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The Critics Are Wrong About IPAB

Jul 31, 2013• 21

By Peter R. Orszag

For Medicare, this has been a summer of good and bad news. On one hand, the program’s costs continue to rise remarkably slowly. So far this fiscal year, they have gone up by only 2.7 percent in nominal terms, the Congressional Budget Office reports.

On the other hand, opposition to the Independent Payment Advisory Board — created as part of the Affordable Care Act — continues to mount. And opponents continue to mischaracterize the whole point of the board.

What they seem not to understand is that the board is needed mostly so that that Medicare can continue to encourage slower growth in costs.

One reason costs have been rising so slowly is that systems for paying hospitals and doctors are changing. We’re moving away from the old fee-for-service plan and toward paying for value in health care — and we’re making the shift more rapidly than expected.

Redesigning the payment system is a fundamentally different approach to containing costs. The old way was to simply slash the amounts that Medicare pays for services. And here is where the criticism of the Independent Payment Advisory Board becomes somewhat Orwellian.

The point of having such a board — and here I can perhaps speak with some authority, as I was present at the creation — is to create a process for tweaking our evolving payment system in response to incoming data and experience, a process that is more facile and dynamic than turning to Congress for legislation.

Medicare Experiments
In particular, as Medicare experiments with accountable care organizations, bundled payments and other new strategies, the agency will inevitably need to make adjustments. Questions will come up, such as: How should the payments to doctors, hospitals and other providers be changed to reflect what is learned about the quality of care they provide? How much should the penalties or bonuses be? Is it better to have hospitals face all the costs associated with patient (as in an accountable care organization) or only the costs incurred during a specific episode of care (as in bundled payments)?

Why a New Healthcare Technology Designed to Cut Costs and Increase Efficiency Probably Won’t Put Anesthesiologists Out of Work

Jul 30, 2013• 5

By Shirie Leng, MD

The Wall Street Journal recently contacted me regarding an upcoming article on Sedasys, the new gadget that is supposed to be able to infuse propofol by computer while monitoring vital signs.

If you’ve read anything I’ve written previously, you’ll know that I am NOT a big proponent of technology as a means of “improving” patient care. To me, the more technology you put between the patient and the caregiver, the less medicine you’re practicing, and the more data-entry and computer programming you’re doing.

Sedasys is designed specifically to administer propofol. Propofol is a milk-like substance that produces a range of effects from sedation to general anesthesia. For sedation you just use less, for general anesthesia you use more. Its very quick onset and very quick recovery make it great for outpatient sedation. It has to be given in a continuous drip because its effect goes away so fast. GI docs love it because its so effective. I suspect they also love it because propofol comes with an anesthesiologist to give it.

The only problem is the one Michael Jackson encountered: it has this pesky side effect of causing you to stop breathing. And you can’t tell by looking at a person how much will sedate them and how much will make them stop breathing.

A little old lady with a million health problems might sedate at, say, 40 mg and stop breathing at 60 mg, while an 19-year-old could probably take 150 mg and still be fighting you. It’s not necessarily weight-based.

Stop the Presses: A Disease Management Program Worked

Jul 30, 2013• 17

By Al Lewis

I am known in the disease management and wellness fields as a naysayer, critic, curmudgeon, and/or traitor…and those are only the nouns that are allowed to be blogged across state lines. This is because I am driven not by wishful thinking but rather by data. The data usually goes the wrong way, and all I do is write down what happened. Then the vendors blame me for being negative — sort of like blaming the thermometer because the room is too hot — because they can’t execute a program.

However, the nonprofit Iowa Chronic Care Consortium (ICCC) apparently can execute a program. They reduced total diabetes events by 6% in the rural counties they targeted. This success supports a hypothesis that in rural (presumably underserved) areas, disease management fulfills a critical clinical gap: it provides enough basic support that otherwise would not be provided even to those who actively seek it to reduce near-term complications and exacerbations.

This result will likely produce its own unanticipated consequence: because many people now believe (thanks, ironically, to some of my own past work) that disease management doesn’t produce savings, there will be widespread skepticism about the validity of this study. Quite the opposite: this “natural experiment” is as close to pristine as one could hope for in population health, for five reasons:

There was no participation/self-selection bias because outcomes were measured on all Iowa Medicaid members.
The program was offered in some Iowa counties but not others, so there was no eligibility or benefits design bias, Medicaid being a statewide program.
The program encompassed only one chronic condition (diabetes) rather than all five common chronic conditions normally managed together (asthma, CAD, CHF, and COPD being the other four). Since all five conditions were tracked concurrently, whatever confounders affected the event rate in one of those conditions should have affected all of them. And event rates in the four other conditions did indeed move together in both the control and study counties. Just not diabetes.
The data was collected exactly the same manner by the same (unaffiliated) analysts using exactly the same database so there is no inter-rater reliability issue.
Both groups contained hundreds of thousands of person-years and thousands of events.

As one who has reviewed another high-profile “natural experiment,” North Carolina Medicaid, and found that the financial outcomes were the reverse of what the state’s consultants originally claimed (incorrectly, as they later acknowledged by changing their answer), I can also say that natural experiments in population health don’t harbor some as-yet-unidentified confounder that causes the study population to outperform the control population.

Medicare’s Observation Status-and Why Attempts to Make Things Better May Make Them Worse

Jul 30, 2013• 5

By Bob Wachter, MD

There are tens of thousands of policies in Medicare’s policy manual, which makes for stiff competition for the “Most Maddening” award. But my vote goes to the policy around “observation status,” which is crazy-making for patients, administrators, and physicians.

“Obs status” began life as Medicare’s way of characterizing those patients who needed a little more time after their ED stay to sort out whether they truly needed admission. In many hospitals, “obs units” sprung up to care for such patients – a few beds in a room adjacent to the ED where the patients could get another nebulizer treatment or bag of saline to see if they might be able to go home. Giving the hospital a full DRG payment for an inpatient admission seemed wrong, and yet these patients really weren’t outpatients either. The Center for Medicare & Medicaid Services’ (CMS’s) original definition of obs status spoke to the specific needs of these just-a-few-more-hours patients: a “well-defined set of specific, clinically appropriate services,” usually lasting less than 24 hours. Only in “rare and exceptional cases,” they continued, should it last more than 48 hours.

A recent article in JAMA Internal Medicine, written by a team from the University of Wisconsin, vividly illustrates how far the policy has veered from its sensible origins. Chronicling all admissions over an 18-month period, Ann Sheehy and colleagues found that observation status was anything but rare, well defined, or brief. Fully one in ten hospital stays were characterized as observation. The mean length of these stays was 33 hours; 17 percent of them were for more than 48 hours. And “well defined?” Not with 1,141 distinct observation codes.

To underscore just how arbitrary the rules regarding observation are, an investigation by the Inspector General of the U.S. Department of Health and Human Services released today found that “obs patients” and “inpatients” were clinically indistinguishable. Their major difference: which hospital they happened to be admitted to.

Let’s Have Dinner and Talk About Death: Indiegogo Campaign

Jul 30, 2013• 1

When we launched our Indiegogo campaign earlier this month we blew through our initial goal – raising $7000 in a matter of hours – with funds coming from around the globe.

This makes it clear that people are ready for this conversation, and gives us great momentum as developers continue to work around the clock finishing our site and interactive platform – Let’s Have Dinner and Talk About Death.

Today marks the final day for the campaign.

We are now confident we can break $20,000 – enabling our Global Launch on August 24th in partnership with the Elisabeth Kubler-Ross Foundation.

Support the campaign here.

THCB Calendar: What Change on Capitol Hill Means for Big Data and Health Care

Jul 30, 2013

Co-instructors Aman Bhandari and Dr. Tom Tsang of Merck’s Data Partnership Group will lead the next and final class in Health 2.0 EDU’s summer webseries, Big Data, Big Business, on How HITECH and the ACA Are Changing the Data Landscape, today, Tuesday, July 30th at 3pm PT/6pm ET.

Together Bhandari and Tsang bring decades of experience analyzing, predicting, and writing the legislation that most impacts the use of big data in health care. Join us to learn how the fine print in both the ACA and HITECH is creating both new opportunities and new challenges for using data. If you are a startup and have questions about either piece of legislation do NOT miss this class- Bhandari and Tsang will answer your queries live.

GitHub: How an Open Source Programming Tool With a Funny Name Could Help Revolutionize Medical Research

Jul 28, 2013• 2

By Joyce Lee, MD

Most people I work with in medicine have never heard of GitHub .

For the unfamiliar, GitHub is an online repository, which is an essential tool used by computer programmers to store their programming code. It has a number of virtues, including giving users the ability to track multiple versions of their code (sort of like remembering all the track changes you ever made to your word document). This is an essential tool for programmers but its value goes beyond its function as a track changes repository, as it is a site that facilitates open source collaboration, given its “social” features, similar to social networks like Facebook or Twitter, in which you follow the content of others or others follow you.

The most amazing thing about GitHub is that many users post their code (their work, their blood, sweat, and tears) publicly on their GitHub profile. Individuals will comment on others code, providing valuable input that the owner of the code can use to improve their work. In addition, can “fork” another person’s code repository, and work directly on the code in their own Github profile to make changes or improvements, sort of like a tag team collaboration. GitHub is the tool to help facilitate large-scale open source collaboration for the software/web programming world (such as that which lead to the Linux revolution).

By early 2012 there were apparently 1.2 million users hosting over 3.6 million repositories. Now that’s collaboration to scale!

So again, you may ask, why should physicians or medical researchers care about GitHub? Because it can have broader application beyond the software/web programming world, as shown by its use among non programmers, who are currently repurposing Github to advance collaborate in their own respective fields. They are posting book projects and transcripts of talks on the site, to encourage conversation and collaboration. One user even published his personal DNA information to encourage development of open-source DNA analysis. It has been suggested that Github could even be used by US citizens to “fork” the law so that they can propose their own amendments to their elected officials.

How might we use Github to democratize the world of medical research?

As researchers we do so many different activities that we perform in isolation, which forces us to “reinvent the wheel” constantly, from drafting of ethics board applications, to creation of research protocols, to the writing of snippets of statistical code or code for web programs.

Providers Are Held Accountable. Why Aren’t Technology Vendors?

Jul 26, 2013• 22

By Jordan Dolin

As healthcare shifts from fee-for-service to fee-for-value, hospitals and physicians are increasingly being held accountable for outcomes by the government, payers and patients. Historically, provider organizations only had to meet performance criteria to earn a pay-for-performance bonuses or hospital certification, but with the arrival of Accountable Care Organizations (ACO), Meaningful Use and other programs, payment is now based on to quality of care rather than quantity of services.

Health information technology (HIT) systems are able to track physician actions and measure outcomes down to the individual patient level and allow organizations to closely monitor the quality levels of a given physician. These same tools should be able to monitor the performance of the vendors who are there to support these clinicians. With patient engagement solutions, for example, vendors claim they can help improve HCAHPS scores, treatment adherence, patient outcomes, and reduce costs, but have no evidence to back it up.

Vendors should be willing to commit to their patient engagement promises, present proof showing improved outcomes and face some financial risk for failing to deliver.

Global accountability

Since patient engagement was included in the Centers for Medicare and Medicaid Solutions’ Meaningful Use of Electronic Health Records program, it has become a popular buzzword. Every HIT vendor claims to offer tools to assist providers with this important clinical quality issue, but no one is holding anyone accountable.

A Window of Hope for Fixing Medicare

Jul 26, 2013• 8

By Bruce Chernof, MD

Simplistic rhetoric that Medicare is “broken” fails to diagnose where the real challenge lies in creating enduring financial stability for this critical program. Medicare is doing exactly what it was designed to do: draw in funds from working individuals and beneficiaries to help millions of older Americans and people with disabilities pay for medical care. A fundamental problem is how Medicare pays for services and how the delivery system responds to that payment structure.

The current medical care delivery system that Medicare pays for is fragmented, uncoordinated, favors the health care provider over the person receiving care, and is exceedingly expensive. How traditional Medicare pays for services — through a fee-for-service model that values quantity of services over quality of health outcomes — validates the current delivery system. However, with growing overall health care costs, increased use of expensive high-tech medical services, and the coming of age of baby boomers, rising Medicare costs for this broken delivery system threaten to upend the program and bankrupt the nation. But there is hope: Medicare can be used to transform our broken health care system by changing the way it pays for services.

Medicare’s antiquated payment system and the inefficient health care delivery system it encourages creates an even more egregious problem for those individuals who are part of Medicare’s most expensive population: seniors who have chronic health conditions (such as heart disease, asthma or cancer) combined with difficulty with activities of daily life. They see multiple doctors, take numerous medications, and are faced with the difficult task of managing this complex array of providers, services and treatments on their own. The 15 percent of seniors who have both chronic conditions and functional impairments account for nearly one-third of total Medicare costs. Medicare spends almost three times more on these individuals than on those with chronic conditions alone.

What’s So Wrong About Sexting, Anyway?

Jul 25, 2013• 9

By Glenn Cohen

Like most people, I am both amused and shocked by the latest Anthony Weiner sexting revelations and scandal. It is like a car crash where it is hard to look away even though you know you should.

I am fascinated by the “medicalization” of Weiner’s behavior by some sectors. This CNN clip with therapists is to me a good example.

The words “sexual addiction,” “exhibitionism,” comparisons to alcoholism, “not in control of his actions” are bandied about. This to me has fascinating echoes of the medicalization of homosexuality in the 70s and also the medicalization of the choices made by the transgendered. There like here the strategy is fraught. The patient has to perform the “sick role” as a way of excusing himself from responsibility and/or earn governmental support.

The comparison, though, prompts the following question (and yes I am purposefully trying to be provocative so take it with the appropriate grain of salt): As with homosexuality, what is the underlying problem here that calls out for condemnation? Is this merely legal moralism rearing its head again? What’s so wrong about sexting?

Well, let’s try to answer the question. Let’s take the Weiner situation as our case study. Weiner did many things wrong in the first and more recent revelations. He lied and misled the public about what he had done. He flirted virtually with a woman other than his wife and potentially embarrassed his wife (though this strikes me as less wrong then an extramarital affair which is de rigeur in politics). He showed a technological stupidity in sending it out on his twitter feed. Perhaps he showed “bad judgment” in doing something where he would likely get caught (as an aside, does that mean we want our politicians to be better at doing wrong things so we don’t catch them?)

All of these are contestable, but I will grant they form a basis of condemnation.

But factor these out for a moment. The act of Sexting itself. Why is that wrong? If one person (and to factor out infidelity, lets say both are single) shows off their naked body to another in the form of a photo, what would make that wrong?