Curbside Consult with Dr. Jayne 1/4/16

This year started with a bang as I received my first request to bid on a new consulting engagement over the weekend. I need to do quite a bit of discovery before I decide whether or not I’m going to take it, but I admit I’m seriously intrigued.

It’s from a group of physicians that consults at various extended care facilities and nursing homes where documentation is still done on paper. They’re looking at ways to better manage the use of potentially harmful medications in the elderly. Their needs initially sounded like more of a traditional “assistance with system selection” effort, which I’ve done quite a bit of. That’s how they heard about me. But the more we talked, I understood that they’ve already narrowed it down to three vendors and are looking for some very pointed critiques of the approaches.

In hearing overviews of the proposals, they range from moderately serious to what sounds downright comical. They seem like they would be a good bunch of people to work with, although I’m halfway tempted to tell them they need to choose Door #4 and go back to the drawing board. I can tell from several states away that the one proposal was cooked up by some sales team who really doesn’t understand the business or the needs of the providers and I’m tempted to take the job just to skewer them. I’m not sure I’m going to be able to dedicate enough time to this job as it would likely need, so I may have to take a pass depending on their timing and some other factors.

I worked New Year’s Eve in the trenches, which is always a good time. My experience over the years is that staff members working the holidays tend to be motivated to help move things along as quickly as possible, since you never know when your next rush of patients is going to arrive and you don’t want to be caught behind if you can help it. My shift ended before midnight, though, so I didn’t get to see a lot of the more story-worthy patient visits.

I can say honestly, though, that influenza season is here in full force. If you haven’t received a vaccination yet, there’s still time and I would encourage everyone to do so. If this weekend is any indication, there’s a high potential for this season being quite challenging.

I spent the rest of the weekend getting caught up on email and around the house. My goal this year is to not have an inbox that is perpetually full.

I took particular delight in clicking “delete” on a couple of emails from CMS. One was regarding batch upload for 2015 EHR incentive program attestations. Although I’m still peripherally involved in assisting my clients through this process, I am glad to not be personally accountable for managing the process for my own physician group. The attestation period for Medicare programs starts today and runs through February 29 for those of you playing the home game.

I also enjoyed deleting a CMS “year in review” email celebrating a look back at ICD-10. There were several emails from CMS and ONC covering their joint effort to address quality measure reporting under the various inpatient and ambulatory reporting systems as well as the EHR incentive program. They’re trying (again) to streamline the reporting process and reduce the burden to users, organizations, and vendors, but I’ve not been impressed by their previous work in this regard.

I also found an email from CMS about the new Medicare Drug Spending Dashboard and spent a few minutes checking it out. Drugs were selected for inclusion on the main dashboard due to high total program spending, high annual spending per user, or a large increase in average cost per user. Some of the drugs having the highest jumps were generics – why is digoxin up 298 percent? It’s been generic as long as I’ve been practicing. It’s still relatively cheap in the grand scheme of things, but I was surprised by the numbers.

Not surprising was the inclusion of several medications that are extremely expensive and often-prescribed despite being only marginally more effective or tolerated than the traditional / generic / cheap competitors. There were more than 20 drugs on the list which have more than $1 billion in total spending (2014 data) with some in the $3B range. The original email about the dashboard mentioned that HHS convened a group of consumers, providers, employers, vendors, payers, government agencies, and others to discuss how to balance “the dual imperatives of encouraging drug development and innovation while ensuring access and affordability.” I’d personally like to see Medicare beneficiaries take this list to their doctors and if they are on some of these high-dollar drugs, discuss whether there are alternatives and how much benefit they’re really getting from the Cadillac vs. the Buick vs. the Chevy and how that meets their life goals.

I shudder when I see patients in their 80s and 90s who are on medications that are adding little to their health besides higher costs and an increasing risk of complications due to polypharmacy. I remember when a patient in her early 90s came to “interview” me as she was shopping for a new doctor. She and her daughter (who was 70) came to talk about my philosophy of geriatric care. She was reasonably healthy and shared a home with her daughter and had only been hospitalized once in the previous five years. I honestly told her that I didn’t have a lot of patients in her age bracket, but if she were to join my practice, my main goal would be to prevent as much as possible and to give her medications only if absolutely required. I must have made an impression because she transferred her records the following week.

Some of the reporting around the CMS drug dashboard data shows the shift in disease burden as different populations join the Medicare rolls. Hepatitis C treatment has a significant cost impact along with cancer, diabetes, and pulmonary disease. It also mentions that this is only part of the relevant data – it doesn’t include spending data for commercial payers, Medicaid, the VA, or the military and doesn’t show whether there are rebates or other cost-shifting arrangements.

I expect Medicare to be insolvent by the time I’m 65 and out-of-pocket costs to be absolutely insane, so I’m doing what I can to keep chronic disease off my doorstep. Although I’m not the most disciplined when it comes to food choices (the pastry therapy doesn’t really help either), I’ve got a pretty solid relationship with my treadmill since I upgraded it early last year. Committing to be on it as many days as possible is as close to a resolution as I’m getting.

What’s your New Year’s resolution? Email me.

Email Dr. Jayne.