By STEVE SANDERS, DO    

She sat straight up, gripping the arms of her chair as if by releasing them she might tumble forward on to the floor. “I’m tired of hurting,” were her first words to me as I entered the room. I barely recognized the person I’d seen occasionally over the last two years. She was only 32–years old but now she carried herself as if she were an octogenarian, missing only the rolling walker. “I hurt all over,” she continued. “I can’t sleep. I can barely get around at work; they even sent me home once. I’m exhausted but sleep doesn’t help. I have to do something or I could lose my job.” With that she began to cry softly, struggling to wipe away tears.

Her history came spilling out. Pain in her back, shoulders arms and upper leg muscles. Rest gave her little relief. Her sleep was fitful; if she was able to sleep more than five hours it seemed miraculous. She awoke with pain that started as she climbed out of bed and lasted all day. She tried taking Tylenol, ibuprofen, Aleve, and aspirin, first in separate small doses then in combination. All these drugs seemed to do was upset her stomach and diminish what little appetite she could muster. Consequently, she lost weight; down ten pounds since her last visit six months ago.

Her disturbed sleep pattern, accompanied by tender points of pain in different regions of the body both above and below the waist fit the diagnosis of fibromyalgia. Medicine is just now coming to terms with this disease that has become the most common cause of muscle pain in women ages 20 to 55. These patients can have numbness, tingling or burning sensations in the arms, legs or both. Not surprisingly they develop mood disorders—difficulty concentrating sometimes even frank, severe depression. Some patients with fibromyalgia also complain of chest pain or develop alternating diarrhea with constipation, what we innocently call ‘irritable‘ bowel syndrome. On close questioning she volunteered she had many of these problems.

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By MERRILL GOOZNER   

Beyond the legal challenges, a major new hurdle is emerging for the health care reform law. Recent studies show that the major players in the health care marketplace – insurers, hospitals and physician practices – are consolidating, which increases the likelihood they will collude on prices charged to employers and to consumers and defeat cost control measures in the law.

Government officials are already grappling with the issue as they move to implement one of the signature cost control elements of reform – the formation of Accountable Care Organizations (ACOs). Conceived as a delivery system alternative to health maintenance organizations, ACOs are supposed to achieve greater coordination of care by linking together physician practices and hospitals, and will be financially rewarded if they improve quality while lowering costs.

The rules for ACOs, which are being written now, won’t go into effect until next year and will only apply to the Medicare market. While the Centers for Medicare and Medicaid Services (CMS) is likely to endorse several different payment models, the law calls for sharing savings when the Medicare payments for beneficiaries covered by the ACO fall below recent regional trends.

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By MICHAEL LAKE

EHR vendor performance and project ROI.  KLAS, a health IT product and vendor rating service based on client satisfaction, reported its annual Best in KLAS awards.  For ambulatory EHR systems Epic, eClinicalWorks, Greenway and e-MDs lead their categories by physician practice size, from largest to smallest.  Epic also leads for acute care organizations > 200 beds.  McKesson is best for smaller organizations.  Siemens is most improved.  And there was some interesting cost analysis by CDW, a hardware distributer, which shows us that the biggest expense in an EHR project is potential lost physician revenue.  First year hardware, software and service costs average only 12%, with the rest, $101,250 resulting from physicians seeing fewer patients. Smarter projects can likely do a lot to address this.

Analytic models help demystify the HIT environment.  The government’s Meaningful Use model was updated with its ideas for Stage 2 (2013) and Stage 3 (2015).  Requirements are increased in this stage.  For example, e-prescribing has to touch 40% of patients in Stage 1.  This increases to 50% in Stage 2 and 80% in Stage 3.  The optional measures from Stage 1 become core, for example, formulary checking.  And there are new requirements including chart notes, online patient messaging and a longitudinal care plan. 

PricewaterhouseCoopers (PwC) maps the three stages of meaningful use to three stages of accountable care.  Stage 1 is planning for the ACO; Stage 2 is participating in the ACO; and Stage 3 is performing in the ACO.  John Glaser, CEO at Siemens Health, proposes a model of eight critical IT functions needed to thrive in an accountable care world.  These include patient tracking, decision support, registries, care collaboration tools, event messaging, PHRs, HIEs and analytics.  Glaser sees the ACO provisions in the Affordable Care Act more significant to HIT than the meaningful use regulation itself.

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By MICHAEL MILLENSON

Maybe the uninsured could learn something from Egyptians and the Arab street. At a time when landmark health reform granting most of the uninsured access to medical care for the first time in their lives is being seriously threatened, protests by the uninsured themselves are nowhere to be seen.

In 2009, a staggering 51 million Americans from every walk of life and every corner of the nation had no health insurance. The Urban Institute estimates that 400 of them die each week due to lack of access to care. However, instead of pouring into the streets to protest when an activist judge calls the health reform law unconstitutional or conservative ideologues threaten to cut off funding, the uninsured leave the loudest push-back to (well-insured) political partisans.

This quiescence on a basic human right to care contrasts sharply not only with those braving tear gas and truncheons in Cairo. In this country, merely mentioning gun control fuels a firestorm of protest by firearms supporters. Gay marriage has mobilized liberals and libertarians alike over the “freedom to marry.” The children of undocumented immigrants have dared arrest and deportation to plead publically for the right to become American citizens.

More than one in six Americans is now uninsured. Where are they? The few exceptions to this rule show how much their faces and voices and names are missed. At a hearing by Sen. Tom Coburn (R-OK) in 2009, a sobbing, middle-aged woman confessed she couldn’t afford care for her brain-injured husband. Coburn, a physician, glibly responded that “the idea that government is the solution to our problems…is very inaccurate.” The partisan Republican crowd applauded, in an exchange captured by CNN, but the reaction of ordinary Americans was far more negative.

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By MATTHEW HOLT

Today David Blumenthal, Aneesh Chopra and other government and private sector worthies somehow held a press conference in DC despite the big freeze. It was to announce the first successful use of The Direct Project. Formerly called NHIN Direct, the idea behind The Direct Project is that providers–especially those outside of the large systems that are plugged into the perpetually emerging HIEs, can send secure messages containing patient information to each other and to patients. Imagine you're moving from New York to San Diego–this way your records could be sent securely and electronically essentially as an email attachment from one doc to another. If this works it is, in the Vice-President's words, a Big F–ing Deal; it will mean that doctors and patients can routinely exchange information that today is communicated in one tech CEO's words only by paper aeroplane. So today on THCB we're printing a very detailed article by two of the vendor representatives who've been working behind the scenes to make this happen.

By RICH ELMORE and PAUL TUTEN

The Direct Project has taken off, with the first-in-the-nation production use of the Direct Project for secure direct clinical messaging. Arien Malec, ONC’s Direct Project Coordinator, announced today that pilots in Minnesota and Rhode Island are now live with the Direct Project:

• VisionShare has enabled Hennepin County Medical Center to send immunization information to the Minnesota Department of Health. Testing of immunization (or syndromic surveillance) communication to a public health agency is a requirement for Meaningful Use incentives.
• Rhode Island Quality Institute has implemented provider-to-provider health information exchange supporting Meaningful Use objectives with Dr. Al Puerini and members of the Rhode Island Primary Care Physicians Corporation.

And innovative and high-value pilot projects in New York, Tennessee and California are scheduled to go live later this month. (Much more information about this below the fold)

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By MARK HALL, JD 

On first read, the most striking aspect of Judge Vinson’s ruling today is not its remedy — striking the Affordable Care Act in its entirety — but the impression one gets that the opinion was written in part as a Tea Party Manifesto.  At least half of the relevant part of the opinion is devoted to discussing what Hamilton, Madison, Jefferson and other Founding Fathers would have thought about the individual mandate, including the following remarkably telling passage (p. 42):

It is difficult to imagine that a nation which began, at least in part, as the result of opposition to a British mandate giving the East India Company a monopoly and imposing a nominal tax on all tea sold in America would have set out to create a government with the power to force people to buy tea in the first place.

As I’ve written elsewhere, the same Founders wrote a Constitution that allowed the federal government to take property from unwilling sellers and passive owners, when needed to construct highways, bridges and canals.  But Judge Vinson dismissed those and other examples with the briefest of parenthetical asides:  “(all of [these] are obviously distinguishable)” (p. 39).    Instead, he twice cites and quotes the lower court opinion in Schechter Poultry (pp. 53, 55), which struck down the National Industrial Recovery Act, at the height of the Great Depression and the pinnacle of Lochner jurisprudence.

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By SCOTT SHREEVE, MD

I am on an email list of Bill DeMarco’s, a reputable industry insider who has written and consulted extensively in the physician group and medical management space. He recently sent me a note about several physician aggregation events in New Jersey.

For some reason it struck a nerve with me . . . which led me to fire off the response below:

Bill,

I thought we already saw this movie?

My question for you . . . besides banding together in some megagroup – what are these physicians doing to actual change the delivery of medicine? ACO is just the latest buzzword excuse to aggregate physicians under a new moniker and a supposed new model.

I am highly suspect that these physicians are doing anything to change the relationship with their patients, to use enabling technology to create team based care, or actually be accountable for the outcomes they produce. What systems are they using to tie themselves together? What financial alignment do they have? What measures are they using to demonstrate superior outcomes? What about the patient experience – 7 minute visits that push pills as the “treatment” won’t get it done in the future.

I think your closing statement, “Representatives from Summit and Optimus were unavailable for comment” says it all.

Am I seeing this the wrong way? Is there anything new about this model this time around? Am I getting old enough to see these things cycle through?

PS – and no, I don’t mean a wolf. The sheep get nervous and band together waiting to get pounced on by wolves.

Scott Shreeve, MD, is a consultant, speaker and writer whose professional interest is the convergence of medicine, technology, and business. He blogs at Crossover Health.

By MARYA ZILBERBERG, MD, MPH

I am so tired of this all-or-nothing discussion about science! On the one hand there is a chorus singing praises to science and calling people who are skeptical of certain ideas unscientific idiots. On the other, with equal penchant for eminence-based thinking, are the masses convinced of conspiracies and nefarious motives of science and its perpetrators. And neither will stop and listen to the other side’s objections, and neither will stop the name-calling. So, is it any wonder we are not getting any closer to the common ground? And if you are not a believer in the common ground, let me say that we are only getting farther away from the truth, if such a thing exists, by retreating further into our cognitive corners. These corners are comfortable places, with our comrades-in-arms sharing our, shall we say, passionate opinions. Yet this is not the way to get to a better understanding.

Because I spend so much time contemplating our larger understanding of science, the title “Are We Hard-Wired to Doubt Science” proved to be a really inflammatory way to suck me into thinking about everything I am interested in integrating: scientific method, science literacy and communication and brain science. The author, on the heels of doing a story on the opposition to smart meters in California, was led to try to understand why we are so quick to reject science:

But some very intelligent people I interviewed had little use for the existing (if sparse) science. How, in a rational society, does one understand those who reject science, a common touchstone of what is real and verifiable?

The absence of scientific evidence doesn’t dissuade those who believe childhood vaccines are linked to autism, or those who believe their headaches, dizziness and other symptoms are caused by cellphones and smart meters. And the presence of large amounts of scientific evidence doesn’t convince those who reject the idea that human activities are disrupting the climate.

She goes on to think about the different ways of perceiving risk, and how our brains play tricks on us by perpetuating our many cognitive biases. In essence, new data are unable to sway our opinion because of rescue bias, or our drive to preserve what we think we know to be true and to reject what our intuition tells us is false. If we follow this argument to its logical conclusion, it means that we just need to throw our hands up in the air and accept the status quo, whatever it is.

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