Full impact of the ACA won't be known due to fundamental problems in how U.S. Health care is organized

Posted By News On September 9, 2013 - 9:31pm

Reviewing the objectives of the Affordable Care Act and analyzing the likely outcomes in light of the imperfect hand of the U.S. health care market, J.B. Silvers, PhD, a health care economist at Case Western Reserve University, concludes it is unlikely the potential for higher value care efficiently provided in the best location at a fair competitive price will be fully realized.

He outlines several reasons for this potential shortfall, including problems with how the U.S. health system is organized and paid, the information and choices available, and the pressures and the incentives that persist.

He argues that although the ACA will make the insurance market more competitive, open and fair in access and cost, impediments in the provider and supplier sectors will restrict its impact on the structure of the system and the delivery of care. If public policy is to succeed, he asserts, it will be necessary to correct for market failure.

The Affordable Care Act: Objectives and Likely Results in an Imperfect World, By J.B. Silvers, PhD, Annals of Family Medicine

One-third of Walgreens Vaccinations Are Administered During Off-Clinic Hours, Implications for Improving Vaccination Access and Convenience

With adult and adolescent vaccination rates below national goals, this study of more than six million vaccinations administered in more than 7,500 Walgreens pharmacies across the United States identifies a potentially important public health impact pharmacies can make by providing vaccines during convenient times that expand access to particular groups of people. Analyzing data on 6,250,402 vaccines administered at the pharmacy chain over the course of a year, researchers found 31 percent were provided during off-clinic hours: 17 percent were provided on weekends, 10 percent on weekday evenings and 3 percent on federal holidays. Younger, working-aged, healthy adults, in particular had higher odds of accessing a variety of vaccinations during off-clinic hours when traditional providers are not likely available. Specifically, patients had significantly higher odds of off-clinic vaccination if they were younger than 65 years of age, male, resided in an urban area and did not have any chronic conditions. The authors conclude allowing patients to seek and receive vaccinations at times that are most convenient to them, often when medical offices are closed, could measurably increase immunization rates in the United States. They call for expanding the ability of pharmacists to administer all vaccines in all states by standing orders coupled with expanded hours of operation.

Vaccinations Administered During Off-Clinic Hours at a National Community Pharmacy: Implications for Increasing Patient Access and Convenience

By Jeffery A. Goad, PharmD, MPH, et al University of Southern California, Los Angeles

Note: Three of the four co-authors are employees of Walgreen Co; Dr. Goad serves on the speaker's bureau for Merck and Co. Inc.

Eligible Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Expansion Are As Healthy or Healthier Than Current Beneficiaries, Expenditures May Not Be As High As Projected

The potentially eligible Medicaid population under the Patient Protection and Affordable Care Act-financed Medicaid expansion is similarly healthy as — if not healthier than — the current Medicaid population, according to a new study from researchers out of the University of Michigan. The exception to this general theme is that tobacco smoking and alcohol use patterns are higher among potential Medicaid enrollees than for current Medicaid beneficiaries. Specifically, the analysis of the most recently available nationally representative data on an estimated 13.8 million current and 13.6 million eligible Medicaid beneficiaries indicates eligible adults are expected to have better health status (35 percent "excellent" or "very good," 40 percent "good") than current beneficiaries (34 percent "excellent" or "very good," 32 percent "good"). Additionally, the proportion of potentially eligible beneficiaries who are obese and with depression is significantly lower than current beneficiaries (35 percent vs. 43 percent and 16 percent vs. 22 percent, respectively). They found no significant differences in the expected prevalence of diabetes or hypertension. Current tobacco smoking (49 percent vs. 38 percent) and moderate and heavy alcohol use (22 percent vs. 16 percent and 17 percent vs. 10 percent, respectively) are more common among the potentially eligible population than among current beneficiaries. These findings suggest that federal Medicaid expenditures for newly covered beneficiaries may not be as high as projected by the Congressional Budget Office in the short term, thereby reducing spending anticipated with implementation of the ACA. Given the higher prevalence of tobacco smoking and alcohol use, however, the authors point to the need for broad enrollment and engagement of this potentially eligible population to address their higher prevalence of modifiable risk factors for future chronic disease.

Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries By Tammy Chang, MD, MPH, et al University of Michigan, Ann Arbor

Editorial: ACA Implementation and Three Urgent Tasks for Family Medicine

Drawing on his experience researching and drafting health workforce provisions that ended up in the Affordable Care Act, family physician Daniel J. Derksen, MD, highlights three urgent tasks for family physicians and public health advocates that must be accomplished for the ACA to be effective. First, he calls for the development of new health care delivery models emphasizing integrated, community-based care, as well as the expansion of primary care training programs to ensure access as 25 million uninsured gain coverage. Additionally, he calls for active outreach efforts to help the eligible uninsured population enroll for coverage, with particular emphasis on rural and medically underserved areas and populations. Lastly, he calls on policymakers to ensure prevention, public health and primary care are adequately funded. He asserts that family physicians and public health advocates are uniquely positioned to play a key leadership role in addressing these challenges.

The Affordable Care Act: Unprecedented Opportunities for Family Physicians and Public Health By Daniel J. Derksen, MD Mel and Enid Zuckerman College of Public Health University of Arizona, Tucson

Essay: Medical Homes Should Play a More Active Role in Helping Patients Obtain and Retain Health Insurance Coverage

A family physician reflects on the potential of primary care medical homes to partner with patients to reduce preventable mortality by helping them find and keep health insurance coverage, asserting that ensuring all patients have the best and most continuous coverage available to them under existing and newly expanded programs may be as (or more) important than ensuring all patients have optimal blood pressure control, diabetes control or timely cancer screenings. DeVoe outlines how basic tenets from the chronic care model can be operationalized to build systems that treat the United States' large "uninsurance" problem. Primary care clinicians, she argues, are in a position to see how lack of insurance negatively affects health, and she calls for the development of effective processes and tools within the medical home to help patients obtain health insurance, retain their coverage or make important health insurance coverage decisions. Health care financing, she argues, should no longer be separate from the delivery of health care services. She concludes that by adopting uninsurance and underinsurance as a chronic illness, and applying the tenets and tools of the chronic care model to treat it, medical homes have the opportunity to improve population health and make a positive difference in the lives of patients.

Being Uninsured is Bad for Your Health: Can Medical Homes Play a Role in Treating the Uninsurance Ailment? By Jennifer E. DeVoe, MD, DPhil Oregon Health & Science University, Portland

Systematic Review: Cinnamon May Be Beneficial for Diabetic Patients but Dosing Uncertain

Consumption of cinnamon is associated with a statistically significant decrease in levels of fasting plasma glucose, total cholesterol, low-density lipoprotein cholesterol and triglyceride, and an increase in high-density lipoprotein cholesterol. A meta-analysis of 10 randomized controlled trials evaluating the effects of cinnamon use in 543 patients with type 2 diabetes at doses of 120 mg/d to 6 g/d for four to 18 weeks found reduced levels of fasting plasma glucose (-24.6 mg/dL; 95 percent CI, -40.5 to -8.7), total cholesterol (-15.6 mg/dL, -29.8 to -1.4), LDL-C (-9.4 mg/dL; 95 percent CI, -17.2 to -1.6) and triglycerides (-29.6 mg/dL; 95 percent CI, -48.3 to -10.9). Cinnamon also increased levels of HDL-C (1.7mg/dL; 95 percent CI, 1.1 to 2.2). No significant effect on hemoglobin A1c levels was seen. High degrees of heterogeneity were present for all analyses except HDL-C. Despite the generally positive results, the authors advise caution in applying the results of this analysis to patient care because of the uncertainty of the dose and duration of cinnamon use and uncertainty of the ideal patient population.

Cinnamon Use in Type 2 Diabetes: An Updated Systematic Review and Meta-Analysis By Olivia J. Phung, PharmD, et al Western University of Health Sciences, Pomona, Calif.

Mindful Physicians Have More Satisfied Patients

Physicians rating themselves as more mindful — nonjudgmentally attentive to their own experience, thoughts and feelings — have more patient-centered communication and more satisfied patients. Measuring the mindfulness of 45 clinicians and later assessing the quality of their interactions with patients infected with the human immunodeficiency virus, researchers found mindful clinicians were more likely to be patient-centered in their communications, more positive in their emotional tone with patients and more likely to be rated highly on communication and overall satisfaction by patients. The authors conclude mindfulness may be an important pathway to a more humanistic, effective and satisfying practice of medicine. The highly reciprocal influence of patients and clinicians on one another, they add, is in itself a powerful and positive medical tool — perhaps in some situations more powerful than other interventions that can be offered to patients. They call for future research to determine whether improving clinician mindfulness can also improve patient health outcomes.

A Multicenter Study of Physician Mindfulness and Health Care Quality By Mary Catherine Beach, MD, MPH, et al Johns Hopkins University, Baltimore, Md.

Pilot Study Shows Promising Effect of Brief Mindfulness Course on Physician Job Satisfaction and Well-Being

Given the pervasive problem of physician burnout and low job satisfaction and its negative influence on patient care, researchers evaluate the ability of a short mindfulness training program to increase job satisfaction, quality of life and compassion among 30 primary care clinicians. In this uncontrolled pilot study, they find participating in a brief mindfulness course consisting of a weekend immersion along with two short follow-up evening sessions was associated with reduction in indicators of job burnout, depression, anxiety and stress on three follow-up surveys at one day, two months and nine months post-intervention. Specifically, at nine months post-intervention, participants had significantly better scores on all Maslach Burnout Inventory subscales, emotional exhaustion (P=.009), depersonalization (P=.005), and personal accomplishment (P<.001), as well as on the depression (P=.001), anxiety (P=.006) and stress (P=.002) subscales of the Depression Anxiety Stress Scales-21 and perceived stress (P=.002) assessed with the Perceived Stress Scale. That the effect was maintained over nine months without formal intervention booster sessions suggests that even limited initial training may be sufficient in teaching fundamental mindfulness practices. They conclude mindfulness training appears to be a low-cost, time-efficient tool to help support clinician health and well-being, which may have implications for patient care, and they call for a randomized controlled trial to confirm these promising results.

Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study By Luke Fortney, MD, et al Meriter Medical Group, Madison, Wis.

Simplifying the Diagnosis of Urinary Tract Infections

Researchers in Amsterdam offer a sophisticated analysis of different approaches to diagnosing acute uncomplicated urinary tract infections in women and propose a model that reduces the number of questions asked and urine investigations needed. Analyzing data on 196 women presenting with painful and/or frequent micturition, researchers find that three questions, sometimes followed by a urine dipstick test, can provide a practical level of accuracy. Specifically, they recommend asking 1) does the patient think she has a UTI, 2) is there at least considerable pain on micturition and 3) is there vaginal irritation? Asking these questions, they find, may be sufficient to correctly classify more than one-half of women with painful and/or frequent micturition as having UTI risk of either less than 30 percent or greater than 70 percent. Subsequent performance of nitrite and blood dipstick tests raises this proportion to 73 percent. The percentage rises to 83 percent if a urine dipstick is performed only for patients with a UTI risk between 30 percent and 70 percent after history, which avoids the possibility of a false-negative nitrite tests in patients with high UTI risk (greater than 70 percent) after history. They assert that expensive and time-consuming urinary sediment and dipslide tests appear to add little diagnostic information. The authors call for future research to validate these recommendations.

Toward a Simple Diagnostic Index for Acute Uncomplicated Urinary Tract Infections By Bart J. Knottnerus, et al University of Amsterdam, The Netherlands

Warts Prevalent Among Dutch School Children, Half of Cases Resolve Within One Year Despite Any Treatment

Examining the natural course of cutaneous warts and treatment decisions among primary school children, researchers found a high prevalence of warts, half of which resolved within one year despite any treatment. In the study of 1,099 Dutch children aged 4 to 12 years, researchers found 33 percent of children had cutaneous warts at baseline. One-half of the children found to have warts were free of warts one year later, despite any treatment. Resolution rates were higher among younger children and children with non-Caucasian skin type. During the 15 month follow-up, 38 percent of children and their parents decided to treat the warts, a decision that was more likely when warts were bigger and bothersome. Eighteen percent used over-the counter treatment only, 15 percent used a family physician-provided treatment only and 5 percent used both. The authors expect these findings to be useful in the process of shared decision making with parents and children. They conclude parents and family physicians should weigh the benign natural course, the adverse effects of treatments and the costs on the one hand, and the effectiveness of treatments and the risk of spreading untreated warts on the other.

Natural Course of Cutaneous Warts Among Primary School Children: A Prospective Cohort Study By Sjoerd C. Bruggink, MD, et al Leiden University Medical Center, The Netherlands

Web-based Screening Tool Acceptable Means of Detecting Unhealthy Behaviors and Mental Health Issues

A novel web-based tool for detecting unhealthy behaviors and mental health issues appears to be feasible, acceptable and easily integrated into patients' electronic medical records. Developed by researchers in New Zealand, the web-based eCHAT (electronic Case-Finding and Help Assessment Tool) screens patients for problematic drinking, smoking and other drug use, gambling, exposure to abuse, anxiety, depression, anger control and physical activity, and whether they want help with these issues. In this study, the tool was self-administered on an iPad in the waiting room by 196 consecutive patients visiting two primary care practices in Auckland, New Zealand. Most patients found the iPad easy to use and the questions easy to understand and appropriate. Feedback from clinical and office staff was also generally positive. Domains where patients wanted immediate help were anxiety (9 percent), depression (7 percent), physical activity (6 percent) and smoking (5 percent). No patient requested help with more than one issue during the consultation, and physicians did not report being overwhelmed by the requests. The authors conclude eCHAT appears to be an acceptable tool for systematic finding of cases of unhealthy behaviors and negative mood states in primary care, and they note that the help question posed by the tool empowers patients to control the direction of their consultation. They call for future research to determine whether using eCHAT will lead to improved health outcomes.

eCHAT for Lifestyle and Mental Health Screening in Primary Care By Felicity Goodyear-Smith, MBChB, MD, FRNZCGP, et al University of Auckland, New Zealand

Little Correlation Between Quality of Care Assessed by Clinical Measures and That Assessed by Patient Experience

Researchers in England find little correlation between quality of care assessed by clinical measures and that assessed by patient experience measures, concluding that both are needed to avoid getting an unbalanced picture of quality. Analyzing patient experience and clinical performance data from 7,759 practices in England, researchers found although the correlations between clinical quality summary scores and patient survey scores were all positive, the strength of the associations was weak, with the highest correlation coefficient reaching 0.18, and more than one-half 0.11 or less. They found the strongest correlations with clinical quality were highest for patient assessments of access (ability to get through on the telephone 0.16, availability of urgent appointment 0.15, ability to book ahead 0.18, ability to see preferred doctor 0.17) and overall satisfaction (0.15). They found very low correlations between clinical quality and interpersonal aspects of care. The authors conclude that clinical and patient experience domains of quality need to be considered separately when assessing the overall performance of a family practice.

Relationship Between Clinical Quality and Patient Experience: Analysis of Data From the English Quality and Outcomes Framework and the National GP Patient Survey By Nadia R. Llanwarne, MB, ChB, MA, et al University of Cambridge, United Kingdom

Family Physician's Struggle to Ensure a Time Clock Does Not Compromise Quality of Care

A family physician in Israel reflects on how the introduction of an employee time clock at the health maintenance organization where she works influences small everyday clinical decisions that affect the quality of care she provides her patients. She shares the mantra she routinely turns to with each hastened visit to reaffirm her professional integrity, pledging her allegiance first and foremost to her patients and her own standards of care.

Measuring Up: Musings of a Family Doctor on the Employee Time Clock By Ruth Kannai, MD Hebrew University, Jerusalem, Israel

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