By DANIEL STONE, MD

We all fear that phone call.  A medical report turns out the wrong way and life may never be the same.  When that call arrives we all have the same needs:  A doctor who cares, a place to go for treatment and the finances to afford what’s needed.  Starting on January 20^th, some of my patients will join the 20 million whose lifeline to those fundamental needs becomes jeopardized.  

One of my patients facing this threat lost his job and health insurance during the 2008 recession.   Because he’s a diabetic and has a special needs son, no insurance company would sell his family a policy.   Why would they?   Diabetics and others with serious illnesses pose high risks for future health expenses.  Insurance companies make money by avoiding such risk.   After exhausting all the options, he sweated out 18 months with no coverage.   Finally, the roll-out of the California Exchange, funded by the Affordable Care Act (ACA), allowed him to buy an Anthem Blue Cross policy for his family.  

Do we really want millions of our fellow Americans to relive those nightmares?  We all benefit from the ACA’s fundamental commitment: That everyone deserves access to healthcare regardless of their ability to pay.  The policies guided by this principle moved us toward the achievement of universal coverage without changing the existing care of the majority of working families with employer based plans nor those with self-funded coverage.   

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RAY DESROCHERS

Meet Edith Stowe.

An 83-year-old resident of the District of Columbia, Ms. Stowe has made a routine out of her two to three monthly trips to MedStar Health, a Maryland-based nonprofit health system.

After all, her life literally depends on it. Ms. Stowe has chronic kidney failure, so her 5-mile trips to the hospital aren’t a luxury. She absolutely needs them.

Stowe doesn’t own a car, and taking the bus to get life-critical care isn’t always reliable–or even desirable for an aged patient with a chronic disease.

That’s how Uber enters the frame.

Beginning earlier this year, MedStar has integrated the ride-hailing giant into its platform, allowing patients to easily schedule rides to and from critical appointments. MedStar’s patient advocates will arrange rides for Medicaid patients who don’t have access to its website or app-capable smartphones.Continue reading…

By JEFF GOLDSMITH

Every so often, voters conspire to hand unambiguous control over the federal government to a single political party.  It is rarely the unmixed blessing that party strategists dream it to be.  President  Clinton got a Democratic Congress, and promptly lost it two years later in the wake of the famously unproductive HillaryCare debate.   President George W Bush invaded Iraq.  Lyndon Johnson waged War on Poverty and sent a half-million baby boomers to Vietnam. 

More recently, President Obama had a (brief) filibuster proof Senate majority and an eighty vote House majority entering 2009.  Despite this huge advantage, the passage of ObamaCare turned into a costly, fifteen-month political cliffhanger. A lot of Obama’s problem wasn’t merely an increasingly angry Republican minority but a substantial (and imperiled) moderate wing of his own party. 

What can the resurgent Republicans learn from these cautionary tales as they enter Donald Trump’s Presidency?   What they will come to realize is that often, “friendly fire” is as perilous a risk as anything the other party throws at you.  The Republicans are actually in a much less strong position than they appear as they enter 2017.     

Today’s Republican Party is actually riven into at least four distinct factions, each of which has its own health policy agenda and hot buttons.  Arrayed from Far Right to Center Right, these factions are:

1. The Hamburger Hill Republicans.  (See Wikipedia definition.) Exemplars include the House Freedom Caucus, who won office in the Tea Party rebellion, and would be perfectly comfortable repealing ObamaCare without replacing it, and letting states, particularly of the blue variety, sort out the carnage. A lot of them are “safe seat” Red State Republicans who can afford to take some electoral risks in the name of party principle.
   
2. The Take Your Castor Oil Republicans.  Exemplars include most prominently Speaker Paul Ryan, and also HHS Sec. Designate Dr. Tom Price, who believe that entitlement reform is actually a bigger deal, fiscally and politically, than repealing ObamaCare, and who favor cutting entitlement spending, “pro-competitive solutions” (whatever that means in a highly concentrated health industry), and also compelling “wealthy” Americans to pay a bigger share of their healthcare bill.
3. The Pragmatic Republicans.  Exemplars include:  Lamar Alexander, Orrin Hatch and Kevin Brady, all burdened with the realism borne of Chairmanships of major Committees, all of whom would prefer to strap on a parachute before exiting the airplane on Repealing and Replacing ObamaCare and who are also cognizant of the cost of ownership of the healthcare issue.
   
4. Ten Republican Governors Who Expanded Medicaid.  Exemplars include:  Governors Snyder, Kasich, Brewer, Sandoval, Martinez, Baker, etc. whose states could be on the hook for billions in additional state costs if ObamaCare’s ten million person Medicaid expansion is scaled back.  Each of these Governors has Two Senators to advocate on their states’ behalf.   Vice President to be Pence also expanded Medicaid while Governor of Indiana. 

Interestingly, the new Republican standard bearer, Donald Trump (who was until 2012 registered for thirteen years in New York’s independent but left-leaning Reform party), ran to the left of his Congressional base on healthcare issues.  While he advocated “repeal and replacement ” of ObamaCare with “something terrific” (aka “TerrifiCare”), he also advocated “covering everybody” and “not cutting Social Security or Medicare”. Continue reading…

By NIRAN AL-AGBRA, MD

The Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program—also known as Meaningful Use (MU)—initially provided incentives to accelerate the adoption of electronic health records (EHRs) to meet certified program  requirements.  Many physicians were mandated to change over to electronic records at the cost of tens of thousands of dollars.  Electronic records have never been shown to improve patient care or outcomes with statistical significance, the criteria physicians routinely use when making care decisions.

Physicians who failed to participate in MU would receive penalties in the form of reduced Medicare reimbursements automatically. To avoid a penalty, physicians had to implement certified electronic health records (CEHRT) and demonstrate MU of that technology through an attestation process at the end of each reporting period.  There were 10 data specifications. Approximately 209,000 physicians were facing penalties at the start of 2016, almost one-fourth of the U.S. physician workforce.Continue reading…

By SAURABH JHA

Years ago, when I was less inflexible, I took up Pilates. My instructor, Jim, a charming chap with an infectious laughter, was a 911 truther. I’d egg him on to hear about his conspiracy theories. Jim believed that 911 was concocted by Bush and Haliburton so that the U.S. could invade Iraq to capture their oil. He thought that United Flight 93 never took off. Whatever happened after 911 became the motivation for 911. He was the sort of person who would have concluded that Mahatma Gandhi plotted the Second World War to free India from British rule.

I began to suspect that Jim was, to put it charitably, nice but dim. But he wasn’t that dim. He corrected me when I once, innocently, underpaid him. He was also smart at advertising and when he met my wife, he told her that she should join me for Pilates because it would strengthen our marital bond. My wife politely declined the bond strengthening. He was also very cued up with the nutritional sciences and warned me, without leaving a trace of irony, “don’t believe everything you read about diets.”

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By PAUL KECKLEY

Theranos raised $900 million from investors and achieved a market capitalization of nearly $9 billion. Today, its investors may have lost most of their money and the company is pursuing a new strategy. It’s a familiar story to lenders and investors and likely to be hallway chatter today as the 35th Annual J. P. Morgan Healthcare Conference convenes in San Francisco.

Theranos targeted the lucrative blood testing market offering a new technology that allowed labs to do 30 blood tests almost instantly with a single drop of blood. The company began its operations in 2003 with a $5.8 million investment from Draper, Fisher, Jurvetson and other venture funds. By 2010, it had raised $83.4 million more in three follow-on rounds and then scored a reported $633 million investment in 2014 increasing its market value to $9 billion. In those 11 years, the company operated in relative secrecy: its 60-plus patent filings gave clues about its activities while its CEO, Stanford drop-out Elizabeth Holmes, shunned the spotlight.Continue reading…

By JD KLEINKE

There is no conservative replacement health reform plan for Obamacare — because Obamacare is a conservative health reform plan.

After six years of promising to repeal ‘n’ replace the President’s signature domestic achievement, Republican lawmakers have no coherent alternative to the Affordable Care Act for one good reason: because the Affordable Care Act was once the market-based alternative to a real, not imagined, “government takeover” of health care.

What has always made the ACA a political pariah to Republicans, typified by the bizarre claim by House Speaker Paul Ryan (R-WI) on Wednesday that “Obamacare” has “ruined” and “dismantled” our health care system, is the plan’s namesake — far more than its necessarily complex architecture or any of its actual details, unless you count the details they made up.

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By ROSE, HUSSEY, MARTINEAU and FRIEDBERG

Many providers view the Medicare Access and CHIP Reauthorization Act of 2016 (MACRA) with skepticism. MACRA represents the largest implementation of physician pay-for-performance ever attempted in the United States. Starting in 2019, MACRA will integrate and potentially simplify performance measurement by combining a number of measures and programs. It will also increase the magnitude of financial rewards and penalties, which could help motivate practice change for the better.

One of the more controversial aspects of MACRA is its Merit-Based Incentive Payment System (MIPS) for physicians and practices not participating in alternative payment models. One physician captured the prevalent skepticism when he wrote in the public comments on MACRA: “This rule will wreak havoc with my practice while offering absolutely no evidence that it will do anything to improve patient care.” Partly due to the many public comments, the Center for Medicare and Medicaid Services (CMS) has made substantial changes to the final rule. However, there is room for further changes during the rollout – and potentially strong interest in doing so from Tom Price, the physician nominated to lead the Department of Health and Human Services.

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