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Screen Shot 2015-08-29 at 12.49.35 PM“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.

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flying cadeuciiTo understand why so many medical students (and pre-meds) (and doctors) contemplate business training, let’s consider two real-life examples: Dr. Bob Kocher and Dr. Bijan Salehizadeh. Both trained as physicians, both are currently healthcare investors, and both shared their stories with Lisa Suennen and me on our Tech Tonics podcast. (Kocher’s interview can be found here; Salehizadeh’s will available at the end of the month.)

(My usual disclosure: I work at a cloud genomics company in Silicon Valley; neither my company nor I have a financial relationship with Kocher, Salehizadeh, or their firms.)

Bob Kocher: The Hospital Consultant

Kocher is currently a partner at Venrock’s Palo Alto office, and is perhaps best known for his previous role working in the White House developing the Affordable Care Act in collaboration with Zeke Emanuel and others.

When he was growing up Seattle, Kocher says, his “dream was to be a leukemia and lymphoma doctor at the Fred Hutchinson Cancer Research Center.” He went to medical school, trained in internal medicine at the Beth Israel Hospital in Boston, and was accepted into a prized oncology fellowship at the Dana Farber Cancer Institute.

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flying cadeuciiPerhaps doctors should be more like the President.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the President needs in order to manage his, and all our, business.

That is how things used to work in medicine, too, before computerization revolutionized our workflows: Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and X-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature-needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.

Computers changed all that.

Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the X-ray department faster via their Internet connected computers. But in the typical medical office, we have now turned decision making doctors into frontline mail sorters and de facto bottlenecks of routine information.

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No one knows how Donald Trump’s meteoric rise to the top of the GOP primary race ends, its impact on Campaign 2016 or its domestic and foreign policy implications for the U.S. will play out. What we know is the man knows how to get a crowd, spark discussion, and steal media attention from his 16 GOP primary rivals. He has built his brand as a straight shooter on tough issues and unapologetic foil of political correctness.

Friday night, the Donald show flew into Mobile, AL, and lit up a crowd estimated at 20,000 at the University of South Alabama football stadium. He left town on Trump Air dominating the weekend’s media coverage, perplexing the pundits who were betting the Donald show would flame out.

Political theatre is prone to big stories like “the Donald”. He’s brash, cocky and unfiltered as he talks about dicey issues. He has simple solutions to immigration reform and the threat of ISIS. He promises to be a tough commander in chief in war zones and fierce negotiator in trade pacts. Healthcare is on his list as well.