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Podcast Transcript - March 18, 2008

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Hello, and welcome to this weeks Annals of Internal Medicine Audio Summary for our March 18, 2008 issue. I’m Michael Berkwits, Deputy Editor at Annals.

We have another must-read issue for this week, with articles on hospital-wide surveillance screening for MRSA, colonoscopy screening intervals, the prevalence of cognitive impairment without dementia, and treatment of localized prostate cancer. Plus, I’ll summarize all the other articles in this week’s issue.

But first, here’s an in-depth summary of this week’s feature article.

Health Care Reform in Massachusetts (Time: 00:36)

Our feature article this week is a description of health care reform efforts in Massachusetts. From time to time Annals publishes feature articles under our Current Clinical Issues category; these are essentially health, science, and policy reporting by Jennifer Fisher Wilson, our crack science reporter.

This week’s contribution provides an overview of the state’s efforts to provide universal health care for all of its citizens. Briefly, Massachusetts law now requires all residents to purchase health insurance, and requires all businesses in the state to provide fair and reasonable insurance coverage. The 2006 law creating the program authorized creation of a new state agency, the Commonwealth Health Insurance Connector Authority, which provides subsidized, no-deductible insurance to low-income people who don’t qualify for the state Medicaid program, and which pools individual and small-group insurance markets to offer a choice of lower-cost insurance plans for other citizens. A key feature of the program is enforcement of the mandate; individuals and businesses pay escalating penalties at the time they file their annual tax returns the longer they don’t purchase or provide coverage.

Interview with Jon Kingsdale, PhD, Executive Director of the Commonwealth Health Insurance Connector Authority (Time: 01:50)

The program has generated a lot of attention and interest nationally but I haven’t seen much coverage of it since its launch, maybe because it’s still so early in the game. This week’s article is a great overview, but I wanted to learn more, so I called Jon Kingsdale. He’s the Executive Director of the Commonwealth Health Insurance Connector Health Authority, the state agency that’s implementing the program. He’s also an adjunct lecturer at Tufts University, and he graciously took the time to give me a progress report on the effort. He responded to criticisms of the program, and outlined some challenges ahead.

Q: Mr. Kingsdale thanks for talking to me.

A: My pleasure. Nice to talk with you.

Q: Let’s start with the basics. I wonder if you could describe the main features of the health care reform effort for listeners who don’t know much about it.

A: Sure. Massachusetts in April 2006 launched a very innovative reform that was designed to fill in the holes around the existing ways of financing health care; so preserving Medicare, Medicaid, employer-sponsored insurance, but trying to reach the 8-10% of our population that didn’t have access to health care through those financing mechanisms. And we did it with kind of a shared responsibility approach asking the taxpayers to help those who could not afford to buy insurance on their own to do so, asking individuals to purchase insurance if they could afford it, asking employers to either offer insurance or at least pay a minimum assessment and reforming the insurance market so that, particularly folks buying insurance on their own could have access to good products at a reasonable price.

Q: And what’s your role in the effort?

A: The health care reform here, Chapter 58 as we refer to it, created a new independent authority and that’s this Commonwealth Connector that I lead with its own Board of Directors to decide a number of critical policy issues that the legislature delegated to us and to start and run 2 new programs, one of which is subsidized insurance for low income people who do not have access to employer-sponsored insurance or Medicaid or Medicare and that’s called “Commonwealth Care;” and then also to start a second program which is really a distribution channel or marketplace for private unsubsidized insurance. We try to hook people up or match them with a choice of health plans whether it’s on the subsidized side -- Commonwealth care -- or the unsubsidized side -- Commonwealth choice -- and in doing that we’re trying to create a kind of a managed competition. More choice, clearer choice for people, but to use the competitive choice dynamics to drive efficiencies and better products for folks.

Q: And what’s your take on progress so far and what are the challenges that lay ahead?

A: Well, I think we’re doing reasonably well. We’ve had some spectacular successes and we know we face some major road bumps ahead as well. So let me focus for a minute on what we’ve done. We’ve enrolled well over 300,000 people newly in health insurance in Massachusetts, so that’s over 5% of our population just in the last 18 months since reform started. And about a third of that is in private unsubsidized plans so we’ve actually generated a growth in the commercial insurance market, and about a third of that is partially subsidized, maybe a little less, and the rest of it is fully subsidized by the tax payers for low income people. So there are a whole lot of folks who didn’t have access to medical care previously who now have access to routine, preventive, and private medical practice. So that’s been a terrific accomplishment. I think secondly we’ve built on the high level of support that was manifest in enacting this legislation. We’ve actually enhanced public support for reform. So that’s very important when you’ve talking about refinancing 16% of GDP to keep that level of support and build on it. And thirdly, we’ve actually had some major successes in reforming the insurance market, and particularly what’s called the non-group market, which is the market where individuals directly buy insurance for themselves, we’ve been able to lower that price of insurance 30, 40, 50% and enhance the benefits at the same time. So that’s been a significant achievement. On the other hand, we’re talking about 16% of GNP. So this is all about the money. And this is an economic sector that dwarfs most others transportation, education, agriculture, etc. So it is huge business, it’s a huge commitment, and we have to be very aggressive about trying to moderate the annual increase in the cost of care. And that’s a major challenge. And I’m pleased to say that we have a whole new set of public discourse in Massachusetts, including new legislation that I have mentioned before introduced to contain health care costs of public debate and public focus on it. But it’s tough to contain those costs and we’re going to have to be very inventive and daring in doing that. Nobody likes to have their livelihood or their business changed by government. We’re doing it, and I think that’s a positive thing, but it certainly requires some sacrifice on the part of the health plan.

Q: One key feature of the program is mandated coverage which is enforced with financial penalties for not purchasing coverage. As I’m sure you know there’s at least anecdotal evidence and there may well be data that you’re familiar with that I’m not that some people are foregoing coverage because paying the state penalty is a lot less expensive for them at least for now than paying for the insurance as mandated by the law. So what’s your take on that?

A: This is one of the most significant and controversial pieces of legislation. We are trying to introduce this change in a constructive and generous way. So it starts with fairly modest penalties on the taxpayer who is deemed to be able to afford insurance but chooses not to purchase it, and that specifically is foregoing their individual tax deduction, or $219 on their state taxes for 2007. And then penalties increase in 2008 and they’ll increase again in 2009. So that we hope to convince most people through carrots and sticks -- and the carrot here is that we’ve made insurance more affordable and it’s good stuff to have,, as well as the stick of a tax penalty -- to change their behavior. Now we are dealing with people who if they can afford insurance are by definition folks who have decided not to buy it previously.” So we’re talking about a real change in the mindset. There’s a lot of them who are guys, there’s a lot of them who are young adults, and they kind of figure sickness is something that happens to women and to old people, and they get that something could fall on them, but other than that, they don’t really think they need access to medical care. Of course the reality is they also know that if they step off the curb and they get hit by a bus they will get picked up by an ambulance and we’ll all pay for that. And everybody is just a diagnosis away from a serious chronic illness. But there is a mentality of youth and invincibility and we need to try to persuade them to be a little bit more financially responsible and participatory in our health care system.

Q: The issue of the mandate and its costs to citizens has developed into a point of debate in the Democratic Presidential primary. Senator Clinton has argued her program requires everyone to obtain coverage, just like the Massachusetts program, and Senator Obama claims that defaults in coverage are a reason not to force it on everyone. So I’m wondering if there’s anything you’re learning from the experience in the past 10 or so months in confronting the problem that you think might help listeners think through those competing claims and competing models of health reform at a national level?

A: Well, I hesitate to jump into that debate but I’ll throw out a couple of thoughts. One is that we’re not the first country in the world or the first state in the world to do this. The Swiss and the Dutch also have an individual mandate and it’s pretty effective over there. It gets them to about 99% coverage and it does speak to the community ideal of having everybody involved and everybody covered. It also really helps lower the cost of health insurance for everybody. So most people in this state already have insurance, but by bringing in the remaining 5% or 10% it actually helps spread the cost of care and lower insurance premiums. So those are all good things. Tax time is just about upon us, we’ll find out just how much resistance there is to this mandate and what the problems are that that creates.

Q: The program as I understand it gets some of its funding from a pool of money allocated by the state to pay community health clinics and hospitals for patient care, that’s the free care pool, and one criticism of the effort has been that money which has been dedicated to providing health care for vulnerable populations is now being channeled to insurers where it’s now covering some of their administrative costs. So it’s not being used as efficiently to cover the populations that need to be covered. What’s your response to that criticism?

A: I categorically reject that criticism. I think one of the great advantages of this reform is we’re taking money that has been given out without appropriate accountability to institutions, which they have come to see as their rightful support, and we’re giving it to individuals who can then choose health plans and providers. And if they don’t like the level of service, or the attitude of the people helping them or the facility or anything else about it, they have a card they can take to another physician or another office or another provider. And they can use it to get preventive care and drugs and routine diagnostic care, not just show up in the emergency room as a failure of our health care system and ask for or require acute, expensive remediation of what is really a failure of a full spectrum medical care system to take care of them. You can hear my passion. I feel very strongly that this is better care for our citizens.

Q: And my organization, the American College of Physicians, and others have made the point that a healthcare reform program is only as good as the primary care physician supply, and that in the absence of primary care physicians to absorb newly covered patients improved coverage can’t improve access. So what’s the status of that part of the equation in the efforts so far?

A: Well I think there’s recognition here that primary care is a vital resource and that it’s increasingly in danger of being undersupplied. So there are some initiatives that have already started and are now being enhanced, around increased training for primary care physicians and loan forgiveness to try to retain them, that are specifically designed to increase the supply here or at least maintain the supply into the future. So a lot of effort focused on trying to do what is so important if you’re going to translate financial access into real access to medical care which is at the frontlines of primary care practitioners available and accessible. And I know this is controversial among physicians, but there’s a whole lot of stuff that primary care physicians do that is so routine that it’s really a shame that they go to medical school for 4 years and residency for 3 or 4 years to deal with otitis media and sore throat and flu vaccines. And there is now a recognition that we need allied professionals to help physicians, who are so well trained and so competent, deal with more serious illness. And I point specifically to the development of very rigorous regulations to promote the so-called minute clinics and storefront CVS-like nurses to be able to provide primary care and hopefully relieve physicians of some of that really not good use of their resources and allow them to focus on the kind of stuff that they are trained to do.

Q: It’s still early, but what outcomes are you looking at now? When will you stop, evaluate progress, and make changes as necessary?

A: Well we’re constantly fine tuning this set of programs. For example, we’re now looking at whether the cost-sharing formulas that we set up for highly subsidized care for lower income folks are appropriate. We’re looking at whether the products that we offer in the unsubsidized market place we’ve created for individuals buying insurance are appropriate. So we’re constantly sort of making that kind of fine tuning. I think in terms of real outcome health status and visit rates and so forth, it’s a little early. We still need to get some more experience before we can judge that this has really helped people’s health. And we have lots of anecdotes, but on a population-wide basis we’re a year or two away from being able to begin to judge that.

Q: Is there anything you’ve learned in the past 10 or so months that you wish you’d known when you started and when the whole program started?

A: Well lots of different things I’ve learned. One is how critically important it is to maintain and build support for a public program. You know, we have some private sector functions and in that sense we’re almost entrepreneurial, but we are very much a creature of a public reform urge, and it’s just critically important to have every element of the community involved. And I think we been able to do that. I think one of the reasons that we have well over 300,000 people newly insured over the last 18 months is because we’ve partnered with the Red Sox, we’ve partnered with CVS and we’ve partnered with unions and the Greater Boston Chamber of Commerce and certainly all elements of government and that breadth of commitment and involvement is not only a tangible asset but it’s really critical to continue support for reform because this is tough, costly stuff.

Q: And can I call you back in 6 or 12 months to get a progress report?

A: Absolutely. We’d be happy to speak with you then.

Q: Mr. Kingsdale, thanks for talking to me.

A: Oh my pleasure, thank you.

That was Jon Kingsdale, Executive Director of Massachusetts’ Connector Authority, describing progress to date and challenges ahead in the state’s efforts to provide insurance coverage to all its citizens.

Universal Surveillance Screening for MRSA Infection (Time: 16:31)

Our lead article in this week’s issue describes of the effects of a universal surveillance program for MRSA infection on the incidence of clinical disease. The article reports that a policy of rapid-turnaround PCR testing on nasal specimens of all patients hospitalized in 3 community-based settings, followed by a decolonization regimen of twice daily nasal mupirocin and every-other-day chlorhexidine wash, decreased the prevalence of clinically significant infection, by about 2/3. Clinically significant infections was defined as bacteremia, bloodstream infection, or respiratory, urinary tract, or surgical site infection caused by MRSA,

An accompanying editorialist makes the point that this paper describes the first demonstration of a program that screens all hospitalized patients for MRSA colonization, but urges readers not to duplicate such a program, at least not yet, for three reasons. First, it was a complex program, and the authors didn’t look at which aspects of the program contributed most to the observed effects. Second, PCR testing is expensive, and third, MRSA epidemiology differs by hospital; so institutions will need to develop their own screening programs in the context of its unique needs and resources.

Comments from Ebbing Lautenbach (Time: 17:42)

Interestingly, though, this week’s article and editorial follows by 1 week publication in of a report in JAMA describing the opposite findings from a similar program in surgical patients. So I called Ebbing Lautenbach, this week’s Annals editorialist, and Annals’ infectious diseases editor, and I asked him what he thought accounted for the difference in the study findings.

EL: The studies were done in different geographic regions and in different populations. The JAMA paper focused on a Swiss population and was limited to a single hospital. The paper in the Annals of Internal Medicine was a multi-center study conducted in the U.S., in the Chicago area. While data on race and ethnicity are only provided in the Annals paper, it’s likely that the Annals paper represented a more diverse population.

Secondly, the JAMA paper focused only on surgical patients, while the Annals study included the full hospital population. It’s possible that surgical patients, particularly those coming into the hospital for elective surgery, might be a less sick population than the rest of the hospital. Any intervention might be less likely to show an effect in surgical patients, given the fact that they may be less sick than the general hospital population taken together.

The intervention described in the Annals paper recommended decolonization with mupirocin. In the JAMA study, very few people got decolonization. Now, the data on the impact of decolonization on subsequent MRSA infection remains somewhat controversial, but it’s possible the decolonization in a patient population in the Annals paper may have played a role in conferring the benefit of the intervention when you compare that to the JAMA paper.

Overall, I think the fact that the Annals and JAMA papers come to different conclusions points out that studying the epidemiology of MRSA is incredibly complex, and it demonstrates how difficult it’s going to be to come up with an approach that works across a variety of different types of settings.

There are clearly differences in the epidemiology of MRSA across institutions, and so employing any sort of uniform approach is very unlikely to work. Yet, it’s that sort of “one size fits all” sort of approach that is exactly what’s being proposed in legislation in various states. What most of those initiatives propose is universal screening, meaning that anyone who is admitted to the hospital is screened for MRSA on admission.

These two studies demonstrate that simply identifying somebody as colonized with MRSA may not be the main point. It’s really what you do with that information – and that may differ depending on the institution. So, I don’t think the discrepant results in these two studies should necessarily at all discourage us from continuing work on this.

I think it’s also important to point out that MRSA is not the only organism that represents a major risk for hospitalized patients. There are many other bacterial pathogens both antibiotic resistant and antibiotic susceptible that are major predictors of morbidity and mortality in patients that are hospitalized. And so, the approaches that we think about for MRSA may, in fact, be relevant for a much broader group of organisms as well.

Finally, I think it’s critical to point out that the individual health care practitioner really plays a tremendous role in helping to reduce hospital infections. Complete adherence to hand hygiene in all healthcare encounters is probably the single most important thing that healthcare workers can do. Adherence to contact precautions for those patients who are identified as colonized or infected by a resistant pathogen is also critical.

So, I think while these two studies focus on institution-level approaches to identifying and controlling MRSA, it’s very important to remember that we, as specific healthcare providers, play a huge role in helping to control these organisms both resistant and susceptible just by the way in which we practice and the way in which we approach the care of patients in the hospital.

Those were comments from Ebbing Lautenbach, Associate Professor of Medicine and Epidemiology at the University of Pennsylvania and the author of an editorial this week on universal screening for MRSA at hospital admission.

Other Articles in This Week’s Issue (Time: 21:27)

Other articles in this week’s issue include a look at the predictive accuracy of US postpolpyectomy colonoscopy guidelines, suggesting that current recommendations discriminate poorly between people who will and will not go on to develop a high-risk adenomas

We have a nationally representative survey study of the prevalence of cognitive impairment in the US, suggesting that cognitive impairment without dementia is far more prevalent than dementia and frequently but not always progresses to dementia;

We’re publishing a pair of papers on incontinence. The first is a systematic review of trials of nonsurgical treatment for urinary incontinence in women, reporting resolution of incontinence with pelvic floor muscle and bladder training and with anticholinergic drugs such as oxybutinin and tolterodine; and improvement without resolution of incontinence with duloxetine. The second paper is a United States National Institutes of Health State-of-the-Science statement providing a narrative review of the prevalence, impact, and risk factors for fecal and urinary incontinence; and providing a review of strategies to improve identification of at-risk people, effective preventive measures, and research priorities to reduce the burden of illness from the condition.

Finally, we have a systematic review of the comparative effectiveness and harms of treatment for localized prostate cancer, concluding disappointingly but after an enormous effort and extensive review, that little high-quality evidence is available to guide patients and providers on choice of treatments, and that the current state of the literature precludes saying anything about the comparative effects of available treatments on many clinically important outcomes.

Our On Being a Doctor piece this week is entitled A Geriatrician’s Lab, and that Lab stands for Labrador, not Laboratory. It’s a description of the end-of-life care the author, who’s a geriatrician, provided his dying dog. Now legend has it that Bennett Cerf, co-founder of Random House publishing, when asked for the name of a sure-fire bestselling book title, paused for a minute and said: Lincoln’s Doctor’s Dog. So two out of three of those in this essay isn’t bad, but if I had been editing this piece it I would have pushed the author to name the dog Abraham Lincoln.

And speaking of dogs, I have my own tail between my legs this week with a correction to last issue’s audio summary. Some listeners may have downloaded a version of the summary in which I said that the authors of last issue’s lead article on new tests for diagnosing tuberculosis did not acknowledge their financial interests in the assays they studied. That wasn’t true: that acknowledgement was explicit in a standard conflict of interest statement following the article. So scratch that statement, and I regret any misimpressions that misstatement might have caused.

Well, that’s it for today. We’ll save part 2 of the Institute of Medicine’s panel discussion of comparative effectiveness studies for next time.

Our closing credits are the same change.

Our theme music is by Brian Poole and Kwesi Marles; the clip you heard earlier was the 1942 recording of Massachusetts, sung by Anita O’Day and the Gene Krupa Orchestra. You can get it on a number of compilations.

Send comments, criticisms, feedback, and suggestions about these summaries and the journal to podcast{at}annals.org.

Our double feature review or urinary and fecal incontinence should remind you to screen your patients for both with a clinical history. And this tune is a prescription for what to tell those who screen positive.

Check back in 2 weeks for our regularly scheduled April 1, 2008 issue

I’m Michael Berkwits, and thanks for listening.

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