MedEd in an AI Era

BY KIM BELLARD

I’ve been thinking a lot about medical education lately, for two unrelated reasons.  The first is the kerfuffle between US News and World Report and some of the nation’s top – or, at least, best known – medical schools over the USN&WR medical school rankings.  The second is an announcement by the University of Texas at Austin that it is planning to offer an online Masters program in Artificial Intelligence.

As the old mathematician joke goes, the connection is obvious, right?  OK, it may need a little explaining.

USN&WR has made an industry out of its rankings, including for colleges, hospitals, business schools, and, of course, medical schools. The rankings have never been without controversy, as the organizations being ranked don’t always agree with the methodology, and some worry that their competitors may fudge the data.   Last year it was law schools protesting; this year it is medical schools.

Harvard Medical School started the most recent push against the medical school rankings, based on:

…the principled belief that rankings cannot meaningfully reflect the high aspirations for educational excellence, graduate preparedness, and compassionate and equitable patient care that we strive to foster in our medical education programs…Ultimately, the suitability of any particular medical school for any given student is too complex, nuanced, and individualized to be served by a rigid ranked list, no matter the methodology.

Several other leading medical schools have now also announced their withdrawals, including Columbia, Mt. Sinai, Stanford, and the University of Pennsylvania.  

Now, I am no expert on the methodology and don’t have any particular love towards USN&WR, but I do find rankings to be informative.  As the USN&WR CEO said in response to the HMS withdrawal: “Our mission is to help prospective students make the best decisions for their educational future…we believe students deserve access to all the data and information necessary to make the right decision.”  I mean, who could argue that?

Evidently the medical schools.  I’ve seen lots of reasons cited for their withdrawals, but what I have not seen are suggestions for alternatives – how to make the rankings better, how to more accurately gauge “quality” of medical schools, how to fairly compare different medical schools.  I guess if you are Harvard or Stanford you believe your superiority is obvious.

I’ve brought this up on Twitter and gotten some interesting responses, especially from physicians – e.g., that medical school attended isn’t an indication of how good or bad a doctor will be, and that medical school actually doesn’t matter as much as where doctors do their residency. Those may be very valid arguments, but they leave me to conclude that we not only don’t know which medical schools are the “best,” we don’t even know if medical school has any real bearing on the quality/competence of the physicians it produces (not that we can measure that either).  

As with most things in healthcare, quality is too complex for the professionals to figure out, so they’ll punt to the patients to figure it out for themselves.

I’ve written before about how, in 2023, it makes no sense that we have parallel educational tracks for M.D.s and D.O.s, or, indeed, that our medical education system takes such a narrow and outdated view towards “health.”  Medical schools and graduate medical education programs have become an end unto themselves, and it’s no surprise that training physicians in the U.S. is a longer and more expensive process than anywhere in the world – not that we can show we have better physicians or those physicians achieve better outcomes as a result, of course.

We should be fundamentally rethinking how we train physicians, which brings me to the UT AI program.  

Online graduate school programs are no longer new.  There are a number of them now, for a number of degrees (and, in fact, USN&WR has rankings for them).  It’s not new for UT either; UT started offering an online masters program in computer science in 2019, and in data science in 2021.  But with the explosion of interest in AI, and taking advantage of $20 million in funding from the National Science Funding, UT is now adding this program.

The UT announcement brags that its Master of Science in Artificial Intelligence (MSAI) “will be the first large-scale degree program of its kind and the only master’s degree program in AI from a top-ranked institution to be priced close to $10,000.”  That is considerably cheaper than an in-person program. 

The program will not require an undergraduate degree in computer science but candidates will need some technical expertise.  Professor Adam Klivans, director of the new program, told The New York Times the degree was “something working professionals can participate in to learn the expertise their companies need without leaving their jobs.”

He further says:

The fields of artificial intelligence and machine learning have seen unprecedented growth over the last 10 years.  Our goal is to ensure that every qualified student can access a premier education in AI, one that is keeping pace with this rapidly evolving field. With the MSAI program, we have removed geographic barriers entirely and significantly lowered the cost barrier of graduate study. For our students, this a game changer.

Eric Busch, director of the Computer and Data Science Online program, added: “It’s not just an ‘online degree.’ It’s an immersive and connected community of learners and a credential from UT Austin that opens doors.”

Healthcare does have many online programs, but not, as far as I can tell, for medical school.  Medical schools are starting to use virtual reality, but only as a training tool, not as a replacement for in-person classes.  They’re tip-toeing when they should be taking great leaps.

Where are the medical schools that are seeking, to paraphrase Professor Klivans, to ensure that every qualified student can access a premier medical education, one that is keeping pace with that rapidly evolving field, to remove geographic barriers and to significantly reduce the cost barrier of medical education?

So to all the medical schools upset about the USN&WR rankings: yeah, keep worrying about that.  Keep raising your prices, while raising alarm bells about looming physician shortages (and the associated need for funding increase).  Meanwhile, someone, somewhere, is going to take UT’s AI example and develop an online medical school program that is more geographically available, more open to a wider range of students, more immersive and interactive, and much cheaper.  

Welcome to MedEd in an AI Era.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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Matthew’s health care tidbits: How do you tell the price of a drug?

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

As the average THCB reader is probably all too well aware I live in Marin County, California and therefore my kids are on amphetamine-based medication for ADHD. This is annoying as all get out because, as a controlled substance, this medication needs to be re-prescribed every month (no automatic refills allowed). In addition no 90 day supplies are allowed, and the kids must have checkups with their prescribing physician every 3 months (which are not cheap).

It’s not just prescribing which is complicated. Supply is an issue too and frequently pharmacies run out. This is furtherly frustrating because if one pharmacy is out it can’t move the Rx to another, even in the same chain like Walgreens or CVS. The new pharmacy requires a whole new prescription. I discovered last year that Alto Pharmacy, a VC backed home delivery pharmacy, will deliver controlled medications. This has saved me 12-24 visits to CVS in the past year.

But with a new year there are new problems. The “allowed” price, i.e. the price my insurer Blue Cross of Massachusetts had agreed with Alto Pharmacy (and other pharmacies) for the specific generic for one of my kids somehow went from $29 a month to $107. That’s the amount I actually pay until we hit our $4,500 family deductible. Incidentally because it’s a medication we still pay $10 a month after we hit the deductible.

Alto kept telling me that the cash price was around $50. But of course if we pay the lower cash price (either there or elsewhere using GoodRx) that doesn’t count against the deductible. So if we hit the deductible we are out the $50 (which works out to roughly $1200 per year for 2 kids). I kept asking Alto what had changed that made the cost go up? They kept not telling me an answer, other than it cost $107. I asked the good people at Health Tech Nerds slack group if they could guess what was going on. Their consensus was that the formulary tier had been changed. “But it’s a generic”, (I foolishly thought).

Finally I called the pharmacy number on BCBS Massachusetts website, and ended up talking to someone at CVS Caremark– their PBM. In the course of the 30 minute call they ran a dummy claim with several other pharmacies. All came back at the $107 number. They then looked up the formulary to see if it had changed. Meanwhile I looked at the formulary on the BCBS Mass website while this was going on. The medication was still tier 1. So why has the cost to me and perhaps to the Blues plan gone up from $29 a month to $107? (Yes that’s more than a factor of 3!)

While she was talking to me the Caremark rep was also able to Slack with several other colleagues–relatively advanced for an old world PBM I thought. Eventually the answer came back. The med was indeed tier one. But until we spent our deductible the med was tier 2. In other words if we were paying for the drug the price is $107. As soon as BCBS Massachusetts starts paying for it the price goes back to $29 (of which they only pay $19) as we have a $10 copay.

Why this has happened is beyond me? Is Caremark or BCBS Massachusetts suggesting another cheaper drug? I haven’t heard from them. Are they trying to discourage patients from getting to their deductibles? My cynical conclusion is that Caremark is trying to increase the revenue for CVS– its corporate pharmacy–which that accounts for 1/3 of all outpatient Rx.

Otherwise this pricing strategy makes no sense to me. Of course this is just another example of a completely opaque process. And that appears typical for American health care.

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The “Antebellum Paradox”: What is it and why it matters.

BY MIKE MAGEE

I recently made the case that “Health is foundational to a functioning democracy. But health must be shared and be broadly accessible to be an effective enabler of good government.” I also suggested that the pursuit of good health is implied and imbedded in the aspirational and idealistic wording of our U.S. Constitution, and that the active pursuit of health as a nation is essential if we wish to rise to Hamilton’s challenge in Federalist #1 and prove that we are “capable of establishing good government from reflection and choice.” So why are native white males lagging behind in health?

Our progress as a nation toward health was severely hampered from the start. The reality of self-government “of the people, by the people, and for the people” applied only to 6% of inhabitants, all white male land owners at the time. Health was never voiced as a priority, though modern day critics insist it is clearly implied in the promise of “life, liberty, and the pursuit of happiness.” But what was that promise worth in the late 18th century, in a nation that allowed slavery, disenfranchised women, and slaughtered and dislocated its indigenous brothers and sisters?

In those earliest years of the birth of this nation, in the first half of the 19th century, what was the state of health for enfranchised native born white citizens of this nation? Most may presume (as I did) that the general health and standard of living over the next two hundred years, as reflected in lifespan, was a straight (if gradual) upward slope. But what I learned from a bit of digging is that uncovering the facts on mortality, fertility, migration, and population growth during those early years of our nation is a complex venture at best.

Our federal government did conduct a census every ten years, but one hundred years passed before we reliably collected vital statistics including comprehensive birth and death registration. Beginning in 1850, age, sex, race, marital status, occupation and cause of death were supposed to be collected. But an audit in those years disclosed that mortality (for example) was 40% underreported.

This was not too surprising when one considers what can go wrong with a census even on a blunt entry like death. Solitary household death left no one to report. Loss of a household lead in a large family often meant dissolution of family members. Deaths of infants or elders within 6 months tended to be reported, but after 12 months they were often forgotten. And all of this was made worse by westward migration.

The earliest life tables date back to 1790 in Massachusetts. These can not be extrapolated as representative of the colonies, or growing nation as a whole, because this small northeastern state was largely urbanized, industrialized, filled with immigrants and had lower levels of nuptiality and fertility (1/3 lower than the nation) compared to their neighbors.

To fill in the gaps over the years, academic experts have turned to alternate data sources including family genealogies, biographical data from schools and local legislators, and height as a reflection of nutritional status and general health. By using these sources, and integrating different databases, modern day historians and economists now agree that there was “a significant increase in (native white male) mortality in the antebellum era, especially in the three decades between 1830 and 1860.” 

Termed the “antebellum paradox”, life expectancy at age 20 was six years lower in 1850 than in 1800. In fact, the nation didn’t catch up with 1800 survival rates until 1880. And the question is “why?” What happened to early American health? On average white males between 1830 and 1890 lost 1 1/2 inches in height which experts suggest may have been from a combination of deteriorating diets, early industrialization and urbanization resulting in spread of infectious diseases and traumatic injuries, rising inequality and mass populations on the move westward with the “transportation revolution” utilizing canals, steamboats, and railways.

Other factors that experts have pointed to include the congregation of young children in new public schools aiding the spread of whooping cough, diphtheria, and scarlet fever, and food shortages and elevated food prices in the 1830’s.

The United States of 1860 bore little resemblance geographically to the 1790 version of our nation. Its size had increased from 891,364 square miles to 3,021,295 square miles. Our 16 states had grown to 33 states. And the average center location of our population had now shifted 135 miles west of where it had been.

If it is difficult to quantify life expectancy for white males in the 19th century in America, it is even harder to gauge white female survival. In general, women were often ignored in public records. Their names changed with marriage, and they routinely disappear from observation during these years. What has been pieced together is that white women’s life expectancy in the mid 1880’s at age 20 trailed white males of the same age by about 2 years. This male advantage disappeared by age 35 if a woman survived to that point. 

With up to 10 material deaths per 1000 live births at the time, marital fertility tracked with maternal mortality. But experts believe that tuberculosis was an equal or greater contributor to death in child-bearing women, especially in rural settings. Where food was limited, men and boys were favored with meat and calories. Pregnancy and lactation were nutritional drains, weakening women’s health status and ability to withstand infectious diseases, especially tuberculosis. As for the children, 1 in 5 born alive in 1850 didn’t survive to age 1.

By 1880, the gender gap began to disappear with increased industrialization, urbanization, imposition of public health measures to create clean water and pasteurized milk as the germ theory and sanitation took hold. Women now entered the work force. In addition, fertility in 1900 was about half that in 1840.

The “antebellum paradox” suggests that the health of a nation, as reflected in life expectancy, is fungible. It also can be argued that health status is a reasonable measure of whether a society of humans is “capable of establishing good government from reflection and choice.”

Ohio State University’s Emeritus economic historian, Richard Steckel,  used to ask his students to imagine they were reborn and had to chose their place of birth based on only three of following characteristics: “access to material goods and services; health; socio-economic fluidity; education; inequality; the extent of political and religious freedom; and climate.” It is notable that health and income always scored at the top.

As for human stature in modern times, America’s native white men have stagnated, with average height essentially flat over the past 50 years. This is in contrast to European nations like Norway, Sweden and Denmark with similar genetic stock.  They are two inches taller. All of these nations have national health care systems. Specifically, all are “known for regular pre-and post-natal checkups, which are important for early childhood health.” 

As Steckel reminds us, “We know that on average, stunted growth has functional implications for longevity, cognitive development, and work capacity….it is important to know why Americans are falling behind.”

Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical-Industrial Complex.”

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Return to McAllen: A Father-Son Interview

By IAN ROBERTSON KIBBE

You are going to hear a little more about McAllen, TX on THCB Shortly. And before we dive into what’s happened there lately, I thought those of you who weren’t here back in the day might want to read an article on THCB from July 2009. Where then THCB editor Ian Kibbe interviewed his dad David Kibbe about what he was doing as a primary care doc in McAllen–Matthew Holt

By now, Dr. Atul Gawande’s article on McAllen’s high cost of health care has been widely read.  The article spawned a number of responses and catalyzed a national discussion on cost controls and the business of medicine.  It even made it’s way into the President’s address to the AMA.

Almost overnight, McAllen and the Rio Grande Valley were thrust into the national health care spotlight – the once sleepy border town became, not a beacon on a hill, but a balefire in the valley, representing much of what is wrong with the current medical culture.

But, McAllen wasn’t always like something from an old Western, where doctors run wild and hospital CEO’s compete like town bosses.  I remember McAllen quite differently.  I remember it, because as it turns out, it was where I was born.

It’s also where my father, Dr. David Kibbe, practiced medicine from 1980 to 1990. In order to find out how McAllen earned the dubious reputation it now has, I sat down with my Dad, and asked him what he remembers about that little border town on the Rio Grande.

Ian Kibbe: So Dad, what was your first reaction to reading Atul Gawande’s article?

David Kibbe: Well, Ian, it was sort of “oh-my-gosh, he nailed it.”   And, of course, a flood of memories, good and bad, came back to me about our time there.  My medical career began there, you and your sisters were born there, small town 4th of July parades, etc.  But I left after great disappointment and frustration.

IK: What were you doing in McAllen practicing medicine anyway?

DK: The National Health Service Corps sent me there to work in a clinic for migrant farm workers.  The NHSC had provided me three years of medical school scholarship, and so I owed three years of service in an under-doctored area of the country.  I speak Spanish, and so working as a family doctor in the Rio Grande Valley of Texas, which is the home of many of the country’s Hispanic migrant farm workers, was a good fit.  Hidalgo County, where McAllen is located, was the poorest county in the country, and there was a real physician shortage there in 1980.

I worked in a migrant farmworker clinic with ties to the United Farmworkers, Cesar Chavez’ group, in McAllen. As a young physician from outside the Valley, and working in the one clinic in the county where the poor could receive medical care for free or almost free, I got to see an amazing diversity of medical problems that many physicians in this country never see, such as Dengue fever and leprosy.  It was a great opportunity to be of service, in my opinion.

And then in 1982 we started a family practice in Mission, Texas, about 4 miles west of McAllen, where the physician shortage was even more critical.  You were born in the little 67-bed hospital in Mission the next year.

IK: So, what did McAllen’s health care system look like when you first got there?

DK:  Well, it wasn’t really a system, it was a community.  And I would characterize the medical culture as primary care-oriented for at least the first half of the decade.  Family physicians, internists, and pediatricians were in charge of things, ran the county medical societies, provided most of the medical care including hospitalizing sick patients and delivering babies.  We had a couple of surgeons, and one cardiologist who was board certified.

But starting in the early 80’s things began to change.  In 1982 HCA opened Rio Grande Regional Hospital. Then in 85′ Universal Health opened McAllen Medical Center.  Both were large for-profit hospital chains, with new facilities, and both recruited literally dozens of sub-specialists where there had previously been only a handful.  So within three years, there was a significant change towards subspecialty care, and that trend intensified over the next few years.

At first, the influx of technology and subspecialty care was welcome.  We, the primary care docs, had more help locally, and didn’t need to transfer patients to other parts of the state for subspecialty care or specialized surgery.

IK: Why the sudden interest in McAllen?

DK: Money, plain and simple.  Most of the new subspecialists were guaranteed enormous incomes, by the hospitals. Since I was one of the first American-trained primary care physicians in the McAllen area, and I made an effort to reach out to retirees from the North, or “Snowbirds” as they were called, I guess I created sort of a beachhead as my practice grew. As a result, I was courted very heavily by the subspecialists for access to those retirees and the subspecialty care they could generate.

IK: So, in some ways it was like a medical “gold rush?”

DK: Exactly. What was initially exhilarating change and modernization turned into a “gold rush” atmosphere, as more and more subspecialty doctors came to town and competed to see who could make the most money, admit the most patients, or build the largest homes.  McAllen went from having one cardiologist to having two competing cardiac surgery teams. They created a cascade of demand.  The primary care docs slid to the bottom of the totem pole economically and socially.  I now understand this as the disintermediation of primary care.

IK: Can you give me an example of what you’re talking about?

DK: Sure. So, in 1983 I’d see a patient with intermittent chest pain, and that day refer him to the cardiologist for evaluation.  He’d call me on the phone and say, “David, I’ve seen your patient Mr. So-and-so, examined him, listened to his heart, and have done a tread mill stress test.  Everything seems ok, so I’m sending him back to you for further evaluation for his problems.”   Fine.

But by 1987, I’d make the referral and never hear another word.  Running into the cardiologist in the hospital hallway or locker room, and asking what happened to my patient, I’d get this response:  “Oh, well if I remember correctly I admitted him to the hospital and we did angiography, which was normal.  But he was having a headache, so the neurologist ran some CT scans, and I asked the gastroenterologist to do endoscopy because there was a question of some GI problems.   As I recall, everything was normal, but I still see him every month for his blood pressure.”

So, an evaluation that used to cost a couple hundred dollars turned into many thousands of dollars worth of testing and procedures; and this happened day in day out, week after week, year after year.

Another issue was quality assurance.  I was the hospital staff physician in charge of the quality assurance program at Rio Grande Regional Hospital.  But we could never make any improvements.  There was one cardiac surgeon who kept leaving several tiny needles inside his patients’ chest cavity after heart surgery, and we couldn’t figure out a way to cut that out.  He was too important to the hospital, I guess, to offend.  And he knew he could just blow us off.  It was all about the money.

IK:  What role did you see the large for-profit hospitals playing in this change?

DK:  It seemed to me that the hospitals encouraged the newly arriving doctors’ attitudes about making money.  These were young doctors, for the most part, right out of training. The hospital would pay them large guaranteed incomes to get them to locate in McAllen, and pay the rents on their offices for a number of years, too.  The hospitals were competing openly for procedures and tests, unlike in some towns where there are agreements to share high cost facilities, like heart surgery or cancer treatment centers.  But in McAllen there was out-and-out financial war between the doctors on each of the hospital staffs.

IK: And you were right in the middle of this war?

A: Well, yeah!  As I said, I was courted very heavily by the subspecialists for access to my patients, but at some point that dynamic changed from seeking my referrals to taking my patients.

IK: So why did you hang around for so long?

Well these changes didn’t happen overnight.  I was practicing medicine and taking care of patients.  Also, think I didn’t know any better.  Eventually I got my business degree because I wanted to figure out what the hell was going on!  So, I went to the University of Texas business school part-time during those last two years we were in McAllen, primarily to try to understand what was happening to health care.   It was clear that one needed a business degree to understand medicine in McAllen, Texas.  Also, at the time, getting an MBA seemed like a good idea because everyone was saying medicine was a business now.

IK: Who was saying that?

Many of the doctors and the hospitals, the journals and the literature.

IK:  So when did you say “enough is enough?”  What finally made you decide to leave McAllen?

DK:  We left in 1990 to come to Chapel Hill, North Carolina.  There were a number of reasons I wanted to leave the McAllen area, but the main reason professionally was that the medical culture had become so subspeciality dominated and oriented towards profiteering, that it simply was no longer rewarding to be in family practice there.  I mean, in 1987 there were more MRIs in McAllen than there were in all of Canada!  And most were owned by doctors or groups of physicians.

May I ask you a question?

IK:  Sure.

DK:  What was your best memory of living in the Rio Grande Valley during the first eight years of your life?

IK: Wow, that’s tough.  But I’d have to say I had the best times at those big cookout’s out in the country.  There was something really magical about running through the orange groves with my friends and the smell of ripening oranges mixed with the smell of charcoal, and Texas barbecue.  It was a pretty care-free time for me.  Oh yeah, and the fireworks.  Eight year olds love fireworks.

Well, thanks Dad.  This was fun.

DK:  Love you, son.

Ian Kibbe was in 2009 Associate Editor for The Health Care Blog.  He is also a writer, actor, video producer and editor.

David C. Kibbe MD MBA was in 2009 a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

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THCB Gang Episode 113, Thursday January 26 1pm PT 4pm ET

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday January 19 at 1PM PT 4PM ET are futurist Jeff Goldsmith; THCB regular writer and ponderer of odd juxtapositions Kim Bellard (@kimbbellard); policy expert consultant/author Rosemarie Day (@Rosemarie_Day1);

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

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Cardiology update: Should mRNA vaccine myocarditis be a contraindication to future COVID-19 vaccinations ?

BY ANISH KOKA

Myopericarditis is a now a well reported complication associated with Sars-Cov-2 (COVID-19) vaccinations. This has been particularly common with the messenger RNA (mRNA) vaccines (BNT162b2 and mrna-1273), with a particular predilection for young males.

Current guidance by the Australian government “technical advisory groups” as well as the Australian Cardiology Society suggest patients who have experienced myocarditis after an mRNA vaccine may consider a non-mRNA vaccine once “symptom free for at least 6 weeks”.

A just published report of 2 cases from Australia that document myopericarditis after use of the non-mRNA Novavax vaccine in patients that had recovered from mRNA vaccine myocarditis suggests this is a very bad idea.

The case reports

Case 1 involves a 26 year old man who developed pericarditis after the Pfizer vaccine. Pericarditis, an inflammation of the sac the heart lives in, developed about 7 days after the Pfizer vaccine. The diagnosis was made based on classic findings of inflammation on an electrocardiogram associated with acute chest pain. The symptoms lasted 3 months, and a total of 6 months after the first episode of pericarditis, he received a booster vaccination with the Novovax (NVX-CoV2373) vaccine. 2-3 days after this he developed the same sharp chest pain and shortness of breath with elevated inflammatory markers (CRP) as well as typical findings of pericarditis seen on ECG. To add insult to injury, he contracted COVID 2 months after the second episode of pericarditis, but had no recurrence of the symptoms of pericarditis.

Case 2 involves a 25 year old Australian female who presented with chest pain, shortness of breath and palpitations 2 days after her 2nd dose of Pfizer vaccination. Abnormal cardiac biomarkers suggested damage to the heart muscle confirming myocarditis. The distinction between pericarditis and myocarditis generally hinges on the presence of damage to the cardiac muscle that’s discovered based on blood tests for cardiac biomarkers that suggest ongoing damage/necrosis of heart cells. Case 1 was a case of pericarditis, not myocarditis, because there was no evidence of damage to cardiac cells (cardiac blood test Troponin biomarkers were not elevated).

Myocarditis is generally considered a more serious clinical condition because of the association of damage to the cardiac muscle that is, unfortunately, irreversible. Her course was, as a result, more complicated with persistent symptoms that required recurrent hospital presentations for 5 months. While two-thirds of patients in the pediatric US experience demonstrate a persistent scar on cardiac MRI at 6 month follow-up, a repeat MRI in this case was normal with complete resolution of previously seen abnormalities.

Remarkably, and I suspect in no small part due to the guidance of the Australian technical advisory committee, and the defacto blessing of the Australian cardiac society, she went on to be vaccinated with the Novovax vaccine. 5 days later she once again complained of chest pain, shortness of breath and palpitations. An evaluation revealed another episode of myocarditis. She has had multiple repeat hospital presentations and 2 months later continues to be symptomatic.

There is no clinical history or context provided to help us understand why these two young people needed another COVID19 vaccine booster. It is certainly possible both were considered very high risk for developing a serious COVID infection, but that information is not provided in the published case report. Recall, that the young man in case 1 still went on to contract COVID-19 even after his Novovax booster.

These cases, while unfortunate, do provide some very important insights about the potential mechanism of vaccine associated myocarditis.

Vaccine myocarditis : mechanistic insights

The molecular mimicry theory posits that antibodies the body is induced to produce to the viral S-protein also may recognize parts of the body as foreign and attack itself. But the molecular mimicry hypothesis should result in similar rates of vaccine myocarditis with mrna and non-mRNA vaccines, and this is clearly not the case. Rates of vaccine myocarditis are clearly lower with the more traditional AstraZeneca protein based vaccine.

Hypotheses to try to explain why the mRNA vaccines specifically seem to have more myocarditis focus on the novel nature of using mRNA as a vaccine delivery vehicle.

It is possible that the mRNA strand that is supposed to be locally taken up by muscle cells in the deltoid muscle in the arm, may not be as prone as a protein based system to staying local and instead may be taken up by far flung organs like the heart. Cardiac cells would then transcribe the mRNA message and “present” the S-protein on their cell surface. The inevitable antibody response would result in the body’s immune system attacking cardiac cells that incorporated the S-protein.

Other hypotheses focus on the delivery platform that makes the normally fragile mRNA stable enough to be used as a vaccine : a lipid “sheath” the mRNA is encased in that is referred to as a lipid nanoparticle (LNP). Lipid nanoparticles have a long history of being used as a drug delivery mechanism and the major issue pharmaceutical companies have struggled with using LNPs is immune activation.

As a result, the prior most commonly used drug delivered in a lipid nanoparticle, the cardiac anti-amyloid drug Onpattro, required pre-medication with a high dose of steroids before every 80 minute infusion to make it tolerable for patients.

The arrival of the Novavax vaccine added to the COVID vaccine armamentarium by taking the viral S-protein and enclosing it in a lipid sheath, which is distinct from the widely used Moderna/Pfizer product that encloses RNA in a lipid nanoparticle, and the Oxford-AstraZeneca and Janssen product that puts DNA in a viral vector.

If vaccine myocarditis was primarily a function of mRNA, the protein based Novovax vaccine would hopefully be able to deliver protection from COVID without the risk of myocarditis. Unfortunately, the occurrence of 2 almost identical presentations of myopericarditis with the Novovax and mRNA vaccine suggests otherwise.

The tragedy here is that this wasn’t a surprise. Myocarditis and/or pericarditis were reported by two participants after the Novavax COVID-19 Vaccine, Adjuvanted (0.01%) and no participants after placebo. Events of cardiomyopathy or cardiac failure were reported by eight participants after the Novavax COVID-19 Vaccine, Adjuvanted (0.03%) and one participant after placebo (<0.01%). Per the FDA Emergency Use Authorization, the available information on cardiomyopathy or cardiac failure was insufficient to determine a causal relationship with the vaccine.

Post-approval surveillance brought to light more cardiac activity of the Novovax vaccine. Among a total of 41,546 vaccine recipients aged ≥16 years, six cases of myocarditis or pericarditis were detected; five occurred within 20 days of vaccination. Among these five, four did not have likely alternative etiologies, suggesting a possible causal relationship with vaccine.

In global post-authorization surveillance, among 744,235 doses of Novavax COVID-19 vaccine administered in Australia, Canada, the European Union, New Zealand, and South Korea, 35 reports (representing 36 adverse events) were identified among 20 male and 15 female vaccine recipients with a median age of 34 years (range = 23–62 years).

The 2 case reports from Australia aren’t even the first reports of Novovax myocarditis after mRNA vaccine myocarditis. In July, the CDC reported 29 cases of pericarditis, including five in persons with a history of pericarditis after mRNA COVID-19 vaccine; four myocarditis cases; two myopericarditis cases; and one case of carditis, not otherwise specified. A postmarketing analysis from Australia also identified three cases of myocarditis and 12 cases of pericarditis reported during a period in which 160,000 Novavax COVID-19 vaccine doses were administered.

So even though the US CDC had noted cases of Novovax vaccine related myocarditis in August 2022 in patients with a prior history of mRNA pericarditis, the Australian guidelines fail to list a prior history of mRNA vaccine myocarditis as a contraindication to future COVID19 vaccinations.

If you dig a little bit you will eventually find that the current US CDC guidelines is actually more sane than the Australian guidelines and generally advises prior mRNA vaccine myocarditis cases not receive subsequent doses of any COVID-19 vaccine.

It is a bit confusing as you can see from the CDC summary that recommends COVID-19 vaccination for everyone 6 months of age and older because “the benefits… outweight the risk of myocarditis and pericarditis after receipt of mRNA COVID-19 vaccines”

The just published case-reports should be the nail in the coffin for anyone, anywhere trying to give a COVID-19 vaccine to someone with a prior episode of COVID-19 vaccine myocarditis.

Despite the fact vaccine myocarditis has been associated with the Novovax vaccine since the trials that lead to its approval in the US, vaccine advisory panels and medical societies seemingly stuck their heads firmly in the sand. Those in charge of vaccine policy were so averse to recommending against vaccine administration to anyone, that they couldn’t even explicitly warn those with a prior episode of COVID vaccine myocarditis against receiving future COVID vaccines.

The Novovax myocarditis cases that occurred after the US CDC summer analysis were clearly preventable adverse events. It is very hard to understand, even without this data, how physicians or medical societies sanctioned administration of a COVID vaccine to those who had already had COVID vaccine myocarditis.

Interestingly, the Novovax social media team has clearly picked up on the prevailing mRNA vaccine hesitancy to try to generate demand for their product at a time there is very little demand for any COVID vaccines.

Can't get or don't want an mRNA booster? The Novavax COVID-19 Vaccine, Adjuvanted is a protein-based option that’s available for ages 18+, no matter which primary series you received. Ask your doctor or pharmacist for more information. See Fact Sheet: https://t.co/ZCMADlerOd

— Novavax (@Novavax) December 12, 2022

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The story is a nice distillation of what lies at the heart of the outsize influence random dudes on twitter have developed relative to White House COVID czars. If the real leaders of medicine can’t critically analyze the data to explicitly recommend against those with prior COVID vaccine myocarditis receiving future COVID vaccines, what else are they getting wrong?

Dr. Jha: "The real leaders of American medicine are out there telling you that you need to go get a vaccine. You can decide to trust America's physicians or you can trust some random dude on Twitter." pic.twitter.com/VOC8otAG4x

— Greg Price (@greg_price11) November 22, 2022

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Our public health officials are just not very good. The scorn much of the public feels for the institutions and the credentialed class that purport to have the public’s best interest at heart is well earned. Hopefully Santa has stuffed their stockings with common sense for the New Year.

I’m not holding my breath.

Anish Koka is a cardiologist. Follow him on Twitter @anish_koka.

I have to make the obligatory post-script here that I oversaw the administration of hundreds of mrna vaccines starting in March of 2021 in my cardiology clinic. The vaccine efficacy data for the original data was from thousands of patients and I certainly felt given the devastation wreaked on many of my patients in 2020 that the vaccines were the best chance of avoiding morbidity and mortality. The process to get the vaccines from the city department of health was a somewhat arduous 3 month process, and once the vaccines were on hand, there were daily reporting requirements that I dutifully performed for the many months we were administering vaccines. To accommodate the rush of patients, employees, volunteers, and conscripted children worked multiple weekends to administer the vaccines. So I’m especially disgusted by medical colleagues who label any concerns registered about vaccine adverse events as “anti-vaxx”. Registering concern over a vaccine adverse event does not make doctors or patients “anti-vaxx”. It makes them pro-vaxx!

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Ultrasound is Ultra-Cool

BY KIM BELLARD

AI continues to amaze – ChatGPT is now passing Wharton Business School exams, Microsoft and Google are doubling down in their AI efforts – and I’m as big a fan as anyone, but I want to talk about a technology that has been more under the radar, so to speak: ultrasound.  

Yes, ultrasound.  Most of us have probably had an ultrasound at some point (especially if you’ve been pregnant) and Dr. Eric Topol continues his years-long quest to replace the ancient stethoscope technology with ultrasound, but if you think ultrasound is just another nifty tool in the imaging toolbox, you’ve missed a lot. 

Let’s start with the coolest use I’ve seen: ultrasound can be used for 3D printing.  Inside the body.  

This news on this dates back to last April, when researchers from Concordia University published their findings in Nature (I found out about it last week).  Instead of the more common “Additive Manufacturing” (AM) approach to 3D printing, these researchers use Direct Sound Printing (DSP).  

The paper summarizes their results: “To show unique future potentials of DSP, applications such as RDP [Remote Distance Printing] for inside body bioprinting and direct nanoparticle synthesizing and pattering by DSP for integrating localized surface plasmon resonance with microfluidics chip are experimentally demonstrated.”

As lead author Mohsen Habibi explained it: 

We found that if we use a certain type of ultrasound with a certain frequency and power, we can create very local, very focused chemically reactive regions.  Basically, the bubbles can be used as reactors to drive chemical reactions to transform liquid resin into solids or semi-solids.

The authors believe that DSP can have applications where AM cannot be used, particularly because sound can penetrate objects that light cannot (e.g., the human body).  Bioprinting inside the body is not, in itself, new, but has required open surgery, which DSP would not.  “DSP introduces the possibility of noninvasive deep inside the body printing,” they explicitly point out.  

“Also we can do the repairing of inside bio-organs. That’s a future possibility,” corresponding author Muthukumaran Packirisamy said.  Here’s their video:

I’ve been fascinated with 3D printing for a long time, especially for its healthcare-related uses (e.g.., prescription drugs, blood vessels, prosthetic devices, even organs), but tell me we’ll be able to do those noninvasively, using sound waves – well, consider me entranced.  

————-

All that is cool enough, but ultrasound is being used for many more healthcare applications, such as destruction of tumors.  In fact, that was one of the motivations for the Concordia efforts; Professor Packirisamy noted: “Ultrasonic frequencies are already being used in destructive procedures like laser ablation of tissues and tumours. We wanted to use them to create something.” 

“Focused ultrasound” is the term commonly used; there is actually a Focused Ultrasound Foundation. “Focused ultrasound is a noninvasive therapeutic technology,” Dr. Neal Kassell, founder and chairman of the Focused Ultrasound Foundation, told CNN. “We’ve said that focused ultrasound is the most powerful sound you will never hear, but sound that someday could save your life.”

Some of the uses include:

• Earlier this month Canadian surgeons used ultrasound to deliver chemotherapy to an inoperable brain tumor, the first time this has been accomplished.  “Focused ultrasound is an innovative and non-invasive approach to more effectively deliver chemotherapy directly to the tumour,” one of the researchers said. “Our hope is that this continued research will bring us closer to enhancing treatments to help change the course of the disease.”
• Focused ultrasound has been shown to be equally effective in pain management and quality of life measures for painful bone metastases as external radiation beam therapy, with low adverse even rates.  
• Late last year the FDA approved focused ultrasound to treat the second side of patients with essential tumors; use for the first side was approved in 2016.  New research confirmed the long term effectiveness of its use for essential tremors.
• Researchers at UT Southwestern are using high-intensity focused ultrasound to treat medication refractory tremor in essential tremor and tremor-dominant Parkinson’s Disease, which the researchers believe “enables more precise targeting of the brain, decreases treatment times, reduces side effects, and improves treatment response.”  
• Researchers at West Virginia University Rockefeller Neuroscience Institute used Low-intensity focused ultrasound (LIFU) in the treatment of Alzheimer’s patients.  “This study is also a major step forward for the exciting possibility of combining focused ultrasound with targeted delivery of medications or antibodies that normally have limited capability to cross the blood brain barrier from the blood to the brain.” 
• Similarly, researchers at Yonsei University College of Medicine (South Korea) found that focused ultrasound improved the delivery of Alzheimer’s drugs by over eight times.  “While there is no complete cure for dementia, we hope that open BBB [blood brain barrier] surgery using FUS surgery can help give hope to dementia patients,” the lead researcher said.
• LIFU is showing “promising results” for treatment of major depressive disorder, according to a paper from Delft University.  The paper describes LIFU as “an emerging neuromodulation method with disruptive potential since it allows for non-invasive stimulation across the whole brain with milimetre precision.”
• Focused ultrasound has been found safe and effective for intermediate risk prostate cancer.  
• A 2020 study suggested that focused ultrasound could be used for patients with depression or obsessive-compulsive disorder.  “We demonstrated that FUS is effective in significantly improving symptoms of patients with treatment-resistant OCD and depression,” the lead author said.

That is by no means a complete list. The Focused Ultrasound Foundation claims that focused ultrasound is currently (at this writing) being used by 65 device manufacturers, for 170 clinical indications, in 424 research sites and 895 treatment sites.  Impressive numbers, but still small in the scheme of healthcare. It warns:

Unfortunately, the evolution of a new therapeutic medical device from concept to standard of care can take decades. Complicated and inefficient, the process requires the interaction of many organizations with differing agendas and timelines. There are also numerous technology, economic, regulatory and reimbursement obstacles to overcome.

Too often, the mechanisms that healthcare has developed supposedly to protect us also work against us.  As the Foundation also warns: “Decades is too long for patients and their families to wait for medical breakthroughs.

———–

Clifford Marks, MD, writes in The New Yorker about ultrasound replacing the stethoscope, citing miniaturization, lower costs, and application of AI as factors, but I think he’s not being ambitious enough.  As Diku Mandavia, MD, told him, “But ultrasound—it’s low-cost, no radiation, has so much value for patient care . . . it’s going to be ubiquitous.”  

Let’s hope so.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

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Matthew’s health care tidbits: My retina & what it tells us about primary care

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

I had a little scare the other night. I was driving home from a weekend in the mountains and I asked my wife if she saw that flashing light. No it wasn’t the cops, and no she hadn’t seen it. Turns out that I had a bright flash if I moved my eye a certain way. Oh, well I assumed I was tired and a good night’s sleep would fix it.

Next morning the flash was still there when I looked quickly to the left and a few weird floaters had appeared. I headed to the Mayo Clinic website and it looked to me like I had a detaching retina. I got on the urgent visit video with One Medical. The NP who answered said it sounded like I might have retina problems and I should get it checked by my ophthalmologist. But my eyesight has always been great (other than me needing reading glasses in my old age) and I haven’t got one. So who, I asked, do you recommend?

Here we fall into the crux of the problem. One Medical is an excellent primary care service. So good that Amazon bought it for $3bn. But it’s not a multi-specialty group nor is it a system like Kaiser. The answer was, “we don’t really recommend anyone–that’s not how it works.” The NP ended up looking up ophthalmologists near me & sent me a name as a referral in their app. But that’s not a link to anything and it wasn’t one chosen through some analytical process of seeking quality excellence.

I looked up MarinHealth (my local hospital)’s website and searched ophthalmology. That referred name was on it. I called. The doctor was out this week. They gave me another name. That doctor’s office gave me another name and that third office could see me that same day. I felt some pressure to see them right away as in the case of a detached retina Mayo says “ Contacting an eye specialist (ophthalmologist) right away can help save your vision”. The good news is having spent a couple of hours at the ophthalmologist’s my retina needs watchful waiting not surgery.

But the bad news is that for me, like 90% of Americans, there’s no easy way to get referred into a trustworthy system for specialty care. This can be even worse. My friend Sarah McDonald explains in her book The Cancer Channel how, after being diagnosed with a rare incurable cancer by a head & neck surgeon, the all encompassing support she received was to be given the number of a specialist at UCSF who couldn’t even talk to her for 3 weeks.

Mike Magee talks about the role of the health care system being to reduce patients’ “fear and worry”. Our lack of a specialty care referral system, especially when potentially serious and urgent care is on the line, is a big reason why there is so much fear and worry. I wish I had a concierge advocacy system like Included Health or Transcarent which could get me to the right place and work with me through the experience. But like most Americans at the time I need reassurance the most I’m calling a list of phone numbers hoping someone can see me.

We have primary care, we have specialty care. But we don’t have a system that cares.

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Can Missouri Pass The Muster

BY MIKE MAGEE

A case has been made that a logical approach to reforming America’s violent and racist leanings would be to adopt the values and practices of Health Care for All. These include a commitment to compassion, understanding, and partnership; extending the linkages between individual, family, community and society; addressing fear and worry for individuals and populations; and promoting an optimistic and equitable future for all Americans. 

Nurses and doctors and pharmacists and other health professionals pledge oaths and spend years training to exhibit and practice these values in the course of providing preventive and interventional care to select Americans. Imagine the effect of delivering these many benefits in an equitable way, in all communities, with the intent of making not only Americans, but also the American culture healthy.

Or we could simply continue to accept the values exhibited by the Missouri State Legislature, where misogyny and brass knuckles have risen to the top of their legislative calendar.

In June, 2021, a Missouri News-Press editorial commented that “one vote last week might strike some as a sign that Missouri’s lawmakers could use some help with time management and prioritization.” The Republican led body had soundly passed HB 1462 which included Section 571.020 and 571.107 which read “This act repeals prohibitions on the possession and selling of brass knuckles, firearm silencers, and switchblade knives.” The same act addressed the taxpayer burden for possession of their weaponry by providing “that all sales of firearms and ammunition made in this state shall be exempt from state and local sales taxes.”

Coming off of pandemic induced limited face time, the local legislators are back to giving it their all on behalf of Missouri’s citizens, though their priority list remains pretty debatable. This week, 116 men and 43 women legislators gathered to do the state’s work in earnest. One of their first actions? Updating women legislators dress code in four sentences of a 37-page resolution. 

Democratic women, like legislator Raychel Proud, rose to object, stating, “I think we’re being quite pedantic here by making rules so petty. And what it will ultimately lead to is the disenfranchisement of folks. For example, they don’t make jackets or blazers for women who are pregnant. That can be very uncomfortable.”

Her Democratic colleague, Ashley Aune, added she was personally offended by being given the once over by her male colleagues, adding “You know what it feels like to have a bunch of men in this room looking at your top trying to decide whether it’s appropriate or not? I mean, this is ridiculous.” 

Republican State Representative Ann Kelley, who introduced the new rule, channeling her best inner “Phyllis Schlafly”, feigned confused surprise. “You would think that all you would have to do is say, ‘Dress professionally,’ and women could handle it. You would think elected officials could handle that.”

A decade earlier, fellow Missourian Schafly said, with a polite smile, “We certainly don’t need a committee of foreigners who call themselves ‘experts’ to dictate our laws or customs.” From there it was a straight line to the Dobbs decision, to green lighting weapons of violence, and to challenging women’s autonomy.

Brass knuckles rose to prominence during the Civil War. But their symbolism, along with misogynistic and racist attacks on large segments of our population, can only be described as “deeply disturbing.” None of this would pass the muster in addressing the simple, but very basic question, “How do we make America and all Americans healthy?”

Mike Magee MD is a Medical Historian and the author of “CODE BLUE: Inside the Medical-Industrial Complex.”

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Medicare Advantage UpCoding Has Been Eliminated by CMS Effective 2022

By GEORGE HALVORSON

Medicare Advantage now enrolls almost exactly half the people enrolled in Medicare — and has both significant fans and hardline opponents in the health care policy circles who disagree about its performance.

The biggest attack point that comes from the critics deals with the issues of coding accuracy by the plans. The payment model for the program is capitation — and that capitation is based on the average cost of fee-for-service Medicare in every county. The people who designed the model believed that the country should use the average cost of fee-for-service Medicare in every county as the baseline number and should have the plans paid less than that average Medicare cost going forward every year in their capitation cash flow.

Medicare fee-for-service has a strict and consistent payment level based on a list of approved Medicare services — and they add up the cost of those services in every county and let the plans bid a lower number than that fee for service Medicare cost, if the plans believe they can offer all of the basic benefits and possibly add more benefits and additional services for that amount.

The fee-for-service Medicare cash flow and costs in each county tend to be very stable over time, with a continuous and steady increase in the actual functional cost for taking care of those fee-for-service patients for each year that they receive care. That total cost of fee-for-service Medicare care is a visible and clear baseline number that we can use each year with confidence and knowledge that it is what we are spending now on those Medicare members in the counties.

The direct capitation amount that is then paid to each of the plans is based on the age, gender, health status, and diagnosis profile of the Medicare Advantage members who enroll in the plans. The plans have been reporting those patient profile numbers to the government through the Risk Adjustment Processing System (RAPS) over a couple of decades to set up their payment levels and to create the monthly cash flow for each plan.

That’s where the upcoding accusations relative to the plans arise.

The plans get paid more if the patients have more expensive diagnoses — so the plans have had a strong and direct incentive to make sure that every diabetic enrollee is recorded and reported as being diabetic for their RAPS filings.

They also have a strong incentive to be sure that every congestive heart failure patient has their diagnosis recorded in their RAPS report.

The Medicare Advantage critics say that the plans inflate and tend to over report and even upcode the higher impact diagnosis for their members. There have been multiple media stories about plans doing things like sending nurses into patients’ homes to collect diabetic diagnosis rather than having those deliver care to those patients.

The plans do often have nurses going into patients’ homes, and it is definitely accurate to say that one of the things that the nurses do is make sure that their diabetic patients are all recorded on the RAPS system as being diabetic.

One plan owned its own pharmacies, and that plan was accused of looking at the pharmacy records to identify patients with insulin prescriptions who had not been listed on the RAPS profile as being diabetic. There were a few patients who met that category in the year that the study was done, and that plan did end up with a slightly higher number of diabetics than the RAPS report for that plan would have shown for that year if the pharmacy files and records had not been reviewed for those patients.

There have been a number of both incidents and processes over the years where plan activity that might have increased the diagnosis levels has happened and the plan critics looking at those activities had a consensus conclusion that the total negative impact of that upcoding approach might be inflating the payment levels of the plans. Some critics say that number now approximates 9%.

The critics have said that, even though the Medicare Advantage plans consistently bid 12–20% lower amounts than the fee-for-service average cost per county cost, that consistent 9% upcoding basically offsets those gains. The critics that what appears to be Medicare Advantage’s lower costs in every county isn’t really lower costs because of the RAPS system upcoding.

A number of health care policy people and some of the academics who have looked at those issues have accepted that upcoding argument and some have even accepted that upcoding number.  A number of observers have written various solutions to those approaches which sometimes include eliminating Medicare Advantage as a program, because some have said that the business model of the plans is to upcode not to deliver care.

Medicare Advantage’s supporters point to the fact that plan bids are significantly below the average fee-for-service cost in every county. They also argue that the quality agenda for the plans has reached the level where many care sites across the country publicize their achievements in the Medicare Advantage quality program. Those supporters and advocates say that it would be a major mistake for millions of patients to kill Medicare Advantage.

CMS decided two years ago to directly end the argument about upcoding. They decided to replace the highly contentious old debate about the risk levels of the plans with functional and direct data about the members. More importantly, CMS very wisely, intentionally, and explicitly decided to make upcoding impossible. They made that effective with the 2022 data flow.

It’s done and in place.

CMS actually killed RAPS. They completely eliminated the coding system. Plans can’t upcode anything now, because with the 2022 filing process, they actually can’t code anything.

CMS still needs data to make the payments to plans, so they now get all of their data from direct and individual patient encounter reports. That’s a far superior system. They get both the procedures done for each patient and the medical record for each encounter, and each patient is now the source of the diagnosis. They get the data now in a steady flow of patient information about the encounters rather than getting the risk levels and the diagnosis for the patients in a RAPS summary report that was filed a year or more after the care happens.

That was a very good thing for CMS to do. It is much better information. They now know exactly who is enrolled in every plan. They know their patterns of care and their diagnoses, and they have actual information about their care outcomes that can be derived from that data flow.

CMS’ actuaries have been continuously refining and improving their formulas for projecting future costs. They also have the ability to use the most current data combined with the most current actuarial wisdom to figure out how much to pay the plans to make sure the payment process is accurate as the patient profile for making payments.

Fee-for-service Medicare for low-income people delivers very expensive and often bad care. Fee-for-service Medicare care sites for low-income people have twice as many people going blind and three times as many people with amputations as the Medicare Advantage special needs plan patients who enroll many of those patients now.

The average cost of an amputation for fee-for-service Medicare is slightly over $100,000. Our low-income Medicare patients are 10 times more likely to lose a limb to that procedure. The capitated Medicare Advantage plans know that 90 percent of the amputations are caused by foot ulcers. They also know that you can reduce the foot ulcers by more than 40 percent with dry socks and clean feet for their patients — and the Medicare Advantage plans all do exactly that with high levels of success.

The nurses that the plans have going into homes aren’t there, as the critics said, to “harvest diagnosis” for upcoding. They are there for amputation reduction and they also cut the diabetic blindness levels for patients by more than half. Just by doing that more than 90 percent of patients in Medicare Advantage five-star plans now manage their blood sugar.

The critics who continue to attack the Medicare Advantage plans for having quality goals included in the Five-Star quality program relating to diabetes clearly aren’t thinking of patients when they make their attacks on that part of the Medicare Advantage quality agenda.

Bad care is expensive.

The capitation target amounts for each county include all of that bad care, and that’s why the plans can bid at about eighty to 90 percent of the average local fee-for-service Medicare costs in their capitation in every county and still make both surpluses and profits for their care.

When CMS killed the RAPS system entirely for 2022 that created the opportunity to actually get the right risk-level data on all of the Medicare Advantage patients. CMS used that more complete and more accurate data to set the capitation levels for 2023 for the plans. It turns out that the 9% upcoding and overcharge level that many critics were citing so visibly in those critical attacks was a very wrong number. The actual risk and cost number for real patients was actually 8.5% under-coding when comparing the old risk levels to the actual diagnosis and to the current risk levels for the plans.

Look at the actual CMS 2023 decision, which increased the payments 8.5%. Those numbers are hiding in plain sight and they are based on actual data.

The upcoding accusations that have crippled so much of the Medicare Advantage discussions should now die a permanent death with the new system, because even if a plan somehow now wanted to upcode, there’s no coding left to do. It’s not possible to do any coding when the coding system has completely gone.

It’s time to look at actual plan performance and to make decisions based on actual outcomes, and to trust and understand that the plan discounts on the capitation levels are all direct savings for Medicare. Because the plan bids and actual payments are below the average cost of Medicare fee-for-service in every county, those are real dollars being saved every month for all of the people enrolled in Medicare Advantage.

Five million of the Medicare Advantage members have dual eligibility for Medicaid and Medicare. Those very low-income people have high health care needs and very few resources that help them get through the day without the enhanced dental, vision, and hearing benefits from by the plans. Those benefits were enabled by the surpluses created by having fewer people going blind in the plans.

The Medicare Advantage critics who continue to accuse the plans of upcoding have never pretended or attempted to explain how it’s possible to upcode that set of Medicaid eligible and high need patients.

 CMS did a very good thing to take that issue completely off the table.

Let’s build on what we have in teeing up continuous improvement in some of those areas of care and let’s make the long-term costs at Medicare far lower than any one has projected just by making and maintaining those major improvements in care and having better care cost significantly less because it’s more effective at so many levels.

George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14.

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