By Robert Laszweski

I have no idea which way the Supreme Court will rule this year on the Affordable Care Act. Let me go out on a limb and predict a 5-4 vote on the question of whether the individual mandate is Constitutional. Just don’t ask me which way the vote goes.

I found the recent Obama administration brief submitted to the Court on the mandate question somewhat ironic. Not surprisingly, the Obama Justice Department argued that a finding by the Court that the individual mandate is unconstitutional should not jeopardize the vast majority of the new health law.

But the Obama Justice Department did concede that there are two provisions of the Affordable Care Act that should also be declared invalid if the Court rules the individual mandate is unconstitutional—the health insurance guaranteed issue and community rating provisions.

Now, I know there are lots of other people, many of them filing briefs with the Court, that disagree arguing that the whole law needs to be found invalid because the mandate is the lynchpin for all of it. But I will suggest it is significant that the administration would appear to be building a firewall for the rest of the law as they concede these points.

But consider this potential scenario.

Continue reading “Dismantling the Affordable Care Act”

By Michael Millenson

You can’t get much cooler than HealthTap: slick Silicon Valley start-up, social media darling, savvy and successful backers. But when you closely examine the service HealthTap actually provides, the money and good looks fall away. Like in the fable about “the emperor’s new clothes,” behind the buzz, there’s nothing there.

OK, maybe one thing: a really risky way to get medical advice.

Here’s how a Feb. 4 New York Times article described the company’s website:

[U]sers post questions and doctors post brief answers. The service is free, and the doctors aren’t paid. Instead, they engage in gamelike competitions, earning points and climbing numbered levels. They can also receive nonmonetary awards — many of them whimsically named, like the “It’s Not Brain Surgery” prize, earned for answering 21 questions at the site.

Fellow physicians can show that they concur with the advice offered by clicking “Agree,” and users can show their appreciation with a “Thank” button.

So far, so good. But there’s more. The professional credentials of the physician answering your question, such as a board-certified specialty, are not available on the site. Instead, you get a crowdsourced “reputation level” built up by accumulating HealthTap awards, by  clicks of approval from other doctors and by other measurable activities at the site.

Continue reading “The Emperor’s New Social Network”

By David Shaywitz

In my last column, I discussed the need for a better way of connecting the discrete healthcare-related problems identified by patients and physicians with solvers who might be able to develop a solution – perhaps an immediate fix, perhaps a longer-term effort.

I’m grateful for the volume of feedback received about this idea, which has included specific suggestions from patients; an introduction by several CEOs to a range of relatively-new efforts designed to tackle different key elements of this idea; and a few frustrated entrepreneurs who poignantly describe their struggles trying to change a fairly intransigent system.

A few observations about some of the online patient communities that I’ve encountered: First, there appear to be a number of patient-support (peer-to-peer) communities, both disease specific and more general. Several in the general category (e.g. MDJunction, Inspire, HealingWell) seem at least superficially similar; presumably the user experience depends upon the level of participation within a particular patient community.

Other models seem obviously distinctive: for example, AskaPatient provides fairly detailed patient-submitted reviews of various medications; the prose tends to be a bit less dry than the typical drug label – for example, a recent user of one neuropsychiatric medication reported that “Having an orgasm is like smashing a pimple. I am not sure if I want to continue taking this drug.” Yes, think that one over.

HealtheTreatment, a website that explicitly aspires to be the Trip Advisor or Yelp of chronic diseases, solicits and concisely presents patient experiences and ratings, so that you can immediately see, for a particular condition, what therapies other patients have received and how they felt the various treatment options worked for them. Of course, as Eric Topol emphasizes in his topical new book, “The Creative Destruction of Medicine,” the real challenge is personalizing therapy so you are treating a specific patient, not a population; understanding the breadth of potential responses to a drug doesn’t necessarily provide insight into how you, individually, will respond.

As I’ve discussed in a number of recent pieces (e.g. here, also this NRDD article with Eric Schadt and Stephen Friend), it would be extremely powerful to link the sort of detailed phenotypic measurements captured by HealtheTreatments with whole genome sequencing and gene expression measures, and then interrogate this coherent dataset with a robust analytic platform; these sorts of efforts are just starting to take off now, and are likely to become table stakes for serious drug discovery in the not-too-distant future. Continue reading “Getting Better”

By Mike Miliard

Healthcare reform is arguably the hot-button political issue of our time. And with the Supreme Court locked and loaded to decide the fate of the Affordable Care Act this summer, it’s a safe bet the controversial two-year-old legislation will have a huge impact on the 2012 election and beyond.

But what about health IT? If “Obamacare” has been a lightning rod, sparking historically nasty partisan bickering – Congress vs. President Obama, Republicans vs. Democrats, Fox News vs. MSNBC, the Tea Party vs. MoveOn.org – Washington’s efforts to spur healthcare information technology have enjoyed much broader support, on both sides of the aisle.

Just last week, a Washington think tank whose healthcare wing is led by two erstwhile rival Senate Majority Leaders put its weight behind smarter and more widespread use of technology and data exchange in healthcare organizations nationwide.

“To deliver high-quality, cost-effective care, a physician or hospital needs good information,” said former senator Bill Frist, MD, upon the release of a report, on Jan. 27, from the Bipartisan Policy Center’s Task Force on Delivery System Reform and Health IT. “Data about patients has to flow across primary care physicians, hospitals, labs, and anywhere that patients receive care.”

Continue reading “The Political Economy of Health Information Technology”

By Robert A. Berenson and Nicole Cafarella

One of the few health policy issues that receives bipartisan support is the need to dramatically alter the way providers are paid, shifting from “paying for volume” to “paying for value” to alter the trajectory of health care spending while improving health care quality.

To facilitate this shift, the Affordable Care Act equipped the Centers for Medicare & Medicaid Services with a range of cost-cutting and quality-enhancing tools―the most significant of which might be its new Center for Medicare and Medicaid Innovation. In this blog post, we share insights from recent research funded by the Robert Wood Johnson Foundation on the Innovation Center’s new role, organization, and model selection criteria.

Based on interviews with senior leadership, it’s clear the organization sees its role as two-fold: complementing existing efforts to innovate; and delving into new ideas.

Most of the Innovation Center’s efforts to date have focused on the former―implementing congressionally-mandated demonstrations or ideas that Congress or policy experts have already conceived (e.g., accountable care organizations). More recently, the Innovation Center has begun to seek new ideas from innovators across the country and to promote bottom-up innovation―primarily through its Innovation Challenge.

Continue reading “Is the Center For Innovation Innovating Too Fast?”

By Aaron Carroll MD

Lots of interesting feedback on my post on sugar regulation. Some of you have accused me of making straw man arguments; others have used straw man arguments to question my post. So let me take a few minutes to be clear about what I was saying. The article I referenced specifically questioned whether sugar should be regulated like alcohol and tobacco.

We regulate alcohol by making it illegal to use it before the age of 21. Period. We regulate alcohol by making businesses get a specific, and often hard-to-get, license to sell it. Where I live, it’s illegal to sell it on Sunday. We don’t regulate alcohol by limiting the amount you can put in a drink. Any bar can make any drink they like, with as much or as little alcohol as they want.

We regulate tobacco by making it illegal to use it before the age of 18. Period. We regulate it by making businesses sell it in specific areas, often hard-to-get at. It’s illegal to put it in vending machines. But we don’t regulate tobacco by limiting the amount you can put in a cigar. Any cigar maker can put as much or as little tobacco in as they want.

So when someone says that they want to regulate sugar like alcohol or tobacco, that’s what I think of. And it was what they meant, according to reports:

Sugar is so toxic it should be controlled like alcohol, according to new report that goes so far as to suggest setting an age limit of 17 years to buy soda pop.

Continue reading “Should Sugar Be Controlled Like Alcohol? Part II”

By John Goodman

You know we have entered the silly season when a major national debate gets underway over whether people should be given something for free that they could easily pay for out-of-pocket. Take the decision of the Obama administration to force Catholic universities, hospitals and charities to provide health insurance that includes free contraceptives. The reaction was poignant and hyperbolic, but (what can I say?) completely deserved:

• “An edict delivered with a sneer,” wrote Michael Gerson in The Washington Post.
• “An attack on Christianity so severe that every single church in Florida had a letter read from the bishops,” said Newt Gingrich.
• “We can’t just lie down and die and let religious freedom go,” said a spokeswoman for the Conference of Catholic Bishops.
• “We do not happen to think pregnancy is a disease,” said the president of the Association of Catholic Colleges and Universities.
• People who postpone conception with “chemicals and latex” are part of the “culture of death,” said Archbishop Timothy Dolan.

What makes this so amazing is that it is déjà vu all over again, as Yogi Berra might say. Do you remember the death knell for HillaryCare? I bet you can’t.

Mammograms and Pap smears. Hard to believe, isn’t it?

[Yes, I know. There were many things that helped derail HillaryCare. The biggest mistake was the White House's failure to throw everything aside and endorse the Senate Republican health plan, which was about as close to HillaryCare as RomneyCare is to ObamaCare. Hillary would have ended up with about 90% of everything she wanted. More about that, perhaps, in a future Alert.]

Continue reading “A Better Way to Avoid Pregnancy”

By JOHN HALAMKA

In my career, there have been a few perfect storms, defined as “a confluence, resulting in an event of unusual magnitude”.

When I was an undergraduate at Stanford University in 1980, two geeky guys named Jobs and Wozniak dropped by the Homebrew Computer Club to demonstrate a kit designed in their garage.   IBM introduced the Personal Computer and MSDOS 1.0.   I purchased an early copy of Microsoft Basic and began creating software in my dorm room including early versions of tax calculation software, an econometric modeling language, and electronic data interchange tools.   Every day brought a new opportunity. The energies of hundreds of entrepreneurs created an industry in a few intensely creative months that laid the foundation for the architecture and tools still in use today.   A guy named Gates offered me a job and I decided to stay in school instead.

In 2001 when I was first hired at Harvard, a visionary Dean for Medical Education, a supportive Dean of the Medical School,  talented new development staff, and a sleepless MD/Phd student came together to create one of the first Learning Management Systems in the country, Mycourses.   Robust web technologies, voice recognition, search engines, early mobile devices, and new multi-media streaming standards coincided with resources, strong governance, and a sense of urgency.  Magic happened and in a matter of months, an entire platform was created that is still powering the medical school today.

Continue reading “The Perfect Storm For Innovation”

By Alexander Prisant

You start coming out from under the deep anesthesia. First your eyes start to open. They work. Then you haphazardly try to move an arm, your head, and your lips to speak. And none of that works at all.

You’re strapped in and breathing through a machine and taped up 32 ways against Tuesday. So you go back to your eyes, which work. Mounted over the foot of the bed is a clock. Those big, easy-to-read hospital clocks. You’re a little dopey, but you slowly realize it says three minutes to six. The last time you were conscious, you think, was about 8:45 in the morning.

What??

Now you’re not dopey; you’re stunned and scared and reflexively lurch to get up. But all the medical machinery holding you down keeps you down.

And for some reason there is no pain at all, even though you are already suspecting you’ve been filleted like a flounder.

Continue reading “The Journey We Take Alone.”

By Jason Shafrin

One of the provisions in the Patient Protection and Affordable Care Act (a.k.a ACA, a.k.a. Health Reform, a.k.a. Obamacare) is that it limits the profits of health insurance companies. The ACA imposes a minimum medical loss ratio (MLR) on all insurers. The MLR is the amount of money spent on covered person medical care divided by the total revenue received through premiums. There is some debate of what constitutes ‘medical care’ (e.g., do investments in electronic health records count as medical care?), but insurer profits certainly are non-medical.

The ACA requires health insurers in the individual and small group market to spend 80 percent of their premiums (after subtracting taxes and regulatory fees) on medical costs. The corresponding figure for large groups is 85 percent. According to a recent Kaiser tracking poll, 60 percent of the public views the MLR concept favorably, although only 38 percent was aware that the provision is in the ACA. Insurance brokers may be getting squeezed for insurers to meet this amount.

Even though the MLR is a national law, it may not apply in your state. Continue reading “Does Obamacare Limit Profits for Health Insurance Companies in Your State?”