Author Archives

John Irvine

Would Patients Pay For This?

Jan 8, 2016

By HANS DUVEFELT, MD

Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the Government and Corporate America want them to have.

Up until this point, the momentum has been with the payers, Medicare and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash is becoming.

It will come down to this, a kind of “straight face test” for health care: Would patients pay for this?

The Annual Wellness visit, better named “Medicare’s Non-Physical” and some forms of “Population Management” are examples. Both are great ideas; an annual health review and planning session as well as doctors maintaining an overview of, and reaching out to, high risk groups of patients – in theory neither would be anything to argue with.

Like Uber for Health Care With Sherpas?

Jan 6, 2016• 12

By ROB LAMBERTS

2015 was a hard year for my father. He’s a remarkably healthy 89 year-old, with no diabetes, no hypertension, and (most importantly) he’s got a sharper mind than I do on most days. Perhaps that’s a low bar to cross, but it’s pretty good for him. I think this is from all the crossword puzzles he’s done over the years.

Dad’s troubles started around the middle of the year when he started having low back pain. This pain progressed from mild pain to being so severe that he required a wheelchair to get around the house. This is the man who, a year after breaking a hip, was impossible to keep off of a stepladder to fix something on his roof. It was a big change. After trials of conservative treatment, he was eventually diagnosed with a compression fracture of his lumbar spine (presumably from steroids he took for an inflammatory problem).

Given the severity of his pain, he ended up going to a back specialist to get a procedure to fix the compression fractures and, presumably, reduce his pain. Unfortunately, his pain increased and changed after the procedure. It got so bad, in fact, that he ended up being hospitalized in November for pain control.

The hospitalization was confusing for both him and me. It wasn’t clear if his pain was from a problem in his back, as it had moved to his leg. Yet while in the hospital he didn’t get any radiological study to determine the source. Plus, he’s quite resistant to the effects of narcotic pain medications. I really don’t like to intervene on behalf of family members unless it’s absolutely necessary, but I finally ended up talking to the hospitalist who was quite nice, but not much help. Dad was being discharged to rehab the next day and I still wasn’t clear on what was wrong after a week in the hospital.

What Would a Health Care Mutual Look Like?

Jan 5, 2016• 8

By MARC-DAVID MONK, MD

For a few years I’ve been fantasizing about what a healthcare insurance/ delivery mutual would look like. I’ve yet to see one but I like the idea a lot.

Here’s the idea behind a mutual: A mutual structure means that the company is owned by its clients or policyholders. Since a mutual’s customers are also its owners, they get to share in any surpluses though they are mostly reinvested in the business.

Wikipedia has a nice writeup on the fundamentals of mutuals:

A mutual exists with the purpose of raising funds from its membership or customers (collectively called its members), which can then be used to provide common services to all members of the organization or society. A mutual is therefore owned by, and run for the benefit of, its members – it has no external shareholders to pay in the form of dividends, and as such does not usually seek to maximize and make large profits or capital gains. Mutuals exist for the members to benefit from the services they provide and often do not pay income tax.

Mutual structures are most common in the banking (credit unions) and insurance industries. The main advantage to mutuals, as compared to public or privately held businesses is that they avoid the “principal-agent” problem (where the company’s desire to serve itself and the customer are at odds).

In a mutual, customer and owner are one.

Mutuals have been around for a few hundred years: “friendly societies” have been active in the UK and the US for a couple hundred years. Friendly Societies… were the original form of social network, where a group of people contributed to a mutual fund, to then receive benefits at a time of need.

Why I Left My Health Care Executive Role to Join a Startup

Jan 5, 2016• 4

By CAROLYN BRADNER- JASIK, MD

Six months ago, I made the decision to join a digital health startup, after directing the inpatient EHR roll-out at the University of California San Francisco (UCSF) Benioff Children’s Hospital. This may not seem that surprising: there is a lot of discussion lately of the growing dissatisfaction among doctors with the healthcare system, and “digital dropouts” leaving medicine to work in tech.

The difference is that I am neither 28 nor right out of residency. I’m a 40-year-old healthcare executive who is squarely mid-career, and I did not make the change for the usual reasons: the lure of money, job dissatisfaction, etc. I loved my job at UCSF, and in fact, I continue to see patients there. So why did I leave a promising academic career for a riskier role at a startup? Because we need more seasoned clinicians at the front lines of digital health to get us to scale. Our institutions have made huge financial investments, and now it’s time for us to make a more personal commitment.

Changes In Work Hours and Employer Insurance Not Borne Out

Jan 5, 2016• 3

By RICK KRONICK

Today, two AHRQ-sponsored studies were released that conclude that the Affordable Care Act (ACA) has not reduced the availability of full-time work or the work incentive for low-wage workers.

In the first study, researchers examined the effects of the requirement in the ACA for employers to provide health coverage to employees working at least 30 hours a week or pay a penalty. Using data from the Census Bureau’s Current Population Survey, an interview of approximately 60,000 households monthly, researchers did not find increases in the frequency of working either 25-29 hours weekly or fewer than 25 hours weekly in 2013, 2014 or the first half of 2015. Researchers also did not find a reduction in 2014 or 2015 in the frequency of working 30-34 hours, further demonstrating that employers have not reduced employee work hours below the 30-hour threshold to avoid the requirement to provide coverage.

In the second study, researchers assessed the impact of the expansion of Medicaid coverage on low-wage workers by analyzing job loss, job switching, and full- versus part-time status. Based also on data from the Census Bureau’s Current Population Survey, researchers compared states that had not expanded the program to states that have done so. The researchers found no statistically significant changes in labor market behavior as a result of Medicaid expansion, contrary to claims that the law would substantially reduce labor supply.

Think Again: Health Insurers Have No Reason To Reduce the Price of Health Care

Jan 1, 2016• 7

By JK WALL

If the mega-mergers among health insurers are allowed to go through, it will create insurers with more bargaining power that can hold the line on prices paid to doctors and hospitals.

At least that’s been the standard rationale given in the business press for why Anthem Inc. is trying to buy Cigna Corp. and Aetna Inc. is trying to buy Humana Inc.

It’s also one reason why doctors and hospitals fear the deals. The American Medical Association cited lower prices as one key reason in its request for the U.S. Department of Justice to block the Anthem-Cigna deal.

“When mergers result in monopsony power and physicians are reimbursed at below competitive levels, consumers may be harmed in a variety of ways,” wrote Dr. James Madara, CEO of the American Medical Association, in a November letter urging the U.S. Department of Justice to block both the Aetna-Humana and the Anthem-Cigna deals.

But this fretting over price negotiations is a side show, as everyone in the finance departments of health systems knows—or ought to know.

That’s because health insurers like Anthem and Aetna have little to no incentive to hold down the price of care. Rather, they directly benefit when the price of care rises.

Let me explain how.

What the Wall Street Journal Tells Us About Complications After Surgery: Not Much

Dec 31, 2015• 7

By ANISH KOKA, MD

The Wall Street Journal published an article on Christmas day that told the story of an 83 year old woman who suffered a heart attack after a joint replacement at a rural hospital. The story serves as an introduction to a piece about the higher cost and poorer care delivered at rural hospitals. There are certainly some very interesting points I was not aware of with regards to financial incentives provided by the government to do procedures at rural ‘critical access’ hospitals, as well as higher 30 day mortality after joint replacement surgery at these rural hospitals.

The Wall Street Journal article does provide this nugget from a Harvard public health researcher: “Patients are getting bad outcomes, probably because they are getting procedures at hospitals without the experience to do it well.”

This certainly may be true, but no data exists in the article to back-up this assertion. Are there more infectious complications of the surgery? Are there more re-operations? Are the surgeons that operate at these centers less experienced?

21st Century Cures Act: Away From the “Valley of Death”

Dec 31, 2015

By STEVEN ZECOLA

Most people would agree that the number of cures for debilitating and costly illnesses such as Alzheimer’s disease, Parkinson’s disease and cancer have been too few and far between.

To address this issue, the U.S. House of Representatives recently passed the 21st Century Cures Act, which now resides in the U.S. Senate for action. The main thrusts of the Act are to increase government funding for research and to improve several regulatory processes.

Unfortunately, the Act does not address the root cause of the dearth of cures; namely, the inhospitable investment climate for research and development (“R&D”) culminating in the “Valley of Death” for most health-related discoveries.

How Should Errors In the Patient Medical Record Be Addressed?

Dec 30, 2015• 3

By PETER ELIAS, MD

This summer an article in USA Today talked about Regina Holliday’s efforts to make the medical record more easily and promptly available to patients so it becomes as a tool patients use as they engage in co-managing their own care. Her cause is just and her story is compelling, so I was dismayed at the pushback saying: Not so fast. There are lots of errors and ambiguities in the record, so it is in everyone’s best interest to make the record hard for patients to obtain.

What a concept.

The commonest examples listed by opponents of patient access to patient information reflected a combination of poor communication with patients and concern about the extra work that transparency might require for institutions and clinicians. For example:

“…the majority of patients don’t understand differential or provisional diagnoses and want those removed, because they say they are an error. The majority of patients don’t understand trade versus generic drug names, and want those removed because they are an error. The majority of patient’s don’t understand autopopulation of fields (when you click normal) and say the doctor didn’t ask me those things, and want them removed because they are an error; the majority of patients don’t understand spontaneous abortion, and definitely want that removed it, because they never had an abortion; the majority of patients don’t want “dependence on” anything included in their records, and want it removed because it’s an error…. they are very unhappy with all the errors in their medical record. And then, there are the legitimate errors due to poor documentation on admission, hospitalists who see the patient once and don’t review the record adequately, and nursing staff who just want to get their charting done and go home.”

Wow! Everyone who works with medical records knows that the record is full of both errors and ambiguity. The question is what to do about it. There are two general categories of response.

The 2016 Regulatory Landscape: A Review For Health Care Watchers

Dec 30, 2015• 1

By PAUL KECKLEY

The healthcare industry in the U.S. is highly-regulated at the state and federal levels, and the balance between the two depends on what part of the industry you’re in. To illustrate—

Health insurers are overseen by state insurance regulators, but the Affordable Care Act added a new layer of federal oversight. The current tussle between HHS and the National Association of Insurance Commissioners over what constitutes an accessible network of providers is a case in point.

The 56,000 retail pharmacies are overseen by states, but drug manufacturers and distributors are overseen by the FDA and FTC, and the 3000 compounding pharmacies find themselves regulated by both.

Physicians are primarily self-regulated by their state licensing and disciplinary boards, but federal rules that require transparency (Physician Sunshine Act) about their performance and prescribe limitations in their business dealings (Stark rules) take precedent.