Large coverage expansions under the Affordable Care Act have reignited concerns about physician shortages. The Association of American Medical Colleges (AAMC) continues to forecast large shortfalls (130,000 by 2025) and has pushed for additional Medicare funding of residency slots as a key solution.
These shortage estimates result from models that forecast future supply of, and demand for, physicians – largely based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment. Here are a few reasons why.
1. Most physician shortage forecast models assume insurance coverage expansions under the ACA will generate large increases in demand for physicians. The standard underlying assumption is that each newly insured individual will roughly double their demand for care upon becoming insured (based on the observation that the uninsured currently use about half as much care). However, the best studies of this – those using randomized trials or observed behavior following health insurance changes – tend to find increases closer to one-third rather than a doubling.
2. A recent article in Health Affairs found that the growing use of telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25% or more.
3. New models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians. If these models, fostered by the ACA, continue to grow, they could reduce predicted physician shortages by half.
Continue reading “Is There Really a Physician Shortage?”
Filed Under: THCB
Dec 5, 2013
I want to update you on ComChart EMR’s “Meaningful Use Certification” status.
ComChart EMR will continued to be certified as a Complete EMR for Stage I Meaningful Use. Unfortunately, we will not be able to meet the Stage 2 (or greater) Meaningful Use certification requirements as these requirements are technically extremely difficult to implement.
In addition to the Meaningful Use mandates, there continues to be a never ending stream of new mandates such as ICD-10, PQRI, Meaningful Use 2, Meaningful Use 3, SNOMED, ePrescribing, LOINC, Direct Project, health information exchanges etc. As a result of the mountain of mandates, ComChart EMR and the other small EMR companies will have to choose to implement the mandates or use their resources to add “innovative” features to their EMR. Unfortunately, the small EMR companies do not have the resources to do both.
(I suspect this is also true, to some extent, for all EMR companies.)
While the individual people involved in promulgating these EMR mandates (mostly) have the best of intentions, they clearly do not understand what transpires in the exam room, as many of the mandated features confer little or no benefit to either the patient or the healthcare provider.
In addition to a lack of understanding of what is important during the process of providing healthcare, it has also become apparent to me that the Federal and State health information technology agenda is now largely driven by the strongest HIT companies and health institutions; the individual physician is only an afterthought in the entire process.
Continue reading “Open Letter From a Small EMR Vendor To Our Customers and Our Friends In Washington”
Filed Under: THCB
Tagged: EHR, Hayward Zwerling, Meaningful Use Stage 2, Physicians
Dec 5, 2013
A few weeks ago Lisa Suennen, founding partner of Psilos Group and fledging best-seller author, wrote ”Times of massive system transformation, such as we are in today, pave the way for new market entrants and disruptive technologies a la Clayton Christensen’s stories about other industries that have endured dramatic change. ” She was talking about health insurance exchanges, but could just as well have been talking about care transitions.
Health 2.0 Advisors is the Innovation Analytics and Acceleration business unit of Health 2.0, helping companies make sense of the – often ‘noisy’ – innovation landscape. Recently, innovation in care transition improvement became an important area of demand among hospitals and many startups have been developing new technologies, tools, and solutions to improve care transitions. Next week, Health 2.0 Advisors will be publishing a report that synthesizes barriers to adoption of such innovation in hospitals, lessons learned from those who succeeded, and share information about untapped areas of opportunity.
This report is based on a project done for the Gordon and Betty Moore Foundation, which included interviews with (100+) CIOs, CMIOs of hospitals, as well as startups of varying sizes and degrees of success in working with hospitals.
Check out the special presentation of highlights from this report during the mHealth Summit in Washington D.C. on the 8th. The report will be available for download after that and I will write a follow up post with some additional highlights and perspectives. If you want to receive a copy of this report but cannot make it to the mHealth Summit, send an email to firstname.lastname@example.org and we will email you the download link after the mHealth Summit presentation.
Filed Under: Health 2.0, health care reform, Health Policy, THCB
Dec 5, 2013
East Coast THCB reader writes:
“Ok. Here’s my situation. I’ve tried signing up for coverage at Healthcare.gov several times without success. (I got a combination of the weird glitches and other symptoms other readers have reported. ) After the last fail, I decided to hold off on any further attempts on the theory that things are bound to get better.
Based on the news reports I’m seeing, that may or may not be happening. I’m starting to worry that if I wait too long I may get caught up in the mad rush as people scramble to beat the deadline. Given what’s happened so far, I’m not highly confident that Healthcare.gov will be working.
So here’s my question: am I better off waiting or should I try to push my application through the system now?”
Filed Under: THCB
Tagged: December 23 Deadline, Healthcare.gov
Dec 4, 2013
Through a series of small grants, we’re is exploring the utility of applying behavioral economic principles to perplexing health and health care problems—everything from getting seniors to walk more to forgoing low-value health care.
At a recent meeting in Philadelphia we challenged grantees to compete in an Innovation Tournament. The goal was to identify testable ideas that leverage behavioral economic principles to help make people healthier by working with commercial entities. Participants were assigned to groups and made their best pitches to their colleagues. And of course we used a behavioral economics principle (financial incentives) to increase participation: Each member of the first, second and third place teams received Amazon gift cards.
Eight teams made the finals:
1. Love Lock: This team addressed the issue of driving and texting by proposing an app that could be installed on your cell phone that would send reminders not to text while driving. This team would work with car insurance and mobile phone carrier companies and provide discounts to those who get it installed. The behavioral economics principles being tested are default choice and opt-out.
2. McQuick & Fit: Too many people eat unhealthy food. This team’s idea was to have a rewards card that can only be used to purchase healthy food. With each purchase, the customer would earn points toward free, healthy foods. Online orders would be placed through a website that would feature salient labeling and allow for defaults to order healthy meals. The behavioral economics principles at play include pre-commitment, default choice, labeling, and incentives.
3. Just Bring Me Water: The problem tackled by this team is “regrettable” calories—mindlessly consuming whatever is put in front of you, such as free bread at a restaurant, or soda on a plane. The innovation: when booking a table online or calling for a reservation, you could ask to “opt-out” of the complimentary bread or chips that are offered. This would reduce the consumption of regrettable calories.
4. Lunch Club: This group looked at addressing gluttony through a partnership with a chain restaurant. When going out for a meal, portions are typically bigger and diners consume more. But what if you had the option of doggy-bagging one third of the meal for another meal—framed as “buy dinner and get lunch free”? And, if you took this option, you would get a scratch off as an enhanced incentive and immediate reward. The behavioral economic principles being tested here include loss aversion, active choice, and incentives.
5. Snooze, But Don’t Lose: People don’t get enough good sleep, which leads to poor executive functioning and safety issues. To increase safety, productivity, and efficiency, this group proposed using a Fitbit to build in reminders to go to bed earlier and provide feedback on good sleep. The behavioral economic principles at play are pre-commitment and loss aversion.
Continue reading “Eight Bright New Ideas From Behavioral Economists That Could Help You Get Healthy.”
Filed Under: THCB
Tagged: behavioral economics, Deborah Bae, Incentives, RWJF Pioneer, Wellness
Dec 4, 2013
Here is a thought experiment. Assume that every hour you run you extend your life by an hour.
I have chosen a one-to-one ratio between the increase in longevity from running and the time running because higher ratios lead to the immortality paradox. Lazarus aside, the all-cause mortality for Homo sapiens is 100 % and will remain so for the foreseeable future.
This arithmetic means that at one point you will literally be running for your life: your life being extended precisely by the time spent running. But ignore this logical fallacy.
You run an hour every day for 40 years. Your life is extended by 1.67 years. Your costs are a new pair of running shoes every three months, which might even be covered at zero co-payment by insurance if USPSTF gave running a grade A or B recommendation.
A back of the envelope calculation, assuming the shoes cost $ 80, yields cost per life year of roughly $7664. There is, of course, more nuance. I am not including injuries that may result from running. I am not discounting time: I am assuming we value an hour now the same as an hour 40 years from now.
I am also not factoring the costs avoided of treating late stage cardiovascular disease, which must be balanced against the additional social security checks that the individual will draw because of living longer, not to mention the costs of treating diseases of extended longevity such as cognitive impairment, Alzheimer’s disease, recurrent falls.
But please continue to indulge my approximation. The point is not precision of economic calculations but a principle.
$7664 for an additional life year. Compared to the benchmark of $50, 000 per quality-adjusted life year that’s a bargain!
Was it worth it then?
Continue reading “Healthism: The New Puritanism”
Filed Under: THCB
Dec 4, 2013
From 27,000 enrollments in October to a reported 100,000 enrollments in November, the Affordable Care Act’s website is apparently working better and getting more people signed up.
But is it fixed well enough to handle the expected wave of at least many hundreds of thousands of people eager to get guarantee issue health insurance for the first time or replace a canceled policy by January 1?
Here are some of the press reports covering the December 1 HealthCare.gov relaunch:
- Reuters: “A surge of visitors clogged the U.S. government’s revamped healthcare insurance shopping website on Monday, signaling that President Barack Obama’s administration has a way to go in fixing the portal that showcases his signature domestic policy.”
- Bloomberg reporting on a navigator’s experience: “It’s still kind of glitchy. Now it just kicked me out. It went back to the front page. I’ve been here all afternoon and it’s been like that.”
- Miami Herald: Long waits, error messages, unresponsiveness. Hallmarks of the troubled launch of the Health Insurance Marketplace at healthcare.gov continued to stymie South Florida residents and counselors trying to access the website on Monday––more than two months after the October 1 launch, and despite the government’s self-imposed deadline of Nov. 30 for the system to function smoothly for the ‘vast majority of Americans.”
- Los Angles Times: “The Obama administration’s overhauled healthcare website got off to a bumpy relaunch Monday as a rush of consumers caused an uptick in errors and forced the administration to put thousands of shoppers on the HealthCare.gov site on hold.
- Ezra Klein, Washington Post: “Of course, that means the site still suffers a disastrous outage rate.” And, “We have no idea whether the 200 fixes left on the list are really important ones, or really difficult ones. The repair job is likely proceeding quickly enough to protect Obamacare from the most severe threat to its launch: Democrat-backed legislation unwinding the individual mandate or other crucial portions of the law.
And then there is the backroom. The administration apparently decided that it was more important to fix the front-end of the system before the back-end was fixed. Do they think that big customer service issues come January, if the “834″ back-end enrollment problems are not fixed by then, will be blamed on the insurance industry and not the administration?
- Associated Press: “Private insurers complain that much of the enrollment information they’ve gotten on individual consumers is practically useless. It is corrupted by errors, duplication or garbles. Efforts to fix the underlying problems are underway, but the industry isn’t happy with the progress and is growing increasingly concerned.”
As I have said before, the Obama administration is likely in the midst of a four month project to properly fix and test this system. It will likely be at least late January or early February before not just HealthCare.gov but the other key information systems supporting the new law are built and repaired to just minimal standards.
Continue reading “Healthcare.gov Is Working. But Is It Working Well Enough to Withstand the Enrollment Surge?”
Filed Under: THCB
Tagged: December 23 Deadline, Enrollment, guaranteed issue, Healthcare.gov, Robert Laszewski, The Affordable Care Act
Dec 2, 2013
It’s officially the holiday season, which means 70,000 people have temporary jobs at Amazon fulfillment centers to ensure that your gifts arrive exactly when they’re supposed to. While these jobs aren’t exactly easy or high-paying – there’s been plenty written about the not-so-awesome working conditions – it’s in many ways remarkable that Amazon is able to easily leverage the population of a small town less than 15 years after a panic-filled Thanksgiving led to the mammoth and tightly-controlled supply chain system that’s in place today.
The “Save Santa” incident, described in Businessweek reporter Brad Stone’s recent book The Everything Store: Jeff Bezos and the Age of Amazon, was an “all-hands-on-deck emergency” in 1998 resulting from one of the biggest problems an online store can have: there were far more orders coming in than shipments going out. This required all employees – including the executives – to work a graveyard shift at one of two warehouses. “They brought their friends and family,” writes Stone, “ate burritos and drank coffee from a food cart, and often slept in their cars before going to work the next day.” Bezos held contests to see who could pick items off shelves the fastest. Then he vowed the company would never have an inventory shortage again.
“The underlying truth is that Amazon becomes, like almost like all retailers, a different company during the holidays,” Stone explained to me over the phone. “Volume grows over the previous year. The already aggressive and fast-moving environment in the headquarters and fulfillment centers become manic. I describe it as two Amazons: one that operates for 10 months and the other that operates for two months out of the year.”
Continue reading “How One Bad Thanksgiving Shaped Amazon”
Filed Under: Tech, THCB
Tagged: Amazon, Gretchen Gavett, Pharma
Dec 2, 2013
Facing thousands in extra insurance costs, smokers appear to be the Affordable Care Act’s (ACA) biggest losers. Employers are allowed charge smokers up to 50% more for their medical coverage than nonsmokers , starting in 2014.
On November 25, Fox News put it best: “Obamacare Policies Slam Smokers,” , noting that “smokers are the only group with a pre-existing condition that Obamacare penalizes.” THCB itself has headlined: Smokers Face Tough New Rules under Obamacare.
And these headlines are absolutely accurate — meaning that, with the possible exception of the e-cigarette, ACA is the best thing that has happened to employed smokers ever.
Here is how we arrive at this conclusion. The data is mixed on whether smokers incur much higher healthcare costs or just slightly higher healthcare costs during their working ages than non-smokers do. None of the data shows that their costs are lower, but let’s say there is no impact on health spending.
Nonetheless, the following is incontrovertible: smokers take smoking breaks.
Remarkably, there are no laws specifically governing smoking breaks, and like most other quantifiable human resources issues, no one has quantified them. But we all observe these breaks, and about a fifth of us participate in them. They reduce productivity. By definition, if you are outside smoking, you are not inside working.
Sure, some smokers make up the time by working harder when they aren’t smoking…but (1) many non-smokers work hard too and (2) some workplaces, such as inbound call centers, don’t offer the luxury of catching up later because they operate in real time. Lacking quantification, fall back on your imagination…and imagine what you would do if you ran a company in which non-smokers spent as much time mulling around outside as smokers do. That should give you an understanding of the impact of smoking breaks on productivity.
Continue reading “Are Smokers Really the ACA’s Biggest Losers?”
Filed Under: OP-ED, THCB
Tagged: Al Lewis, Employers, smoking, smoking cessation, The Affordable Care Act, Vik Khanna, Wellness
Dec 1, 2013
A THCB reader in Tennessee writes:
Thanks for listening. I am a single 55 year old male in Tennessee. I’m not offered insurance from my employer. June of 2012 I was diagnosed with Essential Thrombocytosis. A blood disease that messes up your platelets. Took every test they could think of to figure it out. In and out of hospital, adding up debt by the second, I stopped going to doctors, stopped buying meds. I drag myself to work, every day, just to survive. Under Obamacare it will be, for the worst plan, $571.00 a month, with a $ 5100.00 deductible. I can’t afford that. I would rather die in my home as it would be better than being homeless. Is this a joke?
Filed Under: THCB
Dec 1, 2013