Author Archives

John Irvine

Trump Issues Obamacare Proposed Rule to “Increase Patients Health Insurance Choices For 2018”

Feb 15, 2017• 7

BY THE EDITORS

CMS this morning released the following statement:

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.

“Americans participating in the individual health insurance markets deserve as many health insurance options as possible,” said Dr. Patrick Conway, Acting Administrator of the Centers for Medicare & Medicaid Services. “This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.”

The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:

Open Enrollment Period: The rule proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017. This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.
Special Enrollment Period Pre-Enrollment Verification: The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
Guaranteed Availability: The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.
Determining the Level of Coverage: The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.

Teaching Health Delivery Science in the Digital Age

Feb 14, 2017• 3

By BRENNAN SPIEGEL, MD

Our health system is facing an existential crisis. We’re not alone. As the largest hospital in the western United States and a member of the 2016-17 U.S. News & World Report Best Hospitals Honor Roll, Cedars-Sinai Medical Center is known for its exceptional quality of care… but also for its high cost of care. In an era of value-based healthcare financing and full-risk contracts, it is an existential challenge for health systems like Cedars-Sinai to bend the cost curve while maintaining or improving patient outcomes, satisfaction, and safety. If we can’t bring down costs, then insurance companies may take their business elsewhere.

To meet the challenge, healthcare systems like ours must become facile with managing and interpreting big data; learn how to implement health information technology in clinical practice; perform continuous self-assessments to ensure high-quality, safe and effective care; measure and address patient preferences and values; master the principles of digital health science; and, ultimately, ensure all these activities are cost-effective. This is exceedingly hard to do, but there is a science for doing it all. It’s called health delivery science.

We recently launched a new Master’s Degree program in Health Delivery Science (MHDS) at Cedars-Sinai, the first of its kind in the nation. Having struggled with the challenges of adapting to the requirements of value-based healthcare, we’ve learned enough lessons to fill not only a textbook, but an entire curriculum. So, we decided to develop a comprehensive degree program to teach others about our own successes and failures. We hope that other organizations can benefit from our blueprint. This article outlines our new curriculum as a framework for how to define and teach health delivery science in the digital age.

Travel Ban Is Revealing—but Does Not Threaten American Medicine

Feb 13, 2017• 38

BY JANE ORIENT, MD

A 90-day ban on travel from seven countries has sparked tremendous outpourings of worry or outright opposition by some 33 medical organizations.

“The community is reeling over the order, fearing that it will have devastating repercussions for research and advances in science and medicine,” states an article in Modern Healthcare.

Certainly the order is disrupting the lives of individual physicians who have won coveted positions in American medical institutions and were not already in the U.S. when the order was issued. Also their employers have a gap in the work schedule to fill. War tears people’s lives apart, however innocent they may be. And countries that sponsor terrorism have effectively declared war on the U.S.

But is American medicine so fragile that it can’t survive a 90-day delay in the arrival of physicians, most of them trainees, from Iran, Iraq, Libya, Syria, Yemen, Somalia, and Sudan? After all, every year more than a thousand seniors in U.S. medical schools do not land a position in a post-graduate training program through the annual computerized “Match” of graduates with internships.

Say You’re Sorry, Donald

Feb 13, 2017• 15

By GEOFFREY RUBIN, MD

I’ve never met Dr. Suha Abushamma or Dr. Kamal Fadlalla.

But of all the frustrating stories circulating since President Trump issued an executive order barring immigrants from several predominantly Muslim countries, their travails hit closest to home.

Both Suha and Kamal are internal medicine resident physicians. From Cleveland Clinic and Brooklyn Interfaith Medical Center, respectively. Like me, they have endured the rigorous calling that is American medical training, including not only graduation from medical school, but also the completion of four board exams, a vigorous interview process, acceptance to a medical residency and ultimately working long hours caring for very sick patients.

Should We Blame Technology For the Growth In Healthcare Spending?

Feb 13, 2017• 8

By MICHEL ACCAD, MD

Should we blame technology for the growth in healthcare spending? Austin Frakt, a healthcare economist who writes for the New York Times, thinks so. Citing several studies conducted over the last several years, he claims that technology could account for up to two-thirds of per capita healthcare spending growth.

In this piece, Frakt contrasts the contribution of technology to that of the ageing of the population. Frakt notes that age per se is a poor marker of costs associated with healthcare utilization. What’s important is the amount of money spent near death. If you’re 80 years old and healthy, your usage of healthcare services won’t be much more than that of a 40-year-old person.

An Open Letter to Kaiser Permanente Northern California

Feb 13, 2017• 4

By RACHEL KATZ

I am writing this letter because for two months I tried to get ahold of Darryn Carter, a case manager at your company who was assigned to process a complaint I filed about care I received that I feel was harmful and irresponsible.

The legal and rational reason for this current writing is this: the letter I received from Darryn Carter rejecting my complaint claim stated that I have a legal right to see the documentation and evidence used to make the decision about my case. I would like to see that evidence file, and I have not been able to get in touch with Mr./ Ms. Carter or anyone else at Kaiser to send the file.

The emotional and human reason I want to talk with Darryn Carter–and I think it’s appropriate to share this reason too, given that you are a care provider–is that I believe I received bad care at Kaiser, and yet no one at Kaiser has ever listened to what I have to say about it, despite months of my trying to tell someone. My concern and frustration, which is so strong that it drove me to spend a Saturday writing this letter, is not primarily about the bad care I believe I received but rather the wholehearted dismissal that your organization has levied through an unnavigable bureaucracy. This dismissal has kept me up nights, sometimes crying, sometimes fuming, sometimes brooding, always feeling that special type of indignity reserved for a patient with a care provider who blatantly and systematically refuses to care.

ACA Enrollment Final Numbers for 2017—A Cautionary Tale for Trump and Republicans

Feb 12, 2017• 4

By STEVEN FINDLAY

Graphic Credit: AP

For the record and as we crawl chaotically towards repeal & replace or repair, the final numbers on ACA enrollment for 2017 are in. They reflect coverage in the 39 states that operate through healthcare.gov plus the 11 states and DC that run their own insurance exchanges.

A total 12.2 million people signed up. That’s 3% to 4% fewer than last year. HHS and the Associated Press (AP) put enrollment through healthcare.gov at 9.2 million; AP puts the number of enrollees in the 11 states plus DC at 3 million.

Of the 9.2 million who signed up through healthcare.gov, 6.2 million were returning customers and 3 million were new.

According to an analysis by Charles Gaba, who runs the website acasignups.net, enrollment through healthcare.gov was down about 5% while enrollment in the 11 states and DC was up 2%.

Gaba and other analysts attribute the healthcare.gov decline to consumer confusion about the fate of the ACA and the Trump administration’s pull back on consumer outreach and ads in the final weeks of sign-up in January. So the last minute rush this year was much reduced.

Gaming the System

Feb 11, 2017• 30

By NIRAN Al-AGBA, MD

As physicians ready themselves for the future of medicine under onerous MACRA regulations, it seems appropriate to glance into the future and visualize the medical utopia anticipated by so many. Value-based care, determined by statistical analysis, is going to replace fee for service.

Six months ago, I received my first set of statistics from a state Medicaid plan and was told my ER utilization numbers were on the higher end compared to most practices in the region. This was perplexing as my patients tend to avoid ER visits at all costs and can be found milling about in my parking lot at 7am on Mondays with their sick children waiting for my office to open.

A Purpose-Driven App Tests Work-Life Balance

Feb 9, 2017• 2

By MICHAEL MILLENSON

Your employer sends out an email saying they want to make sure you’re getting enough sleep and physical activity, are eating well and feeling creative and, finally, have a sense of “mindfulness.” So they’re providing a free app designed to facilitate finding your “anchoring purpose in life.”

Sound like a nice perk? Now add in one more detail.

All the information, albeit with individual data de-identified, goes into a giant database meant to boost productivity and reduce medical costs by improving worker physical and mental health.

Any less excited?

The app, from a start-up called JOOL Health, raises the question of when good engagement can bleed into overtones of Big Brother. The answer is complicated.

JOOL is the brainchild of Victor Strecher, a professor of health behavior and health education at the University of Michigan School of Public Health and a successful entrepreneur. Marketed to third parties rather than direct-to-consumer, the app was pitched at a recent consumer experience conference sponsored by America’s Health Insurance Plans (AHIP) as a way to go “from wellness to engaged wellbeing in the Digital Age.”

Don’t Believe the Media Narrative. Repeal + Replace Is On Track For 2017

Feb 9, 2017• 1

By ROBERT LASZEWSKI

Many recent press reports have centered around the notion that Republicans are stuck in the mud trying to get their repeal and replace promises moving.

That line appeared to be reinforced over the weekend when President Trump said, in a pre-Super Bowl interview, that the process could draw out into next year. My sense is that what Trump was talking about was the fact that the whole process, that includes implementing the replacement, could take well past 2017. Trump, never one for getting the details right, was taken literally by the press looking to write stories about how the whole process was foundering.

Speaker Paul Ryan quickly countered in his press briefing that Republicans will legislate a repeal and replace of Obamacare this year.