Archive for February 2011

Ethics in the era of genetic testing

While I’m at home trying desperately to figure out how to set adequate parental protections on out Internet browsers and restrict my kids’ access to any and all Showtime original series on streaming Netflix, researchers at Baylor College of Medicine are posing some challenging ethical questions physicians are ever more likely to face. What if you tested a patient’s genes and found that he or she was likely the child of an incestuous relationship? What would your ethical responsibility be?

The BCM researchers write in the Feb. 12 issue of The Lancet that they have witnessed several of these cases while performing genomic tests on children. The topic is broad, with various implications regarding the age of the parents at the time of conception, their relational status, the possibility of criminal behavior or abuse, not to mention the emotional stigma and distress involved for the patient.

With all the promise genetic testing holds for understanding, identifying, and treating various conditions and disease states, the ethical ramifications are staggering, and this is just one particularly interesting and puzzling question to explore. Check out the article: http://tinyurl.com/47k7unt. We’d be interested to know your thoughts, so use the comment feature. What are your thoughts on the ethics of finding evidence of incestuous parentage through genetic testing, or just the ethics of genetic testing in general?

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BCM on the closing of Kelsey-Seybold FMRP: “They just didn’t want to be in the education business”

The Senate Finance Committee has held hearings for the past two weeks on every section of the budget, and because so many primary care programs suffered cuts (as did most other programs), many interesting exchanges have come to light. In all the discussions, though, both lawmakers and those testifying agree that primary care is of the utmost importance to ensuring Texans’ access to care.

Because residency programs play such a large role in producing the primary care physician workforce, here enters Paul Klotman, M.D., president and CEO of Baylor College of Medicine. He testified during the Feb. 8 hearing of the Senate Finance Committee, and Sen. Bob Deuell of Greenville questioned him on the closing of the Baylor College of Medicine Kelsey-Seybold Family Medicine Residency Program. Here’s their exchange.

Sen. Deuell: A family medicine program closed. What’s your take on that?

Dr. Klotman: Our family medicine program is doing fine. [Person in audience speaks]. Oh, are you talking about Kelsey-Seybold?

Deuell: Yes.

Klotman: My understanding is they just didn’t want to be in the education business, that they didn’t want to continue to have residents there.

Deuell: Was that because of finances?

Klotman: They’re driven by patient care, they’re at risk now, they need efficiencies in their system. It’s hard. One of the challenges is working in the educational piece into efficient organizations, but I actually believe you can do that. It just needs to be done in an integrated way and I don’t think that’s their primary mission.

My understanding is they just didn’t want to be in the education business, that they didn’t want to continue to have residents there.

–Paul Klotman, M.D., President and CEO, Baylor College of Medicine

So why did the program close? It turns out that it was financial. As Jonathan Nelson writes in “On the Brink,” the cover story of the first-quarter 2009 issue of Texas Family Physician, it began in 2006 when the program’s primary teaching hospital, St. Luke’s Episcopal Hospital, cut support for the program in half.

That sent Baylor and Kelsey-Seybold FMRP scrambling to find new sources of funding, none of which were stable from year to year. By fall 2009, they agreed that the program was no longer financially sustainable. Kelsey-Seybold needed a subsidy from BCM of between $400,000 and $450,000 to keep the program viable. But Baylor, which has operated at a substantial deficit for the past several years, couldn’t save the program.

Baylor College of Medicine’s 2010-2011 appropriation for GME formula funding— money intended to support their affiliated residency programs—is $15.3 million. That’s $2.5 million more than they received in the previous biennium.

The program closing certainly wasn’t because of lack of interest from the faculty or the applicants. Again, from “On the Brink”: In an era when family medicine residencies only manage to fill 45 percent of available residency positions with U.S. medical school graduates, 97 percent of the recruitment classes at the Kelsey-Seybold program over the last three years graduated from U.S. medical schools. More than 600 physicians applied for the four open positions at the residency in 2009, and of the four chosen, two are from out of state. “I’m constantly bombarded with people that would just love to come to our program,” says Tricia Elliott, M.D., F.A.A.F.P., the residency’s program director.

Read the full article here.

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HHS Commissioner to Senate Finance: Spare primary care

When Tom Suehs, executive commissioner of Texas Health and Human Services, addressed the Senate Finance Committee in a hearing on Feb. 1, he told the 15 senators in no uncertain language that going through with cuts to primary care proposed in the Senate’s draft budget will damage access to care.

Suehs (pronounced “seas”) is pushing for exceptional items that would reduce the cut in payment for primary care physicians treating kids enrolled in Medicaid and CHIP from 10 percent to 2 percent. This would cost the state around $125 million in general revenue next biennium, according to a Feb. 1 article in Quorum Report.

“I’m really concerned about having to cut primary care rates for physicians treating children,” Suehs told the committee. “We’ve already cut 2 percent this biennium from when y’all wrote the [2010-2011] budget. I believe that’s about as far as I can tolerate to maintain the access to primary care so I’m asking to put back not all 10 percent, but 8 percent. Exceptional item 1A is for Medicaid children, exceptional item 1B is for CHIP.”

Suehs emphasized his desire to make “targeted cuts to minimize hits to access to care” rather than an across-the-board cut for providers—as has happened in the past.

More than the provider pay cuts in Medicaid and CHIP, primary care took a beating in the draft budgets released by the House and Senate (read the “Bleak House” post). The House version eliminates funding for the Texas Family Practice and Primary Care Residency programs, the Physician Education Loan Repayment Program, and the Primary Care Preceptorship Programs. The Senate version cuts the residency programs by 29 and 45 percent, respectively, with other cuts to graduate medical education.

TAFP CEO/EVP Tom Banning says in a Feb. 2 article in the Texas Tribune that this isn’t the time to make cuts to primary care. Instead, lawmakers should explore ways to reduce health care costs to the state by investing in programs that reward doctors to achieve the best medical outcomes. It sounds contradictory to spend more to save, but outcomes-based initiatives that support primary care are gaining ground; pay-for-performance programs and medical home initiatives, for instance.

Banning supports Suehs’ commitment to preserving primary care and sees it as a positive indicator that primary care will survive a tough session. He wrote in an e-mail to Academy leaders, “I think this clearly points to the value and importance that HHSC and the legislative leadership is placing on primary care. This should play well into our strategy to restore higher education funding to produce the primary care workforce Texas needs to achieve their policy objectives.”

Before ending on too positive of a note, John Reynolds in the Quorum Report article foretells a battle if primary care receives special treatment and other providers receive the full cut. “What to one person is protecting a vital part of the health care system from being dismantled might sound to another like creating a set of winners and losers. And that’s a formula for conflict.”

Here’s the link to the Quorum Report article (full text for subscribers only): http://www.quorumreport.com/Subscribers/Article.cfm?IID=16647

Here’s the link to the Texas Tribune article: http://www.texastribune.org/texas-health-resources/health-reform-and-texas/are-payment-reform-texas-budget-in-conflict/.

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