Grand Rounds Vol. 7 No. 40

Welcome to Grand Rounds!  It’s the third time we’ve hosted Grand Rounds at the Colorado Health Insurance Insider and we’re honored to be hosting again. It was a pleasure to read so many great articles for this edition.  Since our blog tends to focus on health care policy and reform, I’m starting things off with the posts that pertain to that topic.  Enjoy!

Health Care Policy And Reform

HealthBlawg’s David Harlow analyzes the Massachusetts Attorney General’s report on health care costs, which is particularly interesting given that the state is considering moving to ACOs and global payments.  It turns out that quality of care doesn’t necessarily explain the differences in payments made by health insurers, and that global payment systems don’t always result in lower overall costs.  Global payments and payments based on quality of care have long been a goal of health care reform, but the data from the AG’s report indicates that it might not be as simple as it seems. Based on the data in the report, the AG makes several recommendations that would probably make sense in other states aswell.

Dr. Doug Perednia of The Road To Hellth considers the various ways that both here in the US and in other countries, government health care initiatives are not always the most efficient mechanisms.  Electronic medical records, inadequate provider reimbursements from government health insurance programs, pay-for-performance systems that don’t result in improved performance, wildly inaccurate economic predictions in terms of health care costs… the list is long.  So although our current system (a hodge-podge of hundreds of health insurance carriers, with a myriad of different networks, policies, forms, and procedures) is administratively very wasteful, his concern is that a single payer system might fall victim to gross inefficiencies of its own.  If we were to pursue a single payer system of any sort (public or private) we would need a way to address these issues.

Dr. Rich of the Covert Rationing Blog explains why medical guidelines are not always followed… looks like it has something to do with money.  His article notes that although there are six proven therapies for heart failure that – if implemented correctly on all patients – could save tens of thousands of lives each year.  But implantable defibrillators are not cheap, nor is prolonging the life of a person with heart failure who is consuming a lot of health care.  And thus Dr. Rich’s position is that the government will look the other way if doctors aren’t following all of the guidelines for treating heart failure.

Medical Care

Treating diabetes with medications has left many doctors and patients stuck between a rock and a hard place lately, with concerns being raised about the safety of various diabetes drugs.  Dr. Pullen gives us the details.  Some medications are still ok, and of course the old standbys of losing weight, eating nutritious food, exercising, and not smoking are all still excellent advice for patients with diabetes… but from a doctor’s perspective, it’s tough to get patients to follow through on lifestyle changes (see Dr. Meek’s post in the Psychology section, about getting someone else to change…)

DiabetesMine interviews Gil DePaula, inventor of the Pancreum and winner of this year’s DiabetesMine Design Challenge.  This nifty little device is half the size of a cell phone and is expected to be able to hold 400 units of insulin.  It hasn’t cleared FDA approval yet, but it looks like an exciting step forward in the world of diabetes treatment.

Dr. Val Jones of Get Better Health writes about the importance of yearly eye exams, and reminds us that just because our vision isn’t changing doesn’t mean we should skip our eye exam.  And for people who put off getting an eye exam because their health insurance won’t cover it, Dr. Jones notes that eye exams at retail outlets can be as low as $45 or $50.

Nora OBrien-Suric of the John A. Hartford Foundation writes about post-operative confusion and delirium in older people who have major surgery with general anesthesia.  Her own experience indicates that many doctors – even those who are performing surgery on older patients – may not be aware of the connection, and this could lead family members and caregivers to needlessly worry that the patient has developed dementia.

Healthline’s Dr. Paul Auerbach explains how Biphosphonates work to reduce the number of broken bones in people with osteoporosis.  As with any drug, there are possible side effects, and anybody with osteopenia or osteoporosis should work closely with their doctor to make sure that whatever therapy they choose is having the desired effect.  In addition, weight bearing exercise helps to increase bone density… but care should be taken to avoid falls, which can be especially problematic for people with low bone density.

Ethics And The Health Care Provider

Jessie Gruman from Prepared Patient Forum discusses whether doctors should provide empirical evidence and risk information to patients in order to help them make effective decisions about their own treatment.  Her view is that it makes little sense for doctors to withhold important information from patients based on the doctor’s opinion (formed during a 15 minute consultation) of whether or not the data would be helpful to each particular patient.

Dr. James Logan shares his perspective on whether doctors have an obligation to make medicine their highest priority, above other things like family and outside interests.  His article is in response to an op-ed in which the author felt that doctors do indeed have such a responsibility.  Dr. Logan takes the opposite side in Medicine Is My Day Job, stating that “A doctor’s relationship to his or her profession and the number of hours per week that he or she decides to practice is a matter of personal, philosophical reflection, not a matter of moral obligation or public debate.“  I couldn’t agree more, and I would argue that this holds true for all professions.

In an ACP Hospitalist post that echos a similar sentiment, Dr. Kimberly Manning writes about the day 15 years ago when she graduated from medical school, and had an epiphany about her decision two years earlier to skip her sister’s law school graduation ceremony in order to study for an exam.   She writes that “[her] hope for [her] students and residents is that they indeed care for their patients with all their might and attack all there is to learn about medicine with zeal, but never at the expense of family and important relationships. It’s a bit of an oxymoron considering medicine is often a selfless pursuit…but again, it is those who maintain self who are able to give the most.“  Well said, Dr. Manning.

Psychology

Dr. Jesse Hellman, guest blogging at Shrink Rap, delves into the story of Tarzan and frames it against what we now know (and don’t yet know) about traits that are hardwired versus those that are learned and acquired as a product of our environment.  Things are far more complex than Edgar Rice Burroughs could have known a hundred years ago.

Dr. Phil Hickey of Behaviorism and Mental Health describes a study conducted by the National Institute of Mental Health (NIMH) which was designed  “…to determine the effectiveness of different treatments for people with major depression who have not responded to initial treatment with an antidepressant.”  But the study was riddled with flaws, and all of the errors had the effect of making antidepressants seem more effective than they actually were.  This is often the case when studies are funded by the pharmaceutical companies, but Dr. Hickey notes that it’s particularly sad to see “the NIMH fall victim to pharmaceutical rapacity.”

Psychologist Will Meek, PhD details the five stage process that most people go through when making a change in their lives – quitting smoking, for example.  And although he confirms the common wisdom that you can’t make someone else change, he also provides some strategies that might help to set the groundwork for getting someone else to begin the process of making changes.

Research, Studies, And Things That Make You Go Hmmmm….

In Bladder Up!, Hank Stern of InsureBlog tells us about new research which finds that we make more rational long-term decisions when our bladders are full versus when they are empty.  That comes as a surprise, since it seems that when one’s bladder is full, one’s thoughts tend to be focused more on finding a nearby restroom than on making rational decisions.  Perhaps a full bladder makes us work faster and thus filter out trivial information in order to get to the important details needed for a rational decision.

Patricia Walling, guest posting at In Sickness And In Health writes about a study that found that amputees experienced real pain when they saw pictures of other people experiencing pain in their hands or feet.  Our bodies are able to feel someone else’s pain via mirror neurons, which helps to explain why we hurt when we see a loved one hurting.

In the growing debate about cell phones and brain cancer, ACP Internist examines a recent report in the American Journal of Epidemiology, which found that gliomas are not concentrated in parts of the brain closest to where the patients held their cell phones.  The article also points out that the part of our bodies closest to our cell phones is our hand, but nobody seems to be concerned about hand cancer…

That’s it for this week’s edition.  Be sure to check out Doctor Fizzy for next week’s Grand Rounds.

-Louise