A few weeks ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”
Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services. Physicians were not actually party to the deal.
Nevertheless, doctors were expected to greet the news with cheers. As Rich Duszak reported, Adam Slavitt, acting administrator for CMS, also declared that “patients and care providers deserve a uniform approach to measure [sic] quality.”
Indeed, we all deserve uniform quality measures. Equality in quality!
“Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.”
This is not by any means a new proposal. Despite being supported by most Republican Presidential candidates, it has lingered around for decades without going anywhere. And for good reason.
The driving argument is that this would permit increased competition amongst insurers which would lower premiums. While it is true that competition might increase, it is highly doubtful that the result would be lower premiums, and there are considerable consumer protection concerns as well.
This is what The Oracle tells Neo when they first meet in The Matrix. Who we are and how we learn is a combination of our biology and our personal experiences. The plasticity of our minds and our genes make us individual persons in the world. Our individual mind and experiences are hard to offset. Sometimes we make decisions counter to our long-term wants because the wiring of our minds and our conditioned responses. Often it seems as if we are a slave to our desires and incapable of realizing our long-term goals. Would knowing myself better help me make better decisions?
Let me give you an example. As someone who has struggled with my weight, I would like nothing more than to make only healthy, evidence-based decisions when it comes to diet and exercise. But sometimes I don’t. A few months ago, I decided I needed to tip the scales in my battle against my desires. I downloaded a weight loss app, started counting steps and continued a lifelong practice of mindfulness, all in an effort to override those short-term desires and work toward my long-term goals. And I, like Oprah, lost 26 pounds over several months (both of us eating bread)!
Most of us struggle in one way or another with some sort of addiction, desire, impulse or emotion — by just being human — and understand all too well what it means to be enslaved to the biological machine. The awesome thing is now we seem to have digital tools to help set us free.
While walking (miles according to fitness tracker) at the HIMSS16 conference, something dawned on me. Many of the enterprise health IT software solutions that I saw at the conference and have spent most of my professional life with would do little to help me with obesity and to prevent me from developing diabetes. They are very helpful if I end up sick in a hospital but have little to do with preventing me from getting there. The consumer-centric technology counting my steps or my mobile solution helping me become aware of what I am eating might just do it.
Why can’t we have nice things? As a self-anointed health policy wonk, I find myself asking this question many times. It seems that every potentially transformative (to use a tired cliché) health care trend must eventually go through a process I’ll call “meme-ification.” And I’ll preface by saying that this applies across the political spectrum.
Take the hobby horse of many progressive reformers – single payer. If you’ve spent any time immersed in health care policy, you’ve probably heard it all: every other advanced country does it, insurance companies (and profits) are evil, health care can’t be a for-profit (evil) industry etcetera.
Of course, if you’ve spent any time immersed in health care policy you probably also understand that attempting to extrapolate lessons from the U.K. (relatively homogeneous, over 250 people per square kilometer, and about 1 homicide per 100,000) to the U.S. (about as diverse as you can imagine, about 35 people per square kilometer, and nearly five homicides per 100,000) is at best, an uphill battle.
Anyone who has spent a few years in Washington knows the federal budget dance: President stands behind podium with a fancy seal and flags and unveils a giant tome. The next morning newspapers declare the tome DOA, Dead on Arrival. And we all return to regularly scheduled programming.
This year was no exception. Even the White House seemed to acknowledge the fact by releasing the 182-page blueprint on the same day as the Iowa caucuses with Donald Trump, Bernie Sanders and Ted Cruz grabbing the headlines.
But budget nuggets have a way of seeping into the policy fabric and eventually taking hold. Legislative staff scrub the document for ideas, not to mention numbers. Candidates steal liberally, adding favorites to their rhetorical arsenal. Eventually, some of those candidates become lawmakers, cabinet secretaries and even president. So the ideas live on.
Happily, President Obama chose his final budget proposal to draw attention to the inexplicable, indefensible rise in drug prices in this country. Our nonprofit, provider-sponsored plans know better than most the clinical value of so many of today’s medications. At ACHP, we have the privilege of partnering with organizations that are in pursuit of the 4Rs – the Right patients receive the Right treatments at the Right time for the Right price. From Capital Health Plan’s Center for Chronic Care, which reduces health costs for the entire community by providing concierge-type care for the sickest one percent of Capital members, to Group Health Cooperative of South Central Wisconsin’s pioneering initiative embedding pharmacists in primary care clinics to track patients who may need additional treatment management, ACHP members are working to ensure patients always receive the medications they need.
This is the first of a series of interviews I’m doing at the behemoth HIMSS conference. They will hopefully give you a quick overview of the companies, and give you a sense of where the system is going.
First up, grabbed in the corridor is a quick interview with Omar Hussain, CEO of widely used data security company Imprivata. (They incidentally had a rocking party last night, and in case you were wondering this interview was filmed before not at the party!)
As Barack Obama’s presidency draws to a close, we anticipate growing discussion of his legacy. Much of that discussion will focus on the Affordable Care Act (ACA), his signature legislative accomplishment. The legislation is complex and in some cases ineffective and cumbersome. It can be argued, for example, that the complexity of the ACA favors the same high-cost, legacy health care players that the bill was designed to address.
But one of the major goals of the ACA was to provide more accessible, more dignified, and more effective health care to the poor. And in this respect, we believe that the Affordable Care Act – at least in those states that have elected to expand Medicaid – has been a success.
Our perspective on health care reform comes from ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth to study the impact of health care reform. We have just released our latest report, The Effects of the Affordable Care Act through 2015, which focuses on the impacts of insurance coverage expansion for patients and providers, with an emphasis on primary care. This report analyzes data from 21,900 health care providers on athenahealth’s network for at least five years. These physicians, who serve communities across the nation, are broadly representative of the country as a whole (please refer to the Appendix of the latest report). This allows us to compare physician practice before and after the coverage expansion provisions went into effect in 2014.
In June 2012, the Supreme Court ruled in “National Federation of Independent Business (NFIB) v. Sebelius” that states could choose whether or not to expand Medicaid eligibility. Although the federal government would cover the full cost of coverage expansion through 2016 and gradually decreasing to 90 percent of it thereafter, about half of the states declined to provide expanded Medicaid access to low income people. Since that time, six of those states have changed course and made Medicaid available to more of their residents.
In those states that agreed to loosen Medicaid eligibility requirements, there was no guarantee that the law would improve health care access for low income people. Because Medicaid payment levels are much lower than commercial rates, some observers were concerned that physicians would not open their schedules to see more Medicaid patients. And when patients did come in for care, no one knew whether they would form ongoing relationships with physicians or merely receive one-off care for acute or symptomatic issues.
Twenty years ago this month, California created an organizational architecture for integrated delivery systems taking global capitation—the restricted Knox-Keene (RKK) license.
At its creation, I envisioned the RKK as a pathway to virtual Kaisers.
This post distills the RKK’s guideposts for provider organizations on that pathway.
It also summarizes a straightforward path to transcend the biggest barrier to fluid, integrated care—healthcare’s Tower of Babel.
Organizational architecture for full risk. Many provider organizations do a very good job delivering patient care; very few have the systems or experience to effectively administer benefit arrangements.
Taking full risk for patient care requires both.
RKK provider organizations meet all Knox-Keene standards governing the provision of healthcare services, including requirements to provide continuity of care, assure timely access to healthcare services and separate medical decisions from fiscal management.
Without a strong financial footing, provider systems taking full risk put their patients at risk for care disruptions. RKK licensees must maintain a minimum net worth and assure that incurred-but-not-reported claims are reflected in the organization’s books and records.
Licensees also need grievance systems to address patient and non-contracting provider complaints.
It’s been an exciting 2016 already in the realm of cloud computing and patient engagement. As I was preparing for the HIMSS16 conference, I was reflecting on how things are moving so quickly with the addition of new technologies and yet some of the core challenges around gathering the information to provide better medicine are still in the dark ages. So here is the question ringing in my head for this year at HIMSS…
How much longer must we wait to finally have a ‘patient cloud’ – a sharable and relatively complete cloud based health record for each patient?
This is seemingly an obvious prerequisite condition so that providers can deliver better care for patients. The patient controlled medical record is an old idea that goes back to the Guardian Angel manifesto published in 1994 at the dawn of the Internet era and yet 22 years later we have haven’t achieved the first steps of the fundamental core of a universal life long patient record.
Now it’s clear. On Thursday, the Office for Civil Rights, responsible for HIPAA enforcement and protecting the public, published a new guidance to interpret HIPAA with respect to data blocking. The limits of the current law are now evident. In the interest of affordable health care, the Precision Medicine Initiative, and common sense, it’s time for Congress update HIPAA. Believe it or not, HIPAA still allows hospitals and other electronic health record (EHR) systems to require paper forms before they release data under patient direction. Along with an allowed 30-day delay in access to electronic health records, this data blocking makes second opinions and price comparisons practically inaccessible. Over $30B in stimulus funds have been spent on EHRs and now it is still up to Congress to give to patients full digital access to digital data.
Data blocking is the result of deliberate barriers designed into current EHRs that prevent patients being able to use their own data in efficient and innovative ways. It is practiced by both EHR vendors and healthcare institutions to avoid competition by favoring the services they control. As hospitals consolidate into massive “integrated delivery networks”, the business logic for data blocking becomes clear and irrefutable. Data blocking ensures the largest health delivery networks will get larger and control pricing. The bigger they are, the more data they have about each patient and the more money each patient’s data is worth to outside interests like pharmaceutical companies and data brokers. The results are ruinous healthcare costs and hidden discrimination in insurance, credit, employment, and other key life opportunities.