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My Ideal EHR

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flying cadeuciiGive me technology which improves my life and that of my patients, or give me death.  Medical records must be informative, efficient, and flexible; like the physicians they serve.  For me, a medical record does not contain just a collection of problem lists, prescribed medications, and immunizations; it is a noteworthy account of the health care provided to another human being over a lifetime.

Recently, I attended a baby shower of a patient who is now an adult.  (I am a pediatrician.) I brought her medical chart wrapped with a satin bow as one of her gifts.  I was her physician for many years; my father had taken care of both her and her mother as children.  Her growth, development, immunizations, and illnesses were all recorded; but so were 25 years of life experiences, trials, triumphs, and tribulations.  The back section contains drawings she had given me, newspaper articles of her achievements, graduation announcements, and her wedding invitation.  Obviously, medical records register growth parameters, vital signs, and sick visits; but they also encompass my relationship with my patients.

Self-Driving Health

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Screen Shot 2016-08-22 at 10.39.39 AM

Lots of news about this recently.  Five years ago, you would shake your head and say “no way – not in my lifetime.”  Now you know that this is our future.  It will be safer, will save billions of dollars, and will be have positive consequences we can barely imagine.  The kids need to go to soccer practice?  Send them.  Get the dog to the vet for his check-up?  Plop him in the car and off he goes. It’s real. It will happen.  Soon.

So why is it so hard for us to imagine self-driving health?  Do we have a crisis of under-supply of primary care?  Yes.  Today we do .  But I wonder if that’s because we’re asking the wrong question.

Aetna’s Obamacare Surprise

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Screen Shot 2016-08-21 at 10.41.37 AMDid Aetna just pull a nasty, Trump-like move and up the ante on the Obamacare debate in advance of the election and exchange open enrollment for 2017?

The allegation is that the company withdrew from 11 state insurance exchange marketplaces for 2017 after the Justice Department failed to heed Aetna’s warning that it would do so if Justice didn’t approve its $37 billion purchase of Humana.  The Justice Department announced last month that it was challenging that deal and Anthem’s proposed merger with Cigna, saying both deals threaten to sharply reduce competition in the health insurance marketplace.

A July 2016 letter from Aetna to Justice, unearthed by Huffington Post, contains the threat.   But in announcing its exchange pullback this past week, Aetna made no mention of the letter and insisted its action was prompted by existing and expected future financial losses in the exchanges.

More Than a Lollipop: Helping Kids Get Through the Hospital Experience

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Screen Shot 2016-08-02 at 7.03.56 AMIn the latest installment of the Who Cares: Hospital Talk podcast we chat with Kristin Colby, a specialist with Children’s Hospital of Atlanta about the challenges of preparing kids for the uncertainty and trauma of hospital care. Could working with kids just maybe teach something to the rest of us? Maybe. Just maybe ..

The Exchanges Part II

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flying cadeuciiI wrote earlier here about the exchanges, how they are failing, and why.  It is unsurprising that what I wrote is coming true, not because I am some clairvoyant, but because I’ve lived in the insurance world and understand it.  The causes are very, very obvious.

The most recent whipping boy is Aetna, which announced that it is exiting most of its exchange markets, citing losses of $200 Million in the second quarter. From correspondence, it is clear that Aetna was willing to be a good citizen and accept such losses if its proposed acquisition of Humana were not opposed by the feds.  Well, the feds are opposing.  And predictably, Aetna is sending back a message that it’s willing to be a good citizen, but only up to a point.

Might we wonder what the Obama Administration is thinking regarding the exchanges?  All of this is so predictable.  The exchanges were designed to fail economically.  Fundamentally, insurance is a financial matter.  Money in, money out.  If the exchanges were designed to be something else (a socially-conscious program to afford (so to speak) coverage to everyone that would require tax subsidies), it might be time to admit to that.

The Iora Health Fellowship: A Call For Applicants

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flying cadeuciiAs physicians, we pride ourselves on our clinical wins – nailing the diagnosis of a rare disorder or helping a patient achieve control of their long-standing diabetes. However, we commonly face intense frustration and high rates of burnout due to socioeconomic, political, and bureaucratic forces that prevent us from delivering impactful patient care. This frustration is compounded by the constant proliferation of changes in healthcare policy and care delivery to address alarming increases in healthcare cost and waste. Between the deluge of paperwork, regulations, and resource constraints, we often ask ourselves: Why does the system often hinder rather than enhance the physician-patient relationship?

The truth is that physicians can no longer sit on the sidelines. The questionable value of so many clinical procedures and the immense cost baked into the system are clearly unsustainable. Given that physicians – with their patients – ultimately make decisions regarding care plans, they are uniquely positioned to move the healthcare system to one that rewards doing only what is best for the patient. Yet, current physician training rarely incorporates curriculum designed to create systems thinkers capable of leading multi-discplinary care teams.

Enter Iora Health and its unique fellowship in primary care innovation and leadership. Iora is an innovative primary care delivery startup that is committed to restoring humanity to healthcare. It advances a high-impact, relationship based primary care model that is backed by talented health coaches, robust technology, and payment that is focused on patient outcomes.

Value-Based Government (GACRA)

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We decided that if MACRA is good for physicians, then the same thinking is probably a pretty good idea for the US government. We need Value-Based Government. It’s clear that past methods of paying for US Government services have been terribly inefficient. Costs keep going up. Quality keeps going down. We thought about doing this nationwide, with all US government personnel, but we will just do CMS leaders for now. Let’s call it a demonstration, we’re calling it  GACRA, Government Access and CMS Revaluation Act.

Eventually we want all US government employees to be value- based, no more salaries. This is an obvious improvement on how we will pay you,  The way you are paid now does not seem to work. Everyone agrees our government is too expensive to run and nothing gets done.

Here’s how value-based government works:

Every CMS leader will send in a code for every 10 or so minutes of work and exactly what they did. Yes, Andy Slavitt and Sylvia Burwell, you will not be paid as you were previously.

You will now be paid for value.

The American Medical Association Takes a Step In the Right Direction

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flying cadeuciiI am very glad the AMA is studying the issue of aid in dying. Opponents to the legalization of aid in dying put quotes around the term, apparently to indicate that it is a euphemism for what they believe is physician-assisted suicide. But aid in dying is not suicide.

On 9/11 witnesses saw a number of people trapped in the World Trade Center intentionally jump to their deaths. None of those deaths were ruled suicides by the medical examiner. The death certificates for the jumpers list the cause of death as homicide.

Similarly, in the states in which aid in dying is legal, the death certificates do not list “suicide” as the cause of death; instead, they list the underlying terminal disease as the cause. Just as the 9/11 jumpers chose death by falling over death by burning, those terminally ill people fortunate enough to live in an aid in dying state can choose a peaceful, quick death at the time and place of their choosing over a drawn-out, miserable death that may end alone, intubated in an ICU rather than at home with loved ones present.

Capping Co-Pays Doesn’t Lower Drug Costs

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flying cadeuciiPoliticians are concerned about your drug costs. Unfortunately, their proposals could actually raise drug prices and force you to pay more, albeit indirectly. For instance, presidential candidate Hillary Clinton proposes to cap your prescription drug co-pays at no more than $250 per month. Rising drug costs are now a political issue because the number of diseases and conditions that can be treated using drug therapy has grown tremendously over the past 25 years. Arguably, one of the main reasons patients visit their doctors is to obtain or renew prescriptions. When they visit their doctors’ offices, Americans leave with a prescription in hand about three-fourths of the time. This is hardly a travesty; and few patients are drowning under the cost of prescriptions drugs. Most prescription costs are paid for by prescription drug plans sponsored by insurers and health plans.

Insurers and health plans use multiple techniques to make drugs affordable. One of the ways employers, insurers and pharmacy benefit managers (PBMs) hold down costs is through drug formularies with multiple tiers. The purpose of tiered formularies is to steer enrollees to lower-cost alternatives when appropriate, using differing levels of cost-sharing and co-pays. Drug plans typically encourage generic use by requiring little if any cost-sharing when a generic drug is dispensed. Prescriptions are dispensed in generic form about 88 percent of the time. Generic drugs are cheap compared to brand drugs — accounting for less than three percent of national health care expenditures.

Patients Without Borders

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More about Jess Jacobs, who died on Saturday–also known as #UnicornJess. (That link will take you to the twitter memorial on Sunday night, but also check out remembrances from Ted Eytan & Carly Medosch). Today I’m re-running a beautiful, and very personal piece (on Medium) from her friend Whitney Bowman-Zatzkin who was a key patient advocate for Jess in Washington DC–Matthew Holt

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I attended a walking tour once where the guide was going on about Von Gogh’s quest to paint yellow in the most yellowy of yellow ways. Even NIH articles talk about it. Theories abound.

As we walked, I gained an appreciation for the lengths this guy went to on his quest for a single portrait of yellowy yellowness. I remember the guide saying something like:

“Van Gogh sought his whole career to paint in a way that demonstrated how yellow made him feel.”

The tour was years ago but that line stuck with me. Has anything ever trapped you like that? Like a quest to craft a brushstroke for how something made you feel?


My treasured friend Jess Jacobs died this weekend. She flooded my life with laughter and jokes, expanding what I knew in what it is to love a friend in the very best of ways.

Jess and I met in a classroom at Georgetown where she swiftly passed out in front of me when I returned for the final pitches of my first-ever code-a-thon. Later she’d tell of waking up to a blur of people and a certain bow tie being in focus.

Shortly thereafter, she fainted in front of me again and I soon learned how to trust a new friend and be there for her more than I ever had before. That pattern continued throughout my whole friendship with Jess. She gifted me a new definition of trust and capability.

Some of the scariest words I’ve ever known in health care existed in Jess’ medical profile, yet she was always the outlier redefining what it meant to have those diagnoses.