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Doctors Without State Borders: Practicing Across State Lines

Feb 24, 2014• 18

By Robert Kocher, MD

In the United States, a tangled web of federal and state regulations controls physician licensing. Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).

This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.

We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses. To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.

The Current System And Its Drawbacks

State licensure of physicians has been widespread in the United States since the late nineteenth century. Licensure laws were ostensibly enacted to protect the public from medical incompetence and to control the unrestrained entry into the practice of medicine that existed during the Civil War. However, it no longer makes sense to require a separate medical license for each state.

Today, medical standards are evidence-based, and guidelines for medical training are set nationally through the Accreditation Council for Graduate Medical Education, the Centers for Medicare and Medicaid Services’ Graduate Medical Education standards, and the Liaison Committee on Medical Education. All U.S. physicians must pass either the United States Medical Licensure Examinations or the Comprehensive Osteopathic Medical Licensing Examination.

Although the basic standards for initial physician licensure are uniform across states, states impose a patchwork of requirements for acquiring and maintaining licenses. These requirements are varied and burdensome and deter doctors from obtaining the licenses required to practice across state lines.

What A Green Three Ring Binder Says About the State of Meaningful Use and Health Information Exchange

Feb 24, 2014• 5

By Rob Cronin

The photo says it all.

The green notebook and pen represent the latest and greatest health IT innovations used by the hospital nurse to record my wife’s health information in the hours before her surgery to re-attach a fully torn Achilles tendon.

(Apologies for the cheeky intro and to my wife and anyone else for any HIPAA violations I may have committed in the capturing of this image).

It’s not that the hospital does not have an electronic health record.

They do – from a vendor widely considered a leader in the industry: Meditech. Same goes with the physician practice where she receives all her care and where her surgeon and primary care doctor are based.

They too have an EHR from another leading vendor: NextGen.

The problem? These systems are not connected. Thus, confirming the not so surprising news that health data interoperability has yet to make its debut in our corner of the NYC burbs.

Fortunately for my wife, she is well on her way to recovery (a bit more reluctant to juggle a soccer ball with her son in airport passenger lounges, but nevertheless feeling much better…and mobile). By everyone’s estimation – hers, mine, friends who suffered the same injury and friends who happen to be doctors – she received high quality care.

What’s more, we feel the overall patient experience at our physician practice and the hospital was quite good. That said, I cannot help but ask myself a series of ‘what ifs?’

What if…we forgot to mention a medication she was taking and there was a bad reaction with medication they administered as part of the surgery or afterwards?

What if… the anesthesiologist or surgeon couldn’t read the nurse’s handwriting?

What if the next time we go to the hospital, it is a visit to the emergency room and the attending clinicians have no ability to pull any of my family’s health records and we are not exactly thinking clearly enough to recall details related to medical history?

Seven Reasons Why Your Doctor Is Still Using Technology That Sucks

Feb 24, 2014• 8

By Charlene Ngamwajasat

Did you ever walk into a doctor’s office and then have to fill out a long paper intake form with the same information you’ve filled out multiple times before (name, date of birth, insurance etc)? Or notice that your doctor is writing notes on pieces of paper that remind you of your days in school? Did you ever see someone carry a pager around? Was that person wearing a white coat?

You can bank and pay for your Etsy/Amazon/Target/Apple “gotta have that now” stuff online. You can Skype with your family who lives thousands of miles away. You can order a pizza & know the exact moment it comes out of the oven. You can interact with @Oreo, @TacoBell @Grumpycat online.

So why can’t you easily see your health charges online? Why can’t you get a quick text or email that you’ll be seen by your doctor in 10 minutes? Why can’t you Skype with your doctor?

1. Until recently, your doctor has probably had little to no training or exposure to the world of digital health.

If you do a quick and dirty poll and ask the MD’s in your life what it is, you’ll likely get a ?-mark look or an answer related to apps, electronic medical records, or meaningful use. How can that be? Don’t most doctors have smartphones & tablets? Yes, a lot do but their use in a professional capacity isn’t 100% yet.

Until recently, there were no courses in med school or noon lectures in residency related to health information technology, wearables, personalized medicine, medical apps etc

It’s hard to use something or integrate it into your daily life if you’ve never heard of or really used it before.Continue reading…

CVS Caremark Enters CommonWell

Feb 24, 2014• 4

By John H. Hammergren

One of the most critical issues facing our healthcare system is the fact that the IT systems we’ve put in place have not yet led to a more connected, intelligent approach to patient care.

While we have made notable headway toward interoperability through health information exchange solutions, we must dramatically accelerate our progress to support the transition to value-based care and realize our full potential as an industry.

With this vision in mind, McKesson, Cerner and other leading healthcare IT companies announced the CommonWell Health Alliance last year at HIMSS13. Members of the Alliance are united by a shared commitment to develop a core set of interoperability services and standards that will enable patient data to be shared securely across care settings and electronic health record (EHR) platforms.

In the twelve months since, tremendous progress has been made in making this aspiration a reality. CommonWell is running robust initial projects and collaborating with a myriad of practices. We’re also continuing to expand with new members who share our ideal of the trusted exchange of patient data, regardless of vendor, system, or setting.

Now, the Alliance is welcoming its first pharmacy member in CVS Caremark. This is a watershed event for several reasons.

CVS Caremark is one of the nation’s largest retail pharmacy chains and pharmacy benefit management companies. Few organizations in any segment of healthcare have more access to patient data and more trusted influence.

But CVS Caremark’s role in driving innovation in our healthcare system, and its importance to the goal of interoperability, is vital for other reasons.

Can Oscar Succeed In Making Health Insurance Fun? Maybe Not Just Yet. But the Startup Is Shaking Things Up …

Feb 24, 2014• 3

By Kate Greenwood

Last week I went to a panel presentation sponsored by the group NYC Health Business Leaders on the rollout of New York State’s health insurance exchange. Among the speakers was Mario Schlosser, the co-founder and co-CEO of the venture-capital-backed start-up health insurance company Oscar Health, which offers a full range of plans through New York’s exchange.

As NPR reported last month in a story about Oscar, “it’s been years since a new, for-profit health insurance company launched in the U.S.”, but the Affordable Care Act created a window of opportunity for new entrants.

Schlosser began his talk by giving us a tour of his personal account on Oscar’s website, www.hioscar.com. Among other things, he showed us the Facebook-like timeline, updated in real time, which tracks his two young children’s many visits to the pediatrician.

He typed “my tummy hurts” into the site’s search engine and the site provided information on what might be wrong and on where he might turn for help, ranging from a pharmacist to a gastroenterologist, with cost estimates for each option.

Additional searches yielded information on covered podiatrists accepting new patients with offices near his apartment and on the out-of-pocket cost of a prescription for diazepam (which was zero, since there is no co-payment for generic drugs for Oscar enrollees).

As an audience member noted, none of this is new exactly. What is new is to have this kind of data-driven, state-of-the-art user experience being offered by a health insurer. Schlosser told the audience that Oscar’s pharmacy benefit manager and other vendors are providing the company with real-time data that other insurers have not demanded.

What You Need to Know About Patient Matching and Your Privacy and What You Can Do About It

Feb 21, 2014• 4

By Adrian Gropper, MD

Today, ONC released a report on patient matching practices and to the casual reader it will look like a byzantine subject. It’s not.

You should care about patient matching, and you will.

It impacts your ability to coordinate care, purchase life and disability insurance, and maybe even your job. Through ID theft, it also impacts your safety and security. Patient matching’s most significant impact, however, could be to your pocketbook as it’s being used to fix prices and reduce competition in a high deductible insurance system that makes families subject up to $12,700 of out-of-pocket expenses every year.

Patient matching is the healthcare cousin of NSA surveillance.

Health IT’s watershed is when people finally realize that hospital privacy and security practices are unfair and we begin to demand consent, data minimization and transparency for our most intimate information. The practices suggested by Patient Privacy Rights are relatively simple and obvious and will be discussed toward the end of this article.

Health IT tries to be different from other IT sectors. There are many reasons for this, few of them are good reasons. Health IT practices are dictated by HIPAA, where the rest of IT is either FTC or the Fair Credit Reporting Act. Healthcare is mostly paid by third-party insurance and so the risks of fraud are different than in traditional markets.

Healthcare is delivered by strictly licensed professionals regulated differently than the institutions that purchase the Health IT. These are the major reasons for healthcare IT exceptionalism but they are not a good excuse for bad privacy and security practices, so this is about to change.

Health IT privacy and security are in tatters, and nowhere is it more evident than the “patient matching” discussion. Although HIPAA has some significant security features, it also eliminated a patient’s right to consent and Fair Information Practice.

Bigger Hospitals Mean Bigger Hospitals with Higher Prices. Not Better Care.

Feb 20, 2014• 52

By Shannon Brownlee & Vikas Saini, MD

Hospitals are busily merging with other hospitals and buying up groups of doctors. They claim that size brings efficiency and the opportunity to deliver more “value-based” care — and fewer unnecessary services.

They argue that they have to get bigger to cut waste. What’s the evidence that bigger hospitals offer better value? Not a lot.

If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts.

The Dartmouth Atlas of Health Care and other sources have shown time and again that some of the biggest and best-known U.S. hospitals are no less guilty of subjecting patients to useless tests and marginal treatments.

Larger hospitals are also very good at raising prices. In 2010, an analysis for the Massachusetts attorney general found no correlation between price and quality of care.

A study published recently in Health Affairs offered similar results for the rest of the country: On average, higher-priced hospitals are bigger, but offer no better quality of care.

The Weightlessness of Obamacare

Feb 18, 2014• 3

By J.K. Wall

So many old rules in health care and insurance no longer seem to apply.

I keep stumbling upon situations, where, what used to be up is now down and what used to be down is now up.

No one seems to know for sure how things will settle out under the new reality created by Obamacare and the even more unpredictable reactions to the law by health care companies, employers and, most especially, you and me.

I’ve started using the term “weightlessness” to describe this state we’re in. Picture the astronauts on the international space station, floating through a room, flipping at will, as likely to settle on a wall or on the ceiling as on the floor.

That’s what life is like under Obamacare now—for physicians, hospital administrators, insurance executives, benefits brokers and employers.

Here are a few examples:

1. I wrote last week about how a chunk of workers, even at large employers with generous benefits, would actually get a better deal on health insurance from the Obamacare exchanges than from their employers. So their employers are starting to consider whether they should deliberately make health benefits unaffordable for those low-wage workers, so they can qualify for Obamacare’s tax-subsidized insurance.

That could be good for both employers and employees. The effect on taxpayers, which would switch from granting a tax credit to employers to instead granting it to the employees, is unclear.

2. Even though insurers were certain that price would be king on the Obamacare exchanges, that hasn’t led most customers to buy the plans with the cheapest premiums. As I wrote Friday, 76 percent of those shopping on the exchanges in my home state of Indiana have picked the higher-premium silver and gold plans, with only 24 percent picking bronze plans.

“There are a few geographies where we believe we are gaining share despite lower price competition which points to the value of our local market depth, knowledge, brand, reputation and networks,” WellPoint Inc. CEO Joe Swedish said during an January conference call with investors.

It’s possible that’s a result of older and sicker patients being the earliest buyers on the exchange, and that as healthier people buy coverage, they’ll gravitate to the low-cost bronze plans. But that hasn’t happened—which, as I wrote on Friday, has proved wrong hospitals’ concerns about the super-high deductible bronze plans.

In Defense of the Defense of Mammograms

Feb 18, 2014• 12

By SAURABH JHA, MD

To the two certainties of life, death and taxes, add another two: mammograms and controversy surrounding mammograms.

The Canadian National Breast Screening Study (CNBSS) has reported results of its long term follow-up in the BMJ: no survival benefit of screening mammograms.

To paraphrase Yogi Berra “it’s mammography all over again.”

Is the science settled then?

No.

Before I wade further it’s important to understand what is implied by “settling the science.”

Einstein said “no amount of experimentation can prove me right; a single experiment can prove me wrong.”In physical sciences a theory need only be disproven once for it to be cast aside. Heliocentricity cannot coexist with Ptolemy’s universe. The statement “all swans are white” is disproven by a single black swan.

What do we do with the studies that showed survival benefit of screening mammograms? Why does the CNBSS not close the debate over mammograms, like Galileo did with celestial egocentricity?

The simple and simplistic answer is because there are powerful advocacy groups, special interests; the pink-industrial complex who have a vested interest in undermining the science.

But that lends to conspiratorial thinking. Special interests cannot undermine Maxwell’s equations or Faraday’s laws just because they do not like them.

The testability of Maxwell’s equations is inherently different from verifying that screening mammograms increase life expectancy. We must acknowledge two types of science; the former, physical science, a hard science; the latter, a hybrid of biology and epidemiology, soft science.

Soft science is a misnomer. There is nothing soft about performing a randomized controlled trial (RCT), the methodological gold standard; in ensuring factors that falsely augment or attenuate impact of screening mammograms are evenly distributed, data reliably collected, cause of death accurately recorded and correctly inferred. But the human factor and all its inevitable foibles are unavoidable in soft sciences.

How Much Is Health Care Worth?

Feb 17, 2014• 18

By Paul Keckley

Higher education has a relative value problem.

The product of higher education is widely embraced in the United States: 20 million students attend our 3000 schools of higher learning.

Per the Bureau of Labor Statistics, a college grad can expect to earn 1.7-2.7 times the lifetime income of a student who finished high school and entered the workforce.

A college degree provides higher employment security: in 2012, the unemployment rate for college grads was 4.5% versus 8.3% for those with high school diplomas.

Colleges play a key role in our local communities—for economic development, workforce development and as a major employer.

And a recent Pew Research survey (February, 2014) found 9 of 10 with college degrees believe the investment has or will pay off.

Higher education does not have a value problem: its value proposition against the option of not getting a degree is solid.

But higher education has a relative value problem.

Since 1985, the price of higher education has increased 538% versus medical costs (+286%) and the consumer price index (+121%).

Stated differently, annual tuition increases have been 7.4%–more than healthcare (5.8%) housing (4.3%) and family income (3.8%). Last year, students and families paid $154 billion in tuition and fees to attend college: 60% borrowed $106 billion to help pay their bill.

In the end, 38% enrolled in four-year degree programs and 21% in two-year degree programs will not graduate on time. One in seven with student loan debt will be delinquent on their debt, and student loan indebtedness, now at $1 trillion, will shortcut household discretionary spending that might otherwise be injected in our economy. And incomes for college grads have stagnated for the past 12 years.

The perplexing question facing higher education is this: does a college degree pay? And more precisely, what is relative value of each institution’s offering given alternatives?