Category: Uncategorized

Rick Scott is an Idiot

May 22, 2015• 3

By STEVE FINDLAY

I’ve never met the man, and I don’t mean this personally, but Florida Gov. Rick Scott is an idiot. Rather, more specifically, the way he has managed Florida’s Medicaid expansion, or lack thereof, is idiocy on the altar of political ideology and kneejerk Republican healthcare doctrine.

Other governors are fighting Medicaid expansion, of course. It’s a major battleground in the implementation of the Affordable Care Act (ACA). But Scott, 62, and governor since 2011, has raised his resistance to the level of high political theater that defies commonsense and hurts Florida residents.

If you haven’t been following this lately, here’s a quick recap: In April, Scott filed suit against the federal government (HHS) over federal funding for a special Florida program, launched in 2005, called the Low Income Pool (LIP). The funding—due to be about $1.3 billion in 2015-16 and combined with about $1 billion in state funds—compensates safety-net hospitals for care of low-income, uninsured people. It’s set to expire on June 30 and must be reauthorized by HHS.

Scott and Florida claim in the suit that HHS is trying to force the state to expand Medicaid against its will and in violation of federal law—that law being the now-famous 2012 Supreme Court decision that gave thumbs up to constitutionality of the ACA but nixed the law’s mandate requiring states to expand Medicaid. Medicaid expansion is thus voluntary. (A half dozen or so Republican governors who were initially opposed to Medicaid expansion have relented; the most recent are in Utah and Missouri. To date, 29 states plus DC have expanded Medicaid under the ACA and 17 have not. In four states, including Fla, it’s being debated.)

The Purpose-Driven Hospital

May 21, 2015

By JOSHUA LIU, MD

I was incredibly impressed by the announcement this week that three top U.S. health systems – Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan Health System – will be enforcing standards that prevent low-volume hospitals from performing certain surgeries.

This comes on the heels of a major U.S. News story which showed that patients who had surgeries at low-volume hospitals faced significantly higher risks of complications and death.

The data itself is not surprising. The relationship between low procedure volume and worse outcomes has been well documented since a first major publication on the topic in 1979.

It’s also common sense. The more times you perform a procedure, the better you will be at it. If you’re only performing a hip replacement surgery 3 times a year, chances are you won’t do it as well as a surgeon who performs 200 a year. Practice makes perfect.

Instead, what’s surprising is that these three major medical systems are putting their feet down, even though they don’t need to.

There’s no Obamacare incentive. In fact, this decision could cost these health systems a lot of revenue. And this will certainly upset some surgeons and staff who want to keep performing those surgeries.

Value-Based Care’s Data Problem

May 21, 2015• 2

By RACHEL KATZ

Lisa is an administrator at an Accountable Care Organization, or ACO — a new healthcare payment model that encourages coordinated, high-quality, and efficient care. Lisa’s ACO facilitates the program at about 100 clinics around California, and her mission in the first year of operating might seem elementary to an outsider: to report a set of metrics to Medicare that indicate the health of patients who had been seen at these clinics.

At the start of 2015, Lisa received a panel of patients to review. She had expected a list of about 600, but instead there were 2,400. For each, she needed to report on a specific outcome or physician practices — like which beneficiaries with hypertension had blood pressure less than 140/90 and which had been screened for a risk of falling.

The kicker: she had just six weeks to submit this data. Most of the clinics didn’t have staff to do the required reporting, so Lisa contracted an assistant to travel from clinic to clinic, collecting the information they needed. About a quarter of the clinics used paper records, so the pair of administrators leafed through stacks of paper charts for the blood pressure and screening data.

In six weeks, Lisa collected 2,400 data points from across the clinics and submitted them to a third party vendor who would produce reports for Medicare. Lisa will wait until August to find out whether the ACO met its goals.

New York Innovates in Medicaid—But Ignores a Key Member of the Team

May 20, 2015• 2

By JOSEPH ANTOS and YEVGENIY FEYMAN

New York has an opportunity to make real improvements to its Medicaid program; but it is leaving out key health care providers which might be best positioned to cut costs and improve value.

The state has undertaken a $6.4 billion dollar initiative, the Delivery System Reform Incentive Payment (DSRIP) program, to reduce avoidable hospital use by 25 percent over the next 5 years. DSRIP is testing ways to do everything from cutting unnecessary emergency room visits to reducing transmission of HIV/AIDS.

This could lead to healthier, more productive lives for New York’s 6 million Medicaid beneficiaries and could generate positive spillover effects for all New Yorkers—if hospitals, physicians, and other providers adopt better ways to manage Medicaid patients, they are likely to use those improvements to assist all their patients.

A team approach, coupled with preventive health care to avoid hospitalization and appropriate follow-up care, is an important part of the strategy. Better coordination between community physicians and the hospital, and better information for patients, can save money and improve health outcomes.

The problem? New York’s DSRIP program is mainly confined to “safety net” providers, including hospitals, academic medical centers, nursing homes, individual physicians, and others with a high volume of Medicaid or uninsured patients. The state limits the participation of physician groups known as Independent Provider Associations (IPAs) because they are not considered Medicaid providers.

A Call For a New Accreditation Body For Health IT Privacy

May 19, 2015• 2

By JOEL KUPERSMITH, MD

As shown by breaches of personal information on innumerable individuals over the years, our approach to IT security falls short. Recent intrusions at Sony Pictures Entertainment and Anthem Health (80 million individuals) against a backdrop of substantial losses of personal health (PHI) and other IT information previously again brought this deficiency again to public attention. According to one estimate, almost 1 billion records were stolen via 1500 breaches in 2014, a 78% increase from the previous year and a clear indication of an increasing problem. Among personal information, health records are particular targets, bringing in $20 per record versus $1-$2 for a credit card and surveys consistently show considerable public concern about the privacy of PHI.

In a recent commentary, David Brailer proposed that raised security standards for health information be one of four principles underlying new privacy legislation. I strongly agree and would add a specific step to apply this principle – privacy accreditation for health data custodians.

Whether the information is stored for care, insurance or research, the public lacks understanding of the complexity of their stored PHI and the large number of individuals with access to or custodial responsibility for it. There is thus a wide gap and power differential between data providers and those who hold enormous amounts of sensitive health data. This circumstance creates a need for an empowered intermediary to act on the public’s behalf, i.e. an accreditation body.

The Readmissions Penalty at Year Three: How Are We Doing?

May 19, 2015• 12

By ASHISH JHA, MD

A few months ago, the Centers for Medicare and Medicaid Services (CMS) put out its latest year of data on the Hospital Readmissions Reduction Program (HRRP). As a quick refresher – HRRP is the program within the Affordable Care Act (ACA) that penalizes hospitals for higher than expected readmission rates. We are now three years into the program and I thought a quick summary of where we are might be in order.

I was initially quite unenthusiastic about the HRRP (primarily feeling like we had bigger fish to fry), but over time, have come to appreciate that as a utilization measure, it has value. Anecdotally, HRRP has gotten some hospitals to think more creatively, focusing greater attention on the discharge process and ensuring that as patients transition out of the hospital, key elements of their care are managed effectively. These institutions are thinking more carefully about what happens to their patients after they leave the hospital. That is undoubtedly a good thing. Of course, there are countervailing anecdotes as well – about pressure to avoid admitting a patient who comes to the ER within 30 days of being discharged, or admitting them to “observation” status, which does not count as a readmission. All in all, a few years into the program, the evidence seems to be that the program is working – readmissions in the Medicare fee-for-service program are down about 1.1 percentage points nationally. To the extent that the drop comes from better care, we should be pleased.Continue reading…

Patient Engagement: Much Bigger Than Patient Portals

May 19, 2015• 1

By Tom Giulianni, MD

There is no doubt that the topic of patient engagement has taken center stage in healthcare. It was the hot topic at HIMSS 2015 where a major national study was unveiled, Three Perspectives of Patient Engagement. And that was just one of the many sessions, events, and booths focused on patient engagement at the event.

Thanks to Meaningful Use, a lot of the focus on patient engagement has been around patient portals. It makes sense since practices have to meet specific thresholds in both MU2 and MU3 for portal use. They certainly play a key role in providing patients with access to medical records, test results, and even tools like online scheduling and billpay. The benefits have not gone unnoticed by providers. Over 80% of doctors believe a patient portal helps with patient satisfaction and 71% believe it helps with patient/physicians communication. The benefits haven’t gone unnoticed by patients either. Two-thirds of patients say they would be more loyal to physicians who provides a portal through an EHR.

Despite the undeniable value of portals, they are just one component of true patient engagement. This was clear in the presentation about the new national study released at HIMSS. According to the presentation, the biggest problem in creating patient engagement isn’t providing access to health information. The problem is shifting the attitudes and expectations of both clinicians and patients.

Resolving this problem requires a major culture change in healthcare. Despite the fact that patients and providers say they want improved access, communication, and outcomes and that patient engagement may hold the key, change is slow.

An Interview with BID-Plymouth CIO Ron Rutherford and Clinical Informatics Nurse Jean Marie Grupillion

May 18, 2015

By MICHELLE RONAN NOTEBOOM

An Interview with BID-Plymouth CIO Ron Rutherford and Clinical Informatics Nurse Jean Marie Grupillion

Michelle Noteboom: Give me a bit of background on your hospital.

Ron Rutherford: Jordan Hospital is a 100-plus-year-old, 155-bed community hospital that was acquired and became a part of the Beth Israel Deaconess Health System in January of 2014. We’re a full-service community hospital serving approximately 200,000 residents in eleven communities. There are few healthcare services we don’t provide.

MN: You recently implemented the Voalte smartphone solution. What led you to seek a new communication platform?

RR: We recognized the need for our clinical users to communicate in the most efficient way possible, and we were aware of some technology tools that could make that happen. We also needed to make sure the solution was secure and HIPAA-compliant.Continue reading…

Forks In the Road

May 18, 2015• 2

By NORTIN HADLER, MD

On Saturday, Dr. Hadler delivered the commencement address at the University of Michigan Medical School. THCB is pleased to feature his remarks.

Thank you, Class of 2015, for the privilege of sharing this special occasion with you, your families and the community that has come together to celebrate with you. This is a rare day of pure self-indulgence. Our professional life allows little room for self-indulgence and seldom applauds when one of us makes the room. For those of you who are drawn to a career anchored at the bedside, the trade-off is the quiet, internalized quest to become the best physician you can be. I have pursued this goal nearly all my life – literally, I have been working in hospitals since I was 12. If I had it to do over, I would pursue the same goal.

This goal demands expertise. Expertise requires intellect and discipline. I have a superabundance of both and so do you. Expertise is necessary but not sufficient. More than expertise, one must understand myriad contexts in which illness plays out.

Medicine is not a science. Medicine is a philosophy informed by science.

I was a medical student when this dawned on me. Like you, I entered clinical rotations brimming with the pathophysiology of all those diseases that are poised to smite a mighty blow. Was I missing the forest for the biochemistry? Many of our patients are elderly patient and plagued by more than one serious disease. As we set to the task of confronting each in turn, it occurred to me that I might not care as much about what kills me as I care about when, and what the journey was like? Today, we have a good handle on that “when”. I can make a strong argument that if you manage to stay well to 85, you’re off warranty.

Notions of “fatal diseases” and of “saving a life” demand a temporal component. Realize that in America, you can’t die without a diagnosis. In the mid-1980s, I started to sign the death certificates of frail elderly patients with “It was her time.” I would get a call from Raleigh; Doctor Hadler you can’t do that. I’d respond, “Which of the several diseases vying for the honor do you want me to list?” Whenever you hear of the epidemic of cancer or heart disease or stroke, ask the “When” question.

Value-based Interoperability: Less is more

May 18, 2015• 36

By MARGALIT GUR-ARIE

Interoperability in health care is all the rage now. After publishing a ten year interoperability plan, which according to the Federal Trade Commission (FTC) is well positioned to protect us from wanton market competition and heretic innovations, the Office of the National Coordinator for Health Information Technology (ONC) published the obligatory J’accuse report on information blocking, chockfull of vague anecdotal innuendos and not much else. Nowadays, every health care conversation with every expert, every representative, every lobbyist and every stakeholder, is bound to turn to the lamentable lack of interoperability, which is single handedly responsible for killing people, escalating costs of care, physician burnout, poverty, inequality, disparities, and whatever else seems inadequate in our Babylonian health care system.

When you ask the people genuinely upset at this utter lack of interoperability, what exactly they feel is lacking, the answer is invariably that EHRs should be able to talk to each other, and there is no excuse in this 21st iCentury for such massive failure in communications. The whole thing needs to be rebooted, it seems. After pouring tens of billions of dollars into building the infrastructure for interoperability, we are discovering to our dismay that those pesky EHRs are basically antisocial and are totally incapable or unwilling to engage in interoperability. The suggested solutions range from beating the EHRs into submission to just throwing the whole lackluster lot out and starting fresh to the tune of hundreds of billions of dollars more. When it comes to sacred interoperability, money is not an object. It’s about saving lives.