Year: 2014

The Flu Shot and a Patient’s Right to Choose

Jan 25, 2014• 12

By Jennifer Anyaegbunam

Jennifer Anyaegbunam is a Fellow at The American Resident Project. Her post appears on THCB as part of The Health Care Blog’s partnership with ThinkWellPoint. Stay tuned for more. Follow the American Resident’s Project on Twitter @Amresproj.

I’ve spent the past four weeks learning about primary care on my Family Medicine rotation. A significant portion of patient care in this setting is focused on “health maintenance” or disease prevention.

Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.

According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.

Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?

I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.

This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.

Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.

The Black Box at the Center of Health Economics

Jan 25, 2014• 11

By Richard Gunderman, MD

When Michael injured his knee, he did what any responsible person would do. He was not incapacitated, and though the knee was painful and swollen, he could get around pretty well on it. So he waited a few days to see if it would get better. When it didn’t, he saw his primary care physician, who examined it and quite reasonably referred him to an orthopedic surgeon. The orthopedic surgeon considered ordering an MRI of the knee but worried that insurance would not cover a substantial portion of the $1,500 price tag, so he suggested a less expensive alternative: a six-week course of physical therapy that would cost only $600 – a quite responsible course of action.

At the end of this period of time, Michael was still experiencing pain and intermittent swelling. The orthopedic surgeon made another quite responsible decision and ordered the MRI exam, which showed a torn meniscus. The orthopedic surgeon could have recommended arthroscopic surgery, which would have earned him a handsome fee and generated revenue for his physician-owned surgery center. Instead he again acted quite responsibly, advising Michael that the surgery would actually increase the pain and swelling for a time and probably not improve his long-term outcome. Based on this advice, Michael declined surgery.

Though everyone in this case proceeded responsibly, the ultimate outcome was inefficient and costly. Many factors contributed, but perhaps the most important was the fact that Michael’s physician outlined choices based on an inaccurate understanding of the costs associated with his recommendations. The orthopedic surgeon thought that the cost of six weeks of physical therapy was 60% less than the MRI. In fact, however, the actual payment for the MRI from the insurance company would be only $300, not the “retail” price of $1,500. What appeared to be the less expensive option was actually twice as expensive, and it delayed definitive diagnosis by six weeks.

This story is emblematic of a larger problem in contemporary healthcare. No one – not the patients, the physicians, the hospitals, or the payers – really understands in a thorough way the true costs of their decisions. After receiving care, patients routinely receive by mail multi-page “explanations of benefits” that show huge differences between list prices and actual payments. Most find it baffling to try to determine who is paying how much for what. Physician practices and hospitals get calls every day from panicked patients who believe that they are being billed for exorbitant costs, when in fact most or all of the charges will be paid by insurance at a huge discount.

Good News! A Workplace Wellness Vendor Saying You’re Sick Means You’re Probably Healthy

Jan 25, 2014• 3

By AL LEWIS and VIK KHANNA

THCB is excited to announce the first official e-book release from THCB Press, “Surviving Workplace Wellness” by contrarian Wellness industry observers Al Lewis and Vik Khanna.” What exactly is the “Wellness industry” anyway? How scientific is the “science” behind wellness programs? Are stop-smoking programs a good idea? Should your company really be paying to send employees to the gym?

Should you be using technology to help your employees monitor and understand their health? You may not always agree with the authors (we certainly don’t here at THCB world headquarters, where Al and Vik have started more than a few food fights) but we still think you’ll find this title a provocative examination of many of the fundamental assumptions underlying prevention and wellness today.

You can order your digital copy from Amazon.com here at the discounted price of $9.99. If you’re a healthcare insider trying to understand the controversies facing wellness or a conscientious wellness professional trying to get a handle on developing a program that works for your employees, this is the e-book for you.

Be sure to look out for upcoming releases from THCB Press in the months to come. If you’d like to be placed on the THCB Press mailing list to be notified of upcoming new releases, send us an email with “update me” in the subject line. Author inquiries and partnership requests should go to this same address. — John Irvine

Continue reading…

Prices Drop When Health Consumers Shop Around For Healthcare

Jan 25, 2014• 22

By William H. Frist, MD

Here’s a point most of us can agree on. Tackling ballooning health care costs requires more than insurance reform because the charge and cost structure for health services in the U.S. is inconsistent and irrational. The same quality CT scan that costs $500 at one outpatient facility costs $2,000 at a nearby teaching hospital.

Obamacare’s typical high-deductible insurance plans encourage many cost-conscious consumers to shop around for low-ticket items below their deductible — and that is good. However, the bulk of health care spending is attributable to patients who rapidly blow through their deductible, after which they have no incentive to shop for value. Those 5 percent of people — who spend a whopping 50 percent of the nation’s health care dollars — have little incentive to consider price. With the cost of multiple medications, frequent doctors visits, use of specialists and one or more hospitalizations a year, these 5 percent will exceed even the highest deductible in the first few months of each year.

So what might be the single most powerful tool to slow the seemingly intractable yet unsustainable increases in health spending affecting practically every family in America? “Referenced-based” pricing for health services encourages patients — most significantly, those with the highest costs — to act as smart consumers by seeking the most cost-effective care, even after they have exceeded their deductible.

Here’s how it works. Insurance companies or employers set a limit they are willing to pay for a specified service of excellent quality — say, $1,000 for a CT scan — and communicate that reference price clearly to consumers. If patients choose a location where the charge is below the maximum set reimbursement rate, they pay nothing. If they choose a provider where the charge is higher, they pay the difference.

As patient-consumers shop around for the best price and quality services, competition in the market pushes prices down and value up.

Are Death Spirals Real? Has Anybody Ever Seen One?

Jan 24, 2014• 8

By THCBist

A THCB reader in Virginia writes:

“As a small business owner, I’ve been following the arguments about Obamacare with a mixture of amusement and total horror. Just when you thought Washington couldn’t screw things up any worse, they find new and creative ways to do exactly that.

My question concerns the phenomenon of the “death spiral” the terrifying sounding scenario that observers predict will occur if not enough people buy insurance. According to this theory, if not enough people buy health insurance, insurers will be forced to abandon unprofitable markets. As a business owner myself, this argument resonates. But I still don’t get it. This seems like common sense.

It is certainly true that if nobody buys my goods and services, my business will go into a “death spiral.” I will no longer be able to make a living selling my widgets. I will be forced to invent a new widget. Or go get a new job. This is like my kid saying if he doesn’t to play more Call of Duty IV he will go into an “entertainment death spiral” and be unable to do his homework ever again or be a productive member of society.

Or McDonalds warning that if too many people take up vegetarianism, its business will go into a horrible “hamburger death spiral.” So what evidence do we have? I need documentation. Like, let’s say, a picture. Or a YouTube clip.

Seriously, when has this happened? Otherwise, the death spiral thing sounds like really good economic spin to me …”

The Conservative’s Faustian Fear

Jan 24, 2014• 6

By Saurabh Jha, MD

Avik Roy has done the unthinkable. In a recent op-ed title he used “conservative’s case” and “universal healthcare” in the same sentence. And bridged these disparate words by the preposition for.

Spoiler alert: Roy has asked Republicans to embrace universal healthcare.

The Twitterverse is abuzz. An angry Gary P. Jackson, a self-affirmed conservative, tweeted:

“there is NEVER a conservative case for Marxism….especially Universal healthcare.”

Stated differently, universal healthcare is the worst form of Marxism except for all other forms of Marxism.

Thus far Roy has not been asked to produce his birth certificate, which is just as well. Roy, a prolific Forbes columnist and a scholar at the Manhattan Institute, was healthcare policy adviser to Mitt Romney. He is not a cheerleader of the Affordable Care Act.

There are things one may disagree with Roy. However, his short treatise, How Medicaid Fails the Poor, was impressive, as it deftly dealt with Medicaid’s structural problems. That a right-of-center policy analyst would write a book with that title is one of the many ironies I am now accustomed to encountering (the other delicious irony was the love of Cadillac health plans by unions).

In The Washington Examiner and National Review Online, Roy urges conservatives to acknowledge and embrace universal healthcare, in no uncertain terms:

“…[conservatives] have to agree that universal coverage is a morally worthy goal.”

The arguments put forward by Roy are pure common sense. No one objects to public education as “socialized education.” If conservatives are afraid that universal healthcare means big government, government is already heavily involved in healthcare.

And not just Medicare, which a certain tea party placard asked the government to keep its hands off!
Continue reading…

Pilots with Hospitals, the Chicken or the Egg Problem

Jan 24, 2014• 1

We know that as a health tech entrepreneur, piloting your technology and getting that first customer validation is extremely challenging. There’s frequently the ‘chicken or the egg’ problem. Most providers are unwilling to work with young technology companies that have yet to validate or prove the effectiveness of their product. Meanwhile, health technology companies need that first pilot for a chance to validate their technology. That’s why the New York City Economic Development Corporation, in partnership with Health 2.0, is excited to launch Pilot Health Tech NYC 2014, a program that provides $1,000,000 in funding to innovative projects that pilot new health technologies in New York City. The program seeks to vet and selectively match early-stage health or healthcare technology companies (‘innovators’) with key NYC healthcare service organizations and stakeholders (‘hosts’), including hospitals, physician clinics, payors, pharma companies, nursing associations, foundations, major employers, and retailers.

The 2013 program was a tremendous success, with participation from 25 provider organizations, over 250 innovator companies, 200 matchmaking meetings, 41 joint applications, and finally, 10 pilot winners. Since ‘Pilot Day’ 2013, an event during which last year’s winners were announced, the inaugural class of Pilot companies has raised more than $14 million in private investment, including $4.5 million in the last six months and their pilots have enrolled more than 1,000 patients. Check out the video below to hear what some of the winners from the 2013 program have to say!

[vimeo width=”450″ height=”315″]http://vimeo.com/84067044[/vimeo]Continue reading…

MOOCs Ain’t Over. Till They’re Over …

Jan 24, 2014• 1

By Michelle R. Weise

Over the last month, journal headlines have been heralding the death of massive online open courses (MOOCs). You could almost hear the sigh of relief from the academy. With Sebastian Thrun himself acknowledging the “lousy” quality of the MOOC product, told-you-so skeptics have been giddily pointing out that Udacity, in its failure to disrupt higher education, is now moving on to vocational training.

Sadly, what audiences are missing is that Thrun’s shift to workforce training is precisely what has the potential to disrupt and severely impact traditional postsecondary education. We at the Christensen Institute have already written extensively about how MOOCs were not displaying the right markers for disruption (see here, here, here, and here), but we became more hopeful as they started to offer clusters of courses. Coursera announced Foundations of Business with Wharton, while edX and MITX introduced the Xseries in Computer Science as well as Supply Chain & Logistics.

These moves appeared to map better to employer needs and what we describe as areas of nonconsumption. In their turn away from career-oriented training, colleges and universities have unwittingly left unattended a niche of nonconsumers—people over-served by traditional forms of higher education, underprepared for the workforce, and seeking lifelong learning pathways.

What most people forget when they bandy about the term “disruptive innovation” is that disruptive innovations must find their footholds in nonconsumption. McKinsey analysts estimate that the number of skillsets needed in the workforce has increased rapidly from 178 in September 2009 to 924 in June 2012. Unfortunately, most traditional institutions have not adapted to this surge in demand of skillsets, and as a result, the gap has widened between degree-holders and the jobs available today.

Some Predictions on How Medicare Will Release Physician Payment Data

Jan 23, 2014• 5

By CHARLES ORNSTEIN

The federal government’s announcement last week that it would begin releasing data on physician payments in the Medicare program seems to have ticked off both supporters and opponents of broader transparency in medicine.

For their part, doctor groups are worried that the information to be released by the Centers for Medicare and Medicaid Services will lack context the public needs to understand it.

“The unfettered release of raw data will result in inaccurate and misleading information,” AMA President Ardis Dee Hoven, MD, said in a statement to MedPage Today. “Because of this, the AMA strongly urges HHS to ensure that physician payment information is released only for efforts aimed at improving the quality of healthcare services and with appropriate safeguards.”

On the other hand, healthcare hacker Fred Trotter has raised concerns about CMS’ plan to evaluate requests for the data on a case-by-case basis. That isn’t much of a policy at all, he wrote, giving federal officials too much discretion about what to release.

So, how is this all going to shake out?

Three recent examples offer some clues.Continue reading…

A Little Advice for Karen DeSalvo

Jan 22, 2014• 13

By John Halamka, MD

Karen DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014. After my brief discussion with her last week, I can already tell she’s a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health.

She is a cheerleader for IT, not an informatics expert. She’ll rely on others to help with the IT details, and that’s appropriate.

What advice would I give her, given the current state of healthcare IT stakeholders?

1. Rethink the Certification Program – With a new National Coordinator, we have an opportunity to redesign certification. As I’ve written about previously some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world.

One of the most negative aspects of 2014 certification is the concept of “certification only”. No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature. An example is the “transmit” portion of the view/download/transmit patient/family engagement requirements.

There is not yet an ecosystem for patients to ‘transmit’ using CCDA and Direct, yet vendors are required to implement complex functionality that few will use. Another example is the use of QRDA I and QRDA III for quality reporting.

CMS cannot yet receive such files but EHRs must send them in order to be certified. The result of this certification burden is a delay in 2014 certified product availability.