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Two Former Obama Health Advisors Whistle in the Dark about End of Health Insurance Companies

Oct 1, 2018

By Richard Reece, MD

Ezekiel Emanuel and Jeffrey Liebman, a regular contributor to the New York Times and professor of public policy at Harvard, respectively, say health insurers will disappear by 2020.

In their opening paragraph in a January 30 blog in the New York Times, “The End of Insurance Companies”, they assert:

“Here’s a bold prediction for the new year. By 2020, the American health insurance industry will be extinct. Insurance companies will be replaced by accountable care organizations — groups of doctors, hospitals and other health care providers who come together to provide the full range of medical care for patients.”

They presume this development will leave no room for insurers.

They continue, “A new system is on its way, one that will make insurance companies unnecessary.” The new system, they confidently predict, will consist of accountable care organizations, made up of collaborating hospitals and doctors. ACOs will offer bundled payments. Fee-for-service payments will cease to exist.

ACOs, the two Obamanites imply, will sprout, flourish, and metastasize across the land from sea to shining sea.

Their prediction may be bold, but I believe it is wrong.

A Question of Worth

Oct 1, 2018

By Eijean Wu, MD

As an OB/GYN resident, I tried to reconcile quality and cost of care every day. This is the story of one patient who cost the system a lot of money, but I don’t know to this day if it was too much.

Cheryl (name changed) had HIV, a history of cervical cancer, and 3 kids. At age 35, she had been cured from cervical cancer after surgery and radiation therapy. However, due to treatment-related fistulas, she had been in and out of the hospital for most of the year. I was taking call for the gynecology service the last time her family brought her in, delirious and with black, sticky stool oozing from an opening in her unhealed abdominal incision. She needed wound care and close monitoring in the intensive care unit (ICU). I paged the ICU team.

The ICU fellow came promptly, and briskly refused to accept her to his unit. “She is a poor use of scarce resources,” he stated matter-of-factly. “Further treatment is futile.” Without missing a beat, I looked him in the eye and countered, “What if this was your sister? Your mom?” He relented begrudgingly, but added, “This is why health care is so expensive in this country. You surgeons don’t know when to let go.”

Too Expensive to Treat? God and Medicine in the Neonatal ICU

Oct 1, 2018

In Too Expensive to Treat? Charles Camosy takes readers deep into the emotionally charged and expensive world of the neonatal intensive care unit to examine the hard truth about heath care rationing in the United States. While fully affirming the human worth of even the tiniest baby, Camosy maintains that all people have equal dignity and should have an equal right to a proportionate share of community health care resources. Readers may find Camosy’s arguments provocative, even troubling — but the conversation he draws them into is one that cannot be ignored.

Daniel Sulmasy
— University of Chicago
“A substantial contribution to the literature on controlling health-care costs. . . . Camosy has written a provocative book, marrying the ordinary/extraordinary means tradition to Catholic social teaching and arguing that it is morally necessary to take costs into account in making decisions about who should receive high-tech neonatal intensive care. Since the magnitude of the problems Camosy addresses will only increase, this is a book that should be read for years to come.”

Steven R. Leuthner
— Medical College of Wisconsin
“This book is a must-read for neonatologists and bioethicists, for religious leaders of all Christian traditions, and for policy makers. While Camosy focuses on the imperiled newborn and Medicaid, his argument could easily be expanded to imperiled cases of any age.”

Gerald McKenny
— University of Notre Dame
“Camosy not only shows us how to solve a pressing social and bioethical problem. He also shows us how principles regarding human dignity, ordinary and extraordinary means, and social justice unite to form a coherent bioethical approach to health care justice that resonates far beyond the Catholic tradition. Camosy’s proposal will delight some and disturb others, but it deserves the closest attention of neonatologists, bioethicists, health policy experts, and anyone who hopes for a more just health care system in the United States.”

Let Them Eat Cheesecake!

Oct 1, 2018

By John Goodman

Atul Gawande’s piece in the New Yorker elicited . In today’s post John Goodman writes .

This is Atul Gawande, writing about The Cheesecake Factory in The New Yorker:

You may know the chain: a hundred and sixty restaurants with a catalogue-like menu that, when I did a count, listed three hundred and eight dinner items (including the forty-nine on the “Skinnylicious” menu), plus a hundred and twenty-four choices of beverage.

How many different dinners — say with two food items and one beverage — can you draw from 308 food choices and 124 beverages? I used to know how to do this. It must be in the millions. So how do you make that work? Timing is everything:

Computer monitors positioned head-high every few feet flashed the orders for a given station. Luz showed me the touch-screen tabs for the recipe for each order and a photo showing the proper presentation. The recipe has the ingredients on the left part of the screen and the steps on the right. A timer counts down to a target time for completion. The background turns from green to yellow as the order nears the target time and to red when it has exceeded it.

The restaurant doesn’t just get plates on the table, however. It aims for perfection:

Meaningful Use — A Pinch of 3 and a Dash of 4

Oct 1, 2018

By Margalit Gur-Arie

While most folks are busy trying to keep up with Meaningful Use Stage 1, and Meaningful Use Stage 2 only recently emerged from the customary rulemaking process, those who plan for distant futures are providing us a glimpse of what is being considered for Meaningful Use Stage 3 and here and there a hint at the possibility of a never before mentioned Stage 4 and beyond. Since Stage 2 is still somewhat theoretical, there is little value to enumerating the proposed measures of Stage 3, which is not due to take effect until 2016, but it may prove instructive to take a general look at the overall direction that seems to be favored by policy makers for future design and use of EHR technologies. To that end, several new proposed measures seem most enlightening.

The New US Census Bureau

Stage 1 of Meaningful Use added language, race and ethnicity to the customary demographic information collected from patients, such as name, address, date of birth, gender, etc. Stage 2 proposes to add language, race and ethnicity to clinical summaries provided to patients or sent to other providers of care. So the patient header of a Stage 2 clinical summary might look something like this:

It’s The Platform, Stupid: Capturing the Value of Data in Campaigns — and Healthcare

Oct 1, 2018

By David Shaywitz, MD

If you’ve yet not discovered Alexis Madrigal’s fascinating Atlantic article (#longread), describing “how a dream team of engineers from Facebook, Twitter, and Google built the software that drove Barack Obama’s re-election,” stop right now and read it.

In essence, a team of technologists developed for the Obama campaign a robust, in-house platform that integrated a range of capabilities that seamlessly connected analytics, outreach, recruitment, and fundraising. While difficult to construct, the platform ultimately delivered, enabling a degree of logistical support that Romney’s campaign reportedly was never able to achieve.

It’s an incredible story, and arguably one with significant implications for digital health.

(1) To Leverage The Power of Data, Interoperability Is Essential

Data are useful only to the extent you can access, analyze, and share them. It increasingly appears that the genius of the Obama campaign’s technology effort wasn’t just the specific data tools that permitted microtargeting of constituents, or evaluated voter solicitation messages, or enabled the cost-effective purchasing of advertising time. Rather, success flowed from the design attributes of the platform itself, a platform built around the need for inoperability, and guided by an integrated strategic vision.

A Cowardly New World

Oct 1, 2018

By Brian Goldman, MD

Last month, the National Post’s Tom Blackwell reported that a growing number of hospitals say patients and their families are secretly recording doctors and nurses. Some say it’s a symptom of the breakdown of trust being patients and their physicians. Welcome to a Cowardly New World.

The biggest examples that reported in the National Post included a video camera installed in a clock radio to secretly record doctors and nurses as they treated a patient. The footage was used as evidence regarding substandard care at Sunnybrook Health Sciences Centre in Toronto. At Toronto’s University Health Network, a video camera was reportedly concealed inside a teddy bear. A camera concealed in a wrist watch was used to record evidence against a Calgary psychiatrist. Smart phones are also being used overtly and also surreptitiously.

I have experienced this first hand in the ER. On one occasion during a night shift, as I was about to stitch up a patient’s cut, his buddies asked if they could record me doing it. I thought it was kind of cute and innocent. The recording took place in a closed room away from other patients so there was no risk anyone else could be filmed surreptitiously.

To be clear, that example was overt. I had another patient encounter that was quite different. I remember seeing an elderly patient who came to the ER with a medical problem. Both the patient and a relative were present in the room the first time I saw him. I came into the room a second time to give the patient and the relative some test results. As I walked into the room, I noticed that a cell phone was on a chair in the room; it was seated in the middle of the seat cushion, sort of like an invited guest. I paid no further attention to it.

The relative said the patient’s daughter (a physician) and was en route the hospital to speak with me. I started to tell the patient and the relative my working diagnosis and my management plan. Suddenly, the cell phone talked! A voice emanated from the smart phone’s speaker disagreeing with me! The daughter had been surreptitiously listening in all along.

Will Healthcare Law Pit Obama vs. Roberts?

Oct 1, 2018

By James F. Simon

President Franklin D. Roosevelt reacted with fury when major legislative pillars of his New Deal were declared unconstitutional by a Supreme Court anchored by four ideological conservatives. He lashed out at the justices, accusing them of practicing crass politics disguised as constitutional law.

Seventy-five years ago last month, FDR proposed his ill-fated court-packing plan that would have allowed him to stack the court with new appointees sympathetic to the New Deal.

Will history be repeated this term when the Roberts court decides the constitutional fate of President Obama’s signature legislation, the Affordable Health Care Act?

The justices will hear five-and-a-half hours of arguments over three days, March 26-28, on the healthcare law and deliver their judgment by the end of the term. If the court strikes down all or part of the law, Obama, like FDR before him, will almost certainly denounce the court’s decision. After all, he has already had practice in publicly criticizing the court. At his 2010 State of the Union address, with the justices sitting directly in front of him, he accused the court majority in the Citizens United decision of reversing a century of constitutional law to open “the floodgates for special interests… to spend without limit in our elections.”

Besides the willingness of both FDR and Obama to criticize the court, there are other parallels between the two Democratic presidents. Both came to office as liberal reformers who envisioned a large role for the federal government in promoting the nation’s welfare. But in defending their policies, they revealed their very different political styles and temperaments.

Supreme Court Needn’t Fear Healthcare Law’s Individual Mandate Provision

Oct 1, 2018

By Vikram Amar and Alan Brownstein

The Affordable Care Act faced a possibly fatal challenge when the constitutionality of its individual mandate provision was argued in the Supreme Court.

Much of the terrain was easy going. Neither the justices nor the lawyers doubted that the healthcare and healthcare insurance markets involve interstate commerce — insurance and healthcare providers are usually national or at least regional operations, folks who cross state lines get sick and must be cared for away from home regularly, and people are often unable to relocate to another state for fear of losing employer-based coverage. Nor was it disputed that the mandate was sincerely motivated by and closely related to the regulation of these interstate markets. Those two conclusions are usually sufficient to justify the exercise of congressional power under the commerce clause of the Constitution.

But then things got more treacherous. The problem, suggested by numerous questions from the conservative justices on the court, was the slippery slope they saw created by the mandate — the idea that Congress was requiring individuals to buy something. If the feds can require each person to buy health insurance, what can’t they force people to purchase?

Obamacare HHS rule would give government everybody’s health records

Sep 1, 2018

By Rep. Tim Huelskamp

It’s been said a thousand times: Congress had to pass President Obama’s health care law in order to find out what’s in it. But, despite the repetitiveness, the level of shock from each new discovery never seems to recede.

This time, America is learning about the federal government’s plan to collect and aggregate confidential patient records for every one of us.

In a proposed rule from Secretary Kathleen Sebelius and the Department of Health and Human Services (HHS), the federal government is demanding insurance companies submit detailed health care information about their patients.

(See Proposed Rule: Patient Protection and Affordable Care Act; Standards Related to Reinsurance, Risk Corridors and Risk Adjustment, Volume 76, page 41930. Proposed rule docket ID is HHS-OS-2011-0022 http://www.gpo.gov/fdsys/pkg/FR-2011-07-15/pdf/2011-17609.pdf)

The HHS has proposed the federal government pursue one of three paths to obtain this sensitive information: A “centralized approach” wherein insurers’ data go directly to Washington; an “intermediate state-level approach” in which insurers give the information to the 50 states; or a “distributed approach” in which health insurance companies crunch the numbers according to federal bureaucrat edict.