Friday, December 17, 2010

America's New Health Goals: Healthy People 2020



The US Department of Heath and Human Services (HHS) recently released their once-a-decade health objectives for the country, entitled Healthy People 2020. This is the fourth edition of the framework, which provides ambitious but achievable goals in a number of areas of health and health care.

Though by no means a mandate, the goals provide measurable objectives while identifying previous areas of weakness that could benefit from additional research efforts in order to reduce poor health outcomes and improve the investments we make in our health system. This decade there are a number of new metrics that reflect emerging needs for topics like genomics, healthcare-associated infections, and disaster preparedness. You can explore the list on the 2020 Topics and Objectives page.

Saturday, December 4, 2010

Senate Passes Monumental Food Safety Law

Responding to several recent outbreaks and reports of questionable food safety practices this year, the Senate this week passed S. 510, The FDA Food Modernization Act. The bill passed with wide bipartisan support in a 73-25 vote, marking the largest overhaul to food safety law in over a half-century. Though the American health care system rates poorly on numerous factors in a global comparison, our food safety is the gold standard in terms of public health surveillance and response and this bill will help bring these practices into the 21st century. The House needs to make a minor revenue adjustment to the bill though, meaning the bill must sent back to the Senate for a final vote before it can go the President to sign into law. Below is a summary of the bill, from the American Public Health Association (APHA):


  • Provide FDA, for the first time, with a specific statutory mandate to prevent foodborne illness.
  • Improve coordination across federal, state, and local governments and providing grants to build state and local capacity for foodborne illness detection, surveillance, testing, and response.
  • Require food processors to identify where contamination may occur in the food production process, and then requiring them to take steps to prevent the contamination.
  • Base the frequency of FDA food processing plant inspections on the risk of the product being produced, increasing the frequency of foreign inspections, and establishing, for the first time, a statutory minimum frequency for FDA inspections of domestic food processing facilities.
  • Require imported food to meet the same safety standards as food produced in the U.S.
  • Establish science-based minimum standards for safe agricultural production of fresh fruits and vegetables that pose the highest risk.
  • Providing FDA, for the first time, with mandatory recall authority.
  • Offer grants to enhance education, training, and technical assistance related to compliance with the new requirements.
  • Establish traceability requirements that strike the right balance between protecting public health and preventing any undue burden to small businesses.

Wednesday, November 24, 2010

The Primary Care Problem



Here is a good piece from PBS that lays out one of the greatest challenges we face in health care, and it just so happens to feature members of the UC Davis Health System and School of Medicine! With a decreasing primary care workforce and a projected 30 million individuals gaining insurance coverage after 2014 through health reform, it is imperative that we ready ourselves to meet this increasing demand.  Below is an excerpt from one of my past posts at the ITUP Spotlight on Health Reform that looks at opportunities for improvement, entitled "Insurance Does Not Guarantee Access...and We're Short on Docs":


Make no mistake about it: there is a severe doctor shortage in the United States and the problem is only getting worse, especially in primary care. The Association of American Medical Colleges estimates that we could face a shortage of as many as 150,000 PCPs in the next 15 years. The reasons for this trend vary, though the comparatively lower pay, steep medical school debt, and even the personality types of those accepted to medical school are clear contributors. As a future physician, I understand the implications (and potential consequences) of this reality, and recognize that swift action must be taken. The health reform law makes significant improvements to the status quo by setting a clear priority for docs to enter primary care. Some of the provisions include:

-Up to $1 billion annually for the National Health Service Corps (a loan forgiveness program for PCPs to provide care in shortage/underserved areas), supporting more than 16,000 new primary care physicians by 2015. Learn more here.
-$125 million annually for state loan forgiveness programs in primary care
-A 10% Medicare payment bonus to primary care physicians
-Increasing Medicaid payments to Medicare levels
-Shifting unused residency slots to high-need primary care areas
-Expanding primary care residency to non-traditional (non-hospital) sites such as community health centers

-$50 million annually to expand Teaching Health Centers, with $230 million appropriated for primary care training


Though these efforts will surely be of benefit, many recognize that the root of the problem is a shortage in medical resident positions. In 1997, Congress capped the number of resident slots at 15,000, as training is tied to Medicare payments. It will be necessary to revisit the expansion of this funding (currently $9.1 billion), which did not make it into the legislation. More-so, it will be necessary to think outside the box, with a focus on non-physician providers like Nurse Practitioners and Physicians Assistants. Though somewhat controversial in expanding their scope of practice into traditionally physician's turf, the endeavor is promising (if not essential) in order to tackle the issue.

Saturday, November 13, 2010

Debrief from the Doctor Congress


One of the hats I wear is to represent UC Davis as the Alternate Delegate for the American Medical Association (AMA) Medical Students Section. Last week was the annual Interim Meeting down in San Diego, where students and physicians from around the country convened for a week of regional strategy meetings, speeches, and policy steering in regard to the present and future issues facing the medical profession.

The Medical Student Section is the 'kids table' of the organization, where we have the opportunity to set our own policy priorities. The governing body acts much like Congress, with individuals or groups submitting resolutions to change/renew/add policy to the books, the House of Delegates hearing arguments for and against the resolutions, providing amendments, and ultimately voting on each one. Besides getting to say fun things like "Thank you Mr. Speaker...", "Point of order...", and "I move to close debate and call for an immediate vote", the event offered a fascinating look into the spectrum of issues that med students across the country see as important. Major topics included advocating for student debt relief, calling for a study on the effects of agricultural subsidies on access to nutritious food, and supporting the need for broader regulation on direct-to-consumer genetic testing. UC Davis submitted two resolutions to improve Medicaid access near state lines and to advocate for taxing sugar-sweetened beverages, both of which passed (good work team!). You can see the full list here.

The Main Event opened following the close of the Med Student Section, where we heard speeches from the President of the AMA among others. Central to the talking points was the fact that even though health reform was a fierce debate fraught with disagreement, coming together and looking forward to effective implementation are the key to ultimately improving the American health care system. Physicians are the glue of the system, and as such must take an active guiding role in this transformation. Here are some of the guiding principles specific to health reform that the AMA decided on:
  • The establishment of accountable care organizations (ACOs) under health reform must be physician-led and patient-centered
  • The flawed Medicare payment formula (called the Sustainable Growth Rate) that threatens a 20% cut to reimbursements must be fixed permanently
  • Medical malpractice (tort) reform was insufficient in the Affordable Care Act, and should be addressed legitimately on the federal level
  • The AMA will initiate a grassroots campaign for adoption of the Medicare Patient Empowerment Act, a proposal that would allow patients to contract privately with physicians while retaining access to Medicare coverage

Wednesday, October 27, 2010

Understanding the Affordable Care Act



Here are two entertaining videos featuring Jack Black (Part 2 below) that satirize a very real occurrence going on across the country. The fierce debates that persisted in the run up to the new health reform law brought with them a slew of falsities and misinformation; death panels, socialized medicine, and jail-time for those who don't buy insurance are a few of the more popular ones. One of my personal favorites is 'national insurance cards with computer chips that monitor your every move.' Poll after poll currently show a roughly 50-50 split in support/opposition of the new law. That's not what concerns me. It is polls like this one that are most troubling:


I don't discount that the bill is incredibly complex. It is. The problem lies in the fact that opposition groups have taken advantage of this knowledge gap to create widespread confusion in the hope to weaken it's fundamental provisions.

What is most interesting are the surveys showing that when taken by it's individual components (guaranteed issue of insurance, subsidies to make insurance affordable, investing in primary care), these provisions are overwhelmingly supported, some by a 9 to 1 margin. And when these basic components are explained to poll responders before asking their opinion on the law, the favorability margin increases significantly.

The new law is not perfect, and it is crucial that our conversations revolve around how to improve it over the following years of implementation. National debate is what makes our country great, but it is important to stay in the realm of reality.

The Mis-Informant Part 2 - with Jack Black as Nathan Spewman

Monday, October 18, 2010

Health Reform in the Judicial Branch

If you need a high school civics refresher, just follow the new health care bill. The bill passed Congress, was signed by the President, and literally minutes later the law had a number of lawsuits filed against it. Of the 20 lawsuits, the major theme deals with the Individual Mandate, where starting in 2014 most individuals will be legally required to have some type of health insurance. Opponents claim that the provision in 'unconstitutional,' as citizens should not be required to purchase a private product. Though logical on the surface, the argument falls short on a number of levels especially in terms of finances.

For one, there is a 1986 law on the books that any individual who enters an Emergency Room (insured or not) can not be denied care (Thanks Reagan!). And that care is always paid for. If the individual happens to be uninsured, all those emergency room costs are more often then not picked up by the taxpayers in the form of 'uncompensated care.'  Opponents to the provision should understand that if we the taxpayer are going to pay for it anyway, health insurance and prevention are FAR cheaper than the emergency room, where an infection treated early through primary care costs a fraction of the price. This is a clear-cut way to reduce the public burden. The argument could develop into 'well then maybe they shouldn't get treated if they can't pay up front', but this would brew a whole new set of moral and ethical issues that only a distant band of the political spectrum would support.

The second financial argument deals with the insurance market reforms. Almost everyone likes the idea of banning pre-existing condition exclusions and rescissions, and guaranteeing access to health insurance, but these are impossible without the mandate. The three legged stool of 1) insurance subsidies, 2) consumer protections, and 3) individual mandate can not be separated, at risk of creating adverse selection, where individuals who are guaranteed insurance will simply wait to purchase it until they get sick. As all Americans  access the health care system at some point in their lives, this would inherently upend the entire insurance model, which is designed to spread risk across a pool and not concentrate it. Google the death spiral to learn more.

Back to the lawsuits, I would bet my right tunica albuginea that one of them eventually reaches the Supreme Court (most likely the Florida or Virginia case, as the Michigan suit was thrown out last week). When it does, the lawsuit will most likely be dismissed for 'not buying insurance' effects our society as a whole given the assessed costs, in addition to the basis of the 'Commerce Clause' where Congress has the right to regulate commerce. The use of this Clause would be unprecedented in this sense as now 'economic inactivity' (NOT buying insurance) would be included, so we can expect an increasingly fierce debate as one or more of the suits makes their way to higher benches.

Tuesday, October 12, 2010

Mapping our Health

I ran across digital cartographer Eric Fischer's Flickr site the other day, and perused his new series of maps on race and ethnicity in the nation's 40 largest cities. Below are two examples of the maps, featuring Los Angeles and San Francisco. The maps use the Census 2000 data, with each dot representing 25 people and colors corresponding to race (red=Caucasian, blue=blacks, orange= Hispanics, green=Asian). The striking geographic divides are clearly evidential in many of the cities, which can provide valuable information for learning tools and various community development endeavors.

I can't help but think of the myriad of applications when looking into race and other demographic factors like income, mortality, and per capita resources, especially with the Census 2010 data soon to be released. Specific to health care, imagine the wealth of information that could help develop strategies and outreach programs for issues like access limitations to health services, disease progression, and chronic disease management to name a few. For example, integrating data from multiple sources like hospitals, health plans, and health care providers can reveal important information regarding health costs, the effectiveness of treatments, and other factors so we in the medical field can make well-informed decisions when weighing treatment options. Real-time surveillance data could even help track and combat infectious disease outbreaks. The sheer volume of data needed for these efforts is staggering, but is becoming reality. Electronic health records will be central to this effort, and health reform also includes a number of provisions to improve data integration including insurance market data transparency and the new Patient Centered Outcome Research Institute which will help to synthesize the latest research for efforts in comparative effectiveness.


Wednesday, October 6, 2010

California, A New Pioneer for Health Reform

Much of the 'rubber meets the road' responsibility of health reform implementation falls to the states; this is by design as each state has a unique set of circumstances and qualities that must be adequately considered. Last week, California became the first state in the nation to make law one of the pillars of health reform, the health insurance exchange. The state bills, AB1602 and SB900, will establish what will be known as the California Health Benefit Exchange in 2014.

This Exchange will allow individuals and small businesses to easily compare health insurance plans on factors like price, performance, and consumer satisfaction, with many gaining access to insurance subsidies in order to help make insurance affordable. In all, nearly 3.5 million individuals will be eligible for these tax credits (totaling nearly $14 billion in tax cuts) who are today left to the unprotected, and overly expensive individual market. Moreso, the Exchange itself will be able to flex bargaining power in order to negotiate lower rates much like large businesses do now, and will force insurers to compete based on the quality of their product and not who can most effectively exclude 'unprofitable' individuals.

During his signing ceremony last Friday, Governor Schwarzenegger also unveiled a new web portal intended to provide pertinent information on reform's implementation, which will most likely become the online access point for the Exchange itself, as well. Check it out here.

Saturday, October 2, 2010

Health Reform: The Basics


Want to hear me ramble about health reform? Sure you do!

I had the opportunity to present this lecture to the UC Davis Medical School community last week as part of our AMA/CMA speaker series entitled Health Reform in America. The talk covers the basics of the new law, so if you are still unsure of what is actually in it or just want to understand it better go ahead and listen in. The video feed is a little hazy, so I've included the slides below that you can use to follow along with.

Health Reform in America: An Overview of the Patient Protection and Affordable Care Act

Wednesday, September 29, 2010

A 21st Century FDA

We have been learning a lot about the new generation of cancer drugs, some of which have the potential to bring us tantalizingly close to the holy grail of "cure". Many are in the controlled trial stages of FDA approval, where the treatments are scrutinized for their long term effects before hitting the open market. I ran across this NYT article last week, which weighs the pros and cons of the  approval process against the very real need for dying patients to receive proven treatments.

The story goes that two cousins happened to be diagnosed with invasive melanoma around the same time that a novel therapy was entering its final Phase III trial. Both cousins qualified for the trial, but only one was given the new treatment (the other was placed in the 'control' group with a less effective treatment). The first cousin's condition improved; the second succumbed to the disease.

It is complicated scenarios like this one that exposes the limitations of our outdated FDA approval process. The cumbersome path puts doctors in the awkward position of telling a patient "Sorry, you can't have this life-saving treatment" and more importantly puts patients lives in jeopardy. Worse, the current 'fast-track' process would limit approval to only the sickest patients, which gives drug companies an incentive to wait for long-term results in order to gain approval for a wider market.

The debate is full of complexity, including factors like cost effectiveness, quality vs. length of life, and insurance coverage. Obviously, we want a rigorous safety/efficacy test for emerging treatments so we don't poison our patients (Vioxx, Avandia, etc), but 21st century research deserves an equally responsive FDA. The "priority review voucher" law passed in 2007 has the potential to speed up the process, which helped accelerate approval of Coartem, an anti-malaria drug. The idea may soon expand to some cancer research as well, where a bill was recently introduced to include rare pediatric cancers in a very capacity. The expansion of Health Information Technology (HIT) and health reform's Patient Centered Outcome Research Institute must play crucial roles in the evolution of obtaining such research data, as well, though I'll leave these concepts for a future post.

Friday, September 24, 2010

Health Reform: Six-Month Anniversary

Yesterday marked the 6 month anniversary of the President signing health reform into law. How time flies...what did you do with your copy of the 2,700 page law to celebrate your anniversary? I took mine to a nice steak dinner...

Aside from the nostalgia, the 180-day mark is an critical juncture for the new law. Numerous provisions went into effect yesterday, and some of the worst abuses in the health insurance market are now a thing of the past. Here are some of the major ones:

-Young adults up to age 26 will be guaranteed to be able to stay on their parents insurance, helping over 2 million Americans gain coverage
-Children can no longer be denied insurance coverage because they have a pre-existing condition
-Ends the practice of rescissions, making it illegal for insurers to drop an individual who gets sick and 'unprofitable'
-Ends lifetime caps on insurance claims for all individuals, assuring individuals with a chronic disease or medical emergency the security to access vital services
-Requires new plans to offer proven preventive care (mammograms, vaccinations, blood pressure/cholesterol screenings, etc.) with NO cost sharing or co-pays, assuring access to these vital services even in economic hardship
-Allows women to directly access OBGYN services, without the need of a referral

Thursday, September 23, 2010

Welcome!!

Greetings!

I would like to officially welcome you to my new blog, where I hope to explore a diverse range of topics in health, medicine, and policy. As a two-month old medical student, I couldn't think of a more important and exciting time to be entering the field. Health reform implementation, emerging medical discoveries, and the advancement of health care into the 21st century will fundamentally change how the American health care system operates. Whether you are a fellow medical student, policy wonk, or someone with any interest in health care topics, I hope that this blog can be a source of useful, thought-provoking material and commentary.