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Month: October 2013

Health 2.0 Co-Founders Address How to Adapt to a New World of Health Care and the Problems it Encompasses

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Health 2.0 co-founders Matthew Holt and Indu Subaiya gave separate keynote speeches on the second day of Health 2.0’s 7th Annual Conference earlier this month, setting the tone for the remainder of the event.

Holt began by giving an overview of the rapidly changing world of health care and his advice for the viewers in adapting to such changes.  He spoke of the comparatively low use of EMRs, the importance of trackers, and sharing data between consumers and professionals as specific challenging trends.

Watch Matthew’s full keynote here.

CEO Indu Subaiya followed Holt and addressed the “seven deadly sins of health care,” which ranged from too much testing to end of life care.  She compiled this list after an active conversation with eight of her trusted colleagues about the parts of health care which might not be “typically kosher.”  Subaiya shifted perspective from specific negativities to look at the health care system in a new way; shining light on potential ways to improve these problems. Subaiya’s keynote left the room with an optimistic view of real problems in the health care system.

Watch Indu’s full keynote here.

Redefining Health Care with Health 2.0 Bottom-Up Thinking

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By Lori Houston

Santa Clara, CA- Lt. Governor Gavin Newsom urged a crowd of over 2000 health IT entrepreneurs and thought leaders to forge ahead in leading the health care revolution and not to wait on the government in his keynote at the Health 2.0’s  7th Annual Fall Conference this year.

Newsom observed that the innovation happening in health care technology embodies the “bottom-up” thinking that is defining the future of both health care and society in general. “It’s a whole new level of thinking: it’s platform thinking, not machine thinking. The world will be defined by mobile, social, and local trends. It’s not top down. The pyramid has inverted. That’s what Health 2.0 is all about.”

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How Naïve Can Democrats Get?

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By Uwe Reinhardt

Beholding David H. Howard’s rendering of the crazy-quilt of financial sources that have been tapped by the designers of the Affordable Care Act of 2010 (hereafter ACA ’10) to finance the new entitlements they put in place – a little nuisance tax here, a little nuisance cut in other federal spending there – reminds me once more of the sincere, indeed touching, naiveté with which Democrats tend to go about enacting new entitlements.

It is a totally counterproductive and inelegant approach. To be sure, none of the added taxes or spending cuts in the bill seriously disrupt anyone; but they do spread a little pain all around. Therefore, it seems almost deliberately designed to maximize opposition to it from many quarters.

It also leads to acute embarrassments, such as having to postpone by a year (and perhaps more years) the unseemly penalty imposed on employers with 50 or more employees each working 40 your or more etc etc, even at the appearance of having broken the law – or so we are told.

When will the Democrats ever learn?

And from whom might they learn?

From the Republicans, of course.

Dream back to the good old days – 2003 – when the Bush Administration and the Republican Congress pushed through, with deft parliamentary maneuvering and some arms twisting, H.R. 1 (2003), the Medicare Prescription Drug, Improvement, and Modernization Act – hereafter the MMA ’03.

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Should We Sacrifice Medicine’s Sacred COW?

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By Richard Gunderman, MD

Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!”  Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion.  Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.

One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows.  In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.

Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds.  In this case, the cow is not an animal but a machine.  In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base.  It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.

As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence.  For one thing, people in hallways and patients’ rooms are constantly making way for the COW.  As an expensive and essential piece of equipment, it is handled gingerly.  Often only the senior member of the medical team or his or her lieutenant touches the COW.

Others know that they have said something important when they see the chief keyboarding the information into the COW.  Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. Continue reading…

When Talking About the Exchanges, It’s Probably a Good Idea to Look Beyond Opening Week Returns

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By David Dranove & Craig Garthwaite

It was an up and down week for supporters of the Affordable Care Act. Republicans appear to have stopped linking government funding with partial repeal of the ACA. And well-publicized software problems plagued the 36 federally managed exchanges, making it difficult for enrollees to complete the application process. Still, supporters could crow about the large number of insurers who are offering products and the millions of Americans who visited the online exchange enrollment sites as a clear sign of the success of the Affordable Care Act.

We should never confuse activity with accomplishment.

A few software updates will not be sufficient to assure the success of the exchanges. Two more important things must happen: Visits to web sites must translate into enrollments, and enrollees must represent the kind of cross-section of risks that will keep insurers in the exchanges in years to come.

Not surprisingly, enrollment figures vary considerably by state, with some states operating their own exchanges reporting some of the highest enrollments to date. But upon even minimal inspection, current enrollments leave much to be desired. In New York, 40,000 individuals completed applications in the first week, not bad until you consider that several million state residents are eligible for insurance.

Washington State has 1 million eligible residents and just over 10,000 applicants. Reporting that 29,000 California residents had completed their enrollment applications, exchange Executive Director Peter Lee stated that this “blew his socks off.”

Let’s put this in perspective.

With 7.1 million uninsured in California, an application pool of 29,000 shouldn’t knock any garments off of anyone!

These are the “success” stories. At the other end of the spectrum, at last count Maryland had a whopping 566 applicants. And lest we forget, applications are not the same thing as enrollments. Some insurers have claimed that applications are incomplete – potentially leading to a troubling situation where uninsured individuals may incorrectly think that they have secured insurance.

Before patting themselves on the back, exchange supporters should stand back and see what happens. Coming from the nation’s entertainment capital, California’s Mr. Lee should be especially aware of the dangers of judging success from opening week returns. Will the exchanges be like The Lone Ranger, which topped the box office in its opening week and then quickly faded away? Or will they be more like Argo, which gradually built its audience over time? Time will tell.

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Of Course, Then There’s The Fact That You May Be Better Off Waiting To Buy Coverage, Anyway …

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By Trudy Lieberman

Will all the White House messages, the stream of breathless Twitter updates on the number of hits and enrollments, and the press hype surrounding opening day send the uninsured public into panic mode? Will they prompt buyers to consider only the premium and click to enroll ASAP? And why not? For weeks the administration, state exchange officials and supporters of the Affordable Care Act have been telling the public how cheap premiums will be — much cheaper than expected.

A Pennsylvania woman told me she was chomping at the bit to enroll because she was eager to dump her policy from Aetna for a cheaper model from Blue Cross. Never mind that she had no idea whether the coverage was better, the same, or worse.

A Nebraska woman heard there was a worksheet to fill out and it had to be completed by October 1. It was first-come-first-served, an agent had told her.

If cheap premiums were the only thing shoppers had to consider, this sense of urgency might be fine. But it’s not. Here’s the problem.

Selecting a health insurance policy is fraught with potential missteps and misunderstandings. As the Nebraska woman told me, “You’re walking into a chasm of uncertainty. It’s like shopping for a used car. You don’t know if you’re getting a lemon,” a lemon you’re stuck with until the next open enrollment.

For consumers, the key advice right now is: don’t rush into anything. Tuesday, October 1st marked the first day of a six-month open enrollment period, not the last. Coverage doesn’t even begin until January 1, 2014, so there’s no need to buy the first policy you see. If you do want coverage on January 1, the deadline for enrolling is Dec 15.

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The End of the Era of Coronary Angioplasty

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By Nortin Hadler, MD

In a single generation, the evidentiary basis for the practice of medicine has grown from a dream to a massif. No longer need physicians rely solely on experience and opinion in formulating diagnostic and therapeutic approaches to the care of the patient.

However, for any given clinical challenge, the available science is never flawless, monolithic or comprehensive, nor is it likely to be durable in the face of newer studies.

The international medical community has mounted two approaches to sorting the wheat from the chaff: One targets the doctor in convening committees to formulate guidelines for patient care. The other targets the patient for evaluating options, so-called informed medical decision making. Both approaches are now sizable undertakings clothed in organizational imprimaturs and girded by self-promotion.

But they are largely parallel undertakings with work products that can cause considerable cognitive dissonance on the part of the patient and the physician. In a recent article in the British Medical Journal [1] the Guideline Development Group convened by the National Institute for Health and Clinical Excellence (NICE) summarized the thinking behind the guidance it was offering regarding the management of STEMI. This is an object lesson in such cognitive dissonance.

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Paying for the ACA: A Field Guide

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By David H. Howard

Like many health policy experts, I’ve closely followed and participated in the debate over the Affordable Care Act. I’ve spoken at town hall events, fielded questions from reporters, and discussed the ACA with students, friends, and colleagues.I have been asked a wide range of questions about the ACA, but I am always amazed by the one topic that almost never seems to come up: how the deeply indebted federal government will pay the roughly $200 billion annual cost of expanding coverage.

The inattention to the financing of the ACA by the public, the media, and even Republicans is a testament to the skill of its drafters. The benefits of the ACA are highly visible, the costs are concealed.

Consider the ACA’s treatment of Medicare hospital reimbursements. Reimbursements to hospitals increase from year to year based on the projected increase in hospitals’ labor and capital costs. The ACA reduces the rate of growth in payments by 0.1 percentage points per year plus an additional factor based on projected economy-wide productivity growth. It is possible that the application of these factors will result in a net reduction in payments, but, more likely, payments will not increase by as much as they would have in the absence of the law.

This provision, which will raise $64 billion in 2020, may result in the closure of some hospitals and reduce quality in those that remain open. However, these effects are uncertain and difficult to summarize in a soundbite.

Other financing provisions are only slightly less obtuse. About one quarter of Medicare beneficiaries are enrolled in private health plans, the so-called Medicare Advantage plans. The ACA will revamp the formula used to set payments to these plans for a savings of $19 billion in 2020. The ACA will reduce subsidies to so-called Disproportionate Share Hospitals (hospitals that serve a large number of low-income patients) for a 2020 savings of $9 billion.

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Commentology: What Your Employer Is Secretly Thinking As Obamacare Goes Live Part II

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By THCBist

In response to Kip Piper’s recent post, “What Your Employer Is Secretly Thinking As Obamacare Goes Live” Michael Turpin writes:

A very comprehensive article and predominantly spot on. I do have a few alternative views.

Employers are waiting to see if public exchanges are viable alternatives – As a consultant who works with employers every day, the universe of employer sentiments is varied. The preponderance of public exchange options with be narrow network, lower level reimbursement plans that will not be like for like equivalents to employer sponsored open access PPO plans. With low individual mandate penalties and higher costs for younger exchange enrollees due to 3:1 community rate banding, there is concern that the first enrollees will select against the plans and not be offset by younger, healthier participants who will balk at the prospects of higher premiums.

Self insurance will be highly prevalent – The average employer can save as much as 6% by self funding their insured benefits. It is true they take on higher liability but the first 6% is essentially playing with house money because the employer will not pay taxes on insured benefits or insured PPACA taxes. Employers, especially those with young healthy employees, would be better served self insuring to avoid community rate cost old to young shifting and insured premium taxes. Younger consumers use fewer benefits. Average year over year medical trends will likely be low single digits — much lower than the likely community rated increases tendered the first year in the exchanges.

Private exchanges will gain some traction – The IBM decision is only for retiree medical benefits. Walgreens is the first major retailer to adopt a private exchange for actives. A private exchange is to health plans what the 401k was to defined benefit pension plans. A true private exchange pits multiple insurers against one another in a Cost Co type private market where individual enrollees are given an annual stipend to buy benefits. Each enrollee can choose between a range of plans and insurers.

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Confessions of a Self-Tracker

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By Michael Painter, MD


Hello.  I am Mike Painter, and I track. I don’t necessarily have a compelling reason to track health parameters such as exercise patterns, heart rate, weight, diet and the occasional blood pressure. Yet I do.  I do most of my tracking with several small devices, simple sensors and software applications. My tracking is also pretty social—meaning I share much of my data widely and daily. You’re welcome to see it—most of it is on Strava. Admittedly, I still keep some data daily on a paper calendar, and I do monitor diet and sleep in my head—i.e., nobody needs to remind me about my food splurge days. The local bakery is intimately aware of that data point as the employees witness me charge in, wild-eyed and drooling for a giant cinnamon roll every Thursday morning—almost without fail.

It all feels pretty normal to me.

Here’s the rest of the story: I track to enhance athletic performance rather than monitor my health, per se, or even really my wellness. I am an avid cyclist and have tracked miles, location, accumulated elevation, heart rate and power readings and other data for years. I share that information with both cyclist colleagues I know and don’t know on Strava. That site eagerly ingests my data—and among other things, plops it into riding (and running) segment leader boards, riding heat maps—and, most importantly, in training, trend graphs like the attached. All that data is incredibly helpful to me—it empowers me by making me face the numbers—it makes my training data- and reality-based. I don’t have to guess to maximize my fitness and minimize my fatigue level in anticipation of a big event. I follow the numbers.

Is all that bad? To me, my obsession with tracking my athletic performance seems like an extension of observing data for health and wellness.

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