Category: Uncategorized

My Name is Rob. And I’m a Recovering Doctor.

Jun 22, 2013• 13

By Rob Lamberts, MD

Yeah, I am recovering…doing a lot better, actually. Things are tough, but they are a lot better since I left my destructive relationship with Medicare, Medicaid, and insurance companies. I’ve had to learn how to manage my own money (now that I can’t count on them to bail me out any more), but things are looking a lot better. I am beginning to see how much better it will be to be on my own.

The key was when I realized that the system wasn’t going to change no matter how much I accommodated its unreasonable requests. I felt that if I only did what it asked of me, however unreasonable, it would stop hurting me and, more importantly, my patients. But I’ve come to see that all the promises to take care of me and my patients were written in sand, and that it couldn’t resist the temptation to cheat on me. I tried to do what it asked of me, but as time went by I couldn’t take how dirty it made me feel.

I want to believe it was sincere when it told me it wanted to change. I think at its core, it wants to help patients and doesn’t want to go on those spending binges. But no matter how sincere the promises sounded, I was always left alone as it threw its money at every sexy treatment, procedure, or drug that walked by. Then it would go off on tirades about how much I spent and that I didn’t do enough to keep to our budget. It was always my fault. I think it’s just easier to pass blame on others than it is to do the hard things necessary to really change. To be honest, I think it was terrified at how much real change would hurt.

But I can’t sit around and wait for the system to change any more. My patients were getting less and less of my time, and I was getting to the breaking point. I know there are a lot of other doctors who are willing to do whatever the system asks, but I can’t sit around and watch it self-destruct. It’s not what’s best for the system, for us doctors, and for our patients. Sometimes the best thing you can do for someone is to let them self-destruct and pray that they finally take responsibility and learn the hard lessons. I just hope that happens soon.

Physicians Aren’t Driving Up Health Care Costs

Jun 21, 2013• 66

By John I. Allen, MD

Recent interest in variability of cost for medical procedures is justified and long overdue. In an article in the New York Times on June 2, 2013, “The $2.7 Trillion Medical Bill,” Elizabeth Rosenthal writes from the point of view of a patient who has received a bill for colonoscopy. She then researches costs of the procedure in a number of markets in the U.S., finding a range of pricing from an average of $1,185 to a high of $8,577. There is an implication within this article that “doctors” are charging these prices. The truth is that physicians are often pawns in much larger negotiations among other entities.

While charges for procedures performed in an office setting or practice-owned ambulatory surgical center (ASC) are largely under the control of physicians, many of the highest prices come from hospital owned facilities — an area that is not at all controlled by physicians.

I called the lead negotiator for payor contracts at my institution and asked him about price variability for colonoscopy. It was clear from my conversation that the current arguments about colonoscopy price variation miss some key components. We need to better explore the true drivers of price variation.Continue reading…

How Misplaced Reimbursement Incentives Drive Healthcare Costs Up

Jun 21, 2013• 7

By David Mokotoff, MD

For all of those out there anticipating the 2014 official role out of Obamacare, also known as the ACA (Affordable Care Act), here is a cautionary tale.

Many years ago, as I was growing my cardiology practice, it became evident that diagnostic services for my specialty, like stress tests, echocardiograms, etc., were done less efficiently and cost more at the local hospital, then in the office. This stimulated many groups in the 1980s and 90s to install their own “ancillary” diagnostic services. Patients loved not having to deal with the long waits and higher copay prices at the hospitals. And yes, the cardiologists did increase their revenues with these tests. However, lower costs to patients, insurance companies, Medicare, and improved patient satisfaction were just as powerful a stimulus to the explosive growth of these diagnostic tests, and later even cardiac catheterization labs, when integrated into the physicians’ offices.

As the growth in testing spiraled upward, the hospital industry saw their slice of the outpatient revenue pie nosedive. Hospital lobbyists and policy-makers cried foul and complained of greed and self-referral, which they said was spiking the rapid rise in healthcare costs.

Studies laying blame on self-referrals being the major culprit for escalating healthcare costs, have been inconclusive. However, after years of lobbying and the passage of ACA, the hospital industry finally had the weight of the Federal government on their side. It did not take long for Medicare to start dialing back the reimbursements for in-office ancillary tests and procedures, and outpatient cardiac catheterization labs were one of their main targets. Hospitals had lost millions of dollars to the burgeoning growth of these labs inside the cardiologist’s office.

Our twelve-man group had a safe and successful lab for about ten years. Then after the ACA was passed, Medicare began to cut the reimbursements for global and technical fees in this area. The cuts were so Draconian that it became impossible financially to continue the service. Never mind that we could provide the same service as the hospital more efficiently, with better patient satisfaction, and at a third of the cost.

RAND Shrugged

Jun 19, 2013• 19

By Vik Khanna & Al Lewis

The long awaited federally-mandated RAND Corporation report on workplace wellness programs is finally out, after months of anticipation. Despite an odd now-you-see-it/now-you-don’t release, both wellness proponents and critics anxiously awaited the report’s public deliverance.

Like many documents emanating from the political cauldron, the RAND report has elements in it to please both camps, although proponents will have to reach deep into the document for snippets of hope built around simulations, models, and what they term “convenience” samples of employers predisposed to support health-contingent workplace wellness programs.

For critics of health-contingent workplace wellness programs, the conclusion is much more straightforward: even using prejudicial data sources and lacking a critique of the quality of the evidence, the impact of workplace wellness on the actual health of employees and the corporate medical care cost burden, is, generously stated, negligible.

This is not worth $6BN a year, which is the purported size of the US market for health-contingent workplace wellness programs (“purported” because like everything else in wellness, the size of the industry itself is totally opaque). There are clearly better ways to spend these funds; at the very least, it must be possible to get the same dismal results for far less money and with vastly less complexity.

With the push of the Affordable Care Act, the drive to implement health-contingent workplace wellness programs is accelerating. The RAND report, rather than contributing propellant, ought to give responsible business leaders pause as they consider whether to step up the pressure (i.e., increase incentives and penalties) for employees to participate in these highly intrusive, clinically dubious, spendthrift programs that yield health in RAND’s hypothetical world of models and simulations, but perhaps not so much, as RAND notes, in a more earthbound reality.

The lesson for executive leaders is that the nearly hagiographic employer belief in the value of health-contingent wellness is completely undone by the fact that RAND says virtually no employer (2% of their sample) measures program impacts and, as we have written previously, it doesn’t look like any employer, benefits consulting firm, or vendor actually knows how to do so.

The Health Insurance Shell Game

Jun 19, 2013• 2

By Nortin M. Hadler, MD & Janet Schwartz

The insurance industry had a rocky start a century ago. It was clear that there were untoward events that could befall any of us with catastrophic results, from the incineration of a home to the loss of the ability to maintain gainful employment from injury or death.

Insurance offers a mechanism to share this risk. The stumbling block was the possibility that the insured might burn down their home to collect. Once it was realized that “moral hazard” could be held at bay by investigating for fraud, there was little to hinder the growth of an industry designed to serve our risk adverse proclivities. Almost every adult has some experience valuing the expense of sharing risk for a variety of hazards. After all, automobile insurance is generally compulsory and most of us are familiar with notions of deductibles and riders when it comes to homeowners’ policies. The possibilities are not an abstraction; we can envision the house or its contents damaged, destroyed, or stolen leaving us bereft. What would reducing that prospect be worth to us? As is true for many value-based decisions, the answer brings a mix of reason and intuition (1)that can produce surprising outcomes (2).

Health insurance is even more complex, and has always been so. The industrial revolution saw the development of “Friendly Societies” in Britain and the Prussian “Krankenkassen”. These were trade-based institutions that allowed advantaged workers to purchase insurance to provide “sick pay” but there was little else. The sea change was the Prussian “welfare monarchy” (3),an extensive insurance scheme that encompassed universal health care and a complex approach to disability insurance (4). Modifications of the Prussian scheme spread across the industrial world. It made landfall in the United States in time for the presidential election of 1912. Only one component took root in America: Workers’ Compensation Insurance but not as a national insurance scheme. It fell to the each state to regulate an insurance scheme to compensate injured workers for lost income and medical expenses.

This set the stage for state-based regulation of employer-sponsored private health insurance schemes going forward. But forward momentum appears anything but swift or linear in a country that trusted physicians to charge “commensurate with the services rendered and the patient’s ability to pay” (AMA Code of Medical Ethics, 1957.) Health Insurance as both an industry and a product has become a frustrating web of inefficiency and confusion.

Will the Federal Health Insurance Exchanges Be Ready On Time?

Jun 19, 2013• 1

By Robert Laszewski

After months of speculation on just where the Obama administration is toward the development of the new health insurance exchanges, the Government Accountability Office (GAO) has issued a 48-page report complete with timelines and a detailed report on just where the Obama administration is––or at least was last month.

The key summary:

“Much progress has been made, but much remains to be accomplished within a relatively short amount of time. CMS’s timelines provide a roadmap to completion; however, factors such as the still-evolving scope of CMS’s required activities in each state and the many activities yet to be performed—some close to the start of enrollment—suggest a potential for challenges going forward. And while the missed interim deadlines may not affect implementation, additional missed deadlines closer to the start of enrollment could do so. CMS recently completed risk assessments and plans for mitigating risks associated with the data hub, and is also working on strategies to address state preparedness contingencies. Whether these efforts will assure the timely and smooth implementation of the exchanges by October 2013 cannot yet be determined. ”

Regarding the Data Hub:

“FFEs [the federal exchanges] along with the data services hub services are central to the goal under PPACA of having health insurance exchanges operating in each state by 2014, and of providing a single point of access to the health insurance market for individuals. Their development has been a complex undertaking, involving the coordinated actions of multiple federal, state, and private stakeholders, and the creation of an information system to support connectivity and near real-time data sharing between health insurance exchanges and multiple federal and state agencies. Much progress has been made in establishing the regulatory framework and guidance required for this undertaking, and CMS is currently taking steps to implement key activities of the FFEs, and developing, testing, and implementing the data hub. Nevertheless, much remains to be accomplished within a relatively short amount of time. CMS’s timelines and targeted completion dates provide a roadmap to completion of the required activities by the start of enrollment on October 1, 2013.

Why Texting Public Health Messages Is a Brilliant Idea. Except When It’s Not…

Jun 19, 2013• 8

By John S. Wilson

A new service has partnered with a Los Angeles school district – the second largest in the country – to not only deliver STD results by text message, but also to promote the idea children share their “status” as easily as they share the highlight of their day on Facebook. But when it comes to children having sex, it’s never quite that simple now is it?

Qpid.me is the brainchild of Ramin Bastani and operates from the following premise: “We believe that sharing is a good thing and that it can lead to better sexual health decisions, more (safe) sex and fewer STDs.” Bastani went on to tell CNN in an interview: “If it’s cool for a beauty queen to share her STD status [Qpid.me’s celebrity sponsor is Tamie Farrell, Miss California 2009], then maybe kids will start to think it’s cool to share their own results. We want to normalize the idea of sharing your status.”

The process is fairly straightforward. Qpid.me requests patient test results from health clinics (with patient permission, of course) then transmits those results via text, email, and provides access to their online site. The concept of delivering STD results electronically is not necessarily new, or controversial. The danger lies in convincing children there are no concerns about sharing such private information among peers who may not respect their privacy, or, worse may shame them for contracting curable diseases.

The PCORI Patient Engagement Awards: A Call for Proposals

Jun 19, 2013

By Anne C. Beal, MD, Susan Sheridan & Suzanne Schrandt

One of our core beliefs at PCORI is that patients, clinicians, and other front-line caregivers, and others across the healthcare community have the potential to become valued and real partners in the patient-centered outcomes research (PCOR) we support. We practice what we preach in the requirements we place on applicants for our funding and the way we evaluate their proposals.

So we’re pleased today to announce the latest example of how we’re making that principle real – a new funding program called the PCORI Engagement Awards and the first funding opportunity under this program, the Pipeline to Proposals Award.

Listening to our stakeholders

We got the idea for the Engagement Awards program last October, during our first patient engagement workshop. We asked workshop participants to provide input into how we can better serve and connect with patients and the communities interested in being involved with rigorous PCOR– which is, comparative clinical effectiveness research focused on and guided by the needs and concerns of patients. The response was a clear and broad expression of passion, expertise, and willingness within the patient and broader healthcare community to help us pursue this approach to research. The question was how best to do it.

From that discussion was born our Engagement Awards program, which is designed to leverage the community’s passion and expertise by offering targeted funding to dozens of groups of patients, providers and other healthcare community stakeholders interested in supporting the expansion of high-quality, useful PCOR and the implementation of its results.

Our philosophy is that, when the research process incorporates the perspectives of the entire healthcare system and focuses on the questions important to patients and those who care for them, the results are far more likely to be meaningfully incorporated into clinical decision-making and practice.

The Engagement Awards program will have three distinct categories:

Knowledge Awards, which will fund activities such as background papers, landscape reviews, and development of mechanisms to share research results.

Self-Care and Caregiving Apps Development

Jun 18, 2013• 6

By Rajiv Mehta

Have I gotten to the end of the beginning in developing tools that help people take care of themselves?

With the recent release of Unfrazzle, an app for caregivers, I believe I have. Unfrazzle builds upon the learnings of Zume Life and Tonic, earlier apps I developed. There were key lessons from hundreds of users and family caregivers that influenced Unfrazzle’s product design, driving it in directions very different from and hopefully much more useful than what you might expect.

These key lessons, explored in more detail below, I group into three themes:

Care regimens constantly vary, and so tools must accommodate such variation

We live in a network of mutual caregiving, and simple notions of “the patient” or “caregiver–care recipient” match few people’s reality

Living, yes living, is much more important than adherence

For those unfamiliar with Unfrazzle, here’s a brief description:It is an iPhone app (Android coming soon) that helps users remember and keep track of anything they do to take care of themselves and their family (parents, friends, children, pets), and to stay in-sync with other caregivers in their family. Unfrazzle is a Design-It-Yourself app — it essentially provides a platform, a framework that the user then shapes to meet his own ever-changing needs.

If that sounds clear as mud, try this: take your favorite pill reminder app, and imagine that you can change all the screens and forms to accommodate any health & wellness activity (not just pills but also other things such as exercises, moods, symptoms, observations, and chores). Then imagine that you can share any of your data with others also using the app, so that you can see each other’s entries. Imagine you can even allow others to make entries for you, then you’ve got the gist of Unfrazzle.

Care Regimens Constantly Vary

From the start, beginning with Zume Life, our focus has been on making it easier for people to remember and track their health regimens. We began by targeting a simple, logistical problem — in our busy lives it is easy to forget little details.

Our idea was that adherence would be improved if we had a memory aid.

Our tool had to be somewhat flexible, because we took the approach that we could not possibly know everything a person might be doing for his health. For example, allowing a person to include their supplements in their list of medications, and not just their prescriptions.

Building Cost and Quality Into the Electronic Medical Record

Jun 18, 2013• 17

By Hayward K. Zwerling, MD

Trends in US healthcare expenditures are financially unsustainable (1). I would like to propose two tweaks of the healthcare delivery process that may, in a small way, help rectify this problem.

Although there is a widespread impression that health information technology (HIT) will eventually “bend” the cost curve and put healthcare spending on a sustainable course, there is, as of yet, little data that convincingly supports this hypothesis (2).

Kaiser Permanente is a large, integrated healthcare delivery system which has invested heavily in HIT. George C. Halvorson, the chairman and CEO of Kaiser Permanente appears to have concluded that this investment will not solve the healthcare cost issue, when he was quoted in the New York Times (3/20/13) as stating “We think the future of health care is going to be rationing or re-engineering.”

Because HIT, as currently implemented, will probably not solve the healthcare cost problem, I would like to suggest a minor “re-engineering” of the electronic health record user interface which may help bend the cost curve.

At every office visit, the physician must make a myriad of decisions which incrementally effect the nation’s total healthcare expenditures. For example, the physician will have to decide which medicine to prescribe, and which radiology study or laboratory test to order.

In many situations, there is more than one acceptable choice. The physician’s ultimate decision will integrate their understanding of the disease process, the treatment’s side effect profile, their familiarity with the treatment options, patient preferences and many other variables.

I would suggest that every time a physician is about to order a test or a prescription, the cost of the test or prescription should be displayed to the physician. In the same vein, whenever a computer displays a test result, the cost of the test is immediately available to the reader. This information could then become an additional factor that the physician may choose to integrate (or ignore) at the moment when he/she is about to commit the patient and society (which is now paying >50% of all healthcare bills) to another healthcare expenditure. In terms of a risk/benefit analysis, I can see little downside to providing this cost information to physicians.