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Trying to Bring Down Oz

July 22, 2014

snake oilConcerned with the public health impact of Dr. Mehmet Oz’s health advice, in 2013 University of Rochester medical student Benjamin Mazur asked state and national medical associations to take action. However, though for over a hundred years the federal government has passed legislation and created agencies to prevent consumers from being deceived or harmed by “bad medicine,” the situation is a complicated one. For instance, though the Federal Trade Commission has the legal authority to prosecute people who mislead and injure consumers, they can’t do anything about Oz since he’s not actually selling the products he talks about.

With regard to his concerns, Mazur noted: “I’m definitely not the only one.”  Sen. Claire McCaskill, for instance, told Dr. Oz during a Capital Hill hearing: “The scientific community is almost monolithic against you in terms of the efficacy of…three products that you called miracles.”

Mazur explains his concerns:

This issue was brought up by a number of physicians I worked with during my family medicine clerkship. We had all of this first-hand experience with patients who really liked his show and trusted him quite a bit. [Dr. Oz] would give advice that was really not great or it had no medical basis. It might sound harmless when you talk about things like herbal pills or supplements. But when the physicians’ advice conflicted with Oz, the patients would believe Oz.

Mazur is not entirely anti-Oz, of course; as he explains, “I would probably say that he does have the health interest of his viewers in mind. But in the long term, undermining good science and the relationship patients have with their current physicians is probably doing much more harm than good. If they’re not going to listen to advice from physicians—who are providing good, evidence-based advice—if they’re going to listen to other doctors on the show, it’s going to do more harm than good.” Read more…

The Growing Risk of Measles

July 11, 2014

measlesMCNTalk has written about the question of foregoing childhood immunizations multiple times over the past few years. As these two articles (Measles Cases in U.S. Reach a 20-Year High and Putting Us All at Risk for Measles) notes, consequences of individual choices are serious ones, not just for those involved in the decision to not vaccinate, but for society at large. As editorialist Pauline W. Chen, MD succinctly explains: In any given population, there would always be individuals who would not develop immunity to measles, even after receiving the vaccine, or who could not receive the vaccine because they were too young (less than a year old) or had immune systems already weakened from diseases like cancer or AIDS.

But health care experts discovered that if at least 95 percent of a community were immunized against measles, all the members of that group would be safe. Even if someone with the disease entered the community, the immunized majority would serve as a “buffer zone” preventing further spread to unimmunized individuals.

The initial study indicating a possible connection between vaccinations and autism has been thoroughly debunked, and its author debarred from the practice of medicine for ethical lapses, but the number of measles cases in the US and worldwide continues to increase. In fact, measles remains the greatest vaccine-preventable cause of death among children worldwide. At what point do individual rights outweigh the public good? Read more…

Opioid Deaths Drop in Florida as the State Cracks Down

July 9, 2014

florida pain pill millsPrior postings have decried deaths and abuse in prescribing of opiates. Florida was the poster child of abuse, with strip mall featuring “pain clinics” where patients from other states would fly into to receive bogus prescriptions.

The sheer number of prescriptions nationwide has helped drive abuse in the United States. In 2012, more than 259 million prescriptions for pain pills were dispensed, federal researchers said, enough for every American adult to get a bottle of them. For the past decade, more than 20,000 Americans have died each year from prescription pain pill overdose.

As this article and associated editorial demonstrate, change is possible. Florida and other states have made a good start in curbing abuse. Lives have been saved in the process. There is more to be done in curbing the misuse of opiates for chronic pain. Opioid painkillers are dangerously overprescribed, but Florida has shown how states can confront this problem.

Vaccinations: The Soaring Price of Prevention

July 7, 2014

childhood vaccinesMCNTalk has long taken on the vaccination story and has advocated rational and life saving public health policies that promote vaccination.

As this article demonstrates, the dark side of vaccinations is not the overstated risk of side effects, but the predatory cost escalation. The short answer to why the manufacturers are driving up prices is because they can.

This is further enabled by the requirements that some vaccinations be administered for school admission and other public good.

Also the lack of marketplace pressures since the cost is generally borne by government and insurance carriers promotes insensitivity and indifference among those who benefit from them. Finally, monopolies granted via patents and regulations do nothing to induce competition among manufacturers.

MCN Achieves Remarkable Performance Metrics for our Clients

July 1, 2014

LoginScreen-1-rasterizedFrom time to time we wish to update our clients and consultants on company progress and activities. As always we thank our valued clients, for trusting us with your examination and review needs. We also thank our staff nationwide as well as our physician/consultants for their great work in support of MCN. Our staff and managers have worked hard to achieve many notable results, some of which we will share in this report.

The period 2013-2014 has been and continues to be a remarkable one for MCN as we continue to set the standard within the industry for technological and performance advancements. While not the oldest in our space (MCN was founded in 1985) MCN was the first company in the medical assessment field to develop a web presence – thus the valued 3-letter url mcn.com – the first to pioneer online ordering and access, and the first national network, moving from a regional to national presence in 1997. Achievements reached in 2013-2014 include the following:

  • In the second half of 2013 the company released a new information management system after about two years of development. This system is internally called Cadence, and replaced the original system called Andante that we deployed in 2000 (we enjoy musical terms). Cadence is a robust program that contains, in a secure environment, all data pertaining to our work. This includes individual claim files, claimant information, and client tracking as well as physician/consultant information such as credentials and report delivery statistics.
  • MCN has continued to enhance our client portal, a platform where clients may order services, access select information in real-time, and complete functions such as uploading and retrieving files and receiving case status updates.
  • In the coming weeks we are launching an updated provider portal, following strenuous testing and development. This portal allows physician/consultants access to their files for retrieving and reviewing records, editing and uploading reports, and performing other important functions.
  • We are undergoing a security certification process and will receive our SSAE-16 SOC1 certification later this summer.
  • All of our data is maintained at the highest level of security using secure socket layer (https) for data in motion and 256 bit AES (Advanced Encryption Standard) for data at rest.
  • We have significantly grown our URAC-accredited Independent Review Organization (IRO) division, providing peer reviews for healthcare claims for some of the largest carriers in the nation. This team processes evidence-based reports that address medical necessity and appropriateness of treatments or services.
  • We have grown our physician recruiting development department to maintain our status of having a large, comprehensive and national physician network credentialed to the highest standards.

We have a fine group of managers overseeing operations, client service, information systems, human resources, and sales and account management. We are proud of our team, especially the great bench of talent residing at MCN which has allowed us to source most new leaders internally with promotions to their new roles.

We are proud of a number of data points and gains flowing from an initiative started in earnest in the first quarter of 2014. We have challenged many assumptions present in our marketplace that make little sense in the larger scheme of health care. Primary among these initiatives was a decision to more strongly engage our suppliers (our consultant physicians) in being responsible for holding up their end of quality in terms of fully addressing all aspects of their evaluation assignments and being timely in their report delivery.

As a company designed around medical services and led by a physician, we found ourselves asking why the industry that we are in has tended to not expect the best from consultants, instead regularly relying upon inspection and correction by non-clinical staff after the report is provided by a consultant to address any concerns and to achieve quality. Medical training and practice does not include a non-clinician shadowing and correcting doctor errors. Why in the medical review business did this become the norm? Rather, in the world of most health care services, it is expected that doctors are accountable for their work product. Prior to our changes, we relied upon inspection and correction, leading to rework that was often not to up to our standards, and often led to delays in report issuance with the back and forth processes that were required before the report was acceptable. We have been heartened by the results of setting clear standards to consultants. Our consultants by and large welcomed respect and accountability that this involves, and the ability to deliver the quality that they have been trained in and practice in the course of their clinical work.

While our turnaround times have always been competitive with the work of our peers, as a result of these efforts to-date this year we’ve experienced more than a 30% reduction in total turn-around time from date of examination to delivery of report. We have also seen a sizable reduction in rework and clarifications that contribute to this reduced time.

Our new focus embraces modern quality concepts common to hospital initiatives and general business trends. These are often given names like TQM (Total Quality Management), ISO 9000, Six Sigma, and others. All these include a variety of principles including the importance of root cause analysis, continuous improvement, and supplier/contractor engagement and accountability. One basic truism of achieving quality is that it can’t be achieved by inspection and correction – rather, it requires that quality is built in the entire system and involves the engagement of all stakeholders. In our case this means MCN’s clients, consultants, and staff.

We prepared for these changes by sharing the concepts with consultants and staff, redoubling our efforts in orientation and credentialing, and providing clear and concise documentation along with examination files. We communicated the responsibility for consultants to be accountable for producing a finished product within required time parameters, and personally proofing for content and syntax before allowing their signature to be affixed.

Many consultants have expressed support and appreciation of our joint efforts on quality. MCN staff are pleased to be part of this improvement effort as they see the improved impact of their work with less need to engage in frustrating rework, clarifications, or calling on late reports. We are very appreciative of all who have participated in this significant cultural and process change, which is ongoing.

Importantly, the clients’ experience is being positively impacted and is supported by their own data and audits.

One client, a national carrier, provided us first quarter data that demonstrated:

  •  MCN’s average turnaround time is 9.8 days with the contracted time of 15 days being met 92% of the time. Their other vendors have an average turnaround time of 13 days with 81% within specifications.
  • In addition to our superior turnaround, MCN had an exception rate of 3% vs. 20% among competitors serving this client. Exceptions include meeting turnaround specifications as well as 25 other measures including clinical metrics.

It is common to tout one’s processes and attributes but what really matters is how it is experienced by clients. The difference is being experienced and is a source of delight by those who order our services, and one of great pride for the great staff and consultants who are working together to achieve these meaningful results. Our clients are noticing with growth in referrals, and the awarding and renewals of a number of significant and prestigious contracts with global, national and regional companies.

From all of us at MCN, both staff and consultants, we thank our valued clients for their support and business as we work hard to innovate and excel in our field.

Politicians’ Prescriptions for Marijuana Defy Doctors and Data

June 30, 2014

marijuanaBrian L. Grant MD

This is a fascinating article on a number of levels. The comments by readers as well as the article are illuminating. I come to it as a person who came of age in the 70s, trained in psychiatry and reside in Washington State. I also have an interest in medical anthropology which among other issues looks at cross-cultural health care systems and beliefs. Finally, I have a strong interest in medical politics and economics which are major drivers of policy and practice in US Healthcare.

Washington State is one where medical marijuana (cannabis) is legal and recreational marijuana will be legal in July with a rigorous permitting and taxation system. In observing the medical marijuana “industry” and practice in Washington, what has been clear is that it is a parallel system whereby anyone can obtain a prescription for medical marijuana and that a tiny minority have the sorts of diagnoses such as glaucoma, terminal pain, cancer, and the like that were invoked to justify medical marijuana in the first place. Furthermore, given the wide array of symptoms that may be “helped” by medical marijuana, most of which are subjective, such as pain and anxiety – there is not a person reading this post who could not receive authorization if they so choose. The dispensaries that provide pot use nice euphemisms such as “medicine” to describe cannabis, and “donations” as what one pays to receive their medicine. Whether one can obtain marijuana while declining a donation is not clear.

So in my view, medical marijuana at least in principle, if not in practice, is by and large a sham. It makes liars out of decent people who want to get high, have a good time, harm nobody in most cases, and perhaps relieve some real symptoms. Similarly, it promotes disingenuous behavior on the part of practitioners who prescribe it, some of whom are true believers, but all of whom are paid good money to write a script often based upon one visit with someone they will never see again.

Therefore, with reasonable reservations and concerns, one should be pleased to see marijuana become legal for recreational use. Like alcohol, which was touted during prohibition as having medicinal value as a way to access whiskey and other drinks  and more, read here and here), marijuana as a medical substance has by and large been a back door to access by those who want to smoke it for its mood altering attributes.

There are many similarities between alcohol and marijuana. Both are substances that can alter one’s thinking and are psychoactive. Both can be sources of enjoyment and conviviality and both can and do cause harm. One is by and large legal and the other not and therein lies the problem. If we as a society wish to ban all substances and behaviors with potential for harm, the list would be long, not end with alcohol, and would certainly start with tobacco and include excessive caloric consumption and other quite legal and common substances. Unlike alcohol, or increasingly prescribed opiates, marijuana has little propensity for physical addiction and tolerance.

Relatively speaking, the end organ damage and aggressive behaviors that excess or chronic use of alcohol induce significantly outweigh the degree of harm seen in typical marijuana users. The numbers of those who use alcohol abusively with resulting damage to themselves or others is significant. Since marijuana use is generally defined as abuse per se, studies looking at actual damage from the use of marijuana need to focus on objective rather than regulatory criteria. Is marijuana harmless? Of course not. Dosages are imprecise as one smokes something with inconsistent intake and varying amounts of active THC. “Edibles” can be misused or accidentally fall into the hands of children. One can simply lack balance and overuse marijuana in lieu of more productive and useful activities, just as could happen with alcohol consumption. And the impact of smoking marijuana is of unknown concern as at least one study suggests that lung damage from typical use is not an issue.

Neither cannabis nor alcohol belong in the hands or mouths of children and make no mistake – increased access to either creates some collateral damage that non-use would avoid, just like opiates or the 70 MPH speed limit on the highways.

Interesting systemic questions include: What is the role of the health care system in deciding that it owns a portion of the human experience, or that something is a medical issue rather than a component of general life? What are the economics of the system and the impact of a substance like marijuana that can be easily grown and distributed outside of the pharmaceutical industry with no inherent barriers to entry other than access to sun or artificial light, soil, fertilizer, water and seed stock? Could there be an element of those in power wanting to maintain control of an income stream, resulting in criminalization, and restrictive regulations along with false or distorted claims of harm to control distribution and access?

Finally, what damage has flowed from criminality of cannabis? How many have died as a result of criminal and gang drug traffic? How many harmless individuals have been prosecuted and jailed for use or distribution of marijuana? How many of the judges, prosecutors, and jurors sitting in judgment on these defendants can with a straight face deny their own use of cannabis in their own lives at some point? What can we learn from countries like Holland where cannabis has long been legal?

We are about to embark on an experiment in Washington state, already started in Colorado, with legal recreational marijuana. The ultimate results remain to be seen. Whatever one’s personal views on legalization of cannabis, facts and data should inform both personal and government decisions on the policies and use of cannabis and other products. Unfortunately the subject is often polarized by advocates and opponents.

Judge Upholds Policy Barring Unimmunized Students from School during Outbreaks

June 25, 2014

Brian L. Grant MD

vaccines-child-needs-400x400MCNTalk has been following the vaccination refusal controversy for some time. As noted in this recent Times article, a NY court has affirmed the right to deny access to schools by unvaccinated children when another student is ill with a vaccine-preventable disease.

These particular cases are interesting because they illustrate a clash in values between sincerely held beliefs, religious or otherwise, and the public good. It leaves unanswered or at least unresolved the question of whether beliefs may trump good science. Also un-addressed is the practice in place whereby one can invoke religion where convenient, though scriptures are silent on vaccines and many other practices that individuals may choose to invoke religion to justify or excuse behaviors and choices.

Vaccines are a medical miracle that have virtually eliminated smallpox, diphtheria, measles, pertussis, and polio, maladies that have killed and maimed untold millions in the world and which can easily re-emerge when there is a sufficient number of unvaccinated to allow for transmission from person to person, versus current herd immunity that keeps the diseases in check.

Beyond the bad science claiming dangers of vaccinations are the polarizing effect of well-meaning parents and others who have come to believe these claims, clashing with other parents and authorities who do not want to support policies that in turn support the unvaccinated exposing their children and others to preventable risk.

The comments by readers, available along with the article, contain many compelling arguments worth considering on the topic.

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