Sure, I’ve always wanted to write a clickbait headline that sounds like a promo for the bastard child of Buzzfeed and the Federal Register. But, seriously: you will not believe what Medicare just did about patient engagement in a draft new rule dramatically changing how doctors are paid.
And, depending upon the reaction of the patient community, you definitely won’t believe what happens next.
With no apology offered, I will be venturing into a very subjective realm, namely, a characterization of today’s healthcare dialogue and what, in my opinion, might be an improvement.
I would suggest we have fallen into the trap that was partly enhanced by email and blogs, namely, that we can say outrageous things impolitely and without consequence. With email we tend to be much blunter and impolite than we would be face to face. On blogs, we can be positively toxic. It’s like driving in a car with a tinted windshield that no one can see through. You are anonymous and therefore can act less responsibly.
Another vignette. I grew up in a very small upstate New York town where everyone knew everyone else. You used your car horn to beep “hi” or to warn, and not in anger, ever. When you waved at someone, it was with all five fingers. And so on. I think you get my point.
The healthcare debate always has stoked emotions like almost no other. It is intensely personal, and the stakes are high. We’re all involved and engaged.
As I’ve written in the past, I first earned my stripes as a lawyer representing my local Blue Cross plan in rate hearings. These rate hearings always started with “public comment.” The comment ranged from pure outrage to controlled anger to discontent coupled with suggestions. What did we pay the most attention to? Of course, the latter.
Seven years ago, Congress passed a law to spur the country to digitize the health care experience for Americans and connect doctors’ practices and hospitals, thereby modernizing patient care through the Electronic Health Records (EHRs) Incentive Programs, also known as “Meaningful Use.” Before this shift began, many providers did not have the capital to invest in health information technology and patient information was siloed in paper records. Since then, we have made incredible progress, with nearly all hospitals and three-quarters of doctors using EHRs. Through the use of health information technology, we are seeing some of the benefits from early applications like safe and accurate prescriptions sent electronically to pharmacies and lab results available from home. But, as many doctors and patients will tell you (and have told us), we remain a long way from fully realizing the potential of these important tools to improve care and health.
That is why, as we mentioned earlier this year, we have conducted a review of the Meaningful Use Program for Medicare physicians as part of our implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), with the aim of reconsidering the program so we could move closer to achieving the full potential health IT offers.
THCB is pleased to introduce the 2016 Healthcare Town Hall, a special online feature brought to you in partnership with Health Catalyst. This is an experiment. The idea is to open up an ongoing dialogue around the issues that are transforming healthcare in the second decade of the 21st Century.
We’re kicking things off with an online panel featuring THCB Editor John Irvine and the HealthCatalyst leadership including Dale Sanders, John Haughom and Bryan Oshiro.
John Irvine: Let’s start with the recent decision at CMS to transition from the Meaningful Use the program to a new program that will be a component of MACRA. A lot of people were extremely surprised with the news that Meaningful Use is going away. The follow up development, of course, is that CMS has agreed in principle to a new set of core clinical quality measures that will change the way doctors are evaluated. I’m hearing a lot of positive feedback about the Meaningful Use decision. Reactions?
Dale Sanders: I was surprised, yes. As I think you know, I’ve spent a lot of time in Washington. I know how government works. People in government generally do not reverse themselves, unless it is very clear that there is no other available option. That’s Washington 101. Read into that what you will. It’s far easier to allow a program to keep on going than to admit that something isn’t working or that it has outlived it’s usefulness. I think a lot of people are missing the fact that It took political courage to do that. I will say that I was one of the first to publicly call for the suspension of Meaningful Use, and you guys posted the blog that I wrote about it. At Northwestern, we published a one page policy entitled, “Principles of EMR Utilization” that was written and endorsed by our physicians, facilitated by me when I recognized that our EMRs were being used for little more than a multi-million dollar word processor. That one-page document is all we needed to achieve the same concepts as Meaningful Use. The last time I counted, the Meaningful Use regulations totaled over 350 pages. In typical fashion, the government turned a good concept into a mess. So, I’m cautiously optimistic that we are going to return to common sense.
Accountable care organizations (ACO’s) promise to save us. Dreamed up by Dartmouth’s Eliot Fisher in 2006, and signed into law as a part of the Patient Protection and Affordable Care Act (PPACA) in 2010, we have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time. I dare say that Brahma, Vishnu and Shiva together would struggle to accomplish those lofty goals. Regardless of the daunting task in front of them, the brave policy gods who see patients about as often as they see pink unicorns, chose to release the Kraken – I mean the ACO – onto an unsuspecting public based on the assumption that anything was better than letting those big, bad, test ordering, hospital admitting, brand name prescribing physicians from running amuck.
I realize I am being somewhat harsh towards the creators of the ACO morass. But, while they all may be well-meaning, hard-working folks that own a Harvard crimson sweater, their intent is to fundamentally change how health care is provided – this mandates a withering evaluation. As Milton Friedman aptly said, “One of the great mistakes is to judge policies and programs by their intentions rather than their result.” Thus, with little regard to intent, and with an eye on the end result, I say unequivocally : ACO’s do not work.Continue reading…
I can’t get Dan Lyons out of my head.
Lyons is the author of Disrupted, the buzzy new book about what happens when a curmudgeonly fifty-ish tech writer gets unceremoniously dumped from a plum role at Newsweek and takes a job as a “content generator” at Hubspot, a white-hot Boston startup selling marketing software.
Best known for creating a “Fake Steve Jobs” blog, and more recently for his work on the writing team for HBO’s achingly funny Silicon Valley, Lyons has a taste for the absurd, and his prologue (excerpt here)–describing his initial experience at Hubspot–is a laugh-out-loud takedown of tech startup culture.
The fun only lasts a few chapters, however (captured perfectly in this review by Erin Griffith), as Lyons hopes to convey a more serious point (conveniently summarized in an op-ed in today’s New York Times): that the excitement around technology companies is largely empty hype, enthusiasm used to sucker naïve young adults to work for peanuts (and candy), and to enrich savvy founders and venture capital investors, and the investment bankers who enable them, at the expense of the gullible mom and pop investors who buy shares of these fast-growing but often profitless companies after they go public.Continue reading…
In a time when evidence-based prescribing and clinical guidelines are hot topics in medicine, trying to access a not-yet-approved drug to use in a patient can feel like navigating uncharted waters. Many physicians are unaware that the US Food and Drug Administration (FDA) allows the use of unapproved drugs outside of clinical trials and — even if they did know it is possible — have no idea how to access such investigational drugs for their patients.
This knowledge is largely sequestered into certain clinical specialties, such as oncology or rare disease, and it is not taught in medical school or during residency: instead, is largely self-taught. Thus, while some physicians have become very accustomed to requesting pre-approval access to drugs, the majority lack this knowledge. In this essay, I use a fictional case to trace the process for requesting access to an unapproved drug. I hope to explode several myths about the process, such as the notion that the FDA is the primary actor in granting access to unapproved drugs and the belief that physicians must spend 100 hours or more completing paperwork for pre-approval access.
Imagine you are a physician, and you have a pregnant patient who has tested positive for Zika. While she is only mildly ill, she’s terrified that her unborn child may be impacted by the virus, which has been provisionally linked with microcephaly and other abnormalities. She’s so concerned that she is contemplating an abortion, even though she and her husband have been trying to have a child and were overjoyed to learn she was pregnant.
Against your better judgment, you’ve just checked your contact lens-enabled news feed. You’re annoyed, because President Meghan McCain has just used the Trump Doctrine to “fire” Medicare’s lead administrator over the botched roll-out of the Agency’s block-chain claims payment system. The mild spike in sweat stress chemicals detected by your clothing sensors prompts a boost in the transcutaneous dosing of the blood pressure pharmaceuticals from the networked skin patch on your thigh.
It’s the year 2030, and personalized “eDxTx” (ecosystems of Diagnosis and Treatment) has arrived for a lucky few who are able to afford it. That has created political headaches for the President and her campaign promise to bring Medicare out of the 20th century. Your decision to opt out of “Medicare for All” (a.k.a “TrumpCare”) has been expensive, but worth it because your Geico insurance plan includes eHealth as a covered benefit. Geico’s ability to automate all underwriting and claims handling means high service standards and keeping costs down. Plus, those video ads are still cool.
Thanks to ubiquitous wireless connectivity, cloud-based machine intelligence and mass-personalized medicine, you and your private doctor’s team were able to configure a suite of customizable off-the-shelf apps that meet your goals for living well as well as long. The first step was your $2 psychometric, biomic and genetic testing (the expense of a mitochondrial analysis was offset with an agreement with the laboratory, Theranos, to pool your data with other customers) that spotlighted the optimum mix of nutrition and pharmaceuticals to blunt your risk of Type 15 Hypertension and GAB15a-linked gastrointestinal cancer.
My last post discussed the wide gulf between healthcare and the rest of the world in the area of customer service. To sum up what took over 1000 words to express: customer service in healthcare totally sucks because the system promotes that suckiness and does nothing to penalize docs who make people wait, ignore what they say, rush through visits, and over-charge for their care. We get what we pay for.
But shouldn’t we judge the system for what it was build for: the quality of the care we give? Sure, the service is overwhelmed with serious suckitude, but that can be forgiven if we give good quality care for people, right?
Even if that was the case, there is no excuse for the lousy service people get from our system. The lack of respect we, as medical “professionals” show to our patients undermines the trust our profession requires. Why should people believe we care about their health when we don’t care about them as people? Why should they respect us when we routinely disrespect them? No, the incredibly poor service we have all come to expect from hospitals and doctors is, and never should be overlooked or forgiven.
Still, I already wrote a post about that. Go back and read it if you missed it. This post isn’t going anywhere. Now I want to cover the actual care we give, and how it too has moved away from the needs of the people it is supposedly for. The people question how much providers care (verb) mainly based on the (lousy) service they get. The care (noun) we give is all about the quality of the product purchased by whoever pays for that (be they third-party or the patients themselves). The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.
Giving consumers information and data on providers’ quality of care and clinical results is one important path to enhanced transparency, patient engagement, and better health care.
Two publications out this month add significantly to the dialogue on this issue. The journal Health Affairs devotes most of its April issue to the theme of “patients’ and consumers’ use of evidence to inform health care decisions.” And the cover story in the May issue of Consumer Reports is entitled “What You Don’t Know About Your Doctor Could Hurt You.” Accompanying that story online is Consumer Reports’ latest ratings of doctors in six states and two metro areas.
(Disclaimer: I contributed an article to the April issue of Health Affairs and was involved in one element of the Consumer Reports piece.)
Among observations in the Health Affairs papers:
Star-based provider ratings, summarized information (instead of details) and well known signifiers of quality such as blue ribbons work best to compel consumers to both pay attention and make wise choices among health plans and providers.
Getting consumers to consider quality and cost (and the concept of value) remains a challenge. A survey of some 2,000 people found that most don’t think cost and quality of care are necessarily related. That’s good and bad. Good because previously published research indicated that most people leaned to believing that higher price means better quality. Bad because the new survey signals that people are still disconnected from pursuing value in health care by consciously choosing lower-cost/high-quality providers. Continue reading…
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