Author Archives

John Irvine

An Epidemic of Septicemia?

Jun 17, 2016• 10

By AL LEWIS

While prevention efforts have largely been focused on chronic disease, spurred in part by the Centers for Disease Control and Prevention’s (CDC) insistence that 86% of healthcare dollars are spent on patients with chronic illness, it turns out that the largest, fastest-growing and possibly most preventable diagnosis is arguably the most acute diagnosis of all: septicemia.

Septicemia is any persistent systemic blood-borne bacterial infection, generally caused by contamination from an invasion of the bloodstream by an outside pathogen, and generally not easily addressed with antibiotics. Its many complications include death, 13% of the time. (There is some confusion about the various definitions of and distinctions among sepsis, septicemia and septic shock.)

The Statistics

The statistics below are drawn from the Agency for Health Research and Quality’s Healthcare Cost and Utilization Project (HCUP) database, and as such are easily replicated by entering ICD-9 “038.9” as “principal diagnosis.” The most recent year available, 2013, is the source of the screenshots.

According to the most recent statistic available, septicemia is not only #1 in total spending, but it’s also almost twice as costly as the next-highest ICD9.

In Silico Medicine

Jun 17, 2016• 3

By NICOLE VAN GRONIGEN

flying cadeucii Could computers develop the drugs of the future? The short answer: probably, but not yet.

Computer simulation is a cornerstone in the development and optimization of “mission-critical” elements in industries ranging from aerospace to finance. Even the smooth functioning of nuclear reactors – where failure would be catastrophic – relies on a computational model called a Virtual Reactor, which allows scientists and engineers to observing the reactor’s real-time response to operating conditions.

The analogous model in medicine – a “virtual human” – doesn’t yet exist. We still rely on living, breathing animals and humans to test drugs and devices. Discoveries are made largely by trial and error. But the age-old approach that led to the discovery of antibiotics, cardiac catheterization, and organ transplantation is becoming increasingly unsustainable.

All Risk is Local

Jun 16, 2016• 11

By JEFF GOLDSMITH and BRUCE HENDERSON

flying cadeucii We all knew how this was going to go, or thought we did. Fee-for-service payment for health services was going to disappear, and be replaced by population health risk-based payment (or as some term it, “capitation”- fixed payment for each enrolled life). Hospitals and care systems invested substantial time and dollars building capacity to manage the health of populations, yet many are discovering a shortage of actual revenues for this complex new activity. Was population health a mirage, or an actual opportunity for hospitals, physicians and health systems?

The historic health reform law passed by Congress and signed by President Obama in March, 2010 was widely expected to catalyze a shift in healthcare payment from “volume to value” through multiple policy changes. The Affordable Care Act’s new health exchanges were going to double or triple the individual health insurance market, channeling tens of millions of new lives into new “narrow network” insurance products expected to evolve rapidly into full risk contracts.

In addition, the Medicare Accountable Care Organization (ACO) program created by ACA would succeed in reducing costs and quickly scale up to cover the entire non-Medicare Advantage population of beneficiaries (currently about 70% of current enrollees) and transition provider payment from one-sided to global/population based risk. Finally, seeking to avoid the looming “Cadillac tax” created by ACA, larger employers would convert their group health plans to defined contribution models to cap their health cost liability, and channel tens of millions of their employees into private exchanges which would, in turn, push them into at-risk narrow networks organized around specific provider systems.

Three Surprising Developments

Well, guess what? It is entirely possible that none of these things may actually come to pass or at least not to the degree and pace predicted. At the end of 2015, a grand total of 8.8 million people had actually paid the premiums for public exchange products, far short of the expected 21 million lives for 2016. As few as half this number may have been previously uninsured. It remains to be seen how many of the 12.7 million who enrolled in 2016’s enrollment cycle will actually pay their premiums, but the likely answer is around ten million. Public exchange enrollment has been a disappointment thus far, largely because the plans have been unattractive to those not eligible for federal subsidy.

The Team Sport of Diagnosis: A Culture Shift Can Reduce Missed Diagnoses

Jun 15, 2016• 5

By DAVID E. NEWMAN-TOKER

flying cadeucii Every American will experience a missed or delayed diagnosis at some point in his or her lifetime. Saying that is not a scare tactic — it’s a reality, according to a 2015 National Academy of Medicine report titled “Improving Diagnosis in Healthcare.” Yet we have not made effective use of a simple solution: teamwork.

Among U.S. adults seeking outpatient care each year, 12 million are misdiagnosed. One in 20 hospital deaths results from a diagnostic error. Estimates suggest that costs of unnecessary tests, harms from misdiagnosis and legal payouts exceed $100 billion per year in the U.S. In short, inaccurate diagnoses are the most common, catastrophic and costly medical errors.

From a public health standpoint, we are in crisis.

Medicine is complex, and diagnosis is not an exact science, so we can’t always be right. But there is strong evidence that we can do a lot better than we do now. When we don’t follow best diagnostic practices, we tend to undertest patients who need it most, missing chances to provide prompt treatments for dangerous disorders. Continue reading…

Confession of a Liberal

Jun 15, 2016• 32

By MARGALIT GUR-ARIE

Screen Shot 2016-06-15 at 7.30.34 AM

TRIGGER WARNING: Long read, Trump

Reason #1: Feeling the Bust. I am a woman and I am an immigrant to this country. I am Jewish by birth and atheist by faith. I am fairly well educated, borderline socialist and straight Democratic ticket voter. I have no use for guns, I despise hunting, and I believe the death penalty is state sponsored murder. I think abortions are perfectly fine and I think everybody should be free to choose how they use their own body for their own happiness and joy. I have no respect for authority, strength, power or large wads of cash. Come to think of it, I have no respect for anything or anyone in particular.
On November eighth, barring any natural disasters, I will be voting for Donald Trump and according to my liberal bible, I will be doing so for all the wrong reasons.

Confusion over HIPAA Causes Grief in Orlando

Jun 14, 2016• 8

By ARTHUR CAPLAN, MD & CRAIG J. KONNOTH

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After the horrific shootings in the gay dance nightclub that killed 49 individuals, 53 survivors were rushed to surrounding hospitals. In the hours that followed family members anxiously sought updates about their loved ones. Yet, confusion over the privacy rules that govern health information prevented them from getting immediate access to what they surely needed to know. Confusion was not restricted to hospital staff. Reporters and political officials alike were confused about what the law permitted.

This is not the first time that HIPAA related confusion affected a gay patient: in 2010 President Obama took steps to address anti-gay discrimination when Janice Langbehn was denied visitation and updates about her partner’s condition in a Florida hospital.

Rules under the Health Insurance Portability and Accountability Act (HIPAA) generally prohibit release of patient information without their explicit consent. The CEO of the Orlando Regional Medical Center reportedly asked Orlando Mayor Buddy Dyer for a HIPAA “waiver” so that the victims’ loved ones could be informed of their condition. The Mayor sought such a waiver from the White House.

Numerous news outlets reported that the mayor had received his waiver. One outlet called this waiver “unique.” By declaring a “national emergency,” it explained, “President Barack Obama and Secretary of Health and Human Services Sylvia Mathews Burwell made it easier for family and friends to gain quicker access to information—the right move in such a circumstance.

Assessing the Validity of MACRA’s Risk Adjustment Methods

Jun 14, 2016• 2

By KIP SULLIVAN

flying cadeucii The feedback doctors will receive from CMS under CMS’s proposed MACRA rule will arrive in two forms: Money (more or less of it) and data. Neither form of feedback will be accurate. For that reason, the behavior desired by Congress and CMS – “smarter care” (as CMS puts it) producing lower costs and higher quality – will not materialize.

As I noted in the first installment of this three-part series, the two most important sources of noise in CMS’s feedback will be CMS’s inability to determine which patients “belong” to which doctor (the attribution problem) and its inability to adjust cost and quality scores for factors outside physician control (the risk-adjustment problem). [1] In my first installment I showed that the method of attribution CMS will use is unacceptably sloppy. In this installment I review the risk-adjustment problem and CMS’s irresponsible claim that it can measure physician “merit” even with sample sizes as small as 20 patients.

FUD Part II: The Return of Fear, Uncertainty and Doubt

Jun 13, 2016• 2

By JOHN HALAMKA

John Halamka A Time of Uncertainty …

The upcoming presidential election has everyone spooked – what if Donald Trump is actually elected? What will the transition of administrations, regardless of who is elected mean to healthcare and existing healthcare IT regulations? Will our strategic plans and priorities need to change?

I’ve spoken to many people in government, industry and academia over the past month about the rapid pace of change stakeholders are feeling right now. Here are a few of their observations:

1. In the next year or two there will continue to be consolidation in the healthcare IT industry. Many smaller EHR companies will fold due to declining market share and some established incumbents with older technologies are likely to sell their healthcare IT businesses or reduce their scope.

2. Mergers and acquisitions will continue to accelerate, reducing the number of stand alone community hospitals and practices. The end result is that the market for software supporting midsize hospitals and small group practices is likely to shrink since ACOs/networks/healthcare systems will probably mandate a single centralized EHR solution for the enterprise.

3. Although the election may change the regulatory burden, many incumbent vendors will be spending the next year or two complying with certification demands, reducing their ability to innovate. It’s quite a conundrum. The market is demanding innovative solutions in the short term, but vendors cannot produce them because their development resources have been co-opted by regulatory demands. Thus, vendors may see a reduction in new sales, which will diminish their ability to hire new staff to meet the regulatory demands, putting them even further behind. It reminds of a classic unstable system – beer pong. The more you miss, the more you drink, the more you miss. The more regulation, the fewer new sales, the less ability to deal with regulation.

A Bill You Can Understand: One Page, One Line, One Price

Jun 12, 2016• 6

By FRED GOLDSTEIN and BRIAN KLEPPER

At the recent Health Datapalooza conference, Sylvia Burwell, the HHS Secretary announced a new initiative, A Bill you Can Understand, :

a challenge to encourage health care organizations, designers, developers, digital tech companies and other innovators to design a medical bill that’s simpler, cleaner, and easier for patients to understand, and to improve patients’ experience of the overall medical billing process.

This is a laudable if perhaps slightly misdirected effort.

Why are we looking to create an extra layer of service to explain a very poor function, which will inevitably increase system costs? Because this is healthcare’s typical way of adding more layers and costs to an already bloated system, instead of fixing the underlying problem.

When you buy a car do you receive separate bills for the labor, motor, body, tires, glass, oil and gas, carpet, electronics, air conditioning? I know, there are a few lines – base price, options, transportation fees, dealer fees – but it’s just a few and there are not multiple bills coming from all the components.

Furthermore, this simplification greatly reduces the number of people and systems that a dealer and its suppliers need to staff for the billing and collection process.

What healthcare needs is to simplify and combine the entire billing process and function. We need to bundle pricing that is all-inclusive in advance, just like everything else we buy.

The Opioid Crisis: Nociception, Pain and Suffering

Jun 10, 2016• 6

By MARTIN SAMUELS, MD

flying cadeucii In order to understand the concept of pain and its relationship to the current opioid crisis, it is prudent to review the neurology of pain an why it exists. Several concepts are important to integrate.

Nociception: Nociception is the capacity to sense a potentially tissue damaging (noxious) stimulus. To illustrate this one should place a forefinger in a glass of ice water and determine how long passes until an unpleasant sensation arises. If one performs this experiment in a large group, one can recognize that, although the stimulus is the same (a glass of ice water), the sensation arises at different rates in different people.

In fact, a bell shaped curve will describe the distribution in any population of people. Within 30 seconds almost all will have perceived an unpleasant sensation that is known at pain. Nociception is a very primitive sensation.

It is present in virtually all animals, even those without a brain, such as Aplysia, the sea slug. Though it lacks a brain, it has nerves and ganglia that allow it to sense and move away from a noxious stimulus. Nociception is absolutely essential to our survival and well-being. Without it, one would suffer tissue damage and ultimately death. The human disease, leprosy, is a salient example of an infection that destroys the nerves that are responsible for nociception. That lack of nociception is what causes all of the disfigurement that is characteristic of leprosy. Anyone who has had a dental anesthetic is aware that one can inadvertently bite one’s own lip until the anesthetic wears off.