Medicaid expansion under Obamacare had little effect on ER visits

A new study at Johns Hopkins found that the expansion of Medicaid under the Affordable Care Act had little effect on the number of emergency room visits.

Researchers at Johns Hopkins School of Medicine analyzed the ACA Medicaid expansion in 2014 in Maryland to see if the program made a difference in the amount of patients visiting the emergency room.

“Through the Medicaid expansion, there were some people who believed more patients would choose to go to primary care providers instead of the emergency department, because now they have health coverage, and there were some people who believed that the expansion would swamp the emergency department,” Eili Klein, an assistant professor of Emergency Medicine in the Johns Hopkins University School of Medicine, said in a press release. “We wanted to look at what actually happened.”

Researchers examined patient visits at emergency departments across the state of Maryland for an 18-month time period before and an 18-month time period after the ACA Medicaid expansion took effect in 2014. The first six months of 2014 were excluded from the study.

The study, published July 24 in the Annals of Emergency Medicine, found the number of people covered by Medicaid in the state increased more than 20 percent as 160,000 Maryland residents enrolling in Medicaid. The total number of emergency room visits fell by more than 36,000 during the same time period.

“Thirty-six thousand may seem like a lot of visits, but, in Maryland, that only equates to about a 1 percent change,” Klein said. “So, the effect of expanding Medicaid seems to have had no effect on emergency department utilization at an aggregate level.”

The study found that Medicaid covered 6 percent more visits during that time period, but the number of uninsured patient visits also decreased by 6 percent.

“When the patients came in to the emergency department, the payer mix changed,” Klein said. “So people were much more likely to be insured now than they were previously. And most of that was people who were uninsured who then became insured by Medicaid.”

Researchers stressed that even though the ACA did not reduce the burden on emergency departments, the program does have benefits in that it protects patients from expenses of health care services and provides increased financial security to hospitals.

Source: Medicaid expansion under Obamacare had little effect on ER visits –

Posted in Government Regulations, Industry Updates

Opioid Prescriptions Are Down But Not Enough, CDC Finds

Doctors are cutting back on opioid prescriptions but not by nearly enough, federal health officials reported Thursday.

The number of prescriptions for the painkillers has tripled since 1999, driving the opioid addiction and overdose epidemic, the Centers for Disease Control and Prevention reported.

Image: Opioids Map
Morphine milligram equivalents (MMEs) of opioids prescribed per capita in 2015 and change in MMEs per capita during 2010-2015, by county — United States, 2010-2015 Centers for Disease control and Prevention / CDC

This means doctors have to cut back even more, saving opioids for acute pain — after surgery or for people with incurable cancer and other terminal conditions, for instance. Arthritis, back pain and other long-term conditions should be treated with other methods, CDC Acting Director Dr. Anne Schuchat said.

The CDC surveyed opioid prescriptions and broke them down county by county.

“Despite significant decreases, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country,” the CDC team said in their report.

They used a measurement called morphine milligram equivalents — their best way to come up with one single way of describing the different drugs and different doses.

They found the number and amount of opioids prescribed peaked in 2010, at 782 morphine milligram equivalents per person that year. By 2015, that had fallen slightly to 640 per person.

It’s way too much, Schuchat said. “That 640 level is the same as if everyone in the country is on round-the-clock opioid medication for three weeks,” she said.

“It’s still too high. We are heading in the right direction but we have a long way to go.”

There’s no question the U.S. is suffering from an opioid abuse epidemic. Opioid overdoses killed more than 33,000 people in 2015, the CDC said.

“Among opioid-related deaths, approximately 15,000 (approximately half) involved a prescription opioid,” the CDC team said.

Image: Opioids Map
Morphine milligram equivalents (MMEs) of opioids prescribed per capita in 2015 and change in MMEs per capita during by county from 2010-2015. Dept of Health and Human Svcs

“In addition, an estimated 2 million persons in the United States had opioid use disorder (addiction) associated with prescription opioids in 2015.”

The survey also confirmed what many other reports have shown about the opioid abuse epidemic: It’s hitting counties where people are mostly white, have lower incomes, less education and more unemployment. The more doctors and dentists there are per capita, the more likely people are to get prescriptions for opioids.

People in the worst-hit areas have higher rates of diabetes, arthritis and disability and have higher rates of suicide, the CDC team found.

Other research shows that once people become addicted, they often turn to cheaper street drugs such as heroin.

There’s no one single factor to blame for the epidemic. When synthetic opioids like as OxyContin and fentanyl hit the market in the 1990s, many doctors thought they were less addictive than opiates such as morphine or codeine. Manufacturers aggressively marketed them, and the pain community got organized and vocal in demanding them.

“Clinicians did start to practice with the idea of trying to eliminate pain,” Schuchat told NBC News. “Pain isn’t really a vital sign but many people started to track it.”

The CDC has been trying to get doctors to prescribe opioids only when absolutely necessary, and to prescribe as low a dose as possible for the shortest time possible.

“Previously, opioids had primarily been reserved for severe acute pain, postsurgical pain, and end-of-life care,” the CDC team, led by health economist Gery Guy, wrote in the report.

“This change in prescribing practice increased the amount of opioids prescribed for three reasons. First, opioid use for chronic non-cancer pain increased the number of opioid prescriptions. Second, the use of opioids to treat ongoing chronic conditions increased the average lengths of time for which opioids were prescribed,” they added.

Image: Opioids Chart
Sociodemographic characteristics of counties by MME per capita quartiles* — United States, 2015 CDC / CDC

And the longer a patient takes an opioid, the higher the dose he or she needs. That raised dosages over time. “Together, these changes placed more persons at risk for opioid use disorder and overdose,” the CDC team wrote.

Schuchat said CDC’s new guidelines have helped and she said the agency is beginning a new push to educate doctors and patients about when opioids are needed and when they are not.

Source: Opioid Prescriptions Are Down But Not Enough, CDC Finds – NBC News

Posted in Industry Updates, Opioid Epidemic

Painkiller maker stops sales at FDA request because of abuse | Fox News

The maker of opioid painkiller Opana ER is pulling the drug off the market at the request of federal regulators because it’s being abused.

Endo International PLC said Thursday it will voluntarily stop selling the pills, approved for use in patients with severe, constant pain, after consulting with the U.S. Food and Drug Administration. It’s the first opioid drug that the FDA has sought to remove from the market due to abuse.

The drugmaker said in a statement that the extended-release opioid is safe and effective when used as intended, and that Endo still believes Opana ER’s benefits outweigh its risks.

But last month, the FDA said it had concluded the drug is too risky. The agency said it had seen a “significant shift” from people crushing and snorting the pill to get high to injecting it instead. Besides contributing to overdoses, abuse of Opana ER was blamed for a 2015 outbreak of HIV and hepatitis C in southern Indiana linked to sharing needles, according to the FDA.

Opana ER got U.S. approval in 2006. In 2012, Endo changed the drug’s formulation to try to make it harder to abuse. The FDA approved sales of the new version but refused to let Endo market it as abuse deterrent.

The agency asked the company to stop selling Opana ER after its advisers, reviewing its safety at a March hearing, voted 18-8 against keeping it on the market.

Dublin, Ireland-based Endo, which has U.S. headquarters in the Philadelphia suburb of Malvern, said it will work with the FDA to try to minimize disruption for patients, who will need to switch to alternative treatments.

Endo primarily makes generic medicines, as well as a number of brand-name specialty drugs. Endo reported that Opana ER last year posted net sales of $159 million. The company said it will take a pre-tax charge of about $20 million to write off the drug’s remaining value.

As of June, there were no generic versions of the reformulated Opana ER on the market, according to the FDA, but two generics of earlier versions are on sale, called oxymorphone.

The agency said it would also review other opioid painkillers and could take further action.

U.S.-traded shares of Endo fell 1.9 percent to $11.17 Thursday, more than twice the rate of decline on a down day for the broader markets. When the FDA urged Endo to pull Opana ER on June 8, company shares plunged 13.4 percent.

Source: Painkiller maker stops sales at FDA request because of abuse | Fox News

Posted in Industry Updates, Opioid Epidemic

Schools, on guard against deadly opioids, stock naloxone

School districts on Long Island and statewide are stocking naloxone on-site in school buildings to have the opioid antidote at the ready because of the growing issue of abuse of the deadly drugs, educators and health officials said.

At least 340 schools across the state, including dozens on Long Island, have provided training for school nurses or other personnel about how to administer naloxone, according to the state Education Department.

The Long Island Council on Alcoholism and Drug Dependence, based in Westbury, also has seen interest grow in instructing school personnel about the antidote, said Reisa Berg, director of education and prevention.

“Initially, I think some people were saying, ‘Why are we talking about this at a middle or high school level when we are not seeing a lot of overdosing?’ ” she said. “But now when I go [to trainings], I say, ‘Raise your hand if you know someone who is struggling with opiates?’ and almost all the hands in the room go up.”

Berg’s assessment is stark: “Unfortunately, this is a Long Island issue.”

Almost 500 people died from opioid overdoses on Long Island in 2016, the most ever, records provided this spring by the medical examiner’s offices in Nassau and Suffolk counties showed. Opioid overdose now is the leading cause of accidental death in New York City, surpassing even motor vehicle accidents, according to New York City’s Health Department.

Nationally, drug overdose is the leading cause of accidental death, with 52,404 lethal drug overdoses in 2015, according to the Maryland-based American Society of Addiction Medicine. Opioid addiction is driving the epidemic, with 20,101 overdose deaths related to prescription pain relievers and 12,990 overdose deaths related to heroin that year, the society said.

Naloxone, commonly known by the brand name Narcan, is the widely available treatment for opioid overdoses, including heroin, the synthetic drug fentanyl and the painkiller oxycodone. Delivered by injection or nasal spray, it blocks access to opioid receptors that may be activated by the drugs. While it can cause withdrawal symptoms in opiate users, there are few reported side effects for those who do not use the drugs.

State Education Department regulations about opioid overdose prevention in schools went into effect in August 2015. The state Health Department works closely with the Education Department, as well as the state Office of Alcoholism and Substance Abuse Services.

The state also asks schools to report if naloxone has had to be administered for an opioid overdose. Jill Montag, a state Health Department spokeswoman, said two administrations of naloxone in a school setting have occurred statewide — including one for a 14-year-old at a school in Suffolk County in November 2015. In both cases, the outcome was successful, said Montag, who declined to name the Suffolk district because of privacy issues.

School systems have more than one way to arrange for training programs that include how to administer naloxone: They register through the state Health Department or work with other agencies, such as the Long Island Council on Alcoholism and Drug Dependence, or LICADD.

The agency, which has been training nonmedical personnel on how to use naloxone for years, has instructed more than 2,000 people, Berg said, including 14 school districts and six local colleges, such as Adelphi University and Suffolk County Community College. Some of the school systems where naloxone training recently was conducted are Connetquot, Garden City, Islip, Syosset and Smithtown, as well as Kellenberg Memorial High School in Uniondale, which has grades six through 12.

Both the kits and the training, which takes about an hour, are provided free to schools. Typically, the council distributes five kits per school building.

Administrators in Levittown schools were among those who recognized the issue early, implementing an opioid overdose prevention program in 2015 that includes training on naloxone administration both for school nurses and social workers. Now, naloxone kits are stocked in every building, including the six elementary schools.

“The district has always taken a preventative approach to alcoholism and substance abuse,” said Donald Sturz, Levittown’s assistant to the superintendent for pupil services, who noted that the district took action after seeing reports of the growing opioid epidemic. “We as a district try to be ahead of the wave, and we jumped right on it and developed a district policy.”

The district has not had to use the kits, Sturz said.

Today, there are more than 400 opioid overdose prevention programs registered with the state Health Department across New York State — including in 73 school districts — in which people without medical backgrounds are trained in opioid overdose recognition and response. Those responses include calling 911 and administering naloxone, which is furnished through the programs.

The state Health Department does not select schools to have opioid overdose programs. Districts make that choice through their superintendents or boards. School systems also have the choice of registering with the Health Department or working with another entity, such as a county health department.

The first program registered with the state Health Department was the Ellicottville Central School District in Cattaraugus County, south of Buffalo, in 2015.

Source: Schools, on guard against deadly opioids, stock naloxone | Newsday

Posted in Industry Updates, Opioid Epidemic

CMS proposes Quality Payment Program rule for 2018 

The Centers for Medicare and Medicaid Services has proposed a new rule for its Quality Payment Program in an effort to simplify reporting requirements with updates for the second and future years of the program.

In October 2016, CMS published a final rule to implement the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA), designed to reward providers for value and improved health outcomes. As part of the program, clinicians have two tracks to choose from—the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternate Payment Models (APMs), based on their practice size, specialty, location or patient population.

The new reimbursement approach in MACRA incorporates payments to reward providers for their use of information technology and data.

“The proposed rule would amend some existing requirements and also contains new policies for doctors and clinicians participating in the Quality Payment Program that would encourage participation in either APMs or the MIPS,” according to the agency’s June 20 announcement.

“Additionally, CMS has used clinician feedback to shape the second year (2018) of the program,” states the announcement. “If finalized, the proposed rule would further advance the agency’s goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery. Moreover, CMS is making it easier for rural and small providers to participate.”

The agency says it is sensitive to stakeholder concerns that small, independent and rural practices in particular are not sufficiently prepared for the Quality Payment Program. By providing additional flexibility in its proposed rule, CMS contends that barriers will be reduced further, enhancing the ability of small practices to participate successfully.

In particular, the rule calls for an increased low-volume threshold that will exempt eligible MIPS clinicians with less than $90,000 in allowed charges or fewer than 200 Medicare Part B beneficiaries from having to participate in the program. The threshold in 2017 was $30,000 in allowed charges or fewer than 100 beneficiaries.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma in a written statement. “That’s why we’re taking a hard look at reducing burdens.” 

When it comes to health IT, CMS proposes reduced burdens and increase flexibility to help clinicians to successfully participate in QPP by continuing to allow the use of 2014 Edition Certified Electronic Health Record Technology, while encouraging the use of 2015 edition CEHRT.

“By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork,” Verma added. “CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”

Industry groups were quick to respond to the proposed rule with praise for the agency’s flexibility, including the American Medical Association.

“CMS is proposing a number of policies to help physicians avoid penalties under the Quality Payment Program. In particular, it is suggesting several actions to assist small practices,” said AMA President David Barbe, MD. “The administration showed it heard the concerns raised by the AMA on behalf of practicing physicians.”

Barbe pointed out that “not all physicians and their practices were ready to make the leap, and many faced daunting challenges.” However, he believes that CMS’s “flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country.”

Likewise, Tom Nickels, executive vice president of the American Hospital Association, said AHA was “encouraged by CMS’s proposal for a facility-based clinician reporting option that may promote better alignment and collaboration on efforts to improve quality among hospitals and clinicians.”

In particular, Nickels applauded CMS’s proposal to “provide much-needed relief from unrealistic, unfunded mandates for EHR capabilities by extending the use of modified Stage 2 Meaningful Use requirements through 2018,” and he encouraged the agency to “provide the same relief to hospitals.”

AHA also encouraged CMS to provide additional opportunities for clinicians to earn incentives for partnering with hospitals to provide better quality, more efficient care through advanced alternative payment models.

“We will review the details of the proposed rule and will provide input to the agency to help ensure CMS’s polices enable patients to benefit from the transformation of care envisioned by MACRA,” Nickels concluded.

CMS will accept comments on the proposed rule until 5 p.m. on August 21. However, not all industry groups responded favorably to the agency’s proposed rule.

While the American Medical Group Association said it recognizes the burden MACRA places on small practices and appreciates the options for them to participate, it said it’s concerned that the proposed rule delays the transition to value and does not recognize the investment that its members have made in preparing for a value-based healthcare system.

“If CMS wants to transition to value-based payment for care, the program needs to be fully implemented,” said Chester Speed, AMGA’s vice president for public policy. “We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program.”

Source: CMS proposes Quality Payment Program rule for 2018 | Health Data Management

Posted in Government Regulations, Industry Updates

Dr. Lawrence Weed, Pioneer in Recording Patient Data, Dies at 93

Dr. Lawrence L. Weed, who created a system for organizing patient information that is used all over the world, at a lecture in 1971. CreditVisualDX

Dr. Lawrence L. Weed, who introduced a system for organizing patient data in the 1950s that is now used in hospitals all over the world, and who led the way in developing a computerized method for aiding in the diagnosis and treatment of diseases, died on June 3 at his home in Underhill, Vt. He was 93.

His son Lincoln confirmed the death.

In the early 1950s, Dr. Weed was a professor of medicine and pharmacology at Yale, where he spent most of his time doing research on microbial genetics. On occasion, though, he would accompany students on their hospital rounds and watch as they struggled to interpret the often chaotic patient notes left by doctors.

It was a sobering experience. “I realized then — and it was very upsetting — that they weren’t getting any of the discipline of scientific training on those wards,” Dr. Weed told The Journal of the American Medical Informatics Association in 2014. “When I pick up a chart that is a bunch of scribbles, I say: ‘That’s not art. It certainly isn’t science. Now, God knows what it is.’”

He responded by creating the problem-oriented medical record, or POMR, a way of recording and monitoring patient information. Two of its features have become nearly universal in health care: the compiling of problem lists and the SOAP system for writing out notes in a patient chart. SOAP stands for subjective, objective, assessment and plan, reflecting the steps that doctors and other health care providers should follow as they move from an initial patient encounter to tests, diagnosis and treatment.

Dr. Weed presented his new method in a two-part article in The New England Journal of Medicine, “Medical Records That Guide and Teach.” Published in 1968, it is one of the most frequently cited articles in the field of medical informatics.

“Saying that POMR was revolutionary almost understates it,” Dr. Charles Safran, the chief of the division of clinical informatics at Beth Israel Deaconess Medical Center and Harvard Medical School, told The Economist in 2005. “There’s probably no one who has more fundamentally affected the way we organize our work than Larry Weed. He fundamentally changed American medicine.”

With a grant from the Department of Health Education and Welfare (now Health and Human Services), Dr. Weed developed a computerized version of POMR that came to be known as Promis — the Problem-Oriented Medical Information System.

This led him, in the 1980s, to another innovation: “knowledge coupling” software linked to a database of medical knowledge derived from thousands of journal articles. Doctors could input the information gathered in the POMR process and then receive a list of possible diagnoses and treatment options, with arguments for and against each option.

Many doctors took a dim view of Dr. Weed’s innovation, regarding it as a challenge to their professional expertise. Dr. Weed saw it as a solution to an intractable problem — the unrealistic expectation that one brain, no matter how well trained, can store and apply the medical knowledge required to make proper decisions.

“For every complaint, for chest pain or abdominal pain, there can be 50 or 60 causes, and the doctor cannot remember all of them,” he told The Boston Globe in 1987. In an interview with The Permanente Journal in 2009, he said, “An epidemic of errors and waste is occurring as we persist in trying to do the impossible.”

Lawrence Leonard Weed was born on Dec. 26, 1923, in Troy, N.Y. His father, Ralph, was a salesman. His mother, the former Bertha Krause, was a homemaker.

Lawrence, known as Larry, was a gifted pianist with a fine baritone voice, but an interest in science led him to earn a chemistry degree from Hamilton College in Clinton, N.Y., in 1945.

After receiving a medical degree from Columbia University in 1947, he took mixed internships in medicine, chest medicine, surgery and clinical pathology at University Hospital in Cleveland and Bellevue Hospital in Manhattan.

Before completing a residency at Johns Hopkins University, he did basic research in biochemistry and microbial genetics at Duke University, the University of Pennsylvania and Walter Reed Army Medical Center (now the Walter Reed National Military Medical Center) in Washington. He then accepted a double appointment at Yale in pharmacology and medicine.

In 1952 he married Laura Brooks, a fellow intern in Cleveland with a medical degree from Yale. She died in 1997. In addition to his son Lincoln, he is survived by two other sons, Christopher and Jonathan; two daughters, Dinny Adamson and Becky Weed; a sister, Nancy Weed; two granddaughters; and two stepgranddaughters.

Dr. Weed’s eagerness to bring scientific rigor to medical record keeping led him in 1956 from Yale to Bangor, Me., where he accepted an offer to direct the new medical internship and residency program at Eastern Maine General Hospital. There he worked out the concepts of POMR.

After four years he became an assistant professor of microbiology at Case Western Reserve University in Cleveland, where, beginning in 1964, he also directed the outpatient clinic of Cleveland Metropolitan General Hospital. In his spare time, he sang with the Cleveland Orchestra Chorus under Robert Shaw.

It was in Cleveland that he began working with computers to develop the Promis system, which he took to the University of Vermont in 1969, where he became professor of community medicine. In the early 1980s he left to start the Problem-Knowledge Coupler Corporation, which developed knowledge-coupling software as well as a PC-based version of the POMR. He left the company in 2006. It was acquired in 2012 by the Atlanta-based company Sharecare, whose AskMD app uses Dr. Weed’s coupling software.

Dr. Weed could be a prickly ambassador for his ideas. He was not shy about criticizing American medical education — he proposed that traditional medical schools be radically restructured — and went a few steps beyond tough love in telling doctors about their limitations.

At one medical conference, as he argued for the superiority of his computer programs over traditional medical expertise, an unhappy surgeon rose to protest. Surely, the surgeon said, experience and intuition counted for something. Dr. Weed met him halfway.

“Well, I’m not saying you don’t have intuitive feelings,” he recalled answering in The Journal of the American Medical Informatics Association. “What I’m suggesting is that they may be worthless.”

Dr. Weed was the author of “Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool” (1969); “Your Health Care and How to Manage It: Your Health, Your Problems, Your Plans, Your Progress” (1975); “Knowledge Coupling: New Premises and New Tools for Medical Care and Education” (1991); and “Managing Medicine” (1993).

His last book, the polemical “Medicine in Denial” (2011), written with his son Lincoln, outlined his plan for an overhaul of medical practice, with education aimed at fostering skills rather than knowledge.

He was impatient to see changes. “People have been saying to me since the 1960s, ‘You’re ahead of your time,’” he told the journal Modern Healthcare in 2012. “I say, ‘My God, you want me to live until 160? How long are you going to take?’”

Source: Dr. Lawrence Weed, Pioneer in Recording Patient Data, Dies at 93 – The New York Times

Posted in Industry Updates, Providers Perspective

Sloppy Citations of 1980 Letter Led To Opioid Epidemic

A one-paragraph letter, barely a hundred words long, unwittingly became a major contributor to today’s opioid crisis, researchers say.

“This has recently been a matter of a lot of angst for me,” Dr. Hershel Jick, co-author of that letter, told Morning Edition host David Greene recently. “We have published nearly 400 papers on drug safety, but never before have we had one that got into such a bizarre and unhealthy situation.”

The letter, published in the New England Journal of Medicine in 1980, was headlined “Addiction Rare in Patients Treated With Narcotics.” Written by Jick and his assistant Jane Porter of the Boston Collaborative Drug Surveillance Program at Boston University Medical Center, it described their analysis of hospitalized patients who had received at least one dose of a narcotic painkiller. Among the nearly 12,000 patients they looked at, they found “only four cases of reasonably well documented addiction in patients who had no history of addiction.” Their conclusion was that despite widespread use of narcotics in hospitals, addiction was rare in patients who had no history of addiction.

“We believe that this citation pattern contributed to the North American opioid crisis by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy,” they write, pointing out that citations soared after the introduction of OxyContin in the mid-1990s.

Jick says that when the letter was published in 1980, it was almost inconsequential. “Only years and years later, that letter was used to advertise by new companies that were pushing out new pain drugs,” he says. “I was sort of amazed. None of the companies came to me to talk to me about the letter, or the use as an ad.”

He says the drug companies used his letter to conclude that their new opioids were not addictive. “But that’s not in any shape or form what we suggested in our letter.”

Asked whether he regrets having written the letter, Jick says, “The answer is, fundamentally, sure. The letter wasn’t of value to health and medicine in and of itself. So if I could take it back — if I knew then what I know now, I would never have published it. It wasn’t worth it.”

Source: Sloppy Citations of 1980 Letter Led To Opioid Epidemic, Researchers Say : Shots – Health News : NPR

Posted in Industry Updates, Opioid Epidemic, Providers Perspective

A new doctor discovers the ‘gritty’ downside of modern medicine

I arrived at the hospital, white coat and stethoscope in hand. It was my first day as a doctor, and I was filled with a nervous mix of optimism and excitement.

I walked up to the medicine team room, entered the code on the door and introduced myself to the other residents — some of them newly minted doctors like me. I was about to receive handoff from the night team for the patients assigned to me. Years of school had led up to this point. I had dreamed about this moment. I was about to care for patients as a doctor for the first time.

That’s when the realities of practicing medicine hit me like a freight train.

My computer credentials didn’t work, so I couldn’t log on to the hospital’s system. As I waited on hold with the IT department, I tried to keep up with the handoff. I needed to learn about their conditions, medications and treatment plans. Labs were waiting to be followed up. Consults had to be placed.

My pager started going off. Questions piled in from nurses, case managers, social workers and other co-workers: Is this patient being discharged today? Can you sign this disability form? Have you placed that clinic referral yet?

 I paused to collect myself and performed a ritual well known to physicians and other health-care providers. I grabbed a blank piece of paper, folded it in half and wrote down my patients’ names. Underneath each name, I began listing my checkboxes, or tasks for the day.

Before I knew it, we residents and the supervising physician were off to see patients. I had only just met some of the people whom we were going to be sending home. We wheeled computers with us, placing orders as we went from room to room. Still grappling with the unfamiliar electronic medical record used by the hospital, I could barely find the right buttons to click. The list of checkboxes on my folded paper grew and grew.

Later in the day, we all slumped back to the team room. Discharge summaries needed to be signed. Progress notes had to be written. Families wanted updates. My fellow residents and I typed away at our computers, phones to our ears, pagers ringing out.

My first day as a doctor was overwhelming, to say the least.

While medical school introduces budding physicians to the science of disease and treatment, residency trains us how to care for patients within the labyrinth of the U.S. health-care system. We have to learn how to work within hospitals and clinics with the goal of becoming independent practitioners. We come face to face with the gritty realities of insurance coverage and electronic medical records. The bureaucracy of providing patient care in many ways defines how we learn to practice.

In medical school, clinical medicine often comes down to “Drug A treats Condition Z.” During residency, we learn that A treats Z if you can figure out how to order A in the computer, you document why you chose A in your note, the hospital approves the choice of A, insurance covers A, the patient can afford A’s co-pay, you sent the prescription for A to the right pharmacy, the patient actually picks up A from the pharmacy, and you coordinate follow-up appointments to see if A is helping the patient.

As my first year of residency has gone by, I’ve become increasingly aware of how much time we dedicate to the administrative side of medicine — and the very real costs for up-and-coming physicians. I can write a comprehensive hospital discharge summary, but I can hardly place an IV in a patient. I know what a prior authorization form looks like, but I don’t know what my patients’ pills look like. I often spend 12 busy hours in the hospital but less than a few hours with my patients.

Often, it seems that administrative skills have begun to outweigh the human connection necessary between caregivers and patients.

Of course, some of these concerns are magnified during residency training. In academic medical centers, much of the grunt work of patient care, from placing orders to writing notes, falls upon residents.

But in other ways, young doctors are just scratching the surface of the health-care bureaucracy. As residents, we’re often shielded from the complexity of medical billing. We don’t yet have to grapple with establishing our own practices, maintaining staff, hospital contracts or malpractice insurance.

This is a broader problem in American medicine. A study published in 2013 found that internal medical interns spent 40 percent of their time on computers. Residents often spend more than four hours per day on documentation and electronic charting, according to several studies. A 2010 review of studies suggests hospital physicians on average spend less than one-fourth of their time directly caring for patients. In a study released last year, researchers found that doctors in clinics spent nearly two hours on desk work for every one hour with patients.

All this paperwork is straining physicians. A nationwide study found that more than 90 percent of medical residents felt the amount of required documentation in patient care was too much. In a 2016 survey of more than 6,000 doctors, half did not feel the level of clerical work in medicine was reasonable. Editorials in top journals across medicine have cited administrative workloads as part of the reason for the alarming rates of burnout in the profession.

When I look back on medical school, I remember sitting with patients for hours, chatting with them, learning about their lives. As medical students, we’re often given the time to do so, protected from the bureaucracies of medicine so we can spend time learning how to care for people. By comparison, as I reflect on my first year as a doctor, I cringe at how many days I spend sitting at computers, clicking away in windowless rooms, staring into screens, separated from patients.

I find hope in those words. My days are measured by countless checkboxes, but whenever possible I try to add just a few more — I tell myself they’ll be worth it. Go to the bedside during free moments. Check in with my patients before going home. Stop by for those chats again, even if I’m tired and it’s late.

It’s been nearly a year since that first day in the hospital. Today, I’m far more efficient as a physician. My typing has sped up, and I have templates for virtually every kind of note. I can now find orders in the computer by muscle memory. I’ve learned how to admit patients into the hospital, transfer them between units, discharge them, refer them to specialists and follow up with them in clinic.

I’m becoming better at providing health care, but does that mean I’m better at taking care of patients?

Source: A new doctor discovers the ‘gritty’ downside of modern medicine – The Washington Post

Posted in Industry Updates, Providers Perspective

Colorado Hospitals Unite to Combat Prescription Opioid Abuse

A group of doctors and administrators has come up with an ambitious plan for Colorado hospitals to reduce the amount of opioids they prescribe while still treating pain effectively, according to an article in the Denver Post. The plan will roll out this year as a six-month pilot program at eight hospitals and three freestanding emergency rooms.

Health officials hope to analyze data from the program at the three-month mark to determine what’s working best and what’s not, said Diane Rossi MacKay of the Colorado Hospital Association (CHA).

The effort is part of a broad rethinking in the medical world about the place opioids, blamed for an epidemic of addiction and overdoses, should hold in medicine, according to the Post article.

“For far too long, pain has equaled an opioid,” said Dr. Don Stader, an emergency room physician at Swedish Medical Center in Denver. “And that’s what got us into this problem.”

The Centers for Disease Control and Prevention (CDC) and state regulators across the country have issued guidelines calling on doctors to reduce their opioid prescribing. In addition, the FDA recently announced that it is seeking to remove one opioid, Opana ER (extended-release oxymorphone, Endo Pharmaceuticals), from the market because its addictive potential outweighs its medical benefit.

The new program that Stader helped put together—along with the CHA and members of the Colorado chapter of the American College of Emergency Physicians—aims to go even further by combining a number of ideas. Not only does the program encourage doctors to prescribe fewer opioids, it also provides them with condition-specific guidelines for treatments that can be used to control pain effectively without narcotics. In some cases, the guidelines might call for substituting doses of Tylenol and other medications for opioids, Stader said. In others, there are “trigger point” procedures that could work.

The plan won’t eliminate opioids in the hospital altogether, Stader said, but they aren’t the first resort in most instances.

In addition, the program calls for hospitals and emergency rooms to become front-line players in providing treatment to people with opioid addiction. Instead of telling patients to find a rehabilitation clinic first, doctors potentially could start patients on medication-assisted therapy with a drug such as buprenorphine or methadone right away. In a state survey conducted this year, people who successfully quit heroin identified such treatment as the most effective way to do so.

At the Swedish Medical Center, Stader said the hospital began implementing some elements of the program a year ago. In that time, the hospital has cut its opioid use by 30%, he said.

“Opioids now aren’t just the only drugs we use,” he said. “They’re part of a large collection of drugs that we use to control pain better.”

Source: Colorado Hospitals Unite to Combat Prescription Opioid Abuse | Managed Care Magazine Online

Posted in Industry Updates, Opioid Epidemic

New tool for overdoses: Emergency box with antidote | Lexington Herald Leader

Defibrillator boxes have become commonplace in public places as a way to help people having a heart attack. Now, a group in Rhode Island has come up with a similar idea for a different medical crisis: drug overdoses.

The NaloxBox is meant to give bystanders in public areas easy and quick access to the opioid overdose antidote naloxone. Just as with a defibrillator box, the NaloxBox puts a lifesaving intervention in the hands of a layperson.

“That person could have no training at all,” said Geoff Capraro, an emergency room doctor and faculty member at Brown University’s medical school. “I wanted to give people the ability to help their neighbor.”

Capraro worked with a group of professors and students at Rhode Island School of Design to design and build the box, and the first were installed Friday in Amos House, which provides recovery services, shelter and other programs to help people struggling with addictions.

More than 30 are set to be installed in the coming weeks at around a dozen social services organizations around Providence, said Claudia Rebola, an industrial design professor at RISD who worked on the project.

Amos House CEO Eileen Hayes said her staff has seen many overdoses, which are part of the process of recovery. The benefits of the NaloxBox are twofold, she said. It will provide quick access to naloxone, and it also sends a clear message to people being treated for addictions that they have to think about keeping themselves safe.

“We’re talking about life and death here, and we have had multiple situations and been affected by just too many deaths. We have to do whatever we can to keep people safe,” she said.

While naloxone — which can be administered via nasal spray under the brand name Narcan — is available without a doctor’s prescription in Rhode Island and other states, that requires a person to go into a pharmacy to get a dose, then carry it around with them.

If they overdose, they can’t help themselves.

That model is “insufficient,” Capraro said. The boxes provide what he calls a “public capacity.”

“We’re giving capacity that doesn’t exist,” he said.

The box holds two naloxone kits with two doses each and directions on how to use them, as well as a breathing mask to help a rescuer administer CPR. Also inside is information on how people can get their own naloxone or get treatment. The box can hold either the shot or spray form of naloxone, and opens easily with a Velcro-type strap.

When fully installed and connected to power, it will alert the owner via text message whenever it has been opened. That way, they can check it and refill it when needed. The boxes can be made for around $100 each, Capraro said.

Rebola expects the first iteration of the box will need some design changes, but they are interested for now to see how it’s used. Their hope is to eventually spread them further: to clubs, universities and other public areas.

Capraro has suggested facilities installing the box put it next to their defibrillator. He envisions some version of NaloxBox someday being one of three life-saving interventions people will see on a wall for good Samaritans to use: the defibrillator, the fire extinguisher and naloxone.

Source: New tool for overdoses: Emergency box with antidote | Lexington Herald Leader

Posted in Industry Updates, Opioid Epidemic