Sunday, June 30, 2013

Blood Pressure tracking is best done outside of the doctor's office

Thursday, June 27, 2013
The Record
Your name has been called in the doctor's office. You take a seat, roll up your sleeve, stick your arm in a cuff, squeeze, and then a nurse or doctor reads your blood pressure. It's been done this way for years.
But a growing number of medical experts say that doctors' office blood-pressure readings can be flawed when it comes to diagnosing hypertension, an often symptomless condition that affects a third of adults, and is a major risk factor for heart attack, stroke and kidney disease. According to the American Heart Association, about 20 percent of patients experience "white-coat hypertension" — high blood pressure in the doctor's office due to the anxiety of being examined. Another 30 percent may experience "masked hypertension," blood pressure readings that are normal in the doctor's office, but high during the rest of the day.
"You can't make a decision to commit someone to taking a lifetime of blood pressure medications without having good data," said Dr. David Landers, a cardiologist at Hackensack University Medical Center. "One blood pressure reading in the office is not useful. What you need is more data points."
Some doctors maintain these two devices are better at tracking hypertension: home blood pressure monitors, which have become more affordable (about $45) and accurate in recent years; and an ambulatory blood pressure monitor (ABPM), a cigarette-pack sized device worn by patients for 24 hours and prescribed by their doctors. Fitted with a microchip, it automatically records blood pressure at regular intervals.
In the United Kingdom, ABPMs are routinely used. Anyone suspected of having high blood pressure is ordered to wear an ABPM before going on medication, as recommended by the national health service. In the United States, on the other hand, ABPM is not considered standard care and thus, according to Dr. David Wild, a cardiologist at Holy Name Medical Center in Teaneck, health insurance providers won't always cover it. Medicare will cover ABPM, but only if it's suspected a patient has "white coat hypertension."
Some doctors maintain ABPM is best. By wearing it for 24 hours, patients can have their sleeping blood pressure recorded, which for a small segment of the population may be critical. On average, a person's blood pressure dips by about 10 to 20 percent during sleep. But for some this dipping does not occur, and recent studies show that this group is at very high risk for heart attack or stroke, according to Dr. Craig Bowron, a Minneapolis-based internist and medical writer.
For those already being treated for hypertension, ABPM can also be useful in monitoring how well blood pressure medicines are working throughout the day, Boron said. With this information, a doctor may want to adjust the dosage or, depending on their daily blood pressure variances, even the time a patient takes his/her medication.
"We may be misdiagnosing patients," said Wild. "We should be doing more ABPM. It's the most accurate way to diagnose hypertension."
For Landers, a home blood monitor is good enough. "It's more user-friendly," he said. Though home monitors can become obsessive. "They can make people neurotic," said Bowron, "the same way people follow the stock market's ups and downs in a day."

Medicare To Tie Doctors' Pay To Quality, Cost Of Care

APR 15, 2012
This story was produced in collaboration with wapo
Twenty thousand physicians in four Midwest states received a glimpse into their financial future last month. Landing in their e-mail inboxes were links to reports from Medicare showing the amount their patients cost on average as well as the quality of the care they provided. The reports also showed how Medicare spending on each doctor's patients compared to their local peers in Kansas, Iowa, Missouri and Nebraska.
The "resource use" reports, which Medicare plans to eventually provide to doctors nationwide, are one of the most visible phases of the government's effort to figure out how to enact a complex, delicate and little-noticed provision of the 2010 health care law: paying more to doctors who provide quality care at lower cost to Medicare, and reducing payments to physicians who run up Medicare's costs without better results.
Making providers routinely pay attention to cost and quality is widely viewed as crucial if the country is going to rein in its health care spending, which amounts to more than $2.5 trillion a year. It's also key to keeping Medicare solvent. Efforts have already begun to change the way Medicare pays hospitals, physicians and other providers who agree to work together in new alliances known as "accountable care organizations." This fall, the federal health program for 47 million seniors and disabled people also is adjusting hospital payments based on quality of care, and it plans to take cost into account as early as next year.
But applying these same precepts to doctors is much more difficult, experts agree. Doctors see far fewer patients than do hospitals, so making statistically accurate assessments of doctors' care is much harder. Comparing specialists is tricky, since some focus on particular kinds of patients that tend to be more costly.
Plus, properly assessing how a doctor affects costs must include not just the specific services she directly provides, but also care other providers may give, either because the patient was referred to them or because the original doctor didn't take the right preventive steps to avoid more expensive treatments later on. And without properly adjusting for patients' health problems, paying bonuses to physicians who use fewer Medicare resources might encourage doctors to stint on care or shun patients with expensive-to-treat ailments.
"It may be the most difficult measurement challenge in the whole world of value-based purchasing," said Dr. Donald Berwick, the former administrator of the federal Centers for Medicare & Medicaid Services, or CMS. "We do have to be cautious in this case. It could lead to levels of gaming and misunderstanding and incorrect signals to physicians that might not be best for everyone."
Dr. Michael Kitchell, a neurologist and chairman of the board at the McFarland Clinic in Ames, Iowa, one of the state's biggest multi-specialist practices, predicted the Medicare reports "will be a huge surprise to almost every physician." That's because the calculations of how much those doctors' patients cost Medicare include not just the services of the individual doctor but of all the doctors that provided any treatment to the patient. Kitchell said his own patients saw on average 13 other physicians besides himself.
"You're a victim or a beneficiary of your medical neighborhood," Kitchell said. "If the primary care doctors are doing the preventative screening tests, you'll get credit for that, but if you're in a community where the community doctors are doing a poor job, you're going to look bad."
Medicare officials are trying to refine the way they judge doctors as they follow the health care law's directive to phase in the new payment system, called a Physician Value-Based Payment Modifier, starting in 2015. It will initially apply only to physician groups and some specialists selected by the government, but by 2017 the payment change is supposed to apply to most if not all doctors.
The assessment "is a very important change we're putting into place, one where we're going to need a lot of feedback and deliberation," said Jonathan Blum, CMS's deputy administrator. "We're not blind to the challenges that are coming toward us."
Although the program is still being devised, it will become reality for many doctors starting in January, because CMS plans to base the 2015 bonuses or penalties on what happens to a doctor's patients during 2013.
As the nation's biggest insurer, Medicare's adoption of this approach would be "a game changer" in terms of making physicians directly accountable for costs, said Anders Gilberg, senior vice president at the Medical Group Management Association, which represents physicians groups. Medicare is "going to be shifting money from … physicians who are deemed to be high cost relative to their peers to low-cost physicians. That's going to create all kinds of new incentives in fee-for-service."
Private insurers may follow Medicare's lead, said Paul Ginsburg, president of the Center for Studying Health System Change, a Washington think tank. The formula Medicare ultimately designs to judge and pay doctors, Ginsburg said, could become "a valuable asset for private insurers, with a tool that will be somewhat bulletproof, that physicians won't attack because they've been part of the process of developing them."
But getting physician support may not be so easy, said Margaret O'Kane, president of the National Committee for Quality Assurance, a nonprofit in Washington. "Doctors are a very powerful political segment," she said. In addition, she added, "Patients are not behind this agenda. The public is very scared about managing costs."
In the reports, Medicare measures the average payments it made for each doctor’s patients, as well as subgroups of patients with common chronic conditions, such as chronic obstructive pulmonary disease, diabetes and heart failure. Medicare adjusts the costs to take into account differences in patients' age, gender, poverty and history of medical conditions.
For the resource reports, CMS has come up with a preliminary method to determine how central a role a doctor played in a patient’s care. If a doctor was responsible for at least 35 percent of a patient’s evaluation and management services, they are presumed to have "directed" the beneficiary’s care. If they didn’t direct the care but accounted for at least 20 percent of the physician fees billed for the beneficiary, they are considered to have "influenced" the care. And if they did less than that, they are considered to have "contributed" to the care.
But that method is widely considered so crude that few expect CMS will ultimately use it in payment. CMS is trying to develop more refined methods to compare physicians’ parsimony or extravagance with Medicare dollars using software programs called "episode groupers." These programs determine the combined cost for all the services—including doctors, labs, hospitals and pharmaceuticals—that were used to treat a distinct medical situation, such as urinary tract infection or hypertension attack, over a set period of time.
Initially, Medicare attempted to use existing programs devised by commercial insurers but found they didn’t work with Medicare data, according to a report from the General Accounting Office. "It is not clear that all the problems identified with the commercial groupers can be solved by a Medicare specific grouper and the timeline for its development is challenging," the report said.
Dana Gelb Safran, who oversees quality measurement for Blue Cross Blue Shield of Massachusetts, says she doubts it will be possible for the government to judge individual doctors. She predicts CMS will ultimately have to find ways to evaluate doctors as parts of groups- either formal affiliations as part of group practices or informal affiliations among doctors who refer to each other.
"There really are very few measures that we can reliably evaluate on the individual doctor level," she said. "When they move forward with the value-based modifier, there is going to have to somehow allow physicians to identify other physicians with whom they say they practice and who they say they share clinical risk for performance."
This article was produced by Kaiser Health News with support from The SCAN Foundation.

Meaningful use incentives ascend past $14.5B

June 06, 2013 | Diana Manos, Healthcare IT News
As of the end of April, the federal government has paid out $14.6 billion in EHR incentive payments, according to Robert Anthony, deputy director of the HIT Initiative Group at the Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services.
At the Health IT Policy Committee meeting on Wednesday, Anthony said the numbers were the most current available and show an increasing number of providers are interested in the program. There were 395,000 eligible providers and hospitals in “active registration” in the federal meaningful use program--out of a total pool of 532,000.
Though Medicaid providers lag behind Medicare providers in the program, CMS is encouraged by the steady increase in Medicaid eligible providers signing up to participate. To date, there are some 13,000 Medicaid meaningful users. “We’re seeing more and more come in month-to-month,” Anthony said. “In April, 3,200 came in and demonstrated meaningful use.”

Anthony said CMS is seeing an upward trend of meaningful users — both Medicaid and Medicare — who are not in primary care. Currently, 61 percent are in specialty care.
The numbers are slightly lagging behind those paid out a year ago at this time, but this relates to the fiscal year when certain providers are able to attest according to the program, Anthony said. “We will likely see more eligible providers and hospitals come in after the close of the fiscal year (October 1),” he said.
According to the latest data, a little more than 77 percent of hospitals have been paid under the program, and registration for eligible providers continues “pretty handily” at 75 percent, Anthony said. Three out of every four four eligible hospitals have made a financial commitment to an electronic health record, he said.
Also, according to Anthony:
  • Approximately 50 percent or one out of every two  Medicare EPs are meaningful users of EHRs
  • Approximately 63 percent of all Medicaid EPs have received an EHR incentive payment
  • 10 percent of Medicaid EPs are meaningful users
  • More than 55 percent – one out of every two  Medicare and Medicaid EPs have made a financial commitment to an EHR.
More than 292,000 Medicare and Medicaid eligible providers have received an EHR incentive payment as of the end of April. Not all EPs are new, some are returning from a previous year, Anthony said. “Depending on how the numbers come together, we believe we’ll surpass 300,000 unique providers paid under the program, by the end of May.”
CMS analysis, with data through April, showed 194,080 eligible providers had attested: 193,867 successfully and 213 unsuccessfully. Some 2,977 hospitals had attested, all successfully, Anthony reported.