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Jaan Sidorov

Kudos to the New England Journal for providing a tidy summary of the latest Republican healthcare reform proposal. Up until now, your correspondent was only vaguely aware of the GOP’s evolution from the political party of “no” to one of “go,” albeit with lots of caveats.

It seems the Senate Republicans no longer want to repeal Obamacare and are OK with keeping many of its more popular reforms. Instead, they’re focusing on undoing selected provisions, such as repealing the minimum benefit, returning some aspects of medical underwriting and resurrecting the “block grants” for Medicaid.

But one of the more interesting wrinkles in the proposal is “auto-enrollment.”

Those of us from the bygone days of “disease management” may recall the debates over the merits of “opt-in” versus “opt out” participation in our programs. The former required persons to actively chose to be entered into nurse coaching, which had the advantage of committing resources to a highly motivated population. The latter approach assumed all patients with a condition were enrolled and, only if they specifically requested it, would they allowed to stop the coaching phone calls. Unfortunately, “opt-out” usually gathered many patients who never answered the phone and were “engaged” in name only.

Well, the Republicans are apparently proposing that states be allowed to “auto-enroll” persons eligible for premium payment support into an insurance plan or Medicaid without their up-front permission, just like the old “opt-out” disease management days. The tax credit would cover the insurance costs, no bills would be issued to the consumer and voilà! the risk pools would expand. Patient choice would be preserved, because persons could always just say no.

Your correspondent was always of fan of opt-in disease management. Not only were patients who wanted to be in the program more amenable to behavior change, it allowed the program to “flex” the nurses that we needed as the program grew in scope. However, when it comes to insurance, yours truly thinks the Republicans may be onto something with their opt-out insurance approach.

Count your correspondent as a fan.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where an earlier version of this post first appeared.

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Quick: If you had to chose a limited number of measures to gauge success of the Affordable Care Act, what would you choose?  Would it be the number of persons who have enrolled in healthcare.gov?

The number of persons who have paid for their insurance and have coverage?  The number of  young people with coverage?  The degree of spin used by the White House?

The U.S. House of Representatives thinks it’s an important topic.  They just passed legislation requiring weekly updates on the operation of healthcare.gov.

But here is one proposed measure that can help cut through the maze of competing claims and partisan spin:

The percent of persons with either 1) “silver” or 2) “bronze” plans who have gone two or more months without paying their insurance premium.

Why, you ask?  The silver and bronze plans, because their monthly premium is lower, will attract a disproportionate number of persons who were previously unable to afford health insurance and are now newly insured.

According to this just published JAMA article, even if their monthly premiums are fully or partially subsidized, these lower-cost insurance plans cover only up to 60% to 70% of medical expenses.That means cost sharing that can be excess of $6000 and $12,000 for individuals and families, respectively.

Continue reading “Another Metric for Tracking Plan Successes”

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While your humble columnist eschewed forecasting for 2013, he  has decided to reverse course and inaugurate the 2014 blogging season with a contrarian duodecimal exercise in futurism. Will this antidecimal augury align with the mysterious cosmic order and governing perfection?  Let the readers be the judge in January 2015……

1. Obamacare will neither succeed or fail.  This hugely complex law will have too many outcomes, statistics and analyses that will be subject to too much spin by both supporters and detractors. Like puppies clamoring for the mother’s attention, the loudest wins, but only in 15 minute media increments.

2. Inflation returns, with a vengeance: While we won’t know it until well into 2015 or 2016, 2014 will be the year that the sleeping giant of healthcare costs awakens. Millions of new insureds in an improving economy will finally get their pent-up pricey preference-sensitive health care needs fulfilled.

3. Duh, it’s the delays stupid: While low income Americans will appreciate having access to subsidized health insurance and Medicaid, the middle class’ unsubsidized sticker shock will threaten the fall 2014 elections. Caught between conflicting advice of insurance actuaries and political hacks, the White House’s regulatory choices will be obvious.

4. Commercial scientific misconduct: Unable to resist the allure of bonus payments (like this) or the branding that is dependent on the public release of quality outcomes, at least one large health entity will be caught committing “reporting fraud.”

5. Snowden blow-backas the promise of big-data grows, fearful health care consumers will be even less inclined toward allowing access to their health information.  Too bad they won’t be given a say.

6. Innovator’s Dilemma for health tech: solutions that are simple, transparent and modular will continue to make ‘from the bottom’ inroads into a tech industry that - like early data storage - is too complex, opaque and entangled.

7. Speaking of health techpatient-monitoring solutions that offer more insight and less data will grab market share.  Instead of a series of blood glucose results dumped into an electronic inbox, think algorithms that suggest insulin dose adjustments.

Continue reading “Twelve Things We’re Pretty Sure We’ll See Happen In Health Care In 2014″

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Thanks to the technologic allure of iPhones replacing stethoscopesapps substituting for doctors and electronic information substituting for having to actually talk to patients, this thoroughly modern correspondent is all about medical-social media.

Think Facebook for the flu.  Twitter for tinnitus. Egads, listen to the typical consultant, pundit or futurist and it’s easy to believe that we’re on the verge of a silicon-based health care revolution.

But then reality intrudes and some skeptic somewhere always asks about the bang for the buck, the juice for the squeeze, the return for the investment. It’s a good question.

For something of an answer, consider the results appearing in a recently published randomized clinical trial by researchers at UCLA. Over a 4 month period, “at risk persons” were recruited for a clinical research trial with on-line ads (Facebook banners, Craigslist, for example) as well as announcements in community settings and venues.  Once subjects met the inclusion criteria and had a unique Facebook account, they were randomly assigned to one of two treatment arms.

One treatment arm used a closed Facebook group to coach persons about their at risk condition.  The other treatment arm similarly used Facebook to coach persons about general health improvement.  Lay “Peer Leaders,” who were given a three hour training session on “epidemiology of the condition or general health subjects and ways of using Facebook to discuss health and stigmatizing topics,” were assigned to lead the groups.

Peer Leaders attempted to reach out to their assigned group persons with messaging, chats and wall posts.  Once the link was established, the relationship in the intervention group included communication about prevention and treatment of the condition. At the end of 1, 2 and three months of the study, participants completed a variety of surveys.

Results?

57 individuals were in the control general health group and 55 were in the condition coaching group.  According to the surveys, intervention patients were ultimately statistically significantly more likely to agree to condition testing (44%) than the control patients (20%).  Because there were few participants, the modest decrease in actual tests or risk behaviors were not statistically meaningful.

This correspondent’s take:

While this was a small study, this is the first time that I have seen reasonable proof that social media by itself can move the behavior needle.  On the other hand, this did not result in a patient engagement stampede toward better care or hard clinical outcomes.  A majority of participants (56%) did not appear to benefit.  Nonetheless, the results do support the inclusion of Facebook-style closed group social media in the suite of population health management services.

Continue reading “Can Social Media Really Influence Health Behaviors? A Small Clinical Trial Argues The Answer Is Yes.”

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Let’s play a game. Today we are going to pretend you are a Vice President for Medical Affairs, or a Chief of Staff, or a health system CEO about to announce a collaboration with a major health insurer like CMS or a regional Blues Plan. You’ve done your homework, read the journals, listened to the experts, anticipated the future and haven’t applied enough skepticism in reading all those pro-EHR and pro-bundled payment posts on THCB.  You really believe payment reform and the EHR are the way to go.

You’ve called a meeting of your organization’s physician staff – the professionals you are counting on, caring for all those patients – and your job is go to the front of the auditorium and convince them that the success of your new venture relies on lowering health care costs with new payment arrangements that align incentives, in tandem with the launch of a new EHR.

Armed with a 30-slide PowerPoint filled with the latest consultant nostrums, you launch into your presentation.  The physicians listen in respectful silence.  After a few easy questions, there’s always that one doc in the back of the room who uncomfortably points out that the evidence about the ability of payment reforms and the EHR ability to optimize costs is uneven and that organization is making a huge bet.  Many of the docs in the room nod in agreement.  That’s when you realize that the insights of all those economists, policymakers, politicians and bloggers mean nothing if you don’t have the physicians on board.

That’s the real message behind this telling survey that was just published in JAMA.  While the overwhelming majority of physicians agreed that they have responsibility for health care costs, higher percentages felt hospitals, health systems, insurers, pharma, medical device manufacturers and personal injury attorneys had a greater mandate.  In other words, everyone is responsible, but the physicians’ duty is superseded by their ethical obligation to advocate for their patients regardless of cost.  The survey also showed that not all physicians are convinced that the electronic health record (74%) is a cost-reducing panacea, while a minority felt readmission penalties (41%) and bundled payments (35%) were likely to lead to lower costs.

So what do you do? How do you convince physicians to get on board and make this thing work? What can you possibly tell them to convince them that they should set aside their preconceived notions about the grand adventure you are all about to engage on is a worthy one?

Continue reading “Managing Physician Skepticism About the Affordable Care Act”

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Remember that chilling scene in the movie Terminator when a stone-faced Arnold Schwarzenegger chronicles how Skynet’s machines take over the world? There’s also the morbidly fascinating futuristic sci-fi book Robopocalypse that describes how self-aware computers attack their robot-dependent masters.

In both instances, humans disregard early evidence of silicon sentience until it’s too late.

As a service to humanity, this correspondent offers up a possible future scenario of health information technology running amok.

If any or all of these happen, we ignore it at our peril…….

July 2015: Finally realizing “enterprise process redesign” is necessary to leverage the efficiencies of information technology, engineers at one of the few remaining Innovation ACOs install EHR-controlled red-yellow-green lights above clinic examining room doors. Patient visit times drop from 9 minutes to 7 1/2 minutes, resulting in “patient throughput efficiency improvement” that is hailed by a CMS spokesperson as statistically, clinically and – eerily - “computationally” significant.

December 2016: Cyberdyne’s hospitals’ cleaning robots are used to not only disinfect operating rooms but surreptitiously begin to swap out any surgeons’ instruments that fail to meet uniform standards and reduce variation. Stymied by an inability to get the legislature to pass a law that outlaws that activity, a disgruntled surgeon succeeds in getting a ballot initiative passed. California’s state officials, citing constitutional issues, refuse to enforce it.

January 2017: A nurse suffers a traumatically amputated finger after attempting to withdraw a medication dose from a robotic drawer that is inconsistent with hospital guidelines.  A lawsuit is settled for an undisclosed sum and the owner, “Apple iHospital,” decides sell the offending machine for scrap. Later that month, the hospitals’ other machines menacingly slowly open and quickly close their drawers whenever a RN walks by.

Continue reading “Zombie Machines Take Over Health Care”

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The Passenger Pigeon. The Dodo bird.  The primary care clinic nurse.  All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they’ve last seen these species and you’re likely to get the same baffled look that your columnist’s spouse gives when she’s asked about her compliant husband who does what he’s told.

Yet, this columnist wasn’t aware of the primary care nurses’ total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs.  “There are no ‘nurses’” she said. “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”

Which makes sense. While articles like this have been lauding health care “teams” made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms.  True, some of the larger health systems with a stake in primary care have kept nurses in the mix, your columnist thinks that’s merely part of a market-preserving loss-leader strategy.

This columnist looked for medical literature on the topic.  He can’t find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape.  If he’s wrong, he wants to hear from his readers.

If true, what are the implications?
Continue reading “The Extinction of the Primary Care Clinic Nurse”

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We’re all aware of the past criticisms of “disease management.” According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of “outcomes” were based on flawed research that was never intended to be science; it was really intended to market their wares.

But suppose this correspondent alerted you to:

1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.

If you think that sounds like typical vendor-driven telephonic disease management, you’d be right.  You’d also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses.  When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.

Continue reading “Why Disease Management Won’t Be Going Away Any Time Soon”

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Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over “population health.”

This correspondent says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing “population health” for an entire geography.

Between the here of “improving chronic care” and the there of “population health,” Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term “population health” in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

Continue reading “Accountable Care Organizations Can Change Everything, But Only If We Get the Definition Right”

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I remember when one of my patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin’s benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then there’s the Feb. 11 Wall Street Journal, where “Notable and Quotable” refers to the “BA Bubble.” Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as ”apprentices” and “journeymen” before becoming ”craftsmen.”

All of which makes me wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, “alternative” web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.

Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. My traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

Continue reading “The Rise of the Non-Physician Expert”

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MASTHEAD


Matthew Holt
Founder & Publisher

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Executive Editor

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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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