DCMedical News: Friday, June 25, 2021
DCMedical News-DCMN
Washington, D.C.
Friday, June 25, 2021
DCMedical News is published every day both the House and the Senate are scheduled to be in session. The House (only) is in session next week, the Senate (only) July 12-16; both the House and Senate, and publication of DCMN, resume July 19.
THE BIG STORY
Infrastructure Bill Lives, Medicaid HCBS Not Included, But Other Initiatives May Follow
A “bipartisan” group of legislators reached agreement with President Biden on a $1 trillion infrastructure bill (news report here, from The Financial Times). The paper reported that “Biden pins down milestone $1tn cross-party spending package”; that “The agreement with a bipartisan group of senators falls short of the $2.3tn plan unveiled by Biden in March, and does not address the $1.8tn in social safety-net spending that the president proposed in April”; but that “Nancy Pelosi, the House Democratic speaker, said that the legislation would have to be linked: the lower chamber of Congress would only consider the bipartisan infrastructure package if Biden’s broader economic priorities — including tax increases on corporations and the wealthy — had first passed the Senate.”
Other legislators (here) may seek to include a $400 billion home and community based services Medicaid expansion, with a goal of improving wages in home care, reducing waiting lists and substituting home for institutional based care, continuing (during any gap period) the 10% enhanced Medicaid match of the American Rescue Plan/COVID-19 relief bill.
The Administration has also indicated that it may use the waiver process to expand and enhance Medicaid coverage. Bloomberg Health Law & Business reports “CMS Administrator Chiquita Brooks-LaSure is expected to follow the playbook of Seema Verma, her predecessor under Trump, by telling states about how she wants them to experiment with covering more people using waivers.” One target is turnover, and state efforts to enroll and maintain coverage for Medicaid beneficiaries, a 2016 study (here) having shown that a quarter of Medicaid beneficiaries lose coverage during the course of a year, known as “churn.” From that 2016 study, “Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status.” The Kaiser Health Network reports on Medicaid (and other) coverage expansion strategies, here.
DOCTORS, NURSES AND OTHER HEALTH CARE PROFESSIONALS
Cutting and Pasting May Be Passé, or Should Be
Dr. Fred Pelzman of Weill Cornell issues a plea in MedPage Today (here): “Screen after screen of labs, cut and pasted data from imaging and procedures and prior consult notes -- on and on it went. But even reading through it in detail, we never really got a sense of what this provider was thinking, and what they thought should happen next . . . Many of our colleagues have started moving the assessment and plan up to the top of their notes, since I think they have found that that's really all everyone's looking for, all they are reading -- what they think is going on, and what they recommend.”
Dr. Pelzman notes that the January 21 changes to Medicare billing and coding compliance (MLN, here) mean that “No longer are the billing and compliance auditors going to be reviewing our charts and counting up the number of organ systems reviewed, the details in each complaint in the history of present illness, or whether a particular field was clicked as reviewed.” He writes, “Let the level of service be almost entirely driven by the level of medical decision-making: the number of problems addressed, the medical complexity, the risk to the patient. This is how we thought it should be all along, and it has been incredibly refreshing to see the change come about at last . . . It has definitely been hard for providers to transition to this new system, and I think our instincts are still to copy forward, cut and paste, and include everything. I think the time has come for this all to become unnecessary, for us to build the electronic medical record as a repository for each patient's healthcare journey, but not require any longer that we pull every old detail, into each and every note we write. With the popularity of the Open Notes movement, and the fact that our patients are going to be reading and reviewing more and more of the notes we write about them, it makes sense that we focus on clarity, brevity, truth-telling, and communication. The echocardiogram report is right there in the same electronic medical record; I don't need to copy it into my note.”
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Failure to Rescue: Are Rapid Response Teams the Answer? Or Just Better Communication, Coordination
A study in JAMA this week (here) resurrects the question of whether “Rapid Response Teams” from the 1990s are an answer to the growing problem of “failure to rescue” in hospitals. “Failure to rescue (FTR) is a patient safety phenomenon of medical or surgical mortality following a major complication, and it generally represents a delay in recognizing or responding to in-hospital complications. Originally a surgical quality measure, FTR is not specific to a particular pathology or disease state; therefore, use as a quality metric across specialties can represent hospital performance rather than patient illness severity. Rapid response teams (RRTs) are a proposed patient safety practice to address FTR and are endorsed by the Institute for Healthcare Improvement and the Joint Commission. These clinical care teams (often multidisciplinary) rapidly assess a patient after an identified critical change in clinical status and determine if a change in care setting (e.g., transfer to an ICU) or treatment plan (e.g., endotracheal intubation) is necessary.”
But evidence for the effectiveness of RRTs seems to be that they are in use by many hospitals: “RRTs as a patient safety practice have strong face validity, as evidenced by the widespread utilization in hospital environments. However, definitive evidence that RRTs are associated with reduced rates of FTR is inconclusive.” And the quality of the evidence, already low, is unlikely to improve: “Overall, there is little current evidence on the direct benefit of RRTs on FTR . . . many of the included studies were conducted more than 5 years ago and most included studies were of low to moderate quality. Conducting randomized clinical trials . . . may be challenging because RRT system use is widespread both in the US and internationally.” Targets for improvement, according to these authors: “Poor hospital safety culture, communication breakdown and inadequate event detection.”
Pediatrics Beds and Units in Hospitals Decreased 2008-2018
A study in Pediatrics (here) found that “Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children’s hospitals.” During the study period, “Pediatric inpatient units decreased by 19.1% . . . and pediatric inpatient unit beds decreased by 11.8% . . . Rural areas experienced steeper proportional declines in pediatric inpatient unit beds . . Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
OIG Faults Medicare on Lack of Cybersecurity Oversight for Medical Devices in Hospitals
The HHS Office of the Inspector General reported (here) that “Medicare Lacks Consistent Oversight of Cybersecurity for Networked Medical Devices in Hospitals,” and also faulted accreditation organizations for not exercising initiative in reviewing device security.
Census Bureau Reports Significant Decrease in Uninsured Adults Under 65, 2013 to 2019
The Bureau’s Small Area Health Insurance Estimates found (here) that “Estimated county uninsured rates ranged from 2.4% to 35.8%, with a median county uninsured rate of 11.0%; The Northeast and Midwest had the nation’s largest share of counties with low (below 10.0%) uninsured rates, and the South had the biggest share with high (above 15.0%) uninsured rates; County uninsured rates of working-age adults (ages 18 to 64), living at or below 138% of the poverty level, ranged from 6.1% to 61.9%; In states that expanded Medicaid eligibility, 9.2% of counties had an estimated uninsured rate above 20% . . . compared to 84.8% of counties in states that didn’t expand it.”
Having Health Insurance vs. Having Affordable Health Care
Connecticut’s Office of Health Strategy takes aim at affordability, even (and especially) among the insured. The Office announced a new Health Affordability Index tool (here, summary here, additional report here) and noted that “Approximately 18% or 165,000 households in Connecticut with adults under the age of 65 face unaffordable health care costs,” and that “An estimated 42% of households who purchase their insurance through Access Health CT, the state’s insurance exchange, face health care costs that exceed the affordability target while 16% of households with employer-sponsored insurance experience health care costs that exceed the target.”
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References (alphabetical) may be found here.
2021 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
July 19, 20, 21, 22, 26, 27, 28, 29, 30
August - none
September 20, 21, 22, 23, 24, 27, 28, 29, 30
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.