Author Archives

John Irvine

How Insane Could This Get?

Jul 25, 2017• 13

STEVEN FINDLAY

At long last, the Senate is poised to begin voting today on a measure to repeal and/or alter portions of the Affordable Care Act.

Much remains in flux regarding process and the substance of what will be voted on. According to multiple media sources today, Senate leaders latest strategy is to hold a vote on a narrower piece of legislation than those circulated in recent weeks.

The substance of such a measure—if indeed, it exists and is submitted for a vote—is unclear as of this posting. But it reportedly could contain just a repeal of the ACA’s individual and employer mandates and a few of the law’s taxes, such as the one on medical device companies.

This narrow, or “skinny,” bill would not have any provisions pertaining to Medicaid.

The idea, apparently, is to pass this initial piece of the puzzle—to get things going—and then to take up the larger and more controversial issues that have so deeply divided the Republican caucus.Continue reading…

ONC Interoperability Meeting Raises More Questions Than Answers

Jul 25, 2017• 2

By ADRIAN GROPPER, MD

ONC’s first public event under the new administration was very well organized and run. Eight leading health information exchange incumbents were able to describe their current approaches and plans, the patient advocate position was clearly stated, and a nice synthesis of the issues raised by the trusted framework approach to interoperability was prepared by a consulting organization. Much to ONC’s credit, they went out of their way to provide access and public comment to an extent that is unprecedented in my experience. Slides and recordings will be posted soon and a 30-day comment period runs through August 24. Kudos to ONC.

The proceedings raised a lot more questions than answers and, from my perspective, call into question the whole approach to interoperability that we’ve inherited from the HITECH-era ONC.

Algorithmic (and coercive) patient identity matching has no solution in sight
Interoperability between HIPAA and non-HIPAA entities has no solution in sight
Different frameworks with different governance principles can only interoperate at a lowest common denominator, frustrating both clinicians and families
Identity proofing of patients confuses pretty much everyone
All agree that accountability is important but nobody proposed how patients can hold anyone accountable for anything
Incumbent systems are built around clunky document exchange instead of modern APIs and API Task Force principles
There is no consensus on who will pay the rent the health data brokers are seeking
Patient access is an afterthought for most of the data brokers and no solution seems to be in sight
The 21st Century Cures goal of a Longitudinal Health Record was not mentioned by anyone at all

By contrast, in the patient perspective presentation by Cynthia Fisher, we heard a call to turn the interoperability problem on it’s head: to start with the patient and caregiver not the provider and EHR vendor. “We paid for it already…we own it and should have it”, she said.

Health + Design, Refactored

Jul 25, 2017• 1

By ANDY ORAM

Health care providers love to vaunt the unique and subtle needs of patients. How many ads have you heard from cancer centers or health clinics touting their flexibility and showing grateful, tear-flecked patients?

But key aspects of our health care systems turn out to be rigid and heartless in practice. Despite the compassion of individual staff, our organizations tell patients in dozens of ways that they are widgets on an assembly line:

We force patients to come early for every appointment and fill out the same paperwork each time with information they have given before.
Patients traverse long, crowded corridors from one station to another, asking at each station for information they don’t get and never knowing how long each stop will take or how many more stations remain on their Kafkaesque journey.
Patients rush to undergo batteries of mysterious tests, sometimes repeatedly, only to wait long periods to hear the results.
We refer them to specialists who, it turns out, can’t see them, or who issue contradictory opinions without coordination.
After frustrating and unsuccessful attempts to learn the costs of procedures in advance, they receive cascades of arcane bills and watch their funds bleed out to charges that bear little relation to their experience in the clinic or hospital.

More fundamentally, our field has stuck to a cycle of diagnosis and treatment that leads to people suffering through death in a welter of tubes and IVs, while 28% of all Medicare costs are incurred in the last six months of life. Pharmacologist Jay Gupta claims that nearly 50% of all seniors in the US take a medication that is not clinically necessary. This is expensive, debases their health, and leads to greater risks of adverse reactions.

I Finally Understand US Health Policy

Jul 20, 2017• 11

By UWE REINHARDT

The following exchange occurred during an interview of President Trump with journalists of the NYT:

HABERMAN: That’s been the thing for four years. When you win an entitlement, you can’t take it back.

TRUMP: But what it does, Maggie, it means it gets tougher and tougher. As they get something, it gets tougher. Because politically, you can’t give it away. So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, “I want my insurance.” It’s a very tough deal, but it is something that we’re doing a good job of.

Watching Trumpcare Die

Jul 20, 2017• 6

By KIP SULLIVAN

It’s hard to know what “Trumpcare” is, but whether it’s “repeal” or “repeal and replace with something terrific,” it was and is going to fail. It was either going to fail to be enacted by Congress, or if it was enacted, it was going to set off such a bipartisan backlash it would be repealed, either by a chastened Republican Congress or a new Democratic Congress and president.

The reason Trumpcare was doomed was that health care is not like global warming or police shootings or use of military force in foreign countries: It is an issue a large majority of Americans agree on, and it is an issue voters can assess with their own eyes in their own kitchens.

Republican voters are almost identical to Democratic voters in what they want in a health care system. They want comprehensive coverage, low out-of- pocket costs and affordable premiums, freedom to choose their own doctors (they could care less about freedom to choose between Aetna and Humana), and freedom from interference by bureaucrats (be they public or private). Obamacare became a liability for Democrats because the public clearly perceived that the ACA could not meet those requirement for millions of Americans. The public now clearly perceives Republicans want to enact legislation that would be even worse than the ACA.

Is Trumpcare Dead?
Was It Ever Really Alive?

Jul 18, 2017• 32

By JOHN IRVINE

Senators Mike Lee and Jerry Moran said yesterday that they would not vote for the Better Care Reconciliation Act, effectively killing the legislation. As anybody who has been following this story would have predicted, President Trump reacted publicly on Twitter on Tuesday morning, vowing to let the ACA marketplace collapse and then rewrite the plan later.

Senate Majority leader Mitch McConnell attempted a quick punt this morning, calling for an immediate Senate vote on the House bill, a trick card that if it worked, would give Republicans two years to work things out.

Unfortunately for McConnell, it probably won’t.

The White House sees the failure as saying more about the political establishment in Washington than itself, which shouldn’t be all that surprising. Caught up in the drama of the Watergate-Russia emails-Trump family narrative, major media outlets like the Washington Post and the New York Times see a historic defeat rather than a temporary setback. That may or may not turn out to be true. Predictably, conservative commentators and the alt-right believe the defeat says more about the mainstream media and the Deep State than it does about the Trump Presidency. For their part, Democrats clearly think they have found their issue and can be expected to continue to exploit it using legislative Viet Cong tactics (attack on social media, melt into the jungle, lob snarky public Molotov cocktails) to punish Republicans and keep the story on the front page.

One thing is clear. Instead of repealing and replacing Obamacare, the GOP now has to rewrite and replace its own plan. Doing that would be difficult under the best of circumstances, but in the current climate in Washington it is difficult to see how it would be possible without a major shift in the political landscape.

All of this is bad news for hospitals and health plans and a frightening development for consumers, although not the really bad news some had feared. The President’s threat to let the insurance marketplace die and then “figure it out” sounds good as a rallying cry to the troops on social media, but is not the kind of thing that investors and CEOs like to hear. Realistically though, at this point everybody knew that the uncertainty would likely continue through the year (best case) or a year or longer (worst case) as the gridlock in Washington plays out. As depressing and frustrating as it is that the uncertainty will continue, by this point the industry is used to it. Insiders will continue to look for ways to minimize risk and for business opportunities to capitalize on the uncertainty.

Trump’s plan to allow the insurance exchanges to collapse is the kind of confrontational talk Trump and his advisors relish. In theory, the idea could work. There are in fact signs that it already is, as major insurers leave the marketplace and consumers hesitate before committing to expensive insurance policies. In reality, however, the collapsing exchanges will create a political crisis that is even worse than the current one for the administration, with news cycle after news cycle dominated by stories of terminally ill cancer patients and parents with children with horrible diseases and no insurance coverage. At this point, it will be difficult for the party doing the collapsing to point at the other side and say “It was them. They did it!”

Regulatory Capture Tests the New Administration

Jul 17, 2017• 3

By ADRIAN GROPPER, MD

The bipartisan 21st Century Cures Act charges HHS / ONC to deal with two issues that previous laws (HIPAA and HITECH) and the Obama HHS left in-progress: information blocking and longitudinal health records. ONC needs to deal with these two issues at a time when there are calls to delay or rescind some Meaningful Use regulations, in an administration that does not favor regulations, with some vendors already starting to ship Meaningful Use Stage 3 EHR products, and while the budget for ONC is still undetermined. ONC can’t be too careful.

Judging by the agenda, the July 24 21st Century Cures Act Trusted Exchange and Common Agreement (TFCA) Kick-Off Meeting is a step in the wrong direction. Listening to the “health IT stakeholders” is a prescription for advancing the interests of the health IT stakeholders instead of dealing with patients and physicians as the stakeholders. Framing the issue as “National Trust Frameworks and Network-to-Network Connectivity” is a recipe for continued ineffective interoperability as the “stakeholders” line up for another round of regulations that promote rent-seeking middlemen with catchy names like Direct Trust, and CommonWell.

The Most Important Questions About the GOP’s Health Plan Go Beyond Insurance and Deficits

Jul 13, 2017• 5

By ROSS KOPPEL and JASMINE MARTINEZ

Ending healthcare for those who need it will not make them or their problems disappear. On the contrary, the GOP plan will shatter American families and the economy. Nothing magical happens if we stop caring for the elderly, the ones who need vaccinations, the small infections that can be treated for $2 worth of antibiotics, the uncontrolled diabetics, and those with contagious diseases who clean our schools’ offices and homes. They don’t just get healthy.

As George Orwell said in Down and Out in Paris and London, “the more one pays for food, the more sweat and spittle one is obliged to eat with it.” Cutting care only exacerbates illnesses, infection, disability, the effects of age and the costs to society. The burdens continue or increase but the cost is shifted to American families, businesses, and states.

Fifteen years ago, one of the authors showed that lost productivity from workers caring for Alzheimer’s patients cost US businesses over $60 billion a year. Employee-caregivers, usually at the peak of their responsibilities and corporate experience, quit, prematurely retired, were constantly distracted, or engaged in presentism (e.g., at work but focused on mom burning down the house). Business cost were incurred by the need to replace workers, extra training of replacement workers, and increased pressure on other workers to cover for caregivers. The more expensive the employee, the longer and more costly the search and the longer the time to get them up to speed. But that study examined just a miniscule number of patients and workers compared to the tens of millions of people affected by the proposed GOP bill. As noted, it’s not only those needing care, but our society and our families that must deal with the elderly, ill, disabled, under and uninsured, children not receiving even ordinary care, people not being screened for preventable illness, and countless others.Continue reading…

The Entertainment Presidency: A Primer For Health Care Professionals

Jul 11, 2017• 4

By RICHARD GUNDERMAN, MD and BENJAMIN GRAY, MD

Many physicians have expressed dismay at the conduct of US president Donald Trump. But whether colleagues find his politics objectionable or congenial, his conduct bold or vulgar, and the man himself an imbecile or a genius, it is important for healthcare professionals to understand that the Trump presidency is a predictable consequence of our times. In particular, it is an entirely natural outgrowth of the forms of media that characterize our age.

The Medium Becomes the Message

In 1964, media theorist Marshall McLuhan famously declared the medium the message. McLuhan argued that the consciousness of a people is more profoundly shaped by media themselves – for example, Gutenberg’s movable print, radio, or television – than by the content they convey. To understand the character of a presidency, McLuhan would argue, we need to shift our attention from specific policies to the media by which the president operates.

When candidates Abraham Lincoln and Stephen Douglas engaged in their famous 1858 debates for an Illinois Senate seat, broadcast media had not yet been invented, and the newspaper dominated. As print media, newspaper articles could examine a candidate’s position on an issue in great depth, and 19^th century debate audiences expected candidates to develop real arguments for their policies. As a result, each of the Lincoln-Douglas debates was formatted to last three hours.

Today’s media prefer sound bites. In fact, McLuhan argued that the medium of television operates “at the speed of light.” It permits “no continuity” and “no connection.” Instead, he said, with television, “It’s all just a surprise.” In contrast to the time Lincoln took to carefully craft his arguments, a television president might be expected to rely less on argument than on astonishment, not taking the time to trouble himself over non-sequiturs and contradictions.

Shopping For a Health Insurance Plan Again. Seriously?

Jul 10, 2017

By PAUL KECKLEY

On the golf course, my son Jason has an uncanny ability to hit any tree within earshot of his intended target line. It’s fait accompli in his book. And his reaction is always the same: “seriously!”

The same is his plight with health insurance. Though a self-employed healthy single male with a successful career and no need for government assistance in buying coverage, he just got this letter from his insurer:

“The last seven years within the health insurance market have led all of us to decisions we have never before considered. It has remained a very challenging environment as the debate over the 2010 Affordable Care Act (ACA) continues today.

At TRH Health Insurance Company, we have arrived at another critical decision point, which, unfortunately, will affect you. This letter (and the enclosed notification letter as required by the ACA) is our notice that we will not be offering plans in the non-subsidized marketplace in 2018. Your current plan remains effective through December 31, 2017.”

It’s the third time in five years he’s been dropped. Though paying his premiums dutifully and shrinking his coverage to reduce his monthly cost, his premium has increased more than 10% every year. And he’s healthy.

As the GOP Senate leadership weighs its options in moving toward a Repeal of the Affordable Care Act and its replacement, their greatest political risk is the potential that up to 22 million will lose their insurance coverage per the Congressional Budget Office’ most recent score. They have bet their political calculus on stories like Jason’s, one of 18 million in the individual insurance market whose premiums have skyrocketed. More than 8 million of these get a subsidy to buy their policy because their incomes fall below 400% of the federal poverty level. Those subsidies are likely to go away. For the rest, like Jason, it’s a crap shoot. Individual insurance plans that feature less coverage, narrow networks, high premiums, high out of pocket costs and the high likelihood the underwriter will cancel the policy the next year is standard fare. Or, they just choose to go without.