OP-ED

OP-ED

Government as an Engine for Innovation

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I’ve been thinking a great deal about the newly formed Center for Medicare and Medicaid Innovation. (CMI). This entity was established as a result of the Affordable Care Act (the new healthcare reform legislation) and its purpose is to “research, develop, test and expand innovative payment and service delivery models that will improve the quality and reduce the costs of care for” patients covered by CMS-related programs.  The legislation gives this entity over $10 billion dollars initially and broad authority to figure out new ways of doing things better and differently than before.   What is great about CMI is that they have the authority to run their programs much more like a business would without many historical governmental constraints.  That’s great news for innovation, which is sorely needed in the U.S. healthcare system.

Among the key objectives that the administration has discussed is how to transition the collective mindset from one of healthcare to one of health.  In other words, if a person is healthy, they do not need health CARE. This is a very important distinction; it puts the emphasis on prevention and wellness as opposed to what you do when somebody is already sick.  In order to affect such a transition, there must be an emphasis on innovation to change the way we have traditionally looked at the healthcare world.

This is an interesting challenge and one that requires a great deal of thoughtfulness in how to approach the universe of innovation opportunities. As venture capitalists, I and my colleagues vet, select and monitor deals and specifically focus on how we pick winners and avoid losers.  It’s a little like being asked to handicap who’s going to win the World Series, but then again, that is pretty much our job as VCs: to act like Billy Beane and pick those most likely to succeed in a capital efficient way based on detailed analysis of trends and meaningful data, not solely based on experience.

#Whitecoats4Blacklives

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Screen Shot 2014-12-11 at 1.27.35 PMAt 3PM EST on December 10, 2014, medical and dental students at over 70 schools participated in the “National White Coat Die-In.” The event was organized on Facebook and spearheaded by students at University of California, San Francisco (UCSF) School of Medicine who described the event as “a demonstration in response to the events in Ferguson and New York because #BlackLivesMatter.”

Across the country, there have been numerous protests against the grand jury’s decision in Fergurson, Mo. not to indict officer Darren Wilson who shot and killed Michael Brown, an unarmed teenage boy. Similarly, in Staten island, NY, the grand jury decided not to indict officer Daniel Pantaleo who killed Eric Garner, an unarmed black man, using a banned chokehold.

Mandate On Its Way To the Supreme Court?

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It may have looked like a non-event, but it was a significant one.

Monday September 26 was the last day on which the Obama administration could ask the Eleventh Circuit Court of Appeals to reconsider its three-judge panel’s ruling that the Affordable Care Act’s individual mandate was unconstitutional. The fact that the Justice Department took no action almost certainly means that its intent is to ask the Supreme Court to decide the issue.

The administration’s thinking was most likely dependent on three factors. First, given that the full Eleventh Circuit is considered even more conservative than the three-judge panel that struck down the mandate, the only advantage of a second hearing would have been to delay consideration by the Supreme Court. Against this was presumably factored the political risk of a further well-publicized rejection of the mandate providing additional ammunition for opponents of reform.

Second, the administration may still be able to delay a Supreme Court decision either by filing its request for a hearing at the last possible moment in November, or even by asking for a filing extension—something that the Court might be willing to consider, given the potential impact of a decision in the middle of a presidential election.

Pop the Cost Bubble: Unallot Medicare

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Victor Sandler

Here’s a dirty little secret: Cutting health care costs is not that difficult, nor will it harm patients. That’s because it only involves giving up unnecessary medical care—tests and treatments patients may want but really don’t need because they don’t benefit their health.

How is this supposed to happen? In Minnesota we call it “unallotment.” When the state had to reconcile a projected multibillion dollar budget deficit this year, and the Republican governor and Democratic lawmakers couldn’t agree on how to do it, the governor simply “unalloted” billions of dollars of planned expenditures.

Medicare should do the same. All Congress has to do is pass the MedPAC Reform Act of 2009 (SF 1110) and give it teeth. We can then unallot the 30 percent of Medicare expenses that most health care experts believe are unnecessary. That’s the 30 percent that goes for tests, drugs, and devices that don’t have any proven benefit but sell like hotcakes anyway.

When Gov. Tim Pawlenty decided to cut medical expenditures during the unallotment process, he took no prisoners. More than 30,000 indigent adults will simply have their medical insurance eliminated starting next March. Medicare would take a higher road, eliminating unnecessary care and costs, not “unnecessary” people.

Would the World End if We Eliminated the Deductible?

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While Congress ponders a true fix for the Affordable Care Act (ACA), consider this about health coverage.

Problem #1, Can’t Use It: Healthy people, or people who don’t make a lot of money, sign up for the cheapest health insurance policy available. It gives them catastrophic coverage, protecting their family and home in the event of a big-time medical condition. But it also makes them mad. They pay a monthly fee for health insurance they can’t use until a large deductible is satisfied. For example, a person might pay $300 a month but have a $7,000 deductible. Do the math. That’s well over $10,000 before that person gets to use what they are paying for every month.

Problem #2, January Comes Too soon: Health is not an annual event. Maybe you go all year and suddenly need a bunch of medical help in December. The deductible hasn’t been reached so you pay the bill “out of pocket.” Nasty, because in January you still need medical care for the same thing, yet the deductible goes back to square one. Not nice. This makes more people mad. Solution for Problem #1 and Problem #2: eliminate all annual deductibles and replace with co-pays.

Problem #3, We Need To Build a Wall: Even by eliminating deductibles there are people who are required to pay more than they can afford. Fixing or replacing the ACA needs to build a wall of protection that limits the total amount—a percentage of income—paid by individuals or families in a calendar year—a guarantee that includes the cost of prescription drugs.

How PCORI’s Research Will Answer the Real World Questions Patients Are Asking

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As a physician, I know the challenge of helping patients determine which health care options might work best for them given their personal situation and preferences.

Too often they — and their clinicians — must make choices about preventing, diagnosing and treating diseases and health conditions without adequate information. The Patient-Centered Outcomes Research Institute (PCORI) was created to help solve this problem — to help patients and those who care for them make better-informed health decisions.

Established by Congress through the Patient Protection and Affordable Care Act as an independent research institute, PCORI is designed to answer real-world questions about what works best for patients based on their particular circumstances and concerns. We do this primarily by funding comparative clinical effectiveness research (CER), studies that compare multiple care options.

But more research by itself won’t improve clinical decision-making. Patients and those who care for them must be able to easily find relevant evidence they can trust. That’s why our mandate is not just to fund high-quality CER and evidence synthesis but to share the results in ways that are meaningful to patients, clinicians and others.

We’re also charged with improving the methods used in conducting those studies and enhancing our nation’s capacity to do such research.

We will be evaluated ultimately on whether the research we fund can change clinical practice and help reduce the variations and disparities that stand between patients and better outcomes. We’re confident that the work we’re funding brings us and the audiences we serve closer to that goal.

Recently, some questions have been raised in health policy circles about our holistic approach to PCORI’s work. That view holds that direct comparisons of health care options — especially those involving high-priced interventions — should be the dominant if not sole focus of PCORI’s research funding approach as a path to limiting the use of expensive, less-effective options.

We agree that discovering new knowledge on how therapies compare with one another is a critical mandate of PCORI and is essential to improving the quality and effectiveness of care.  However, ensuring that patients and those who care for them have timely access to and can use this knowledge, so that they can effectively apply it to improve their decisions, is also very important.

What Do Millennials Want from the Healthcare System?

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The 18-34 year old segment of our population is large, growing and important in our society. They are 80 million strong. Their attitudes, beliefs, values and actions are re-shaping the way every organization, business and institution thinks about its future.

According to a Pew Research report released last week, Millennials are independents and skeptics: 50% have no political affiliation, 29% no religious affiliation, and 19% say they do not trust established institutions to do the right things (versus 40% for Baby Boomers).

Millennials worry about money. A study by the Investor Education Foundation of the Financial Industry Regulatory Authority concluded that their concerns about their auto, credit card and school debt trump other issues.

Most think economic stability should come before marriage and family life. Half who went to college have a student loan to repay, and one third moved into the homes of their parents at some point to make ends meet.

And they worry about the future. Paul Taylor’s The Next America: Boomers, Millennials, and the Looming Generational Showdown predicts economic battle between Millennials and Baby Boomers:

“Every family, on some level, is a barter between the generations…If I care for you when you’re young so you’ll care for me when I’m old…But many Millennials won’t be able to afford that…The young today are paying taxes to support a level of benefits for the old that they themselves have no prospect of receiving when they become old.”

Pew survey data supports his contention:

  • 51% of Millennials do not think there will be any money for them in the Social Security system by the time they retire.
  • 39% believe they’ll get reduced benefits

So what do Millennials want from the health system? Their view is likely to disrupt how industry leaders operate their businesses and how policymakers make laws that govern its commerce.

HITECH in High Gear

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By DAVID BLUMENTHAL, MD

We’ve known for years that health information technology can improve health care. But until recently, the implementation rate among providers has been low, except for a few early adopters.

In the last two years, however, there has been a significant upward inflection in the adoption rate. For primary care providers, adoption of a basic EHR increased by half from 19.8 percent in 2008 to 29.6 percent in 2010.

And with HITECH Act programs now in full swing, it looks clear that adoption and use of health information technology will go into high gear. Already, 81 percent of hospitals and 41 percent of office physicians are saying they intend to achieve meaningful use of EHRs and qualify for Medicare and Medicaid incentive payments.

A recent edition of the American Journal of Managed Care (AJMC) helps us understand why the accelerated move to EHRs is so important. This special issue devoted to health information technology presents perspectives on health IT from a wide range of stakeholders—providers, policymakers, and patients. Contributors include representatives of private companies and public agencies, managed care organizations and academic medical centers, medical educators and a medical student—confirmation that the potential of health IT is compelling for a broad spectrum of Americans.

The Congressional Shift and Health IT

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Following the shift to a Republican majority in the U.S. House of Representatives, the pre- and post-election focus of GOP leaders on repealing all or parts of the Patient Protection and Affordable Care Act (PPACA) have led to much discussion and media attention on whether the few true health IT aspects of the Act are in jeopardy, and has even extended speculation – and in some cases confusion – as to whether physician and hospital incentive funds within the government’s previous Meaningful Use initiative are also a target.

There are several foundational elements – and one major point of Meaningful Use funding – that should allay concerns for current and future funding for the adoption of certified electronic health records (EHRs).

Fundamentally it’s important to note that the Health Information Technology for Economic and Clinical Health (HITECH) Act, from which the Meaningful Use program and its funding originates within the American Recovery and Reinvestment Act (ARRA) of 2009, is an entirely different statute than PPACA.

Bipartisan support for the tenets and the spirit of HITECH dates back at least seven years, and it is also noteworthy that the Office of the National Coordinator for Health Information Technology (ONC), which administers Meaningful Use, was created by the Bush administration and a Republican Congress.

Politics aside though, the reason that Meaningful Use funds are secure is because they are drawn from the Medicare Trust Funds held by the U.S. Treasury, and are therefore not subject to annual Congressional budget appropriations or oversight.

In other words, the funding is grounded in law, and has inherent flexibility to encompass the number of ambulatory practices and hospitals seeking Meaningful Use incentives capture. The incentive payments are procured through the Centers for Medicare and Medicaid Services (CMS).

MD vs. DNP: Why 20,000 Hours of Training and Experience Matters

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As southern states entertain legislation granting nurse practitioners independent practice rights, there are some finer details which deserve careful deliberation. While nurse practitioners are intelligent, capable, and contribute much to our healthcare system, they are not physicians and lack the same training and knowledge base. They should not identify themselves as “doctors” despite having a Doctor of Nursing Practice (DNP) degree. It is misleading to patients, as most do not realize the difference in education necessary for an MD or DO compared to a DNP. Furthermore, until they are required to pass the same rigorous board certification exams as physicians, they should refrain from asserting they are “doctors” in a society which equates that title with being a physician.

After residency, a physician has accrued a minimum of 20,000 or more hours of clinical experience, while a DNP only needs 1,000 patient contact hours to graduate. As healthcare reform focuses on cost containment, the notion of independent nurse practitioners resulting in lower healthcare spending overall should be revisited. While mid-level providers cost less on the front end; the care they deliver may ultimately cost more when all is said and done.