Category: Uncategorized

Massachusetts, Utah, or Nothing: How States Should Address Exchanges

Jan 22, 2011• 2

By JOHN GRAHAM

PPACA prescribes states’ “flexibility” in structuring exchanges. Libertarian and conservative policy analysts have criticized Massachusetts’ bloated and intrusive Commonwealth Connector, the country’s first pre-Obamacare exchange. Some, however, have pointed to the Utah Health Exchange, re-launching next year, as a more consumer-friendly alternative. According to this line, even states opposed to Obamacare should go forth and establish Utah-type exchanges, which will blunt the worst effects of Obamacare.

These grounds for collaboration, unfortunately, do not survive careful scrutiny. In the pre-Obamacare world, exchanges were suggested as a way to get around the major government failure in American health care: Congress’s grant of monopoly control of our pre-tax health dollars to our employers.

The Utah Health Exchange allows spouses to aggregate defined contributions from different employers. For example, suppose a husband’s employer contributes $300 per month to the exchange for health insurance. His wife works for another employer which does the same. The household has $600 to spend on a family policy that they, not their employers, choose. The husband and wife can then decide to which of their employers they wish to affiliate, satisfying federal regulations for group coverage. That sounds pretty good. However, this “premium aggregator” has not yet been tested. It goes into effect this month, for members who applied via open enrollment at the end of last year.

Is the Culture Finally Shifting?

Jan 22, 2011• 5

By DAVE deBronkhart

Thanks to friend Kavita Patel for pointing out this sign of shifting winds, in this week’s Time online: Googling Symptoms Helps Patients and Doctors. It’s a watershed moment, because the last physician column I saw on this was the unpleasant 2007 When the Patient is a Googler, by Scott Haig MD.

It drove me up a wall, because the title suggested Googling was the problem, when the story was actually about a nightmare patient who was just plain rude. To brand “googlers” as wack jobs was imprecise at best. I responded with one of my first posts here, March 2008: When the Patient is a Yahoo.

Shortly after, our Alan Greene, physician c0-chair of SPM and co-founder of DrGreene.com, posted here about the article, with links to coverage in Salon.com. He summed up our status:

We live in a time of rapid tectonic shifts in what it means to be a doctor and what it means to be a patient. I’m not surprised that there are clashes of ideology and practice. Our labyrinthine, barnacle-encrusted healthcare system resists change. So do our social structures that have lasted for millennia.

But already many e-patients and many e-doctors are actively enjoying a new way of relating, rooted in mutual respect and open access to health information.

There was so much blog discussion that Dr. Haig led a physician roundtable, How to deal with the digitally empowered patient, reported in Orthopedics Today. Haig cited that twenty major blogs hosted lengthy discussion of his “When the Patient” article. (John Grohol posted here about the roundtable.)

For ‘Liberating the NHS’ Read ‘Dismantling the NHS’

Jan 22, 2011• 3

By CLIVE PEEDELL

The NHS white paper is the government’s roadmap for a market based healthcare system, which is designed to encourage increasing roles for the private and third sectors, whilst diminishing the role of the public sector in the England. The NHS is going to be dismantled by using the market forces of ‘creative destruction’. This will have profound effects on the medical profession with attacks on T+Cs, pensions, medical training, professionalism. More importantly, the knock on effects for patient care will be devastating.

The key policy levers enabling this to happen are:

1. The purchaser provider split, with GP commissioning consortia taking the leading role on the purchaser side of the divide.

2. Patient Choice.

3. Competition between a plurality of ‘any willing providers’.

4. Payment by Results with price competition.

5. Patient held budgets.

6. Foundation trusts becoming social enterprises and the abolition of the cap on their private income.

These policies are mutually reinforcing and this is how they will work:

GPs will be formed into GP consortia and will control 80% (£80bn) of the NHS budget to buy in services for their patients from a variety of providers (including FTs, private hospitals and third sector organisations) competing against each other in competitive healthcare market. Market competition will be enforced by applying EU competition law and overseen by the economic regulator, Monitor, as well as the new National Commissioning Board. Money will follow the patients via the Payment by Results (PbR) system. This has traditionally been a fixed pricing system, but the tariffs will now be opened up to price competition (I’ll come back to this).

Geomancy, Haruspex and Contextual Discovery

Jan 21, 2011

By ALEX EPSTEIN

What if your internet interface knew what you wanted – before you even knew you wanted anything?

Would it help or hurt?

Would you wind up doing things you didn’t want to, simply because of suggestion?

Would you give in to digital peer pressure?

If an alternative is presented as THE solution does it become a self-fulfilling prophecy?

Is the future knowable?

The question becomes relevant because “contextual discovery” is leaving the realm of nice to have and entering the realm of on the verge.

Using a witches brew of past searches, personal attributes, GPS coordinates, and chicken bones, a search engine company thinks it can provide answers for me, before I even know the question.

In other words, it can tell me my future.

Now, I have always hated the idea that statisticians and data miners could predict my behavior.

I am an individual with fee-will living in the land of the free. Hell, I don’t even know what I am going to do tonight, let alone where my synapses will take me in the next 10 seconds.

Yet, I guess I am, in aggregate, totally predictable.

Health Bill Sets Out Details of Cameron Plan to Reform NHS

Jan 21, 2011• 2

By MIKE BROAD

The controversial Health and Social Care Bill has been published, paving the way for GPs to control 80% of the NHS budget from 2013.

Unions warn the plans are the first step towards privatising the health service, while the health select committee said the way they have been rushed in has taken the NHS by “surprise”.

But the government argues the changes will improve care and accountability.

The plans will lead to the scrapping of PCTs and SHAs, GPs taking responsibility for commissioning and a greater role for private and voluntary sector providers in delivering services.

Health Secretary Andrew Lansley said: “In order to meet rising need in the future, we need to make changes. We need to take steps to improve health outcomes, bringing them up to the standards of the best international healthcare systems, and to bring down the NHS money spent on bureaucracy.

“This legislation will deliver changes that will improve outcomes for patients and save the NHS £1.7 billion every year – money that will be reinvested into services for patients.”

The BMA described the Bill as a massive gamble.

Updates on Proposed Stage 2 and 3 Meaningful Use Criteria

Jan 21, 2011• 6

By VINCE KURAITIS, JD

The Health IT Policy Committee has published proposed Stage 2 and 3 Meaningful Use Recommendations and they’re open for public comment until February 25.

I’ll share a couple of particularly useful and well written analyses and commentaries by colleagues.

Health IT guru and thought leader Dr. John Halamka writes about The Proposed Stage 2 and 3 Meaningful Use Recommendations.

This is a great article to get a thumbnail overview of all the proposed recommendations. John lists 38 criteria and provides a quick commentary on how challenging he sees each of them. (Keep in mind that he’s CIO at one of the most HIT-advanced health systems in the country — your definition of “easy” and his might not be alike.)

It caught my eye that the more challenging criteria generally are ones involving inter-organizational health data exchange, care coordination and care management. See his comments on the following criteria: 7, 17, 20–21, and 23–34.

Dr. Halamka concludes:

…areas of concern are chemotherapy automation, recording patient communication preferences, judging clinician performance based on patient adoption of PHRs, EMAR implementation, maturity of HIE capabilities, widespread rollout of longitudinal care planning, and public health readiness.

The ACC’s Cardiac Stress Testing Appropriate Use Criteria Answer the Wrong Question

Jan 20, 2011• 1

By ADAM ROTHSCHILD, MD

Dr. William Follansbee is the chairman of the American College of Cardiology/American Society of Nuclear Cardiology (ACC/ASNC) task force on non-invasive cardiac imaging and the director of nuclear cardiology at the University of Pittsburgh Medical Center Cardiovascular Institute.He recently published an editorial in the Pittsburgh Post Gazette in which he criticized the local Blue Cross/Blue Shield carrier, Highmark, for restricting the use of nuclear cardiac stress testing in favor of sonographic cardiac stress testing (a.k.a. stress echocardiography). Dr. Follansbee made several arguments as to why he believed that Highmark’s restriction of nuclear cardiac stress testing was wrong.

One of his core arguments is that “patients will be…denied access to appropriately indicated nuclear cardiology tests ordered by their physicians” (emphasis is mine). He (indirectly) references the ACC’s 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging in support of this argument. This document identifies clinical scenarios where a group of experts reached consensus that nuclear cardiac stress testing was appropriate. Dr. Follansbee fails to mention that the ACC also publishes an analogous document called 2008 Appropriateness Criteria for Stress Echocardiography, which uses the same methodology to identify clinical scenarios where a group of experts reached consensus that sonographic cardiac stress testing was appropriate and which illustrates that indications and test performance characteristics for nuclear and echocardiographic stress testing are virtually the same. That said, neither of these ACC documents explicitly identifies where nuclear cardiac stress testing is preferable to sonographic cardiac stress testing and vice versa.

EMR and the Falling Patient

Jan 20, 2011• 8

By STEVE SANDERS, DO

Is Mom at risk of falling?

Electronic medical records (EMR) efficiently capture physician’s keystrokes—yes or no—to this question and tuck it along side other data about our so–called medical lives.The physician’s judgment has to take into account many factors: is the patient elderly and ‘frail,’ do they have an orthopedic or neurological problem causing them to lose their balance, can they get up from a chair without having to use their arms to push-off, importantly do they live alone. Most of the answers to these questions come quickly through discussions with the patient or their family, or by simply observation. Nine times out of ten physicians can predict that a patient will fall before it happens.

Now, the EMR owns this critical piece of information. But the next most obvious question, as many of you can guess, seems clear: now what?

Ideally by clicking yes, a sequence of events occurs; (a) Home health receives an electronic message requesting a patient safety visit. Specially trained home health nurses look for loose rugs that may slip out from under the patient, extension cords waiting to snag an unsuspecting foot, toilets without support for getting up and down, or the need for an electronic alert system bringing help quickly (b) An alert goes to the patient’s pharmacy requesting a drug–drug interaction report, detailing which drugs interfere with each other causing precarious side effects. Alerts also goes to the primary physician highlighting which of the patient’s medication tend to cause problems in the elderly (c) Schedules an appointment with physical therapy for balance and strengthening exercises (d) Arranges for a visual examination and hearing test, after checking on previous tests. These steps become placed into motion within a nanosecond after clicking ‘yes.’

The Proposed Stage 2 and 3 Meaningful Use Recommendations

Jan 20, 2011• 2

By JOHN HALAMKA, MD

On January 12, the Health Information Technology Policy Committee published its proposed Stage 2 and 3 Meaningful Use recommendations for public comment.

Robin Raiford from Allscripts created a Quick Guide to the recommendations, making it easy to compare Stage 1, 2 and 3 in a single PDF.

Here’s my analysis of the proposed Stage 2 and 3 criteria.

1. CPOE – Stage 1 requires more than 30% of unique patients with at least one medication in their medication list have at least one medication order entered using CPOE Stage 2 expands this to 60% of patients for at least one medication, lab or radiology order. Stage 3 expands this further to 80%. CPOE orders do not need to be transmitted electronically to pharmacies/labs/radiology departments. This is a very reasonable rate of CPOE adoption. The hardest part of implementing CPOE is getting started, which happens in Stage 1. Adding different types of transactions (without requiring electronic transmission to back end service providers) is more about workflow and behavioral change than technology change.

2. Drug-drug/drug-allergy interaction checks – Stage 1 requires that interaction technology be enabled. Stage 2 adds that it will be used for high yield alerts, with metrics for use to be defined. The idea is that many drug databases contain too many false positive interaction rules, so adoption is slowed by alert fatigue. If only high yield alerts are required (here’s what we’ve done at BIDMC ), clinicians are more likely to trust drug interaction decision support. Stage 3 adds drug/age checking (such as geriatric and pediatric decision support), drug dose checking, chemotherapy dosing, drug/lab checking, and drug/condition checking. These are all reasonable goals, but automating chemotherapy protocols is quite challenging. BIDMC built an Oncology Management System and added a full time research nurse to ensure all chemotherapy protocols are updated and accurate. It may be asking too much to require chemotherapy dosing decision support nationwide by 2015.

Not Colon Cancer

Jan 19, 2011• 22

By DAVIS LIU, MD

My mother’s oncologist ordered the blood test, carcinoembryonic antigen (CEA), to check for the recurrence of colon cancer. The good news was that there was no evidence of recurrence. The bad news was that she didn’t have colon cancer.

She had breast cancer.

Though she was feeling better, the chemotherapy and radiation had taken its toll. For the past couple of months, she had experienced constant nausea and vomiting. During and after treatment, her hands and feet felt like they were on fire. Many times she wanted to give up and quit. Yet she persevered and felt emotionally stronger after the ordeal. She started to feel like herself again. Life began to have some normalcy. Until an insurance bill appeared asking for hundreds of dollars.

Apparently over the past year, her oncologist had routinely ordered the CEA test multiple times as part of her cancer follow-up. When she called to contest the charge, the insurer told her to talk to her doctor. She didn’t know this test was unnecessary until the bill. And until she called me, her son, a primary care doctor.

She asked her oncologist about the repeated blood tests. He simply shrugged. No apologies. No explanation. No acknowledgment of the error. Didn’t he get the lab results of the CEA? Shouldn’t he have been aware that the test was not relevant for her care?