Author Archives

John Irvine

Seven Pillars of Trumpcare

Mar 26, 2016• 18

By SAURABH JHA, MD

flying cadeucii It is possible that in a few months from now, only Nate Silver’s prediction models will stand between Donald Trump and the White House. I will leave it to future anthropologists to write about the significance of that moment. For now, the question “What will President Trump be doing when he is not building a wall?” has assumed salience.

This is relatively easy to answer when it comes to health policy. Just ask what people want. Seniors don’t want Medicare rescinded. Even the free market fundamentalist group, the Tea Party, wants Medicare benefits as they stand. At one of their demonstrations against Obamacare a protester warned, without leaving a trace of irony, “Government, hands off my Medicare.”

Rest assured, Trump will protect Medicare. Even raising the eligibility age for Medicare may be off the cards as far as he is concerned. He has promised that no one will be left dying on the streets. That people no longer die on the streets, but in hospitals, because emergency rooms must treat patients regardless of their ability to pay, is irrelevant. The point is that Mr. Trump knows that the public values their healthcare. Trumpcare will show that Trump cares.

HillaryCare 2.0 – Back to the Future

Mar 25, 2016• 4

By JIM PURCELL

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It was 1993, nearly a generation ago. President Bill Clinton had delegated massively to the First Lady the task of putting meat on the bones of his ambitious healthcare announcement. Ms. Clinton, in turn, undertook the task of drafting and then selling to Congress what was titled the “Health Security Act of 1993,” but what is remembered as “Hillarycare.”

No one doubts Ms. Clinton’s intelligence and determination. That she was so completely derailed and the way it happened is nothing short of remarkable. In many ways, we were then so ready for reform. Many things were aligned, including a newly robust economy that lasted for over 7 years.

There are many reasons why Hillarycare failed back then, not the least of which were the AHIP sponsored television ads, Harry and Louise, who became famous for their very effective skewering of what was loosely represented to be the effects of the Act. The entire debacle became a cautionary tale about how healthcare IS different and is extremely resistant to change.

Overoutrage and the Asymmetric Skepticism of Healthcare Journalists

Mar 20, 2016• 17

By SAURABH JHA, MD

flying cadeucii I like healthcare journalists. Some of my best friends are healthcare journalists. I’d rather read Larry Husten on clinical trials than the constipated editorials in peer review journals. Healthcare journalists are an important force against overdiagnosis, overtreatment, overprescription, overdoctoring and overmedicalization. They’re articulate and skeptical. But they seem to have a blind spot – overoutrage.

Overoutrage is excessive moral outrage. Outrage is excessive anger. Anger is excessive emotion. Emotion is excessive anti-reason. Overoutrage is the mother of all overdoing.

Overoutrage is the healthcare journalist’s kryptonite. These skeptical Rotweillers become credulous poodles when they see overoutrage. Overoutrage axiomatically assumes a moral high ground – for the transgression must have been severe for the outrage to occur. Overoutrage is circular reasoning without an exit. Overoutrage is more powerful than any randomized controlled trial. Much of healthcare policy, indeed civic life, is shaped by it.

A recent event highlights this phenomenon very well. NEJM’s national correspondent, Lisa Rosenbaum, wrote about a surgeon’s determined, and widely publicized, advocacy to ban morcellation, a procedure to treat uterine fibroids. Dr. Hooman Noorchashm’s wife, Amy Reed, underwent morcellation to treat uterine fibroids. Unbeknownst, she had uterine cancer, and the morcellation almost certainly worsened the prognosis by spreading the cancer beyond the uterus. Banning morcellation would be a no-brainer except that morcellation has fewer complications than open surgery for fibroids, and that the chances of undiscovered uterine cancer in a woman with fibroids are exceedingly rare.

How the Health Co-Ops Can Meet Their Financial Obligations

Mar 19, 2016

By WILLIAM SNYDER

flying cadeucii A congressional subcommittee held a hearing Thursday to examine the health insurance co-op loan program established by the Affordable Care Act. The program provided $2.4 billion in taxpayer-backed loans as seed money for the co-ops, which are private companies that were originally intended to bring competition, choice, and innovation to the health insurance market. In spite of this seed money, co-ops are off to a rough start. Since their inception just over two years ago, 12 of the original 23 co-ops have closed due to financial concerns. Taxpayers aren’t the only ones at risk of getting left with the tab for the co-ops.

A co-op left doctors and hospitals in Iowa and Nebraska holding over $80 million in unpaid claims when it closed. Worse still, consider that unpaid claims left behind by failed insurance companies are often allocated by state guaranty funds to the surviving insurance companies, who ultimately pass them on to consumers. One way or another, you’re likely to pay for any obligations the co-ops can’t meet. The co-ops’ leaders don’t offer much comfort, either. One co-op CEO recently offered this assessment of the co-ops’ prospects for re-paying their loans: “Will there be a little money left? Yeah, maybe.” Fortunately, the surviving co-ops have an often-overlooked asset they can tap to stay in business and meet their obligations: the recovery rights to their overpayments.

More on Loneliness as a Major Health Risk Factor

Mar 18, 2016

By TOM EMERICK

flying cadeucii One of the myriad reasons wellness programs are not performing well is that all humans have about 100 risk factors, of which obesity, high blood sugar, high blood pressure, and high cholesterol are only four. If those four are in pretty good shape but the other 96 are out of whack, don’t expect good health results.

Further, putting bandages on symptoms of metabolic disease has limitations. Such bandages do not address the root causes of metabolic syndrome. According to Wikipedia:

“Root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. A factor is considered a root cause if removal thereof from the problem-fault-sequence prevents the final undesirable event from recurring; whereas a causal factor is one that affects an event’s outcome, but is not a root cause.Though removing a causal factor can benefit an outcome, it does not prevent its recurrence within certainty.” (Emphasis mine.)

One thing sorely missing from most modern wellness methods is RCA. Unless one deals with RCA in metabolic syndrome it will continue to recur.

Some other huge health risks factors are job misery, terrible marriages, very poor money handling skills, envy, general lack of contentment in life, and loneliness. Another health risk is how far you live from a “dial-911-first-responder”. Yet another is how safe your neighborhood is. I could go on and on. Worksite wellness does nothing to address the vast majority of personal health risks. My book, An Illustrated Guide to Personal Health*, elaborates on such health risks.

Unique Device Identifiers: Medicare Claims Should Include Implant IDs

Mar 18, 2016• 4

By JOSH RISING, MD

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New findings from Medicare’s independent auditor indicate that faulty medical implants—such as cardiac pacemakers and artificial joints—are harming seniors and costing taxpayers billions of dollars. According to the Department of Health and Human Services inspector general, the solution is a step recommended by patient safety experts and the Food and Drug Administration: collecting device-identifying data in Medicare claims.

In a letter to Senators Chuck Grassley (R-IA) and Elizabeth Warren (D-MA), the inspector general wrote, “Collecting UDI [unique device identification] data on claims forms would add significant long-term value and benefits.” The auditor’s investigation finds that taking this step would not only help the Centers for Medicare & Medicaid Services (CMS) improve care for beneficiaries, but would also strengthen Medicare’s program integrity, because the costs associated with defective devices could reach several billion dollars due to additional hospitalizations, surgeries, and other care.

While FDA and multiple groups of experts have called for this change, the inspector general indicates that, to date, CMS has not taken action or developed plans to support the policy.

What Healthcare Can Learn From Silicon Valley

Mar 16, 2016• 4

By ED PARK

flying cadeucii As consumers, we expect that when we bank, our ATM card will work in any machine worldwide, dispensing the cash we need and sending the record back to our home financial institution. Similarly, we would be enraged if we bought a new MacBook and couldn’t access our Gmail or load Microsoft Office. We expect this level of connection in so many aspects of our lives. Yet we accept a great deal less from health care than we do from our ATM cards and MacBooks.

How we got to this state is a long and complicated story. Health care has had few incentives to open up to innovation. Hospitals and physician groups have worked on their own closed information systems, hoarding data to keep their care in-network and maintain market share. This practice discouraged innovation and created a generation of ugly, unusable, and disconnected technology that has failed woefully to connect care for patients.

Rethinking How U.S. Health Care Policy Approaches the Mouth

Mar 16, 2016• 7

By MARKO VUJICIC

flying cadeucii

Dental care has traditionally been financed and delivered separately from medical care. This is despite the Surgeon General’s report in 2000 that emphasizes the importance of oral health to whole body health. Now, new data show the consequences of the approach taken in U.S. health care policy to oral health.

Medicaid Children Seeing Big Gains in Access to Dental Care

The American Dental Association Health Policy Institute (HPI) recently launched The Oral Health Care System: A State-By-State Analysis. This first-of-its-kind data repository brings together data from multiple sources related to oral health and is meant to serve policy makers and researchers. One of the most significant findings from these data is that access to dental care has been increasing steadily among Medicaid children for more than a decade.

Nationally, the percent of Medicaid children who visited a dentist within the past twelve months went from 29% in 2000 to 48% in 2013, the most recent year for which data are available. What is striking is that the trend is remarkably widespread across states, with all but one state experiencing gains over this time frame. As a result, the gap in dental care utilization between Medicaid- and privately-insured children has been shrinking steadily. In fact, it narrowed in every single state for which we have data between 2005 and 2013 (see figure below). There are two states – Hawaii and Texas – where there is actually a “reverse gap”: children enrolled in Medicaid are more likely to visit a dentist than children who have private dental benefits. Moreover, this progress has all been happening during a time when the number of children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) has been rising steadily. In 2013, nearly four out of ten children in the U.S. were enrolled in Medicaid or CHIP compared to two out of ten in 2000.

The End of Civilization and the Real Donald Trump

Mar 15, 2016• 17

By ART CAPLAN

Screen Shot 2016-03-15 at 9.13.00 AM The pandemic started quietly. In the spring of 2017 A few hundred dead chickens appeared in markets in Hong Kong and a few other cities in China. Public health officials in China were slow to respond. They did not want to panic the public about an avian flu outbreak. Nor were they eager to take the steps necessary to contain such an outbreak—the killing hundreds of thousands of chickens and poultry with devastating economic consequences. While the delay went on a few cases began to occur on Canadian and American poultry farms. Department of Agriculture experts traced the outbreak to waterfowl migrating from Northern flyways, probably from Asia. Inquiries were made about avian flu outbreaks in Asian nations. Then the unthinkable happened. Humans in Hong Kong began to get sick. Very sick. Some died. Those who died were in their twenties.

The avian flu virus had mutated. H7N9m had transformed into an agent that not only could infect humans but did so with a transmissibility and lethality that had not been seen since the Spanish flu outbreak of 1918.

Then the first American died. A young man back from a business trip to Hong Kong. The media, already primed for hysterical coverage following the severe Zika outbreak in the Southern United States in the summer and fall of 2016, went into full panic-dispensing mode. ‘Experts’ began to appear on the cable channels who suggested that the outbreak was the result of irresponsible genetic research in China. Still others suggested that it was the bioterror work of North Korean scientists. One or two pointed toward ISIS arguing that they had grown desperate in the face of the massive air war that the new administration had launched. Still others saw the hand of right or left wing domestic terrorists. And an accident at an American lab was put into the boiling cauldron of speculation and conspiracy.

The 5 Stages of EMR Acceptance (With Apologies to Kubler-Ross)

Mar 15, 2016

By FRANK MEISSNER

DENIAL

I can’t believe they are making me use this system!

ANGER

I CAN’T BELIEVE THEY ARE MAKING ME USE WHAT
THEY LAUGHINGLY CALL A SYSTEM!

BARGAINING

‘Look if I agree too willingly and cheerfully use this system, can you ask for and fund these change orders, add these features, re-engineer this screen…..blah! blah! Blah!, etc. ‘

DEPRESSION

I can’t beeeelieeeeeeve (sob, sob, sob, sob) theeeey (sob, sob, sob) are making meeeee (pouring tears from both eye tear wells) use this system!’

ACCEPTANCE

I believe they are making me use this system.

(Resigned Sigh)

And just as in the original Kubler-Ross model, our only release from EMR agony is death……. an eventuality that I used to accept stoically as inevitable, but now positively look forward to its release (as do my carpal-ly tunneled wrists!). Continue reading…