Month: May 2014

With November Elections Six Months Away Obamacare Is Up for Grabs

May 14, 2014• 3

By ROBERT LASZEWSKI

House Energy and Commerce Committee Republicans seemed surprised last week when representatives of the insurance industry reported that they didn’t have enough data yet to forecast prices for next year’s health insurance exchanges, the market was not about to blow up, and that so far at least 80% of consumers have paid for the health insurance policies they purchased on the exchanges.

The executives also reported there are still serious back-end problems with HealthCare.gov––particularly in being able to reconcile the people the carriers think are covered and the people the government thinks are covered.

These are all things that you have read about a number of times on this blog.The insurance companies are doing their best to make Obamacare work.

Why?

Because if they want to be in the individual and small group markets, Obamacare is the only game in town––it has a monopoly over these markets. The same rules that apply to the individual market also apply to the even larger small group health insurance market.

Unless Obamacare is repealed this is the business reality insurance companies have to deal with. So, you make the best of it.

Republicans are right to think Obamacare is unpopular. The latest Real Clear Politics average of all major polls taken since open-enrollment closed still has 41% of those surveyed favorable to the law and 52% opposed to the law––about as bad it is always been.

But Obamacare is not going to be repealed. The sooner Republicans come to understand that the better for them.

I really think Democrats have the potential to take back, or at least neutralize, the health care issue by the November elections if Republicans aren’t careful.

Government (Or, How My Cousin the President Nearly Killed My Company)

May 14, 2014• 59

By Jonathan Bush

I WAS NOW the CEO of a rising medical data company.We built automated systems to handle the administrative chores for thousands of medical practices. They didn’t buy anything from us. Instead, they subscribed to a service on the Internet.

This was what would later be called a cloud-based service, but in these early days of Internet era, we were still searching for a name for it. My partner Todd used to say in speeches that he would give Polynesian fruit baskets for life to anyone who came up with a single name for the combination of software, knowledge and work that we were selling. We had moved back east and had a new headquarters in a historic brick armory building along the Charles River near Boston.

Our future looked fabulous, except for one problem: My cousin, the 43rd president of the United States, was about to sign a bill that could destroy us.

This bill, like so many governments initiatives, stemmed from the best of intentions. The idea was to encourage the migration of the health care industry from cumbersome binders full of paper to electronic records. How was this to be accomplished? Well, hospitals and doctors were forbidden by so-called anti-kickback laws from exchanging services, information or products of value with each other. (It’s a law that infuriates me, for reasons I’ll go into later.) The bill before Congress in 2004 offered a regulatory safe harbor for hospitals to provide doctors with all the digital technology the bureaucrats could think of: servers, software licences, and training. That was absolutely the right answer . . . for 1982. The long and short was that hospitals could buy all the old stuff from our competitors, but none of the new still-to-be-named services from us. As often happens, the technology was advancing much faster than the law.

I caught the shuttle down to Washington and commenced lobbying with the fervor of a man with a gun to his head. I raced up and down the marble halls Congress, looking for someone, anyone, who would take the time to learn why this bill was so very wrong, so backward, so devastating, so lethal—at least to athenahealth.

But let me tell you, if you walk into Congressional offices sputtering about a clause in a bill that practically no one has read, something that has to do with hardware and software and online services, people tend to hurry away, or point you toward the door. I could find no one to pay attention. And as I grew more frantic, I started talking louder and faster. That didn’t help things.

Some might find my frustration strange, considering that during this drama my cousin was sitting a mile away, in the Oval Office. Wouldn’t a Bush, facing legislative trouble in Washington, contact someone in the White House entourage? The answer is no. Placing a call to him was not even a remote possibility. For starters, it’s unethical. It is also politically foolish. It would place him, me, and my company in scandal and bring shame upon our family. I would be much more willing to climb the steeple of the tallest church and bungee jump naked in the middle of the night than to call my cousin. And even if I were dumb enough to make the call, I trust George would have the good sense to tell me to get lost.

Some Serious Medication Instructions …

May 14, 2014• 5

By THCBist

mercilon tabs

HAT TIP : @nickdawson

Cheeseburger Please, and Make It a Double

May 14, 2014• 36

By Vik Khanna

Consider that for the last year or so, we have been treated a deluge of entreaties to reduce our salt intake, with the American Heart Association going so far as to claim that daily sodium intake should not exceed 1,500 mg. This puts it at odds with the Institute of Medicine, and now European researchers whose data indicates that the healthy range for sodium intake appears to be much higher.

Our conversation about sodium, much like advice about purportedly evil saturated fats and supposedly beneficial polyunsaturated fats, exemplifies a national obsession with believing eating more or less of a one or a small number of nutrients is the path to nutritional nirvana.

A few weeks back, an international team of scientists did their level best to feed this sensationalistic beast by producing what’s become known since then as the meat-and-cheese study, because it damned consumption of animal proteins.

The authors correlate cancer mortality with age and protein intake, but they never bother to correlate it with body mass index or waist circumference, the latter of which is an increasingly important measure of body composition. Average waist circumference of the mostly older study subjects was just barely below risk thresholds, meaning that they were fat. Abdominal adiposity induces a damaging pro-inflammatory metabolic state than abets cancer development. Cancer is predominantly a disease of aging with incidence and death rates after age 50 that are 13x greater than before.

Growing Up in the Era of Work-Hour Restrictions

May 14, 2014• 2

By Danielle Jones, MD

In 2008, the IOM study on resident work hours came out and in the years that followed the Accreditation Council for Graduate Medical Education (ACGME) subsequently implemented a gamut of “recommendations.”

As a medical student, I remember thinking it was a much needed change – why wouldn’t it be a good idea to improve patient safety and decrease resident fatigue?

Alas, as a newly minted intern growing up in the era of work-hour regulations, it’s become apparent that many of these changes may actually make life harder without achieving their main goal of improving patient care.

The 80-hour work week cap is fine; it’s been in effect on its own since 2003 and overall it seems to have made residency more humane. Most programs have found reasonable ways to limit work hours to this full-time-times-two amount, at least when hours are averaged over four-week periods.

However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.

So, what do the bullet point regulations look like in the hospital?

They look like: Interns can’t work 24-hour shifts.

So, what used to be a two-and-a-half shift weekend turns into a four shift weekend. At a four intern/year program like mine, that means instead of two people splitting the weekends and having a post-call day after 24 hours on, one intern is committed to night-float six nights/week for a month while the remaining three interns take the three leftover weekend shifts.

The result: Fewer hours at a time in the hospital, but more working days in a row and more days/month away from your family.

An Unfunded Mandate For Behavioral Health

May 13, 2014

By EDMUND BILLINGS, MD

Why politics, parity and performance requirements mean behavioral health hospitals should adopt now.

Imagine you go to work one day and your boss says all employees will be evaluated based on the performance of a new set of job skills that require additional training and, perhaps, new computer hardware and software. The boss also announces that some employees will be reimbursed for the cost of acquiring these skills and tools. You aren’t among this privileged group.

In government, this is called an unfunded mandate. The unlucky employee in this case is psychiatric hospitals, who aren’t eligible for Meaningful Use incentives even while Congress and the Obama administration have legislated greater accountability:

A precursor to the 2010 Affordable Care Act (ACA), the Mental Health Parity and Addiction Equity Act of 2008 mandated that insurers must make the financial cost of benefits—co-pays, deductibles, out-of-pocket maximums—equal for psychiatric and physical care.

By making behavioral health an Essential Health Benefit, the ACA requires health plans to cover mental health on par with other types of care.

On October 1, 2012, CMS launched the Inpatient Psychiatric Facility Quality Reporting Program (IPFQR), a pay-for-reporting program in which facilities could lose federal dollars by not providing data on Hospital Based Inpatient Psychiatric Services (HBIPS):

Screening for violence risk, psycho trauma Hx, patient strengths
Hours of physical restraint use
Hours of seclusion use
Patients discharged on multiple antipsychotic medications
Patients discharged on multiple antipsychotic medications with appropriate justification
Post discharge continuing care plan created
Post discharge continuing care plan transmitted to next level of care provider upon discharge

Whether explicit or implicit, these programs amount to unfunded EHR mandates. How so?

Organizations still on paper records will find it expensive and inefficient to capture events and collect results for both reporting to government and submitting claims to insurance companies. Hospitals will need to train clinicians to document post-discharge continuity of care plans.

They will have to train staff to send plans by snail mail or fax to the provider at the next level. Then they will also need to do chart reviews to assure that all these steps took place and the data is recorded in a spreadsheet or database. Any quality improvement process that requires benchmarking and scoreboarding of performance based on these measures will be a tremendous challenge using paper records.

The Cost of One Wild Night

May 13, 2014• 10

By Sammy Ta

The clock read 9:30PM and in front of me was dozens of notes, PowerPoint slides, and practice exams to review before 8AM.

The all-too-familiar finals week all-nighter beckoned, and though I’ve had my fair share of experiences with studying until the sun rose, I decided to forgo the typical mug of coffee and take some over-the-counter caffeine pills instead.

My friend proclaimed that they would help more than any energy drink would. I laid out all my exam materials, popped in a couple caffeine pills, and strapped myself in for a wild night of allopatric speciation and coadaptation. A wild night did ensue, but there was no evolutionary biology involved.

Around 11:30PM, what could only be described as the worst headache of my life, detracted me from my desk and led me to the bathroom floor. I decided something needed to be done. Student services at the university health system were closed, so that only left me with the ER as an option.

An ER visit was outside the coverage of my standard student health insurance provided with tuition and I didn’t have a personal health insurance plan. I was wary of any costs that I might incur in the ER.

Instead of an ambulance, my best friend, Eric, drove me to the hospital.

A Doctor’s Guide to Botched Executions

May 13, 2014• 11

By Karen S. Sibert, MD

I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

Not for amateurs

Though lethal injection is supposed to be more humane than the electric chair or the gas chamber, often it doesn’t work as planned. Mr. Lockett died on April 29 after the injection of midazolam, vecuronium, and potassium chloride into his system. It is unclear from media reports how much of which drug he actually received. Apparently, prison staff had difficulty finding a vein.

The drugs were injected, they thought, into the large femoral vein in Mr. Lockett’s groin, which should have killed him within moments.

Doctor Paul Revere Fails to Light the Fire

May 13, 2014• 3

By Saurabh Jha, MD

Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).

As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.

The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.

The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.

Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.

Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.

How Community Health Centers are Taking on Accountable Care for the Most Vulnerable

May 12, 2014• 4

By Farzad Mostashari, MD & James Colbert, MD

Like many participants in the Medicare Shared Savings ACO Program (MSSP), Family Health ACO is sailing in uncharted waters.

All ACOs are facing significant challenges in better understanding patient utilization patterns, identifying high-risk patients, and implementing care coordination strategies.

Even more unique is that Family Health ACO (“Family Health”) is composed entirely of federally qualified health centers (FQHCs). FQHCs are community based organizations that provide critical primary and preventive care for millions of underserved and uninsured Americans, regardless of their ability to pay.

Nationwide, there are over 1200 FQHCs serving the health care needs of the working poor, the unemployed, the undocumented, and anyone else in need of primary medical care. Family Health provides care to over 200,000 patients and spans nine counties in New York State; from the bustling streets of New York City to the rural landscapes of the Hudson Valley.

Partners in the Family Health ACO include Open Door Family Medical Centers (“Open Door”), The Institute for Family Health (“The Institute”), and Hudson River Health Care (HRHCare).

Collectively the ACO includes 120 physicians, 60 advanced practice nurses and physician assistants, and nearly 100 dental providers.

These organizations have a strong history of collaboration, including their first venture in 2008 to form the Hudson Information Technology for Community Health (HITCH). HITCH enabled the organizations to pool resources and work collaboratively on cancer screening and diabetes management outreach programs.

The ACO partnership is helping to further strengthen the ties between these three community-based health care organizations and their communities.