Trump Does Health Care ‘End Run’ Around Congress – Critics Call Executive Order ‘Callous Sabotage’

Interestingly in a country where many debate the psychological state of this president, the American Psychological Association says Donald Trump is taking us backward in healthcare. Other critics are much, much harsher.

For much of the year, Trump has been upset that one of his signature campaign themes was not realized, the overturning of Obamacare. After all, for his base, his hard-core supporters, what had he done, beyond the mood swings? Every once in a while, in between tweets denouncing “false media” or criticizing the NFL, he took stabs at Congress for not passing a bill to rid the Affordable Care Act.

He wanted the wrecking ball and the GOP leadership didn’t come through.

Yesterday, he went off the legislative track and stayed on the executive: Trump signed an executive order to take steps that he says were designed to expand choices and alternatives to Obamacare, while increasing competition to reduce costs. Not so fast, critics say.  Trump also is moving to end billions of dollars of key so-called “cost-sharing” payments by insurers that help lower-income people pay for insurance, opponents say. The actions could undermine the entire Obamacare marketplace, and result in insurance policies with reduced benefits.

Many groups are concerned that the Trump action targets the most vulnerable: those people who need services the most may be left out in the cold. Some say that they are concerned that health plans ultimately would not provide the essential health services such as maternity care and services for children, and cheap and narrow plans would be structured outside of the Affordable Care Act  that might draw healthy people, but leave sicker people or those with pre-existing conditions facing what some term as “impossibly higher premiums.”

In a tweet this morning, Trump suggested he wants to work with Democrats on Obamacare. “The Democrats ObamaCare is imploding,” he wrote. “Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!.”

“The time has come to give Americans the freedom to purchase health insurance across state lines, which will create a truly competitive national marketplace that will bring costs way down and provide for better care,” Trump said in an earlier statement.

Trump poked at the flaws of Obamacare: the percentage of workers at small firms receiving coverage through their employer had declined from nearly half in 2010 to about one-third in 2017, according to the White House.

The subsidies that Trump seeks to get rid of impact about 6 million people, the Department of Health and Human Services says, costing about $7 billion in 2017, according to CNN.

Once again, instead of trying to rebuild flaws in the current system, Trump seems intent on undoing it. He’s an interesting kind of developer. He destroys and then….His critics say with the executive action and others, healthcare in the country is becoming Trumpcare and the problems are his, at least politically.

“The executive order begins by reciting perceived failures of the Affordable Care Act; rising premiums for ACA coverage, reduced insurer participation in exchanges and reduced exchange enrollment,” Timothy Jost, a contributing editor at Health Affairs and emeritus professor at the Washington and Lee University School of Law, wrote in a Health Affairs blog. “However, many of the problems the individual market is experiencing are certainly due to actions the Trump administration has taken to undermine ACA coverage, and there is good evidence that the ACA market could have stabilized absent those actions,” Jost added.

The order essentially encourages health plans “to pick and choose” services they cover and won’t help those who desperately need mental health, substance use, and other critical services,” Antonio Punte, PhD, president of the American Psychological Association said in a statement. “Before the Affordable Care Act, more than one-third of individual market plan plans chose not to cover mental health services and nearly half chose not to cover substance abuse.”

Punte noted these are especially tough times: 91 Americans a day, for instance, are dying from opioid overdoses.

“Today health plans are competing on how efficiently and effectively they provide care, but the president’s executive order, if carried out, would take us backward by letting plans once again compete on how fewer services they cover and ignore state health insurance protections,” Punte said. “We are deeply disappointed that the administration continues to try to dismantle our health care system, instead of trying to increase enrollment and stabilize insurance markets.”

“Now that President Trump and the Republican Congress failed to end the Affordable Care Act by legislation, the president is sabotaging the law by executive action,” said Vanita Gupta, president and CEO of The Leadership Conference on Civil & Human Rights. “Today’s move is their effort to put another nail in the coffin. This order will only drive up costs for the sick and put the health of millions at risk.”

Trump’s executive order “will result in fewer protections for the most vulnerable Americans, such as those with pre-existing conditions, and will encourage sham, loosely regulated health insurance plans that won’t provide adequate benefits,” said Randi Weingarten, head of the American Federation of Teachers in a statement. “Ultimately, this could lead to the collapse of individual health insurance markets through which millions of Americans obtain coverage.”

“Donald Trump owns the unwinding of the Affordable Care Act,” Weingarten said. “He is ignoring the rule of law, refusing to compromise, and doing an end-run around Congress in order to strip people of their healthcare. Millions of Americans will be worse off because of his actions. There is an ongoing pattern of the Trump administration’s callous sabotage of Obamacare, and it will cause real harm to American families.” – Joe Cantlupe

To Err In An Electronic Medical Record

After spending a lot of my time recently visiting my mom in a hospital, I couldn’t help but think every time the nurse came by, with pills and a small plastic cup of water, about what physicians, nurses and patients must confront: what is the right medication, when is it too much, what isn’t enough? What if they make a mistake about those medications?

Yes, despite electronic medical records, which have enabled sweeping changes in healthcare over the last few years to improve coordination efficiency, and quality of care, there are still wide gaps in the information that exists and not used properly.

That’s one of the reasons some numbers, like those of medication errors, are not where we want them to be.

According to the FDA, medication errors increased from 16,689 in 2010, to over 93,930 in 2016 – showing a whopping 463 percent jump. Those errors contributed to at least 230,000 deaths annually, some studies show, making them responsible for being the third largest cause of fatalities.

As in any error, there are many variables and reasons for each of them. Ironically, the increasing errors come at a time when hospital officials say there have been many data significant improvements in medical data systems. They include “alerts” in electronic medical records when the computers identify something that procedurally may be wrong, such as the kind of – or amount of – medications being given to a patient.

The latest statistics on medication errors show that more safeguards and tools are needed to help physicians, nurses and other staff overcome human flaws in assessing these alerts, such as “alert fatigue” when too many red lights go off, and the staff believe they know better than what machines are telling them, as if the computers are crying wolf once too often, and the physicians or nurses just walk on by to the next patient.

Shobha Phansalkar, MD

Shobha Phansalkar, RPh, PhD, director of informatics and clinical innovation at Wolters Kluwer, has spent years evaluating these so-called clinical information systems, especially the ins-and-outs of how healthcare handles medications and how they are given to patients. Also an assistant professor in the division of general medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, Phansalkar has worked diligently on analytical tools and yes, has examined the human factor in medication errors. In extensive studies she has carried out with colleagues over the years, and in an interview with HealthDataBuzz earlier this year, Phansalkar says the push toward adopting electronic medical records have been key initiatives for hospital quality and safety, but they are deeply flawed and their potential benefits have not been reached, not by any stretch.

In fact, Phansalkar’s studies on medication errors, particularly related to alerts related to drug-interaction, have exposed significant weaknesses in healthcare electronic medical systems and the so-called alerts. One of the major problems, she says, is that there are unclear messages in these alerts, and physicians decide to ignore or “override” them because they are not presented in a clear manner, or give context to what the doctors are doing. Studies by Phansalkar and her colleagues show that as many as 49 to 96 percent of all alerts are ignored, depending on the setting. Or as she and her colleagues have written: Alerts have “lagged behind expectations.”

As such, Phansalkar and her colleagues have been working to develop alert systems that have tools to overcome these limitations, with the “human element” very much a key focus. Wolters Kluwer Clinical Drug Information technology has developed programs to revise the alerting “logic” in electronic medical records to improve patient safety, she says.

“Errors are continuing to take place in every aspect of healthcare,” she says. “And they are taking place especially at the point of care such as when the right medications are chosen or supposed to be chosen. One of the problems is that providers are inundated with these alerts and are overriding a large number of them.”

Electronic medical records are limited in their ability to evaluate drug interactions, which could have sharp negative impacts on patients. This is becoming of greater importance as patients take more prescription medications than ever and often physicians still don’t have access to the entire patient history – despite the electronic medical records, Phansalkar says.

“It’s an age where we can exchange information easily, but somehow healthcare has lagged behind,” she says. “We’ve become more aware of the problem and we have better mechanisms in place, but with a fragmented system, and patients seeking care from multiple numbers of providers, whether it’s by choice or driven by health insurance, providers don’t have access to the entire patient profile. The physician doesn’t have access to all the medications and relies on a piece of the pie and that results in errors.

When a physician gets these “alerts” there are some built-in problems that Phansalkar and others are trying to fix. The lack of context about the medications being prescribed, such as the dose-toxicity or potential dependency of the patient, Phansalkar says.  Also, alerts should be identified as to whether they should be a priority or not, or the impact to the patient when a doctor decides to override them, she adds.  In addition, physicians have to evaluate similarities in different medications to ensure there is a “right bar code,” for instance, that is coordinated with pharmacies, according to Phansalkar.

Another problem in how these alerts are put together, she and colleagues say in a study. That relates to how “designers and vendors sharply limit the ability to modify alert systems because they fear being exposed to liability,” they wrote. That can be overcome through “finely tailored or parsimonious warnings that could ease alert fatigue without imparting a high risk of litigation for vendors, purchasers, and users,” the authors added in the study.  In addition, they said, more government regulation and development of international practice guidelines should highlight the warnings.

As Phansalkar wrote in Health System Management last year, “Alert fatigue remains one of the greatest hindrances to optimal use of clinical decision support at the point of care. Finding the right balance of the volume of alerts to display has been an elusive pursuit for EMR and CDS vendors.”

Phansalkar and her colleagues are working to change the alert system through various new models to improve patient care.

“Warnings could be tailored to a particular clinical environment, taking into account the individual care setting, such as adjusting the type or state of a medication interaction alert if a particular community of physicians is found to respond inappropriately to it,” they said in one study. “A tailored system might advise adjusting a patients medication dosage only when other patient data, such as age, or specific comorbidities, such as a rental function, raise concern, as opposed to alerting indiscriminately for all patients.”

Some healthcare organizations have taken steps to do just that – tinkering with their alert systems, such as the Group Health Cooperative of South Central Wisconsin, which used “filtering mechanisms” to address potential alert fatigue. Using guidelines developed by Wolters Kluwer, the healthcare system reduced the number of alerts from 87 percent to 27 percent, Phansalkar wrote.

MetroHealth in Ohio reduced and streamlined drug dose alerts by some 80 percent to avoid physician fatigue, she added.

Phansalkar is examining the impact of medication errors through and beyond the hospital stay or at a physician’s office.

“We’re are studying the downstream impact, what happens when a patient leaves the hospital, or the provider. Are they being counseled appropriately about medications or drug interactions?” she says. “There is a big opportunity to counsel these patients at that time.”

Indeed, health officials must ensure proper medication adherence from the beginning of a patient’s journey through the healthcare system, from the moment at “the gateway of patient interaction,” Phansalkar says . – Joe Cantlupe.




Let’s Come Together And Have An ‘Apolitical” Approach to End Gun Violence, Johns Hopkins Researcher Says: Multi-Year Health Affairs Study Shows Extensive Gun-Related Injuries

As America reels over the horrendous and heart-breaking mass shooting in Las Vegas, researchers from the Johns Hopkins University School of Medicine coincidentally released a disturbing report about firearm-related injuries in the U.S. that showed more than 700,000 patient visits to hospital emergency departments that resulted from shootings (25 per 100,000 people) between 2006 and 2014.

While shooting deaths are the third leading cause of injury-related mortalities in the U.S., the researchers said they performed the extensive study on firearm injuries because they said there was a lack of information about that aspect of gun violence and the economic impact on EDs.

“I think that the major surprise and interesting finding of our study was the immense number of individuals affected by the issue,” Faiz Gani, postdoctoral research fellow at the Johns Hopkins University School of Medicine’s Department of Surgery and lead author.

In the study published in Health Affairs, the researchers cited the “overall incidence” of ED visits for firearm-related injuries for the period 2006-2014, noting it was 25.3 per 100,000 people. That number was “disproportionately higher” in the U.S. than in other higher high-income countries, such as Germany, Japan and the United Kingdom. Gun-related deaths also are higher in the U.S., with about 36,000 reported in 2015, the researchers said.

The victims’ also were studied, with some possibly startling conclusions. Patients injured in suicide attempts, for instance, were more likely to be from highest income groups, people who were assault victims in shootings had low income, the researchers said.

Suicide attempts involving guns were linked more often – twice as high – among Medicare enrollees, compared to patients enrolled in other insurance, they said.

The results showed that the number of “non-fatal” firearm injuries at EDs was 2.4 times of fatal injuries. Such injuries were about nine times more common among men, ages 20 to 24, then women. Since the study did not include people who died before reaching the hospital or did not seek emergency treatment, the researchers acknowledged the increased burden for hospital EDs.

Not surprisingly, the researchers called for greater gun control laws, noting the immense political debate. Adding to the argument over gun control, the researchers said policymakers should consider universal background checks for gun purchases and limiting access for people with histories of violence or previous convictions, which now isn’t always the case.

“I think it’s extremely tragic that we continue to encounter mass shootings today, particularly given that they are potentially preventable to a degree,” Gani told HealthData Buzz following Sunday’s shooting that resulted in the deaths of 58 concert-goers, the gunman himself, and left more than 500 wounded. “I really hope that moving forward we can all come together and adopt a scientific and apolitical approach to gun violence,” he said.

Gani and his colleagues wrote that policymakers – perhaps in an understatement – “might consider implementing universal background checks” for firearm purchases. In addition, gun access should be limited to “people with a history of violence or previous convictions to reduce the clinical and financial burden associated with these injuries,” they wrote.

They acknowledged that “efforts to reduce firearm-related injuries have been limited as a result of the politicized environment surrounding gun violence and a lack of will to consistently implement proposed policies.”

In their study of gun-related injuries, the cost for each injured person treated at an ED was more than $5,000, and $95,000 for inpatient charges; the total was about $2.8 billion annually or $24.9 billion over the study period.

“It was very interesting to note that over 50 percent of our study population was either uninsured or self-pay,” Gani said. “This finding has broad policy implications. While these patients represent the most financially vulnerable patients, they also often do not have any insurance company negotiating on their behalf and therefore often incur the entire financial charge in the form of high pocket expenses.

Other findings:

  • Among patients who were shooting victims but treated at EDs, handguns were the most commonly used weapons, 27 percent. Then shotguns, 5.9 percent, or hunting rifles, 2 percent.
  • Emergency Care. While there was data that showed reduced shooting related injuries and ED visits for several years, there was an uptick in the most recent year studied, 2014. The incidence of ED admissions for firearm-related injuries decreased from 27.9 ED visits per 100,000 people in 2006 to 21.5 visits in 2013. But there was a “significant increase” in 2014 with 26.6 ED visits per 100,000 people.
  • Mental Health Issues. There was an increase in the number of patients “presenting with a diagnosis of a mental health disorder” at EDs stemming from shootings, from 5.3 percent in 2006-2008, to 7.5 percent in 2012-2014. “Of note, the incidence of mental health disorders was highest among patients injured in an attempted suicide, 40.8 percent patients.” the researchers said. While there have been political debate about gun violence and impacts related to people with mental health issues, the discussion might not be so straightforward, they said. “While policy makers have proposed mental health facilities to curtail gun violence, they would likely reduce the number of deaths associated with mental health disorders, but would have a limited impact on the overall burden of firearm-related injuries, given the small share of patients with such injuries,” the researchers said.

Despite all the debate over guns, research in the field is not funded where it should be – and that’s because of politics, they said.

“Research has been limited due to the politicized nature of this and the lack of appropriate funding despite the high clinical and financial burden associated with this issue,” they added.

As their study was published in in a week of turmoil for the country on gun-related violence, Gani observed: “I hope that our study coupled with work from other gun violence researchers furthers the conversation of gun violence through the use of robust evidence.”

“Only after we understand the complex factors at play can we develop appropriate and effective policies that ensure that we aren’t’ having the same conversation again in a few months,” he said.  — Joe Cantlupe