Simon Nath
ACA Open Enrollment Round 3: The Going Gets Tougher
The third ACA health insurance exchange open enrollment period begins Nov. 1, and things look iffy. The Obama administration this month reduced the estimate of new enrollees for 2016—possibly to lower expectations but also because signs point to the difficulty of luring the remaining uninsured into the fold over the next few years.
It’s time for some fresh strategies to ramp up enrollment and get where we need to go. At the end of this piece I offer some suggestions and invite yours. (This article assumes the ACA will be in place over the next five years even if a Republican becomes president in 2017.)
Health insurance numbers can be confusing (and hyped out of context from both sides of the political aisle), so here’s a quick rundown of the current situation and the Obama Administration’s new projections.
The current U.S. population is 326 million. According to the Census Bureau’s latest authoritative annual report (released in Sept) 10.4% of the population, or 33 million people, were uninsured for the entire year in 2014. That’s down sharply from 13.3%, or 41.8 million people, in 2013. Thus, as of the end of 2014, there were 8.8 million fewer uninsured people, due primarily to Obamacare.
Who Is to Blame for Health Care’s Problems? A Tale of Two Narratives
What to do about the seemingly inexorable rise in health spending has been the central health policy challenge for two generations of health economists and policymakers. In 1965, before Medicare and Medicaid, health spending was about 5.8 percent of GDP. In 2013, it was nearly 18 percent. And GDPquadrupled during this same period.
Over the past 30 years, there are been two warring political narratives explaining health spending growth, with two different culprits and indicated remedies. At their cores, these narratives blame the main actors in the health care drama—patients and physicians—for rising costs.
The Conservative Narrative: The Patient As Culprit
The conservative thesis holds that the demand for health care is unlimited because it has been, historically, a free good for many patients. Moreover, the argument runs, much illness is driven by bad personal health choices — for example, smoking and obesity, and the heart disease and diabetes that follows. Thus, much of our cost problem is actually the patient’s fault.
Is Health IT Finally Ready to Tackle Last-Mile Analytics?
I have spent several years working with specialty medical offices like oncology centers, diabetes clinics, IPAs (Independent Practice Associations), and disease advocacy groups seeking to build health care data warehouses and analytics solutions. During that time, I have seen the same concerns pop up over and over: “How can we understand the value and impact of our care if we only see the component of care that we provide? If we can’t understand our value, then how can we make sure that we are optimizing our care, getting reimbursed for our impact, and executing leading research in our specialties that helps find better medical treatments for our patients? How can we really care for patients effectively in the first place?”
Organizations are highly restricted in the ways they share data. HIPAA allows for data sharing between entities, but doesn’t provide for any mechanism or incentives to do so efficiently or in a scalable method. Also, the groups who should be sharing may find themselves in competitive situations where sharing could be perceived as risky. But in spite of this, some exciting developments have quietly been moving forward in the past few years that can help fill in pieces of the data last mile.
The rise of Meaningful Use 2 (MU2) compliant electronic medical records (EMR) with the objective to enable health information exchange (HIE) between systems now represents a potential solution to this challenge that has been exacerbating the fragmentation of the health care industry for years. Public HIEs have not yet demonstrated that they can resolve analytics issues or workflow changes. Instead, there are some new and useful models of HIE that show great promise that are likely being adapted from the lessons learned from the original HIE designs.
Pink is The New Black
Pink is the new black this October, which marks the 30th anniversary of National Breast Cancer Awareness Month. NFL players are clad in bright pink shoes and wrist bands. American Airlines employees are wearing pink uniform accents and serving complimentary pink lemonade. Police departments across the country are patrolling in pink cruisers. It’s all for a great cause. The money and awareness raised through this campaign helps to fight an insidious disease that will kill more than 40,000 women in the U.S. this year.
But the feel-good spirit is clouded by ongoing debate around the value of breast cancer screening, which is sure to be reignited by the recent announcement of new guidelines by the American Cancer Society. A recent study by JAMA Internal Medicine concluded that more frequent mammography screening results in the “widespread overdiagnosis” of breast cancer, and one its authors opined that, because of the harms caused by false alarms and unnecessary treatment of non-life threatening cancers, we should be doing fewer screenings, not more. This logic is based on data that shows more screening is associated with detection of small cancers but not with serious late-stage cancers or the overall death rate due to breast cancer.
The controversy over too much or too little mammography is completely missing the point. The real problem is our one-size-fits-all approach to breast cancer screening. It doesn’t work—especially not for the nearly 50% of women in the U.S. who have dense breast tissue.
The Writing Is On the (Healthcare) Wall
For the past few months I have been traveling around the globe. In my travels I have been talking to “leaders” from Ministries’ of Health, Insurance Companies, Hospitals, Physicians, and Professional Societies.
In many of the conversations I continue to hear more of the same story:
In order for change to happen, the incentives need to be in place.
Things such as, “…in order for physicians to adopt, the incentives need to support the actions.”
“…until incentives align it is difficult for hospitals to adopt changes in care models.”
“…in order for me to spend more time with patients the payment models need to align accordingly.”
Repeatedly I hear that in order for people to make changes inside of healthcare,that the money trail needs to lead the charge.
Yes, that worked so well with the adoption of EHR/EMR.
Leaders followed the dollars only to adopt and implement data archives that do not talk, interact, or share knowledge across the care continuum for patients.
Since when do “leaders” follow?
The Time-Warp
John Gage, Sun Microsystem’s fifth employee and its former chief researcher, famously said “the network is the computer.” The majority of us experience this every day through interactions with a wide variety of highly-intelligent, super-connected networks including Facebook, which remembers our friends’ birthdays better than we do; ATM networks, which know instantly if we have the cash that matches our request; and the complex, yet seemingly simple interweaving of phone networks, which allows us to communicate smartphone-to-smartphone regardless of carrier. Sadly, healthcare struggles to grasp this important concept.
Earlier this month, I flew to Utah for a conference hosted by KLAS, a major healthcare research outfit, about interoperability. Interoperability is a clunky word that’s talked about endlessly in healthcare, but at its root is an important notion: health care information needs to flow freely. Interoperability means that important information isn’t stuck in proprietary enterprise software that a hospital spent millions of dollars buying years ago. Having this information in the right place at the right time equates to reduced risk of medical errors and makes the delivery of health services more efficient and less costly. I’m convinced more than ever the only way to free information from the silos where it’s currently stranded is for the industry to embrace connectedness by switching to cloud-based, open networks.
The goal is clear. Yet healthcare IT executives and those buying their products remain stuck in the old ways of thinking. In their minds, software is still the computer, and sunk costs keep it so. As such, health information is largely trapped on technology islands that are maintained at great expense onsite at hospitals across our country versus flowing across the care continuum via a universally available information network. Just how bad is the data jam? An Epocrates’ survey earlier this year of nearly 3,000 physicians found that only 14 percent of physicians can access usable electronic health information across all care delivery sites and six out of 10 doctors, even when in the same organization, aren’t effectively sharing information.Continue reading…
ONC’s Interoperability Plan: a Day Late and $19bn Short
Earlier this month, the Office of the National Coordinator for Health Information Technology released an update to Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. The roadmap was first announced back in January, and the changes shared this month aren’t significant.
Ultimately, it calls for all healthcare providers nationwide to be able to send and receive electronic clinical information by the end of 2017.
This is a good plan on the surface, although it comes six years and millions of dollars late, and like other programs it may be more cumbersome that it first seems. Essentially, there are three facets:
1) Data standards to format and request/receive data
2) Incentives (again!)
3) Governance
Despite the intention to move data across the Union, each state will have the right to create its own unique rules on how to manage the exchange of information. This is a problem as we have seen before in the simple Case of e-prescription routing. A few states make it almost impossible to send e-scripts and layer on their own special form of bureaucracy. This inhibits the ultimate goal of reducing costs and errors and increasing Efficiency at the expense of both providers and patients.
Right Care Action Week – What can Radiologists do?
The Lown Institute advocates rational use of medical resources. This is a noble goal and worthy of the attention of radiologists. This week is the right care action week. Here are five simple things any radiologist can do this week, and the following weeks. This will improve patient care by avoiding unnecessary tests.
- Speak to the referring clinician, at least sometimes, if not often, perhaps twice a day. The conversation need not be adversarial. Ask before the imaging two simple questions. What will you do if the test is positive? What will you do if the test is negative? Inquire four weeks after the imaging is done if the study changed the clinical management. Inquire politely displaying academic curiosity not, judgmentalism. Appropriate use is a two-way street.
Don’t call pulmonary hypertension if the main pulmonary artery is > 3.1 cm on CT. Yes, I know this is the threshold, but thresholds are arbitrary. The chances that you will pick up pulmonary hypertension incidentally in someone with a 3.2 cm main pulmonary artery are dwarfed by the chances of an unnecessary right heart catheterization to confirm that the pulmonary hypertension was never there. It’s not fun having a right heart catheterization, even though cardiologists are really nice people.
Follow the ACR guidelines on the management of incidental thyroid nodules. Remember, if you pick up a papillary carcinoma of the thyroid, chances are that this will be overdiagnosed. Just ask the South Koreans. Be daring and bury the nodule in the “body” of the report, not the “Impression.”
Don’t leave the decision to following an incidental adrenal nodule, which is over whelmingly likely to be benign, on CT in an eighty year old to the referring clinician by saying “MRI may be obtained if clinically indicated.” Take ownership of the decision. Do we really believe that net societal suffering is reduced by doing chemical shift MRI on adrenal nodules on octogenarians? We are simply diverting their limited time on this planet from their grandchildren to the magnet.
God invented radiologists so that he could not be ruled out. The hedge is important, on occasion. The hedge cannot be a way of life. Please stop saying “sub segmental pulmonary embolism cannot be excluded.” Sub segmental pulmonary embolismis often an overdiagnosis. Let’s save our hedges for real monsters. On a similar note, just say “normal.”
Radiologists can reduce societal burden of too much medicine. We know the Axis of Futility, by heart.
Saurabh Jha is skeptical by nature not because he hates you. He can be reached on Twitter @RogueRad
The Dangerous Patient Safety Delusions of Eminence-Based Medicine
The eminent physicians Martin Samuels and Nortin Hadler have piled onto the patient safety movement, wielding a deft verbal knife along with a questionable command of the facts.
They are the defenders of the “nobility” of medicine against the algorithm-driven “fellow travelers” of the safety movement. On the one side, apparatchiks; on the other, Captain America.
They are the fierce guardians of physician autonomy, albeit mostly against imaginary initiatives to turn doctors into automatons. By sounding a shrill alarm about straw men, however, they duck any need to define appropriate physician accountability.
Finally, as befits nobility, they condescend to their inferiors. How else to explain the tone of their response to the former chief executive officer of Beth Israel Deaconess Medical Center, Paul Levy? As for patients, Samuels and Hadler defend our “humanity.” How…noble.
To me, healing the sick is an act of holiness, not noblesse oblige. Fortunately, we Jews cherish a long tradition of arguing even with God Himself. A famous Talmudic story ends with God acknowledging that even Divine opinion isn’t enough to override the rule of law. Let’s take a closer look at Samuels’s and Hadler’s opinions in relation to the rules of medical evidence.Continue reading…
