The Health Care Blog – Page 259 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Income Taxes and Healthcare: The Disconnect

Sep 1, 2018

By PAUL KECKLEY

After leaving Navigant in February, my pondering of ‘what’s next’ was interrupted by the reality of income taxes due weeks later. By midnight tonight, 240 million Americans will have filed, 53% will have paid something to Uncle Sam and all of us will be puzzled by where it goes and how it’s used.

Our federal individual taxes provide 47% of the federal government’s revenues, or $1.48 trillion for FY15. Payroll taxes paid jointly by workers and employers make up another 34%, or $1.07 trillion and corporate taxes 11%, or $342 billion.

The federal government will spend more than it receives: for FY2015 just ended, federal receipts from all sources were $3.25 trillion and expenditures were $3.68 trillion billion. And 25% of that went to Medicare and the federal its portion of the CHIP and Medicaid programs.

Healthcare makes up the biggest chunk of Treasury spending followed by Social Security (24%), Defense (16%), and a bucket of expenditures called Discretionary Spending (16%) over which Congress exercises its influence most directly. And when Defense spending for healthcare is added ($51 billion annually), the state portions of Medicaid and CHIP payments are added, and health coverage for federal employees are added, more than 30% of the federal spending goes to healthcare. So one might reason that if individual income taxes are 47% of total federal receipts, income taxes paid for more than $500 billion of the healthcare tab. But that’s not widely known or understood by taxpayers nor is it a complete picture.

150 Ways to Measure Healthcare Quality. Which One is Best?

Sep 1, 2018

By TOM EMERICK and DAVID TOOMEY

In a previous article, we referenced CMS’s new provider reimbursement model, called Medicare Access and CHIP Reauthorization (MACRA), which replaces the current reimbursement formula. MACRA will include an incentive component that will replace the incentive programs in plans today, and the details of the performance criteria are being determined for roll-out in 2019. From the providers’ lens, they are faced with the need to hire more administrative resources to keep up with the tracking of their performance, and the big question is – are consumers making different choices based on the performance results of a physician or hospital? When there are over 150 different measures in place today, how is an occasional consumer of healthcare services able to assess the most important criteria in finding the right physician?

During a recent employers’ conference on the east coast, the forum featured two panels consisting of the healthplans and the providers. The panels were set in a Q&A format to enlist the leaderships’ views on various topics facing the employers, and it was a fascinating dialogue that we have attempted to capture below.

In the first panel with the execs of five major carriers, the opening question asked for a one minute overview of their healthplan’s area of focus in addressing the employers’ challenges. The responses were consistent amongst the leaders – the focus is on the individual consumer and value-based contracting. When we evolved the discussion into quality criteria and outcomes to identify high performing physicians, the leaders acknowledged that defining quality and outcomes is a challenging endeavor, and each health plan has their own formula to assess the providers’ performance. One commented that a physician practicing in the morning could be viewed as a top performer by a carrier, while that afternoon, they could be ranked as a poor performer by another, even though the physician was delivering the same process of care for all their patients. They agreed that the employers really needed to weigh in on what was important to them, so there was greater consistency in the scoring logic with the physician community.

Measurement of Interoperability and the Transaction Receipt

Sep 1, 2018

By ADRIAN GROPPER, MD

Our aptly named Office of the National Coordinator needs your help. Congress wants to know if the regulations are working to enable interoperability and reduce information blocking. So, ONC wants us to “Help Inform the Department of Health and Human Services’ (HHS) Measurement of Interoperability” and has produced a helpful 19-page description of the issue. This interesting issue also made it to last week’s most august Joint HIT Committee for some lively discussion.

The only reasonable way to measure something is to consider the denominator as well as a numerator. Without the denominator to indicate the scope of what’s being measured, the numerator is likely to be misleading. With respect to interoperability, the denominator is simply all transactions that move individual-level patient data in or out of an institution.

Data moves in or out of an institution for different reasons and in different ways. The reasons include HIPAA Treatment, Payment, or Operations (TPO), to business associates, under patient authorization (regardless of whether it’s opt-in or opt-out), for research (e.g.: the Precision Medicine Initiative), and de-identified (to various data brokers and analytics services).

The ways that individual-level data moves is via analog fax, paper and film, digital media, or digital network. Measurement of interoperability would do well to consider all of these transports as part of the denominator.

We can define a data sharing transaction and hopefully allow a patient to request notification of that transaction. As individuals, we expect an accounting for data movement from our banks, email, and package services and we should expect the same for our health records. Specifically, I would define the following essential elements of a personal health data transaction:

Transaction Receipt and Notification

Resource (medication, problem, demographic, note, order, etc…HL7 coded, if possible)
Transport (fax, paper, film, digital device, digital network)
Client / Requesting Party (by institution, app, or individual name)
Date /Time (for any single client or requesting party, a monthly notice might be sufficient)
API Class (is the specific Resource also available through a patient-directed interface?)
Fee (who paid how much for this transaction or a link to the appropriate contract)

For a description of the API Class see https://thehealthcareblog.com/blog/2016/02/22/apple-and-the-3-kinds-of-privacy-policies/

Establishing the denominator from the transaction receipt perspective works whether or not an individual patient chooses to supply an email address for notification. The mere fact that such a notification is available improves transparency, cybersecurity, and trust.

As Bob Wachter has said, http://www.clinical-innovation.com/topics/analytics-quality/wachter-transparency-inexpensive-and-effective-tool transparency is an essential step to health system improvement. Let’s start with a transaction receipt and notification whenever our personal data is shared.

Is Medical Imaging a Ricardian Derived Demand?

Aug 30, 2018• 7

By SAURABH JHA

Medical Imaging and the Price of Corn

After the Napoleonic wars, the price of corn in England became unaffordable. The landowners were blamed for the high price, which some believed was a result of the unreasonably high rents for farm land. Economist David Ricardo disagreed.

According to Ricardo, detractors had the directionality wrong. It was the scarcity of corn (the high demand relative to its supply) that induced demand for the most fertile land. That is, the rent did not increase the price of corn. The demand for corn raised the rent. Rent was a derived demand.

Directionality is important. Getting directionality wrong means crediting the rooster for sunrise and blaming umbrellas for thunderstorms. It also means that focusing on medical imaging will not touch healthcare costs if factors more upstream are at play.

Medical imaging is a derived demand. The demand for healthcare induces demand for imaging. Demand is assured by the unmoored extent to which we go for marginal increases in survival.

Why Cochrane is Wrong About Hypertension. Very Wrong.

Aug 29, 2018• 6

By SWAPNIL HIREMATH MD, MPH

Archie Cochrane and the Cochrane Collaboration

Archie Cochrane was born in Scotland, educated in London (King’s College, University College and London School of Hygiene and Tropical Medicine) and worked in Cardiff, Wales. His work as a doctor during the Spanish Civil War and World War II, especially in a prisoner of war camp in Salonica, is credited with his push towards generating higher quality evidence. In his description of the clinical trial he conducted, he mentions James Lind as his hero. Ironically, that clinical trial – with weak randomization, open allocation, non-blinding of investigator or participants, and use of surrogate outcomes, would rate poorly in the Cochrane risk of bias tool.

But the scientific method of measuring stuck with him, and among many other achievements, he did perform a proper randomized clinical trial (RCT) a few decades later. He continued to be a strong supporter of RCTs and pushed for the Medical Research Council (MRC) to move from purely fundamental research towards applied clinical research. As an aside, the first proper RCT in the modern era was funded by the MRC and was published in 1950 – on the use of Streptomycin vs para-aminosalicylic acid, or a combination, in tuberculosis. Far more influential was his paper (and later book) published as part of the Rock Carling Fellowship, available here freely and worth a read. It’s where he puts forward the vision for RCTs in moving towards what he termed an ‘effective, efficient health service’.

Health in 2 Point 00, Episode 46

Aug 29, 2018• 1

Jessica DaMassa asks me about single payer polling high, big VC for women’s pelvic floor digital therapeutic Renovia, 23andme cutting off API access to its data, plus guest mentions for Shafi Ahmed and Glen Tullman. All in 2 minutes (more or less!)–Matthew Holt

Prior Authorizations: Will They Become Damocles Sword?

Aug 28, 2018• 29

By NIRAN AL-AGBA MF, FAAP

In July 2009, the family of Massachusetts teenager Yarushka Rivera went to their local Walgreens to pick up Topomax, an anti-seizure drug that had been keeping her epilepsy in check for years. Rivera had insurance coverage through MassHealth, the state’s Medicaid insurance program for low-income children, and never ran into obstacles obtaining this life-saving medication. But in July of 2009, she turned 19, and when, shortly after her birthday, her family went to pick up the medicine, the pharmacist told them they’d either have to shell out $399.99 to purchase Topomax out-of-pocket or obtain a so-called “prior authorization” in order to have the prescription filled.

Prior authorizations, or PAs as they are often referred to, are bureaucratic hoops that insurance companies require doctors to jump through before pharmacists can fulfill prescriptions for certain drugs. Basically, they boil down to yet another risky cost-cutting measure created by insurance companies, in keeping with their tried-and-true penny-pinching logic: The more hurdles the insurance companies places between patients and their care, the more people who will give up along the way, and the better the insurers’ bottom line.

PAs have been a fixture of our health care system for a while, but the number of drugs that require one seems to be escalating exponentially. Insurance companies claim that PAs are fast and easy. They say pharmacists can electronically forward physicians the necessary paperwork with the click of a mouse, and that doctors shouldn’t need more than 10 minutes to complete the approval process.

Comprehensiveness is Killing Primary Care

Aug 24, 2018• 20

By HANS DUVEFELT, MD

Dr. Hans Duvefelt

In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.

Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.

A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well-established patients.

A Cross-Party Win: Empowering Consumers Through Digital Health

Aug 23, 2018• 1

By LYGEIA RICCIARDI

These days Americans are more politically divided than ever, disagreeing vehemently about everything from guns to the role of the press. Despite the distrust and inflammatory rhetoric, there are examples of cross-party, trans-Administration collaboration and success. Let’s celebrate them and be motivated by what happens we put differences aside and focus on shared long-term goals.

Using digital technology to empower healthcare consumers is one example of a cross-party win, a still-developing success story that has been cultivated for more than a decade by the efforts of public and private sector leaders from a wide variety of affiliations and political perspectives.

The UN’s Extreme Poverty Report: Further Evidence US Healthcare Is Divorced From Reality

Aug 22, 2018• 5

By DAVID INTROCASO, Ph.D.

Skid Row in Los Angeles

In May Philip Alston, the United Nation’s Special Rapporteur on Extreme Poverty, and John Norton Pomeroy Professor of Law at New York University Law School released his, “Report of the Special Rapporteur On Extreme Poverty and Human Rights on His Mission to the United States.” The 20-page report was based, in part, on Alston’s visits this past December to California, Georgia, Puerto Rico, West Virginia and Washington, D.C. After reading the report and the response to it, one is again forced to question how legitimate is our concern for the health and well being of the poor, or those disproportionately burdened with disease.

The UN report found over 40 million Americans live in poverty, or upwards of 14% of the population. Those living in extreme poverty number 18.5 million and 5.3 million live in 3^rd World absolute poverty. Among other related statistics, Alston cites the fact the US has the highest comparable infant mortality rate, 50% higher than the OECD mean, due in part to an African American mortality rate that is 2.3 times higher than that of whites. The US has the highest youth poverty rate in the OECD. In 2016, 18% of children were living in poverty comprising 33% of all people in living poverty and 21% of those were homeless. These facts are explained in part by the report noting between 1995 and 2012 there was a 750% increase in the number of children of single mothers experiencing annual $2-a-day poverty. US poverty, the report explains is due in part to the continuing growth in income and wealth inequality. The report found in 2016 the top 1% possessed 39% of the nation’s wealth while the bottom 90% lost 25% of its share of wealth and income. Since 1980 annual income for the top 1% has risen 205% and for the top .1% by 636% while annual wages for the bottom 50% have stagnated. The report reminds us the US has approximately 5% of the world’s population but 25% of its billionaires. The US in sum ranks 18^th out of 21 wealthy countries in labor markets, poverty rates, safety nets, wealth inequality and economic mobility.