Category: Uncategorized

Misunderstanding Narrow Networks

Mar 13, 2014• 18

By David Dranove & Craig Garthwaite

In a recent New York Times opinion piece, Obama advisor Ezekiel Emanuel attempts to ease the minds of millions of Americans who may be selecting narrow network plans in the exchanges.

In defending narrow networks, Emanuel cites the well-known example of Kaiser, which has for decades required enrollees to choose among only Kaiser-owned hospitals and Kaiser-employed physicians.

He goes on to propose some “safeguards” for plans in the exchanges such as mandating that insurers disclose the criteria used to establish their network of providers and requiring that insurers pay for second opinions from elite out-of-network providers.

Perhaps surprisingly given our previous commentary, we agree with the general thrust of Emanuel’s argument, which is that freedom of choice is overrated. And while we do not agree with many of his recommended safeguards, our quarrel today is not with his proposals for even more new rules and regulations.

Rather, our primary quarrel is with the vast majority of the individuals who chose to comment on, and often lash out at, Emanuel’s article. These comments are emblematic of the general misunderstanding of the role of narrow network plans in controlling the future growth of health care expenditures.

In a nutshell, this is the archetypal response against Emmanuel’s claim: “Evil insurers have given us narrow networks. The government must intervene in this bloodthirsty lust for profits. Give us freedom of choice! (And preferably with the government taking over the business of insurance altogether).”

Given previous comments on this site, we suspect that many readers of our blog might share similar sentiments. So we would like to take our readers on a stroll down memory lane to explain how insurers ended up creating networks, and why we are all better off for it.

Congratulations, Doctor, On Your Federally-Subsidized “Hardship”

Mar 13, 2014• 32

By Dan Haley

At HIMSS 2014, the health information technology’s (HIT) largest annual confab, the bestest-best news we heard from a policy perspective, and maybe even an industry perspective, was the Centers for Medicare & Medicaid Services’ (CMS) dual announcement that there will be no further delays for either Meaningful Use Stage 2 (MU-2) or ICD-10.

Perhaps we should have immediately directed our gaze skyward in search of the second shoe preparing to drop.

As it turns out, CMS de facto back-doored an MU-2 delay by issuing broad “hardship” exemptions from scheduled MU-2 penalties. To wit: any provider whose health IT vendor is unprepared to meet MU-2 deadlines, established lo these many months ago, is eligible for a “hardship” exemption.

Few would disagree with the notion that it’s unproductive to criticize policy without offering constructive ideas to fix the underlying problems.

Here, the underlying problem is easy to define: it is in point of irrefutable fact fundamentally unfair to penalize care providers for their vendors’ failings—especially when the very government proposing to penalize them put its seal of approval on the vendors’ foreheads to begin with.

CMS’s move to exempt providers from those penalties is correctly motivated, but it seeks to ease the provider pain without addressing its cause.

Instead of issuing a blanket exemption for use of unprepared vendors, CMS should:

Waive penalties only for those providers who take steps to replace their inferior technologies with systems that can meet the demands of the 21^st century’s information economy;
Publish lists of health IT vendors whose systems are the basis for a hardship exemption, along with an accounting of how many of those 21 billion dollars have been paid to subsidize those vendors’ products; and
Immediately initiate a reevaluation of the MU certification of any vendor whose products form the basis for a hardship exemption.

This proposal might seem bold, but if we’re truly looking to advance health care through the application and use of EHR, then what I’ve outlined above simply represents necessary and sound public policy. Current practice rewards vendors whose products are falling short by perpetuating subsidies for those products.

The federal government should stop paying doctors to implement health IT that cannot meet the standards of the program under which the payments are issued. That’s just a no-brainer.

An EHR should not be a federally-subsidized “hardship.”

The ACO Hypothesis: What We’re Learning

Mar 12, 2014• 31

By Farzad Mostashari, MD & Ross White

Last month, the Center for Medicare and Medicaid Services (CMS) reported first-year results from the Medicare Shared Saving Accountable Care Organization Program (MSSP).

As noted in a previous post, shifting to an accountable care model is a long-term, multi-year transition that requires major overhauls to care delivery processes, technology systems, operations, and governance, as well as coordinating efforts with new partners and payers.

Participants in the MSSP program are also taking much more responsibility and risk when it comes to the effectiveness and quality of care delivered.

Given these complexities, it is no surprise that MSSP’s first year results (released January 30, 2014) were mixed. The good news? Of the 114 ACOs in the program, 54 of the ACOs saved money and 29 saved enough money to receive bonus payments.

The 54 ACOs that saved money produced shared net savings of $126 million, while Medicare will see $128 million in total trust fund savings.

At the time, CMS did not provide additional information about the ACOs with savings versus those without.

While a more complete understanding of their characteristics and actions will be necessary to understand what drives ACO success, the recent disclosure of the 29 ACOs that received bonus payments allows us to offer some preliminary interpretations.

Why You Should Care about the New Accreditation Agreement for Osteopaths

Mar 11, 2014• 3

By John Schumann, MD

More than a century of American medical history was turned on its ear last week by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all).

But this should be viewed as good news across the land. As someone who trains doctors from both ‘traditions,’ I certainly welcome a more level playing field.

First, a little background:

Osteopathic physicians (those with a D.O., or Doctor of Osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 ‘allopathic’ institutions, the kind that confer the M.D. (Doctor of Medicine) degree.

Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core.

Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness.

This tradition, known as Osteopathic Manipulative Treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.

The OpenNotes Toolkit

Mar 10, 2014• 58

By Steve Downs

In writing about OpenNotes last summer, I argued that the practice of sharing clinicians’ notes with patients had moved beyond the question of whether it was a good idea (the landmark study published in Annals of Internal Medicine was pretty clear on that) to questions of how best to implement it.

As more organizations adopt the practice, it’s clear that we’re now in a phase of implementation, and experimentation with different approaches and learning. Tom Delbanco, MD, one of the project leads, often compares open notes to a drug — it does have some side effects and some contraindications for some people and some circumstances — and we all need to understand those nuances.

To make it easier for health care organizations to offer the service to their patients, the OpenNotes project team has just released a new toolkit.

The toolkit focuses on two challenges: helping organizations make the decision to implement open notes and helping organizations with all the steps involved in implementing open notes.

It includes a slide deck that lays out the results of the study and makes the case for implementation, a video profile of how a patient and her doctor have used the practice, profiles of the implementations at the pioneering sites, FAQs for clinicians and patients, and tips for clinicians on how to write open notes.

Please check it out and tell the OpenNotes team what you think: is it valuable? How could it be better?

The Open Notes Toolkit: Writing Fully Transparent Notes

Mar 10, 2014• 1

By Open Notes Staff

Since HIPAA entitles virtually all patients to obtain copies of their complete medical records at any time, it is always best to write notes with the assumption that patients may read them.

However, as electronic portals provide patients with easy access to their records, clinicians may feel new pressure to be more mindful about how they write their notes. They may alter their approach to or even omit sensitive information to avoid worrying patients unnecessarily. They may try to balance clinical and non-technical language to avoid confusing patients; they may feel they need more time to write notes that patients can read.

They may be concerned about how patients might choose to share their notes, including posting a clinician’s note on Facebook, medical forums, or other social media.

Most doctors in the OpenNotes study found that they generally didn’t need to change how they wrote their notes. Patients did not expect doctors to write notes aimed specifically at them and were grateful simply to have a window into their medical record.

However, a minority of doctors reported that they changed how they documented potentially sensitive topics. These included mental health, obesity, substance abuse, sexual history, elder, child or spousal abuse, driving privileges, or suspicions of life-threatening illness. These are not new dilemmas, but they gain urgency in an era of shared visit notes.

Recommendations

Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed with your patients (and conversely, to talk about content you will write about). Many clinicians already follow this practice, and some choose to dictate notes with their patients present.

When documenting sensitive behavioral health issues, we recommend trying to describe behaviors descriptively, rather than labeling them or suggesting judgments. We also suggest highlighting the patient’s strengths and achievements alongside his/her clinical problems. This can help the patient gain a broader context within which to consider his or her illness and tackle difficult behavioral changes.

CareCloud CEO Albert Santalo Talks IPO and the EHR Market

Mar 10, 2014• 13

By Kim Krueger

[youtube]http://www.youtube.com/watch?v=XThHGrQyo1Y[/youtube]

Matthew Holt sat down with CareCloud President and CEO Albert Santalo to discuss the latest news from the Miami-based cloud practice management and EHR services provider. CareCloud got started in 2009 and since then has raised $55 million in angel and private venture funding and grown to 270 employees.

Currently, about 5,000 doctors use CareCloud for their practice management services with about a quarter of those doctors also using the CareCloud EHR. Santalo expects that number to grow to about 12,000 by the end of the year, explaining in three points why he thinks the market is primed for CareCloud’s cloud-based, integrated practice management and EHR system.

While Santalo’s grin says more than his answer when asked about a potential IPO, he shares some interesting thoughts on practice consolidation, meaningful use requirements, and the cloud in in-patient settings in this interview recorded at HIMSS last month.

HIMSS Unplugged

Mar 10, 2014• 5

By ANDY ORAM

HIMSS has opened and closed in Florida and I’m in Boston with snow up to my rectus abdominis. After several years of watching keynote pageants and scarfing up the amenities at HIMSS conferences, I decided to stay home this year.

Writing articles from earlier conferences certainly called on all my energy and talents. In 2010 I called for more open source and standards in the health care field. In 2012 I decried short-term thinking and lack of interest in real health transformation. In 2013 I highlighted how far providers and vendors were from effective patient engagement.

In general, I’ve found that my attendance at HIMSS leads moaning and carping about the state of health IT. So this year I figured I could sit in my office while moaning and carping about the state of health IT.

In particular, my theme this year is how health IT is outrunning the institutions that need it, and what will happen to those left behind.

The scissors crisis: more IT expenditures and decreasing revenues

Although the trade and mainstream press discuss various funding challenges faced by hospitals and other health providers, I haven’t seen anyone put it all together and lay out the dismal prospects these institutions have for fiscal health. Essentially, everything they need to do in information technology will require a lot more money, and all the income trends are declining.

Certainly the long-term payoff for the investment in information technology could be cost reductions–but only after many years, and only if it’s done right. And certainly, some institutions are flush with cash and are even buying up others. What we’re seeing in health care is a microcosm of the income gap seen throughout the world. To cite Billie Holliday: them that’s got shall get; them that’s not shall lose.

Here are the trends in IT:

Meaningful Use requires the purchase of electronic health records, which run into the hundreds of thousands of dollars just for licensing fees. Training, maintenance, storage, security, and other costs add even more. The incentive payments from the federal government come nowhere near covering the costs. EHR providers who offer their record systems on the Web (Software as a Service) tend to be cheaper than the older wave of EHRs. Open source solutions also cost much less than proprietary ones, but have made little headway in the US.

Hot on the heals of Meaningful Use is ICD-10 compliance, a major upgrade to the diagnostic codes assigned to patient conditions. Training costs (and the inevitable loss of productivity caused by transitions) could be staggering. Some 80% of providers may miss the government’s deadline. The American Medical Association, citing estimated prices for a small practice of $56,639 to $226,105 (p. 2), recently urged the government to back off on requiring ICD-10. Their point of view seems to be that ICD-10 might have benefits, but far less than other things the providers need money for. Having already put off its deadline, the Department refuses to bend further.
Continue reading…

The Death of SGR Reform

Mar 9, 2014• 18

By Billy Wynne

Late last week, House Republican leaders declared their intention to bring H.R. 4015, the bipartisan, bicameral SGR repeal measure, to the floor for a vote.

Good news, you’d think, for doctors and the broader healthcare system, that we might finally be rid of the SGR’s broken machinations and perverse cycle of congressional intervention.

But House leaders added a footnote: the measure would be paid for by delaying the individual mandate, which CBO opined last week would save money through reduced enrollment in Exchanges and Medicaid. To cover the approximate $150 billion cost of the SGR measure, the mandate would probably need to be delayed by at least 10 years.

While sparing us a rehash of the individual mandate debate here, suffice it to say that the Obama Administration, the authors of the Affordable Care Act, and most healthcare insurers and providers consider it to be a linchpin of the health reform regime.

Without it, most agree, the consumer protections established by the ACA would precipitate spiraling premiums that would quickly destroy the market.

In other words, the House measure is DOA in the Democrat-controlled Senate and White House, which House leaders know all too well. In a move whose political deftness is hard to quibble with, they are coupling two very popular measures into a single package that they know the vast majority of Democrats can’t support.

Good politics? Probably. Good for enactment of SGR repeal? More like the opposite.

But don’t blame House leaders for the demise of SGR repeal. This move is a symptom, not a cause, of its end. As previously reported, the well-intentioned negotiators were having difficulty finding common ground on the so-called extenders package that would be included, and were miles apart on the offsets that would be used to fund it.

This train had already come off the tracks.

The Dangers Of Quality Improvement Overload

Mar 9, 2014• 9

By Brooks, Gorbenko, van de Ruit & Bosk

Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients.

As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.

We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.

National Quality Improvement Initiatives

Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.

We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.

To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”

While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change.

Frontline providers often bristle at expectations from those they believe have little understanding of the demands of their daily work.