Jerod Smith: Health care crisis? There’s an APP for that

Dr. Gene Battistella ( “Pending bills could impact patient care in Pa.,” Oct. 3, TribLIVE) maintains that the number of clinical training hours for nurse practitioners and physician assistants directly influences a patient’s outcome. This is not true. Studies have compared the practice patterns of nurse practitioners with those of physicians and determined that nurse practitioners performed as well as physicians in all areas of primary care delivery and patient outcomes.

The Federal Trade Commission states that “a growing body of evidence suggests that APRNs (nurses with at least a master’s degree in nursing) can, based on their education and training, safely perform many of the same procedures and services provided by physicians.” I have personally observed that quality education and superior mentors produce excellent professionals in the field.

Battistella anticipates an increase in opioid prescriptions if nurse practitioners and physician assistants gain independent full-practice authority. He forgets that all providers must follow prescription guidelines or risk both losing professional licensing status and facing criminal charges.

He urged lawmakers to “take a step back and consider the unintended consequences that these proposals would have on their constituents.” In response, I say, “I’ve got an APP for that.”

Unfortunately, the current health care environment fails to recognize the value of advanced practice providers (APPs), and this results in underutilization. For our health care system to become not only efficient but also effective, it needs to be intellectually honest concerning the benefits that such providers offer.

American life has adapted to the changing health care environment and, were it not for the polarized fight over health care, the use of APPs would have kept pace as well. Throughout the national debate, two situations have remained constant: the shortage of primary care physicians and an underutilization of APPs.

The United States has nearly 250,000 licensed nurse practitioners and almost 125,000 licensed physician assistants. If properly utilized, the solution to the health care crisis already exists.

The challenge is for APPs to clarify the quality of the care and recognize the scope of the specialties within the profession, thus optimizing the value that an APP provides. By implementing reliable standard measurements, APPs can be a beneficial part of the solution.

The midterm elections made it clear that health care is a major concern. There is general agreement that a successful health care system must have universality, quality and affordability. Properly utilized, advanced practice providers can be the key to having all three. Allow APP programs to grow through clinical experience, mentorship and increased collaboration with physicians, as well as increased autonomy, and what will emerge will be step one in neutralizing the primary care physician shortage.


Retail outlets using telehealth pose significant privacy, policy concerns for health care

A significant shift in the health care market is well underway, with various insurers, medical groups, vendors and supply chains pursuing acquisitions and mergers to expand their services, and retail outlets, from Walmart and Amazon to Rite-Aid and Albertsons, delivering health care services, including telehealth.

But do current policies adequately protect patient privacy and anticipate the capabilities of artificial intelligence and other rapidly advancing technologies? And do retailers who are rapidly expanding into traditional health care markets have significant advantages in terms of access to data over current health care organizations?

Telehealth leaders at UC Davis School of Medicine and Harvard Medical School say more needs to be done and that HIPAA, net neutrality and other policies need to be re-evaluated and updated to offer the appropriate guidance.

The researchers explore these and other policy issues in a study published in the December issue of Health Affairs. They also will present the findings at a news briefing/webcast at the National Press Club in Washington, D.C., Dec. 4, 2018 at 10:30 a.m.

“Retail outlets using telehealth have unique advantages and opportunities for delivering convenient care to consumers,” said Keisuke (pronounced kes-kay) Nakagawa, a postdoctoral scholar in the Department of Psychiatry and Behavioral Sciences at UC Davis Health and first author of the study. “But it is important to monitor developments and consolidations in the health care market to ensure our policies are well-designed, relevant and anticipate future applications of telehealth.”

While Nakagawa is in support of innovative technologies in health care, a new world is emerging with smartphones, wireless internet and smart-home devices improving access, and collecting and storing unique data, from video and audio to text and biological measurements.

With the majority of telehealth consultations occurring in the home, sessions offered through smart home devices could create a channel where both consumer and health care data flow seamlessly through one device back to a commercial retailer.

Peter Yellowlees, professor of psychiatry and senior author on the study, raises concerns about the lack of policies to guide the health care industry and the general public about the potential convergence of personal health information (PHI) with non-PHI data.

“Retail outlets have access to a wealth of consumer data, and health care organizations have access to medical data,” Yellowlees said. “While some convergence is already happening through data brokers selling consumer data to health care organizations, the precision, granularity and flexibility to analyze the data could be much more significant when retail organizations have access to both health care and retail-data sources directly.”

The study has no external funding. Researchers conducted the study as leaders in academic medicine and telehealth. Joseph Kvedar, vice president for connected health, Partners HealthCare and a professor of dermatology at Harvard Medical School is a co-author of the study.


Collaborating to transform healthcare’s frontline

As the nation celebrates the 70th year of the NHS and all that it has achieved, there has also been focus on its long-term sustainability and what the future might hold. There’s no denying that there continues to be a spotlight on the increasing pressure on hospitals, particularly as
we enter the winter period.

The government has announced increases in NHS funding over five years, beginning in 2019/20, with the NHS tasked with contributing to a ten-year plan for how this funding will be used.

Like most NHS Trusts, we are always on the lookout for ways to improve patient outcomes and productivity without driving higher costs. When our orthopaedic product tender came up for renewal, we saw the opportunity to do things differently. We wanted to find a solution that supported our mission to transform the service provided to patients and improve pathways to care through innovation.

Defining the objectives of the partnership

In short, we set out to find an external partner that would help us do a number of things, such as improving patient outcomes whilst reducing time spent in hospital; releasing capacity in our orthopaedic theatres; increasing the Trust’s income by improving patient throughput; optimising the patient pathway through raising the standard of clinical practice; and achieving good value in procurement by innovating in the way we undertake commercial partnerships.

When Johnson & Johnson Medical Devices Companies (JJMDC) put in its tender, which included the value-based CareAdvantage offering, we were really pleased as we felt that this matched what we were setting out to achieve.

Diagnostic and goal-setting

A dedicated team was put on-site to work with us and, following an extensive diagnostic exercise to identify areas of improvement, a number of plans and ways of working were put in place to help us meet our objectives of delivering increased utilisation of hospital resources, specifically via:


Apple Maps Recovers From Multi-Hour Outage Affecting Users Globally

Apple Maps Recovers From Multi-Hour Outage Affecting Users Globally


Apple Maps on Friday faced a multi-hour outage that affected navigation and location search services for several hours. The outage wasn’t limited to a specific region. As per the system status available on Apple’s website, all users were affected by the issue that was resolved after over four hours of its emergence. The prime cause of the issue hasn’t been revealed formally. However, Apple said that it investigated and fixed the issues. Users weren’t notably able to access navigation or search for places through the mapping service in the duration of the outage. Some users even spotted its impact on third-party apps, including weather apps, using Apple’s location services.

The system status page on Apple’s site shows that the Maps Routing & Navigation and Maps Search services were down between 6:18pm and 10:35pm IST. While the company didn’t specify the issue, it mentioned on the status logs that all users were affected by the problem.

As folks at Apple Insider report, users on Apple Maps weren’t able to find a route as the app shows a warning message that reads, “Directions Not Available, Route information is not available at the movement.” The Apple Maps app was also showing errors while searching any locations. The Verge notes that the app was showing the error “No Results Found” after attempting to load search results for about 30 seconds before timing out. Furthermore, weather apps on iOS weren’t able to show real-time weather information due to the limited access to Apple’s location services.

Apart from iOS devices, the outage was impacting location-based experiences on Apple Watch and in-dash systems powered by Apple’s CarPlay. The issue apparently affected the Maps Routing & Navigation and Maps Search services, while Maps Display and Maps Traffic services didn’t face any issue.

Launched in September 2012, Apple Maps is competing against services such as Google Maps and Here. Apple recently revealed that it has started using drones to improve its mapping service.


Poor healthcare in jails is killing inmates, says NHS watchdog

Overcrowding and staff shortages are making it difficult to care for prisoners’ health needs.

Almost half of England’s jails are providing inadequate medical care to inmates, whose health is being damaged by widespread failings, the NHS watchdog has told MPs in a scathing briefing leaked to the Observer.

Healthcare behind bars is so poor in some prisons that offenders die because staff do not respond properly to medical emergencies, the Care Quality Commission (CQC) says.

Mental health services for the 40% of inmates who have psychological or psychiatric problems are particularly weak, which contributes to self-harming and suicides among prisoners, according to the care regulator’s confidential briefing to the Commons health and social care select committee.

It blames chronic understaffing, problems getting to medical appointments and guards knowing too little about ill health to recognise problems.

The mixture of NHS and private companies that provide healthcare in England’s 113 adult jails and young offender institutions “frequently struggle to deliver safe and effective services”, the commission tells MPs.

However, it adds, this is often “due to issues outside of their control” such as shortages of prison and healthcare staff and the environment of jails not offering suitable space for consultations.

It adds: “In 2017-18 we completed 41 joint prison inspections [with the prisons inspectorate]. We found breaches of [CQC] regulations in 47% (19) of these inspections and took corresponding regulatory action, in some cases against more than one registered provider.”

The CQC ordered providers to take remedial action because the care offered to inmates was unacceptable in its quality or safety and breached the watchdog’s five fundamental standards that require providers to ensure services are safe, caring, effective, responsive and well led.

The document details a litany of problems including:

Mental health nurses are unable to assess, care for and treat prisoners because they are too busy responding to inmates having breakdowns or being given drugs.

Shortages of prison guards to escort them means prisoners are missing out on NHS appointments outside the jail.

Inspectors frequently find “inadequate mental health awareness among prison staff and their inability to recognise mental health issues and seek appropriate support for prisoners”.

Incarceration can worsen prisoners’ existing conditions or lead to them developing new problems as a result of “limited exercise and exposure to sunlight (causing vitamin D deficiency), poor diet, illicit drug availability, assault/injury, exposure to communicable diseases, psychological deterioration, self-harm and suicidal ideation”.

Follow-up inspections frequently reveal “poor progress in achieving the intended improvements”.

The charity Inquest said it was concerned about “repeated failings [by prison healthcare providers] around communication, emergency responses, drugs and wider issues of mental ill health and healthcare provision resulting in death.

“Evidence from our casework, supporting families whose relatives have died in custody, indicates that prisons are unhealthy and unsafe environments. A patient in prison has very little autonomy, control and access to medication and appointments. Prisons, at their core, are environments of toxic, high health risk,” said Rebecca Roberts, its head of policy.

In oral evidence to the committee in July Peter Clarke, England’s chief inspector of prisons, painted a bleak picture of inmates’ health and healthcare provision behind bars. Prisoners’ mental health was suffering because overcrowding means that many thousands do not have a cell to themselves, and cells must serve as living room, dining room, kitchen and toilet.

The illicit drugs trade in jails has led to a toxic mix of violence, fear, debt and bullying for many prisoners, Clarke added. As a result “they self-segregate and self-isolate, and instances of self-harm and suicide tragically flow from that”. Inmates’ inability to get to medical appointments, due to staff shortages, has produced “an inevitable knock-on effect on their health and wellbeing”.

Paul Williams, a Labour member of the select committee, which will publish a report into prisoners’ health next week, said: “In too many prisons a profoundly unhealthy environment and woefully inadequate staffing results in prisoners’ health getting much worse because of their time inside. Missed appointments lead to missed cancers, and severely mentally ill people are kept in cells instead of hospital wards.”

Professor Steve Field, the CQC’s chief inspector of primary medical services and integrated care, added: “During our programme of inspection in partnership with Her Majesty’s Inspectorate of Prisons, we have found some poor care and I have serious concerns that the issues we have found are affecting the health of some the most vulnerable people in society.

“I’m anxious that the issues highlighted in our evidence around mental health provision, staff training, particularly nurse and doctor training and inadequate pharmacist oversight of prescribing are dealt with as a matter of urgency.”

A government spokesperson said: “We are investing tens of millions of pounds extra in prison safety and decency. We are spending an extra £40m to improve safety and tackle the drugs which we know are fuelling violence and healthcare problems, including X-ray scanners and drug-detection dogs. Over 3,500 new prison officers have been recruited in the last two years which will help improve access to healthcare services.”


Competition Commission’s policy prescriptions to make healthcare transparent, affordable

Earlier this week, the Competition Commission of India (CCI) released a first of its kind policy note on “Making Markets Work for Affordable Healthcare”. The statutory body, which has so far received 52 cases about anti-competitive practices in pharmaceuticals and the healthcare sector, has prescribed some policy and regulatory action to address the issues.

Here are some of the key recommendations made by the CCI:

Role of intermediaries in drug price build-up

One major factor that contributes to high drug prices in India is the unreasonably high trade margin, which is a form of incentive and an indirect marketing tool employed by drug companies. Trade associations contribute towards high margins as they control the entire drug distribution system to reduce competition.

CCI suggests that efficient and wider public procurement and distribution of essential drugs to circumvent the challenges arising from the distribution chain, supplant sub-optimal regulatory instruments such as price control and allow for access to essential medicines at lower prices.

The competition watch dog also suggests electronic trading of drugs, with appropriate regulatory safeguards, can bring transparency and spur price competition.

Quality perception behind proliferation of branded generics

Worldwide, generic drugs are seen as a key competitive force against patent-expired brands marketed at monopoly prices. In India, the pharmaceutical market is dominated by “branded generics” that limit generic-induced price competition. The branded generic drugs enjoy a price premium owing to perceived quality assurance that comes with the brand.

However, CCI observes that the brand proliferation is to introduce artificial product differentiation in the market, offering no therapeutic difference, but allows firms to extract rents.

The competition watchdog suggests a regulatory apparatus to address the issue of quality perception by ensuring consistent application of statutory quality control measures and better regulatory compliance.

Regulation and competition

Due to multiple regulators governing the pharmaceutical sector at the state and centre levels, implementation of regulations is not uniform across the country. This has resulted in multiple standards of the same product and different levels of regulatory compliance requirements.

The CCI has called for a mechanism to be devised by CDSCO to harmonise the processes followed by state licencing authorities to ensure uniformity in interpretation and implementation. The commission has asked for making approvals of new drugs time-bound along with publication of detailed guidelines governing each stage of the approval process.

The body advocates one-company, one-drug, one-brand name price policy.

Vertical arrangements in healthcare services

In view of the incentive-based referral system that pervades the healthcare landscape, CCI recommends issuing of periodic validated data by hospitals relating to mortality rate, infection rate, number of procedures etc, which could help patients make informed choice.

It has also recommended regulation of in-house pharmacies of super specialty hospitals, which are completely insulated from competition as inpatients are typically not allowed to purchase any product from outside pharmacies.

The competition body has recommended the government to ensure all accredited diagnostic labs meet the same quality standards in terms of infrastructure, equipment and skilled manpower to ensure the same degree of reliability and accuracy of test results across labs.

It has recommended regulatory framework to ensure portability of patient data, treatment record and diagnostic reports between hospitals.

It has said that lack of portability constrains patients in switching from one hospital to another and creates a lock-in effect. Portability of patient data can help ensure that a patient is no longer locked into data silos and do not bear additional cost for switching medical services and that doctors and hospitals can have timely access to patient data.

Will they be ever implemented?

It’s commendable for India’s competition watchdog to come up with a set of policy prescriptions that impede competition and thereby make healthcare expensive. It makes a strong case for the government to act.

But most of these recommendations are anything but new, healthcare policy makers and activists have been raising these issues of information asymmetry, market distortion and profiteering in healthcare for years.

To be sure, there were some well-meaning efforts in the past to regulate the exploitative practices, but these attempts were diluted or nipped in the bud by well entrenched lobbies.

An overwhelming 62 percent of healthcare expenses in India are met by out of pocket expenditure by the individual, and healthcare expenses are cited as one of the primary reasons in India for families falling into debt traps and poverty. India needs not piecemeal but structural reforms in healthcare.