Author Archives

John Irvine

The Rust Belt Is Burning: Republicans Lay Waste to their Base on Health Reform

Mar 8, 2017• 45

By JEFF GOLDSMITH

William Tecumseh Sherman, who laid waste to the South at the end of the Civil War, famously said, “War is Hell”. So, too, is health reform. And like Sherman’s infamous March to the Sea, where he burned town after Confederate town, the Republican War on Obamacare entered its attrition phase with the introduction on Monday in the House legislation to repeal and replace ObamaCare. Except that Ryan is marching in the wrong direction; his troops are marching “north” and burning towns behind their own lines.

Ryan’s bill released Monday was greeted with a chorus of derision from the newly empowered Republican base; some conservative wags dubbed the bill “RINOCare”. Thoughtful conservative analysts savaged it. Michael Cannon, the hard core libertarian Cato Institute health analyst, called it “a trainwreck waiting to happen” and suggested that “ it will create the potential for the sort of wave election Democrats experienced in 2008” In Reason.com, Peter Sunderman wrote, “it’s not clear what problems this particular bill would actually solve.”

Ryan’s draft neither repeals nor replaces ObamaCare. Continue reading…

The House Republicans’ Terrible, Horrible, No Good, Very Bad Obamacare Replacement Plan

Mar 7, 2017• 2

By ROBERT LASZEWSKI

It won’t work.

Obamacare works for the poorest that have affordable health insurance because all of the program’s subsidies tilt in their favor.

Obamacare doesn’t work well for the working and middle class who get much less support––particularly those who earn more than 400% of the federal poverty level, who constitute 40% of the population and don’t get any help.

Because so many don’t do well under the law, only about 40% of the subsidy eligible have signed up and, with so many insurers losing lots of money, the scheme is not financially sustainable because not enough healthy people are on the rolls to pay for the sick.

To fix it, House Republicans are proposing a very attractive program for the better off and, with the Medicaid rollback, gutting the program for the poor to be able to pay for it.

Hey, Machine Learning

Mar 6, 2017

By LEONARD D’AVOLIO

Hey Machine Learning,

I heard what Forbes said about your “setback” at MD Anderson. I also heard rumors going around HIMSS that maybe it’s “too soon” for you to be in healthcare. At first I thought, “serves you right.” There was so much hype that I could barely recognize you.

Then I realized that, in a way, we’re all to blame. The journalists, vendors, researchers, and data scientists – all of us that tried to make you popular in healthcare. I guess things just sort of got out of hand.

You have to believe me when I say we meant well. We wanted people to see how special you really are. And the whole “30+ years of clinical research and thousands of published studies” wasn’t working. Apparently, evidence is only cool with your research buddies.

So you got a makeover. The cool kids in marketing gave you new nicknames. People started rumors about all these crazy things you were up to. Suddenly, after years of being invisible Machine Learning was the talk of the town. Did you hear, Machine Learning is now going by Artificial Intelligence! Artificial Intelligence will cure cancer! I heard Big Data will replace doctors! Do you mean Machine Learning? I don’t know but I heard Cognitive Computing just created the latest fashion craze!

Really, it was all just too much for any one set of methods to live up to.

But that doesn’t change who you are and what you’re capable of. Yes, Queries and Dashboards are more popular. But you don’t get caught up constantly dwelling on the past like they do. And sure, Traditional Statistics have prestige. But we both know they can be a bit myopic at times. And Risk Scores…don’t even get me started on Risk Scores.

You are different. And that’s a good thing.

I personally have seen you consider millions of different data points – even free text notes – to spot falls in hospitals, prevent admissions of elderly patients, and route people with serious mental illness to appropriate care sooner. You don’t need to be a doctor. Because you can make doctors better at doctoring.

In (Gasp) Defense of the Coronary Stent

Mar 6, 2017• 25

By ANISH KOKA, MD

A kerfuffle ensued recently when an oncologist and expert on evidence based medicine took the field of cardiology to task over the evidence for placement of the ubiquitous coronary stent. What started with a lengthy article in Propublica that included coronary stenting for stable coronary disease as a prime example of a procedure done without evidence to back it up turned into this fiery twitter exchange between Drs. Kirtane (cardiology) and Prasad (oncology).

The crux of the debate revolves around placement of coronary stents in patients with stable coronary artery disease. Stable coronary artery disease refers to narrowing of the arteries by a build of plaque that has occurred slowly over time. Unstable coronary artery disease refers to eruptions that occur within the coronary vessel when a plaque ruptures, quickly leading a patent vessel to become completely occluded or nearly occluded. Unstable coronary artery disease, otherwise referred to as an acute coronary syndrome is regarded as an emergency that requires urgent intervention by skilled operators (interventional cardiologists) who must race against time to abort a process that if left unchecked may lead to death or severe damage of the heart muscle.

Figure 1. Stable angina/Acute Coronary syndromes

Stable coronary artery disease on the other hand is not considered an emergency, but can result in patients being symptomatic because of diminished blood flow through the culprit artery. Angina pectoris is the descriptor one uses to describe chest pain that relates to a mismatch between the blood flow the heart muscle needs and what it receives. It is almost always the case that angina in stable coronary disease is triggered by activities such as physical or emotional stress that require more blood flow than the narrowed artery can supply.

A Great Leap Forward (Or Backward) For the National Health IT Agenda?

Mar 5, 2017• 2

By JOHN HALAMKA, MD

At HIMSS, I listened carefully to payers, providers, patients, developers, and researchers. Below is a distillation of what I heard from thousands of stakeholders.

It is not partisan and does not criticize the work of any person in industry, government or academia. It reflects the lessons learned from the past 20 years of healthcare IT implementation and policymaking. Knowing where we are now and where we want to be, here are 10 guiding principles.

1. Stop designing health IT by regulation

Through its certification program, ONC directs the specific features, functionality, and design of electronic health records. As a result, technology developers devote the majority of their development resources to fulfilling government requirements instead of innovating to meet market and clinician demands. The certification program has established a culture of compliance in an industry ready for data-driven innovations. ONC’s role in the health IT industry made sense eight years ago when IT adoption in healthcare lagged considerably behind all other sectors, but today the certification program impedes a functioning market and must be reformed.

Imagine Ransomware, For Your Body

Mar 3, 2017• 2

By JOE FLOWER

Wired has an article up, “Medical Devices are the Next Security Nightmare.” It’s all about how vulnerable almost all of these implantable devices and hospital telemetry devices are, with old, unpatchable operating systems, open ports, all that.

Let’s just think about this. Imagine someone hacking your implanted defib or insulin pump.

Wait. No need. Imagine just getting an email telling that they have hacked into it. They have the keys to your body’s engine. And they want something in return for not turning it off.

“Give us your credit card and bank account information — all of it. Now. Or we will start screwing up your body, a little bit or a lot, whenever we feel like it, dumping all the insulin into the bloodstream at once. Or just giving you a heart attack. You have until 5pm EST.

Yep, Health Care Is Complicated

Mar 2, 2017• 4

By STEVE FINDLAY

Yes, Mr. President, health care is complicated.

So glad you now understand this. But, um, within 24 hours of acknowledging that complexity, you made a speech to Congress that backtracked.

Namely, you once again said ACA repeal and replace legislation would “expand choice, increase access, lower costs, and at the same time provide better healthcare” even as you referred to Republican ideas and proposals that would, in fact, not easily achieve any of those goals, according to independent analyses.

You also said: “The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we will do.”

An achievement devoutly to be wished—if by lowering health care prices and costs. If achieved by making insurance skimpier or through even higher deductibles and co-pays, not so good.Continue reading…

How to Blow Up the Health Insurance Market In One Easy Step

Mar 2, 2017• 19

By ROBERT LASZEWSKI

I call support for giving insurance companies the ability to sell insurance across state lines the cockroach proposal.

As bad as it is, you just can’t kill the damn thing!

Last night, President Trump once again listed this idea in his address to Congress as one of his health care talking points.

Any candidate that suggests such a scheme only shows how unsophisticated he and his advisers are when it comes to understanding how the insurance markets really work––or could work.

I gave a speech to 750 health insurance brokers and consultants in DC last week.

When selling health insurance across state lines, something Trump and a number of other Republican presidential candidates have been pushing, was mentioned the audience literally laughed. That’s what health insurance professionals who spend their days in the market think of it!

This is about as dumb an insurance “reform” idea as has ever been proposed.

This is nothing more than an attempt to take the market back to the days of cherry picking risk––figuring out how to sell policies to only the healthy people. If this were ever enacted it would only serve to shuffle the healthy people into one set of health insurance policies and the sick into another thereby driving down costs for the healthy and in return just driving costs up for the sick––and accomplishing nothing toward fundamentally making insurance cheaper.

Paying Doctors For Outcomes Makes Sense in Theory. So Why Doesn’t it Work in the Real World?

Mar 1, 2017• 18

By STEPHEN SOUMERAI and ROSS KOPPEL

For decades, the costs of health care in America have escalated without comparable improvements in quality. This is the central paradox of the American system, in which costs outstrip those everywhere else in the developed world, even though health outcomes are rarely better, and often worse.

In an effort to introduce more powerful incentives for improving care, recent federal and private policies have turned to a “pay-for-performance” model: Physicians get bonuses for meeting certain “quality of care standards.” These can range from demonstrating that they have done procedures that ought to be part of a thorough physical (taking blood pressure) to producing a positive health outcome (a performance target like lower cholesterol, for instance).

Economists argue that such financial incentives motivate physicians to improve their performance and increase their incomes. In theory, that should improve patient outcomes. But in practice, pay-for-performance simply doesn’t work. Even worse, the best evidence reveals that giving doctors extra cash to do what they are trained to do can backfire in ways that harm patients’ health.

Costs of A Hospital Monopoly in One Underserved County

Feb 28, 2017• 27

By NIRAN AL-AGBA, MD

There is a growing body of evidence that hospital mergers lead to higher prices for consumers, employers, insurance, and government. It is imperative to educate patients and lawmakers as to how the consolidation of hospitals and medical practices raise costs, decrease access, eliminate jobs, and ultimately reduce care quality as a result. Lawmakers should focus on this “first pillar” of cost control as they go back to the drawing board.

In 2010, there were 66 hospital mergers in this country. Since the Affordable Care Act went into effect the rate of hospital consolidation has increased by 70 percent. By creating incentives for physicians and health providers to coordinate under accountable care organizations (ACOs), the ACA hindered the ability of regulators to block hospital mergers while incentivizing hospital consolidation.