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Category: Health Policy

Why Medicare for All Will Not Cure What Ails the Hahnemann

By ASEEM R. SHUKLA, MD

The impending closure of Hahnemann University Hospital is a local tragedy.  Eliminating a 170-year old institution is certain to exaggerate the daily travails of the economically disadvantaged inner-city population that Hahnemann serves as a safety-net hospital.  The closure is also a national tragedy. Hospitals are the towering, visible monuments of our healthcare system, and closings imply that something insidious ails that very system—that all is not well.  

Hospitals are complex entities with varied financial drivers, and the solution is never simple.  And the moment is too rich for politicians who see Hahnemann’s failure as the culmination of their dystopian predictions.  Bernie Sanders, most prominently, stood on the hospital’s doorstep and pitched his deceptively simple solution—Medicare for All.  Medicare for All, Sanders said, would ensure that every patient carries the same coverage, hospitals are paid a predictable rate, and voila, no hospitals need to close.  Private insurance would disappear, and no one would be without coverage.  

Even physicians have jumped on the Medicare for All bandwagon.  Some doctors insist that once profit is removed as a motive for hospital bottom lines, and government bodies decide which hospitals can buy a surgical robot, build a new wing or offer proton beam treatment cancer treatment centers, then all hospitals will do better.  

But these arguments miss a fundamental point: why pitch government insurance for all, like Medicare and Medicaid (a federal and state insurance plan to cover low income adult and children) as a remedy, when it is precisely government-run insurance that is killing Hahnemann and other hospitals in distress? 

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Protecting Health Data Outside of HIPAA: Will the Protecting Personal Health Data Act Tame the Wild West ?

Vince Kuraitis
Deven McGraw

By DEVEN McGRAW and VINCE KURAITIS

This post is part of the series “The Health Data Goldilocks Dilemma: Privacy? Sharing? Both?”

Introduction

In our previous post, we described the “Wild West of Unprotected Health Data.” Will the cavalry arrive to protect the vast quantities of your personal health data that are broadly unprotected from sharing and use by third parties?

Congress is seriously considering legislation to better protect the privacy of consumers’ personal data, given the patchwork of existing privacy protections. For the most part, the bills, while they may cover some health data, are not focused just on health data – with one exception: the “Protecting Personal Health Data Act” (S.1842), introduced by Senators Klobuchar and Murkowski. 

In this series, we committed to looking across all of the various privacy bills pending in Congress and identifying trends, commonalities, and differences in their approaches. But we think this bill, because of its exclusive health focus, deserves its own post. Concerns about health privacy outside of HIPAA are receiving increased attention in light of the push for interoperability, which makes this bill both timely and potentially worth of your attention.

HHS and ONC recently issued a Notice of Proposed Rulemaking (NPRM) to Improve the Interoperability of Health Information. This proposed rule has received over 2,000 comments, many of which raised significant issues about how the rule potentially conflicts with patient and provider needs for data privacy and security.

For example, greater interoperability with patients means that even more medical and claims data will flow outside of HIPAA to the “Wild West.” The American Medical Association noted:

“If patients access their health data—some of which could contain family history and could be sensitive—through a smartphone, they must have a clear understanding of the potential uses of that data by app developers. Most patients will not be aware of who has access to their medical information, how and why they received it, and how it is being used (for example, an app may collect or use information for its own purposes, such as an insurer using health information to limit/exclude coverage for certain services, or may sell information to clients such as to an employer or a landlord). The downstream consequences of data being used in this way may ultimately erode a patient’s privacy and willingness to disclose information to his or her physician.”

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Everyone Is Having the Wrong Healthcare Debate

By STEVEN MERAHN, MD

In 1807, in an effort to spite the British and French for shipping interference (and forced recruitment of American citizens into military service), the United States Congress passed an Embargo Act, effectively shutting down trade with these two countries. Britain and France quickly found other trading partners; the US, then limited in our capacity to sell products outside our borders, was left with a devastated economy and a gaping hole in our face. It took only weeks before Congress passed a loophole; they repealed the act within 15 months of its passing. It was a great lesson in unintended consequences.

Today, ignoring history, both Republicans and Democrats seem to spar continuously around healthcare: whether the message is about tearing down the Affordable Care Act or about some version of Medicare (For-All, For Whoever Wants It, For America, or For Better or Worse), both parties are terribly wrong.

Assuming the social imperative for healthcare is to eliminate preventable morbidity and disability (and associated costs) and improve (or sustain) quality of health of all our citizens (in order to help as many of them as possible remain productive, contributing members of society), another approach to ‘universal care” would be to flip the figure/ground relationship for our current efforts: instead of developing better payment systems, let’s develop and commit to a universal clinical operating framework that ensures that every member of society has the same opportunity to optimize their health status.

“Centralizing” the methodology around a universal model for how we plan for care, and allocate resources to ensure care plan goal achievement, would be far more valuable to society than centralizing the sources of funds to pay for care, because then we’d know what we’re paying for.

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The Rebellion of the Buyers

By JOE FLOWER

Did you catch that headline a few weeks back?

An official of a health system in North Carolina sent an email to the entire board of the North Carolina State Health Plan calling them a bunch of “sorry SOBs” who would “burn in hell” after they “bankrupt every hospital in the state.”

Wow. He sounds rather upset. He sounds angry and afraid. He sounds surprised, gobsmacked, face-palming.

Bless his heart. I get it, I really do. Well, I get the fear and pain. Here’s what I don’t get: the surprise, the tone of, “This came out of nowhere! Why didn’t anyone tell us this was coming?”

Brother, we did. We have been. As loudly as we can. For years.

Two things to notice here:

  1. What is he so upset about? Under State Treasurer Dale Folwell’s leadership, the State Health Plan has pegged its payments to hospitals and other medical providers in the state to a range of roughly 200% of Medicare payments (with special help for rural hospitals and other exceptions). In an industry that routinely says that Medicare covers 90% of their costs, this actually sounds rather generous.
  2. What is the State Health Plan? It’s not a payer, that is, an insurer. It’s a buyer. Buyers play under a different set of rules and incentives than an insurer.
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How a Value Focus Could Change Health Care

By BRIAN KLEPPER, PhD

How will the drive to health care value affect health care’s structure? We tend to assume that the health care structure we’re become accustomed to is the one we’ll always have, but that’s probably far from the truth. If we pull levers that incentivize the right care at the right time, it’s likely that many of the problems we think we’re stuck with, like overtreatment and a lack of accountability, will disappear.

A large part of getting the right results is making sure that health care vendors have the right incentives. All forms of reimbursement carry incentives, so it’s important to align them, to choose payment structures that work for patients and purchasers as well as providers. Fee-for-service sends exactly the wrong message, because it encourages unnecessary utilization, paying for each component service independent of whether its necessary and independent of the outcomes. Compare US treatment patterns to those in other industrialized nations and you’ll find ours are generally bloated with procedures that have become part of practice not because they’re clinically necessary but simply because they’re billable.

By contrast, value-based arrangements are really about purchasers demanding that health care vendors deliver better health outcomes and/or lower cost than what they’ve experienced under fee-for-service reimbursement, and the payment structure often asks the vendor to put his money where his mouth is, at least where performance claims are concerned. In a market that’s still overwhelmingly dominated by fee-for-service arrangements, one way for a vendor to get noticed is to financially guarantee performance. Integrated Musculoskeletal Care, a musculoskeletal management firm based in Florida, guarantees a 25% reduction in musculoskeletal spend on the patients they touch. This typically translates to a 4%-5% reduction in total health plan spend, just by contracting with this vendor, a compelling offer in an environment that makes it hard for upstarts to get market traction.

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Health Data Outside HIPAA: The Wild West of Unprotected Personal Data

Deven McGraw
Vince Kuraitis

By VINCE KURAITIS and DEVEN McGRAW

This post is part of the series “The Health Data Goldilocks Dilemma: Privacy? Sharing? Both?”

“…the average patient will, in his or her lifetime, generate about 2,750 times more data related to social and environmental influences than to clinical factors”

McKinsey analysis

The McKinsey “2,750 times” statistic is a pretty good proxy for the amount of your personal health data that is NOT protected by HIPAA and currently is broadly unprotected from sharing and use by third parties.

However, there is bipartisan legislation in front of Congress that offers expanded privacy protection for your personal health data. Senators Klobuchar & Murkowski have introduced the “Protecting Personal Health Data Act” (S.1842). The Act would extend protection to much personal health data that is currently not already protected by HIPAA (the Health Insurance Portability and Accountability Act of 1996). 

In this essay, we will look in the rear-view mirror to see how HIPAA has provided substantial protections for personal clinical data — but with boundaries. We’ll also take a look out the windshield — the Wild West of unprotected health data.

Then in a separate post, we’ll describe and comment on the pending “Protect Personal Health Data Act”.

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HardCore Health Podcast| Episode 3, IPOs, Privacy, & more!

On Episode 3 of HardCore Health, Jess & I start off by discussing all of the health tech companies IPOing (Livongo, Phreesia, Health Catalyst) and talk about what that means for the industry as a whole. Zoya Khan discusses the newest series on THCB called, “The Health Data Goldilocks Dilemma: Sharing? Privacy? Both?”, which follows & discuss the legislation being passed on data privacy and protection in Congress today. We also have a great interview with Paul Johnson, CEO of Lemonaid Health, an up-and-coming telehealth platform that works as a one-stop-shop for a virtual doctor’s office, a virtual pharmacy, and lab testing for patients accessing their platform. In her WTF Health segment, Jess speaks to Jen Horonjeff, Founder & CEO of Savvy Cooperative, the first patient-owned public benefit co-op that provides an online marketplace for patient insights. And last but not least, Dr. Saurabh Jha directly address AI vendors in health care, stating that their predictive tools are useless and they will not replace doctors just yet- Matthew Holt

Matthew Holt is the founder and publisher of The Health Care Blog and still writes regularly for the site.

A Proposal to Improve Healthcare and Make It More Affordable

By STEVE ZECOLA

Americans spend about $3 trillion per year on healthcare, or about $10,000 per person per year. Despite these expenditures, Americans are worse off than their international counterparts with respect to infant mortality, life expectancy and the prevalence of chronic conditions.

In policy debates, Republicans mostly prefer to let the marketplace devise the appropriate outcomes, but this approach ignores the market failures that plague the industry.

On the other hand, Democrats propose a variety of solutions such as “Medicare for All” which nationalizes all healthcare insurance or, as a variant, “Medicare as an Option for All” which further extends the federal government into the provision of healthcare insurance. Such approaches could actually result in a less efficient outcome, or worse yet, create a market beset by political ping pong when Administrations change.

This paper proposes a new standards-based approach for fixing the inefficiencies plaguing the healthcare industry in the United States. As described herein, a non-profit standards body would be established by Congress to bring a coordinated approach to healthcare for each of the top ten chronic diseases.

Such an approach would establish consistent priorities and practices across all of the components of the healthcare industry affecting these chronic diseases, including standards of care, areas of research emphasis and insurance guidelines.

Under such an industry structure, patient care would improve and the overall costs for the provision of healthcare would drop significantly.

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Off the Couch, Onto the Stage: My First, Only and Not-So-Great Presidential Debate

DETROIT, MICHIGAN – JULY 31: Democratic presidential candidate former Vice President Joe Biden (C) speaks while Sen. Kamala Harris (D-CA) (R) and Sen. Cory Booker (D-NJ) listen during the Democratic Presidential Debate at the Fox Theatre July 31,
GETTY IMAGES

By MICHAEL MILLENSON

I could’ve been Kamala Harris, Joe Biden and Marianne Williamson all rolled into one. That’s how I might have handled my first, only, and not-so-great presidential debate. 

No, I wasn’t actually running for president. But I was involved in the campaign of someone who was: Barack Obama. In September, 2008, the campaign asked me to serve as a surrogate in a debate with John McCain’s health care adviser when one of Obama’s close advisers – as opposed to me, who’d met the candidate once at a campaign event – couldn’t make it. 

As a policy wonk and politics junkie, I was ecstatic. Entering the debate, I was confident. Afterwards, metaphorically dusting the dirt off my clothing and checking for cuts and bruises, I was chastened. 

Getting off the couch and onto the stage, even a small one, is tougher than it looks. Watching the cluster of Democratic presidential candidates go at it on health care, I scoffed and sneered along with other experts at their obfuscations and oversimplifications. (More on that in a moment.)  But I also sympathized. 

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Doctors Will Vote With Their Patients

By MIKE MAGEE, MD

As Robert Muller’s testimony before Congress made clear, we owe President Trump a debt of gratitude on two counts. First, his unlawful and predatory actions have clearly exposed the fault lines in our still young Democracy. As the Founders well realized, the road would be rocky on our way to “a more perfect union”, and checks and balances would, sooner or later, be counter-checked and thrown out of balance.

On the second count, Trump has most effectively revealed weaknesses that are neither structural nor easily repaired with the wave of the wand. Those weaknesses are cultural and deeply embedded in a portion of our citizenry. The weakness he has so easily exposed is within us. It is reflected in our stubborn embrace of prejudice, our tolerance of family separations at the border, our penchant for violence and romanticism of firearms, our suspicion of “good government”, and –unlike any other developed nation – our historic desire to withhold access to health services to our fellow Americans.

In the dust-up that followed the New York Times publication of Ross Douthat’s May 16, 2017 article, “The 25th Amendment Solution for Removing Trump”, Dahlia Lithwick wrote in SLATE, “Donald Trump isn’t the disease that plagues modern America, he’s the symptom. Let’s stop calling it a disability and call it what it is: What we are now.”

Recently a long-time health advocate from California told me she did not believe that the majority of doctors would support a universal health care system in some form due to their conservative bend. I disagreed.

It is true that, to become a physician involves significant investment of time and effort, and deferring a decade worth of earnings to pursue a training program that, at times, resembles war-zone conditions can create an ultra-focus on future earnings. But it is also true that these individuals, increasingly salaried and employed within organizations struggling to improve their collective performance, deliver (most of the time) three critical virtues in our society.

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