Month: June 2013

What is the Future State Vision for Health Care Delivery System Transformation?

Jun 9, 2013• 7

By Jim Hansen

“You’ve got to be very careful if you don’t know where you are going because you might not get there.”

– Yogi Berra

“Would you tell me, please, which way I ought to go from here?” said Alice.
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where —” said Alice.
“Then it doesn’t matter which way you go,” said the Cat.
“— so long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

– Alice’s Adventures in Wonderland

The country is in the midst of an unprecedented transformation of the health care system and may even be at a ‘tipping point’, yet many of us find it astounding that we have no official (or unofficial for that matter) collective vision of where we are headed, thus how the heck do we know if we are on the right path to get there? Given the very high stakes and costs that extend far beyond financial ones, why is it acceptable to not have a future state in mind so that the current state can be quantified and a gap analysis roadmap can be created to address it? Sure, we have the Triple Aim as the overall goal but what are the ‘guardrails’ that help build the road to it?

The truly great news is that we actually have those ‘guardrails’, and in fact have had them for over a dozen years. It is just that most people have not been aware of this hidden time-tested gem, created by incredibly thoughtful health system transformation forefathers and foremothers back in 2001. This visionary team has overwhelmingly been praised for creating the powerful and gutsy call to action in their Crossing the Quality Chasm Institute of Medicine (IOM) report. What many have missed is that in addition to all the highly visible work, the group created a set of 10 key new rules to inform a future state for the health care system (see figure 1).

Figure 1 Source: Institute of Medicine, “Crossing the Quality Chasm,” p. 67, 2001.

Twelve years later, the chart in Figure 1 strikes many of us in two powerful ways: 1) How the ‘New Rule’ column has stood the test of time for the vast majority of its intended direction and spirit, and 2) how sad and disappointing that many of the 2001 ‘Current Approach’ column items are still entrenched even today.

60% of Massachusetts Doctors Will Not Meet State Electronic Record Mandate

Jun 8, 2013• 3

By Josh Archambault

Putting aside a lengthy discussion over the merits of and cost saving potential of EMRs for a minute, comes this gem from the land of not so well thought out policy making…

In 2010, the Massachusetts Legislature passed a law requiring that, as a condition of licensure starting in 2015, Massachusetts physicians must demonstrate proficiency in the use of electronic health records, computerized order entry, e-prescribing, and other forms of health information technology.

Last year [ in chapter 224], the Legislature amended that statute to state that physicians must “demonstrate the skills to comply with the ‘meaningful use’ requirements.” There was no further language to explain the intent or scope of that amendment.

Given that even the most optimistic forecast holds that only 12,000 eligible providers in Massachusetts would achieve Meaningful Use certification by 2015 (more than 30,000 physicians hold a Massachusetts license), the MMS is committed to ensuring that the statute is interpreted broadly, and does not unintentionally disenfranchise thousands of physicians, thereby creating an extreme health care access issue.

-Massachusetts Medical Society

So 60% of doctors are projected to be non-compliant?!? I guess a doctor shortage will take on a whole new meaning in the state.

This is what happens when you pass major policy bills in 14 hours without anyone reading the whole thing first, but I digress…

This issue prompted a recent call to action from a local doctor in North Chelmsford, Dr. Hayward Zwerling.

Josh Archambault is director of health care policy at the Pioneer Institute in Boston (www.pioneerinstitute.org), publisher of “The Great Experiment: The States, The Feds and Your Health Care.”

When Retiree Benefits and Obamacare Collide

Jun 7, 2013• 16

By David M. Walker

Oct. 1, 2013 is a focus of increasing anxiety in this country. That’s the date when enrollments begin for the federally run health insurance exchanges, created under the Affordable Care Act (ACA). No one really knows what to expect, but it could be far worse than advertised —and for a reason that has more to do with the federal deficit than health care.

What’s anticipated is unsettling enough. President Obama speaks of inevitable “glitches and bumps” in the implementation. Senate Finance Committee Chairman Max Baucus (D-Mont.) sees the possibility of “a huge train wreck” if the public isn’t adequately educated and prepared. Supporters of the ACA, especially Democrats in the Congress, are nervous about taking the blame if the exchanges don’t unfold as intended.

All these worries are legitimate. The American people, already burdened by a numbingly complex, inefficient and inequitable tax system, now wonder if an increasingly government-run health care system will follow suit. Many are concerned that some employers will dump their current health care plans and pay the relatively modest fine. There’s also worry that young people will opt out of the exchanges (preferring to pay the small penalty), leaving the exchanges with a disproportionately older and sicker pool. Then there’s the very real uncertainty surrounding the ACA’s ultimate cost — illustrated by the impact of Medicare alone, which the Office of the Chief Actuary of Medicare estimates could cost cost $10 trillion more than claimed.

Amid all these concerns and speculations, almost no attention is being paid to the opportunity that the ACA’s insurance exchanges could represent for state and local governments’ retiree health care programs. It’s time to think about it because the consequences could be far-reaching.

States in a deep hole

We already know that many state and local governments are in a financial hole that keeps getting deeper. A newly released report by the U.S. Government Accountability Office (GAO) makes clear that, absent significant reforms, the fiscal picture for most state and local governments will steadily worsen through 2060. A main cause, in addition to Medicaid, is the cost of health care for state and local government retirees. These largely unfunded obligations are similar to the pressures on the federal government to fulfill its unrealistic Medicare promises.

Knocking the Palooza Out of the Data

Jun 7, 2013• 16

By Jonathan Bush

Just back from the Health Datapalooza confab that took place last week – an event now in its 4^th year hosted by the federal government. I had a few lingering thoughts to share. First, on the event name: I’m guessing it came out of my old business partner and current national CTO Todd Park’s experience in Washington, where trying to get any single distinct thought through “the interests” could knock the “palooza” out of a grown stallion.

You’d think the federal government would be the last ones to host a Datapalooza, but the fact is NO ONE ELSE has stepped up!

So they did.

And complain as I might about the G-men and G-women being industry conference conveners (makes me want to bathe with a wire brush) they pulled it off pretty darn well. The Department of Health & Human Services (HHS) attracted hundreds of serious entrepreneurs… and hundreds more wannabes (who real entrepreneurs desperately need in order to feel cool).

And boy were there some great bloopers…

Kaiser came blistering onto the scene with an open API—to the location and hours of operation of its facilities! Kinda sounds like Yelp to me…I’d be surprised if developers will come a runnin’ to that one. Kaiser’s CIO (a very cool guy whom they or anyone in health care would be lucky to get) broke this news in a two-minute keynote speech. Imagine President Obama announcing, in a State of the Union address, that the green vegetables in the White House cafeteria were now much crunchier!

HHS Secretary Kathleen Sebelius applied similarly excessive fanfare announcing the release of cost data for 30 ambulatory procedures. The whole idea that Toddy (Park) was trying to get going with this Palooza was not to release REPORTS on things but to release the SOURCE data so that anyone with proper security and privacy clearance could INVENT a million reports that no one had ever conceived before!

So here are my thoughts on all of this, some of which I shared at the conference in my way-longer-than-two-minute keynote:

1. Release the data!! Secretary Sebelius announcing the release of cost data for 30 ambulatory procedures during her keynote felt like the Secretary of Energy serving up a can of 10W30 to oil companies to drill into.

Her words were great. To wit: “The fact that this [unlocking the data] is growing by leaps and bounds is a good indication that we can leapfrog over years and decades of inaction into an exciting new future.” YES! GO GIRRRL! OK, so…where’s the data?

From the Case Files of the Robert Wood Johnson University Hospital, Dec 2015

Jun 7, 2013• 16

By James Salwitz, MD

May 30-8:12pm: 27 yo teacher, Pam S., is out for her evening run. The delicious evening air fills her nose and lungs. She feels strong, healthy, and alive.

May 30-8:13pm: Pam pushes up a gentle hill. She feels sudden and severe pain, as if stabbed deep by a flaming splinter. Pam stops, almost falling. She struggles the mile home. The searing throb begins to fade. A long hot shower gives some relief.

June 3-5:45am: The torment progressed through the weekend and curled around pillows, drenched in sweat, she has not slept all night. As traces of sunrise light frame her bedroom window, she decides to get medical care.

June 3-9:22am: Pam tells her story to her Primary Medical Doctor (PMD) and is examined. Her pain is intense with any movement and he is worried. He orders blood work, pain medication and calls an orthopedic surgeon. The PMD completes his history and physical report, as well as his differential, in his Electronic Medical Record (EMR). The note is transmitted instantly to the surgeon.

June 3-9:59am: STAT blood work is drawn at a lab down the street.

June 3-10:37am: Pam picks up the pain medication.

June 3-11:25am: The orthopedic surgeon reads the PMD’s note, listens to Pam’s story and examines her. He orders an emergency MRI.

Calling All Patients: Blue Button Patient Co-Design Challenge

Jun 7, 2013• 1

By Pat Salber

June 3rd was the kick-off for an amazing Challenge – the Blue Button Patient CoDesign Challenge. Developers everywhere are being invited by the Office of the National Coordinator to develop apps and other tools to use patient data, acquired via the Blue Button. You might be thinking: why is that so amazing? Because the entire Challenge has been designed to actively involve the ultimate users of the tool – patients. Imagine that!

Here are the details:

http://www.health2con.com/devchallenge/blue-button-co-design-challenge/

From now until June 11th, patients (which includes almost all of us) are invited to go to Health Tech Hatch to post their ideas about how they want to see their data used to create tools that they can use themselves or with their doctors. There are already over 50 ideas already posted, which include:

Please help my wife manage our children’s immunizations
A tool that simplifies the management of chronic multiple conditions,
Make my prescription management stink less (my favorite)

Data Points: Scope of Practice. When You Get Right Down To It, We’d Rather See a NP/PA Than Wait …

Jun 6, 2013• 10

By Mike Miesen

In my last post on California and Texas’s imminent expansion of their scope of practice regulations, I didn’t cover one important question: what do patients actually want?

Fortunately, a study just released in Health Affairs looked into it, and the results are clear: many patients want to be seen by nurse practitioners (NPs) and physician’s assistants (PAs) – especially if it allows them to be seen sooner.

To be clear: generally, Americans still prefer being seen by a physician. But preferring a NP/PA – or “not having a preference” between a NP/PA and a physician – is a big deal; it insinuates that, for certain ailments, the public views a NP/PA as just as effective a clinician. That has significant repercussions for how care is delivered, particularly for young people and underserved populations.

The researchers conducted a survey that focused on three different scenarios to judge patient preferences: a straight-up comparison of preference for physicians vs. NPs/PAs; a scenario where a patient could see a NP/PA today vs. a physician tomorrow for a minor ailment; and a scenario where a patient could see a NP/PA today vs. a physician in three days for a minor ailment. Continue reading…

Physicians Face Unexpected Obamacare Loophole

Jun 5, 2013• 17

By Matthew Wayt

Doctors who contract with state health insurance exchanges next year might find themselves on the hook for treatment costs resulting from what many are calling a loophole in the Affordable Care Act.

Some say the provision might prompt doctors to avoid the exchanges altogether, while other experts say few health care providers are aware of the issue and likely won’t know about the loophole until it’s too late.

Provision Permits Care Without Coverage

Under the ACA, if families who obtain subsidized health plan coverage through the exchanges fail to pay their premiums, they have a three-month grace period before the policy is cancelled. However, insurers are responsible only for paying claims during the first month of that grace period.

During the other two months, families are asked to pay their doctor’s bill or their insurance premium if they seek health care services. However, if they do not pay either bill, physicians are left to cover the cost of the treatment.

Such families would face a tax penalty for missing payments, but they would not receive a fine, a premium rate increase or a repayment order. They also would not be barred from purchasing another subsidized plan during the next enrollment period.

A ‘Laudable’ Design With Flaws

“I believe this part of the law was designed for logical and laudable reasons,” Lisa Folberg — vice president of medical and regulatory policy at the California Medical Association — said.

She explained that the three-month grace period was meant to ensure continuity of care for low-income families who might be between jobs and cannot afford to pay their premiums for a few weeks.

Why Is Obamacare So Unpopular?

Jun 5, 2013• 7

By Jason Shafrin

Views on the Affordable Care Act (a.k.a. Obamacare, a.k.a. Health Reform) are mixed. Despite the fact that many people support individual provisions, overall, the measure is unpopular. Why would that be the case?

A revealing Health Affairs interview with Cythnia Morgan, may reveal the answer. Morgan is a fifty-eight-year-old former hotel manager, has been out of work and uninsured for the past three years. Her income is low, but not low enough to quality for Medicaid. She is exactly the type of person the health insurance exchange is supposed to help. So why wouldn’t like someone like her support the Exchanges?

After being told of how the ACA’s health insurance exchanges would work, she stated:

“Oh, God, that would be great—if there’s going to be a plan that’s affordable. But come on now, it’s really hard to believe.”

A Democrat would read this and claim that Mrs. Morgan is ignorant of the provisions and yes, in fact, this is exactly what the ACA will do. Republicans will say that Mrs. Morgan is 100 percent correct. Although the provisions do promise affordable care, she is correct to be skeptical that government can deliver on this promise when private industry could not.

Datapalooza Report on Data Economics and a Call for Reciprocity

Jun 5, 2013• 4

By Adrian Gropper, MD

Uwe Reinhardt said it perfectly in a Tuesday plenary but I can only paraphrase his point: “health information is a public good that brings more wealth the more people use it.” Or, as Doc Searls puts it: personal data is worth more the more it is used. Datapalooza is certainly the largest meeting of the year focused on health data, and our Health and Human Services data liberation army was in full regalia. My assessment is: so far, so good but, as always, each data liberation maneuver also reveals the next fortified position just ahead. This post will highlight reciprocity as a new challenge to the data economy.

The economic value of health data is immense. Without our data it’s simply impossible to independently measure quality, get independent second opinions or control family health expenses. The US is wasting $750 Billion per year on health care which boils down to $3,000 per year that each man, woman and child is flushing down the drain.

Data liberation is a battle in the cloud and on the ground. In the cloud, we have waves of data releases from massive federal data arsenals. These are the essential roadmap or graph to guide our health policy decisions. I will say no more about this because I expect Fred Trotter (who is doing an amazing job of leading in this space) will cover the anonymous and statistical aspects of the data economy. Data in the cloud provides the basis for clinical decision support.
Continue reading…