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2012 Potpourri XXIX

By October 5, 2012Commentary

The American Journal of Managed Care has an article describing an automated system of decision support designed to encourage appropriate ordering of advanced imaging.  The system is an alternative to radiology benefit managers.  The study was based on orders in Minnesota from 2003 to 2010.  From 2003 to 2006, orders rose an average of 9% a year.  Thereafter, orders leveled off, which was coincident with implementation of the decision support system for 45% of ordering physicians and a prior authorization system for the rest.  Physicians expressed a strong preference for the clinical decision support approach and it will now be used by 80% of ordering doctors.  Because many physicians find prior authorization by payers intrusive, an automated alternative may be more successful and less costly.  (AJMC Article)

Massive system reforms like those in Massachusetts and the ACA are supposed to reduce the number of uninsured, thereby allowing them to have complete access to care.  A Perspective in the Journal of the American Medical Association suggests that for some people, health care just can’t get free enough.  The article purports to identify an issue whereby for those residents of Massachusetts with public insurance, even the very nominal copayments are just too much of a cost burden and impair their access to care. The implication of course, is that we should make their health care totally free, so that they can get whatever they want whenever they want it.  Nevermind that the working citizens of that state and this country not only are paying for all that free care, but average thousands of dollars in out-of-pocket costs for their own health care.  There is absolutely nothing fair or socially just about this ludicrous approach, which only encourages unhealthy behavior and lack of personal responsibility.  (JAMA Perspective)

The New England Journal of Medicine carries a study regarding mortality and access to care for adults in states which expanded their Medicaid eligibility.  The authors looked at three states which expanded eligibility and compared them to neighboring states that did not.   According to the authors, these expansions were associated with a 6% reduction in all-cause mortality.  There are methodological shortcomings with the research, but the findings of the article are pretty much irrelevant anyway, because fiscal reality is hitting the states hard and they will all be cutting back Medicaid eligibility and benefits dramatically.  The program is completely unsustainable in a time when budget deficits continue to plague most states and for most, Medicaid has become the largest, and usually the fastest growing, budget category. (NEJM Article)

Telemonitoring continues to show inconsistent results in clinical research.  A study reported in the Archives of Internal Medicine examined its use for 205 elderly patients randomized to either use the Intel Health Guide for telemonitoring or usual care.  The telemonitored data was reviewed daily for nurses, with appropriate followup.  The primary outcomes were hospitalizations and ER visits.  The study was pretty negative for telemonitoring, since hospitalizations and ER were no better, if not worse, in that group and mortality was actually higher.  So it is very likely that costs, especially when the cost of telemonitoring is figured in, were higher in that group as well.  (Archives Article)

Another Perspective in the New England Journal of Medicine traces the history of health reform in the United States, a journey it refers to as “unfinished”.  More likely what they mean is that the “reformers” haven’t finished off health care! In any event, the author provides a good, if brief, summary of the developments in health care coverage and regulation up to and through the wonderful ACA, which can soon be referred to as the UACA (as in unaffordable).  The author views that law as at least partially a failure because it may leave as many as 30 million people uninsured; many of who incidentally would choose to have that status.  And even the author notes that nothing has really been done to tame the growth of health spending in excess of inflation and GDP growth.  The author thinks we will be at a crossroads after this election: more reform or going backwards.  It is a crossroads alright, but the choice is continued growth in government involvement in health care that leads inevitably to lower quality and higher spending, a false reform, or to a return of the system to sounder economic and social principles of personal responsibility, financially and behaviorally.  (NEJM Perspective)

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