American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, April 23, 2014

The medical monopoly you've never heard of

Have you had a prescription filled electronically?

The difference is no longer being handed a written prescription and having to take it to a pharmacy to be filled. E-prescribing enables the doctor to electronically send the prescription right from her computer. Fast. Clean. One stop shopping. If she picks a medication that’s a) not covered by your insurance or b) risky for a medication interaction, then the computer alerts her and she can make a different choice.

This is all possible because of Surescripts, a consortium consisting of national pharmacy chains, independent pharmacies, and the big “pharmacy benefit managers” (groups like Express Scripts or Caremark). Last year, the Surescripts network surpassed the 50% mark: half of all prescriptions are now generated electronically. It’s a big number: Surescripts reports handling 6 billion electronic transactions a year.

Imagine Coke and Pepsi uniting with artisanal/local cola makers to create a single distribution and delivery system nationwide, in which they’d share proportionally in the costs and the utilization. Seems inconceivable. Yet it’s exactly what’s happened in the retail drug industry.

Read more about it here, on NPR’s Shots blog.

One exception to e-prescribing I didn’t cover in the piece: Most states still require written prescriptions for narcotic (opioid) pain medications (think Vicodin, Lortab, Percocet, etc.) This is to add hurdles to the process for a variety of reasons. Fodder for future posts.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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The bending cost curve

I attended a really interesting conference last week on “Innovation in Health Care” that was cosponsored by The Advisory Board and the Aspen Institute. It was a 1-day affair in Washington, attended by about 1,000 people from around the country who were treated to talks by a star studded cast that included Health and Human Services Secretary Kathleen Sebelius, Peter Orszag, Jeffrey Brenner, former U.S. Senators Tom Daschle and Bill Frist, and a guy with more titles than I can count, Patrick Conway.

A few things stuck with me.

First, the overall message, from across the political spectrum and from different corners of the health delivery landscape is that fee-for-service is—and ought to be—dying as the predominant mechanism of health care financing. In fact, the day often seemed like a requiem for fee-for-service; it was mostly discussed in the past tense, with the new world of value based purchasing and accountable care in its many forms the focus.

Patrick Conway (wearing his CMS Chief Medical Officer hat) reviewed some amazing data regarding declining readmissions and improving quality metrics among Medicare beneficiaries. Perhaps most striking was the slide he showed illustrating that the growth of Medicare spending has dramatically slowed over the last several years, and is now lower than the growth in overall GDP.

This has been pointed out before but this is a very big deal.

Peter Orszag explained why. First, he reviewed many of the things that are not responsible for the downward growth curve. It is not a reflection of the great recession; it is not a result of lower prices; it is not a consequence of baby boomers swelling the ranks of Medicare beneficiaries at the low end of utilization. No, the explanation is lower utilization across the board of medical services, and specifically a decline in the rate of hospitalization among Medicare recipients.

Orszag went on to speculate why this is happening, which is where this really got interesting.

He believes that providers are changing practice in anticipation of new models of payment. He cited as an example the work that many hospitals have done to lower their readmission rates even when their current and short-term economic interests are better served by filling the beds. The implication of this interpretation of the data is clear. Whatever gains have been made in “bending the cost curve” are fragile, and can only be baked in if payment models continue to evolve away from fee-for-service. If CMS does not continue to ratchet up the impact of value based purchasing or expand novel payment models, or if commercial payers do not accelerate their transition to risk-based contracting, the curve will likely bend right back up.

Oh, and one more thing, in case you don’t think it is important which way the curve bends. Orszag also pointed out that if current trends continue, all of the long-term fiscal challenges facing the United States, which seem to be driving so much of the invective in Washington, just go away. Completely. Imagine that.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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QD: News Every Day--False-positive mammograms may not increase long-term anxiety

False-positive mammograms were associated with increased short-term anxiety but not long-term anxiety, and such results increased women’s intention to undergo future breast cancer screening, a study found.

Researchers conducted a telephone follow-up survey among 1,000 women as part of a quality-of-life sub-study. Randomly selected women with positive and negative mammograms requiring follow-up testing or referral without a cancer diagnosis were assessed for their willingness to undergo future mammographic screening. They were also presented with a hypothetical scenario in which they could travel and stay overnight to undergo a new type of mammography that would identify as many cancers with half the number of false-positive results.

Results appeared online April 21 at JAMA Internal Medicine.

Women’s plans to undergo mammography within the next 2 years did not differ by screening outcome. But, 25.7% of women who had a false-positive mammogram characterized themselves as “more likely” to undergo future breast cancer screening compared with 14.2% of those who had a negative mammogram. However, there were no differences in women’s attitudes toward the anticipated anxiety they would feel if they were to have a positive mammogram in the future.

Women’s experience of a false-positive mammogram did not influence their willingness to travel to avoid a false-positive mammogram in the future, with the vast majority of women in both groups being willing to travel up to 4 hours to avoid such a result. A small minority in each group were willing to travel and stay overnight to avoid a false-positive mammogram (10.5% in the negative and 9.9% in the false-positive group). When women were asked to choose between a new type of mammography that would avoid breast compression and one that would avoid false-positive mammograms, most (81.6%) chose the latter.

The authors wrote: “The fact that women’s anticipated anxiety about future false-positive mammograms was a correlate of willingness to travel and stay overnight to avoid such a result, but the actual experience of a false-positive mammogram was not, further highlights opportunities to educate women about screening outcomes.”

In an editorial, Kurt Kroenke, MD, MACP, wrote, “These adverse consequences would be less concerning if false-positive mammograms were an uncommon event. However, the cumulative probability of a woman receiving at least 1 false-positive mammogram within 10 years is 61.3% with annual and 41.6% with biennial screening. The cumulative probability of biopsy recommendations based on a false-positive mammogram is 7% with annual and 4.8% with biennial screening. This increase in likelihood of a false-positive mammogram over the screening life span of a woman amplifies the adverse consequences at a population level.”

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Tuesday, April 22, 2014

Do regulations predispose to diagnostic errors?

Last week I presented my diagnostic talk, “Learning to Think Like a Clinician” at the Virginia ACP meeting. Afterwards several physicians wanted to discuss the reasons for diagnostic challenges. They convinced me that many regulations from CMS and other insurers have influenced policies that increase anchoring and diagnostic inertia.

When the emergency department physicians admit to the hospital, they have to give an admission diagnosis. At least in the United States, I believe they cannot admit for abnormal chest X-ray, or fever, but rather they must postulate a diagnosis. That diagnosis then drives case managers and protocols. Patients often receive their first treatments before the admitting physician has even met the patient.

The emergency physicians get criticized if they do not proceed in a timely fashion. The hospital worries that they have a diagnosis that supports admission rather than observation status. If they designate the wrong status, they face a financial problem.

But patients do not always arrive with diagnoses. Some diagnoses take time. Patients would benefit if the diagnosis was purposely made unknown disease with manifestations rather than pick a diagnosis for billing and quality purposes.

Too often, the physicians stated, a diagnosis induces a therapeutic freight train. And then if the patient is not discharged promptly (according to the expectations of the admission diagnosis) the admitting physician gets criticized.

Something is wrong with the system. (Actually much is wrong because we do not really have a system, rather we have rules.) We need ways to more acceptably label a patient as a diagnostic puzzle. We need the “system” to allow us to not know the diagnosis and realize that pursuing the diagnosis is job #1.

We must develop systems to avoid diagnostic anchoring and inertia. Our patients deserve our full diagnostic attention. Unfortunately, we see too many diagnostic misadventures.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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