OP-ED

OP-ED

ONC Report on Health Information Blocking: A Solid Double, But NOT a Home Run

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flying cadeuciiLast Friday ONC (the Office of the National Coordinator for Health IT) released a long-awaited Report On Health Information Blocking. The ONC blog capsulizes the report:

Health information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information. Our report examines the known extent of information blocking, provides criteria for identifying and distinguishing it from other barriers to interoperability, and describes steps the federal government and the private sector can take to deter this conduct.

We were struck with two major reactions to the ONC Info Blocking Report:

  • It’s a solid double: it does a credible job of recognizing that the major problems of interoperability and blocking are not technical or due to a lack of standards, but rather due to business practices and business models. The report also proposes a baseline of potential solutions.
  • It’s not a home run: the report misses the opportunity to describe a comprehensive approach to combat information blocking.

The Facebook Model for Socialized Health Care

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Screen Shot 2015-02-26 at 5.06.17 PMAs government involvement in U.S. health care deepens—through the Affordable Care Act, Meaningful Use, and the continued revisions and expansions of Medicaid and Medicare—the politically electric watchword is “socialism.”

Online, of course, social media is not a latent communist threat, but rather the most popular destination for internet users around the world.

People, whether out of fear for being left behind, or simply tickled by the ease with which they can publicize their lives, have been sharing every element of their public (and very often, their private) lives with ever-increasing zeal. Pictures, videos, by-the-minute commentary and updates, idle musings, blogs—the means by which people broadcast themselves are as numerous and diverse as sites on the web itself.

Even as the public decries government spying programs and panics at the news of the latest massive data-breach, the daily traffic to sites like Facebook and Twitter—especially through mobile devices—not only stays high, but continues to grow. These sites are designed around users volunteering personal information, from work and education information, to preferences in music, movies, politics, and even romantic partners.

So why not health data?

Pharma and Volume-to-Value: The Big Throwdown

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Joe FlowerThe collision between the “volume-to-value” movement and the pharmaceutical and biotech industries over the next few years will have a powerful impact on them and on the healthcare industry and on us as customers, patients, and payers. 

On the one hand, pharma is perhaps the part of the healthcare industry least exposed to direct price regulation under the Obama reforms. The actual costs of pharmaceuticals have been rising as a percentage of what people spend on healthcare, and are seen as the part they have the least influence on. At the same time, many new drugs for cancer and other life-threatening diseases have come with astonishingly high price tags, often not fully covered by insurance (due to the high deductibles and co-pays of the new plans), and with few ways for regulators or the market to push back on them. The public perceives these huge price tags as threatening people with a Hobson’s choice of bankruptcy or death. In the volatile political atmosphere of the 2016 elections, this leaves the pharmaceutical industry highly exposed to political attack and actual new price regulation.

On the other hand, the pharmaceutical and biotech industries also potentially offer some of the best answers to bringing the cost of healthcare down through the use of personalized medicines, smart medicines, new methods of administration such as implants, as well as the possibilities glimmering at us from recent research of real breakthroughs in such important chronic disease areas as Alzheimers, diabetes, addiction, behavioral medicine, and functional medicine. For the most part, though, these answers remain potential. We will not see them adding to the “value” side of the equation until they become fully integrated into a system that is at risk for the health of its customers and using every trick in the handbook to bring those costs in line.

Rethinking The Gruber Controversy: Americans Aren’t Stupid, But They’re Often Ignorant — And Why

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flying cadeuciiM.I.T. economist Jonathan Gruber, whom his colleagues in the profession hold in very high esteem for his prowess in economic analysis, recently appeared before the House Committee on Oversight and Government Reform. Gruber was called to explain several caustic remarks he had offered on tortured language and provisions in the Affordable Care Act (the ACA) that allegedly were designed to fool American voters into accepting the ACA.

Many of these linguistic contortions, however, were designed not so much to fool voters, but to force the Congressional Budget Office into scoring taxes as something else. But Gruber did call the American public “stupid” enough to be misled by such linguistic tricks and by other measures in the ACA — for example, taxing health insurers knowing full well that insurers would pass the tax on to the insured.

During the hearing, Gruber apologized profusely and on multiple occasions for his remarks. Although at least some economists apparently see no warrant for such an apology, I believe it was appropriate, as in hindsight Gruber does as well. “Stupid” is entirely the wrong word in this context; Gruber should have said “ignorant” instead.

PCMH Fails Natural Experiment

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flying cadeucii

Medical Homes Fail Yet Another “Natural Experiment”

Three “natural experiments,” three failures.  Such is the fate of patient-centered medical homes (PCMH), a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy.

By way of review, a natural experiment is an experiment in which the design is outside the control of investigators, yet mimics an experiment.  The first two natural experiments below involve applying the intervention across entire states. The third involves a stimulus-response experiment in one specific community.

Statewide Natural Experiments: North Carolina and Vermont

In North Carolina, a statewide Medicaid PCMH was implemented years ago and steadily expanded until most Medicaid recipients belonged to one.  There was no reduction in relevant event rates (for ambulatory care-sensitive admissions) and costs increased. While the overall Medicaid budgets were routinely exceeded and that should have caused legislators to realize that something in their PCMH was amiss, Milliman fabricated data to pretend the PCMH program was a success.  Milliman got caught making up data (and ignoring other data that quite definitively invalidated its conclusion, and changed their story 180 degrees, a tacit admission that they lied.  And shortly thereafter (at least “shortly” by the standards of state government), North Carolina announced that it is abandoning this failed experiment.

On the Wondrous U.S. Market For Prescription Drugs

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Citing a recent report in the Los Angeles Times, an article in FirecePharma entitled “Some generic drug prices soar despite heavy competition” rises questions on the ability of market forces to reign in drug prices – for example, on the idea that the price of Mylan NV’s EpiPen would not have risen to $614 per 2-pack from about $100 per 2-pack or less in 2007 if the Food and Drug Administration (FDA) had not prevented Sanofi’s and a new product by Teva to come on market, leaving Mylan NV in full monopolistic control, of this blockbuster market.

According to data assembled by the Los Angeles Times, prices of generic drugs can rise sharply even if multiple manufacturers compete for market share. As an illustration, the article cites the generic drug ursodiol for gall stones, produced by no less than 8 manufacturers. “Several years ago, the wholesale price ran as low as 45 cents a capsule. In May 2014, Lannett Co. ($LCI) bumped its price for ursodiol to $5.10 a capsule, a price hike of more than 1,000%. Rather than keeping their own generic versions of ursodiol low to steal market share, each competitor followed Lannett’s lead and priced their versions the same or close.”

A Brief History of Why the Republicans Have No Replacement For Obamacare

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There is no conservative replacement health reform plan for Obamacare — because Obamacare is a conservative health reform plan.

After six years of promising to repeal ‘n’ replace the President’s signature domestic achievement, Republican lawmakers have no coherent alternative to the Affordable Care Act for one good reason: because the Affordable Care Act was once the market-based alternative to a real, not imagined, “government takeover” of health care.

What has always made the ACA a political pariah to Republicans, typified by the bizarre claim by House Speaker Paul Ryan (R-WI) on Wednesday that “Obamacare” has “ruined” and “dismantled” our health care system, is the plan’s namesake — far more than its necessarily complex architecture or any of its actual details, unless you count the details they made up.

The Fairy Tale of a Non-Profit Hospital

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Nonprofit hospitals have higher profit margins than most for-profit hospitals after accounting for their tax obligations.  3900 (62%) of U.S. Hospitals are non-profit and therefore tax-exempt: they pay no property tax, no federal or state income tax, and no sales tax.  An article published in Health Affairs found seven of the nation’s 10 most profitable hospitals were of the non-profit variety, each earning more than $163 million from patient care services. Revoking their property tax-exempt status for not functioning as a charitable entity could return billions in healthcare dollars to local government, communities, and citizens, struggling to afford quality health care.

The idea of exempting nonprofits from paying taxes in the first place is based on the belief these entities provide charity for the underserved and underinsured who would otherwise require the government to lend a helping hand.  As the percentage of uninsured declines as a result of the ACA, the justification for tax exempt status is being called into question.

Private Equity in Health Care

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Frank Pasquale

As lawmakers squabble
over the “carried interest” tax rate, it’s nice to find a big picture
overview of some of the economic activity they’re discussing. I recently
read Josh Kosman’s book The
Buyout of America: How Private Equity Will Cause the Next Great Credit
Crisis
, and I highly recommend it to our readers. Kosman painstakingly
describes
the byzantine financial maneuvers behind marquee private
equity firms which bought “more than three thousand American companies
from 2000-2008.” He describes in detail how they resist transparency
(164) and “hurt their businesses competitively, limit their growth, cut
jobs without reinvesting the savings, and generate mediocre returns”
(195). The recipe for high earnings is simple: the firms “get large
fees up front and are largely divorced from their results if their
transactions fail” (195).

Like Kwak and Johnson’s account in 13 Bankers, Kosman offers
a political economy account of private equity’s favored treatment by
government. As he notes,

[F]our of the past eight Treasury Secretaries joined the
PE industry . . . . and they have significant influence in Washington.
President Bill Clinton, and both President Bushes, have also advised PE
firms or worked for their companies. . . . KKR retained former
Democratic House majority leader Richard Gephardt as a lobbyist and
hired former RNC chairman Kenneth
Mehlman
as head of global public affairs. (196)

Having analyzed a wide array of buyouts, Kosman concludes that “PE
firms manage their businesses to satisfy short-term greed, not for
long-term survival” (51). This is a particularly dangerous attitude in
health care, an industry too long dominated by short-run thinking.

Training Day

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Screen Shot 2015-04-06 at 7.20.19 PMDr. Samuels’ day-long training experience is unfortunate, but it’s only the opening chords of a much longer symphony of time commitments required by electronic medical records (EHRs).  Many studies document the extra time that EHRs impose on doctors and patients. Research in U.S. hospitals and medical offices suggest that these systems can add a half-hour or much more time to a day. A study by McDonald et al (2013 JAMA Internal Medicine) found EHRs added 48 minutes/day to ambulatory physicians, and Hill et al found that in a large  community hospital emergency room 43% of all physician time was spent entering data into the EHR. This almost doubled the time spent caring for patients, and tripled the time needed to interpret tests and records. (Annals of Emergency Medicine, 2014).

Some of that extra time is spent with clunky interfaces and  hide-n-go seeking for information that should be immediately available, such as arbitrary or unexpected  presentations of data, e.g., having to find a patient’s history by clicking on her current room number, or lab reports that may be arranged by chronology, by reverse chronology, by the lab company, by the organ system, by who ordered them, or by some informal heading, such as “blood work” or “tests” or “labs.”  Then there’s the constant box clicking (or what clinicians call “clickarrhea”).  EHRs also send thousands of usually irrelevant alerts that desensitize doctors to legitimate clinical recommendations.