Category: Uncategorized

How Many States Are Really Opting In?

Feb 27, 2013• 8

By Dan Diamond

Same story, different week: A governor who opposed the Affordable Care Act changes course and announces plans to opt into the Medicaid expansion.

Supporters of the ACA rejoice, conservatives grumble, and a new number gets tacked on the board — 24 states opting in, at last count.

Yet there’s more to the story than governors’ speeches. In at least eight of those states, lawmakers are warning that they may not go along with expansion plans.

Those legislative logjams — and what governors need to do to circumvent them — vary state by state , but the fights are falling out along party lines.

In Missouri, two GOP-led House committees this week voted down Medicaid expansion plans, despite Democrat Gov. Jay Nixon’s pledge to opt into the measure last year. Republican lawmakers in Arkansas, Montana and Washington have similarly been skeptical of their Democratic governors’ expansion positions. Meanwhile, four GOP governors who have backed the expansion are having difficulty corralling members of their own party.

Now For The Rest Of The Story On Massachusetts Cost Control

Feb 27, 2013• 5

By Josh Archambault

A bureaucracy-centric governing philosophy is spreading in health care, and with it comes heavy reliance on “experts” to determine how to curb costs outside the normal legislative and democratic process. This was embodied at the national level by the Affordable Care Act (ACA), and most recently at the state level in a new Massachusetts growth-capping law. (Supporters refer to the law as cost control and payment reform or Health Reform 2.0; the legal name is Chapter 224 of the Acts of 2012).

The new Massachusetts law was discussed by Mechanic, Altman and McDonough in a past Health Affairs issue, and on the blog by Turnbull and Lee. Yet, the unintended consequences of using this method to reform health care have not been fully explored.

What’s In The Law?

Promising savings of $197 billion over 15 years, Chapter 224 sets a cap on statewide health care spending growth by tying it to state growth, enforced by a flat $500,000 civil penalty if health care entities don’t meet reporting deadlines or take reform efforts seriously enough. The law grants strict preference to alternative payment methods (capitated or bundled payment contracts) and accountable care organizations (ACOs).

Certifying apps? Happtique’s big new idea

Feb 27, 2013• 2

By Matthew Holt

Happtique has been spending a lot of effort cataloging all the health, clinical and fitness Apps in the Apple App Store, Google Play and more. Their goal is to create prescribable apps, and proprietary app stores for providers. The idea is that a hospital or clinic can help its physicians suggest the right apps to patients by giving them a select group to choose from, and by having them cataloged in a way that is far more detailed than Apple or Android can do.

That in itself is a big advance, but even though they’ve cataloged 15,000 of the approx. 40,000 health apps out there, they don’t think it’s enough. Happtique is introducing a new certification program today. The idea is to have all apps assessed both for technical proficiency and also for content. Happtique will be reviewing the applications for technical, security and privacy–in other words, where any data goes and whether the app does what it says it does. In addition it’ll assess whether the app links properly to a particular devices or a particular EMR–something that presumably is pretty important to users. (I had an Android phone once which a major tracking device could not link to, even though the device had an Android app!). Here’s the release.

Happtique’s partners (academic med center group AAMC, nurse credentialers CGFNS International & testing lab Intertek) will provide clinicians and other experts who will review the apps for content. The idea here is not to rate or review the content but to see whether the content is from a valid source, and is true to what it says it is.

The HIT Job

Feb 26, 2013• 44

By Bob Wachter, MD

I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).

Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”

Death of an Evangelist

Feb 25, 2013• 37

By Rob Lamberts, MD

It feels like part of me is dying. I am losing something that has been a part of me for nearly 20 years.

I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996. My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization. I saw electronics as an excellent organization system for documents. Templates could make documentation quicker and I could keep better track of labs and x-rays. I could give better care, and that was a good enough reason to use it.

But the EMR product we bought, as it came out of the box, was sorely lacking. Instead of making it easier to document I had to use templates generated by someone else – someone who obviously was not a physician (engineers, I later discovered). So we made a compromise: since it was easier to format printed data, we took that data and made a printed template.
Continue reading…

Praying For Obamacare to Fail

Feb 24, 2013• 53

By J.D. KLEINKE

“Make it work.”

This advice on health reform to Democrats earlier this month illustrates that President Clinton knows what the opponents of Obamacare also know: success is the best political revenge.

As the health reform law moves off the drawing board into the real world, its opponents are doing their best to make it not work — by shifting their energies from fulminations about the boogeymen they imagine in the law to hampering, complicating or outright obstructing its implementation.

For openers, half the states have announced they will probably not expand their Medicaid programs under the law — though there have been defectors, most notably Florida. This will leave a large segment of the uninsured priced out of even the subsidized insurance markets created under Obamacare, while adding enormous complexity and uncertainty for small businesses and multi-state employers who want to comply with the law and cover their lower-income workers.

The same states, more or less, are also refusing to establish health insurance exchanges — online marketplaces where small businesses and individuals can purchase private health insurance — the fulcrum of the law’s provision for those not covered by Medicaid. As of last Friday’s deadline, 24 states and the District of Columbia were going ahead with exchanges and 26 were not.

Data Mining Systems Improve Cost and Quality of Healthcare – Or Do They?

Feb 24, 2013• 3

By William Hersh, MD

Several email lists I am on were abuzz last week about the publication of a paper that was described in a press release from Indiana University to demonstrate that “machine learning — the same computer science discipline that helped create voice recognition systems, self-driving cars and credit card fraud detection systems — can drastically improve both the cost and quality of health care in the United States.” The press release referred to a study published by an Indiana faculty member in the journal, Artificial Intelligence in Medicine [1].

While I am a proponent of computer applications that aim to improve the quality and cost of healthcare, I also believe we must be careful about the claims being made for them, especially those derived from results from scientific research.

After reading and analyzing the paper, I am skeptical of the claims made not only by the press release but also by the authors themselves. My concern is less about their research methods, although I have some serious qualms about them I will describe below, but more so with the press release that was issued by their university public relations office. Furthermore, as always seems to happen when technology is hyped, the press release was picked up and echoed across the Internet, followed by the inevitable conflation of its findings. Sure enough, one high-profile blogger wrote, “physicians who used an AI framework to make patient care decisions had patient outcomes that were 50 percent better than physicians who did not use AI.” It is clear from the paper that physicians did not actually use such a framework, which was only applied retrospectively to clinical data.

What exactly did the study show? Basically, the researchers obtained a small data set for one clinical condition in one institution’s electronic health record and applied some complex data mining techniques to show that lower cost and better outcomes could be achieved by following the options suggested by the machine learning algorithm instead of what the clinicians actually did. The claim, therefore, is that if the data mining were followed by the clinicians instead of their own decision-making, then better and cheaper care would ensue.

How Much are Misaligned Incentives in Health Care Costing Tax Payers?

Feb 23, 2013• 28

By Elizabeth Dzeng, MD

On Christmas Eve, I took care of a patient who had just undergone surgery for an infected artificial shoulder. He was to be discharged on intravenous antibiotics three times a day for six weeks. This is a pretty common treatment. Patients are generally able to give themselves this medication with the help of a home care nurse who visits once a week. The total cost of this is approximately $7000 for nursing visits, antibiotics and supplies ($120 per visit for eight nursing visits plus $143 per day for antibiotics)

The social worker informed him that Medicare would not pay for home care nurse visits or supplies. BUT, Medicare pays for inpatient rehabilitation, which he would be eligible for to receive these antibiotics. Given the choice of paying $7000 for home administration versus $0 for inpatient rehabilitation, naturally he chose inpatient rehabilitation.

The problem is, is that his inpatient stay costs taxpayers approximately $21,000. $350 for room and board plus additional costs for antibiotics and supplies, totaling approximately $500 a day. Furthermore, although he was well enough to be discharged home before Christmas, he needed to stay until he could be placed in rehab. Because of holiday scheduling, most rehabilitation facilities were not accepting admissions. Thus, he had to stay in the hospital an extra four days in the hospital over the weekend and holidays. Given that the average cost of a hospital stay is $2338 in Maryland that added an additional $9352 or so of unnecessary expenses.

In sum, because financial incentives encouraged my patient to spend $0 rather than $7000 out of pocket, Medicare spent an unnecessary added $30,000 on his hospitalization and care.

Delivering Progress. Choosing Wisely.

Feb 22, 2013• 12

By Amy Romano

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Association of Family Physicians (AAFP) have joined the campaign, drawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, the practice has persisted. But a confluence of recent reforms has made it increasingly difficult for providers to perform elective deliveries before 39 weeks. Quality collaboratives have supported hospitals to implement “hard stops” that prevent these deliveries. Payers have used carrots and sticks to disincentivize them. CMS has funded a national public awareness campaign to reduce consumer demand.

Rick Scott’s Privatization Experiment in Florida

Feb 21, 2013• 10

By Robert Laszewski

A million Floridians will now be eligible for Medicaid––the Obama administration is happy about that.

Republican Rick Scott gets to do it his way––in an almost entirely private market.

This from today’s Tampa Bay Times:

His [Scott’s] endorsement of the expansion came hours after the federal government agreed to grant Florida a conditional waiver to privatize Medicaid statewide for the state’s more than 3 million current recipients, more than half of which are children or people under age 21.

Scott has agreed to only a three year trial expansion and the legislature must vote in favor of it––not a certainty. And, the Obama administration is taking some big risks––a five county trial of Scott’s privatization program has had lots of problems.

In prior posts I have said that Republican governors, so adamantly opposed to “Obamacare,” ought to go to Washington and negotiate a deal on Medicaid expansion. If they believe they can manage Medicaid better than the traditional federal route, which is what they claim every time they demand block grants, then they should put a deal on the table. Ultimately, the feds will pay 90% of costs and the state will pay 10% of the cost of the expansion. The Republican governors don’t believe they can save 10% if given more flexibility?