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How the Health Co-Ops Can Meet Their Financial Obligations

flying cadeuciiA congressional subcommittee held a hearing Thursday to examine the health insurance co-op loan program established by the Affordable Care Act.  The program provided $2.4 billion in taxpayer-backed loans as seed money for the co-ops, which are private companies that were originally intended to bring competition, choice, and innovation to the health insurance market. In spite of this seed money, co-ops are off to a rough start.  Since their inception just over two years ago, 12 of the original 23 co-ops have closed due to financial concerns.  Taxpayers aren’t the only ones at risk of getting left with the tab for the co-ops.

A co-op left doctors and hospitals in Iowa and Nebraska holding over $80 million in unpaid claims when it closed.  Worse still, consider that unpaid claims left behind by failed insurance companies are often allocated by state guaranty funds to the surviving insurance companies, who ultimately pass them on to consumers.  One way or another, you’re likely to pay for any obligations the co-ops can’t meet.  The co-ops’ leaders don’t offer much comfort, either.  One co-op CEO recently offered this assessment of the co-ops’ prospects for re-paying their loans: “Will there be a little money left?  Yeah, maybe.”  Fortunately, the surviving co-ops have an often-overlooked asset they can tap to stay in business and meet their obligations: the recovery rights to their overpayments.

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The NFL is Not Big Tobacco: Overdiagnosis and Chronic Traumatic Encephalopathy (CTE)

Screen Shot 2016-03-18 at 3.48.30 PMAs a general rule, if you keep clobbering a body part it may, in the long run, get damaged. This is hardly rocket science. Soldiers marching long distances can get a stress fracture known as “March fracture.” The brain is no exception. Boxers can get “dementia pugilistica.” This is why we frown upon people who bang their heads against brick walls.

Footballers are at risk of brain damage, specifically a neurodegenerative disease known as chronic traumatic encephalopathy (CTE). CTE was described in a football player by forensic pathologist, Bennet Omalu, who performed an autopsy on Michael Webster, a former Pittsburgh Steeler. Webster died of a heart attack but had a rapid and mysterious cognitive decline.  Webster’s brain appeared normal at first. When Omalu used a special technique, he found a protein, known as tau, in the brain.

Omalu’s discovery inspired the movie Concussion in which Will Smith plays the pathologist. The Fresh Prince plays convincingly a god-fearing, soft-spoken but brilliant physician, who is up against incredulous colleagues and the National Football League (NFL). The NFL clearly has a lot to lose from Omalu’s discovery. However, the director’s attempt to emulate The Insider, where big tobacco tailgates the scientist, fails at many levels.

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More on Loneliness as a Major Health Risk Factor

flying cadeuciiOne of the myriad reasons wellness programs are not performing well is that all humans have about 100 risk factors, of which obesity, high blood sugar, high blood pressure, and high cholesterol are only four. If those four are in pretty good shape but the other 96 are out of whack, don’t expect good health results.

Further, putting bandages on symptoms of metabolic disease has limitations. Such bandages do not address the root causes of metabolic syndrome. According to Wikipedia:

“Root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. A factor is considered a root cause if removal thereof from the problem-fault-sequence prevents the final undesirable event from recurring; whereas a causal factor is one that affects an event’s outcome, but is not a root cause.Though removing a causal factor can benefit an outcome, it does not prevent its recurrence within certainty.”  (Emphasis mine.) 

One thing sorely missing from most modern wellness methods is RCA. Unless one deals with RCA in metabolic syndrome it will continue to recur.

Some other huge health risks factors are job misery, terrible marriages, very poor money handling skills, envy, general lack of contentment in life, and loneliness. Another health risk is how far you live from a “dial-911-first-responder”. Yet another is how safe your neighborhood is. I could go on and on. Worksite wellness does nothing to address the vast majority of personal health risks. My book, An Illustrated Guide to Personal Health*, elaborates on such health risks.

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Interview: Steve Curd, CEO Wanda

Another interview from the HIMSS conference earlier this month. The idea behind these interviews is that they give you a quick overview of the companies, and a sense of where the system as a whole is going.

As opposed to interviews with Philips & Xerox, this is one with a real start up called Wanda. CEO Steve Curd was early on at Healtheon (later WebMD) and then CEO of a startup called CareinSync which sold to Hearst. Now Wanda is a brand new well-funded startup (from a UK based-fund called Net Scientific) focused on patient engagement and behavior change using an interesting mix of psychology and analytics (unlike Monty Python’s suggested technique of sarcasm and extreme violence!).

What Healthcare Can Learn From Silicon Valley

flying cadeuciiAs consumers, we expect that when we bank, our ATM card will work in any machine worldwide, dispensing the cash we need and sending the record back to our home financial institution. Similarly, we would be enraged if we bought a new MacBook and couldn’t access our Gmail or load Microsoft Office. We expect this level of connection in so many aspects of our lives. Yet we accept a great deal less from health care than we do from our ATM cards and MacBooks. 

How we got to this state is a long and complicated story. Health care has had few incentives to open up to innovation. Hospitals and physician groups have worked on their own closed information systems, hoarding data to keep their care in-network and maintain market share.  This practice discouraged innovation and created a generation of ugly, unusable, and disconnected technology that has failed woefully to connect care for patients.

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Congress Has a Little Drug Problem

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The Congressional committee that recently demanded Martin Shkreli’s appearance must have hoped to spotlight a smug jerk responsible for the outrageous prescription drug pricing that we’re all up against. Of course there are lots of Shkrelis running drug companies, but most are shrewder and less brash, and might not make for such good theater.

Rep. Elijah Cummings (D-MD), one of the Committee’s questioners, seemed to think that his witness could move healthcare forward by disclosing the machinery of the drug sector’s excesses. “The way I see it, you could go down in history as the poster boy for greedy drug company executives or you could change the system. Yeah, you.”

Excessive treatment and cost are at the core of the entire U.S. healthcare crisis. The fact that other societies and a few innovative firms here consistently deliver equal or better quality care at dramatically lower cost betrays the idea that conventional U.S. healthcare is necessarily superior or even appropriate.

Every part of healthcare is guilty, but the pharmaceutical sector is a case in point. An open record of lobbying spending and what pharma has obtained from Congress makes clear that its contributions have worked to that sector’s economic advantage and against the interests of American patients and purchasers.

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The 5 Stages of EMR Acceptance (With Apologies to Kubler-Ross)

                                                   DENIAL  

                 I can’t believe they are making me use this system!

                                                 ANGER

                I CAN’T BELIEVE THEY ARE MAKING ME USE WHAT 
                     THEY LAUGHINGLY CALL A SYSTEM!
                                                BARGAINING 

‘Look if I agree too willingly and cheerfully use this system, can you ask for and fund these change orders, add these features, re-engineer this screen…..blah! blah!  Blah!, etc. ‘
                                               DEPRESSION 

I can’t beeeelieeeeeeve (sob, sob, sob, sob) theeeey (sob, sob, sob) are making meeeee (pouring tears from both eye tear wells) use this system!’ 
                                             ACCEPTANCE 

           I believe they are making me use this system.
                                         (Resigned Sigh) 
And just as in the original Kubler-Ross model, our only release from EMR agony is death……. an eventuality that I used to accept stoically as inevitable, but now positively look  forward to its release (as do my carpal-ly tunneled wrists!). Continue reading…

Xerox–Tamara StClaire interview

Another interview from the HIMSS conference earlier this month. The idea behind these interviews is that they give you a quick overview of the companies, and a sense of where the system as a whole is going.

Today is an interview with Tamara StClaire, chief innovation officer of Xerox Healthcare. She not only has some information on what Xerox is up to (including a hint about its new population health management platform) called Health Outcomes Solutions. But also some data from a study Xerox did on the readiness of providers to move to value based care (Hint: not very!) I also want to know what inspired the eyeroll in the video still below? Not me, surely!

The Paradox of Evidence-based Medicine

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While many doctors remain enamored with the promise of Big Data or hold their breath in anticipation of the next mega clinical trial, Koka skillfully puts the vagaries of medical progress in their right perspective. More often than not, Koka notes, big changes come from astute observations by little guys with small data sets.

In times past, an alert clinician would make advances using her powers of observation, her five senses (as well as the common one) and, most importantly, her clinical judgment. He would produce a case series of his experiences, and others could try to replicate the findings and judge for themselves.

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PCMH Fails Natural Experiment

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Medical Homes Fail Yet Another “Natural Experiment”

Three “natural experiments,” three failures.  Such is the fate of patient-centered medical homes (PCMH), a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy.

By way of review, a natural experiment is an experiment in which the design is outside the control of investigators, yet mimics an experiment.  The first two natural experiments below involve applying the intervention across entire states. The third involves a stimulus-response experiment in one specific community.

Statewide Natural Experiments: North Carolina and Vermont

In North Carolina, a statewide Medicaid PCMH was implemented years ago and steadily expanded until most Medicaid recipients belonged to one.  There was no reduction in relevant event rates (for ambulatory care-sensitive admissions) and costs increased. While the overall Medicaid budgets were routinely exceeded and that should have caused legislators to realize that something in their PCMH was amiss, Milliman fabricated data to pretend the PCMH program was a success.  Milliman got caught making up data (and ignoring other data that quite definitively invalidated its conclusion, and changed their story 180 degrees, a tacit admission that they lied.  And shortly thereafter (at least “shortly” by the standards of state government), North Carolina announced that it is abandoning this failed experiment.

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