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In a development that Washington insiders had been quietly predicting for months,  Kathleen Sebelius announced Thursday that she is resigning as HHS Secretary. Critics were quick to point to the disastrous launch of Healthcare.gov and the glitch-filled rollout of the administration’s signature health law.

President Obama is expected to nominate  OMB  Director Sylvia Mathews Burwell to replace Sebelius Friday morning.  The Washington Post notes that Mathews-Burwell is well regarded for her “strong management skills”  and cites her experience in global health after ten years with the Bill and Melinda Gates Foundation.

Politico reports that while publicly praising Sebelius for having overseen a late surge in enrollments that brought signups up to the 7.5 million mark  by the time she announced her departure today,  many Democrats are said to be privately “furious” about how badly the Obamacare rollout went and are worried that debacle could cost them control of the Senate in November.

If you’re curious about Burwell’s resume – after all – we’re talking about the woman who will (probably) be the official face of Obamacare until at least 2017 – WonkBlog did some digging back at the time of the hearings for the OMB job.

Continue reading “ACA Signups hit 7.5 million. Sebelius Steps Down. Mathews-Burwell to Lead HHS.”

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This morning, the tally of enrollees in health exchanges is between 6 and 7 million.

Many of these will not finalize their paperwork until April 15, and many more might not pay their premiums.

Nonetheless, given the underwhelming rollout of Healthcare.gov, and well-funded campaigns in some states to discourage enrollment, the number is impressive. But the rest of the story is more important.

In coming weeks, these questions will be answered:

How many of these new enrollees will actually pay their premiums next month and be insured?

Are the new enrollees healthy or sick and in need of medical attention? How will the delivery system respond to these needs?

Did the penalty induce enrollment, or were other factors more important to individuals? Was it the attractiveness of subsidies or something else?

How will employers that provide health coverage assess the viability of health exchanges in their benefits strategies? Can these exchanges serve as a viable marketplace for employee insurance purchases (and allow employers to shift purchasing responsibility to their employees)?

Continue reading “The Rest of the Story on Health Exchange Enrollment”

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This week, the U.S. Centers for Disease Control and Prevention issued two reports that are simultaneously scary and encouraging.

First, the scary news: A national survey conducted in 2011 found that one in every 25 U.S. hospital patients experienced a healthcare-associated infection. That’s 648,000 patients with a combined 722,000 infections.

About 75,000 of those patients died during their hospitalizations, although it’s unknown how many of those deaths resulted from the infections, the CDC researchers reported in the New England Journal of Medicine.

On the bright side, those numbers are less than half the number of hospital-acquired infections that a national survey estimated in 2007. And a second report issued this week found significant decreases in several infection types that have seen the most focused prevention efforts on a national scale.

Noteworthy was a 44 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2012, as well as a 20 percent reduction in infections related to 10 surgical procedures over the same time period.

These infections were once thought to be inevitable, resulting from patients who were too old, too sick or just plain unlucky. We now know that we can put a significant dent in these events, and even achieve zero infections among the most vulnerable patients.

At Johns Hopkins, we created a program that combated CLABSI in intensive care units through a multi-pronged approach—implementing a simple checklist of evidence-based measures while changing culture and caregivers’ attitudes through an approach called the Comprehensive Unit-based Safety Program (CUSP). The success was replicated on a larger scale across 103 Michigan ICUs and then later across most U.S. states, withimpressive results.

These and similar successes have changed caregivers’ beliefs about what is possible, and inspired more efforts to reach zero infections.

What will it take to attain this goal—or at least get much closer?

Continue reading “Hospital Acquired Infections: How Do We Reach Zero?”

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Human beings are big data. We aren’t just 175 pounds of meat and bone. We aren’t just piles of hydrogen and carbon and oxygen.  What makes us all different is how it’s all organized and that is information.

We can no longer treat people based on simple numbers like weight, pulse, blood pressure, and temperature. What makes us different is much more complicated than that.

We’ve known for decades that we are all slightly different genetically, but now we can increasingly see those differences. The Hippocratic oath will require doctors to take this genetic variability into account.

I’m not saying there isn’t a place for hands-on medicine, empathy, psychology and moral support. But the personalized handling of each patient is becoming much more complicated.  The more data we can gather, the more each individual is different from others.

In our genome, we have approximately 3 billion base pairs in each of our trillions of cells.  We have more than 25,000 genes in that genome, sometimes called the exome.  Each gene contains instructions on how to make a useful protein.  And then there are long stretches of our genomes that regulate those protein-manufacturing genes.

In the early days, some researchers called this “junk DNA” because they didn’t know what it did.  But this was foolish because why would evolution conserve these DNA sequences between genes if they did nothing?  Now we know they too do things that make us unique.

Continue reading “Is Medicine a Big Data Problem?”

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THCB reader and occasional contributor Dave Chase had this to say about Bill Crounse, MD’s recent post ”Why the Creative Destruction of Healthcare May Not Be a Good Idea.

“There is no doubt there are some obnoxious people throwing around arrogant/naive ideas. However, the “creative destruction” and “disruptive innovation” that has been most impactful has come from physician-entrepreneurs. Often, they are the most provocative and hard-hitting in their language.

It seems loosely similar to how the most virulent anti-smokers are former smokers. They want others who they can relate to experience the liberation they’ve experienced.

I wouldn’t assume ill-intent from these MD-entrepreneurs using direct language. They simply were fed up with what they experienced as “broken” and stepped up with approaches that have out-performed.

I’m thinking about the MD-entrepreneurs and innovators who have led CareMore, Nuka Model of Care, Qliance, Iora Health, MedLion, Healthcare Partners, etc. Sometimes to catalyze change, one must use stark, hard-hitting language.

That doesn’t seem like a foreign concept to the many excellent MDs I’ve known over the years. I have enormous respect for any entrepreneur, especially one coming from tradition-bound professions who are willing to stick their neck out and endure enormous personal financial risk.

Bob Margolis shared how his colleagues referred to him as a “communist” and his team-based model as “communism” yet Bob’s org achieved far better outcomes. He had the last laugh when that “communist” sold his business for $4.4B last year.

The comments from these MD-entrepreneurs is they feel they aren’t doing their MD friends any favors by candy-coating what is widely recognized as a system that isn’t close to reaching its full potential.

In contrast, the orgs those MD-entrepreneurs are running are the reigning “Triple Aim Champs” that we should celebrate — colorful language or not. Often the most impactful entrepreneurs aren’t particularly “polite” in their language — Steve Jobs, Bill Gates, Larry Ellison et al called it like they saw it.

What’s wrong with that?”

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The most significant force for health system transformation in the United States is employer activism.

This month’s decision to delay the Affordable Care Act’s employer mandate until 2016 coupled with dramatic increases in health insurance premium costs assures employers will play a stronger role going forward.

The facts:

57% of all companies provide health insurance covering 149 million in the population. But participation varies widely by industry and size of company.

Participation: Manufacturing (72%), Services (65%), Transportation/Utilities/Communications (62%), Agriculture/Mining/Construction (60%), Wholesale (54%), Healthcare  (51%), Financial services (49%), Retail (29%) (Kaiser/HRET Survey of Employers)

Size: Smaller companies under 199 are less likely to provide health benefits than larger companies, though premiums they pay to insurers are slightly lower than their larger counterparts.

Declines in employer sponsored coverage declines are due to costs, not the Affordable Care Act. Consider: the percentage of non-elderly workers with employer-sponsored coverage decreased from 68% in 2000 to 61% in 2009 before the law passed.

Employers pay 82% of health costs for singles and 71% of costs for those in their family health plans. Over the past decade, they have shifted more financial responsibility to their employees.

  • Premiums for employers from 2003-2013 increased 80% but employee contributions increased 89%.
  • At the same time, employers have reduced coverage for retirees and dependents, and in many industries, kept wages low to offset health cost increases.

Continue reading “Employers 2.0″

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Berg, the company the brought along fun internet-connected concepts and products such as the Little Printer released this interesting video recently.

The amazing part of this is that Cloudwash is foundational and will just be built on. It shows where the current state of the Internet of Things is and where it can go in the future. What Berg did was amazing to me.

It took a regular “dumb” appliance with software and electronics that were trapped in and made the interaction richer and its meaning and value richer.

In a way, they radically changed the way I viewed how devices could be connected and created the possibility for a new class of devices in our daily lives.

And in a way, I saw so many parallels to healthcare.

In the video, Berg mentioned how the action of washing clothes can be quite complicated. There are baroque symbols on how clothes should be treated and this in turn is reflected by different sets of complicated icons on machines

Healthcare delivery can be far more complex though.

“In any given hospital, as many as 15 medical devices, including monitors, ventilators and infusion pumps, are connected to an ICU patient, but because they are made by different companies, they don’t “talk” with one another. Patient-controlled analgesic pumps that deliver powerful narcotics, where a known side effect is respiratory depression, aren’t linked to devices that monitor breathing, for example.”Today’s ICU is arguably more dangerous than ever,” says Peter Pronovost.

Just last week, I had the privilege of shadowing the pain service team at work. The team had to go one by one to each patient while rounding throughout the hospital. At each patient, a nurse practitioner checked their PCA. These are supposed to the safest ways to deliver analgesics and are self-containing boxes that are locked except for their interface.

No one except the pain service team is supposed to even touch those boxes due to the level of training needed to even interface with them. But it relies on human systems to ensure that the correct concentration of drug is put in with the right dosage according to each patient.

Yet like Dr. Pronovost mentions, these pumps aren’t linked to devices that monitor breathing so that IF a wrong dosage is placed in the PCA, there is no way of stopping it before its too late.

Continue reading “How a Washing Machine Inspired Me to See the Future of a Safer ICU”

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First, let’s get the plug out of the way, shall we? Here’s the deal: The Robert Wood Johnson Foundation has a new initiative, Flip the Clinic—and we want you to join us.

We’re launching the new Flip the Clinic site this week. Here’s the trailer. Please take a look, and then let me know what you think:

So, what’s with all this flipping business?  What’s all this talk about health conversations?

Continue reading “TED 2014: Flip the Clinic!”

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We are hearing that Republicans are considering proposing high-risk pools as part of an alternative health insurance reform proposal to Obamacare.

A high-risk pool proposal would likely mean the Congress giving states the flexibility, and perhaps funding, to set up these risk pools. Risk pools by definition are a place where people can go when they are not able to buy health insurance in the regular market because they have a health problem.

That means Republicans would be turning the clock back to a time when insurance companies could turn people down for health insurance because of their health status.

Presumably, the Republicans are contemplating a market where insurance companies could once again choose just who they wanted to cover––the healthy but not the sick.

Anyone turned down could then go the high-risk pool to be assured of having health insurance. Presumably, Republicans would assure consumers that they would be able to access the same kind of comprehensive health insurance and at the same market rates as those able to buy from insurance companies would be able to get.

Let me be clear at this point that I don’t know of anyone in the insurance industry asking to go back to the days when a carrier could exclude people as a result of their health status and make money just covering the healthy.

Whether it’s Obamacare or a risk pool concept, policymakers are faced with the same dilemma: How do you insinuate the unhealthy and otherwise uninsurable into a health insurance system in a way that benefits are comprehensive and costs are affordable for everyone?

Continue reading “Republicans Considering Proposing High-Risk Pools: Health Insurance Ghettos???”

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Lists guide our lives.  Some are easy, even fun, like a menu or shopping list.  Some are simple tick-offs for work, like my wife’s honey-do list.  Others are frightening, like a draft list.

Some are melancholy, such as the inventory in a Will.  We are inspired by our bucket-list.  Finally, some are exciting, but stir conflict, like awedding invitation list.

I have a list, which makes me slightly anxious, a little depressed, and which takes modest courage to open up.  That is my patient’s list of daily X-ray reports.

Our Electronic Medical Record (EMR), as based around a home page or “Inbox.”  This is a continuously updated assembly of data and messages from our practice and patients.

There are medical orders to approve, questions from nurses and patients, billing inquiries, documents to sign, lab results and emergency alerts about patients in trouble.

Except for the drudgery of pushing through a pile of CMS documentation, those lists have scant emotional impact on me.  Not so the eighth list, just four from the bottom:  Radiology Documents.

These are the results delivered electronically of any MRI, CT scan, bone scan, chest X-ray or other imaging study, that I, or other doctors, have ordered on my patients.  Every 24 hours, between 15 and 30 new reports pop-up.

Opening this section I see three columns; the patient’s name, the date the test was performed, and the type of test.

One click on each line yields a neat, formatted, typed report. These are more than just data.  More than simple facts.  These are final, cold, hard answers to the biggest questions of all.

Is Sue’s cancer is responding to therapy? Does Pete’s shortness of breath mean “just” pneumonia or a blood clot, or has his kidney cancer has metastasized to his lungs?  Did Sid pull his back shoveling snow or is that sharp pain a vertebra fractured by prostate cancer?

Is Alan’s forgetfulness fatigue, Alzheimer’s or perhaps something more insidious, the bloom of glioma cells deep in his brain?

Continue reading “The Oncologist’s List”

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MASTHEAD


Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

Jonathan Halvorson
Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Maithri Vangala
Associate Editor

Michael Millenson
Contributing Editor










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