Category: Uncategorized

If I Ruled the World

Dec 4, 2010• 23

By DAVID DRANOVE, PhD

If you study previous attempts to reform healthcare delivery through the private sector, there is one common thread. These attempts all failed because of an absence of proper management information systems. We need integrated electronic health records. And not just to improve medical decision making. We need EHR that can be used for management decision making – for contracting, measuring costs, measuring and rewarding quality; I could go on and on. We are trying to solve management problems in a $2 trillion industry using management information systems that would be an embarrassment in nearly any other sector of the economy.

Of course, the industry has been pushing EHR for decades and there are places where EHR is really first rate. Kaiser is a great example but also a special case because of its thorough vertical integration and long history. And even Kaiser has been unable to replicate itself outside of its core markets. The sad fact is that most providers have little incentive to adopt EHR, and even when they do, they have little incentive to be compatible with other providers. Unfortunately, the network externalities benefit purchasers and consumers a lot more than they benefit providers, so don’t expect the compatibility problem to solve itself.

My proposal is simple. Assemble a panel consisting of medical professionals, managers, and insurers. “Lock them in a room” for 72 hours and tell them to choose from among the many fine existing EHR systems. Tell them they can combine the best features of each if they wish. Once we have settled on an EHR system, give every provider one year to adopt it. If they refuse, deny them Medicare and Medicaid payments. Combine the stick with a carrot – subsidies to providers who have limited financial resources. I believe the total one-time subsidies would be less than $50 billion, a drop in the bucket compared with the size of the system.

The Libertarian Mind

Dec 3, 2010• 9

By RONALD PIES, MD

“It is an eternal obligation toward the human being not to let him suffer from hunger when one has a chance of coming to his assistance.” –Simone Weil

Libertarianism is much in the news these days, as the political divide in the U.S. seems to widen almost before our eyes. Before providing a rough, notional definition of “libertarianism”, I should offer readers some caveats. First, I am not a political scientist, professional philosopher, or economist, though scholars in these fields have offered many pointed critiques of what is loosely called libertarianism (see references). Furthermore, as a psychiatrist, I am trained to diagnose individuals whom I have professionally examined. I am not in the habit of “diagnosing” movements, ideologies, or political groups; indeed, the idea of doing so is clearly outside the purview of medical or psychiatric practice.

Nonetheless, as a lecturer on bioethics and humanities, it is impossible for me to read the platform and proclamations of the Libertarian Party without drawing some tentative conclusions as regards the nature of this movement; its psychological underpinnings; and its ethical implications for the poorest and sickest among us—those sometimes referred to as “the destitute sick.”

I do not propose to “psychoanalyze” particular individuals, or to speculate on the motives of political figures who figure prominently in American politics. And, because the term “libertarian” has such a wide range of meanings, I will focus my attention on the official platform of the Libertarian party, which is very lucidly spelled out in a publicly-available venue (http://www.lp.org/platform). For the most part, I will deal with the Libertarian party’s position on health care and social support systems, while offering some tentative impressions on the “psychology” of libertarian theory.Continue reading…

Blood Test Surprise

Dec 3, 2010• 24

By BRAD WHITE

In the spring of 2005, the sinus infection returned. I awoke severely congested with a pounding forehead and pain around my eyes that grew worse when I bent to tie my shoes. The feeling was familiar. Two years earlier, I had similar symptoms, but was uninsured and endured a miserable week with nothing but over-the-counter medication. Now they were back.

Fortunately, when I started graduate school, my father insisted that I have health insurance. As a healthy 24 year old, I didn’t see the need, but he agreed to foot the bill for a high-deductible insurance policy to cover me in the event of catastrophic illness. Except for four physician office visits subject only to a $35 co-payment, my policy offered no benefits until I spent $3,000 out of my own pocket. With my sinuses throbbing, I knew I needed to use one of those visits. Overwhelmed by the list of “in-network” providers on the insurer’s website, I picked an internist based on convenience—his practice was located in a medical complex near my home.

Arriving for my appointment, I checked in and presented my insurance card to the receptionist. “Your visit today will be $35,” said the woman behind the desk. I was relieved to hear that my coverage was working as promised. A nurse ushered me to an exam room, where the physician promptly entered, half-heartedly listened to my complaint, and confidently asserted that I did not have a sinus infection because I had no fever. I wanted to say “Really? Mind handing me a tissue so that I can show you what’s been coming out of my head?” but resisted the urge. Instead, I clarified that fever or no, I didn’t feel well, and believed my sinuses were the culprit. At this, the internist lost patience. He ordered some lab work and a sinus CT scan to rule out infection, and said that I could have everything done downstairs.Continue reading…

Understanding Medicare Reimbursement?

Dec 2, 2010

By HERBERT MATHEWSON, MD

I opened my “Medicare Summary Notice” from CMS (Centers for Medicare and Medicaid Services) with great anticipation to see the explanation of Medicare benefits for my recent medical care. At last, I might have a chance to understand Medicare reimbursement, an understanding that has to date eluded me both as a pediatrician and a hospital administrator

The ER physician’s bill for both the visit and the suturing of three lacerated fingers was $448.00. Medicare “approved” $163.88 and “paid” $131.10. It also stated that I could be billed the $32.78 difference, but I knew I wouldn’t because “balance billing” is not permitted in Massachusetts. A reminder that even though Medicare is a federal program, its reimbursements and reimbursement rules vary by state, by region, and even by county.

Then I noticed a small “a” in the last column to the right that instructed me to “See Note Section”. On the bottom of page 2 that little “a” in the Note Section told me that “Medicare paid the provider for this claim $197.81” a figure quite different than $131.10. I tried, but could not reach the new figure by adding up any of the other amounts. I had no clue as to where that number came from.

Moving on to the next encounter, a scheduled spinal tap in the Ambulatory Procedure Area of my hospital for a different clinical problem, I was surprised to run into more complexity. The hospital charged $697 for the procedure and $634 for the 6 lab tests done on the spinal fluid for a total hospital charge of $1,331.00. No “approved” amount nor “paid” amount was listed, but then I noticed…again far over to the right, another set of little letters; “b” and “c”. Note “c” on the bottom of the page told me that Medicare paid $388.23. There was no clue what that reimbursement of 29% of charges was actually for.

OK, OK, I know that hospital charges and reimbursement are complicated, so I moved along to the physician’s claim summary information. Surely this will be easier to understand.

FTC Proposes New Safeguards for Online Privacy

Dec 2, 2010• 3

By NAOMI FREUNDLICH

Yesterday the Federal Trade Commission proposed a broad framework for protecting consumer privacy both on the Web and offline. The framework is meant to help guide policymakers in crafting legislation to prevent the tracking and wholesale collection and sale of consumer information that is practiced by large online companies like Google, Mozilla, and Microsoft. Yesterday I wrote about health information “data mining;” (see post here) the collection and sale specifically of web user’s health data, including the conditions they suffer from, medications used and identification information like name, age, gender and even personal doctor. As the FTC notes in its proposal; “The more information that is known about a consumer, the more a company will pay to deliver a precisely-targeted advertisement to him.”

The FTC noted that current privacy efforts by most online companies were inadequate. Some did not alert consumers to the fact that data was being collected in the first place, others provided lengthy and incomprehensible warnings that most Web users ignore and others did offer the chance for individuals to block collection of their personal data, but this action has to be repeated at the beginning of every transaction.

Instead, the FTC framework proposes a “Do Not Track” option that consumers can chose to activate on their browsers. Similar to a “Do Not Call” list that prevents most (but not all) telemarketers from contacting you by phone, the “Do Not Track” option would prevent most data miners from surreptitiously collecting personal information online. The FTC says that the Do Not Call registry currently contains 200 million telephone numbers.

Publicity is Cheap, Privacy is Expensive

Dec 2, 2010• 2

By JOHN HALAMKA, MD

When I was 18 years old, publicity was hard to come by. Media outlets were limited to newspapers with very high editorial standards, television with few channels and very limited news time, and a few high profile news magazines.

My first 15 minutes of fame came in 1981 when I was interviewed by Dan Rather for a CBS Evening News spot on entrepreneurialism in the Silicon Valley. In 1982, I appeared in Newsweek, as a student correspondent at Stanford, writing about religion, politics and the culturally important trends of the day. In 1983, I appeared in US News and World Report in an article about the emerging importance of software.

Today, blogs, wikis, forums, YouTube, Facebook, Twitter, and Google enable fame and publicity without editorial control. Use your phone to take a video of a squirrel doing something amusing and a few minutes later you’ve got publicity and thousands of people watching your work.

The Non-Scalability of Charisma

Dec 1, 2010• 19

By BOB WACHTER, MD

Early on, many social movements depend on a charismatic leader to focus attention, build a burning platform, and inspire people to action. You know when the movement has made it when it no longer needs such a leader for fuel.

The safety and quality movements have picked up tremendous steam over the past decade, but they haven’t yet hit that self-sustaining tipping point. Last week, there were two things that reminded me of this: the announcement of a new leader of the Institute for Healthcare Improvement (IHI), and a doleful JAMA essay by Peter Pronovost.

During the circus that was Don Berwick’s recess appointment to lead the Centers for Medicare & Medicaid Services (CMS), all eyes were trained Inside the Beltway. But 440 miles north, in Cambridge, MA, arguably the most important organization in the quality and safety galaxy needed to get on with its business. On July 8th, IHI announced its choice of Maureen Bisognano to become its new CEO. Maureen is a nurse and former hospital exec who has spent the last 15 years at IHI as Don’s consigliere. She is a terrific person, with boundless energy and great organizational skills – insiders will tell you that she was the reason that IHI’s trains ran on time for the past decade, as Don is the quintessential big picture guy.Continue reading…

The Conservative Way Forward on Health Care

Dec 1, 2010• 75

By RICHARD AMERLING, MD

The landslide Republican victory, in taking the House and electing some strong conservatives to the Senate, can be interpreted as a mandate to rein in government spending, and specifically to repeal ObamaCare, as these issues were clearly behind the large turnout. There is still a very real possibility the Supreme Court will find the “individual mandate” to buy private insurance unconstitutional. If this provision is thrown out, it’s hard to see how the law survives, since the mandate is needed to finance it.

Now is an excellent time to construct a conservative alternative vision for true reform of our health care delivery system. Since most current problems with the health care system stem from government, a conservative plan should seek to reduce its role.

It goes without saying that the Patient Protection and Affordable Care Act must be repealed since, like all the laws passed by this administration, it does precisely the opposite of what its name suggests. By massively increasing the health care bureaucracy at the expense of actual providers of care, it will make care harder to access and more expensive. Many physicians will take early retirement and the already great physician shortage will be exacerbated.

Are prescription drugs going the way of Napster, YouTube and iTunes?

Nov 30, 2010• 2

By DAVID E. WILLIAMS

The distribution of prescription pharmaceuticals is beginning to take on some of the characteristics of online videos and music. Traditionally, access to prescriptions works as follows:

Patient has a problem
Patients sees his/her physician
Physician diagnoses problem and writes prescription
Patient takes prescription to traditional pharmacy or PBM-owned mail order company
Pharmacy fills prescription with a drug manufactured by an FDA-regulated brand name or generic pharmaceutical company
Patient takes medication
If patient needs more medication after initial prescription and refills are exhausted, patient requests renewal from physician and repeats steps 4 to 7

But steps 2 through 7 are breaking down. Instead of seeing their physicians, increasing numbers of patients are either going directly online to order from pharmacies or are borrowing pills from friends and family who’ve received prescriptions. According to MedPage Today (Adults Commonly Share Prescription Drugs with Friends and Family) almost 30 percent of adults reported sharing prescription medications with others. Younger people are the most likely to share.

Meanwhile, shady web-based pharmacies that don’t require prescriptions and often sell counterfeit drugs are becoming increasingly sophisticated and impressive. MarketMonitor estimates that about 1000 shady pharmacy sites generate an average of 100,000 hits per day each and that such pharmacies spend about $25 million per year on search advertising. An acquaintance who works in the pharmaceutical security business told me that these pharmacies aren’t what they used to be. In fact they are adopting marketing and customer service best practices that are used by legitimate vendors. Rather than going for a quick score, the web-based companies are looking for repeat business and word-of-mouth referrals by providing products that work, offering easy-to-navigate websites and low prices.