumni.uchicago.edu Gerald Gruber If the private payer is an insurer, then the fact this has been happening for a long time has permitted it to be included in the premium charged to the insured. Most insurers are quite happy to earn a steady percentage of premiums as profit, and the higher the premiums, the higher the profit. If the private payer is the insured, the insurer provides irrefutable proof of the amount paid, and in the absence of a conflict of interest (fraud) between the provider and the insurer, there is not much more to discuss. I do not think the tax rate is an important factor, except it being a fact of life. The above would seem to be the "rule" as long as the system is opaque; and it will be as long as the three primary parties to its opacity have no reason to desire transparency (the primary parties being the benefitting public payers, the insurers, and the insured).

Health Tracking: The Effect Of Physician-Owned Surgicenters On Hospital Outpatient Surgery Lynk and Longley ( July/August 2002 ) [Abstract] [Full text] [PDF] The Effect Of Physician-Owned Surgicenters On Hospital Outpatient Surgery What About Hospitals? 12 November 2009 James Breit, Plastic Surgeon PSA Send comment to journal: Re: What About Hospitals? Breit_t{at}hotmail.com James Breit If physician-ownership of an ASC is unfair to hospitals, than isn't a hospital that owns the patients insurance, employs the patient's doctors, and mandates what doctors its insured patients should see and where they can and can't have their surgery a problem, too? Avera and Sanford are examples of this, and in my opinion this type of monopoly hurts health care the most -- in quality and cost. At least physician-owned surgery centers create competition because they offer better care more cheaply than a hospital. The truth hurts, but any doctor who has worked in both settings would know this. In the end I get paid the most when i am operating. I can do 6 cases at the ASC in the time I do 3 cases at the hospital. Time is money, and that is the ultimate factor. No hospital I have been to yet is more efficient than a surgery center -- and never will be unless physicians are running it.