HealthyCal.org

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By Lynn Graebner
California Health Report

Across the country, doctors, hospitals and insurers are forming new healthcare entities to increase the efficiency and quality of healthcare, and lower the cost of it. Called accountable care organizations (ACOs), these groups are gaining ground, even though critics consider them a repackaging of HMOs—some of which have given managed care a bad name.

An ACO is a group of healthcare providers such as doctors, hospitals and others, including insurance companies, who agree to work together to provide overall care to their patients. Those providers are accountable for the quality and cost of that care. If they reduce costs while improving patient care, they share in the savings. If they don’t deliver, they may risk losing money.

While the idea has many proponents, critics are concerned about the creation of large healthcare groups that could have too much influence over physician decisions. That could backfire and ultimately result in increased healthcare costs.

“Hospitals controlling and running ACOs – that makes our members very nervous,” said Francisco Silva, vice president and general counsel for the California Medical Association based in Sacramento. “It’s absolutely important that ACOs are physician led…The ACO model can be a very good thing, but it needs to be done carefully as a collaborative effort,” he said. “We learned from the HMO experience. There were a lot of stories of folks being denied care.”

But there is increasing support for changing the way healthcare is delivered and making all parties in the system accountable for the cost.

“Right now I’d say there is a growing consensus that accountable care is the future of healthcare,” said David Muhlestein, an analyst with Leavitt Partners LLC, a Salt Lake City-based healthcare analyst firm.

But a clear definition an ACO has yet to be determined, he added.

ACOs are emerging both through Medicare and in the private sector. The Affordable Care Act required the Centers for Medicare and Medicaid Services (CMS) to develop an ACO program, which, as of July 9, has 154 ACOs serving 2.4 million Medicare patients. These ACOs must meet patient care standards based on 33 quality measures.

Similar ACO models are developing in the private sector led by doctors groups, hospitals and private insurers. Most of those have patient care quality benchmarks similar to the Medicare ACOs, Muhlestein said.

One of the leading tools for improving efficiency and patient care is the adoption of electronic health records for recording and sharing patient data.

“Now we find out who the patient is attributed to and track all his or her other doctors and connect them,” said Cynthia Guzman, CEO of Coast Healthcare Management LLC, which manages Premier ACO Physicians Network, a subsidiary of Lakewood IPA in Lakewood, Calif. Premier is a Medicare ACO which launched in April.

The group is also hiring nurse advocates to help patients get in to see their doctors, to answer questions and to coordinate care.

Hiring advocates is meant to help prevent some common problems. If a patient leaves the hospital and needs antibiotics but they aren’t delivered on time, for example, that could result in the patient being readmitted to the hospital, Guzman said.

“It’s the wave of the future,” she said, “so you enter into it, and hopefully we’re better off for it, but there are no guarantees.”

Blue Shield of California has six active ACOs in California. Two of those launched in July of 2011 and are contracted with the Health Service System City and County of San Francisco. They serve 25,000 beneficiaries and are intended to provide competition in the marketplace, said Lisa Ghotbi, chief operating officer for the Health Service System. Blue Shield originally estimated annual savings of $10 million to $15 million for the city and county.

“We are on track to meet that target and will have final numbers by December 2012,” said Kristen Miranda, vice president of provider network management for Blue Shield.

Premium increases in 2012 for city and county employee and retiree members and their dependents were very minor, Ghotbi said.

But next year’s premium was originally going to increase about 13 percent.  On July 3, the Health Service System board approved moving from a fully-insured HMO to a self-insured /flex-funded HMO, and subsidizing the family rate, so that members with families could afford to stay with Blue Shield, Ghotbi said. Those measures got the rate down to a 3.05 % increase.

As a result of that restructuring, the City and County of San Francisco will now bear more financial risk, so they are even more focused on ensuring the continued success of both ACOs, Ghotbi said.

“We have seen enough evidence to be assured that the ACO model is an improvement to our current healthcare system,” she said.

A big part of cutting costs lies in avoiding preventable hospitalizations and unnecessary emergency room visits, Ghotbi said.

One way to do that is to provide an appropriate level of care when people need it. For instance Brown & Toland Physicians Group, a member of one of the two Blue Shield ACOs for the city and county of San Francisco, opened an After Hours Care facility in San Francisco in March. Patients can be treated for asthma, fever and flu symptoms, wounds and other ailments that might otherwise have landed them in the emergency room.

Another area many ACOs are scrutinizing is specialty care. Blue Shield reported some early results from its Sacramento-based ACO for California Public Employees Retirement System members. They found an overutilization of hysterectomies and elective knee surgeries. The physicians’ group and hospital are now investigating therapy and treatments that should be tried before resorting to surgery, Blue Shield reported.

“There’s evidence that there are a lot of procedures out there that don’t improve health,” said Kelly Devers, a senior fellow in the Health Policy Center at the Urban Institute, a Washington D.C.-based non-partisan economic and social policy research organization. “We’re clearly spending more money than anyone else in the world, but we don’t see the results in our populations’ health.”

Traditionally, specialists like cardiovascular surgeons and oncologists have been the heroes, the profit centers of hospitals, but under an ACO model, those doctors will likely become the focus for cost savings, she said.

And many clinicians are tired of the productivity treadmill, being compensated for the numbers of patients they see and procedures they do rather than for the quality of the care they are providing, Devers said.

But in order for healthcare providers to take on the responsibility for the overall health of a large group of patients, more coordination between physicians is necessary, requiring even more integration among primary care providers, surgical centers, cancer centers, nursing homes and others, said Devers and Muhlestein.

The upside is better physician communication, reduced waste and more preventative medicine. A potential downside is that with consolidation of doctors, hospitals and specialty clinics, ACOs could become so powerful they may start setting healthcare prices in the future, leading to an overall increase in costs, Muhlestein said.

This healthcare reform model also carries a huge potential downside for some providers who will bear more financial risk, possibly resulting in the closure of some physician groups and hospitals, Muhlestein said.

Despite all that there is a strong feeling of hopefulness in the industry.

“There is an enormous amount of potential for taking the waste out of the system and for improving patient care and helping us control costs,” Ghotbi said.

Olivia Destandau, in the hospital outside the pain clinic. Photo: Julia Landau/California Health Report

By Julia Landau
California Health Report

Olivia Destandau was a graphic designer working in San Francisco when a car running a stop sign crushed her body against the left side of her scooter, tearing the major tendons along the outside of her leg. Thanks to immediate surgery she was soon walking, but the impact left her with severe nerve damage. The ache in her leg nagged upward, punctuated by erratic twinges in her shoulder and neck, and never stopped.

That was 1995. Destandau, now 62, learned to mute the pain with high dose opiates. She was prescribed Vicodin or Oxycontin, depending on her doctor’s inclination. The pain kept pace, though, as if it learned to outmaneuver the drugs. But last year, a different doctor disrupted Destandau’s unhappy pharmaceutical routine.

Uninsured and anxious about her dwindling Vicodin supply, she went to the emergency room of Highland Hospital, the go-to hospital for Oakland’s low-income residents. They had launched a new clinic that embraced a sort of maverick program, including a different medication for chronic pain, called buprenorphine.

Commonly known as an “addiction drug,” buprenorphine is rarely used for chronic pain in the U.S. Destandau stumbled into one of a few clinics in the country that would offer buprenorphine to her, a patient with no history of substance abuse.

After years of strategizing, Highland administrators departed from convention with the Pain Management and Functional Restoration Clinic. Both chronic pain and opiate addiction are endemic in the low-income communities that make up their patient base. They wanted to address the first problem adequately, without adding to the second.

Fatal prescription drug overdoses have more than tripled since 1999. Emergency room admissions involving prescription narcotics now outnumber those from all illicit drugs combined.

Howard Kornfeld, the Highland pain clinic’s flagship physician, persuaded hospital administrators to adopt buprenorphine as the core pharmaceutical option. It could kill two birds with one stone, he said: effective for pain but far less habit-forming than other opiates.

“Buprenorphine has been, next to methadone, the sort of light at the end of the tunnel,” says Kornfeld. “Maybe this can help us solve the addiction problem.”

About half of the clinic’s 85 patients are taking or transitioning to buprenorphine—and results have been heartening.

Like many people with chronic pain, Destandau wanted to break her dependence of heavy dose opiates. They felt like a shackle. She found that buprenorphine, a partial opiate, doesn’t reproduce the roller coaster of pain and reprieve typical of full opiates.

The FDA approved buprenorphine in 2002—not for the treatment of pain, but rather for opiate addiction. Buprenorphine, which scientists refer to as a “partial opioid-agonist,” has proven effective in curbing cravings and reducing relapse to heroin. The drug is pharmacologically unique: it can ease pain while muting the euphoric blast produced by full opiates.

But buprenorphine is branded in the U.S. as an addiction medicine, and its possibilities for pain are often overlooked.

When it was discovered in the 1970s, some christened buprenorphine the Holy Grail of opiate pharmacology. It fastens to the brain’s opiate receptors tightly, inhibiting dopamine from flooding the bloodstream. Scientists label this the “ceiling effect.” Taking more buprenorphine won’t heighten opiatic sensations. The reduced euphoria lowers its potential for abuse or overdose. This has led many researchers to identify buprenorphine, ideally combined with cognitive therapy and social support, as a key to resolving a major medical controversy.

“In medical school, doctors are taught to treat acute pain with opioids. But when pain becomes chronic, you start having problems,” says Dr. Steven Grinstead, a psychologist who trains professionals in the treatment of chronic pain and addictive disorders.

Full opiates like Vicodin and Oxycontin are medically useful. The surge of optimism produces swift, albeit temporary, relief for patients—useful for doctors in a pinch.

But Grinstead says his experience with chronic pain patients has demonstrated the limits of opioids long-term.

“Buprenorphine might work better for many people than OxyContin or oxycodone or even methadone,” says Grinstead.

Kornfeld agrees, saying opiates often become not only insufficient, but harmful. Some patients develop hyperalgesia, a condition wherein pain is actually exacerbated from opiates. Full opiates effect miraculous relief in the short term, he says, but tend to bring diminishing returns for persistent pain.

“[Chronic pain] patients don’t always do well on opiates,” he says. “They develop tolerance, so the benefits don’t last long enough. They become more disabled over time,” rather than more functional.

Kornfeld specializes in both addiction and pain. His rare medical niche shows him victims from both sides of the opiate war. As an addiction doctor in wealthy Marin, he treats teenagers who’ve become severely addicted to Vicodin or Oxycontin, which they acquire from friends or classmates, or appropriate from medicine cabinets with surplus prescriptions.

But while some doctors are too liberal with painkillers, others are overcautious. Kornfeld sees pain patients, abruptly cut off from opiates by their doctors, after months of high doses. This causes a downslide with potentially dangerous side effects like acute depression; plus the added stress of being treated like a criminal.

Destandau says opiates gave her fleeting relief. Her pain subsided for an hour or two before symptoms sprouted up. On bad days, she dwelled in a cycle of dread and anticipation of the next dose.

“Opiates are a masking effect,” Destandau says. “Then I’d start noticing that my attention is being drawn away. I’m adjusting my seat, my spine is burning, my knee starts to throb.”

And the daily drugs depressed her, and deadened her senses. She tried methadone, which was longer-acting, but she found herself steadily needing higher doses.

“Ultimately our goal is to get them off everything,” says Kornfeld. “Once they are stable on buprenorphine, they can start lowering it incrementally, whereas patients on morphine or Vicodin, or methadone—they very rarely lower the dose.”

Destandau says buprenorphine now works as well as the old regime. And, she says, “I have mental clarity.”

Buprenorphine, though permitted for off-label use by the FDA, is tightly regulated by law enforcement. In order to prescribe buprenorphine for opiate addiction, doctors need a special license from the Drug Enforcement Agency. Once certified, they can maintain a maximum of 30 patients with buprenorphine at a time.

When prescribed for pain, there are no such restrictions. But doctors who don’t have specific curiosity about buprenorphine are unlikely to become acquainted with it, says Grinstead.

“Because buprenorphine hasn’t been marketed for chronic pain, everyone says ‘it’s for addicts,” he says.

Since its inception in the 1960s, methadone wasn’t used for pain. Only in the last ten years or so, as worries about opiates rose, has it become a standard for use in chronic pain.

“Eventually, the word catches on,” says Grinstead.

Contrary to popular perception, studies show the majority of people who are prescribed opiates for medical reasons do not become addicted. Addiction implies continued, nonmedical use despite harmful effects. Opiate-related accidents and overdoses mostly happen when drugs are diverted—sold, given away, or stolen from people who had prescriptions. One large study of patients entering treatment for OxyContin addiction showed that most had never received a legitimate prescription for the drug.

Buprenorphine is much more difficult to abuse—it actually diminishes the effect of other opiates—and so less frequently diverted.

The Highland clinic does not rely solely on pain medication. Patients see psychiatrists for depression, and meet with counselors; they examine the psychosocial issues that arise with long-term pain, like employment and housing instability.

“I’ve noticed certain triggers for pain,” said Destandau. “Behaviors and attitudes that make it worse.”

Destandau never thought she’d be cured of pain—she says she doesn’t entertain miracles. But the clinic has helped to change her perspective.

“It gave me a break from this opiate-induced life I was having,” she says, “It presented another idea. I thought, ‘Hey, if I can stabilize some other things, maybe I won’t need so much medication.’ I can actually see living without the opiates. I would never have imagined that before.”

Note: This story has been updated. An earlier version of this story stated incorrectly that Howard Kornfeld is board certified in psychology.

By Daniel Weintraub
California Health Report

Low-income Californians want closer relationships with their doctors’ offices — but not only with their doctor, according to a new poll that plumbed the needs and desires of a population that will be at the heart of federal health reform.

The survey, released Monday, found that most low-income patients would be happy to have a “team approach” to treatment that included not just a doctor but nurses, medical assistants, dieticians and health outreach workers.

The key finding is that these patients now often feel disconnected from their medical provider, and they want a personal relationship with someone who knows their name, what ailments they have and what treatments have been tried in the past.

The survey of a representative, random sample of 1,024 low-income Californians aged 19 to 64 also found that a surprising number of people would like to use new technology to communicate with their health care provider, but relatively few do so today.

The poll was managed and analyzed by Langer Research Associates of New York and funded by the Blue Shield Foundation of California. (Note: The Foundation is also a financial sponsor of healthycal.org.)

Gary Langer, president of Langer Research, said the broad survey of low-income Californians, believed to be the largest of its kind ever done, is especially relevant as the federal Affordable Care Act takes full effect over the next 18 months. The population polled – those whose incomes are below 200 percent of the federal poverty rate – will gain new access to health coverage and more choices for how they get their health care.

But as millions of Californians who are now without insurance get coverage, experts fear that there will not be enough doctors to go around. In some communities, low-income people in the state Medi-Cal program already have difficulty finding doctors who will accept the government-subsidized health plan.

“There is a stated desire for a regular personal doctor, which can be a challenge for many providers,” Langer said. “What we found in the study is that that really is an expression of a desire for a personal connection, a desire to have someone who knows you on a personal level and to have someone you can see on a regular basis.

“Both of these speak to a level of connectedness.”

The answer, some believe, is to offer patients a team-based approach headed by a physician but including other medical professionals who are less costly and, because their jobs require less training, can be added more quickly to the health care workforce. This model meshes well with the idea of a “medical home” – a health care provider where a team of professionals keep track of a patient’s history, the medications they are taking, and the progress they are making.

The survey found that 81 percent of low-income people who don’t have team-based care today say they would be willing to try it. And an astounding 94 percent of people who do have it now say they are satisfied – a level of satisfaction rarely found among any institution or service.

Similarly, just one in six low-income Californians said they now have what is known as a health care “navigator” – someone to guide them through the medical system and its bureaucracy. But 91 percent of those who do have a navigator say they are satisfied.

How important can that connection be for patients? Very.

Eighty percent say it is important to have someone at the doctor’s office who “knows you pretty well.” But only 38 percent report having someone like that now.

Because the traditional, doctor-dominated model remains the most prevalent, most people who report having that personal connection have it with a physician. Fifty percent of patients who go to a private doctor’s office report have a personal connection, but just 38 percent of patients at community clinics say they have a connection, and just 36 percent of patients who use Kaiser Permanente report having that personal link that they desire.

“People are open to new models of care,” said Peter Long, president and Chief Executive Officer of the Blue Shield of California Foundation. “They want a good relationship and an ongoing connection. And when they have these things they are willing to take more responsibility for their own care.”

Long also noted that low-income patients, especially young ones, are eager to embrace new technology. He said concerns about privacy have so far prevented widespread use of e-mail and texting to communicate with patients, but patients seem to want to use those tools, and electronic communication could vastly improve the productivity of the medical profession.

Six in ten low-income Californians, for example, said they would be willing to substitute a phone conversation for a personal visit on routine matters. And around 60 percent of those surveyed also said they would be willing to use e-mail and the Internet to schedule appointments, review their medical records and renew prescriptions. Only 5 percent are doing so now.

“There is a gap between what people want and what they are getting,” Long said.

The survey was conducted in English and Spanish from March 12 to April 18. Results for the full sample have a margin of error of plus or minus 3.5 percentage points.

By Melissa Flores
California Health Report

Lisa Krieger’s 88-year-old father, who was suffering from dementia, was very frail when he developed an infection.

“I rushed him to the ER because that’s what you do when you have a sick loved one,” she said.

But Krieger, who writes about health for the San Jose Mercury News, soon learned how difficult end-of-life decisions can be. She was an only child, and deciding how far to go to try to extend her father’s life fell to her.

“It is like being on a freeway of technology where you can’t find the exit ramps,” she said. “I learned the system is built to save people. It is easy to get care and very hard to say no.

“What really resonates is that it is important to have goals and make sure technology use is in line with those goals,” she said.

Such questions about how to approach the end of life, especially for family members or friends making decisions for loved ones with a diminished capacity to make their own choices, can prove full of dilemmas.
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This article is one in an occasional series on aging with dignity, independent living and public policy that affects both. For a complete archive of the articles, click here.

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The Hospice Foundation of America tries to address some of the issues each year with its “Living With Grief” video presentation, shown at conferences throughout the United States, including a recent conference in Monterey Bay this spring.

The panel discussion that followed the video brought together medical professionals, lawyers and people who have recently faced end-of-life issues.

Even advanced directives – which can include such information as what treatment or procedures a patient wants such as resuscitation, ventilators or feeding tubes – can have limitations since they cannot foresee all possible situations, said John Hausdorff, the medical director of Community Hospital of the Monterey Peninsula’s hospice program.

“What we really need are discussions,” Hausdorff said. “We need to get it to be okay to talk about these things with family at the dinner table and with physicians. It should be more around ‘What do I value?’ and what do you want to be able to do. When things get very bad, maybe that’s the point you let go – when you can’t recognize your family or joke around.”

It’s important for physicians to take care in what kinds of treatment options are offered at the end of life, said Theodore Kaczmar, a neurosurgeon who is on the bioethics committee at Salinas Valley Memorial Hospital.

“We need to ethically distinguish between treatment that has a low chance of success or no chance,” he said. “Certain care options we don’t present to families because it would be futile. It is much harder to withdraw treatment than not to start it.”

Krieger, speaking from a family’s point of view, said that she would have preferred healthcare professionals refer to treatment as ineffective rather than futile because that implies there is no hope.

“Finally when the palliative care team came in (to care for her father) what really helped a whole lot was they said what they can do,” she said. “‘We can’t cure him but we can make him comfortable.’ The way they framed it wasn’t that they were taking care away but that they were providing a different type of care that would be better for him.”

Hausdorff described a patient he had seen once who was 90 years old, had cancer, bad lungs, diabetes, dementia and problems with her legs. The family brought her from a nursing home to the hospital and insisted on CPR even after doctors said she would not be able to survive CPR.

“In homecare we talk with families about end of life – that there is a difference between extending life and delaying death,” said John O’Brien, the chief executive officer of Central Coast Senior Services. “Quite often (family members) are delaying death with what they are talking about but they don’t realize it. They talk about delaying the inevitable but it is going to happen.”

“Medical schools didn’t talk a lot about hospice,” O’Brien said. “Medicine is a world of specialists and they can kick the can down the road to the next physician. The outcome for the family and patient side is lacking…we tend to avoid the conversation.”

Stephen Pearson, a lawyer on the panel, said more education about hospice would help to get people to select it earlier on.

“There needs to be more education about the advantages,” he said.

Hausdorff said as hospice and palliative care programs expand there is a push to teach it in medical schools and with residents.

Krieger acknowledged that it can be hard for families to discuss the topic.

“When someone gets a dementia diagnosis is a good time to talk,” she said. “One thing I keep hearing from people is ‘I thought there would be more time.’”

She said as societal norms change more of these important conversations may start.

“Kids don’t want to talk about it because they don’t want to feel like they are throwing granny off a cliff and parents don’t want to talk about it because it is depressing. But I hope there is a change to the norm so it becomes acceptable.”

By Daniel Weintraub

Today’s Supreme Court decision on President Obama’s health care law will help millions of Californians gain access to health insurance, and the decision could jump start Obama’s reelection campaign. But in an odd twist, even while upholding the law, Chief Justice John Roberts also gave a major legal victory to conservatives, ruling that Congress does not have the power under the Constitution’s Commerce Clause to require people to buy insurance.

Roberts sided with the court’s four other conservatives, including usual swing-vote Anthony Kennedy, in concluding that the mandate to buy insurance violated the Commerce Clause. But then Roberts turned around and agreed with the court’s four liberals that the health law was constitutional under the power of Congress to levy taxes.

The mandate to buy insurance will be enforced as part of the tax code. Thus Americans will have a choice. Buy (or otherwise obtain) insurance, or pay the penalty, or tax. That’s not a mandate, Roberts ruled, but a choice, an option. And the tax people will have to pay, he reasoned, is not so large that the choice becomes meaningless.

So Roberts did the seemingly impossible. He was the only justice on the nine-member court who held the position that the law both violated the Commerce Clause but was still constitutional. And that was the position embodied in the ruling.

Most Americans will probably focus on the court’s upholding of the law. That part of the ruling will validate Obama’s signature domestic policy achievement and probably build support for the law and, ultimately, the president.

But conservatives were as concerned about the long-term implications of the mandate as they were about the health law itself. And they will hope that the 5-4 decision establishing limits on the power of Congress to regulate commerce, indeed to compel commerce, will have a more longlasting and far reaching impact than the health law itself.