The Health Care Blog – Page 288 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Health Care System in 2018: Combat Zones to Watch

Dec 29, 2017• 2

By PAUL KECKLEY

Entering the home stretch on 2017, the stage is set for some classic duels next year: they’re about money and control and they’re playing out already across the industry. Here’s the five combat zones to watch:

Hospitals vs. insurers: This is the quintessential struggle between two conflicting roles in our system. Hospitals see themselves as the protector for a community’s delivery system, bearing risks for clinical programs, technologies and facilities that require capital to remain competitive. Insurers see themselves as the referee for health costs, calling balls and strikes on the necessity and cost-effectiveness of improvements providers deem essential. Each sees the other as complicit in healthcare waste and guard jealously their leverage: hospitals enjoy community support and physician relationships and insurers controls premiums. Around the country, the combat zones involve stand-offs involving reimbursement negotiations and narrow networks (i.e. Mission Health (Asheville NC) and Blue Cross of NC), coverage determinations by insurers that impair hospitals (i.e. Anthem’s decision to deny coverage for unnecessary emergency room use) and others.Continue reading…

What’s Wrong With American Doctors?

Dec 28, 2017• 10

By BRIANNA GRAFF

It is February of 2005, and my grandpa is lying in an Intensive Care Unit bed at Beth Israel Deaconess Medical Center in Boston, critically ill from a renal artery rupture that planted him face-first in his parlor. As a functioning alcoholic who has already been in the hospital for a day, he is beginning to shake periodically, a sign of his withdrawals.

Still, it will take another twelve hours and exasperations from both my mother and grandmother (both nurses themselves) before the physicians get him the Ativan he needs to combat this symptom, which is small potatoes compared to his emergent reason for admission.

While he would eventually make a full recovery, in those few hours my grandpa had tremors he was also the unintended victim of “tunnel vision” exhibited by many physicians: they see the most prominent problem and address it, often losing grasp of a holistic view of the patient and neglecting his humanity in their attempt to treat him. In short, they see the medical problem as opposed to the entire person.

Of course, this doesn’t mean that doctors are heartless: the number one reason doctors choose the profession is to help people, and the grueling work it takes to become an MD is clear evidence of their devotion to their career. So how did we end up here, with doctors overlooking the humanistic nature of their work?

Why Consumers No Longer Want Fitness Trackers

Dec 28, 2017• 1

By HEALTH 2.0

Millions of Americans have adorned themselves with glimmering Fitbits, Jawbones, Nike Fuelbands, and Misfits, Basis, Withings, and Garmin bracelets over the years. The devices have become so mainstream even Grandma has one. Perhaps the fact that Grandma is now tracking her data means that the industry is ripe for a change.

Recently though we’ve seen the popularity of wearables wane considerably. This month Mike and Albert Lee, founders of myfitnesspal announced that they would be departing from Under Armour; and we learned that Adidas is dropping their wearables division entirely.

Why? Its a fairly easy question to answer. Under Armour spent 2017 falling from grace and it’s possible their waning interest in connected fitness is due both to financial constraints as well as a series of departures of senior-level talent including Robin Thurston (MapMyRun), and Mette Lykke (Endomondo). Looking at Adidas though, they are dropping their dedicated connected fitness division in favor of a more distributed and integrated approach.

With this shift upon us, what is next wave of innovation? Let’s look at two companies.

Habit, the bay-area based company, collects genetics, vitals and metabolism of their customers; and uses their data and machine learning algorithms to deliver personal nutrition plans that align with the user’s health goals. Parsley Health is redefining primary care medicine by committing their doctors to whole-body health than to quick fixes and bonuses.

See live demos from Habit, Parsley Health, and more at Health 2.0’s WinterTech event on January 10thduring JP Morgan week.

Tickets are selling quickly so register today!

Why An Individual Mandate Is Important and What States Can Do About It: Lessons from Massachusetts

Dec 27, 2017• 3

By ROSEMARIE DAY

The sweeping tax reform package recently signed into law will eliminate the Affordable Care Act’s (ACA’s) individual mandate in 2019, which is projected to reduce the number of people covered by health insurance by 4 million in 2019 and 13 million in 2027, while increasing premiums in the nongroup market by about 10% annually.1 For taxpayers seeking protection from high health care costs, this is a potentially catastrophic result.
Say what you like about the individual mandate, it is clearly an essential component of the ACA’s “three-legged stool” that – along with guaranteed issue and premium subsidies – has been effective in expanding health insurance coverage to millions.

Why is an individual mandate important?

Several studies show that, in a market that requires insurers to cover individuals with pre-existing conditions, an individual mandate helps ensure a healthy risk pool, which in turn helps to manage cost, affordability and sustainability. We learned this in Massachusetts, in the early days of implementing our version of health reform (which later became the model for the ACA). We had something close to a “natural experiment,” in which we launched a subsidized healthcare program before we implemented the individual mandate (we put the carrots out before we brought in the stick, in other words). Researchers were then able to study what happened to the risk pool, before and after the mandate.

As illustrated below, when the Massachusetts individual mandate went fully into effect in late 2007, there was a much larger increase in the number of healthy enrollees compared with enrollees with a chronic illness.2 What’s remarkable is that nothing else had changed in the program – the subsidy amounts were the same, as were all of the other enrollment requirements. But once people in Massachusetts understood they had to purchase insurance, the number of healthy enrollees jumped up.

Based on these results, and other relevant studies, the following projections have been made regarding the impact of eliminating the individual mandate:

An Ode to Evidence-Based Health Policy

Dec 26, 2017• 9

By ANISH KOKA, MD

A recent kerfuffle ensued when a CDC analyst leaked details of a meeting that noted a list of banned words and phrases that included ‘evidence-based’ and ‘science-based’. This most recent assault on reason from the Trump administration was lapped up by partisans as yet another example of the dangers of having reality stars occupy the White House.

Unfortunately no one apparently told the director of the CDC, who took to twitter to respond:

I want to assure you there are no banned words at CDC. We will continue to talk about all our important public health programs.

— CDC Director (@CDCDirector) December 17, 2017

Details are sparse. A meeting took place. Words were discussed. No Trump administration official has come forward to take ownership of the meeting.

Regardless, we should all be relieved that we can now get back to the business of implementing evidence based health care policy.

How has that been going anyway?

Ten years ago this month Atul Gawande wrote a widely read article in the New Yorker called The Checklist. In it he related a masterful riveting story of a 3 year old girl in Austria who slipped into an icy pond, and was underwater for 30 minutes. On arrival to the intensive care unit, she required massive support – a heart lung machine, treatment and monitoring of brain swelling. The end result in this case was nothing short of miraculous. Two years later, she was like any other than 5 year old. The point Gawande goes on to make is that the complexity of patients in the critical care setting is overwhelming. In these sickest of sick patients even one mistake could be the difference between life and death. Humans can’t do it – and the error rate that inevitably results is not one that society should bear.

What We Know and What We Think

Dec 22, 2017• 5

ROBERT McNUTT, MD

What matters is what we know, not what we think

In the late 1980’s I cared for a pregnant woman with breast cancer. Breast cancer is the most common cancer in pregnancy, but uncommon in number, occurring in about 1 in 3000 pregnancies. It is a compounded emotional treating experience for sure, and at that time uncertainty in how to treat was the norm. The woman had a mastectomy but did not take chemotherapy based on concern for her baby.

Three months after her delivery, now getting chemotherapy for her aggressive breast cancer, the woman asked me to consider treating her newborn child with “mild” chemotherapy, a clear contrarian idea given her reluctance to expose her child while in her uterus. Her reasoning, she said, after giving it “lots” of thought, was that it made sense to her; she had cancer at a young age and reasoned her child would also. In her mind it was rational and reasonable to give her child treatment.

Fear and depression fueled her concern, for sure, and universally we would deny the request. The woman would not live to see her child’s second birthday and wanted to do what she could for her. But, there was no evidence of benefit to the baby, making her request irrational. So, I did not comply. In fact, what would you have thought of me if I had complied with this woman’s concerns?

Dr. Nuance versus the Crusaders of the Lost Art

Dec 19, 2017• 7

By SAURABH JHA, MD

The two writers who got inside my head were polar opposites. Christopher Hitchens was an atheist, who mocked religion incessantly, and spared few sacred cows – he went after both Mother Teresa and Bill Clinton, though for patently opposite reasons. G.K. Chesterton, the sardonic, plump Englishman, went after heretics. Hitchens destroyed orthodoxy. Chesterton mocked radicals. Hitchens once quipped that “what can be asserted without evidence can be dismissed without evidence.” Chesterton quipped that the rebel, the infinite skeptic, was in fact a decerebrate orthodox. If both were on Twitter they’d be trolling each other, non-stop. Though fighting on opposite sides, they had a commonality – they punished sloppy thinking, one with prose and the other with wit.

I’ve long wondered who would be healthcare’s Hitchens and Chesterton. Physician writers have generally been disappointments, because they veer, almost uncontrollably, towards tedious self-flagellation, ever keen to internalize medicine’s original sin – an imperfect science, a stubborn art. Unlike prophets of yore who risked harm in expressing their views, medicine’s prophets moralize from the comfort of their six-figure salaries. “We do too much”, they say, even as they’re grass fed by the excess they so disdain – count me in this army of hypocrites.

For many years healthcare watchers have been fed a steady stream of Disneyland economics, trite platitudes, which have simplified the complexities of healthcare – cheesecake factories and checklists, value not volume, “we must do things for patients, not to patients” (needless to say that often to do things for patients you must do things to patients), amongst others. Whatever purpose platitudes are supposed to serve, they bring all critical thinking to a jerky end. I recall several talks during the passage of the Affordable Care Act in which the speaker would romp to a standing ovation for stating blithely – “let’s pay doctors for doing the right thing”, with me still muttering “how?”

Losing Net Neutrality Could Be Bad For Your Health: Here’s Why

Dec 18, 2017• 5

BY JOHN McDOUGALL, MD

The US Federal Communication Commission’s reversal of Obama-era net neutrality regulations sets the stage for broadband internet service providers (ISPs) to slow or block certain content from reaching their customer’s screens. This is likely to have a significant and potentially negative impact on a healthcare system poised to go fully virtual in the coming years.

Healthcare consumers already depend heavily on internet search results for advice when making healthcare purchases. Coupling preferred content with existing search engine optimization strategies will undoubtably steer consumer behavior. What will be the result? The American healthcare market is unique, both in its expense (higher than any other nation), and its shocking lack of value. Some of this is due to misinformed consumers swayed by direct-to-consumer marketing. Arguably, repealing net neutrality may amplify the problem.

Even more troubling is the prospect of an ISP partnering with a health delivery system. Telehealth – the use of electronic communication technology for healthcare delivery – will become standard of care in the coming years. National telehealth have already managed to get a foothold in today’s highly competitive healthcare market, supplying a disruptive and potentially cost-containing force in the healthcare market. With the elimination of net neutrality, larger, more well-established healthcare delivery systems, seeking to defend or expand their marketshare, can now partner with ISPs to preserve internet “fast lanes” for realtime video doctor’s visits. Smaller, possibly disruptive companies, unable to make these same financial commitment to ISPs, may be marginalized or lost.

Connecting the Dots: Referrals between Medical Care and Community Resources

Dec 18, 2017• 1

By JOELLE JUNG & VALERIE LEWIS

Policymakers and providers all agree that addressing patients’ non-medical needs will be critical to improving health, health care, and health care costs, but little progress has been made towards integrating traditionally segmented services. What can and should a health care organization do? Realistically, most health care organizations will not build new lines of social services into their core clinical operations. Instead, leading organizations are connecting the dots by optimizing referrals to existing community resources. Based on phone interviews and site visits with executive leadership, frontline providers, and community partners, we highlight the work of nine innovative health care organizations. Here, we offer practical steps to reflect upon where your organization stands and where it might look to be in a referral model for community resources.

Fixing MACRA Should Mean Fixing the APM Pathway

Dec 18, 2017• 5

By DAVID INTROCASO and SCOTT HINES, MD

The Medicare Payment Advisory Commission (MedPAC) has been discussing for well over a year how to reinvent the Medicare Access and CHIP Reauthorization Act’s (MACRA) Merit-Based Incentive Payment System (MIPS). As a result the commission intends to finalize substantial MIPS program reform recommendations in January. Though MedPAC has had good reason to question MIPS, the commission’s effort is misguided. By choosing to address MIPS, MedPAC has lost the forest for the trees. MIPS does nothing to fulfill MACRA’s intent. Title I of MACRA is intended to accelerate the Centers for Medicare and Medicaid Services’ (CMS’) efforts to move Medicare Part B providers into participation in what MACRA terms Alternative Payment Models (APMs), or more specifically advanced APMs. This goal remains in the balance.

MedPAC’s Critique

Authorized in 2015, MACRA was designed to replace the 1997 Sustainable Growth Rate (SGR) formula by moving physician practices from Fee For Service (FFS) to pay for performance arrangements, or APMs. The MIPS simply replaces and consolidates three previously existing FFS payment incentive programs that date back to 2006: the Physician Quality Reporting System (PQRS); the Electronic Health Record Incentive Program (termed Meaningful Use or MU); and, the Physician Value-Based Payment Modifier program (termed VM).