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Above the Fold

Repeal and Replace. Repeal and Replace. Repeal …

Jul 9, 2017• 5

By BRIAN JOONDEPH, MD

Repeal and replace. Simple enough on the campaign trail. We heard this promise in 2010, when voters gave the House to Republicans. We heard it again in 2012, when voters gave them the Senate. Despite controlling Congress, Obamacare remained the law of the land. Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Republicans now have their largest electoral majority in nearly a century, and repeal and replace is spinning its wheels, like an old Pontiac stuck in the snow.

Some think a grand bill is still possible, particularly Senate majority leader Mitch McConnell. Others are skeptical. Senators Rand Paul and Mike Lee favor a two-pronged approach: repeal first then repeal later. Herein lies the problem. Republicans can’t agree on anything.

Democrats had no such problem in 2010 when they passed Obamacare. The Bernie coalition didn’t get a single-payer plan as they wanted. Some wanted higher Medicaid reimbursement for their states, as in the “Cornhusker Kickback.” But they came together and passed Obamacare, each Democrat getting most but not all of what he wanted.

Beyond “Repeal and Replace”

Jul 5, 2017• 8

BY DANIEL STONE, MD

The toxic polarization of Washington politics might lead even the most stubborn optimist to abandon any hope for bipartisanship on healthcare. Despite endemic pessimism, the flagging efforts to forge a Republican consensus on “repeal and replace” might set the stage for overdue efforts at compromise. Congress will be tempted to move on to more promising areas such as tax reform and infrastructure funding. That temptation should be resisted. The threat to the nation posed by the current state of American healthcare calls for Congress to resurrect the long lost spirit of bold bipartisanship.

Before considering opportunities for compromise, the obstacles confronting the GOP reform efforts are worth considering. Republicans face the same stubborn reality that confronted the framers of the Affordable Care Act (ACA): Expensive services cannot be covered by cheap insurance. The cost of U.S. healthcare has simply priced low income and even middle income individuals out of health insurance. Without subsides, they get left behind. The Congressional Budget Office’s estimated that the Ryan plan would result in 24 million losing coverage underscored the political divide: Confronted with unmanageable healthcare costs, most Republicans would opt to reduce public expense whereas Democrats plus a handful of Republican moderates prefer more extensive coverage. The effort of the GOP leadership to split the difference by preserving some residual subsidies and the structures supporting them—“Obamacare light”—remains unacceptable to many on the right. No clear middle ground has yet emerged.

Believe Them the First Time

Jul 5, 2017• 10

By NIRAN AL-AGBA, MD

I remember the first time someone threatened to kill me. It was my day off, so I was not in the clinic that day; a Children’s Hospital specialty group was working there instead, and after a staff member called the police, she notified me. A father had walked in saying he wanted to kill me for “taking his children away from him.” Wracking my brain as to this man’s identity, I drew a blank.

The police found him in a local park a short time later and judged him to be “harmless.” Somehow, I did not share their reassuring sentiment. I figured out who the man was, tracked down his mother, and promptly explained the situation. She provided a recent photograph so my staff could be trained to recognize him and contact the authorities the moment he entered our building. That photograph still hangs in our “Most Wanted” section of my front office, amongst other pictures which have been added. Occasionally, I request an updated picture to make sure we are keeping our office environment safe.

The second time a parent threatened my life was over the phone.

I was taking call on the weekend for a group of pediatricians. One of them had evaluated a child for a finger injury and had not quite done their due diligence. It sounded infected and in need of repair as the father described its appearance over the phone. I recommended he take his daughter to the local Emergency Room. He threatened to stab me instead. I called to warn the ER staff and then notified the other practice. The response was less than vigorous from my call partners, “you must have done something to upset him.” Their reaction astonished me; “blame the victim” is an unacceptable response to a colleague in this situation.

Announcing Dr. Don Rucker as a Featured Speaker for the Fall Conference!

Jul 5, 2017• 1

By JILL MERRIGAN

We are pleased to announce that Don Rucker, National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services (HHS) will be a featured speaker and a panelist at our upcoming Health 2.0 11th Annual Fall Conference, October 1-4, 2017 in Santa Clara, California.

Unreformed: Taming the Charge Monster

Jul 1, 2017• 29

By SAURABH JHA, MD

Any backpacker travelling on a shoestring budget in Thailand knows not to blow their entire budget on premium whiskey in a premium hotel on the first night in Bangkok. Rather, you need to skip the occasional meal, stay in a cheap dorm with random strangers, and drink cheap beer on Khao San Road if you wish to see the country and return home without having to wash dishes in a restaurant in Bangkok to repay the loans. Both Democrats and Republicans seem impervious to a simple wisdom that I learnt when backpacking – you save money if you go for cheap stuff. The operative word here is “cheap.”

Both the Affordable Care Act (ACA) and the Better Care Reconciliation Act (BCRA) impose cost sharing, such as deductibles. Deductibles lower premiums by cost shifting. Because the sick, for obvious reasons, are more likely to meet their deductibles sooner than the healthy, deductibles shift costs from the healthy to the sick, or are a “tax on the sick.” Deductibles also reduce premiums by reducing the administrative loading of insurance – because insurers have fewer small claims to process, administrative costs reduce.

Fall Conference Demo Submission Deadline EXTENDED to 7/7/17

Jun 30, 2017

By JILL MERRIGAN

Have an innovative product or solution you want to showcase to the entire health care community?

Show us what you got! Live demos are standalone, but they’re often interspersed into larger panel sessions with commentators reflecting on the demo and how they believe it fits into health care. The 3.5-minutetechnology demos are a major hallmark at the Health 2.0 conferences. We do mean LIVE – no PowerPoint or video allowed!

We review submissions on a first-come, first-serve basis. If you’re uncertain that your product will be completely ready at the time of the conference, let us know of your interest anyway – we like to know what’s going on in the community, and it’s not unusual for us to show products in early stages, too!

To learn more and apply, click here!

Time to Start Over!

Jun 30, 2017• 2

By STEVE FINDLAY

The CBO’s analysis of the House and Senate health bills should kill them both—permanently.

Republicans should go back to the drawing board and work with Democrats in both the House and Senate to achieve bipartisan fixes to the ACA/Obamacare marketplaces for 2018 and 2019.

That is the far and away the best thing to do from a policy and political perspective. The vast majority of Americans would stand up and cheer. Two polls out this week, for example, add to previous surveys showing deeply low public support for the Republican bills.

A USA TODAY/Suffolk University poll found that just 12 percent of Americans overall support the Senate Republican plan, including only 26 percent of Republicans. Similarly, an NPR/PBS NewsHour/Marist poll found 17 percent in favor overall, with Republican support at 35 percent.

Just 25 percent of respondents in the latter poll say the want Congress to repeal the ACA completely—consistent with other polls since late 2016.

Trump has suggested a bipartisan path several times in recent months, although there’s no evidence he ever reached out to Democrats and he just as frequently demonized them as “obstructionists.”Continue reading…

Did “Medicus economicus” Kill Medicare Part B Reform?

Jun 28, 2017• 2

By DAVID, MATTHEWS and MAUGHN

When doctors complain about proposed changes to health care reimbursement, do they speak for patients or their pocketbooks? As the recent debate over Medicare Part B shows, even with access to publicly available billing data, it’s hard to disentangle financial motivations from more altruistic ones.

Since 2005, Medicare Part B has paid for physician-administered drugs like infused chemotherapeutics by reimbursing 106% of the average selling price (ASP) – a formula commonly referred to as “ASP+6”. In order to reduce overall spending and the program’s apparent incentive for physicians to preferentially use high-priced drugs, CMS proposed a pilot program last year to test a new payment formula that would have reduced the 6% markup to 2.5%, but added a flat per-infusion payment – effectively rewarding doctors more for choosing cheaper drugs, and reducing their profit from expensive ones.

The plan to revamp Part B reimbursement was scrapped after many groups – including professional organizations representing cancer doctors – vigorously objected. Oncologists argued that there are few cases in which a cheap anti-cancer drug is therapeutically equivalent to a more expensive one, and that the proposed change would mainly harm oncologists’ ability to provide high-quality care.

These may be valid arguments, but it’s hard to disentangle oncologists’ clinical interests from their financial ones. Many economists might reasonably view cancer doctors who object to Part B reform as the physician manifestation of “Homo economicus,” acting solely to maximize their personal gain. Neeraj Sood at the University of Southern California summed up many observers’ knee-jerk response: “Doctors are human. The fact is, this [new proposed] model changes how much money they’ll make.”

But that raises a key question: how much do oncologists make from “ASP+6,” anyway?

A Real (Living, Breathing) Health Care Reform Plan: Drop MACRA

Jun 27, 2017• 8

By STEVEN SOUMERAI

Dear Washington,

Congratulations! You have listened to the AMA and practicing physicians and made it a little easier to comply (at first) with the Medicare Quality Payment Program, part of the massive MACRA “pay for value” law.

But CMS’ announcements in The Federal Register and “fact sheet” are incomprehensible gobbledygook that will be understood by neither doctors, patients, nor the rest of society. The language personifies the complexity, unwieldiness and confused thinking in this huge national policy.

MACRA is a $15 billion boondoggle that the best research shows will neither improve quality nor control costs. Paying doctors for quality (e.g., doing a blood pressure exam) or efficiency may make sense theoretically, but it doesn’t work. Rather than making a dent in the continuing upward spiral of healthcare costs in America, it can even result in some doctors avoiding sicker patients because it affects their quality scores and income.

Early, poorly designed research suggested that paying for health or cost savings was effective, but these research designs did not account for already occurring improvements in medical practice that the policymakers took credit for. Decades of stronger, well-controlled research debunked these early findings and conclusively showed no effects of these economic policies.

So why does the Congress and administration continue to press ahead with this same tired and impotent policy?