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HIMSS Voter ID_Adrian-GropperHealthcare is abuzz with calls for Universal Patient Identifiers. Universal people identifiers have been around for decades and experience can help us understand what, if anything, makes patients different from people. This post argues that surveillance may be a desirable side-effect of access to a health service but the use of unique patient identifiers for surveillance needs to be managed separately from the use of identifiers in a service relationship. Surveillance uses must always be clearly disclosed to the patient or their custodian each time they are sent by the service provider or “matched” by the surveillance agency. This includes health information exchanges or research data registries.

As a medical device entrepreneur, physician, engineer, and CTO of Patient Privacy Rights, I have decades of experience with patient identifier practices and standards. I feel particularly qualified to discuss patient identifiers because I serve on the Board and Management Council of the NIST-founded Identity Ecosystems Steering Group (IDESG) where I am the Privacy and Civil Liberties Delegate. I am also a core participant to industry standards groups Kantara-UMA and OpenID-HEART working on personal data and I consult on patient and citizen identity with public agencies.

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flying cadeucii

In the midst of sluggish economic growth, finding a sector of the economy growing from 15 percent of the economy up to 19 percent would normally be a cause of celebration, except that this is health care. The lack of good cheer about this growth is an indirect acknowledgement of a stark reality: We are not realizing much increased value as we spend more on health care because too much of our health dollars are going to ineffective (and often harmful) procedures.

Estimates of the waste from this overconsumption of health care range from 30 percent to 50 percent. While all of the experts talk about reducing this waste (the phrase of the day is “bending the cost curve”), the reality is that hospital administrators, pharmaceutical companies, device manufacturers, insurers, consultants, think tanks and government bureaucrats all are seeing their power, control and financial remuneration increase due to this medical-care consumption growth.

All of the reformers’ trendy ideas have failed and will likely continue to fail in spite of the experts telling us they will soon figure it out. Electronic health records are a hugely expensive disaster. So far, they decrease doctor efficiency, reduce quality and increasingly make patients fearful of sharing sensitive information with their doctors for fear hackers or others will access their private data. Accountable Care Organizations turn doctors into rationers, introducing a conflict of interest between doctor and patient. Price controls by Congress or bureaucrats or oligarchic insurers only reduce access to care, demoralize doctors and introduce the risk of game playing by health systems by “up-coding” (labeling a doctor visit as more complex than it is).

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John GoodmanBeginning in 2018, high-cost, private sector health plans will be subject to a special levy, popularly known as the “Cadillac plan” tax. Under a provision of the Affordable Care Act, health plans must pay a tax equal to 40 percent of each employee’s health benefits to the extent they exceed $10,200 for individual coverage and $27,500 for family coverage

In many ways, the Cadillac Plan tax is a stealth tax. It doesn’t even become effective until eight years after the Affordable Care Act passed Congress. And back in 2008, the thresholds were so high that it must have seemed like the tax would apply only to a handful of employers. But health care inflation has a way of escalating base line costs through time.

So much so that a Kaiser Family Foundation study estimates that the first year it is applicable, one in four employers will be subject to the Cadillac plan tax unless they change their benefits. Going forward, the thresholds are indexed to the rate of general inflation – which historically is well below the rate of medical cost inflation. As a result, the study estimates that the share of employers potentially affected could grow to 30 percent by 2023 and 42 percent by 2028.

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“I want to explore employment opportunities with you.”

He is looking at me. Trying his hardest. Passion, yet anger, in his eyes.

Everything I know about him and his tenure in the community helps me understand how difficult this conversation is. Everything I see in his eyes helps me understand how painful this is.

Private practice is dying…on the vine…in America.

The practices fold or reach a critical point and they come running to Big Med to fix all the problems.

Absorb. Acquire. Integrate. Consolidate.

Every week I get a call.

“Will you buy my charts? Why not? I have been a longstanding provider in this community?

“Will you buy my practice? Why not? I have been loyal to the system?”

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flying cadeuciiA new report from the usually sensible Commonwealth Fund got lots of media attention this past week. The report –“Competition Among Medicare’s Private Health Plans: Does It Really Exist?” –quickly led to headlines like “Is private-sector Medicare becoming a monopoly? [PBS]” and “Robust Medicare Advantage competition almost non-existent [Modern Healthcare],” and “Health insurance is staggeringly uncompetitive in America, and is poised to get even worse for everybody [Quartz].”

It sounds like Medicare Advantage is headed for disaster, but is this really the case?

The Commonwealth report’s major findings are summarized in one sentence, likely the one that grabbed media attention: “Using a standard measure of market competition, our analysis finds that 97 percent of markets in U.S. counties are highly concentrated and therefore lacking in significant [Medicare Advantage] plan competition.”

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Joseph KvedarEarlier this summer, I was fortunate to be invited to speak at the recent AHIP (America’s Health Insurance Plans) conference in Nashville. This is an annual gathering of health insurers and it was my first time attending. My experience there, and a few recent news items, got me thinking about about how health care is evolving and whether we once again will ignore Santayana’s admonition, “Those who cannot learn from the past are doomed to repeat it.”

As we continue our journey to change provider reimbursement to a “Pay for Value” system, the lines between health insurers and health care providers are blurring. Physician/hospital systems, like Partners HealthCare, where I work, are taking on risk for populations of patients through contracts with the Federal government and local payers. According to Secretary of Health & Human Services, Sylvia Burwell, this trend is going to continue. She stated recently that HHS set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. Since the whole insurance industry is based on risk, we inevitably have to start thinking more like insurers if we’re going to be taking on risk.

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Screen Shot 2015-08-27 at 12.22.43 PMHealth care pricing is like the Wild West and it is only a matter of time before it catches up with us. In July, the Centers for Medicare & Medicaid Services (CMS) confirmed what many consumers, employers and health plans already knew: there is no cost and quality standard in the American health care system.
Improving our system starts with driving payers and consumers to high value providers. But first, we must know who is charging what. Price transparency tools offer that important information, enabling people to actually comparison shop for their health care services.

In early July, CMS released a proposed rule aiming to address price variation by starting with joint replacements. According to CMS, there were more than 400,000 Medicare inpatient joint procedures, resulting in more than $7 billion in hospitalization costs in 2013. The average Medicare expenditure for surgery, hospitalization and recovery ranged from $16,500-$33,000 depending on geography, with widely varying rates of infection and implant failure post-surgery.

To address this variation, CMS outlined a new payment model that would make some hospitals accountable for the costs and quality of care from the time of surgery through 90 days after.

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Microsoft Office was first introduced by Bill Gates at COMDEX, Las Vegas, in August, 1988.

Here we are almost exactly 27 years later, and if you plug the words ‘hate,’ ‘Microsoft’ and ‘Office’ into Google, you’ll get more than 4 million results. Remove ‘Office’ and Google returns more than 33 million results.

Clearly, some people don’t feel like Microsoft has perfected products to their satisfaction.

The perpetual unhappiness with a monolith like Office comes to mind as I read reports on the most recent surveys of physician satisfaction with electronic health records (EHRs). Let’s sum up, for those unfamiliar with the reports

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Screen Shot 2015-08-26 at 12.13.13 PMEarlier this month the Center for Public Integrity (CPI) published a sharp-edged piece on PCORI—the Patient-Centered Outcomes Research Institute. 

The piece raised some salient issues and it’s timely to take stock of PCORI at the half way point of its authorized funding.  (Unless renewed, PCORI sunsets in 2019.) 

The Affordable Care Act created PCORI as an independent nonprofit (non-government) entity.  But PCORI’s funding and structure makes it more or less quasi-government.  It gets its money from the Medicare trust fund, treasury general funds, and a tax on private insurers and self-funded insurance plans ($2.08 per covered life).  PCORI launched in late 2010 and began funding research in earnest until 2013.  The main focus of that research, mandated by Congress, is to compare treatments in a way that results in meaningful results for doctors and patients as they make clinical decisions.  No small task. 

The CPI piece probes the emerging debate about how PCORI is being operated and spending its money—roughly $450 million a year in 2014 and 2015.  The core lead-in graph of the piece: “On both the right and the left, there’s simmering doubt about whether the unusual nonprofit can live up to expectations, or even what those expectations should reasonably be.”   

The report airs legitimate concerns but it skews overly critical and doesn’t fully appreciate the challenge PCORI faces.  As someone who labored in the fields of comparative effectiveness for several years, I think PCORI deserves time to get fully underway and prove itself.  It certainly doesn’t need ideologically driven attacks and budget threats just because it was launched by the ACA.   (The House Appropriations Committee in late June voted to cut PCORI’s funding by $100 million, dubbing it wasteful spending.) 

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Forgive me, but I simply need to vent. Think for a moment about your hospital or health system’s IT leader. Would you describe this person as controlling or collaborative? Do you even really know? And what difference does it make?

In my role at Microsoft, I meet with many business and clinical leaders in health and healthcare. I also work closely with our account executives and solutions experts who call on IT leaders of hospitals, health systems, and clinics around the world. Over the years, I’ve concluded that IT leadership often falls into one of two categories; controlling or collaborative. Within a few minutes of visiting most healthcare organizations, I can usually tell if the IT leadership is controlling or collaborative. There’s often a very direct correlation to the organization’s ability to innovate and transform.

Although the IT leader in a healthcare organization may hold a variety of titles including IT Director, Chief Technology Officer, or Chief Information Officer, for purposes of this post I am going to refer to the IT leader as the CIO.