The Health Care Blog – Page 334 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Lead Time Bias and Court Rooms

Dec 11, 2016• 3

By SAURABH JHA MD

In 2014, a jury in Massachusetts awarded $ 16.7 million in damages to the daughter of a Bostonian lady who died from lung cancer at 47, for a missed cancer on a chest x-ray. The verdict reminds me of the words of John Bradford, the heretic, who was burnt at the stakes: “There, but for the grace of God go I.” Many radiologists will sympathize with both the patient who died prematurely, and the radiologist who missed a 15-mm nodule on her chest x-ray when she presented with cough to the emergency department few months earlier.

The damages are instructive of the tension between the Affordable Care Act’s push for both resource stewardship and patient-centeredness, and between missed diagnosis and waste. But the verdict speaks of the ineffectualness of evidence-based medicine (EBM) in court. If EBM is a science, then this science is least helpful when most needed, i.e. when trying to influence public opinion.

EBM tells us that had the patient’s cancer been detected thirteen months before it actually was, it would have made little difference to her survival, statistically speaking. Researchers from Mayo Clinic examining the impact of frequent chest x rays in screening for lung cancer in a large number of smokers found that the intensively screened group knew about their cancers earlier, had more cancers removed, but did not live longer as a result. This is known as lead time bias, where early detection means more time knowing that one has the cancer, not more time one is actually alive. This means had the nodule been seen on the patient’s initial chest x-ray she would probably, though not certainly, not have survived much beyond 47.

Could Price Be Right?

Dec 8, 2016• 10

By GILBERT WELCH, MD and ELLIOTT FISHER, MD

If confirmed as Secretary of HHS, Tom Price will oversee a $1 trillion budget – roughly one-third of all health expenditures. His proposed legislation “Empowering Patients First” seeks to control costs by giving patients more choices and providing the information required to make them. He calls for publicly available standardized information on the price and quality of physicians, hospitals and other health care institutions.

It sounds like Dr. Price is prescribing a single data system.

Medicare has had a single data system on the over-65 population for decades. Since 2005, these data have informed Hospital Compare, a consumer oriented website comparing the quality of over 4000 hospitals. And while prices in Medicare are relatively fixed, these same data have shown substantial variation in costs because the quantity of service – the number of hospital admissions, procedures and physician visits – varies substantially from place to place.

But Medicare is only one piece of the data puzzle. A National Bureau of Economic Research report[nber.org] added another piece last year with data from large insurance companies like Aetna and United. For the under-65 commercially insured population, it’s not just the quantity of services that are all over the map – it’s also the prices.

The Case For a Medicare Buy In

Dec 8, 2016• 3

By BOB HERTZ

Here is why we need a Medicare buy-in:

Take the case of a male age 62, in Omaha Nebraska , whose Income is $50,000 a year

His only offers of ACA-qualified health insurance are from Medica and Aetna.

With Medica, he can choose a bronze plan that has a monthly premium of $1,242, a deductible of $6.850.

What an awful policy! For a premium that equals about 35% of his after tax income, he gets no benefits until he paid over $20,000 a year. The insurance company is essentially trying not to cover this person- they are just offering the worst policy they can.

The ultimate solution is simple — this man should be on Medicare.

A Different Kind of Meaningful Use Penalty

Dec 8, 2016• 5

By HANS DUEVEFELT, MD

Our clinic is worried about qualifying for this year’s Meaningful Use incentive payments. We have this hastily purchased EMR that was supposed to make life easier and quality better for all of us. The EMR vendor got paid a long time ago but we are still dealing with the administrative burdens imposed by our new system.

By attesting that we can use this thing reasonably properly, we can receive some Government incentive monies, which even under the best of circumstances don’t even begin to make up for all the extra expenses and productivity losses we have incurred through going digital.

What we are up against is a product that doesn’t do, or doesn’t easily do, what we were told it could.

Moonshots, Opioids and Incentives

Dec 8, 2016• 2

By MARSHALL CHIN, MD

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Major disparities in health outcomes have stubbornly persisted throughout both democratic and republican administrations. If you have diabetes and you live in a predominantly African-American neighborhood of Chicago, you have a two-to-five times higher risk of having your leg amputated than if you live in one of the city’s white neighborhoods. If you are a Hispanic child with asthma, you are 50% more likely to be admitted to the hospital than if you are white. And if you are a Vietnamese woman, you are five times more likely to develop cervical cancer than your white counterpart. The incoming Trump administration’s vow to repeal the Affordable Care Act presents a great danger for vulnerable populations. However, incentive principles that underlie Republican Party health policies could be designed to encourage health care organizations and clinicians to reduce health disparities.

Does It Matter If You Get Along With Your Doctor?

Dec 6, 2016• 4

By NATHAN MOORE, MD

Seems like a silly question, right?

No one ever asks if you get along with the cashier at the grocery store or the barista at your neighborhood coffee shop. For most folks choosing a doctor means finding someone in your area who’s taking new patients with your insurance, which usually isn’t too many.

Simply getting an appointment is hard enough, so expecting a pleasant experience and a good relationship with the doctor seems to be an unreasonable request, like asking for a unicorn who also speaks fluent Spanish. Many people don’t think patient-physician relationship is particularly important; they’re looking to the doctor for medical advice, not to be a friend. In these days of electronic medical records and 15 minute appointments, many physicians simply don’t have the time to get to know patients and find out their motivations, goals and fears. It’s even harder for patients with language and cultural barriers; for example, physicians talk more and listen less to black patients than to white patients.

So why do we care?

Why the Affordable Part Didn’t Work

Dec 6, 2016• 7

By PAUL KECKLEY

Paul Keckley On March 23, 2010, Congress passed the “Patient Protection and Affordable Care Act”. It soon became known as the “Affordable Care Act aka ACA” before being labeled “Obamacare”.

Its aims were two: to reduce costs and cover everyone. In the 79 months since passage, it remains arguably the most divisive public policy platform since FDR’s New Deal in the ‘30s and Lyndon Johnson’s Great Society in the 60s. Per Kaiser Family Foundation’s Tracking polls since its passage, the public’s view about the ACA remains split: half think it’s an overreach by the federal government that has resulted in sky-rocketing health insurance premiums across the board, and the other half believe expansion of insurance coverage for 25 million justifies the effort. Each side cherry-picks elements of the law they like and decry parts they despise.

But all concede the law has not addressed affordability as originally intended. News about insurance premium spikes, has dogged the ACA since its passage lending to critics’ conclusions that the law was fundamentally flawed and had to go.

In 2009, I facilitated several meetings for the White House Office of Health Reform seeking industry input into reform legislation.

Letter from Washington:
Don’t Jump … Yet

Dec 5, 2016• 12

By GREG FULTON

Washington, D.C. hardly seems like a town on suicide watch.

As November turned to December, from the venerable Old Ebbitt Grill near the White House, to Charlie Palmer Steak at 101 Constitution and over to The Capital Grille at 601 Pennsylvania, revelers abounded, in both food and drink.

At the Capitol Hyatt on New Jersey Avenue though, some contrasts were evident. While contestants from the Miss World 2016 pageant moved in and out of the upper lobby to awaiting buses, in the lower-level meeting rooms, also from November 30 to December 2, the mood was hopeful optimism meets whistling past the graveyard.

There the Jefferson College of Population Health summit brought forth Andy Slavitt, Michael Leavitt, Farzad Mostashari, NCQA President Peggy O’Kane, former advisors from the George W. Bush and Obama administrations, officials from Johns Hopkins, the Henry Ford Health System, Brookings, Deloitte, AMA, AHA and the American College of Physicians and many more to dissect MACRA and ponder “population health strategy under the new administration.”

The consensus on where value-based care (VBC) is heading?

Wait and see.

A Policy Agenda to Address New Unintended Adverse Consequences of EHRs

Dec 4, 2016• 10

By SITTIG, WRIGHT, ASH + SINGH

flying cadeucii In large part due to the $35 billion, Health Information Technology for Economic and Clinical Health (HITECH) Act incentives more than 80% of acute care hospitals now use EHRs, from under 10% just 7 years ago. Despite considerable progress, we have not achieved all that was originally envisioned from this transformation and there have been numerous unexpected adverse consequences (UACs), i.e. unpredictable, emergent problems associated with health IT implementation, use and maintenance. In 2006, we described a set of UACs associated with use of computer-based provider order entry (CPOE) (see Table 1). Many of these originally identified UACs have not been completely addressed or alleviated, and some have evolved over time (e.g., more/new work, overdependence on technology, and workflow issues). Additionally, new UACs not just related to CPOE but to all aspects of EHR use have emerged over the last decade. We describe six new categories of UACs in this blog and then conclude with three concrete policy recommendations to achieve the promised, transformative effects of health IT.

1. Complete clinical information unavailable at the point of care

Adoption of EHRs was supposed to stimulate a tremendous increase in availability of patients’ clinical data, anytime, anywhere. This ubiquitous increase in data availability depended heavily on the assumption that once clinical data were routinely maintained in a computable format, they could seamlessly be transmitted, integrated, and displayed between health care systems’ EHRs, regardless of differences in the developer of the EHR. However, complete clinical information on all patients is not yet available everywhere it is needed.

Ian Morrison Interview at Health 2.0

Dec 3, 2016

By JESSICA DAMASSA

Hi, today on THCB I’m glad to introduce Jessica DaMassa a new face who’ll be doing many more interviews in the future, focusing on thought leaders in health and health technology.–Matthew Holt

Ian Morrison is probably the best known health care futurist in America, despite being a Scottish-Canadian-Californian. He gave the keynote at last Fall’s Health 2.0 Conference, and gave his thoughts about the role of technology in the future of care delivery.