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Sense and Sensibility on Hypertension

Dec 19, 2013• 17

By Vik Khanna & Al Lewis

Every now and then even blind squirrels find acorns. The medical care industry, which long ago abandoned sensible fiscal and therapeutic restraint in the quest for new patients, finally treats us to a revised hypertension guideline that thoughtful people can conclude makes a great deal of sense. It is even based on evidence, or actually the lack of it, which is itself a startling admission of reality from an industry that dances around truth with a nimble sophistry envied by even the most mendacious politicians.

The hypertension guidelines are a sharp departure from last month’s cholesterol guidelines, produced by a supposedly equally august panel of “thought leaders” who gave us guidelines that seemed to channel the The Talking Heads quite literally. John P. Ioannidis, along with Nortin Hadler, easily one of the two or three most important physician thinkers of this or any generation, wrote that the cholesterol guideline will be either…”one of the greatest achievements or one of the worst disasters of medical history.”

If you haven’t read the hypertension guidelines, here is a useful summary:

we treat too many people today;
we rely too much on drugs for things that drugs cannot fix;
treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
if we are really going to improve cardiovascular health, which is strongly implicated not just in stroke, heart disease, and kidney disease, but also cognitive health, people are going to have to change behaviors because there aren’t enough pills on the planet to fix what ails us.

Cognitive health is an especially useful guidepost, because contrary to popular myth, it isn’t something that mysteriously disappears in nonagenarians. The seemingly age-related decline is more likely the manifestation of damage done by a lifetime of incremental harms. Isn’t it edifying to have scientists catch up to our moms?

The new guidelines leave us a redefinition of high blood pressure: greater than 150/90, except in cases where a comorbidity compels pursuit of 140/90 or lower to prevent end-organ damage. This has implications not just for medical care but for workplace wellness, which obsesses with hypertension when it is not obsessing with cholesterol and glucose.

The hypertension guidelines yank away from workplace wellness vendors yet another reason to fine or otherwise antagonize employees who don’t show up at health fairs. The progression of hypertension is strongly related to aging, and healthy aging is the most reliable bulwark against premature stroke, heart attack, kidney failure, or dementia. Unless workplace wellness vendors plan to follow people into retirement, which is when the overwhelming majority of heart attack, stroke, and dementia occurs, there is no logical reason to ask any employee what his or her blood pressure or deign to tell them how to address it.

What We Don’t Know Can Hurt Us

Dec 18, 2013• 32

By David Dranove & Craig Garthwaite

As the health insurance exchanges find their footing and potentially millions of Americans gain access to insurance, this may be a good time to step back and take a longer term view of the ACA. When you get down to it, expanding health insurance coverage was the easiest and least controversial part of health reform. There is no shortage of ways to expand health coverage and almost any credible health reform proposal would have done the job, provided enough money was thrown at the problem.

In designing the ACA, perhaps as a result of political pressure, President Obama opted for a combination of heavily subsidized individual insurance exchanges and generous expansions of Medicaid. Freed from political constraints, he might have instead pushed for the single payer system that many of his most ardent supporters desired. Republicans inclined to expand coverage (at least one of us is proof that unlike the unicorn these do exist) might have pushed for a pure voucher program that harnessed market forces.

All of these options would expand coverage to the degree that policymakers were willing to fund them. So while we congratulate the President for his political success (we doubt the other options could have made it through Congress), it is a simplistic mistake to evaluate the implementation of the ACA by counting the numbers of uninsured or waiting for the monthly updates on the enrollment figures from the exchanges website. Any regulator with a big enough purse can, in the fullness of time, expand access. Frankly, that’s the “easy” part of healthcare reform.

But what about the other elements of the so-called “triple aim” of health reform: cost and quality? You see, while we agree that liberal, moderate, and conservative health reforms can all improve coverage, they each will have very different effects on the other important outcomes. Consider for example the oft-discussed “Medicare for all”; i.e. a single payer system. This would increase access without the messiness of the exchanges. It would also allow the government to flex its monopsonistic muscles and quickly reduce costs – though likely at the expense of quality. In contrast, relying on markets may not reduce costs in the short run, and may not necessarily reward real quality (though it has a better short than single payer in this regard).

Evaluating health reform in the context of the “Triple Aim” is important, but even that approach is not nearly enough. There is a broad consensus among that technological change is the most important long run driver of cost and quality. It follows that the most important element of health reform is its impact on technological change.

To understand how technological change affects all of us, consider the profound impact of the top ten medical advances in the last ten years, as listed by CNN:

1. Sequencing the human genome
2. Stem cell research
3. HIV cocktails
4. Targeted cancer therapies.
5. Laparoscopic surgery

Does ICD-10 Pilot Forecast a Perfect Storm for Healthcare?

Dec 17, 2013• 51

By Edmund Billings, MD

Let me concede from the outset that, in this blog post, I lean toward the negative—dire predictions, worst-case scenarios, a bit of doom and gloom, etc.

But I ask you, oh gentle, patient reader, how could I not?

Let’s go to the satellite. You can see warm air from a low-pressure system (Meaningful Use Stage 2, not changed dramatically by the one-year extension) collide with cool, dry air from a high-pressure area (the turmoil of Obamacare) and tropical hurricane moisture (ICD-10). Tell me you don’t see the Perfect Storm yourself.

And here we sit in our little fishing boat, waiting for the mighty ocean to consume us.

Overly dramatic? Certainly, but still not wholly inappropriate, I will argue.

Consider a recent report on the HIMSS/WEDI ICD-10 National Pilot Program collaborative that was created to, “…minimize the guess work related to ICD-10 testing and to learn best practices from early adopter organizations.”

Designed to ascertain the realities of the entire healthcare system adopting and using ICD-10, this pilot included an education and adoption program for all participants, followed by a set of “waves” in which diagnoses for the 100-200 most common medical conditions were actually coded and submitted using ICD-10.

The end-to-end testing approach …

…would encompass a number of medical test cases that mirror actual processing, including situations with multiple “hops” or “steps” between providers, clearinghouses, and health plans; the identification of high-risk medical test cases to help prioritize testing; the identification of available testing partners; and key reporting and sharing of test results. The test environment must mirror production.

And how did this pilot testing go? (Cue dark, foreboding music here …)

The average accuracy was in the 60 percent range with low scores around 30 percent. Yes, some medical scenarios had nearly 100 percent accuracy, which is great. But very low accuracy accompanied a number of very common conditions. Not so great.

Registration is Open for HxRefactored 2014!

Dec 17, 2013

Meetings

A new kind of conference is on the horizon and tickets are available for purchase! Take advantage of the $699 discounted ticket only available until January 1. Sign up at hxrefactored.com.

Through inspirational talks, practical how-to sessions, collaborative design and API workshops, and on-site challenges, designers and developers will gather at this conference to swap ideas and techniques on how to improve the health experience.

Health 2.0’s Co-Founders, Matthew Holt and Indu Subaiya, and Mad*Pow’s Chief Experience Officer, Amy Cueva, are thrilled. Holt and Subaiya say that “HxRefactored is going to empower developers and designers with the skills they need to make big changes to the health care system. We are excited about hosting this event in the emerging health tech hub of NYC and we couldn’t be more fortunate to be partnering with one of the best design firms in the country.” Cueva echoed those sentiments, “We’re so proud to be continuing the legacy of the HxD conference now partnering with Health 2.0 to involve the developer community.”

HxRefactored is sure to be one of the highlight events of the year, so join us on May 13th and 14th at the New York Marriott at the Brooklyn Bridge and get ready for a conference unlike any you’ve seen before.

We Need a New Word. We Can Do Better Than “Concierge Medicine” Can’t We?

Dec 16, 2013• 21

By Leslie Kernisan, MD

What should we call it, when doctors decide to not accept with insurance and instead require patients to pay them directly for a healthcare service?

We should call it what it is: direct-pay. As in, patients pay their provider directly.

But most of the world, it seems, calls it concierge.

This is a bit of a problem. Clarity of thought, after all, often stems from clarity in language and word choices.

Now that a growing number of providers are choosing to not accept insurance, or are supplementing insurance payments with annual fees (this too, has been called concierge), we need to be able to have clear, serious, and meaningful conversations about what this means and where healthcare, especially primary care, might be going.

(Disclosure: I’m one of those physicians who has decided to not accept insurance, at least for the time being. I have my reasons.)

The term “concierge medicine” interferes with this conversation. It’s overly broad, freighted with overtones, and allows us to conflate all kinds of aspects of healthcare that would be best considered separately. These include:

How expensive is the care? Concierge has been used to refer to practices that charge primary care subscription fees ranging from $30/month to $25,000/year.
How does the pay structure correspond to service? Although a “monthly subscription = all the care you want” model is common, we also find fee-for-visit and fee-for-time. And then some practices charge patients both an annual or monthly retainer, plus fee-for-service.
Is insurance still accepted? According to Wikipedia, concierge medicine includes practices which accept insurance and charge an additional annual fee to cover extra services. Fees at One Medical in SF are $149/yr; at GreenField Health, they range from $120-$756 per year, depending on one’s age. At MDVIP, the membership fee starts at $1500/year.
What kind of access to the team and to the personal physician is provided? Some practices promise to give patients the doctor’s cell phone number and invite them to call at any hour. Larger practices seem usually offer 24/7 access to the team. Probably few practices are like my consultative practice, which offers good response time during business hours but no after-hours or weekend coverage.
How individualized is the care? How participatory is it? This is a tricky one, but I think it’s important to at least consider, given everyone’s recent interest in things like personalized care, patient-centered care, person-centered care, and participatory medicine. Just about all the practices labeled “concierge” do offer a more satisfactory patient experience. Whether this equates to individualized care in a way that is meaningful (i.e. correlates to better health outcomes or a better match of care to the patient’s situation/values/preferences) is another story.

In general, it seems to me that the term “concierge medicine” right now is being applied for a few different purposes.

The Doc Fix Is Real

Dec 16, 2013• 4

By Billy Wynne

Congress just had an uncharacteristically big week – with significant implications for healthcare policy. It flew by fast and furious, so here we pause to unpack the most significant developments and what they teach us about the future.

1. The Permanent Doc Fix Effort is Real. You have to hand it to the committees of jurisdiction, they have kept their heads down and plugged away all year at permanently repealing the broken Sustainable Growth Rate (SGR) formula that dictates Medicare payments to doctors. They’ve floated new payment methodologies, added policy addressing the package of “extenders” that perennially travels with the “doc fix,” and now all three have successfully completed bipartisan mark-ups of their respective approaches. Furthermore, the three month SGR patch that was included in the budget deal is an implicit endorsement by congressional leadership that there’s actually a chance this could happen in the first quarter of next year.

The next step is to identify savings to pay the roughly $150 billion price tag, which has always of course been the biggest rub. That process is going to take center stage early next year in a “Super Committee-lite” process of negotiating various potential cuts to healthcare programs. The cynics are still betting against it, but we’re closer than we’ve ever been before to replacing the 15+ year-old SGR.

2. The Long-Term Care Hospital Sector Will Never be the Same. In a lesser-noticed component of the three month doc fix patch alluded to above, Congress eliminated the payment differential for LTCHs (pronounced el taks) and regular inpatient hospitals for patients who do not meet clinical complexity criteria. What began as an esoteric exemption for a small handful of hospitals in the early 1980’s and grew to a $6 billion Medicare benefit annually is now going to start to plateau.

The market liked the change, paradoxically, because it was gentler than some bean counters had recommended and gave plenty of time (four years) for sophisticated companies to adjust. But the hot LTCH business just got some pretty cold water poured on it.

3. The Budget Deal Helps Healthcare Programs. The Murray-Ryan agreement to set spending levels for the next two years alleviated some of the impact of the sequester on discretionary spending programs like those at the FDA, NIH and HRSA. This means that funding for new product approvals, clinical research, workforce development programs and some primary care services will be modestly improved in 2014 and 2015.

Re-Engineering Health Care For Safety and Cost Savings

Dec 15, 2013• 1

By Peter Pronovost, MD

Despite spending $800 billion on technology last year, health care productivity is flat and preventable patient harm remains the third leading cause of death in the U.S.

One reason is that health care is grossly under-engineered: medical devices don’t talk to each other, treatments are not specified and ensured, and outcomes are largely assumed rather than measured.

Other industries rely much less on heroism by individuals and more on designing safe systems and using technology to support work. Today a pilot’s cockpit is much simpler than 30 years ago; it is far more error-proof, and built-in defenses enhance safety. By comparison, hospital intensive care units, which contain anywhere from 50 to 100 pieces of separate electronic equipment, appear unchanged.

Changing this will require unprecedented collaboration between health care’s many stakeholders. That’s one reason why this fall the Armstrong Institute and the World Health Organization convened health care leaders, consumers, providers, regulators and private-industry partners to discuss such topics as how to design safer systems at the Forum on Emerging Topics in Patient Safety held in Baltimore.

One effort to design safer systems at Johns Hopkins is Project Emerge. Supported by a $9.4 million grant from the Gordon and Betty Moore Foundation, Emerge is tapping into the wisdom of a diverse team of engineers, nurses, doctors, bioethicists, and patients and family members — 18 disciplines in all from across Johns Hopkins University— to design safer care in ICUs.

Data Points: More Backroom Chaos and Low State Numbers

Dec 13, 2013• 56

By Robert Laszewski

Shifting Millennial Attitudes on Obamacare December 2013.
Harvard Institute of Politics. Dec 4th, 2013. Poll

A few observations after 10 weeks of Obamacare implementation.

The Obama administration released the first two months enrollment figures this week. With HealthCare.gov still struggling in November, the enrollment of 137,000 people in the 36 states was expected. The main event for the federal exchanges will play out in December now that most people can navigate it

What I found notable in the report was the lack of robust enrollment in the states. In states where the exchange has been running at least adequately for many weeks now, the enrollment numbers are far from what I would have expected.

California enrolled 107,000 people in private plans in the first two months. But California has cancelled 800,000 current individual health plans effective January 1––all of whom have to buy a new plan by January 1 or become uninsured. The only place those who are subsidy eligible can get a subsidized plan is in the California exchange.

It’s Doctors versus Hospitals Over Meaningful Use

Dec 12, 2013• 23

By Adrian Gropper, MD

The Massachusetts Medical Society may be the first to notice that Meaningful Use EHR mandates favor large providers and technology vendors. Control over the Nationwide Health Information Network sets the stage for how physicians refer, receive decision support, report quality, and interact with patients. State health information exchanges and policy makers are caught in the cross-fire over health records interoperability. Are the federal regulations over Stage 2 being manipulated to put physicians and the public at a disadvantage?

On Dec. 7, the Massachusetts Medical Society took what might be the first formal action in the nation. A resolution stating:

“That the Massachusetts Medical Society advocate for a more open, affordable process to meet technology mandates imposed by regulations and mandates; e.g., that all Direct secure email systems, mandated by Meaningful Use stage 2, including health information exchanges and electronic health record systems, allow a licensed physician to designate any specified Direct recipient or sender without interference from any institution, electronic health record vendor, or intermediary transport agent.”

Scott Mace’s column Direct Protocol May Favor Large Providers and Vendors is the first to report on this unusual move by a professional society. Full disclosure: I’m a member of the MMS and the initiator of what became this resolution.

Meaningful Use is intended to support health reform by promoting interoperability and innovation in health service delivery. The Affordable Care Act, Obamacare, is fundamentally a free-enterprise model without single payer or even a public option. Obamacare depends on the market for eventual cost controls and sustainability. Meaningful Use is regulation designed to enable market-driven health reform by reducing interoperability barriers.

Although Meaningful Use regulations have already handed out $17 Billion to drive “voluntary” adoption of interoperable electronic health records, meaningful interoperability is still elusive. Meanwhile, the doctors are chafing about Meaningful Use intrusions and policymakers worry that the regulations will actually increase costs.

Resisting the Rush to Judgement On the Affordable Care Act

Dec 9, 2013• 47

By David Blumenthal, MD

A full, fair reckoning of the impact of the Affordable Care Act (ACA) will take years. In an earlier blog post, we outlined some of the measures—such as reductions in rates of uninsurance and underinsurance and trends in health care costs and quality—by which the law should be judged and the time frames over which those judgments should be made.

In the mean time, however, the rush to reckoning seems irresistible. These interim conclusions could prove as faulty as the ACA websites, but they should at least be informed by the best information available. As of this writing, this is what we know about the major shortcomings and accomplishments of the ACA.

KEY SHORTCOMINGS:

Poor management of the launch of the federal website, HealthCare.gov. The reasons for this failure are still emerging, but are likely multiple: management failures by the Obama administration, poor performance by its contractors, design flaws in the legislation itself, the decision by so many states not to run their own websites, a toxic political environment, and other factors.
Poor messaging by the President. In retrospect, President Obama should have prepared the public better for the inevitability that some Americans would be left worse off by the law because of higher insurance prices or the need to switch health plans.
Failure to prepare fully in advance for adverse impacts of the implementation of the ACA. There may have been more such preparation than meets the eye but if, for example, the administration had anticipated that private health plans might be cancelled, the policy response could have been waiting on the shelf. Instead, there was a last-minute scramble under the media spotlight.

KEY ACCOMPLISHMENTS:

Provision of health insurance to: 7.8 million young Americans covered under a parent’s health plan who likely would not have been able to do so prior to the law’s passage, including 3 million who were previously uninsured; more than 200,000 Americans covered through state marketplaces as of November 25, 2013; and 26,794 covered through the federal marketplace as of November 2, 2013.