THCB

THCB

Creating Value-Based Incentives For Primary Care

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In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.

Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

So when patients come home from the hospital, there is a smooth handoff, and all the necessary information follows them. When they are seeing a specialist, that specialist is coordinating care with their primary care doctor.

This description probably resonates with most health care professionals as a better approach than the current paradigm’s fragmentation and lack of continuity of care. But as with many things in health care, it won’t be easy getting to a value-based health care approach in Medicare and Medicaid. Despite wide acknowledgement that fee-for-service perpetuates our health system’s most undesirable characteristics, the mainstream of American health care seems stuck. One wonders whether CMS can rise above the special interest lobbying, get beyond the interminable pilots and decisively act on payment reform with the conviction required to help save health care from itself.

Still, the idea of value-based reimbursement begs questions. What payment methodology will incentivize the best quality and most efficient care? What path can take us there?

Appellate Court Upholds ACA In Opinion By Prominent Conservative Judge

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Yesterday, November 8, the United States Court of Appeals for the District of Columbia became the second federal court of appeals to uphold the constitutionality of the minimum coverage requirement of the Affordable Care Act.

To date, one federal appellate court has held the minimum coverage  requirement to be unconstitutional (although severable from the remainder of the ACA), while five other appellate court decisions have held that the courts lacked jurisdiction to consider the challenge brought to them, either because the plaintiffs in the particular case had not been injured by the minimum coverage requirement or because a federal statute, the Anti-Injunction Act, denies jurisdiction.

This is a very important decision.  Judge Laurence Silberman, who wrote the majority opinion upholding the statute, is a highly-respected conservative judge, appointed by President Reagan.  Judge Harry T. Edwards, a Carter appointee, joined Judge Silberman in the majority.  Judge Brett M. Kavanaugh, another well known conservative judge appointed by George W. Bush, dissented in an opinion that was much longer than the majority opinion, but on jurisdictional grounds rather than on the merits.  Kavanaugh would have held, as the Fourth Circuit did in the Liberty University case, that the Anti-Injunction Act deprives the federal courts of jurisdiction.  In the course of his lengthy opinion, Judge Kavanaugh suggests that there may be prudential as well as legal reasons why the courts may want to stay out of this fight, and suggests that if there is in fact a constitutional defect with the ACA (which he does not decide), it could be easily fixed by Congress.

This decision comes down two days before the Supreme Court will consider, and quite possibly decide, whether or not to take certiorari in one or more of four other appellate court cases that have been decided in ACA challenges.  Although a grant of certiorari is almost certain at this point, the D.C. Circuit’s decision, as well as the earlier opinion of Judge Jeffrey Sutton, another prominent conservative who sided with the constitutionality of the ACA in a Sixth Circuit case, will certainly be noted by the Supreme Court justices.  Moreover, the media narrative that seemed to explain the district court opinions—Republican appointees strike down the law while Democratic appointees uphold it—seems again not to work for appellate court judges.  It may not work for predicting the Supreme Court vote either.

Can Medicare Reach Its 65th Birthday?

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Every day, 10,000 people in the U.S. celebrate their 65th birthday, making each one of these seniors eligible for Medicare. The very program that gives America’s seniors access to affordable health care will turn a youngish 48 on July 30, but in a biting irony, it could go bankrupt before reaching its 65th birthday.

We cannot wish away or ignore the reality that Medicare’s Part A trust fund — the portion that pays hospital claims — is currently projected to run out of money by 2026. The good news, however, is that it is possible to put Medicare on a sustainable path if we can surmount current political hurdles.

It is no secret that Washington is better known for what it is not doing than what it is doing these days. Partisan gridlock has proved to be an insurmountable impasse for potentially worthy legislative efforts. This is especially true when it comes to making the changes needed to sustain Medicare’s future, where Washington is truly making things much harder than they need to be.

Much of the current debate has focused on reforms that would only slightly defer Medicare’s pending insolvency, with the potential for mere cost-shifting. With many of those recommendations, political disagreement is so strong that an extremely limited chance exists to pass a compromise version. However, even if enacted, these reforms would only address the symptoms of Medicare’s condition rather than the underlying problem. The result would only help Medicare limp to its 65th birthday at best.

There is a much more meaningful reform out there that addresses the underlying problem, and, surprisingly, bipartisan consensus exists around the need to end the fee-for-service system in Medicare.

The current fee-for-service payment system compensates physicians and other health care providers for each service they deliver, such as an office visit, test or other procedure. While it is critical that providers be fairly compensated, Medicare’s fee-for-service structure contributes to inefficient care that is often disconnected with actual patient outcomes. It has accelerated the program’s financial imbalance with inflationary spending that has little or no connection to helping beneficiaries get healthier.

Hyping Cancer Genotyping

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It was 1970. I was in my laboratory at the NIH sequencing a murine myeloma protein in order to define the structure of its antibody combining region. Studies of protein conformation were at the cutting edge of science then; enthusiasm abounded. But it was clear to me that this work, in all its scientific elegance, had little to do with treating myeloma or anything else in mice or man. The reason for all the painstaking effort was the joy of pushing back the frontier of ignorance, even if only a bit. No one could foresee clinical utility then, nor would any become apparent for decades. Today such monoclonal antibodies are widely used to treat many diseases, sometimes with efficacy that justifies the costliness.

Genomics is in a bigger hurry.

Thanks to 40 years of breakthroughs, many earning Nobel Prizes, the chromosome carrying the defective gene underlying a genetic disease, Huntington’s disease, was identified in 1983 and the gene sequenced a decade later. In short order, defective genes underlying a number of single-gene diseases were defined: cystic fibrosis, hemophilia, and others. We all wait with baited breath for these elegant insights to transform into primary treatments for single allele genetic diseases. Attempts to transfect patients with normal genes are encouraging but barely so; it has proved difficult to get the right gene to stay in the right cells. Likewise, directly modifying the abnormal genetic apparatus is still largely just promising. The fallback remains working downstream from the genetic apparatus, replacing or modifying the defective products of many of these pathogenetic genes.  Nonetheless, optimism regarding modifying the genetic apparatus itself is rational as is ever more boldness on the part of molecular biologists.

The Dark Age of Meaningful Use

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A lesson from the future:

We look back at the years between 2010 and 2016  (The lifespan of Meaningful Use) as a dark age in healthcare software.

It was an era where software companies bound by government mandate to churn out horrible software tried to pretend their products increased productivity. “Eligible” providers were brow-beaten to click buttons and fill forms, print things and perform medical decision making without being paid.

Some software companies were successful, in a financial sense, as their armies of sales experts and market segmenters conquered their unassuming customers, brandishing the sabre of “ONC-ACB certified”. Those companies unwittingly managed to stamp out the potential of small physician offices, increasing consolidation to hospitals – and healthcare costs. Eventually, the ONC crest once emblazoned proudly on their chests, became a warning: “This software was designed for Meaningful Use, not Actual Use”.

Linguistically, the term “Meaningful Use” became entwined with “Electronic Health Record”. People forgot that medical software could improve patient care and not tout it’s Meaningful Use certification. An effort was made to ridicule those who believed that government regulations were legitimately harmful to the healthcare industry. The sky was lassoed and we were pulling it down.

A healthcare IT Renaissance:

The tides did turn, however. Visionaries and industry leaders came to realize how harmful Meaningful Use was to innovation.  Lawmakers were educated on how destructive constantly changing software and workflow requirements are to software development and medical workflow management.

Bring Back the Public Option

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The way health care is administered in the United States is unsustainable and in need of fundamental reengineering — right? During the 2008 presidential race, the country appeared to be in agreement on this point. But that all changed somewhere, somewhere after the election of a dark-skinned new president with a foreign-sounding name whom even proud Medicare card-carrying Americans were viscerally driven to deride as a socialist.

This was recently reported in The Hill: “The six largest investor-owned health insurance companies saw a 22 percent increase in combined net income in the third quarter, putting them on pace to break profit records for 2010.” The president was castigated by loud little crowds around the country for championing the overwhelmingly popular idea of a publicly funded, public health insurance alternative to challenge the partly publicly funded, private health insurance companies’ assertion that they simply cannot provide their services any cheaper. Rather than groundbreaking legislation, what we got was the president being caricatured on national television, in effigy, as The Joker — and health insurance executives laughed all the way to the bank.

Obesity Means Lower Pay

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I’ve written before about obesity issues – mostly related to soda and diet soda (the message – even diet soda isn’t good for you – try to drink water instead) and also that even being a little overweight can still result in health problems. But a new study, coming out of the National Longitudinal Study of Youth, shows that obesity can also impact you economically with obese people earning less than the rest of the population on average.

Hopefully this information will help provide greater motivation for people struggling with obesity since sometimes it takes more than a simple understanding of health and self interest to sufficiently motivate people to take action. But it also raises questions about the reasons for average lower pay.

Top Twelve Reasons to be at Health 2.0 Next Week

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And now, for your crassly commercial consideration, I am emerging from my bunker/email queue and relentless rehearsing of 150+ demos to tell you the Top Twelve reasons why you need to join over 1,600 others at the 7th Annual Health 2.0 Fall Conference which starts with pre-conferences on Sunday 29th and kicks off officially on Monday 30th September:

Twelve Teams creating new on-body laboratory grade sensors competing for $2.25 million in prizes in the Nokia Sensing XCHALLENGE

Eleven Pre-conference sessions including International Health 2.0, a design workshop from Mad*Pow on behavior change, Patients 2.0, Doctors 2.0, Employers 2.0 and more!

Ten New Companies introducing their brand new products to the market in Launch!

Nine Developer Challenge Competitions with winners & new challenge announcements on stage!

Eight Start-Ups Competing in the DC to VC start-up showcase from Morgenthaler Ventures with 8 VCs as team captains

Seven Sponsored Deep Dive Sessions from leaders Janssen,  United Healthcare, Cigna, Airstrip, Health Dialog, NaviNet &  The Iron Yard (featuring 10 startups from the South)!

Six Demos showing the latest tools for and about health consumers on our panel called Big Data: Tools & Applications for Individuals

Five Networking Parties for attendees, sponsors, and exhibitors!

Four Cutting-Edge Revolutionary Demos on the Frontier of Health 2.0 panel including SyapseBrainControl and from the labs of Adam Gazzaley at UCSF and Louis-Philippe Morency at USC.

Three Female Health 2.0 Rising Stars: Akhila Satish, CyberDoctor; Hind Hobeika, InstaBeat; Julia Winn, BetterFit Technologies.

Two Engaging Keynotes by movers and shakers –Bruce Broussard, CEO of Humana, and Gavin Newsom, Lt. Governor of California.

One Revolutionary Health Technology Conference you don’t want to miss!

And honestly we could have done a top 100! You can find out more and sign up here! And, to quote a recently late Silicon Valley legend, it will be insanely great.

Tending to the Health Care Workers of America

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flying cadeuciiGiven the attention now paid to implementing national health reform, the bulk of which is now upon us as 7 million new individuals now have health insurance, one important issue remains largely ignored by policy makers and industry leaders–health care workers are very unhappy.

A 2012 national survey of 24,000 physicians across all specialties found that if given the choice, just over half of these doctors — only 54 percent — would choose medicine as a career again.  Fifty-nine percent of physicians in a 2013 survey could not recommend their profession to a younger person, and forty-two percent were dissatisfied in their jobs.  Forty percent of physicians in another 2013 national survey self-identified as burned out.

Nursing has gained the moniker of one of the least happy jobs in America, with nurses traditionally experiencing high rates of job dissatisfaction, burnout, and turnover.  Some of the reason for this malaise among our highest status health professionals has to do with the stressful, uncertain nature of health care work.

But it also is an outcome of the everyday worlds in which all health care workers now find themselves:  a world drenched in paperwork, packed patient schedules, and decreased control.  In short, the new world of health reform.

We are in the midst of a technological and business revolution in health care delivery. We are also on expanding patient demand in ways not seen in generations.  But we are not meeting the needs of health care workers, who are expected to produce at a higher level than ever before.

Patient Power

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What happens when consumers are able to compare the performance of primary care physicians in their state using Consumer Reports, the magazine that’s so highly regarded for its ratings of thousands of products and services we all use every day? Well, for the first time ever, we’re about to find out.

A special Massachusetts version of July’s Consumer Reports magazine will feature a report entitled “How Does Your Doctor Compare?” along with a 24-page insert that includes ratings of nearly 500 primary care physician practices from across the state. The ratings are based on data from a comprehensive patient experience survey conducted by Massachusetts Health Quality Partners (MHQP), a coalition of consumers, physicians, hospitals, insurers, employers, government agencies, and researchers. The physician ratings report is also available online at www.mhqp.org.

In recent years, there’s been a lot of talk in the health care community about the importance of consumer empowerment and patient-centered care. This experimental collaboration between MHQP and Consumer Reports, funded by the Robert Wood Johnson Foundation’s Aligning Forces for Quality program, helps move theory into practice, and will test some key assumptions about the value of transparency in the effort to improve the health care system. In many respects, ratings of primary care physicians are not new to Massachusetts. We at MHQP have been reporting the results of patient surveys and clinical quality data since 2006 and these reports have had a positive effect on health care in our state. But let’s face it, Consumer Reports adds a whole new dimension to the notion of transparency. Not surprisingly, their involvement has been met with both excitement and some trepidation in the physician community.