Category: Uncategorized

Engaging Responsibly In the Health Care Debate

Apr 30, 2016• 18

By JIM PURCELL

flying cadeucii With no apology offered, I will be venturing into a very subjective realm, namely, a characterization of today’s healthcare dialogue and what, in my opinion, might be an improvement.

I would suggest we have fallen into the trap that was partly enhanced by email and blogs, namely, that we can say outrageous things impolitely and without consequence. With email we tend to be much blunter and impolite than we would be face to face. On blogs, we can be positively toxic. It’s like driving in a car with a tinted windshield that no one can see through. You are anonymous and therefore can act less responsibly.

Another vignette. I grew up in a very small upstate New York town where everyone knew everyone else. You used your car horn to beep “hi” or to warn, and not in anger, ever. When you waved at someone, it was with all five fingers. And so on. I think you get my point.

The healthcare debate always has stoked emotions like almost no other. It is intensely personal, and the stakes are high. We’re all involved and engaged.

As I’ve written in the past, I first earned my stripes as a lawyer representing my local Blue Cross plan in rate hearings. These rate hearings always started with “public comment.” The comment ranged from pure outrage to controlled anger to discontent coupled with suggestions. What did we pay the most attention to? Of course, the latter.

Replacing Meaningful Use, Advancing Care Information

Apr 27, 2016• 31

By ANDY SLAVITT and KAREN DE SALVO, MD

Screen Shot 2016-04-27 at 1.46.53 PM Seven years ago, Congress passed a law to spur the country to digitize the health care experience for Americans and connect doctors’ practices and hospitals, thereby modernizing patient care through the Electronic Health Records (EHRs) Incentive Programs, also known as “Meaningful Use.” Before this shift began, many providers did not have the capital to invest in health information technology and patient information was siloed in paper records. Since then, we have made incredible progress, with nearly all hospitals and three-quarters of doctors using EHRs. Through the use of health information technology, we are seeing some of the benefits from early applications like safe and accurate prescriptions sent electronically to pharmacies and lab results available from home. But, as many doctors and patients will tell you (and have told us), we remain a long way from fully realizing the potential of these important tools to improve care and health.

That is why, as we mentioned earlier this year, we have conducted a review of the Meaningful Use Program for Medicare physicians as part of our implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), with the aim of reconsidering the program so we could move closer to achieving the full potential health IT offers.

The World in 2016: MACRA, a New Era For Meaningful Use and (Yet More) Political Change to come

Apr 27, 2016• 5

BY THE EDITORS

Screen Shot 2016-04-27 at 10.16.03 AM

THCB is pleased to introduce the 2016 Healthcare Town Hall, a special online feature brought to you in partnership with Health Catalyst. This is an experiment. The idea is to open up an ongoing dialogue around the issues that are transforming healthcare in the second decade of the 21st Century.

We’re kicking things off with an online panel featuring THCB Editor John Irvine and the HealthCatalyst leadership including Dale Sanders, John Haughom and Bryan Oshiro.

John Irvine: Let’s start with the recent decision at CMS to transition from the Meaningful Use the program to a new program that will be a component of MACRA. A lot of people were extremely surprised with the news that Meaningful Use is going away. The follow up development, of course, is that CMS has agreed in principle to a new set of core clinical quality measures that will change the way doctors are evaluated. I’m hearing a lot of positive feedback about the Meaningful Use decision. Reactions?

Dale Sanders: I was surprised, yes. As I think you know, I’ve spent a lot of time in Washington. I know how government works. People in government generally do not reverse themselves, unless it is very clear that there is no other available option. That’s Washington 101. Read into that what you will. It’s far easier to allow a program to keep on going than to admit that something isn’t working or that it has outlived it’s usefulness. I think a lot of people are missing the fact that It took political courage to do that. I will say that I was one of the first to publicly call for the suspension of Meaningful Use, and you guys posted the blog that I wrote about it. At Northwestern, we published a one page policy entitled, “Principles of EMR Utilization” that was written and endorsed by our physicians, facilitated by me when I recognized that our EMRs were being used for little more than a multi-million dollar word processor. That one-page document is all we needed to achieve the same concepts as Meaningful Use. The last time I counted, the Meaningful Use regulations totaled over 350 pages. In typical fashion, the government turned a good concept into a mess. So, I’m cautiously optimistic that we are going to return to common sense.

The ACO Delusion

Apr 25, 2016• 28

By ANISH KOKA, MD

flying cadeucii Accountable care organizations (ACO’s) promise to save us. Dreamed up by Dartmouth’s Eliot Fisher in 2006, and signed into law as a part of the Patient Protection and Affordable Care Act (PPACA) in 2010, we have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time. I dare say that Brahma, Vishnu and Shiva together would struggle to accomplish those lofty goals. Regardless of the daunting task in front of them, the brave policy gods who see patients about as often as they see pink unicorns, chose to release the Kraken – I mean the ACO – onto an unsuspecting public based on the assumption that anything was better than letting those big, bad, test ordering, hospital admitting, brand name prescribing physicians from running amuck.

I realize I am being somewhat harsh towards the creators of the ACO morass. But, while they all may be well-meaning, hard-working folks that own a Harvard crimson sweater, their intent is to fundamentally change how health care is provided – this mandates a withering evaluation. As Milton Friedman aptly said, “One of the great mistakes is to judge policies and programs by their intentions rather than their result.” Thus, with little regard to intent, and with an eye on the end result, I say unequivocally : ACO’s do not work.Continue reading…

A Spoonful of Inequality Helps the Medicine go Down

Apr 24, 2016• 14

By SAURABH JHA, MD

The conventional wisdom in the circles I hang out in – pro-Hillary, morally conscious,happy bunnies who pretend to enjoy French wine and opera – is that the greatest scourgeon humanity after the bubonic plague is inequality of wealth. They worship Pope St. John Paul Piketty and canonize Archbishop Paul Krugman. Not only is inequality bad for its own sake, they say, it makes people ill, like medically ill.

Their premise always struck me as specious. I once took them through a thought experiment. Imagine, I said, you time travel to the Bengal famine. There was a lot of equality then – people were equally malnourished. Everyone’s ribs protruded equally because of muscle wasting from marasmus. The loss of protein from kwashiorkor made sure everyone’s belly popped out without prejudice. Starvation because of poverty is a great leveler. It cares little about gender, caste or religion. It is non-judgmental.

Confessions of a Health Plan CEO

Apr 23, 2016• 36

By JIM PURCELL

flying cadeucii The fact that I was once the CEO of a health insurer may cause you to read this with some skepticism.

I invite and challenge your skepticism. And I will do my very best to keep this piece strictly factual and not stray into the ambiguities that necessarily accompany complicated matters.

So bear with me.

Health insurers are not popular. No one wants to go to the prom with us. We have been vilified by no less than the President of the United States. Heady stuff. Let us see if this vilification and what I call the cartoonization of insurers has served us well in the healthcare debate. I think it has not, because for reasons I hope to make clearer, it has taken the focus away from the real causes of our cost and quality nightmares.

Health insurance started in the Depression with the Blues, although they were not at first called that. They typically were formed by hospitals (the Blue Crosses) and physicians (the Blue Shields), so that some payment for services rendered might be, well, “insured.” Provider self interest cloaked in the public interest. Perhaps there was alignment. And there was a Depression going on after all.

At first, the role of the health insurer was strictly financial. The insurer financed all or a portion of covered health services, and far, far fewer services were covered then than today. That’s all an insurer did or was expected to do. It was not there to manage doctors or hospitals or patients or anything else. Originally, this financing was done through “indemnity” plans, which allowed patients to see anyone they wanted, and paid a set dollar amount per service or per day of hospitalization (e.g., $50/day of hospitalization). Thus, if you chose a more expensive provider, the difference was on you. Insurers back in the day did not negotiate reduced fees with providers (“fee discounts”). It was much more civil then.

Your Drugs Are About to Get More Expensive

Apr 23, 2016• 1

By DEVON M HERRICK

The Washington Post recently ran an article by Marlene Cimons, a Medicare Part D drug plan enrollee. Her late father had been a pharmacist and he had owned a drugstore while she was growing up. She thought it would be nostalgic to patronize a neighborhood drugstore rather than a big chain pharmacy. She found a neighborhood drugstore in her preferred pharmacy network and had her prescription transfer there. She was stunned, however, when a 90-day prescription that should have required only a $3 co-pay turned out to be $58.

When she inquired the drugstore claimed it stood to lose money on her particular prescription. Who knows; maybe its profit margin wasn’t as high as the pharmacy thought it should be. In order to fill her prescription the drugstore basically required her to willingly pay an extra $55 more than its contractual agreement stipulated. Of course, that violated the contract the drugstore had signed with her Medicare Part D plan. The agreement the pharmacy had signed with her drug plan did not allow it to arbitrarily charge higher prices and Ms. Cimons left without her prescription.

The Mess That is MACRA

Apr 21, 2016• 15

By KIP SULLIVAN

MACRA (the Medicare Access and CHIP Reauthorization Act) is a mess. It is extremely difficult to comprehend, it is based on assumptions that defy commonsense and research, and it may raise costs.

The Medicare Payment Advisory Commission (MedPAC) would never say what I have just said, but MedPAC definitely understands MACRA’s defects. The transcripts of MedPAC’s October 8, 2015 and January 15, 2016 meetings indicate that members and staff perceive daunting impediments to the implementation of MACRA. But those transcripts also suggest that MedPAC won’t tell Congress to rewrite or repeal MACRA. Rather, the evidence suggests MedPAC will mince words. It appears MedPAC will send CMS and Congress a few wishes dressed up as “principles” and wait for MACRA’s inevitable failure before offering more useful advice.

Before I attempt to explain MACRA, let me first convey to you MACRA’s mind-numbing complexity by quoting four commissioners. Each statement below is followed by the last name of the commissioner who made it, the date the statement was made, and the page number of the transcript where the statement appears.

Is Pornography Creating a Public Health Crisis?

Apr 21, 2016• 16

By STEVEN FINDLAY

flying cadeucii Well, it’s not Zika and it won’t kill you, but pornography is being discussed—seriously—as a public health problem, even a “crisis.”

The path to this claim is a long one, with a slow burn over many years. It was kicked into higher gear in recent months with:(a) legislative action in one state;(b) a coverstory in TIME magazine (April 11 issue);(c) a Washington Post op-ed piece by anti-porn advocate Gail Dines; (d) a response to that in Atlantic Monthly; and (e) the publication of two books that discuss at length the effect of porn and the new sexual culture on teen girls—American Girls-Social Media and the Secret Lives of Teenagers by Mary Jo Sales and Girls & Sex-Navigating the Complicated New Landscape by Peggy Orenstein.

The legislative action took place in Utah. The Republican-led House of Representatives in that state became the first legislative body in the nation to pass a resolution declaring pornography “a public health hazard leading to a broad spectrum of individual and public health impacts and societal harms.” Dines and her fellow anti-porn crusaders want to carry that fight to other states.

This is going to be fun to watch! (Pun intended.)

Making Medicine Great Again

Apr 21, 2016

By MICHAEL MILLENSON

The annual Lown Institute Conference advocates for the “right” kind of patient care, as in “the correct course of action.” But the political meanings of “right” and “left” also echo, sounding like a healthcare version of the recover-lost-glory demands of Donald Trump and the moral crusade of Bernie Sanders.

The program for this year’s meeting, held in Chicago, urged attendees to “take back health [care];” you could almost hear a Trumpian, “Make medicine great again!” In an opening address, the institute’s senior vice president, Shannon Brownlee, proclaimed, “We are gathered out of a shared sense of moral purpose and a shared sense of outrage at the state of American healthcare.” The targets of that outrage that “we” need to take back healthcare from comprised a Sanders-type litany of the “pharma, biotech and device companies…[who] have illegally marketed products.”

There was one more villain, very carefully defined. That would be “a culture of overtesting and overtreatment…[that] harms patients, clinicians and communities.” Got that? While Brownlee’s acclaimed 2007 book, Overtreated, repeatedly highlights the abuses of fee-for-service medicine, the Lown Institute’s namesake founder and its president are academic physicians. And so, the doctors and hospitals responsible for and often profiting from overtreatment magically become just one more set of victims of the “culture.”

Ideological blinders notwithstanding, the institute’s work celebrates and highlights an impressive array of individuals working diligently for every conceivable kind of “right care.” There was Dr. Jeffrey Brenner, a Camden, NJ family physician whose description of his dogged, data-driven efforts on behalf of the poor and sick brought a standing ovation. And Dr. Joanne Lynn, a long-time advocate for the frail elderly, explaining why a MediCaring community model that mixed medical and social services was what the vulnerable old and their families really needed.