Category: Uncategorized

Uber and the Twisted Logic of the Affordable Care Act’s Employer Mandate

Jun 25, 2015• 12

By DAVID DRANOVE and CRAIG GARTHWAITE

We have recently blogged about what is perhaps the best feature of the Affordable Care Act – the individual insurance exchanges. These exchanges have the potential to create one of the first well-functioning individual insurance markets in the United States. In addition, they are an implicit recognition of the nature of the contemporary American economy – one where workers frequently move employers and are increasingly serving as independent contractors for multiple firms.

However, a recent ruling by the California Labor Commission reminds us of what must be one of the worst features – the requirement that large employers provide health insurance to all employees working more than 30 hours per week. This mandate is a remnant of a 1950s economy where workers remained employed at the same firm for decades and the Internet was just a series of tubes that existed in our dreams. Ironically, the ACA insurance exchanges not only make the employer mandate obsolete, but the mandate actually weakens the viability of the exchanges by locking a large portion of the healthy population into the employer provided insurance market.

Driving Innovation Through an Apps-Based Information Economy

Jun 25, 2015

By JAAN SIDOROV, MD

In case you think the future for healthcare apps will be characterized by health information technology (HIT) “dead zones” of free downloads, fun gadgetry and vacuous consumerism with nothing to show for it, you should take a look at this article appearing in the peer-reviewed journal Cell Systems.

If authors Kenneth Mandl, Joshua Mandel and Isaac Kohane are even half right, “apps” could truly revolutionize HIT. They argue that a superimposed “apps layer” ecosystem will demolish the “walled gardens” of EHRs and allow for true information sharing across clinics, systems and regions.

And that’s just for starters.

As your correspondent understands it, “Application Programming Interfaces” (or “APIs”) will enable multiple third party apps to bridge to legacy EHRs. That, in turn, will catalyze the creation of newer and better user experiences that reconcile doc and patient preferences with the current clunky one-size-fits-all EHRs.

Two Years Later: How Kynect Has Impacted Kentucky’s Healthcare System

Jun 25, 2015

By CAMPBELLSVILLE UNIVERSITY SPONSORED CONTENT

Since its second enrollment period ended in March, Kentucky’s health benefit exchange has been celebrated by state government leaders as a success story of the Affordable Care Act. Known as Kynect, the exchange has provided thousands of uninsured citizens with health insurance coverage. It has also drawn its share of controversy.

Although much of the discussion surrounding Kynect and the Affordable Care Act has focused on their political implications and other debates, little has been said about how the changes to Kentucky’s healthcare system have affected patients, nurses, doctors and hospitals. With two enrollment periods complete, how has Kynect worked and what benefits has it provided the state?

King vs. Burwell: Supreme Court Backs Federal Health Law Subsidies

Jun 25, 2015• 7

By THCBist

Screen Shot 2015-06-25 at 10.44.49 AM In a 6-3 ruling, the Supreme Court ruled that the federal health law may provide subsidies to help Americans buy insurance on the state exchanges, officially putting a stop to one of the slowest-moving and arguably most mind-numbingly boring — if important — news stories in recent history (with all due apologies to tax credit enthusiasts and the American Academy of Actuaries).

More importantly, the ruling means that 30 million Americans will continue to be eligible for health insurance through the exchanges. Practically speaking, the decision eliminates the last major challenge to the Affordable Care Act.

Health stocks rose on the news, as the uncertainty that has been shadowing hospital and health plan stocks for months was eliminated.

The dissenting opinion in King, authored by Justice Scalia, is already being called an “instant classic*,” is replete with memorable zingers such as:

“Words no longer have meaning if an Exchange that is not established by a State is “established by the State” and “..It is bad enough for a court to cross out “by the State” once. But seven times?

Dissenting opinions in important cases, of course, are almost always hailed as “instant classics” by supporters, just as they are thrashed as “incoherent judge-babble” by critics.

So to be taken with a grain of salt. Or not.

The line that is likely to be remembered, and quoted most widely by opponents of the Affordable Care Act, however, is this one:

“The Act that Congress passed makes tax credits available only on an ‘Exchange established by the State.’ This Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare.”

Real Mentoring Lessons From the Liver Queen

Jun 24, 2015• 1

By MARTIN SAMUELS, MD

In 1970 I had the opportunity to spend time at the Royal Free Hospital in London. One of my professors at The University of Cincinnati College of Medicine, the late Leon Schiff, a renowned liver expert, arranged for me to work under Professor Sheila Sherlock. I was placed in a laboratory that was investigating the presumed immune basis of primary biliary cirrhosis. Roy Fox and Frank Dudley, the faculty in the lab, warmly welcomed me and taught me the basics of immunology research. My first scientific paper in Gut, was based on this work. But, I was a budding clinician and I was drawn to the charismatic Professor Sherlock, so I took every opportunity to attend her rounds and teaching conferences. In many ways a fearsome figure, The Prof dazzled me with her clinical acumen, rhetorical skills, sense of humor and drive. Though only a lowly visiting medical student, she including me in the exercises and even turned to me as a local “expert” on American culture. The entire experience is remarkably memorable. The Prof was filled with pearls, anecdotes, stories and caveats. Here are a few.

The “outpatient” consisted of the Prof seeing patients while the students watched. The room was arranged with six cubicles, three on each side of her desk, each guarded by a watchful nurse (sister) with a neat uniform and starched hat. In front of The Prof’s desk were several rows of chairs; perhaps a total of 16, for students who were to sit quietly unless specifically ask to speak or to feel the liver of one of the patients.

Five Rules for a Real Mentor

Jun 24, 2015

By MARTIN SAMUELS, MD

1. Be a real expert (have something real about which to mentor)

2. Don’t avoid being a mentor because you are not “like” the mentee (e.g. gender, age, field, ethnicity)

3. Give negative feedback when necessary but don’t hold a grudge

4. Use your power to substantively help the mentee

5. Be proud of your mentees and tell them so (take real pleasure in their accomplishments)

Moneyball For Doctors and Nurses (and the People Who Run Hospitals)

Jun 24, 2015• 2

By PAUL KECKLEY

Michael Lewis’ 2003 best seller Moneyball recounts how Oakland Athletics’ manager Billy Beane beat the big-payroll odds in major league baseball by using analytics to field a competitive team. The dynamic between Beane and his Yale-trained geek, Peter Brand is the central theme: together they fought off naysayers using Brand’s sabermetrics model later credited with the Red Sox World Series win the next season.

This week, thousands of financial officers from across multiple sectors in healthcare will descend on Orlando for the Healthcare Financial Management Association Annual Institute (ANI), a four day potpourri of knowledge-sharing sessions punctuated by keynotes from industry luminaries and an active exhibit floor.

The growing complexity of healthcare financial administrative issues is daunting. Case in Point: ANI organizes its 80 sessions in 8 tracks titled Business Intelligence and Analytics, Clinical Integration, Collaboration for Decision-Making, Cost Management-Margin Transformation, Finance-Capital Markets, Payment Trends and Delivery Models, Regulatory and Compliance Updates, and Revenue Cycle and the Patient Experience. There’s something there for everyone—from the rookie in internal audit to the CFO in the C-Suite.

Legislation that Could End Unwanted Medical Treatment

Jun 24, 2015• 3

By Daniel R. Wilson

Roughly 25 million Americans have been subjected to unwanted medical treatment at some point in their lives, and that means we have a healthcare system that is not listening to patients. We all say we believe in patient-centered health care, and now we have a bill in the U.S. Congress that would put our money where our mouths are. Literally.

Senators Mark Warner (D-VA) and Johnny Isakson (R-GA) introduced legislation this month that would make sure Medicare recipients and their doctors know how much or how little treatment those patients would want as they approach the end of life. The Care Planning Act of 2015 would specifically create a Medicare benefit for people facing grave illness to work with their doctor to define, articulate and document their personal goals for treatment. Doctors will be rewarded with reimbursement for helping patients make very important end-of-life decisions when there is time and space to do so thoughtfully, before a crisis and when the patient can advocate for herself.

The Digital Doctor: Is Natural Language Processing the Breakthrough We’ve Been Waiting For?

Jun 23, 2015• 1

By BOB WACHTER, MD

Bob Wachter Natural language processing might seem a bit arcane andtechnical – the type of thing that software engineers talk about deep into the night, but of limited usefulness for practicing docs and their patients.

Yet software that can “read” physicians’ and nurses’ notes may prove to be one of the seminal breakthroughs in digital medicine. Exhibit A, from the world of medical research: a recent studylinked the use of proton pump inhibitors to subsequent heart attacks. It did this by plowing through 16 million notes in electronic health records. While legitimate epidemiologic questions can be raised about the association (more on this later), the technique may well be a game-changer.

Let’s start with a little background.

One of the great tensions in health information technology centers on how to record data about patients. This used to be simple. At the time of Hippocrates, the doctor chronicled the
patient’s symptoms in prose. The chart was, in essence, the physician’s journal. Medical historian Stanley Reiser describes the case of a gentleman named Apollonius of Abdera, who lived in the 5^th century BCE. The physician’s note read:

There were exacerbations of the fever; the bowels passed practically nothing of the food taken; the urine was thin and scanty. No sleep. . . . About the fourteenth day from his taking to bed, after a rigor, he grew hot; wildly delirious, shouting, distress, much rambling, followed by calm; the coma came on at this time.

The cases often ended with a grim coda. In the case of Apollonius, it read: “Thirty-fourth day. Death.”

Achieving Balance After Another ACA Decision

Jun 22, 2015• 3

By SWARTZ, DEHNER and DAY

As the health care community waits for the outcome of King v. Burwell, the latest Affordable Care Act (ACA) challenge, the focus has been on a key question: What happens if the Supreme Court doesn’t allow the federal healthcare marketplace to continue to offer premium tax subsidies? But how such a decision would affect the rate of insurance is just the tip of the iceberg. Eliminating federal subsidies impacts a whole range of ACA policies that were carefully navigated during the legislative process. As we wait for legal decision, we have an opportunity to examine whether the choices made in 2010 remain on solid ground if a significant portion of subsidized coverage disappears.

The ACA is the result of a complex web of compromise and, of course, a healthy dose of politics. By its very nature, the legislative process seeks to balance interests and assign responsibilities. In the case of the ACA, this meant that a dramatic coverage expansion helped define which stakeholders – providers, insurers, employers, and others – would benefit down the line in the form of new customers (and revenue) or reduced costs. In turn, it was reasoned, these stakeholders would bear burdens, in the form of reduced revenue or new tax or regulatory obligations, to help pay for the legislation.

If only the trade offs were that simple. In reality, complex and often charged discussions took place with numerous stakeholders and were linked to policies that extended beyond healthcare coverage (e.g. Medicaid drug rebates). Additionally, since the law passed numerous efforts to repeal, amend, or delay key ACA financing components – including insurer fees, medical device taxes, hospital subsidies, and the small business mandate – have surfaced and threatened to upend the ACA’s attempted balancing act.