There is one way the Trump HHS and VA can thread the needle between provider economic self-interest and burdensome regulation and it’s based on Federal health IT policy.
This past week has seen a number of high-profile announcements from the Trump HHS including Secretary Azar and CMS Administrator Verma about patient empowerment and enhanced transparency as a strategy to breathe life into healthcare reform. Meanwhile, VA Secretary Shulkin is under immense pressure to make their privatized Cerner EHR interoperable.
It’s pretty clear that the Trump HHS wants to do something about the frustrating and ineffective health IT policies that led to the 21st Century Cures Act information blocking provisions and that they’re hoping to leverage the $1 Trillion of federal spending in healthcare as an alternative to heavy-handed regulation. This is all good but what can they actually do?
Most of Secretary Azar’s talk is about disruption:
“In fact, it will require some degree of federal intervention — perhaps even an uncomfortable degree. That may sound surprising coming from an administration that deeply believes in the power of markets and competition. But the status quo is far from a competitive free market in the economic sense of the term, and healthcare is such a complex system, that facilitating a competitive, value-based marketplace is going to be disruptive to existing actors.”
In my last post , I made fun of Ezekiel Emanuel and Joseph Liebman for predicting that ACOs would replace insurance companies by 2020. I noted that the 800 to 1,000 ACOs reportedly in existence today are nowhere near ready to accept full insurance risk because they have shown no ability to cut costs. 
Although Emanuel and Liebman were foolish to predict most ACOs would quickly evolve into successful insurance companies, they shared with all other ACO advocates the understanding that that’s what ACOs are supposed to do – over time they’re supposed to bear more and more financial risk. It’s just never been clear how much financial risk ACOs were supposed to take on. The Affordable Care Act, for example, which authorized CMS to establish an ACO program within Medicare, did not address that question.
A reasonable interpretation of statements and papers by ACO proponents is that they expected a substantial portion of ACOs to morph into insurance companies. According to an early paper by several prominent ACO proponents, including Elliott Fisher, ACOs were expected to accept more risk in three stages: In stage 1 they would accept only upside risk (the opportunity to share in savings if they stayed under a target spending level); in stage 2 they would accept both up- and downside risk; and in stage 3 they would accept full insurance risk (they would no longer be paid fee-for-service, but would instead be paid “capitation” payments, aka premium payments), and would, therefore, have to set aside reserves. Presumably stage 3 ACOs would also have to be licensed by the insurance regulators in the states where they operate.Continue reading…
A National School Walkout Day is planned for March 14, 2018 at 10 a.m. and will last 17 minutes in honor of the 17 students and staff members killed at Marjory Stoneman Douglas High School in Parkland, Florida, on Valentine’s Day. The heart of the nation has seemed to shift overnight regarding the debate on guns, but this change has been almost two decades in the making. United and Delta Airlines pulled their support for the NRA, Dicks’ Sporting Goods will not sell assault-style weapons, and Walmart plans to raise the minimum age to purchase a gun to 21 years old.
I am a pediatrician. I treated the Columbine kids.
I have sat on the sidelines for far too long. I watched from a front row seat as frightened, grieving children who survived the shooting at Columbine High School on April 20, 1999 struggled to put their lives back together. My pediatric internship began June 23, 1999, at the Children’s Hospital in Denver, Colorado, approximately 20 miles north of Columbine High School. Up until that time, a mass shooting inside the walls of a high school had been almost unimaginable. Many students who had survived by hiding under a desk in the library that tragic day crossed my path over the next three years.
As a physician I am bound by strict patient confidentiality laws. For that reason and out of respect for the survivors, I cannot tell you their names. I cannot tell you the stories they told me. Or the awful things I read in their charts. I will let your imagination fill in the blanks.
I can only leave you to guess at what they saw and the nightmares that haunted them. In reality, every student and teacher inside Columbine High School was irreparably damaged forever; they lost a huge part of themselves on that heartbreaking day.
Why has so little changed in almost 20 years since Columbine?
Amazon has chosen its initial partners for its foray into healthcare—Berkshire Hathaway, the third largest public company in the world, and JPMorgan Chase, one of the largest banks in the world. Their mission is ambitious: to check the rise in health costs while concurrently enhancing patient satisfaction and outcomes. Can these three companies, none of which have expertise in healthcare, truly make a dent in healthcare costs? I would argue yes.
Here are three reasons why this partnership is fertile ground to realign innovation efforts with affordability and a long-term focus on health:
Self-insured employers play by different rules
The partnership’s first priority, as JPMorgan Chairman and CEO Jamie Dimon has stated, is to “create solutions that benefit our U.S. employees, their families, and potentially, all Americans.” Many have speculated this equates to covering their employees in a self-insured manner first. If this happens to be the case, the partnership will be constructing its model within a market that is conducive to minimizing costs.
In the private insurance market, private insurance companies are disincentivized to encourage innovation that lowers care costs, in part due to the Medical Loss Ratio. The Medical Loss Ratio is the ratio of expenditures in medical claims paid by an insurer for care of their beneficiaries to premium revenue. Private insurance companies are required to keep their MLR above 80% in the small group market and 85% in the large group market. Though the Medical Loss Ratio intends to ensure care is not withheld from beneficiaries, it also changes the profit maximization strategy for private insurers.
Instead of improving their bottom line with preventive care and finding ways to lower care costs, these private insurers profit when the 15 to 20% of premium revenues not seen as “medical loss” (such as overhead, administrative costs, and profit) is as large as possible. In order to maximize profit, the total revenue collected in premiums must also be as large as possible—pushing insurers to not only cover as many lives as possible, but raise premiums. Such a market discourages innovation meant to control care costs, as any successful initiatives would only end up diminishing the potential for profit.
Selecting an obstetrician or midwife and birth center or hospital is arguably one of the most important decisions that a pregnant woman makes. This choice will determine many aspects of a woman’s pregnancy journey, including the likelihood that she delivers via C-section. To understand how women choose their obstetric provider and their delivery facility, Ovia Health has teamed up with Ariadne Labs to survey women and help shed light on this important decision-making process.
C-sections in America
Few would debate that the United States is experiencing a C-section epidemic. One out of every three babies is born via C-section, despite the fact that 1) research shows that most pregnant women prefer and plan for vaginal delivery and 2) the World Health Organization (WHO) has argued that 10-15% is the optimal cesarean rate, placing the US at double or even triple the optimal rate. As the most common major surgery performed in the United States, C-sections are responsible for 20,000 surgical complications and infections annually, and account for over $5 billion in excess medical spend each year. Although C-sections can be life saving interventions, they still pose significant risks to both mother and child. C-section rates have risen at alarming rates across the United States, and many people, both inside and outside the medical community, are dedicated to uncovering and reversing the root cause of this trend.
According to Gallup surveys, four of five Americans believe the quality of care they receive is good or excellent, and the majority think it is the best available in the world. Surveys by Roper, Harris Interactive, Kaiser Family Foundation, Harvard’s Chan School of Public Health, and others show similar findings. And the public’s view hasn’t changed in two decades despite an avalanche of report cards about its performance, a testy national debate about health reform and persistent media attention to its shortcomings and errors. But is the public’s confidence in the quality of the care we provide based on an informed view or something else? It’s an important distinction.
Two considerations are useful for context:
Measuring quality of care objectively in the U.S. system is a relatively new focus. And we’re learning we’re not as good as they think we are. Historically, the public’s view about “quality of care” has been anchored in two strong beliefs: 1-the U.S. system has the latest technologies and drugs, the world’s best trained clinicians and most modern facilities, so it must be the best and 2-the care “I receive” from my physicians and caregivers is excellent because they’re all well-trained and smart.
1986 was a great year. In the heyday of the worst-dressed decade in history, the Russians launched the Mir Space Station, Pixar was founded, Microsoft went public, the first 3D printer was sold, and Matt Groening created The Simpsons. Meanwhile, two equally important but entirely different scientific leaps occurred in completely separate academic fields on opposite sides of the planet. Now, thirty two years later, the birth of deep learning and the first implementation of breast screening are finally converging to create what could be the ultimate early diagnostic test for the most common cancer in women.
A brief history of deep learning
1986: In America, a small group of perceived agitators in the early field of machine learning published a paper in Nature entitled “Learning representations by back-propagating errors”. The authors, Rumelhart, Hinton and Williams had gone against the grain of conventional wisdom and proved that by re-running a neural network’s output errors backwards through a system, they could dramatically improve performance at image perception tasks. Back-propagation (or back-prop for short) wasn’t their discovery (for we all stand on the shoulders of giants) but with the publishing of this paper they managed to finally convince the sceptical machine learning community that using hand-engineering features to ‘teach’ a computer what to look for was not the way forward. Both the massive efficiency gains of the technique, and the fact that painstaking feature engineering by subject matter experts was no longer required to discover underlying patterns in data, meant that back-propagation allowed artificial neural networks to be applied to a vastly greater array of problems that was previously possible. For many, 1986 marks the year that deep learning as we know it was born.
Every physician is taught to listen to patients. Every physician acknowledges it’s an essential skill. Yet, study after study shows physicians interrupt their patients within a few seconds of their patients’ oral presentation of their problem(s). The author, Prof. Terry Hannan, MD, teaches us to shut up for a few minutes. If we do so, medical care will be safer, more efficient, kinder, and patients will help clinicians be better healers.
This book convincingly demonstrates the value of listening to patients; of discovering what is missing or wrong in the chart, of understanding the real etiology, and of the all-powerful value of honest communication. The book is a passionate defense of the physician as a human being who can listen and communicate with patients to help heal and understand. The physician, granted awesome authority and respect by society, is in a unique position to help patients understand and heal themselves in addition to bringing the needed care and science for their benefit. Included here, is knowing when to prevent unneeded care.
All of that said, the reason everyone should read this book–both clinicians and lay readers–is for the short stories of patient’s lives and experiences as they impact their illnesses and the role of healthcare. The stories are inevitably warm, humane, sensitive, and insightful. They give us hope for humans’ ability to help others, or at least to understand and ease their pain.
Each of the stories is this very short book is only a page or three long. Each is personal and poignant. Each gives us hope for medical care and for humanity.
The 19th century was about the Industrial Revolution. The 20th century, the Digital Revolution. As we march closer to the third decade of the 21st century, it is becoming clearer that this century’s revolution will be the Data Revolution. After all, companies are monetizing it, countries are weaponizing it and people are producing it.
In the medical space, this has fostered conflicting aims. The promise afforded by collecting and analyzing digital health data for insights into population health and personalized medicine is tempered by haziness on who owns and leverages that data.
But even as government actors struggle with the question of how to regulate data, technological progress marches on. Given the dizzying array of technological products claiming medical benefits hitting the marketplace, regulatory agencies have had to contemplate, and take, drastic steps to keep up. For instance, in the past two years the FDA has taken the following steps:
In July 2016, the FDA clarified what constituted a “low-risk” device such as fitness trackers or mobile apps tracking dietary activity.
In June 2017, new FDA Commissioner Scott Gottlieb outlined his vision for a more streamlined process for digital technologies which moves from a “case-by-case” approach to one that allows developers apply consistent safety standards to innovation.
Just a month later, the FDA announced the pilot for a digital health pre-certification program for individual companies which allows those firms that demonstrate a “culture of quality and organizational excellence” and the need for minimal regulation to introduce products to be marketed as new digital health tools with less information communicated to the FDA, sometimes with no “premarket submission at all”.
By September 2017, nine companies, including tech heavyweights Apple, Samsung and Alphabet-backed Verily, had been selected for the pre-cert process.
On February 13, 2018, the FDA further specified that low-risk products would be evaluated by looking at the firm’s practices rather than the product itself and announced its intent to create a new Center of Excellence on Digital Health which would be tasked with establishing a new regulatory paradigm, evaluating and recognizing third-party certifiers and hosting a new cybersecurity unit to complement new advances.
With this flurry of activity, the FDA is clearly moving toward a principles-oriented and firm-based approach to regulating digital technologies. This means moving away from certifying medtech products to the producers.
You may have heard that before you pick a doctor you are supposed to look them up online and see what other people have to say about them before you set up an appointment.
In the Age of Amazon this makes sense. Why wouldn’t you?
Allow me to give you a little insider information. While they may well be a good idea in theory, Yelp.com and other online physician review sites have evolved in recent years to become the bane of my and fellow doctors existence.
This past summer, Physicians Working Together, a non-partisan physician organization, started a petition on Change.org requesting Yelp remove online reviews of doctors.To date, more than 30,000 physicians have signed it but I doubt Yelp will pay much attention.
Recently, the highest-level court in Germany ruled Jameda, an online physician rating site, must remove the name of a disgruntled physician. A dermatologist from Cologne filed the case in the Federal Justice Court demanding Jameda remove her name due to the fact the anonymous nature of the rating site inspires the public to leave spiteful, vindictive comments.Interestingly enough, in 2014, a gynecologist asked to be removed from Jameda, however the Court ruled the right of patients to be “well informed” about their doctor took precedence over freedoms of the physician.
What is the value of rating physicians online?Are consumers becoming “well-informed?”