Author Archives

John Irvine

Don’t Let Zika Stop the Olympics

Jul 10, 2016• 4

By ASHISH JHA, MD

Ashish Jha An expert panel convened by the World Health Organization just declared that there is no scientific basis for canceling, postponing or moving the 28th Summer Olympics in Rio de Janeiro in August or the Paralympics in September because of the Zika outbreak. While many of us experts have expressed concerns about how the WHO handled Ebola and other outbreaks, this time the WHO got it right.

There are ample reasons for alarm: The Zika virus continues to spread in Brazil. Zika infection during pregnancy can have devastating effects on developing fetuses, leading to severe brain damage. The risk is so substantial that the WHO has called the Zika outbreak and its effects on pregnant women a public health emergency of international concern. The Centers for Disease Control and Prevention advises pregnant women to avoid traveling to Zika-affected areas if possible.

No wonder, then, that more than 200 medical ethicists and other experts penned an open letter to the WHO, calling for the Olympics to be moved or delayed. They contend that approximately 500,000 people flying into Rio to participate in or watch the Olympic Games would accelerate the spread of the disease as these individuals returned home, leading to a worldwide Zika outbreak.

These arguments seem compelling on the surface, but they don’t stand up to scrutiny.

First, several new studies estimate an exceedingly low risk of travelers getting Zika. One study suggests that there may be as few as 15 new cases as a result of the Games. And because most people infected with Zika suffer only mild symptoms (the real risk is to pregnant women and their babies), these few infections are unlikely to pose a substantial health threat. August and September are cool months in Brazil, when mosquitoes are far less active. Coupled with efforts to keep mosquitoes under control around Olympic venues, that should mean relatively few new infections.

Focusing on Primary Care for Better Health

Jul 7, 2016• 20

By ANDY SLAVITT

Screen Shot 2016-07-07 at 2.30.28 PM In the United States, we have historically invested far more in treating sickness than we do in maintaining health. The result of this imbalance is not only poorer health, but more money spent in institutions, hospitals, and nursing homes.

The road to a better health care system means correcting this imbalance. We should reinvest in what we value — primary care — as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and team of doctors and clinicians overseeing and coordinating their care.

Changing Prices: Trends overall, and in Texas, from year to year

Jul 7, 2016• 12

By JEANNE PINDER

Summary: Watching cash prices in health care, as we have for the past five years, we have noticed a few trends. Here’s one: cash prices vary across a fairly narrow band, in most cases, for most things. Another: More and more providers are quickly able to quote cash prices than were able to do so when we started doing this in 2011. Yet another thing: Prices charged by providers to insurers and others can vary a lot, and prices paid by insurers to providers can also vary a lot. And finally: the intermediation of the insurance system (a third-party payer) can really affect what you’re charged and what you’ll pay.

Some of our observations come from a recent exercise: updating some of our Texas data. We update annually, though sometimes it slips to 1.5 years.

In truth, quite often the prices do not change all that much. Unless they do.

Do insured prices change more than cash ones?

When the prices do change, it’s sometimes the result of the current wave of mergers and acquisitions in health care.

Here’s one story about that and a passage from The New York Times:

“Imagine you’re a Medicare patient, and you go to your doctor for an ultrasound of your heart one month. Medicare pays your doctor’s office $189, and you pay about 20 percent of that bill as a co-payment. Then, the next month, your doctor’s practice has been bought by the local hospital. You go to the same building and get the same test from the same doctor, but suddenly the price has shot up to $453, as has your share of the bill.”

Here’s a clip from a Stat News (Boston Globe) story about that: “The cost of visiting the doctor is climbing as hospitals scoop up a growing number of physicians’ groups, according to a Harvard Medical School study.”

Here’s an Association of Health Care Journalists overview: WSB-Atlanta recently explored what happens when hospitals buy physician practices, which has been happening all over the Atlanta area. Prices for patients go up. The same physicians – in the same offices, with the same treatments – start charging more.”

An Alternative Proposal For Certification

Jul 6, 2016• 8

By JOHN HALAMKA, MD

John Halamka Some have suggested that my comments over the past few months about the Meaningful Use program, MACRA/MIPS, and Certification imply that we should just give up – throw out the baby with the bath water.

That’s not what I’ve written.

Here’s a clarification.

I believe MACRA/MIPS is the right trajectory – create a set of desirable policy outcomes, then enable clinicians to choose technology, quality measures, and process improvements that are relevant to their practice.

Although the current MACRA formula is overly complex, it’s the right idea and I’m confident that CMS will revise the notice of proposed rulemaking appropriately. My metric for MACRA’s success is simple – can a clinician keep three goals in mind while seeing a patient and be rewarded if successful i.e.:

1. Ensure care is delivered in the most appropriate location in the community (urgent care, home care, rural hospital)

2. Focus on wellness/prevention

3. Avoid redundant and unnecessary testing, medications, and procedures

My issue is that MACRA currently “inherits” the flawed 2015 Certification Rule that is a kitchen sink of immature standards and a black hole for developers. Overly zealous regulatory ambition resulted in a Rule that has basically stopped industry innovation for 24-36 months since it has listed every use case for every purpose including those unrelated to Meaningful Use and MACRA.

FHIR Use Cases: Population Health and Value-Based Care

Jul 6, 2016• 2

By PAUL TAYLOR, MD

Screen Shot 2016-07-06 at 3.22.36 PM As a practicing internist, I have followed the gamut of the sturm and drang surrounding interoperability, and have experienced its pros and cons first hand.

What’s important now is that interoperability must evolve into population health management and value-based care use cases to match where healthcare delivery and payment is quickly going. Along with the approaching permanence of alternative payment models, population-based payments, either condition-specific or comprehensive, are on the ONC/CMS roadmap.

The FHIR API can can advance how the healthcare industry exchanges data, and not just for EMRs. All healthcare information technology products—from lab systems to HIEs, and even population health management tools—will have the opportunity to leverage the new framework.

MACRA Comment: Building a Culture of Health Includes Payment Change

Jul 5, 2016

By TARA S. OAKMAN

Screen Shot 2016-07-05 at 7.12.47 PM The Robert Wood Johnson Foundation (RWJF) is striving to build a Culture of Health in this country where everyone has an equal opportunity to live the healthiest life possible, no matter where they live, learn, work, and play. To get there, we need to make sure that everyone is getting the high quality, affordable care they want and need whether this care is provided inside or outside the health care system. Right now in the U.S., we spend a lot of money on health care, especially as compared to other countries, but we don’t have the outcomes to show for it. Last year, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 that would change how Medicare pays physicians with the goal of getting higher value for our health care dollars. And recently, the Centers for Medicare and Medicaid Services (CMS) proposed rules for how these payment and reporting requirements would be implemented.

On June 23, 2016, RWJF submitted comments on these proposed rules. We believe that changing health care payment in this country to reward better, rather than more care, is critically important. In our comments, we shared lessons and insights from RWJF grantees to encourage CMS to design incentives in ways that will truly transform our health care system to provide measurably better outcomes for all. We focused our comments on three areas: fostering integrated care, ensuring patient goals and needs are at the center of all we do, and providing high value care for everyone.

An EHR-Driven Checklist Manifesto

Jul 5, 2016• 5

By JOHN HALAMKA, MD

Boston Physician Atul Gawande wrote The Checklist Manifesto in 2009 stressing that medicine should adopt “pilot’s checklists” to ensure that operating room teams are “ready for takeoff” before a scalpel is ever opened.

Here’s the “Time Out” done among all OR team members before a case beings – it includes a list of staff participating in the timeout, the agreed upon procedure, the verification of consent, appropriately marked operative site, patient identity verification, and best practices for prophylaxis.

MACRA Comment: CMS + MIPS/APM = Death of the Private Practice Physician

Jul 5, 2016• 5

By NIRAN AL-AGBA, MD

flying cadeucii Small, independent private practices are closing, increasing numbers of physicians are retiring early, and fewer medical school graduates are choosing primary care. The old-fashioned practice my father and I have built is a dying entity. Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter. I am fighting for the subsistence of rural primary care practices. Most will not survive MACRA proposed changes to the reimbursement structure.

Seven days ago, I attended an “informational listening session,” sponsored by the Center for Medicare and Medicaid Services (CMS) for rural physicians to learn more about the new MACRA proposal known as MIPS/APM (Merit-Based Incentive Payment System/Alternative Payment Model.) This new plan will penalize 7 out of 10 small practices with 1-2 physicians in this country. Why? Because they will be overwhelmed complying with fruitless statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients.

The Media, Mixed Messages and Statins

Jul 4, 2016• 5

By SAURABH JHA, MD

flying cadeucii Recently, sitting next to me at a family friend’s wedding, was a middle-aged Indian male, a retired investment banker. He had an axe to grind with doctors. He said, “You doctors don’t know what you’re talking about. One doctor says check your PSA, and another doctor says don’t bother. Can’t you doctors make up your minds?”

He was an aggressive chap, faux aggression really; a tardive alpha male, who’d looked like he’d been hen-pecked most of his life. He had just eaten four pieces of rasmalai, and was storming the fifth. Rasmalai is a sugar-rich Indian desert that’s monstrously tasty and devilishly diabetogenic. I retorted, “Uncle, PSA testing won’t save you if you keep scoffing the rasmalai.☺”

He wasn’t related to me, but Indians call random Indians, “uncle.” “Uncle” had a capacious midriff sculpted by years of disciplined over eating rasmalai and laddu. He had a point, though. Despite our profession’s call for shared decision making (SDM), he, amongst others, wanted doctors to unequivocally tell him what to do. He couldn’t appreciate the controversy of screening for prostate cancer for what it was – uncertainty over true effect size. The controversy reaffirmed his belief that doctors were incompetent.

“Uncle” isn’t alone in taking unkindly to medical controversy. A recent study in the BMJ showed that the controversy over statins, and negative media reports about statins, may have persuaded thousands to stop statins, and might lead to several premature deaths and MIs.

How to End MACRA, Meaningful Use and ONC Certified EHRs Programs/Mandates

Jul 2, 2016• 12

By HAYWARD ZWERLING, MD

flying cadeucii While the Federal Government’s promotion of EHRs via the HITECH act has been successful at increasing the prevalence of EHRs, their continued advocacy of Certified EHRs, Meaningful Use (MU) mandates and MACRA seriously impedes innovation in health information technology realms. For this reason, I think it is time for our Federal politicians to alter provisions of the HITECH ACT so as to end all legal mandates resulting in Certified EHRs, MU and MACRA.

Unfortunately most medical societies have been complicit with the Federal Government / ONC by making encouraging public statements about the evolution of MU into MACRA, and refusing to advocate for an alteration in Federal law which would end the legal underpinnings of MU, MACRA and ONC Certified EHRs. It is my opinion that these organizations are fearful of antagonizing the Federal Government and concerned that if they did such advocacy work, they would be excluded from influencing ONC’s evolution of the HITECH mandates.

Given the failure of these organizations to take a definitive stand against MU, MACRA and ONC Certified EHRs, it is time for the physician to take control of the reins of their organization and use their organization’s influence to end these HITECH mandates.