Year: 2014

A Time For Revolutionary Thinking

Aug 13, 2014• 53

By JOHN HAUGHOM, MD

We need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.

This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

As clinicians enter the debate, they should keep three things in mind.

Promote the leadership role of clinicians

We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.

The Case For Payers to Oppose Meaningful Use

Aug 13, 2014• 12

By NICHOLAS ORLOWSKI

The Meaningful Use program is at a critical inflection point. On one hand, the payers could jump on the MU bandwagon, follow Medicare’s example and demand provider MU attestation.

On the other hand, they could throw private practice a bone and help them weather the storm until MU goes away or loses its teeth. Let me explain.

Payers could take the easy money and penalize according to the upcoming ACA “adjustment” schedule. Lots of people think this is inevitable. This would certainly provide an easy way to increase payer revenue and is as simple as letting the practices [continue] to do all the work.

However, this would be incredibly short-sighted.

Meaningful use, as things stand in 2014, has not been shown to improve patient care. Indeed, it is common for Stage 1 attesting MDs to abandon the program during Stage 2, with many doctors citing lack of efficacy of the program. Stage 3 MU is projected to have even worse results.

What this tells me is that the stress and time-cost of MDs and their staff is not worth the benefits of Meaningful Use. Don’t get me wrong – there are some great things in the MU guidelines, and we are implementing them in the software we create, but they are overshadowed by the onerous, less-effective 5% and it’s all or nothing. There is no MU wiggle-room. These days you have to have real grit and determination to stay in private practice, no matter your specialty.

Without financial support or legislative reform, Meaningful Use will eventually drive independent doctors out of business.

That’s bad news for payers.

Health IT: Will Europe Catch the Wave?

Aug 12, 2014• 5

By STEVE DICKMAN

The US health IT space is white hot. Europe lags far behind both in the number of companies and in the amount of money being invested. There have been very few (no?) exits. I was wondering if Europe will ever catch up and which companies and geographies are emerging winners. So I decided to survey a half-dozen Europe-based VC partners active in healthcare investing some of whom have taken their first tentative steps into health IT investing. Here’s what I found out.

But first the impressive US benchmarks: HealthITNews reported in mid-July that VC investment into health IT surpassed $1.8 billion just in the second quarter of 2014, double the amount that had been raised in the previous quarter. Investors have cashed in on exits from companies such as Castlight Health (NASDAQ IPO in 2014); Humedica (acquired by United Health for a reported several hundred million dollars in 2013); and Healthy Circles (acquired by Qualcomm Life in 2013 for an undisclosed amount).

This makes sense given the obvious drivers for health IT activity in the United States: the mandated shift to electronic medical records (EMRs); consumer interest in web and especially mobile health apps; the boom in analytics in all areas including health; and especially the multi-payer system, one that heavily involves employers. Castlight would not even exist without the employer aspect. Rock Health reported in its excellent midyear funding report published in late June that startups developing payer administration tools took in more VC money (over $200 million in the first half of 2014) than any other subsector within health IT.

A Europe of borders

Meanwhile, as much as Europe has dismantled many of the internal impediments to the single market (local currencies, border crossings), there are many barriers to developing solutions to Europe-wide healthcare challenges. These include:

Language barriers. Start a web site for a consumer-facing business and you will see your user base fracture unless you can communicate in at least three (or four!) languages.
Scaling challenges. Try to remedy the challenges inherent in the healthcare system and you will soon realize that there has been virtually no harmonization yet. Single payer systems are fine as long as you stay within them. If you try to work cross-border, then look out! As Antoine Papiernik, a managing partner at Sofinnova Partners in Paris put it, “Our European system is also messed up, but in a different way than in the US. It is the fact that [EU healthcare systems] are completely state controlled and operated that makes it difficult for a Health-IT play to get to scale as well as it could in the US.”
Missing incentives. When it comes to reducing inefficiencies and shifting responsibility and benefit to the consumer, the US healthcare system is a target rich environment. Similar incentives are hard to find in Europe, especially across borders. Consumers are less incentivized when they get cradle to grave healthcare financed by payments much lower than those in typical US health plans. Therefore, said Anne Portwich, a partner at LSP in the Netherlands, it is hard to imagine a consumer-focused company gaining VC financing in Europe, at least before it has huge traction (some promising examples will come up later). This is because “Something the consumer has to pay for him or herself, even 1 Euro per month, that is a completely different [and more challenging] dynamic and a different business model than what we are familiar with.”
Big data not yet “in.” Finally, a less obvious example. The larger business environment in the States has been largely penetrated by the type of thinking that favors “big data” and “analytics” as solutions to real problems. This way of thinking is years away in Europe, said Simon Meier, investment director at Roche Venture in Basel, Switzerland. Meier went part-time for a year in 2013 to work with a startup in big data and advertising so he observed this firsthand. Even sectors ripe for analytics such as retail and advertising have not yet been overhauled in Europe, he says. Therefore, Meier said, “our data scientists are still occupied in resolving issues or setting up infrastructure in areas from which US scientists have already moved on. There are plenty of markets in the European Union that have not even started thinking about data science. Compared to the US, applying data science to healthcare in Europe is going from a simple sailor knot to a Gordian knot.”

The Right to Die: The Suicide Checklist

Aug 12, 2014• 8

By JAMES SALWITZ, MD

Physician–Assisted–Suicide; the collaboration of two through a professional relationship, to cause the death of one.

Ever since Socrates took hemlock, suicide has been part of society, sometimes supported, often condemned. Today, many argue that we have a right-to-die, sort of an infinite extension of free speech or thought. Regardless, to actively involve doctors is a unique distortion of the medical arts, as if stopping a beating heart can somehow mend disease. For a healer to take life is bizarre and threatens the physician-patient relationship. If individuals really want and require assistance to die perhaps there is another solution.

A long trail of vital documents marks our lives. These include birth certificate, diplomas, driver’s and marriage license, advanced directives, wills and most recently the POLST. Perhaps we should create a new personal document. Its purpose would be to give each person not only permission to kill themselves, but access to the means. A permit controlled by the patient and only their responsibility. A passport for dying. A Suicide Certificate.

The Suicide Certificate would be a kind of application. A legal checklist, which once complete would allow the individual to die by their own hand, but in a controlled and definite manner.

What would go on this form? First, basic demographics; name, birth-date, address, social security number, etc. It is important to confirm that the right person is filling out the form. A photograph might be a good idea.

Next, statements regarding right-to-die laws. This could include a review of the sanctioned methods available, as well as the legal indications and limits for committing suicide. It might remind the applicant that a terminal disease is required, what is and is not a qualifying medical condition, and that suicide pacts are discouraged and therefore forbids sharing the lethal prescription. The whole form might start on-line and as part of the process an instructional video must be viewed and review answers given correctly, before it can be printed. Alternatively, an app could be developed.

What Healthcare Could Learn From a Technology Company

Aug 11, 2014• 29

By BILL CROUNSE, MD

Healthcare is very different from most other industries. It is fragmented, conservative, highly regulated, and hierarchical. It doesn’t follow most of the usual business rules around supply and demand or consumerism. An important aspect of my role at Microsoft is helping my colleagues at the company understand the many ways that healthcare is different from other “businesses”.

Having said that, there are a lot of things that healthcare could learn from a company like Microsoft or other technology companies. When someone asks me what it’s like to work at Microsoft, I often say what someone told me when I started at the company 13 years ago. Microsoft is like a global colony of ants, working independently and yet together but always “neurally” connected by enabling technologies. At any given moment, I can be connected to any one of my 100,000 fellow workers or tens of thousands of partners with just a couple of clicks or taps on a screen. I have tools that show me who’s available, what they do, what they know, and where they are. I can engage in synchronous or asynchronous communication and collaboration activities with a single member or multiple members of my team using messaging, email, voice, video or multi-party web conferencing. We can use business analytics tools, exchange information, review documents, co-author presentations, and collaborate with our customers and partners anywhere in the world from anywhere we might be. Our business moves, and changes, at the speed of light. It is the rhythm of the industry.

I sometimes wake up in the morning and think, “If only my clinical colleagues could avail themselves of similar tools and technologies how different could healthcare be?” I’ve been using information communications technologies in my daily work for so long that I almost take for granted that this is the way work is done. But I also know that in the real world of healthcare the journey is still quite different. That hit home again last week when I asked my mother’s family doctor for a copy of a report on an imaging study he had ordered. It took five phone calls to make something happen and my only choice was to receive the report via fax machine. Fax machine, really?

Is It Ok To Lie To My Insurance Company?

Aug 11, 2014• 3

By ACA DATABASE

After a hiatus, The ACA Database returns with a vengeance this week. Look for entries every day this week. If you have a question about how the ACA works or have had problems with the exchanges or your coverage, send us an email. We’ll publish the questions we like:

Secure Undisclosed location, USA asks:

Is it ok to lie to my insurance company? I know that the Affordable Care Act makes it illegal for insurance companies to deny me coverage for a pre-existing condition, which means that I no longer have to worry about being rejected for health coverage on the basis of my medical history. But what do I have tell my insurance company? What if I want to not disclose a condition, for example? Can my policy still be cancelled or a procedure not covered?I have a history of that involves a lot of things that I’d rather not talk about: an embarrassing STD, a hospitalization for severe depression, several other things that would have allowed insurers to reject me. I have several reasons why I’d rather not disclose this information:

1. I do not want to be stigmatized. 2. I do not want my treatment options or my choice of doctors to be limited on the basis of what my insurance company thinks is better for me.

In the old days, if you lied on your application, you could later be denied coverage. What happens now?

Churn and the ACA

Aug 11, 2014• 14

By HEATHER HOWARD

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Prior to the Affordable Care Act (ACA), with 47 million Americans uninsured, advocates and policy experts focused on expanding health insurance coverage for those who lacked it. Now that the law has broadened access to insurance, states are turning their attention to protecting enrollees from disruptions when they transition from one type of coverage to another, movement known as churn.

Churn is typically caused by a change in eligibility status, which itself stems from fluctuations in income, loss of a job, or changes in family circumstance, such as pregnancy. Short of a system, such as single-payer, where people may stay on the same plan for most of their lives, churn is inevitable. Indeed, in our fragmented health insurance system, millions of people naturally churn over the course of a given year, moving from employer-provided insurance to private insurance, or from private insurance to Medicaid, and so on. At low income levels, employment is particularly unstable, leading to high levels of churn among that population. For example, a newly-eligible Medicaid beneficiary (in an expansion state) who experiences a change in income over the course of a year—such as picking up an extra retail job during the holiday season—may lose his or her Medicaid eligibility as a result. Switching over to the exchange for new coverage could mean a totally different network of doctors, new drug formularies, and higher premiums and cost-sharing, not to mention the complexity and burden of going through a new and different enrollment process.

Is the ACA to blame for churn? No—in fact, the ACA directly reduces one form of churning, and offers tools to mitigate the impact of other forms. Before the ACA, millions churned off insurance coverage for all the reasons mentioned above. And after losing coverage, many people—especially those with preexisting conditions—found it hard, if not impossible, to get it back. Because the ACA makes the individual health insurance market more accessible and affordable, the law creates a new culture of coverage with a continuum of options, and actually cuts down on churning into uninsured status.

The Future Is Calling Us

Aug 6, 2014• 63

By JOHN HAUGHOM, MD

The recent debate surrounding the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program is a microcosm for a transformation in medical practice that is long overdue. The profession of medicine is going through a fundamental shift from a traditional craft-based practice to a more sophisticated, data-driven profession-based practice. The solo-based practice is dying. As the ABMS program suggests, the awareness and acceptance of this shift is already occurring at the national medical board level, but it is not happening as quickly at the individual physician level. It is time for all clinicians to consider a new, more effective and more empowering approach to clinical care.

Let’s take a look at the details. As you may know, the MOC program consists of six Core Competencies for Quality Patient Care that physicians must demonstrate to maintain certification. These competencies are over and above the traditional board certification requirements. The core competencies are professionalism, patient care, medical knowledge, practiced-based learning and improvement, interpersonal and communication skills and systems-based practice. Descriptions of each competency can be found here. In addition to being a new requirement, the program encourages a new style of practice for physicians.

The MOC program has generated considerable friction, especially among physicians, some of whom argue that the requirements place an additional burden on their increasingly burdensome work experience. Others have joined the program and are fulfilling its requirements. As of May 2014, 150,000 physicians were enrolled in the program, but tens of thousands have also signed protest petitions.

Writing the Value-Based Contract

Aug 6, 2014• 2

By CYNDY NAYER and LEONARD KISH

The kiss in the song from classic movie Casablanca is, at its essence, the seal of approval on a relationship. The kiss is meant to symbolize shared reward (love, potentially) and risk (two souls who share a common set of values but now have new lives) built with other people. The recognizable phrase provides a frame for distilling the rewards (opportunities) and risks in true health care innovation.

Innovative health care solutions, such as new value-based benefit designs or emerging treatment for complex chronic diseases, often deliver tremendous value, but they take time (usually 2-3 years), do not deliver consistent benefits across populations (based upon severity of disease) or reduce total costs consistently (based on geographic influences, for example). Generics are often described as an equal substitute for branded drugs, but this is not always the case. Commercials advertise drugs that purport to make quality of life better (the contract for care), but then the rapid-fire “potential adverse effects” statement overtakes the “superiority message,” in effect reducing the value of the contract.

So when Gilead launched a new drug, Sovaldi, that promised a cure for Hepatitis C (cure = contractual promise, or “kiss”), the market place was excited. Then the spell was broken as obvious risk, the US$84,000 price tag, was revealed.

Gilead has a huge opportunity here. It can become the true innovator that it claims to be. It can be the value-driven company that calls for aligning the risks and rewards so that all the parties involved achieve reasonable outcomes.

Curing the highly infectious HepC is a lofty goal for care innovation. Gilead’s new drug purports to cure HepC within 12 weeks (for certain patients) at the cost of $1000/per day in the US. The FDA approved the drug and it launched in January 2014. CMS agreed to fund it for Medicare patients with the right profile, which tends to open the door for legitimacy to coverage in the commercial marketplace.