Wednesday, November 9, 2016

On Call by Casey Ross

Donald Trump's strong victory instantly upends the status quo in health care. We've got lots of coverage on our homepage and will be updating throughout the day. Follow us @statnews on Twitter and like us on Facebook for more.

Repeal is coming. What will replace Obamacare?

The Affordable Care Act isn't likely to make it into February.

Trump’s victory, combined with continued Republican control of the House and Senate, should ensure success at last for the long-running efforts to repeal and replace Obamacare. That will instantly muddy the financial and regulatory picture for hospitals.

But what comes next is still uncertain. Trump, who has repeatedly called the law a “disaster,”  has offered only a conceptual outline of his plan to replace it.

He wants to increase competition by allowing insurers to sell plans across state lines. He also proposes to replace premium subsidies with a tax deduction for the purchase of individual insurance.

Medicaid expansion under Obamacare has bolstered the finances of hospitals that serve low-income populations. Those gains may be at risk because Trump wants to give states more freedom to spend federal dollars as they see fit. That will likely mean less extensive coverage for Medicaid recipients. It could also embolden proposals in some states to require beneficiaries to pay premiums and hold jobs.

As for hospitals, Trump has called for greater pricing transparency to help consumers shop around. Many providers are already estimating prices for consumers, and the president-elect has not proposed a specific measure to accelerate those efforts.

Bottom line? A Trump victory portends a dramatic change in health care policy and finances.

Get ready. 

Single payer health care crushed in Colorado

Memo from Colorado voters: Single-payer health care is a singularly bad idea.

The proposal to create ColoradoCare was crushed at the ballot box, with nearly 80 percent of voters opposing a constitutional amendment to establish the program.

If approved, it would have raised $25 billion to pay for all residents’ medical services through a 10 percent payroll tax. The defeat sends a clear message that, at least in this state, voters don’t want government to control funding for health care services. It's also a stinging repudiation of Senator Bernie Sanders, who backed the plan.

Colorado’s other major health care measure, a medical aid in dying law, passed easily, with support from about two-thirds of voters.

The assisted suicide measure will allow physicians to prescribe a lethal dose of medication to mentally competent adults with terminal illnesses. With the vote, Colorado becomes the sixth state to pass such legislation, joining Oregon, Washington, Montana, California, and Vermont.

Big wins for marijuana and soda taxes

Marijuana advocates racked up big wins across the country Tuesday, as voters in California, Nevada and Massachusetts approved recreational pot use and voters in Arkansas, Florida, and North Dakota gave the green light to medical cannabis.

The results worry some public health experts, who say legalization leads to the availability of more potent marijuana products — some of which can end up in the hands (or mouths) of kids. They're bracing for more cannabis-related visits to emergency rooms.

On another front of interest to the health care community, voters in three Bay Area cities and Boulder, Colo. approved new soda taxes, which proponents hope can help drive down obesity rates.

California voters also approved a whopping $2-a-pack hike in their cigarette tax, which had been among the lowest in the nation. But voters in North Dakota and Colorado rejected similar measures.

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In other news, teamwork is good for the heart

You want to survive a heart bypass without complications?

Don’t look for a good surgeon. Look for a surgeon who’s good at working with a team.

A new study by researchers at the University of Michigan shows that heart surgery patients fared much better when their care was delivered by physicians who frequently work together.

The study examined more than 250,000 bypass surgeries and mapped the interactions between the doctors who treated those patients. A 25 percent increase in physician teamwork resulted in 17 fewer readmissions per 1,000 patients treated. Increased teamwork was also associated with fewer emergency department visits and lower death rates.

The paper’s lead author, Dr. John Hollingsworth, said it shows that efforts to improve care have been too focused on what happens in the hospital. “We believe that this focus is too myopic because it ignores the care delivered prior to the hospital stay and after discharge,” he said.

From On Call’s inbox: A fierce debate on residents’ working hours

Sixteen-hour works shifts for first-year residents never made any sense to Pamela Davis, who directs a family medicine residency program for Dignity Health.

She emailed me to argue that expanding the shift to 28 hours — as a national accrediting body is proposing — would end problems created when the flow of care is disrupted before critical work is done. “The negative side effects of these shifts has made more issues with patient transfers [and] a lack of a sense of ownership of patients and responsibility,” Davis wrote.

But I also received a note of caution from a resident in California. The writer, who asked for anonymity, described the difficulty of making crucial decisions for patients in a “dense cognitive fog" brought on by sleep deprivation.

“I’ve even dozed off at red lights on the drive home,” the resident wrote. “I don’t need a clinical trial to convince me this is unsafe.”

The resident argued the biggest impediment to on-the-job learning is not a lack of time, but the requirement that so much of it be spent updating electronic medical records. In recommending the switch back to 28-hour shifts, the Accreditation Council for Graduate Medical Education agreed with that latter point, suggesting that residency programs find ways to reduce the administrative workload.


  • Thorny questions surround effort to get experimental cancer drugs to patients (STAT)
  • Tennessee physicians sue CMS over Medicaid clawbacks (The Daily Briefing)
  • MedPAC wants more reporting of drug and device company payments to caregivers (MedPage Today)

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Stay well, and come back tomorrow. In the meantime, follow me on Twitter.


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