By STEVEN FINDLAY

Graphic Credit: AP

For the record and as we crawl chaotically towards repeal & replace or repair, the final numbers on ACA enrollment for 2017 are in.  They reflect coverage in the 39 states that operate through healthcare.gov plus the 11 states and DC that run their own insurance exchanges.    

A total 12.2 million people signed up.  That’s 3% to 4% fewer than last year.  HHS and the Associated Press (AP) put enrollment through healthcare.gov at 9.2 million; AP puts the number of enrollees in the 11 states plus DC at 3 million.

Of the 9.2 million who signed up through healthcare.gov, 6.2 million were returning customers and 3 million were new.    

According to an analysis by Charles Gaba, who runs the website acasignups.net, enrollment through healthcare.gov was down about 5% while enrollment in the 11 states and DC was up 2%. 

Gaba and other analysts attribute the healthcare.gov decline to consumer confusion about the fate of the ACA and the Trump administration’s pull back on consumer outreach and ads in the final weeks of sign-up in January.  So the last minute rush this year was much reduced.   

Continue reading…

By NIRAN Al-AGBA, MD

As physicians ready themselves for the future of medicine under onerous MACRA regulations, it seems appropriate to glance into the future and visualize the medical utopia anticipated by so many.  Value-based care, determined by statistical analysis, is going to replace fee for service.   

Six months ago, I received my first set of statistics from a state Medicaid plan and was told my ER utilization numbers were on the higher end compared to most practices in the region.  This was perplexing as my patients tend to avoid ER visits at all costs and can be found milling about in my parking lot at 7am on Mondays with their sick children waiting for my office to open. 

Continue reading…

By ROBERT LASZEWSKI

Many recent press reports have centered around the notion that Republicans are stuck in the mud trying to get their repeal and replace promises moving.

That line appeared to be reinforced over the weekend when President Trump said, in a pre-Super Bowl interview, that the process could draw out into next year. My sense is that what Trump was talking about was the fact that the whole process, that includes implementing the replacement, could take well past 2017. Trump, never one for getting the details right, was taken literally by the press looking to write stories about how the whole process was foundering.

Speaker Paul Ryan quickly countered in his press briefing that Republicans will legislate a repeal and replace of Obamacare this year.

Continue reading…

By UWE REINHARDT

Consider the poor bloke depicted below. He lies, exhausted, on a sand dune in the Sahara desert, literally dying of thirst.

Along comes a camel caravan, evidently with a group of tourists in the lead. The caravan is bound to be loaded with water.

Surmising that the dying man’s demand for water is bound to be highly price-inelastic (the economist’s jargon for “insensitive to price”), one of the camel riders jumps off his camel and waves a bottle of water in front of the dying man’s face, asking him: “What would you give me for this bottle of water?”

“Everything I own,” moans the dying man, knowing that none of his assets would be worth anything to him unless he got water soon.

“Done deal,” says the tourist, beckoning one of his fellow travelers, a lawyer, to draft up the necessary documents, which the thirsting man quickly signs in return for that life-saving bottle of water.   

What might we call this hypothetical transaction and the price the tourist extracted from the dying man for that life-saving bottle of water?

Continue reading…

BY AL LEWIS

There is a saying: “In wellness, you don’t have to challenge the data to invalidate it.  You merely have to read the data.  It will invalidate itself.” Indeed, if there is one thing you can take to the bank in this field, it’s that articles intending to prove that wellness works inevitably prove the opposite. Another saying is that the biggest enemies of Ron Goetzel and his friends (the Health Enhancement Research Organization, which is the industry trade assocation) are facts, data, arithmetic, and their own words.

And Mr. Goetzel, writing in this month’s Health Affairs [behind a paywall], is Exhibit A in support of the paragraph above.  The “overscreening today, overscreening tomorrow, overscreening forever” gravy train of the wellness industry is officially dead. (They can still screen employees intermittently, according to guidelines recommended by the US Preventive Services Task Force, but no wellness vendor ever got rich by doing that.)

It did not die because of his conclusion that companies with lower employee risk factors spend more than companies with higher employee risk factors. That by itself would be worthy of a headline, of course, since it’s quite at variance with the massive savings shown in the Koop Awards he gives to his friends.  But there is much, much bigger news, though in this case he “buried the lead,” in a sleight-of-hand that he knew Health Affairs‘ peer reviewers wouldn’t notice.Continue reading…

By RYAN MARLING

American football is rich with statistics and advanced analytics meant to depict success in specific facets of the game. Once the dust settled after the New England Patriot’s breathtaking Super Bowl comeback against the Atlanta Falcons, I couldn’t help but draw parallels between healthcare—specifically, diabetes, also rich with metrics and indicators—and the approach of legendary football coach, Bill Belichick.

For years, patients with diabetes have relied on their glycated hemoglobin (HbA1c or hemoglobin A1c) levels to assess their success in managing their diabetes. An HbA1c score is known in the field as a steadfast indication of a person’s average plasma glucose concentration over a three-month period. This metric gives patients and their care team an idea of how well their blood sugar is being managed. 

This approach, however, is being reconsidered as healthcare practitioners recognize that the goal of diabetes management should not be to obtain an ideal HbA1c score, but rather to reduce the risk of diabetes-related complications that have direct impact on patients’ day-to-day lives and long-term well-being. In fact, a recent study suggests that strict control of one’s HbA1c does not significantly impact one’s risk of diabetes-related complications.

Continue reading…

DAVID INTROCASO

It is well recognized that over the past several decades US prisons and jails have become the nation’s largest inpatient psychiatric hospitals.  This is not surprising when you realize the majority of the US correctional population, the largest in the world at well over two million, suffers from mental illness. 1  Leaving aside the question whether it is appropriate to incarcerate the mentally ill, at least those with serious mental illness, how we choose to treat a significant percentage of mentally ill inmates is to place them in solitary confinement. 2  This means how we treat a significant percent of the mentally ill in this country is to torture them.

In the editors’ introduction to Hell is A Very Small Place, Voices From Solitary Confinement, a chapter that should be required reading for all health care students, Jean Casella, James Ridgeway and Sarah Sourd note that on any given day between 80,000 and 120,000 men, women and children are held in solitary confinement in US prisons and jails. 3  One-third to one-half of those placed in solitary confinement already suffer mental illness that is frequently accompanied by developmental disabilities, physical disabilities and substance addictions.  

A similar percent of all others placed in isolation will develop psychiatric symptoms, if not complete decompensation, particularly if they are confined for an extended period of time.

Continue reading…

By ALAN PITT

Several months ago I had a conversation with Dr. Robert Spetzler, the Director of the Barrow Neurological Institute. During our interview Dr. Spetzler mentioned that the patient needs to become captain of their own ship. I agree. Although most of us (as patients) would like someone to step in and care for us when we’re sick, rising costs and limited providers make it impossible for the healthcare industry to meet America’s expectations for care. Healthcare needs patient partners.

But in all fairness, I thought to ask a patient what they need. So, with the start of 2017, I thought to ask turned to someone who deals with her care everyday, my mother.

Sheila Pitt is an Art Professor at the University of Arizona. In 2008 my mom suffered a fall from a horse and became a quadriplegic. Since then she has gone back to work teaching and continues to make art with a new process she developed using the abilities left to her. In the past I wrote about my perspectives on her accident. I thought I’d discuss my mother’s journey in healthcare.

Alan: So, Mom, can you tell me when you first realized you were quadriplegic?

Sheila: Yes, I can. I was in my hospital bed having just returned from the surgical floor when one of the nurses referred to me as a quad. And—not to me but to someone else—they said, get this quad ready for whatever the procedure was. I was shocked. I had no idea I was a quad. No one had talked to me about it. No one had explained what that was about. And it was like I wasn’t there. They were talking about me as a quad and I was really quite shocked that they did that. But I realized I must have been a quad.

Continue reading…

By PETER PRONOVOST, MD

Her voice cracked with strain. I could imagine the woman at the other end of the line shaking, overcome with remorse about the hospital where her husband had had esophageal surgery. Might he still be alive, she asked me, if they had chosen a different hospital?

The couple had initially planned to have the procedure done at a well-known medical center, but when she went online to do her homework, she discovered that the hospital’s patient safety scores were poor. Another hospital in her community had stronger patient safety ratings, so they decided to have the procedure there.

It made sense. Why wouldn’t they go to a safer hospital?

What she didn’t know was that multiple studies over several decades have shown outcomes are better when procedures are handled by surgeons and hospitals with higher volumes, and while the well-known hospital had performed the procedure her husband needed many times during the previous year, the hospital they chose had done one.

Continue reading…