Month: July 2010

PPACA: The Individual Mandate

Roger Collier The individual mandate is the single most controversial feature of the Patient Protection and Affordable Care Act. Everyone who can afford coverage—unless an undocumented immigrant or exempted on religious grounds—is required to have it or pay a penalty of $695 or 2.5 percent of income.

The rationale is straightforward: without a mandate, many people would wait until they needed care before buying insurance, driving up premiums for those with ongoing coverage, and potentially creating an “insurance death spiral” as the higher premiums lead to increasing numbers simply dropping their coverage. (This last part is basically what we have today, but will be magnified by PPACA’s ban on preexisting condition exclusions.)

The individual mandate was preferred for obvious reasons over the alternative of a general tax offset by credits for premiums paid. Democratic lawmakers had no wish to be blamed for imposition of a new tax—no matter how reasonable the arguments in its favor. In fact, as President Obama made clear in an ABC television interview “I absolutely reject that notion [that the penalty is a tax].”

The individual mandate has now become the centerpiece in Republicans’ legal fight against reform. Suits challenging PPACA have been filed by the attorneys general of twenty states (with the first, in Virginia, already being argued), with the constitutionality of the mandate a key issue in every case.

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KP Innovation Workshop

Logo At the Sidney R. Garfield Innovation Center, Kaiser Permanente's patients, doctors, nurses, architects and engineers use elements of human-centered design to improve and to innovate physical spaces, technologies and clinical operations in a unique, “movie-set”-style warehouse. Many of these innovations have been spread throughout Kaiser Permanente as well as to organizations nationally and internationally.  

As a result, an inaugural workshop has been developed workshop to share the Kaiser Permanente methodology and some best practices. On August 3rd and 4th, a variety of health care providers, biotech and pharmaceutical companies, policy researchers, architects and more will get together in a hands-on session to explore and experience first-hand how Kaiser Permanente understands it’s users’ needs and ideate and prototype new processes, spaces and technologies. Participants will work in the same space where Kaiser Permanente employees and patients conduct deep-dives and collaborate on new idea generation.

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Aneesh Chopra Gives Keynote Address

At the Health 2.0 Washington DC Conference Aneesh Chopra, Chief Technology Officer of the US Government, gave a keynote address on incorporating new capabilities into the nation’s healthcare system. One of the topics that he spoke to was the culture gap between consumers and government.

ONC announces HITECH amendments to HIPAA privacy, security and enforcement rules

David HarlowThe federales announced a new set of HIPAA regulations today (to be published in the Federal Register on July 14) in a press conference featuring Kathleen Sebelius (HHS Secretary), Georgina Verdugo (HHS OCR Director) and David Blumenthal (ONC Director).  The HIPAA changes are essentially mandated by the HITECH Act.  From the HHS presser:

The proposed rule announced today would strengthen and expand enforcement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security, and Enforcement Rules by:

  • expanding individuals’ rights to access their information and to restrict certain types of disclosures of protected health information to health plans;
  • requiring business associates of HIPAA-covered entities to be under most of the same rules as the covered entities;
  • setting new limitations on the use and disclosure of protected health information for marketing and fundraising; and
  • prohibiting the sale of protected health information without patient authorization.

Two new websites were announced as well.  One is a beefed-up version of the HIPAA data breach notification wall of shame, and the other is a new HHS privacy website directed at the general public, now up at

This website, a joint statement from ONC and OCR posted today, and the tenor of the federales’ remarks today indicate a deep concern about public perceptions concerning privacy and security of protected health information — sort of a “what if we throw a party and nobody comes?” vibe.Continue reading…

Maybe Being Wrong is Better and More Human than Being Right

St. Augustine: “Fallor ergo sum”

When I was in charge of the medical residency programs in Grand Rapids, Michigan, David Leach introduced me to the expanded Dreyfus Model of how physicians can progress from beginners to masters.  I was always struck by how master physicians freely admitted their mistakes and used them as a teaching tool.  As a young surgical and cytopathologist, my sanity was saved more than once by University of California San Francisco’s Dr. Theodore R. Miller, a true master of cytology, being willing to share with me some of his mistakes.  I do not honestly think I could have survived in diagnostic pathology without his guidance and wisdom.  Years later, I still remember Dr. Miller showing me a breast fine needle aspiration biopsy slide of fat necrosis that mimicked ductal carcinoma and a case of wrongly diagnosed pancreatic cancer that turned out to be inflammatory atypia.

Mistakes and errors are on my mind because I just finished reading some extraordinary works.

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Why Obama Made the Right Call on Berwick

The recess appointment of Don Berwick to lead CMS can be seen as a cynical act of political opportunism, sidestepping the Congressional approval process using a tactic worthy of Machiavelli, or Karl Rove. Or it can be viewed as a pragmatic decision by Obama to avoid a lengthy and exasperating re-litigation of the healthcare reform debate.

Death Panels. Been there, done that. So I’m going with Choice #2.

The right side of the blogosphere has erupted, painting Berwick as an effete academic who would have withered under the Klieg lights and piercing questions of the likes of John Ensign and Jim Bunning. Those of us who know Don have no doubt that he would have more than held his own in debating the lessons of England’s healthcare system and the necessity of clear-headed rationing choices. Don is serious, hyper-articulate and intellectually nimble; in a real debate with members of the Senate Finance Committee, all my money would have been on him.Continue reading…

The Health 2.0 Developer Challenge–It’s On!

Today is the formal kick-off of the Health 2.0 Developer Challenge. The challenge was first announced by Federal CTO Aneesh Chopra on June 2 at the Community Health Data Initiative (CHDI) meeting, and it’s partly a continuation of the great work done within CHDI, and partly an expansion of the code-a-thon/developer camp effort to the whole Health 2.0 community. The challenge is supported by HHS. It’s being run by the Health 2.0 Conference, with partners O’Reilly, Internet2, Sunlight Labs, Healthtap & the Health 2.0 Accelerator.

Anyone can submit a challenge or join a team to solve a challenge. But the goal is to get the health care and developer communities working on building new innovative applications in rapid-fire time.

The Challenge has two parts: online and offline. The online challenge process officially begins today—there are four challenges up already and we have several others in the queue, but we’re looking for more!

  • Whyville challenges game developers to build tools for their arcade to help kids understand and apply health data. The kids will vote on the winner!
  • Move your apps; a challenge to develop an app for the Android platform that helps users burn calories, brought to you by Snaptic & Hopelab
  • Practice Fusion‘s Real Time Patient-Driven Data Challenge invites developers to build applications that connect to the Practice Fusion EMR platform.
  • The Szollosi Healthcare Innovation Program wants to see whether a lightweight EMR can be built with blog and wiki software.
  • And……Your challenge here!!

Here’s the link to the challenges page

Teams will be working on challenges over the course of the summer. Selected winners from the challenges will be showcased at the Fall Health 2.0 Conference, and we’ll be building an online community of challengers and teams in the coming weeks.

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Durenberger: Health Insurance Chickens Come Home to Roost

Former Republican Senator Dave Durenberger was always the sensible Republican on health care. He now hangs out in a small institute called the National Institute of Health Policy at a small Minnesota college called the University of St. Thomas. Every so often he puts out great commentary emails. His most recent one contains a really a great description of what happened to health insurance in the late 1990s. You can sign up here. Well worth a read and I’ve reprinted the part about insurance below—Matthew Holt

I’ve watched the ups and downs of health insurance products and “markets” since involving myself as an employer in the 70s in a community-wide effort by large employers to provide employees with a choice of health insurance plans, including the nascent HMO. Our goal was reducing health care costs through informed employees and accountable health plans, creating, in effect, new forms of insurance and competitive markets for insurance and medical services at the community level by using available information and consumer choices to facilitate behavior change.

While experiments like this across the country have been tried with varying success, we are now on the verge of doing a “back to the future” adaptation of our lessons learned. The health reform law (ACA) provides for state-based health insurance regulation, health insurance exchanges and a new emphasis in assisting “smart buys” by employees. Recall what happened to the HMO: It became large national “managed care organizations” like UnitedHealth Care (UHC) who lost community support for their behavior change because savings never stayed with those who earned them.

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Esther Dyson – “Health, Not Healthcare!”

At the Health 2.0 Goes to DC conference Esther Dyson gave a powerpacked 3 minute rant about how the Health ecosystem really works — dividing it into three markets: Healthcare, Bad Health and Health 2.0.

In a Surprise Move, Administration Appoints Berwick to Head CMS

Tuesday night the White House Blog explained: “In April, President Obama nominated Dr. Donald Berwick to serve as Administrator of the Centers for Medicare and Medicaid Services (CMS). Many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points.

“But with the agency facing new responsibilities to protect seniors’ care under the Affordable Care Act, there’s no time to waste with Washington game-playing. That’s why tomorrow the President will use a recess appointment to put Dr. Berwick at the agency’s helm and provide strong leadership for the Medicare program without delay.”

A “recess appointment” means that the president is putting Berwick in place while Congress is on recess (i.e. is taking a vacation). As a result, Berwick won’t have to go through a Senate confirmation hearing. Senate conservatives had made it clear that they hoped to defer this hearing for as long as possible.

The White House Blog notes that “CMS has been without a permanent administrator since 2006, and even many Republicans have called on the Administration to move to quickly to name a permanent head.”

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