Author Archives

John Irvine

So, You’re a Next Generation ACO …

Jan 14, 2016• 5

BY KOFI JONES

Screen Shot 2016-01-14 at 5.45.59 PM CMS recently announced the inaugural class of Next Generation ACOs – the latest accountable care models which includes higher levels of financial risk and greater opportunity for reward than have been available within the Pioneer Model and Shared Savings Program. CMSs goal is to test whether these greater financial incentives, coupled with tools to support better patient engagement and care management, will improve health outcomes and lower costs for Medicare fee-for-service (FFS) beneficiaries.
One of the most exciting opportunities for these ACOs is the ability to leverage telehealth above and beyond what is currently permissible in fee-for-service Medicare.

Since section 1834(m) of the Social Security Act was codified well over a decade ago, telehealth has only been able to serve Medicare recipients when they got in their cars and drove to a clinical site, in a rural area of the nation. Simply translated – no homes or cities count. With the lightning speed of telehealth advancement, this structure is archaic, limiting, and frankly at this point, senseless. Now, with this Next Gen designation, these “Next Gens” will be able to offer care through telehealth technologies regardless of the patient’s location.

Why Your Culture Does Not Matter To Me

Jan 14, 2016• 13

BY UNDISCLOSED LOCATION

flying cadeucii I am a student in a health care profession. I see many different people every day that come to seek treatment at my school. Most patients are local to our area, but many come to our school’s clinic from different countries, cultures, and backgrounds. Our curriculum has recently been updated in accordance with the board of accreditation that our state mandates for professional schools. This curriculum includes a course entitled ‘Cultural Awareness.’ The goals of the course, as stated by the syllabus and our professor, is to:

Emphasize, illustrate and analyze how patient’s background, culture, beliefs and norms may impact health and health outcomes;
Enhance understanding of legal boundaries and provider’s responsibilities in the delivery of care;
Enhance the students understanding of cultural, various societal values and traditions that must be considered during the delivery of care, doctor-patient interactions and treatment outcomes;
Increase awareness of the challenges and mechanisms for providing services to special populations. Except for the second objective, I am not interested in learning about any of these. I am going to illustrate to you why classes like these are a farce, a waste of our time as professionals, and demeaning to every intelligent culture.

As a professional healthcare worker, I am bound by a code of ethics. In fact, this code is a defining aspect of the culture found among healthcare professionals. This code includes virtues like veracity, nonmaleficence, justice, beneficence, and patient autonomy. These virtues lay the groundwork for almost every aspect of clinical decision-making in healthcare. It is a defining aspect of healthcare culture. This code is well recognized by people within and without the healthcare system as it is the basis for the credibility patients give to their doctors, nurses, dentists, optometrists, etc.

And the Stars Looked Very Different Today

Jan 14, 2016

Screen Shot 2016-01-14 at 12.13.44 PM

“This is Major Tom to Ground Control
I’m stepping through the door
And I’m floating in a most peculiar way
And the stars look very different today
For here
Am I sitting in a tin can
Far above the world
Planet Earth is blue
And there’s nothing I can do”

Space Oddity. HD (YouTube.) THCB
With thanks to @jlschuster827

Meaningful Use Is Dead. Long Live Something Better!

Jan 13, 2016• 32

By MARGALIT GUR-ARIE

At the J.P. Morgan Healthcare Conference in San Francisco, Mr. Andrew Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS),announced on January 11th that “The meaningful use program as it has existed will now effectively be over, and replaced with something better”, and later clarified onTwitter that “In 2016, MU as it has existed– with MACRA– will now be effectively over and replaced with something better”. Meaningful Use is dead. Just like that. No apologies. No nothing. As someone who’s been lamenting the havoc wreaked by the program on both doctors and patients, I should be elated nevertheless. Well, I am not.

Let’s start with appearances. The J.P. Morgan Healthcare Conference is the “largest and most informative healthcare investment symposium in the industry which brings together global industry leaders, emerging fast-growth companies, innovative technology creators, globally minded service providers, and members of the investment community”. In other words the event is all about money for the millionaire and billionaire class. J.P. Morgan Chase itself is the largest financial institution in the country. It is the embodiment of Wall Street and its death grip on our collective neck. Was this conference really the best place to make such momentous announcement?

Besides, why would these extractors of wealth be interested in the fate of something as obscure as Meaningful Use? Shouldn’t they discuss more lucrative schemes, such as running all possible blood tests on one tiny blood droplet, or how the makers of Microsoft Office and the largest online retailer of everything are going to jointly solve for cancer? Shouldn’t they be analyzing trillion dollar addressable markets of genomic rainbows, and how mergers, acquisitions and inversions can help squeeze whatever is left in the turnips that are you and me?

Of course they should, and they did all that and much more. But changes to the Meaningful Use program are of strategic importance to all other rainbows, grails and unicorns. Why? Because Meaningful Use, other than funneling a respectable amount of billions of dollars into the health tech sector, is the enabler of data collection which fuels all other investment opportunities.

The Case For Calling the Dietary Guidelines What They Really Are

Jan 12, 2016• 1

By DAVID KATZ, MD

David Katz MD Call me crazy. Or Ishmael, for that matter. I think “Dietary Guidelines for Americans” should be something vaguely like, well, oh I don’t know, maybe: guidelines for Americans. About how to eat well.

What does “dietary guidelines” make you think? Doesn’t it sound an awful lot like: guidelines for people’s diets? Doesn’t that, in turn, sound quite a bit like: here’s what we (whoever ‘we’ is) think you should eat, presumably for health? And doesn’t “guidelines” suggest “guidance” from “guides” who ought to know where they are going, suggesting that the “we” involved should qualify as such?

Yes, that’s exactly what it sounds like. And if we go a step further, and call something “Dietary Guidelines for Americans”- and we don’t say “some” Americans, or Americans in food assistance programs, or Americans eating in school cafeterias- if we just simply say “for Americans”- then doesn’t it sound an awful lot like: this is what we (whoever ‘we’ is) think ALL Americans should be eating?

You bet it does.

And so my friends, we come to it: a steaming mound of misleading BS. Watch where you step.

The Dismal Science Behind Financial Incentives For Docs

Jan 12, 2016• 4

By JAAN SIDOROV, MD

flying cadeucii “It is written: Man shall not live by bread alone.”
Luke 4:4

No matter what you think of the source of that quote, the idea that there may be limits to “aligning incentives” has some merit. In healthcare settings, physicians seem to be supportive of being fairly compensated for their work, but also seem to be quite skeptical about the use of “carrot and stick” style economic rewards to influence clinical practice.

Case in point is this interesting paper describing the results of a randomized clinical trial that used blood cholesterol-level control to assess the relative merits of a) rewarding just the patients vs. b) rewarding just the doctors vs. c) rewarding both patients and doctors vs. d) usual practice, or a control group.

The study took place in three marquee institutions, involving 340 primary care physicians who were already taking care of 1503 adult patients with 1) elevated cholesterol levels who 2) either had coronary artery disease or were at high risk for coronary artery disease.

About half of the patients were already on cholesterol-lowering pills.

The purpose of the study was to determine if real money could be used to increase the rate and level of prescribing a statin drug aimed at achieving levels of cholesterol control that were consistent with national guidelines.

What Do We Know About Medical Errors Associated With Electronic Medical Records?

Jan 11, 2016• 6

By ROSS KOPPEL

Recently, the Journal of Patient Safety published a powerful and important article on the role of EHRs in patient harm, errors and malpractice claims. The article is open access. Electronic Health Record–Related Events in Medical Malpractice Claims by Mark L. Graber, Dana Siegal, Heather Riah, Doug Johnston, and Kathy Kenyon.   The article is remarkable for several reasons:

Considerably over 80% of the reported errors involve horrific patient harm: many deaths, strokes, missed and significantly delayed cancer diagnoses, massive hemorrhage, 10-fold overdoses, ignored or lost critical lab results, etc.

Central to this article’ contribution is its data source and an understanding of the direction of causation of the findings: These errors came to light not because a healthcare provider noted an EHR-related problem, but because the patient was harmed, the provider was sued and there was an insurance payment. Continue reading…

Treating Chest Pain With a Cup of Tea

Jan 9, 2016• 6

By ANISH KOKA, MD

It is very early. I am running to the ‘clinical decision unit’ (CDU) to see a patient of mine sent in the night before from a local skilled nursing facility. Also known as clinical observation units, ‘obs’ units, or short stay observation units, these units were designed to help decompress busy emergency rooms and divert unnecessary, expensive inpatient admissions. The units are typically adjacent to emergency departments, and usually are run by emergency physicians.

My particular patient was admitted due to an episode of chest pain at her facility. A brief conversation the prior night with the emergency room staff revealed chest pain that clinically was not typical for any of the feared diagnoses of a heart attack, pulmonary embolism or an aortic dissection. An electrocardiogram and cardiac enzymes were also initially unremarkable. Regardless, the patient was elderly and had multiple other comorbidities, and was somewhat confused. I recommended a short stay to allow anything malignant to declare itself.

And so, here I was, at the observation unit, digging through pages upon pages of printed gibberish that clearly had achieved the nirvana stage of meaningful use (for those wondering, that’s after stage 3). Ironically, the most useful piece of information lay in a handwritten progress note describing the episode. I could see why the patient had been brought here to be further evaluated, but after 18 hours of negative biomarkers, electrocardiograms, and no recurrence of symptoms, I felt comfortable letting her go back to where she came from. I told the ER staff… who cancelled her stress test. A stress test? Yes, a stress test had been ordered prophylactically. We practice in a climate where every bad outcome has the potential for litigation – malpractice lawyers would have a field day with the case of anyone going to the ER, being discharged without some type of cardiac imaging study, and having a heart attack. My recommendation to discharge the patient shifts the liability of an adverse outcome from the ER squarely on to my shoulders, and thus, poof goes the stress test.

Help Us Build a Hospital In the Cloud

Jan 8, 2016

By JONATHAN BUSH

Since 2011, over $13 billion in venture funding has flooded into digital health. 2015 alone saw well over 200 digital health companies raise more than $2 million each. From personal DNA tests to on-demand doctor’s visits, startups are taking a page from technology giants (Google, Apple, Amazon) and digital unicorns (Uber, Slack) to bring health care into the internet age.

The consumerization of health care is en fuego(!), and rightfully so. With the rise of high-deductible plans, we as patients have been forced to take on greater financial responsibility for our own health. Adding fuel to the flame, the widespread adoption of internet and mobile tech has evolved patients from passive recipients of care into active managers of care. Health care’s consumerization wildfire is thrilling, and it’s created a perfect breeding ground not only for new models of care delivery to take root, but for entrepreneurs to introduce new tools and apps for the patient and provider alike.