HealthBlawg

Nursing home arbitration agreements under fire

An Illinois law bars the use of pre-dispute arbitration agreements signed at the time of admission.  This law was upheld by the Illinois appellate court.  The Supremes refused this past week to hear an appeal, letting the lower court ruling stand, despite the existence of a federal law that permits the enforcement of such agreements.  Massachusetts has ruled in favor of the enforceability of arbitration agreements covering nursing home disputes.  As I've written in the past, Federal legislation has been introduced that would have the same effect as the Illinois law, but arbitration (and mediation) are often far preferable to court process for resolution of many types of disputes.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Grand Rounds Vol. 5, No. 37: The June Is Bustin' Out All Over Edition

June is bustin' out all over . . . .  Lord knows my nose knows it, thanks to all the pollen in the air these days.  Check out the classic movie rendition of this set piece (well worth the eight-minute investment), let your coffee and/or antihistamines kick in, and then let's dive into the past week's medblogging, loosely categorized into insights of patient bloggers, provider bloggers, bloggers I've met in real life (the number keeps growing), bloggers following the money trail through the health care thicket, and bloggers who are or should be dancing and/or shirtless (watch the whole movie clip . . . on second thought, let's leave it at dancing).

  

Last time I hosted Grand Rounds, we delved into the origins of Valentine's Day, so even though we're a couple weeks shy of the vernal equinox, since June is bustin' out all over, the historian in me feels the need to touch on an ur-Spring nugget or two before we get going.  Where do these celebrations of Spring come from?

Attis was a Phrygian god, whose annual death and resurrection were mourned and celebrated at a Spring festival.  (On the other hand, the death and rebirth of the Sumerian Tammuz was a summer solstice thing rather than a vernal equinox thing.)  James Fraser, in The Golden Bough, wrote:

The annual death and revival of vegetation is a conception which readily presents itself to men in every stage of savagery and civilisation: and the vastness of the scale on which this ever-recurring decay and regeneration takes place, together with man's most intimate dependence on it for subsistence, combine to render it the most impressive annual occurrence in nature, at least within the temperate zones. It is no wonder that a phenomenon so important, so striking, and so universal should, by suggesting similar ideas, have given rise to similar rites in many lands.

What I best remember from The Golden Bough, though, is the tale of the king-for-a-year, who ascends the throne as a result of a cultic regicide, and ends his term the same way.  Great stuff.

For further reading linking The Golden Bough, The Holy Grail, Wagner's Parsifal, and T.S. Eliot's The Waste Land, check out Derrick Everett's article on The Waste Land.

I'm not certain that Rogers and Hammerstein had these themes in mind when writing Carousel.  Heck, who knows what they had in mind; they threw in a happy ending that wasn't in their source material (but hey, that's show business).  You, dear reader, certainly didn't have these themes in mind when you tuned in to today's edition of Grand Rounds.  Nevertheless, on with today's show.

Provider Bloggers

At Musings of a Distractible Mind, Dr. Rob discusses Atul Gawande's recent New Yorker piece on health care cost variations across the country (a good read, well worth the time), which focuses on McAllen, TX, a small border town that consumes far more than the average annual per capita amount of health care services.  Gawande loops in the Dartmouth Health Atlas folks, asks the hard questions about physician-owned facilities and financial incentives, and concludes that outfits like Geisinger, Intermountain, Kaiser Permanente and Mayo -- not-for-profit integrated delivery systems with salaried docs -- have the model we should strive to emulate systemwide.  Dr. Rob recounts his own experience with physician-owned facilities.  His conclusion is a folksy twist on Gawande's:

How do we fix it?  There are lots of good answers, and lots of dumb ones as well.  The bottom line is the bottom line, though.  How you pay docs will determine what happens.  It’s America, after all.  It’s what makes us great.  Right?

Right.  The thing is, guys, we've known this for at least forty years.

ACP Hospitalist reports on Sid Wolfe's new Public Citizen campaign to get hospitals to step up reporting of physician wrongdoing.  Bob Wachter, at Wachter's World, delves deeper into the problem, and says:

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

Bongi, at other things amanzi, recalls a suboptimal experience in his training, when the "see one, do one, teach one" approach was reduced to "read an article about one, do one immediately afterwards."

At Providentia, Romeo Vitelli looks at the historical precursors to Jenny McCarthy and the current crop of anti-vaccinationists. 

Ken Cohn, a physician and consultant (who I know in real life [IRL]), recounts a (positive) experience in asking health care administrators to consider ethics in physician-hospital relationships.

I take a baby aspirin a day, and Doc Gurley says I should keep on doing so, because I'm better off puking up blood than having a heart attack.

Seizures and how they have been misunderstood (epilepsy vs. demonic possession) is the subject of this week's selection from Mind, Soul and Body.

Suddenly becoming a first responder at 35,000 feet? On Your Meds' Barbara Olson takes you there.  (The blog is part of Medscape, so free registration is required).

NurseAusmed recounts difficulties in handling patient communications and managing patient expectations at Nursing Handover.

How to Cope With Pain takes a page from a book offering guidance to those who have lost their spiritual way and turns the advice to use for those facing physical, rather than spiritual, pain.

Web 2.0 meets the health care establishment, and KevinMD [IRL] observes that since health care is largely a business, this should not be surprising.  For a window into social media use by health care provider organizations, check out healthsocmed.

The anonymous author of Notes of an Anesthesoboist says it's hard for women doctors to make friends . . . perhaps they should introduce themselves as drug pushers instead?

John Crippen wants to, but the NHS Blog Doctor just can't look away from the kids pushed onto TV talent shows by 21st century stage mothers.

Paul Levy [IRL] goes another round with SEIU Local 1199 at Running a Hospital.

At UDM Solutions, David Siwicki provides a clinical perspective on deciding whether to prescribe opioids for chronic pain patients who use marijuana.

Nancy Brown offers sound advice on talking to teens about alcohol at Healthline's Teen Health 411.

Follow the Money

DrRich, at the Covert Rationing Blog, always follows the money, and this week the trail leads to the following unlikely destination: the American College of Surgeons encouraging malpractice suits -- against overseas surgeons offering services to medical tourists.

Big Pharma also always follows the money, and David Williams, at the Health Business Blog, remains perplexed over Pharma's failure to engage with the public via twitter.  (GSK has already responded to David's post, but in a way that doesn't exactly undercut his point.)  For a window into Pharma's engagement with social media, look no further than Shwen Gwee, who organized the Social Pharmer unconference in conjunction with the HealthCamp Boston unconference I co-organized in late April.  Speaking of social media, feel free to follow me on twitter: @healthblawg.  

Last week, I took a look at the proposed Medicare Inpatient Prospective Payment System (IPPS) updates for FFY 2010.  Among other things in the rule (including payments cut to the bone), I was surprised to see tucked away in there a tacit acknowledgement that the whole "no pay for never events" thing isn't really saving anybody that much money.

Lots of hospitals are touting new private rooms these days.  Seems to help patient care (lower infection rates, better sleep, more privacy), but despite the benefits, Jeffrey Seguritan at nuts for healthcare observes that the private room is being pushed by the AIA, and wonders whether health care dollars really ought to be spent these days on capital projects such as these.  (My brief response: these days, they really aren't, given the tight financial markets).

In a medblogosphere first, The Happy Hospitalist has publicly described an entry in the $10 million X Prize competition:

How do you [reduce health care costs dramatically]?  Here's my theory.  You can do more to affect health care costs by getting 10,000 people to change their lifestyle habits than you can by getting a few hundred docs to change how they document and collect data and prescribe some pills.

So here's what you do.  You bribe the public.  People are inherently lazy, but they respond well to piles of money.

For a fuller introduction to the X Prize competition: Scott Shreve [IRL] posted his twitterview on the X Prize with Bertalan Mesko (@berci) at Crossover Health.  Learn more about it there.

The big HITECH Act pot of money that everyone in health IT is itching to get their hands on is going to have some strings attached: chief among them are going to be definitions of "meaningful use" and "certified EHR."  Them that are likely to be certifying -- CCHIT -- have been the target of some possibly well-deserved pot-shots, and the gloves have come off.  See Gilles Frydman's [almost met IRL at the Health 2.0 conference in Boston a month or so ago] framing of the debate at e-patients.net and John Moore's [IRL] take at Chilmark Research.  

Health technology research and development yielded two bits of news this week: FDA approval of a handheld ultrasound unit, via Vijay Sadasivam's scan man's notes, and Ves Dimov's post at Clinical Cases and Images on the Rovio - a WiFi-enabled mobile webcam, which may be more attractive to medical users given the recent study that found patient satisfaction, physician satisfaction and diagnostic agreement (measured both between face-to-face and virtual vists, and between two face-to-face visits) to be similar for face-to-face and virtual visits.  (Yesterday's Boston Globe took a closer look at this study, virtual visits in general, and American Well in particular.)    

The health IT crowd is working on interoperability and portability of health information.  Google Health is one of the platforms that may enable folks to reach this holy grail.  Brian Dolan at mobihealthnews says that Google Wave, an open-source tool for communication and collaboration, looks like a killer tool for enabling Google Health to do more in terms of provider-provider and patient-provider collaboration.

Evan Falchuk's observation at See First on prevention: it ain't cheap; treatment of preventable disease is more expensive than the savings from avoided disease and complications, so we need to be talking about more than cost-effectiveness.  [Supposed to meet IRL soon.]

Patient Bloggers

For some reason, diabetics are very well-represented among Grand Rounds' usual suspects.  This week, they're turning into media critics as well, following President Obama's nomination of Sonia Sotomayor to the Supremes.  Amy Tenderich [who I also almost met IRL at Health 2.0] touched on the media frenzy regarding the nominee's Type 1 diabetes at The Diabetes Mine, as did Six Until Me's Kerri Morrone Sparling.  Not to leave Type 2 diabetes unattended, Rachel Baumgartel offers tips for the newly diagnosed Type 2 diabetic at Diabetes Daily.  (For those who care to immerse themselves in The Politics of the Sotomayor Nomination, the good folks at SCOTUSblog say come on in, the water is fine.)  For a taste of the difficulties faced by some diabetics traveling through airports with needles and curious liquids, head on over to Tim Brown's post at Shoot Up or Put Up. 

At Getting Closer to Myself, Leslie offers her reflections as a twentysomething with auto-immune disease, specifically a feeling of how she can't go home again to an idealized summer retreat.

Barbara Kivowitz describes a good day at In Sickness and In Health, and invites all of us to do the same.

Bloggers Who Are or Should Be Dancing

Val Jones [IRL] is pretty pleased with her high-deductible health plan (HDHP) - cash-only PCP combo.  I hope her husband is dancing after the office procedure scheduled on a dime last weekend . . . and I hope Dr. Val has all the releases for those photos stashed away somewhere.  It's a good solution for those with no chronic conditions, young kids, or other sources of regular interactions with the medical-industrial complex.  And no less a luminary than Clay Christensen says we're 5-6 years away from the tipping point (to mix metaphors) on HSA/HDHP combos, at which time we're likely to see a significant change in the economics of healthcare (with or without significant movement in DC).  For one example of where this may play out, see my recent post on retail health clinics.

No dancing for you if you're susceptible to one of the side effects of Cipro and its relatives (fluoroquinolones): tendon rupture.  There's a black-box warning regarding this, but many clinicians and patients are unaware, says Paul Auerbach at Healthline's Medicine for the Outdoors.

InsureBlog's Bob Vineyard shares good news for Cuba's pre-op transsexual population: coverage is here.  Surely cause for someone (patients, if not bloggers) to dance.

Well, that's the last dance . . . for this week.  See you around the medblogosphere, and next week at the next edition of Grand Rounds. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Physician recruitment and contracting column published in ACHE Journal of Healthcare Management

The American College of Healthcare Executives' bimonthly journal has a column I wrote with my colleague, Ken Cohn, in the current issue: Field-Tested Strategies for Physician Recruitment and Contracting.  Please let us know what you think.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Health Wonk Review is up

Fellow Bostonian Tinker Ready hosts the current edition of Health Wonk Review at Boston Health News.  Her nod to The Boss reminds me that I'll inevitably be heading to the Jersey shore this summer.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Retail Health Clinic Summit: Can we get there from here?

At one of the pre-summit workshops yesterday, Tom Charland (ex-MinuteClinic exec and now consultant) channeled Clay Christensen (Mr. Disruptive Innovation) for a while and laid it on the line: unless retail clinics find a way to beef up off-season volume for at least 5-6 years, they may be dead in the water.  In that time, if Christiansen is right, HSA/HDHPs will become much more prevalent than they are today -- prevalent enough so that retail clinics could safely opt out of health insurance plan provider networks and have a sufficient patient base to draw from.

In the interim, Tom and I agree that retail health clinics need to break out of current operating modes, particularly into chronic care / disease management.  In fact, I was quoted on this point towards the end of a thoughtful piece on retail health clinics in BNA's Health Care Policy Report last month.  Retail clinic providers (including one from Spain), other consultants, payor representatives, drug and device reps, urgent care center operators, and even the US Armed Forces (planning a pilot project foray into retail health clinics) all showed up for the Summit, which provided a mix of perspectives on challenges and opportunities facing this nascent industry.

Slides from my talk at the summit on the Massachusetts experience, and lessons for the future  -- especially the need to move into chronic care and to partner more effectively with health care systems -- are provided here for your viewing pleasure.  My work with all components of health care systems -- including physicians -- makes clear that these combinations have the potential to be very powerful, and makes equally clear that the groundwork must be laid carefully with physician partners and champions in order to ensure the success of such an undertaking.

Retail Health Clinic Summit 2009 - The Massachusetts Experience and Lessons Learned

View more OpenOffice presentations from DavidHarlow.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Grand Rounds is up at See First; next week's edition right here at HealthBlawg

This week's edition of Grand Rounds is up at Evan Falchuk's See First.  Welcome to the party, Evan. 

Next week's "June Is Busting Out All Over" edition will be right here at HealthBlawg.  Please write your post's URL on the back of a twenty-dollar bill and mail it to the address on my home page (apologies to Click and Clack) or send it to me via email at david AT harlowgroup DOT net with "Grand Rounds" or "Twenty Bucks" in the subject line.  Please include the post title, blog title and URL, and your name or nom de blog (or that of the author if not you) as well.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

FY 2010 IPPS: Federales sucker punch the hospital industry

CMS published the FY 2010 IPPS (hospital inpatient prospective payment system) rule and rates on Friday May 22.  I'll offer just some highlights of the 608-page monstrosity here, focusing on the short-term acute care portion; the long term acute care hospital (LTACH) rates are in here, too.

First and foremost: Acute care hospitals will enjoy just a 0.2% increase in DRG payments for the year beginning October 1, 2009.  The rule provides for a 2.1% adjustment for all hospitals reporting RHQPAPU measures (which is virtually everyone); 0.5% if not reporting.  The sucker punch: a 1.9% negative adjustment to adjust for the shift to the severity-adjusted MS-DRG system in FY 2008-09 and the concomitant attention to reporting, which the federales say resulted in higher reimbursements without a change in acuity.  There is a total 8.5% negative adjustment to be made which CMS is deferring so as not to whack the industry excessively just now.  Congress has come to the rescue once, reducing the cuts and deferring the day of reckoning, but that day has now come.  It remains to be seen whether Congress will seek to defeat or defer these cuts again (and again) a la the SGR.  Comments are invited; the AHA and others are already steamed.

One bright spot: orthopedic MS-DRG codes are bucking the trend and see a more significant increase.

A note of caution for hospitals: Even though complete documentation and coding led to the negative adjustment, folks need to continue to do a good job of documentation and coding, since that's what the MS-DRG system is all about.

On the RHQDAPU front: the federales are taking baby steps towards automating the reporting process, testing the transmission system direct from hospital records to a central repository with three measures not currently used for payment incentives.

This year the proposal is to add two new measures to the 44 currently in use (for FY 2011) (see chart in linked Federal Register document, 74 FR 24171-72, pp. 93-94 of pdf) , and 69 additional measures are identified that might be used in the future (74 FR 24172-73, pdf pp. 94-95).  Also interesting is the fact that one measure is being taken off the list based on research tying IV beta blockers to elevated mortality risk in certain populations, and related practice guidelines evolution.  In addition, other measures may come off the list if they've "topped out" with near-universal compliance -- like a pneumonia oxygenation assessment measure.  Comments are invited on determining when to retire criteria and also on the criteria for establishing new criteria.  These criteria are significant, so I quote this section of the commentary in full:

In the FY 2009 IPPS proposed rule, we solicited comments on several considerations related to expanding and updating quality measures, including how to reduce the burden on the hospitals participating in the RHQDAPU program and which approaches to measurement and collection would be most useful while minimizing burden (73 FR 23653 through 23654). In the FY 2009 IPPS final rule, we responded to public comments we received on these issues (73 FR 48613 through 48616). We also stated that in future expansions and updates to the RHQDAPU program measure set, we would be taking into consideration several important goals. These goals include: (a) Expanding the types of measures beyond process of care measures to include an increased number of outcome measures, efficiency measures, and patients’ experience-of-care measures; (b) expanding the scope of hospital services to which the measures apply; (c) considering the burden on hospitals in collecting chart-abstracted data; (d) harmonizing the measures used in the RHQDAPU program with other CMS quality programs to align incentives and promote coordinated efforts to improve quality; (e) seeking to use measures based on alternative sources of data that do not require chart abstraction or that utilize data already being reported by many hospitals, such as data that hospitals report to clinical data registries, or all-payer claims data bases; and (f) weighing the relevance and utility of the measures compared to the burden on hospitals in submitting data under the RHQDAPU program. Specifically, we give priority to quality measures that assess performance on: (a) Conditions that result in the greatest mortality and morbidity in the Medicare population; (b) conditions that are high volume and high cost for the Medicare program; and (c) conditions for which wide cost and treatment variations have been reported, despite established clinical guidelines. We have used and continue to use these criteria to guide our decisions regarding what measures to add to the RHQDAPU program measure set.

The goals of the RHQDAPU articulated here bear close reading.  These are core values that CMS is seeking to refine further -- comments are welcome -- and it seems to me that these core values will continue to inform quality measurement and value based purchasing initiatives of the agency in the future.  The main problem I have with the approach taken to date (and I've been saying this for quite a while) is that the federales -- and other payors -- are asking providers to track too many indicators.  It is possible to track a small number of indicators that are predictive of other quality performance measures.  (Two key people who agree with this perspective are Don Berwick of the Institute for Healthcare Improvement and Leah Binder of the Leapfrog Group, each of whom I've had the opportunity to talk with about this issue, among other things.)  My other problems with the approach are that too little of the total payment is at stake (2%), and that the system is set up as a pay-for-reporting system, not a pay-for-performance system.     

No new hospital-acquired conditions (HACs) are being added to the no pay for never events rule this year.  A very significant fact was tucked away near the very end of the publication (74 FR 24669; pdf p. 591): The no pay for never events rule is only expected to save the federales $21-22 million a year, because most cases with HACs have other comorbidities that result in higher MS-DRG payments anyway.  Sounds to me like this is a rule crying out to be rewritten:  All the hoo-ha over hospital-acquired conditions and no pay for never events and the federales are saving just a measly $21 million a year???  Either tighten it up so that real savings can be achieved or toss it.

Update May 26, 2009: And while the hospitals are down, CMS is cutting indirect GME capital reimbursement to nil.  At least one state hospital association sees these changes as leading to layoffs and closures.

There are many more proposed changes and updates in this reg, but the last I'll touch on here is the EMTALA sanction waiver, which would essentially provide a 72-hour waiver of EMTALA (except for patient dumping based on source of payment) in case of implementation of a hospital disaster protocol.  There is, of course, a pandemic infectious disease exception (for all you swine flu eschatologists out there) extending the 72-hour waiver til the end of a declared public health emergency.

The comment period is open through June 30; a final rule is expected by the end of July, and new rules and rates will be effective October 1.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Yeah, the GOP has a health reform plan, too

Surprise! The latest and greatest Republican health reform plan has tax credits in it to replace tax deductions for employment-based health insurance, has a great-sounding name -- The Patients' Choice Act, and details "core concepts" that (except for the whole libertarian tax credit thing) could've been lifted from any one of a number of Democratic plans.  (Kaiser Family Foundation has a good side-by-side comparison tool available detailing a bunch of proposals that are on the table.)  There's lots of elements of the Massachusetts plan in there, too -- a plan denounced by our former Republican governor while at home, and which he variously derided or took credit for while on the campaign trail, depending on his audience.  Go figure. 

An op-ed piece in the Wall Street Journal this week (penned by worthies of the Galen Institute and American Enterprise Institute) touting the GOP proposal runs a bit wide of the loyal opposition mark, really dialing up the anti-government rhetoric, and also engages in some magical thinking (e.g., employers who no longer have to pay for health insurance will pass the net savings along to employees in the form of higher wages). 

It's all about talking points, I suppose, since whatever odds one may lay on Baucus reporting out a bill that can pass (and, hey, he's been talking about revisiting tax-deductible health plans, too), the likelihood of the House Republican plan making great inroads are next to none.

Update 5/22/09: Baucus offers a gentlemanly thanks to the GOP representatives, saying he shares their goals but rejects their proposed means.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Baucus and health care reform primer

Here's your reading assignment:

Today, the Senate Finance Committee released the third of three health care reform "description of policy options" papers.  The papers are available on the committee's web site:

Transforming the Health Care Delivery System: Proposals to Improve Patient Care and Reduce Health Care Costs

Expanding Health Care Coverage: Proposals to Provide Affordable Coverage to All Americans

Financing Comprehensive Health Care Reform: Proposed Health System Savings and Revenue Options

Accompanying press releases with highlights are available here:

April 28, 2009 press release

May 11, 2009 press release

May 18, 2009 press release

A brief comment period is open for the final policy options paper. 

See also Sen. Baucus' Call to Action white paper and related resources, and the Columbia Journalism Review Baucus Watch series.

Since the Senator plans to report out a health care reform bill within a month or so, looking over these resources would be a worthwhile exercise.

It will be interesting to see how the dance proceeds among the various parties: Congress, the myriad interest groups that have positioned themselves inside the big tent this time around, and the White House, which has taken at least two different approaches to the whole exercise: a Presidential directive to Congress to deliver something Obama can sign that is consistent with his broad health care platform, and closer staff contact meant to ensure that something workable actually gets crafted and passed, not only in the senate but in the House as well.

Much has been said in recent weeks about the public plan option, and whether it will go by the boards in order to appease vested interests.  Adding a public plan option to the Massachusetts Connector-like exchange is appealing, though, and it can be structured in a way that doesn't undercut private plans and send us directly into ... socialism.  

And finally, the elephant in the room is the question of how the dang thing will actually be financed.  The $2 trillion White House announcement and almost immediate backpedaling by the Administration's "partners" last week do not bode well, nor does last week's Washington Post article on the creative accounting used to come up with early estimates of savings linked to widespread EHR use ....  Eliminating or limiting the deduction for health benefits could help close the gap, and some EHR-related savings may be out there, but as they say: not bloody likely.

Read up and stay tuned.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Dr. Ben Kruskal, Director of Infection Control at Harvard Medical Associates: Conversation with David Harlow about Swine Flu / H1N1

My conversation with Ben Kruskal, MD, PhD, HVMA Director of Infection Control, about swine flu / H1N1 continues. 

In today's installment we discussed incidence of new cases, their concentration among children, chances for emergence of a more virulent strain of flu, and closer coordination between large ambulatory practices such as Harvard Vanguard Medical Associates (which has 400,000 patients) and the state Department of Public Health. 

The audio file of our conversation runs about 10 minutes and is available for download/podcast.

Update 5/15/09: Read the linked transcript or the copy below. 

Our earlier conversation is available here.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Ben Kruskal, MD, PhD, Director of Infection Control,
Harvard Vanguard Medical Associates, May 14, 2009

David Harlow:  Hi, this is David Harlow on HealthBlawg and I have with me today Dr. Ben Kruskal from Harvard Vanguard Medical Associates where he is Director of Infection Control.  We spoke a week or so ago about swine flu or the H1N1 virus, and I am eager to learn whether this week you see any change in the progression of this pandemic or epidemic and what sort of changes you see in its progression?  I looked at the numbers today, here in Massachusetts we’re up to about 133 confirmed cases as of this morning.  So, I'm curious to see if you see a progression or a trend in the past week or so?

Dr. Ben Kruskal:  Well it's pretty clear that the virus has, as predicted, started to spread pretty widely in the community and the number of confirmed cases being reported is clearly a pretty big underrepresentation of the real number of cases because we're not even attempting to test all cases.

David Harlow:  Okay, so these are just lab confirmed cases, is what you're saying?

Dr. Ben Kruskal:  Exactly.

David Harlow:  Okay and what was interesting to me in looking at the Department of Public Health's figures is that the majority of these cases are among school-aged children, and CDC said last week that it felt it was no longer necessary to close schools in the event of children being sick.  I am wondering if these numbers might cause us to reconsider that approach.

Dr. Ben Kruskal:  Well, I think what CDC said was not to not close the school at all, but rather not to close the school for a single case which is what the original advice was.  What they are now saying is that the school should only be closed if there is a significant cluster within the school, so I think they're still acting responsibly in the sense that if the school is clearly a focus of spread, that is the time to close things down.  If there are one or two cases that are well-contained, then the inconvenience to the large number of people would occur from closing the school isn’t worth it.

David Harlow:  Okay, fair enough.  And so I think it was in New York today or yesterday where a number of schools were closed.  There is a cluster of 50 cases in one of the schools, so that's consistent with what you are saying, and the CDC policy.

Dr. Ben Kruskal:  It is also very interesting to see that cases do seem to be concentrated among younger people and the explanation for that isn't clear.  I think the predominant speculation is that older people may have encountered strains that were related enough to afford them some immunity, whereas younger people have never seen a strain like this before.

David Harlow:  Interesting.  So you're referring to the swine flu that we had in the mid-70s?

Dr. Ben Kruskal:  Not necessarily that strain, but some other related strain at some point far enough back -- at least 20 years back -- so the young people who are the predominant population affected so far wouldn’t have had any exposure.

David Harlow:  And are those numbers in terms of age distribution consistent across other areas as far as you know, beyond Massachusetts?

Dr. Ben Kruskal:  It's a little hard to make good sense out of the numbers and areas that don’t have a lot of cases because the people who are being tested are very a skewed population, and probably not representative of all cases.  I think in the areas where many fewer cases are reported the predominance of adults is largely because they're looking at people with travel histories.

David Harlow:  Okay.  So how do you see this playing out over the next weeks and months as we get into the warmer weather, and how do you see this playing out next fall or next winter?

Dr. Ben Kruskal:  Well it's still very much up in the air.  The fact that there is as much transmission as there is, even in the relatively warm weather that we've been having in the last couple of weeks, is a little bit of a concerning sign to me that transmission may continue at a really, really high rate even through the summer.  So in terms of spread, it’s surprising that it’s still going on at the rate its going.  There is a concern based on some previous examples of novel strains that as the virus is transmitted from person to person, there may be selection for more virulent sub-strains and that the severity of disease may increase over time.  In some prior outbreaks, the virus has gone underground for the warm season and then re-emerged in a more virulent form in the fall, but I am somewhat concerned, seeing the level of the transmission we’re still sustaining now, that we may be possibly headed for more severe cases even sooner than the fall.

David Harlow:  So it likely will continue even through the warmer weather which will be unusual as I understand it.

Dr. Ben Kruskal:  Absolutely, but again the degree of spread that we're seeing now is pretty unusual as well.

David Harlow:  But thus far at least, it doesn't seem to be that virulent an illness?

Dr. Ben Kruskal:  No, thank goodness, it has been quite mild in the vast majority of cases.

David Harlow:  So, I’m interested to hear how you are dealing with this on behalf of your medical group in dealing with the large population [of 400,000 patients] that you are responsible for?  What are you and your team doing on a daily or weekly basis in order to help manage this?

Dr. Ben Kruskal:  Well, we started from the very beginning and we're fortunate enough to have a plan in place which we were able to adapt quickly to the current situation.  We focus on providing information for our patients that’s been crafted centrally but we’re not relying every on every individual doctor and nurse to create the message themselves.  We had the help of specialists in communications and we have also been working hard to get timely, consistent and accurate information out to our staff in order to equip them to deal with patients’ questions and concerns.  The patient anxiety clearly has been much, much bigger than the actual number of cases, so I think done a reasonably good job of giving people these tools and giving our patients information directly as well.  In addition, we focus very heavily on protecting our staff, knowing that it's hard to come to work if you think you’re going to be infected with something nasty and we’re taking precautions that may be excessive given the relatively mild nature of the illness, but again being conservative and making sure that our staff feel safe coming to work.

David Harlow:  I also understand there's has been a national stockpile of antiviral medication being distributed, has that been distributed to your group as well or is that going just to pharmacies?

Dr. Ben Kruskal:  It actually was initially meant to be distributed only to hospitals and we were active in lobbying the Department of Public Health to include the ambulatory health care organizations as well and succeeded in getting a significant chunk of the distribution for large practices such as Harvard Vanguard.

David Harlow:  So have you been coordinating with the State Department of Public Health along other lines as well?

Dr. Ben Kruskal:  Yes.  We’ve been talking to them for quite some time about the role of ambulatory care providers in provision of care in pandemics and other disasters and I think we’ve really pushed their attention in the direction of what ambulatory care can provide in a disaster like that, and we have extensive discussions which I think have helped to inform the way they are working with other ambulatory groups as well.

David Harlow:  That's encouraging and it makes a lot of sense, since so much care that was in the hospitals traditionally has really been pushed to the ambulatory setting.

Dr. Ben Kruskal:  Right, and enabling the primary care providers to continue to function during an outbreak has several advantages.  One is that by virtue of the existing relationship that we have with our patients we may be able to convince them of things that they might otherwise feel too nervous to hear from a provider they never met before,  so we can help them comply with public health directives in a way that's much harder for an unknown person to do.  In addition, we can take the load of the worried well and the mildly ill off of the hospital, so they can focus their attention on the things that only they can do, which is caring for the most severely ill.

David Harlow:  That makes a lot of sense.  Thank you for your time.  This is David Harlow on HealthBlawg.  I’ve been speaking with Dr. Ben Kruskal, the Director of Infection Control of Harvard Vanguard Medical Associates here in Boston, Massachusetts.  Thank you again.

Dr. Ben Kruskal:  Thanks David.