Category: Outpatient Practice

Ohio State is about to expand its 340B program to include a free-standing pharmacy and the outpatient infusion centers. It gave me a chance to brush up on what a 340B program is. The 340B program was created by the federal government in 1992 as a way to provide discounted outpatient drug pricing to healthcare institutions that care for the poor. There are 6 categories of hospitals that are eligible that largely have in common that they are tax-payer funded to care for low-income and uninsured patients:

1. Disproportionate share hospitals
2. Children’s hospitals
3. Cancer hospitals exempt from the prospective payment system
4. Sole community hospitals
5. Rural referral centers
6. Critical access hospitals

In addition, hospitals have to either be state/government-owned, be a private not-for-profit hospital that has been granted governmental powers, or be contracted with the government to provide care to low income patients. In addition to hospitals, there are certain outpatient clinics that are also eligible to participate. As of 2014, there were 2,140 hospitals in the program, 90% of which are either critical access hospitals or disproportionate share hospitals.

The way the program works is that the Health Resources and Services Administration (HRSA) sets the maximum amount that drug companies can charge for outpatient medications – on average this is about a 22.5% discount. Medicare part B covers some outpatient medications (eg, cancer chemotherapy and rheumatoid arthritis infusion drugs); however, the hospitals participating in the 340B programs get paid the same from Medicare part B for these drugs as they would if they were not in a 340B program. Therefore, the hospital stands to make money on 430B drugs. On the other hand, drug manufacturers have to sell the hospitals their drugs at the discounted 340B price and so they would like to limit 340B programs so that they can have a higher profit.  All told, 340B programs save about $4 billion per year in drug costs. There are about 7,000 different drugs in the 340B program.

Ideally, hospitals participating the 340B programs use the increased margin that they get from the 340B programs to help support the care of lower income patients. For example, using profits to pay for rheumatoid arthritis infusion drugs for patients who are low income and have no health insurance and otherwise would not be able to buy these rather expensive medications. The danger is that there is the potential for some hospitals to expand chemotherapy and infusion clinics since they can make a higher margin on the chemotherapy and infusion drugs. Overall, 340B sales account for about 2% of total drug sales in the United States so it is not an enormous amount but 340B pricing is disproportionately affecting high cost chemotherapy and rheumatology biologic medications.

I can see both sides of the argument for the 340B programs but at least for our hospital, it will allow us to treat patients who previously were too poor to be treated for conditions like rheumatoid arthritis and inflammatory bowel disease in the past.

October 5, 2016

In the movie, A Few Good Men, the climax occurs when a military attorney played by Tom Cruise questions a colonel played by Jack Nicholson during a trial about a murder on a military base and Nicholson famously says: “You can’t handle the truth”. We now have a lot of physicians saying the same thing about releasing lab test results to patients.

Electronic medical records have changed the way we practice medicine in many ways. As physicians, we are focused on how EMRs affect how we practice medicine. But there are also big changes in the way that patients receive medical care and this is often under-appreciated. In this case, it involves who really owns a patient’s medical record: the doctor or the patient?

There is a long history of doctors and hospitals being loath to share medical records with patients or other doctors. Part of it has to do with HIPAA laws and the fear that medical records will fall into the wrong hands. Part if it has to do with the time and expense that it would previously take to photocopy records. Part of it has to do with a suspicion that anyone asking for medical records is planning on using it to judge or sue the physician. But part of it comes from a fear that patients are going to pester us about every minor lab abnormality and create additional work for us explaining insignificant results.

Enter the electronic medical record. We can now organize and disseminate medical information better and more rapidly than ever before. One of the features of EMRs is the ability to communicate with patients, including electronically releasing their test results to them. When we first acquired our electronic medical record, we did not automatically release any test results and the physician had to decide for each test result whether he or she would release the result electronically to the patient. After a few years, we changed it to auto-release basic test results (like chemistry blood tests and CBCs) after 5 days, thus allowing the ordering physician 5 days to review and act on any results prior to the patient seeing them.

Last year, at our James Cancer Hospital, we made blood test results available to inpatients immediately through their electronic medical record. The patients really liked this a great deal and it improved satisfaction scores. Although there was some concern that hospitalists would be “scooped” by patients who often saw their blood test results before the patient, this really didn’t materialize.

This summer, we extended the auto-release to outpatients. It is only for fairly basic lab tests and not for sensitive results like surgical pathology results, radiology results, or genetic tests. Our hope is that we can improve patient satisfaction but the initiative was met by a lot of resistance by some physicians who were concerned about a barrage of phone calls from patients worried about insignificant test results.

Enter the monocyte count. When you order a complete blood count (CBC), you get 19 different results, most of which, you don’t really care about. One of the ones that most physicians care the least about is the monocyte count that rarely means anything significant if it is too high or too low. But if patients see that monocyte count as being abnormally elevated, they can panic because they don’t know if it is important or not. So the fear that was perpetuated by some of our physicians is that they were going to get inundated by panicky phone calls from patients worried about their abnormal monocyte counts.

My own opinion is that the medical records belong to the patient and not the doctor and patients have the right to see their blood test results. Personally, when I see my own doctor, I really like being able to immediately see what my routine cholesterol, hemoglobin A1C, or hemoglobin is when I’m in for my annual check-up. Most patients are a lot more sophisticated today than they were 20 years ago, before the advent of EMRs, and most patient are like me, they want and expect to see their lab results right away.

So far, I’ve only had one patient call about his high monocyte count after hundreds of immediately released lab tests. It is a pretty small price to pay for improved patient satisfaction. Personally, I think patients can handle the truth.

September 27, 2016