Category: Uncategorized

Beyond the Fiscal Cliff? The Sea of Uncertainty …

Jan 10, 2013• 12

By ROBERT LASZEWSKI

Last week’s deal to avert the “fiscal cliff” settled very little.

For those in the health care market, I will suggest the big takeaway is that we should expect very little will be settled in the coming months and we will continue to face a great deal of uncertainty for years to come.

Without an agreement to alter the course we are on, it is estimated that we will add more than $10 trillion to the national debt over the next ten years. Most experts agree that we need to reduce that amount by about half in order to put our nation’s fiscal course on a sustainable track. The Simpson-Bowles Debt Commission, for example, called for $4 trillion in deficit reduction––a fourth in new revenue and three-fourths in spending cuts.

We’ve heard lots of talk about a “Grand Bargain” between Republicans and Democrats to finally put our fiscal house in order. To be a grand bargain the two sides would have to agree to a deal that at least equaled the $4 trillion Simpson-Bowles proposal in its scope.

But Republicans and Democrats never came close to that kind of solution in the run-up to the recent fiscal cliff deal.

In the end, the two sides agreed to about $600 billion in tax increases. They also spent hundreds of billions more by agreeing to put off the sequester cuts for just two months, fix the Alternative Minimum Tax (AMT) problem, extend some business tax benefits, and extend unemployment benefits. They separately found $30 billion in Medicare savings, mostly from hospitals, to grant the Medicare doctors only a one-year delay in their 27% fee cuts.

Now, Obama says he wants $600 billion in more revenue by limiting tax breaks.

The Breast Density Bill: A (Very) Dense Dilemma …

Jan 9, 2013• 9

By ANUBHAV KAUL, MD and JENNIFER BROKAW, MD

The passage of the Affordable Care Act (Obamacare) and the reelection of President Obama was cause for real hope among those in pursuit of the Holy Grail in medicine: higher quality at lower cost. However, with the passage of what is called the Breast Density Bill in several states, the quality cost equation seems doomed on both ends. The Affordable Care Act mandates coverage of screening mammograms, without co-pay or deductible, but the Breast Density Bill is destined to push utilization of “non-beneficial” imaging, ie imaging that does not clearly save lives, even further.

The new law, authored by Sen. Joe Simitian, was signed into law this past October in California. Beginning April of next year, the bill requires facilities that perform mammograms to include a special notice, within the imaging report sent to patients, regarding the high density of breast tissue and the benefit of additional screening tests. The notice will state the following; “Because your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, depending on your individual risk factors”.

The supporters of the bill make the ethical argument that women have the right to know about how dense breast tissue can obscure mammogram visualization, and should be offered additional test such as ultrasound and magnetic resonance imaging (MRI) to alleviate the doubt. To provide further support, the SOMO INSIGHT Breast Cancer Screening Study is a nationwide research effort to evaluate if automated breast ultrasound done together with routine screening mammogram is more accurate in detecting breast cancer in women with dense breast tissue. The study is funded by U-Systems, Inc.; the Silicon Valley based company responsible for the sophisticated and expensive ultrasound technology used in this study. Thus, one cannot deny the possibility of patient interest being confounded by financial interest.

The patient advocacy movement around breast cancer has been championed by several well-known non-profits, such as Susan B Komen, Are You Dense Inc. and even endorsement by the National Football League. Yet, the confusion about screening is reflected in the variability of requirements for insurance coverage between states. For example, while Texas and Mississippi require screening mammograms to be covered for all women 35 and older, Utah has no coverage requirement and several other states do not require coverage until age 40.¹ Awareness of breast cancer screening is necessary, and the complexities of picking up certain irregularities certainly deserve attention. However, the patient’s “right to know” should also include the right to know about “over-diagnosis”.
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The Hoax of Entitlement Reform

Jan 8, 2013• 41

By Robert Reich

It has become accepted economic wisdom, uttered with deadpan certainty by policy pundits and budget scolds on both sides of the aisle, that the only way to get control over America’s looming deficits is to “reform entitlements.”

But the accepted wisdom is wrong.

Start with the statistics Republicans trot out at the slightest provocation — federal budget data showing a huge spike in direct payments to individuals since the start of 2009, shooting up by almost $600 billion, a 32 percent increase.

And Census data showing 49 percent of Americans living in homes where at least one person is collecting a federal benefit – food stamps, unemployment insurance, worker’s compensation, or subsidized housing — up from 44 percent in 2008.

But these expenditures aren’t driving the federal budget deficit in future years. They’re temporary. The reason for the spike is Americans got clobbered in 2008 with the worst economic catastrophe since the Great Depression. They and their families have needed whatever helping hands they could get.

If anything, America’s safety nets have been too small and shot through with holes. That’s why the number and percentage of Americans in poverty has increased dramatically, including 22 percent of our children.

What about Social Security and Medicare (along with Medicare’s poor step-child, Medicaid)?
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2012 Digital Health Investment Activity: The View From the Valley

Jan 8, 2013• 4

By David Shaywitz, MD

Rock Health recently released a decidedly mixed report on the current state of Digital Health investing, as the data suggest many investors continue to tentatively explore the sector, but most have yet to make a serious commitment.

Overall, VC funding for digital health increased significantly over the past year, from just under $1B in 2011 to about $1.4B in 2012; 20% of this total was associated with just five deals: two raises for transparency companies, Castlight (targeting employees with high deductible plans looking to manage their costs) and GoHealth (targeting consumers contemplating purchase of health insurance); two raises for referral companies, Care.com (helps consumers find the right caregiver – defined broadly, as needs addressed include eldercare, child tutoring, babysitting, and pet care) and BestDoctors (helps employees find the right doctor), and one deal for 23andMe (a pioneering consumer genetics company).

Not surprisingly, the largest thematic area of investment ($237M) was “health consumer engagement,” comprised of companies that – like the first four above – help consumers or employees with healthcare purchases. “Personal health tools and tracking,” the second leading category, captured $143M in funding last year. “EMR/EHR” ($108M) and “hospital administration” ($78M) rounded out the list; the last two numbers seem shockingly low given the apparent size of these markets, and suggest both areas may be perceived as firmly owned by incumbent players, and prohibitively difficult for new participants to enter.

Athenahealth’s just-announced acquisition of Epocrates highlights the competitive pressures even existing EMR companies face as they struggle for traction in an environment that seems to be increasingly dominated by a few large players, most notably Epic. “Our biggest obstacle,” Athenahealth CEO Jonathan Bush told Bloomberg Businessweek, “is that 70% of doctors don’t even know we exist.” In contrast, I’ve suggested that a category I’d broadly define as EMR adjacencies may be primed for growth, as VC’s Stephen Kraus and Ambar Bhattacharyya have also discussed recently in this intelligent post. The related area of care transitions is also attracting considerable entrepreneurial interest, including current Rock Health portfolio companies WellFrame and OpenPlacement, and TechStars alum Careport; it remains to be seen whether a robust business model will emerge here.

Unscience

Jan 7, 2013• 1

By David Katz, MD

According to a widely circulated op-ed in the New York Times by Paul Campos, a law professor at the University of Colorado with whom I don’t believe I have ever managed to agree on anything, our “fear” of fat — namely, epidemic obesity — is, in a word, absurd. Prof. Campos is the author of a book entitled The Obesity Myth, and has established something of a cottage industry for some time contending that the fuss we make about epidemic obesity is all some government-manufactured conspiracy theory, or a confabulation serving the interests of the weight-loss-pharmaceutical complex.

In this instance, the op-ed was reacting to a meta-analysis, published last week in JAMA, and itself the subject of extensive media attention, indicating that mortality rates go up as obesity gets severe, but that mild obesity and overweight are actually associated with lower overall mortality than so-called “healthy” weight. This study — debunked for important deficiencies by many leading scientists around the country, and with important limitations acknowledged by its own authors — was treated by Prof. Campos as if a third tablet on the summit of Mount Sinai.

We’ll get into the details of the meta-anlysis shortly, but first I’d like to say: Treating science like a ping-pong ball is what’s absurd, and what scares the hell out of me. Treating any one study as if its findings annihilate the gradual, hard-earned accumulation of evidence over decades is absurd, and scares the hell out of me. Iconoclasts who get lots of attention just by refuting the conventional wisdom, and who are occasionally and importantly right, but far more often wrong — are often rather absurd, and scare the hell out of me.

And so does the obesity epidemic.

Building a Better Health Care System: Patient-Friendly Orders

Jan 6, 2013• 28

By RONI ZEIGER, MD

Here’s another technically easy and culturally hard product: Patient Friendly Orders.

My version of this idea was born when I was admitted to the hospital for pneumonia about 5 years ago. Even though I had previously worked in that hospital, the quality of communication about my care between the patient and the medical team was poor. This got me thinking…

There should be a touchscreen by my bed that lists all the current doctors’ orders.

They’re not hidden in the chart. They’re not explained only in ephemeral conversations that occurred without me present. And of course, if they’re in front of me, they’re going to have to get written in English.

Let’s organize the orders, too. Imagine a loved one is hospitalized for a severe skin infection which also caused his diabetes to get way out of control. He has difficulty sleeping in the hospital and also needs pain control. All the orders — whether for diabetes, infection, sleep, or pain — are organized according to the problem they address. (While doctors’notes are generally organized by problem, their orders are not. I bet if we implemented Patient Friendly Orders, they’d be useful for doctors if only just for this reason.)

When the doctor or nurse or physical therapist comes in, the patient and family can have a conversation about the current plan, with that plan laid out in front of them. They make a shared decision, and the doctor can update the plan on the same touchscreen. “Sounds like a plan,” the patient says while actually looking at it. When you visit your loved one, he can show you the plan, too. If a question comes up about a given order, or why something is missing from the plan, you can make a note on the touchscreen so the medical team knows to address it when they next come by.Continue reading…

Alice in Healthcareland

Jan 4, 2013• 13

By Michael Turpin

Alice: Cheshire-Puss, would you tell me, please, which way I ought to go from here?

Cheshire Cat: That depends a good deal on where you want to get to.

Alice: I don’t much care where.

Cheshire Cat: Then it doesn’t matter which way you go.

Alice: —So long as I get somewhere.

Cheshire Cat: Oh you’re sure to do that if you only walk long enough.

Lewis Carroll, The Adventures of Alice in Wonderland

2013 has arrived and employers now find themselves on the other side of a looking glass facing the surreal world of healthcare reform and a confusion of regulations promulgated by The Accountable Care Act (ACA) and its Queen of Hearts, HHS Secretary Sebelius. Many HR professionals delayed strategic planning for reform until there was absolute certainty arising out of the SCOTUS constitutionality ruling and the subsequent 2012 Presidential election. They are now waking up in ACA Wonderland with little time remaining to digest and react to the changes being imposed. A handful of proactive employers have begun, in earnest, to conduct reform risk assessments and financial modeling to understand the impacts and opportunities presented by reform. Others remain confused on which direction to take – uncertain how coverage and affordability guidelines might impact their costs.

If reform is indeed a thousand mile journey, many remain at the bottom of the rabbit hole – wondering whether 2013 will mark the beginning of the end for employer sponsored healthcare or the dawning of an era of meaningful market based reform in the US. HR and benefit professionals face a confusion of questions from their companions — CFO’s, CEOs, shareholders and analysts.

The Fix that Failed

Jan 3, 2013• 69

By Dr. Wes

The new “fiscal cliff” legislation hailed by some as a “one-year doc fix” of the scheduled 26.5% sustainable growth rate (SGR) cut that was scheduled to take effect on 1 January 2013, has passed the Senate and House as part of the American Taxpayer Relief Act ( HR 8 ) goes to President Obama for his likely signature.

But was this “one-year doc fix” really a fix?

Not at all.

In fact, once again Congress has failed to resolve the ever-present sustainable growth rate cuts that repetitively surface year after year by kicking the proverbial can down the road another year.

The cost of the one year patch will be $25.1 billion dollars over 10 years and will be paid for almost entirely by health care cuts in other areas.

Hospitals (increasingly doctor-employers now, remember?) will see audits of their billings increase as efforts to recoup some $10.5 billion of “overcoding” charges are seen as the largest source of revenue for the one-year “fix.”
Hospitals will also see an extension of lower Medicaid payments to hospitals that treat a high number of uninsured or low-income beneficiaries, known as “disproportionate share hospitals” to find savings of about $4.2 billion.
Another $4.9 billion offset will be applied to the lowered bundled payments given for patients with end-stage renal disease – some of the sickest people receiving services from Medicare.

Building a Better Health Care System: End of Life Care – A Case Study

Jan 1, 2013• 25

By John Henning Schumann, MD

She was 94 years old with advanced Alzheimer’s. She thought it was 1954 and asked if I wanted tea. Not a bad memory for someone in a hospital bed with a broken left hip.

She’d fallen at her assisted living facility. It was the second time in as many months. She’d broken her collarbone on the previous occasion.

Over the past year, she’d lost thirty pounds. This is natural in the progression of Alzheimer’s. But it’s upsetting to families all the same.

My patient was lucky. She’d lived to 94, and had supportive children who were involved in her care. Her son had long ago been designated as power-of-attorney for her health care. This meant officially that his decisions regarding her care were binding. She was not capable of making sound decisions, medical or otherwise.

The patient had been under the care of a geriatrician. His office chart told me that the option of hospice and palliative care had been discussed with the family. They were interested in learning more; the son had agreed that “Do Not Resuscitate” status was appropriate for his mother. Doing chest compressions on a frail 94 year-old is something none of us want to do.

The morning after her hospital admission for the broken hip, the medical intern called me with an ethical dilemma: “She’s DNR,” the intern explained. “She’s having intermittent VTach on the monitor, and I fear she won’t be stable enough to have the hip repaired. The family is open to the idea of hospice, but I don’t know whether to treat the arrhythmia or not.”

Elaine (not her real name) is one of our brightest interns. She’s thinking about going into geriatrics. Situations like this are in many ways the most meaningful for doctors. Too often we stress about minutiae at the expense of the big picture; helping guide a family and patient through a period of critical illness is of true service.

Why Getting to a Digital Health Care System Is Going to Be Harder Than We Thought Ten Years Ago

Jan 1, 2013• 3

By David Shaywitz, MD and Tory Wolff

A leading scientist once claimed that, with the relevant data and a large enough computer, he could “compute the organism” – meaning completely describe its anatomy, physiology, and behavior. Another legendary researcher asserted that, following capture of the relevant data, “we will know what it is to be human.” The breathless excitement of Sydney Brenner and Walter Gilbert —voiced more than a decade ago and captured by the skeptical Harvard geneticist Richard Lewontin [1]– was sparked by the sequencing of the human genome. Its echoes can be heard in the bold promises made for digital health today.

The human genome project, while an extraordinary technological accomplishment, has not translated easily into improved medicine nor unleashed a torrent of new cures. Perhaps the most successful “genomics” company, Millennium Pharmaceuticals, achieved lasting success not by virtue of the molecular cures they organically discovered, but by the more traditional pipeline they shrewdly acquired (notably via the purchase of LeukoSite, which ultimately yielded Campath and Velcade).

The enduring lesson of the genomics frenzy was succinctly captured by Brown and Goldstein, when they observed, “a gene sequence is not a drug.”

Flash forward to today: technologists, investors, providers, and policy makers all exalt the potential of digital health [2]. Like genomics, the big idea – or leap of faith — is that through the more complete collection and analysis of data, we’ll be able to essentially “compute” healthcare – to the point, some envision, where computers will become the care providers, and doctors will at best be customer service personnel, like the attendants at PepBoys, interfacing with libraries of software driven algorithms.

A measure of humility is in order. Just as a gene sequence is not a drug, information is not a cure. Getting there will take patience, persistence, money and aligned interests. The most successful innovators in digital health will see the promise of the technology, but also accept, embrace, and ideally leverage the ambiguity of disease, the variability of patients, and the complexities of clinical care.
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