THCB

Categories

Month: September 2018

Essential Health Benefits: Balancing Costs, Coverage, And Necessity

By KAVITA PATEL, MD

The much anticipated Institute of Medicine Report on essential health benefits (EHB) was released last week with a series of recommendations that answered some questions and raised many more. The report offers a very important opportunity for researchers, policymakers, providers and patients to fill in some of the white space between the recommendations.

Background on EHB in the Affordable Care Act and some Legislative History

The Affordable Care Act (ACA) tasked the IOM to make recommendations on the methods for determining and updating the essential health benefits that must be offered by qualified health plans seeking to participate in exchanges as defined in section 1301 of the statute. The ACA identified ten categories of items and services that must be included in a package of benefits:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

The Affordable Care Act did not have a conference committee report, which is the product of the House and Senate working to resolve differences between the two chambers’ versions and also helps to highlight legislative intent. So the long history of the decisions behind the language and legislative intent is not as apparent.  Briefly, Congress looked at many design models and previous bills, such as HR 3600 — one of the health reform bills put forward during the Clinton administration — which contained 61 pages of details on benefits. This approach was was felt to be too detailed and prescriptive.  Staff from Senator Kennedy’s Health, Education, Labor and Pensions Committtee used the Massachusetts language on exchange benefits and its promulgated regulations and then made important additions such as habilitative services (educational or long term services, often associated with long terms disabilities or conditions such as autism).

Continue reading…

Obamacare HHS rule would give government everybody’s health records

By Rep. Tim Huelskamp

It’s been said a thousand times: Congress had to pass President Obama’s  health care law in order to find out what’s in it. But, despite the repetitiveness, the level of shock from each new discovery never seems to recede.

This time, America is learning about the federal government’s plan to collect and aggregate confidential patient records for every one of us.

In a proposed rule from Secretary Kathleen Sebelius and the Department of Health and Human Services (HHS), the federal government is demanding insurance companies submit detailed health care information about their patients.

(See Proposed Rule:  Patient Protection and Affordable Care Act; Standards Related to Reinsurance, Risk Corridors and Risk Adjustment, Volume 76, page 41930. Proposed rule docket ID is HHS-OS-2011-0022 http://www.gpo.gov/fdsys/pkg/FR-2011-07-15/pdf/2011-17609.pdf)

The HHS has proposed the federal government pursue one of three paths to obtain this sensitive information: A “centralized approach” wherein insurers’ data go directly to Washington; an “intermediate state-level approach” in which insurers give the information to the 50 states; or a “distributed approach” in which health insurance companies crunch the numbers according to federal bureaucrat edict.

Continue reading…

Suit Says Test Labs Cheat Medicare, Medicaid

By MERRILL GOOZNER

Despite recent court settlements that recouped more than a quarter billion dollars from lab-test companies for allegedly overbilling California’s Medicaid program, the federal government seems to be ignoring similar schemes that drain Medicare coffers.

The cases involve the nation’s two largest medical laboratory-testing companies – Laboratory Corporation of America and Quest Diagnostics – that together control about half the annual $25 billion lab test market. The Medicare suits, filed in federal court in Manhattan by a former industry executive, claim the testing companies charged insurers like UnitedHealthcare unprofitably low rates while squeezing Medicare and Medicaid.

The whistleblower suits allege the schemes relied on sweetheart deals in which managed-care companies required in-network physicians to send their patients’ lab tests to a single testing company. As part of the deal for below-cost prices, the insurance companies allegedly promised to encourage physicians in their networks also to send Medicare and Medicaid patients to the same testing company, which then billed the Centers for Medicare and Medicaid Services (the federal agency that oversees both programs) or state Medicaid agencies at significantly higher rates.

Continue reading…

Do Computers Really Come Between Doctors and Patients?

Davis Liu, MD

One of my favorite movies is Back to the Future starring Michael J. Fox.  I must admit after reading this New York Times piece, titled “When Computers Come Between Doctors and Patients” I have to wonder.

Am I fortunate to be coming from the future?  Because I completely disagree with Dr. Danielle Ofri, again.

I’ve had the privilege and opportunity to work in a medical group which has deployed the world’s largest civilian electronic medical record and have been using it since the spring of 2006.  I don’t see the issue quite as much as Dr. Ofri did.  It is possible that she examined patients in her office with a desk rather than an examination room.

If placed and mounted correctly in the exam room, the computer actually is an asset and can improve the doctor patient relationship. It is part of the office visit. The flat screen monitor can be rotated to begin a meaningful dialogue between the patient and I. We review the lab work together as well as the trends. Look at xrays. Who needs anatomy flip charts when I can Google any image instantly? Patient friendly information to reinforce our discussion is a click away.

Continue reading…

Leaders Of Science-Driven Businesses Should Understand … Science

By David Shaywitz, MD

Even as a med student, I was struck by the discrepancy between how much the junior doctors (particularly the interns and second-year residents) seemed to know, and how much the more experienced doctors knew: with few exceptions, the junior doctors seemed to know a lot more.  Or at least, they would always have a definitive answer at their fingertips.  Such was their apparent understanding of human pathophysiology that they were usually able to offer plausible, immediate explanations of anything, make a rapid assessment, and move on.

In contrast, the expert physicians – the doctors who had spent decades of their lives treating particular types of patients, and studying a specific disease – tended to be far less definitive, and much more likely to say, “to tell you the truth, we really don’t know.”  If a patient responded in a certain way to a new treatment, the experienced doctor is more likely to say “well, that happens sometimes,” while the second-year resident would more likely say, “of course we expect that, it’s because …”

I did most of my clinical training after completing my PhD, which focused on the relationship between several proteins involved in intracellular transport, and I was struck by how difficult it was to define with precision how a handful of proteins interacted, even when I was able to study these proteins essentially in isolation in a test-tube – an extremely reduced system.  It was a struggle to say with certainty exactly what was going on (though the results – here, for instance – seem durable, at least to this point).

Continue reading…

Pay-for-Performance Attacks Hospitals

By Michael Kirsch, MD


This blog has tried to support the virtue of personal responsibility. If you smoke, don’t blame Joe Camel. If you surrender to Big Mac attacks, don’t go after Ronald McDonald. If you love donuts, and your girth is steadily expanding, is it really Krispy Kreme’s fault? And, if you suffer an adverse medical outcome, then…

Medicare aims to zoom in on hospitals, suffocating them with a variation of the absurd pay-for-performance charade that will soon torture practicing physicians. Of course, a little torture is okay, as our government contends, but pay-for-performance won’t increase medical quality, at least as it currently exists. It can be defended as a job creator as several new layers in the medical bureaucracy will be needed to collect and track medical data of questionable value.

Medical quality simply cannot be easily and reliably measured as one can do with a diamond, an athlete or a wine. Most professions resist being graded or claim that the grading scheme is a scheme. Teachers, for example, refute that testing kids is a fair means to measure their teaching performance. Conversely, any individual or profession who scores well on any quality review program will applaud the system’s worth and fairness. Shocking.

Continue reading…

How Much Does it Cost to Have a Baby?

By Kenny Lin, MD

When my wife delivered our second child in 2008, the hospital sent our health insurance company a bill for $8569. The insurance company then wrote off $4117 of that bill, paid $4352, asked us for a copayment of $100. When we found out last year that we were expecting again, we noted that my wife’s new insurance plan requires us to pay 20% coinsurance for all non-preventive care. That would have amounted to several hundred dollars of our 2008 bill, and knowing the rapid rate of health care inflation, we thought it would be good to find out how much it would cost this time around. So we went back to the same hospital, where we expect our third child to be born in a few weeks, and asked if they could give us an estimate of the charges. It seemed like a reasonable enough request, especially since the pre-admission consent form we signed specifically said that patients had a right to know what the hospital charged for its services.

We’re just looking for a ballpark number for our flexible savings account, we said. The charge for an uneventful labor, vaginal delivery and single overnight stay. We understand that unexpected things can happen in childbirth, and we won’t hold you to it.

Continue reading…

Cost Awareness in Health Care: An Idea Whose Time Has Come

By Christopher Moriates, MD

It didn’t take that long during intern year to realize that something was wrong. As I signed so many orders that my signature, once proudly readable, began its gradual but clear progression towards more abstraction, I eventually started to wonder just how much all of these tests were actually costing my patients. After all, once you start checking boxes on an order sheet, the “calcium/phos/mag” just seems to roll off of the tongue. However, not just how much was this “costing” patients financially, but also in potential risks, harms and adverse effects.

I particularly remember being bothered when told by an Emergency Room attending physician that I had to get the Head CT on my 28-year-old male patient presenting with a benign-sounding headache and a normal physical examination, “unless you could go in there and tell him that you personally can guarantee him with 100% certainty that he does not have something bad like a brain tumor.” This did not seem like a fair bar to hop, particularly having put the M.D. after my name a mere few months prior. So I scribbled my name on another form and with the whisk of my pen subjected this patient to a normal CT head examination, saddling this young man with a significant amount of radiation and a hospital bill that now included an approximately $2,500 imaging charge. Nobody seemed to flinch, but it got me thinking.

Continue reading…

The Czar of Ebola

By JOHN IRVINE

Screen Shot 2014-10-18 at 7.54.38 AM

As every American now knows, Ebola is a horrible African hemorrhagic fever with a high mortality rate and relatively low risk of transmission, except in cases where the disease is transmitted, where the risk of transmission is very high.

The disease has infected 8,000 people in West Africa. WHO officials predict that up to 1.5 million people could be infected by the end of January 2015.

In the United States Two people are known to have been infected with the disease.  Both are nurses.  Their names are Nina Pham an Amber Joy Vinson.

We now have an Ebola Czar to educate us about these facts and others as they become available.

Facing criticism from Congress this week over the handling of the crisis, President Obama named Ron Klain, a former chief of staff for vice president Joe Biden and Washington loyalist.  Critics wanted either somebody with a medical backround or experience handling infectious diseases. Until yesterday, Klain worked for Steve Case.

Technically, of course Klain is not a czar, although almost everybody will call him by that title. His technical title is Federal Ebola Response Coordinator.

“He is smart, aggressive, and levelheaded; exactly the qualities we need in a czar to steer our response to Ebola,” said Sen. Charles Schumer (D., N.Y.).

“By appointing a Democrat political operative as the Ebola czar, it is clear that the president sees Ebola as a political crisis and not a health crisis,” said one critic, Rep. Bill Cassidy (R., La.).

Continue reading…