The Health Care Blog – Page 340 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Precision Primary Prevention

Oct 27, 2016• 2

By SAURABH JHA MD

If you’re going to indulge in anticipatory medicine, it is best to anticipate those at highest risk. An elegant study by Wald et al in the NEJM shows how precision primary prevention can be done. The researchers screened toddlers, who presented routinely to their general practitioners for vaccinations, for an uncommon, but not rare, familial predisposition to high cholesterol known as heterozygous familial hypercholesterolemia (FH), in which premature cardiovascular death can be deferred by statins and lifestyle changes. Blood drawn from the toddlers by a heel prick was tested for serum cholesterol and genetic mutations indicative of heterozygous familial hypercholesterolemia (FH). The parents of toddlers who met criteria for FH were also tested for cholesterol and genetic mutations. Obviously identifying affected parents, and increasing their longevity, is also beneficial for their children.Continue reading…

Huge ACA Rate Hikes in 100
Words or Less

Oct 27, 2016• 2

By TOM EMERICK

ACA permits people to sign up even if they are already sick. Real insurance cannot work that way.

Imagine an Accountable Fire Insurance Act that required insurers to sell you fire insurance after your home had burned. Homeowner insurance rates would skyrocket. Anyone who carefully read the ACA would see that coming.

The big insurers knew this would happen but played along in the beginning to avoid attracting political fire.

When 75% of Americans get a taxpayer subsidy under ACA, it isn’t really insurance but more of an income redistribution mechanism…for better for worse.

There it is, 97 words.

Artificial Patients need Artificial Intelligence; The Sick and Worried Amongst Us Deserve Better

Oct 26, 2016• 13

ByROBERT MCNUTT, MD and NORTIN HADLER, MD

Every conversation with a patient is an exercise in the analysis of “big data.” The patient’s appearance, changes in mood and expression, and eye contact are data points. The illness narrative is rich in semiotics: pacing, timing, nuances of speech, dialect are influenced by context, background, and insight which in turn reflect religion, education, literacy, numeracy, life experiences and peer input. All this is tempered by personal philosophy and personality traits such as recalcitrance, resilience, and tolerance. Taking a history, by itself, generates a wealth of data but that’s just the start.

Add into the mix physical findings of variable reliability, laboratory markers of variable specificity, imaging bits and bytes and you have “big data.” Then you mine this data for the probabilistic variance of the potential causes of a complaint based on which you begin to consider values for numerous options for care. So armed, the physician next needs to factor the benefits and harms of multiple treatments’ derived from populations that never perfectly reflect the situation of the individual in the chair next to us, our patient. This is the information necessary to empower our patient to make rational choices from the menu of options. That is clinical medicine. That is what we do many times a day to the best of our ability and to the limits of our stamina.

Take that Watson. You need a lot more than 90 servers and megawatts of electricity to manage our bedside rounds. You need to contend with the gloriously complicated and idiosyncratic fabric of human existence. Poets might be a match, but Watson is not.

Michelle Longmire, CEO Medable

Oct 25, 2016

By MATTHEW HOLT

I never ceased to be amazed by how smart young clinicians solve problems that they see. Michelle Longmire was in residency at Stanford working with colleagues building point solutions when she realized that what they needed was an easy platform on which to develop medical grade apps. Her company Medable was the result. Then she realized that the other big market was clinical researchers, who now have access to Apple’s ResearchKit, but need an easy way to build a study without using developers. I interviewed her recently and she built a study for me using Medable’s new Axon product.

Atul Gawande, ACOs, and the Myth of the Mayo Clinic’s Low Costs

Oct 24, 2016• 35

By KIP SULLIVAN, JD

This is the last of a series of imaginary lectures for President Obama. I am hoping to educate him by criticizing three people who influenced him – Peter Orszag, Atul Gawande, and Elliott Fisher and his colleagues at Dartmouth. In this last installment I focus on Gawande.

Obama was deeply impressed by Gawande’s “The Cost Conundrum,” an article published in the New Yorker in June 2009. By June 2009 Obama had already adopted the managed care diagnosis (overuse) and the latest iteration of the managed care solution (ACOs, “medical homes,” and pay-for-performance, all of which will allegedly be facilitated by electronic medical records). “The Cost Conundrum” did not convert Obama to managed care ideology, but it did strengthen his belief in it.

“The Cost Conundrum” illustrates the good and the bad effects the Dartmouth Atlas has had on American health policy and on intelligent people like Gawande and Obama. The article is about Gawande’s trip to McAllen, Texas to see why per capita Medicare spending in that small town was the highest in the country. [1] Gawande knew it was high because the Dartmouth Atlas said so. Asking why Medicare spending in McAllen was so high was a legitimate question to ask.

But Gawande went way beyond exposing problems with Medicare spending in McAllen. He told his readers that the problems he uncovered in McAllen – overuse of some Medicare services induced by fee-for-service payment – afflicted vast swaths of the medical profession and that “accountable care organizations” were the answer. He specifically singled out the Mayo Clinic in Rochester, Minnesota and an informal cartel in Grand Junction, Colorado as examples of ACOs that had allegedly already proven they could provide high-quality care at very low cost. [2]

But within a few years, research would turn Gawande’s characterization of Mayo and Grand Junction upside down. It would turn out that both the Mayo Clinic and Grand Junction are costly places to be treated when all medical spending, not just Medicare spending, is taken into account. Oops.

But before I elaborate on that mistake, I want to give Gawande credit for the good “Conundrum” did do.

Will Clinton Take Another Look at Value-based Healthcare?

Oct 24, 2016• 1

By PAUL KECKLEY

Paul Keckley “Value” is the most important concept in healthcare today. But it’s problematic.

Futurists say our system is transitioning from volume to value. Device and drug manufacturers tout the value of their products. It even found its way into Wednesday night’s Presidential debate when frontrunner Hillary Clinton answered Chris Wallace’s query Medicare’s long-term viability with the following reply: “We’ve got to get costs down, increase value, emphasize wellness. I have a plan for doing that.”

Value is defined as “a fair exchange in return for a thing” (Dictionary.com). Per Webster’s, it is a “fair return in goods, services, or money for something exchanged; worth in money; usefulness, or importance in comparison with something else.” In essence, it is the relationship between what something costs and the benefits that accrue to its purchaser. Transactions between buyers and sellers based on the purchaser’s deduction of what something costs and the benefits derived are the basis for value-based economics. They’re aided by rating services like Consumer Reports that provide useful methods for making selections: the current issue covers SUVs, coffee makers, nut butters and gas/electric ranges. Very straightforward. Side by side.

Making Accountable Care Organizations Great Again

Oct 22, 2016• 8

By ANISH KOKA, MD

Test your Accountable Care Organization knowledge:

Select all of the options that are True

If you belong to an ACO you qualify for the alternative payment model track in MACRA
Most ACO’s are enrolled in to a two sided risk model – (They share profits and losses with Medicare)
In 2015, ACO’s saved Medicare more than a billion dollars
None of the above

I have been mystified by Accountable Care Organizations ever since I first heard of them almost a decade ago. ACO’s have had a hallowed place in the world of health care policy for some time now. Everyone knew they were coming, and everyone knew they would be the answer. Traditional fee for service medicare that paid based on volume was thought to be the driver of rising health care costs. Regional variation in medicare expenses even when controlling for underlying population risk suggested that lower costs were possible without sacrificing quality. Imposing a capitated model of reimbursement tied to quality metrics seemed to be the answer and ACO’s were the vehicle to make this happen.

I was on board, though I freely admitted to everyone who asked, that I had no idea how they would work. To be fair, I was far more stressed about learning coronary anatomy in the cath lab, than I was about health care policy. By the time ACO’s finally started in 2012, I had been in practice for a few years, and I was paying slightly more attention. The passage of time now allows for the assessment of the value delivered by ACO’s and is a health care policy researchers dream. Clinicians, however, continue to be blissfully unaware of the construct. ACO’s exist in some alternate universe that is interesting and worthy of name dropping to establish your policy-cred, but even the coarse details are shrouded in mystery for most clinicians and patients. What follows is a brief primer and analysis of some recent data that doesn’t require an understanding of linear regression modeling.

Who Cares? Lots of People Do, and This New Podcast Celebrates Them

Oct 22, 2016

By DOUG WALKER

Sometimes in healthcare it’s easy to get caught up in the negative. Rising costs, patient frustrations, challenges for hospitals and providers as we evolve toward value-based care.

So it’s been a great pleasure recently to be involved with something that celebrates the positive things and people in healthcare. We, with the help of the great folks here at The Health Care Blog, recently launched a new healthcare industry podcast called “Who Cares? Hospital Talk.” The podcast gives a voice to people who are passionate about making patient care and experience better.

The Who Cares? Hospital Talk podcast builds positive awareness about the people in all types of roles “who care” and commit to improving patient care and experience. It provides a forum to lead the conversation about people improving healthcare in big and small ways with thoughtful, innovative approaches to advancing care quality, the patient experience, and efficiency in care progression. Continue reading…

MACRA Needs to Use Evidence-Based Interventions

Oct 21, 2016• 15

By NIRAN AL-AGBA, MD

Whether applied to policymaking for individuals, large populations, or administration of health services nationwide, it is imperative regulatory decisions be anchored to empirical evidence. The official MACRA rule has now been released. It is 2,000 pages based on the opinion of many non-practicing physicians, Dartmouth economists, and government administrators with input from a few doctors on the front line. In my opinion, what began as a certain death sentence has commuted us to life in prison; MACRA will regulate physicians without representation.

Let me acknowledge my opinion is limited by my own “small” practice bias. 380 thousand “small” practices (having 15 providers or less) will be exempted if they have less than 100 Medicare patients. Your definition of small and mine are strikingly different. Every single independent practice in my hometown of that “quasi-small” size, has sold to the local hospital already. The “small” practices remaining in my community have 1 or 2 physicians, so I will refer to those as micro-practices for clarity. My micro-practice serves more than 400 Medicaid patients, with a waitlist of more than 50. MACRA rules do not seem to have an answer for when there are not enough micro-practices remaining with which to form a “virtual” group.

MACRA: We Can’t Expect the Feds To Be The Key Lever of Change

Oct 20, 2016• 3

By JOE FLOWER

The final MACRA rules are out. There is plenty of room for debate about them, but one thing is clear: They are a fine example of why we cannot expect the federal government to be the key and most powerful driver of change in healthcare.

This is not a political statement, not an anit-government slogan, not a libertarian assertion. This is a systemic observation.

This is not because the law or the CMS rule-makers are not well-intentioned. To the contrary, MACRA seems like a noble enterprise. Congress is to be congratulated for at least temporarily getting itself unstuck long enough to pass it. CMS is trying their mightiest to push healthcare in the direction of actually offering value for all the money we keep shoveling into it.

But just look at it: Over 2,000 pages, full of complexities, exceptions, subsidiary re-payment clauses, labels and circles and arrow that will keep healthcare lawyers and consultants in fine shape for quite some time to come. As THCB’s Kip Sullivan has pointed out, MACRA is supposed to be rewarding good “volume to value” behavior and punishing its opposite, but it is so complex that few physicians will be able to honestly tell whether they will get rewarded, how much, or for exactly what.

Operant Conditioning

Or when. Have you ever tried to train a dog? If you want them to stop some behavior, like digging in the garden or jumping up on you, you have to catch them in the act and give them a negative response right then. If you want to reward them for something, you have to give them the treat (or the clicker click that signals a reward) the moment they do it, so that they know what the heck you are talking about and how compelling the reward or punishment is. (My lab used to be all, “If it’s not cheese, don’t even bother.”)

People are not that different, especially people trying to run the increasingly complex business of a medical practice out of one hand while trying to actually practice medicine with the other. If you want them to do something that is both different and difficult, give them an impressive reward the instant they do it, a reward that is significant in comparison to all the other influences on their bottom line, and that happens in this billing cycle.