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John Irvine

How to Win Friends and Influence Doctors

Screen Shot 2015-06-29 at 4.07.40 PMI remember the meeting as if it were yesterday.

It was a fine, crisp morning. My Health Catalyst team and I were at a new partner hospital with a national reputation, known for its excellent coordinated care and its outstanding performance on key quality measures.

I was looking forward to a low-key presentation. After the meeting, I planned to escape and take a relaxing run and catch the early flight back home.

Unfortunately for me and my running plans, when we began showing some of the data Health Catalyst had compiled, the confrontational questions began:

“And what does that show?”

“What’s the point of this exercise?”

“Not my patients …”

It was all I could do to not duck behind my notepad and shield myself from the onslaught.

After several years of successful quality improvement initiatives and a string of successes that had the won the hospital national recognition, tensions between the administration and the doctors had reached a breaking point.

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How Population Health Is Driving Merger Mania Among Anthem, Cigna and the Rest of the Big Insurers

The nation’s Big 5 health insurers have thrived under the Affordable Care Act, seeing their profits grow and their stock prices soar.

They also continue to dwarf their main sparring partners—hospital systems—in size. Consider that the largest health insurer, United Health Group, has annual revenue of $130 billion, while revenue at the largest hospital system, HCA, is a tick under $37 billion. The second-largest health insurer, Anthem Inc., has $74 billion in annual revenue, while the second-largest hospital system, Ascension, has $20 billion.

So why are health insurers so desperate to get bigger? Anthem has offered $47 billion to acquire Cigna Corp., and United, Humana and Aetna are all trying to counter with mega-deals of their own.

Well, it’s about economies of scale and all that—the Affordable Care Act and other changes are squeezing the amount of profit insurers can make per customer, even as the pool of paying customers is growing. Also, hospital systems, while still more fragmented than insurers, are consolidating, as are drug and device makers. So insurers want to boost their bargaining power.

But the real reason is population health.

“In order to do population management, you need populations,” Dhan Shapurji, a Deloitte consultant to health insurers, quipped in a phone call with me this week.

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Uber and the Twisted Logic of the Affordable Care Act’s Employer Mandate

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We have recently blogged about what is perhaps the best feature of the Affordable Care Act – the individual insurance exchanges. These exchanges have the potential to create one of the first well-functioning individual insurance markets in the United States. In addition, they are an implicit recognition of the nature of the contemporary American economy – one where workers frequently move employers and are increasingly serving as independent contractors for multiple firms.

However, a recent ruling by the California Labor Commission reminds us of what must be one of the worst features – the requirement that large employers provide health insurance to all employees working more than 30 hours per week.  This mandate is a remnant of a 1950s economy where workers remained employed at the same firm for decades and the Internet was just a series of tubes that existed in our dreams.  Ironically, the ACA insurance exchanges not only make the employer mandate obsolete, but the mandate actually weakens the viability of the exchanges by locking a large portion of the healthy population into the employer provided insurance market.

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Driving Innovation Through an Apps-Based Information Economy

In case you think the future for healthcare apps will be characterized by health information technology (HIT) “dead zones” of free downloads, fun gadgetry and vacuous consumerism with nothing to show for it, you should take a look at  this article appearing in the peer-reviewed journal Cell Systems.

If authors Kenneth Mandl, Joshua Mandel and Isaac Kohane are even half right, “apps” could truly revolutionize HIT.  They argue that a superimposed “apps layer” ecosystem will demolish the “walled gardens” of EHRs and allow for true information sharing across clinics, systems and regions.

And that’s just for starters.

As your correspondent understands it, “Application Programming Interfaces” (or “APIs”) will enable multiple third party apps to bridge to legacy EHRs.  That, in turn, will catalyze the creation of newer and better user experiences that reconcile doc and patient preferences with the current clunky one-size-fits-all EHRs.

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Two Years Later: How Kynect Has Impacted Kentucky’s Healthcare System

Since its second enrollment period ended in March, Kentucky’s health benefit exchange has been celebrated by state government leaders as a success story of the Affordable Care Act. Known as Kynect, the exchange has provided thousands of uninsured citizens with health insurance coverage. It has also drawn its share of controversy.

Although much of the discussion surrounding Kynect and the Affordable Care Act has focused on their political implications and other debates, little has been said about how the changes to Kentucky’s healthcare system have affected patients, nurses, doctors and hospitals. With two enrollment periods complete, how has Kynect worked and what benefits has it provided the state?

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King vs. Burwell: Supreme Court Backs Federal Health Law Subsidies

Screen Shot 2015-06-25 at 10.44.49 AMIn a 6-3 ruling, the Supreme Court ruled that the federal health law may provide subsidies to help Americans buy insurance on the state exchanges, officially putting a stop to one of the slowest-moving and arguably most mind-numbingly boring — if important — news stories in recent history (with all due apologies to tax credit enthusiasts and the American Academy of Actuaries).

More importantly, the ruling means that 30 million Americans will continue to be eligible for health insurance through the exchanges. Practically speaking, the decision eliminates the last major challenge to the Affordable Care Act.

Health stocks rose on the news, as the uncertainty that has been shadowing hospital and health plan stocks for months was eliminated.

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The dissenting opinion in King, authored by Justice Scalia, is already being called an “instant classic*,” is replete with memorable zingers such as:

“Words no longer have meaning if an Exchange that is not established by a State is “established by the State” and “..It is bad enough for a court to cross out “by the State” once. But seven times?

Dissenting opinions in important cases, of course, are almost always hailed as “instant classics” by supporters, just as they are thrashed as “incoherent judge-babble” by critics.

So to be taken with a grain of salt. Or not.

The line that is likely to be remembered, and quoted most widely by opponents of the Affordable Care Act, however, is this one:

“The Act that Congress passed makes tax credits available only on an ‘Exchange established by the State.’ This Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare.”

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Real Mentoring Lessons From the Liver Queen

Martin SamuelsIn 1970 I had the opportunity to spend time at the Royal Free Hospital in London.  One of my professors at The University of Cincinnati College of Medicine, the late Leon Schiff, a renowned liver expert, arranged for me to work under Professor Sheila Sherlock.  I was placed in a laboratory that was investigating the presumed immune basis of primary biliary cirrhosis.  Roy Fox and Frank Dudley, the faculty in the lab, warmly welcomed me and taught me the basics of immunology research.  My first scientific paper in Gut, was based on this work.  But, I was a budding clinician and I was drawn to the charismatic Professor Sherlock, so I took every opportunity to attend her rounds and teaching conferences.  In many ways a fearsome figure, The Prof dazzled me with her clinical acumen, rhetorical skills, sense of humor and drive.  Though only a lowly visiting medical student, she including me in the exercises and even turned to me as a local “expert” on American culture.  The entire experience is remarkably memorable.  The Prof was filled with pearls, anecdotes, stories and caveats.  Here are a few.

The “outpatient” consisted of the Prof seeing patients while the students watched.  The room was arranged with six cubicles, three on each side of her desk, each guarded by a watchful nurse (sister) with a neat uniform and starched hat.  In front of The Prof’s desk were several rows of chairs; perhaps a total of 16, for students who were to sit quietly unless specifically ask to speak or to feel the liver of one of the patients.

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Five Rules for a Real Mentor

1. Be a real expert (have something real about which to mentor)

2. Don’t avoid being a mentor because you are not “like” the mentee (e.g. gender, age, field, ethnicity)

3. Give negative feedback when necessary but don’t hold a grudge

4. Use your power to substantively help the mentee

5. Be proud of your mentees and tell them so (take real pleasure in their accomplishments)

Moneyball For Doctors and Nurses (and the People Who Run Hospitals)

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Michael Lewis’ 2003 best seller Moneyball recounts how Oakland Athletics’ manager Billy Beane beat the big-payroll odds in major league baseball by using analytics to field a competitive team. The dynamic between Beane and his Yale-trained geek, Peter Brand is the central theme: together they fought off naysayers using Brand’s sabermetrics model later credited with the Red Sox World Series win the next season.

This week, thousands of financial officers from across multiple sectors in healthcare will descend on Orlando for the Healthcare Financial Management Association Annual Institute (ANI), a four day potpourri of knowledge-sharing sessions punctuated by keynotes from industry luminaries and an active exhibit floor.

The growing complexity of healthcare financial administrative issues is daunting. Case in Point: ANI organizes its 80 sessions in 8 tracks titled Business Intelligence and Analytics, Clinical Integration, Collaboration for Decision-Making, Cost Management-Margin Transformation, Finance-Capital Markets, Payment Trends and Delivery Models, Regulatory and Compliance Updates, and Revenue Cycle and the Patient Experience. There’s something there for everyone—from the rookie in internal audit to the CFO in the C-Suite.

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Legislation that Could End Unwanted Medical Treatment

flying cadeuciiRoughly 25 million Americans have been subjected to unwanted medical treatment at some point in their lives, and that means we have a healthcare system that is not listening to patients. We all say we believe in patient-centered health care, and now we have a bill in the U.S. Congress that would put our money where our mouths are. Literally.

Senators Mark Warner (D-VA) and Johnny Isakson (R-GA) introduced legislation this month that would make sure Medicare recipients and their doctors know how much or how little treatment those patients would want as they approach the end of life. The Care Planning Act of 2015 would specifically create a Medicare benefit for people facing grave illness to work with their doctor to define, articulate and document their personal goals for treatment. Doctors will be rewarded with reimbursement for helping patients make very important end-of-life decisions when there is time and space to do so thoughtfully, before a crisis and when the patient can advocate for herself.

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