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No, I Didn’t Expect That Either.
What’s Next?

Nov 9, 2016• 5

By MATTHEW HOLT

As a Democrat, I can only hope this is a Dewey defeats Truman moment, but at 2.00am ET on Nov 9, President Trump with a Republican House and a open Supreme Court seat seems to be our new reality. For the health care establishment, this is a bombshell. It’s been easy for Congressional Republicans to vote to repeal the ACA when they knew Obama would veto it. But what happens next when Trump is happy to sign the “repeal”?

It’s hard to figure out what’s there in terms of putting together to “replace” either in the Congressional Republicans or in what passes for policy in what passes for the Trump camp. As Margalit Gur-Aire said on THCB recently other than one speech with some stale talking points about block grants for Medicaid and selling insurance across state lines, Trump seems to have no ideas about health care. (To be fair he doesn’t seem to have any ideas about anything, or he claims they’re a secret).

Then we have the issue of his relationship with Congress. Now he’s President he may declare a truce, but then again he might decide to tweet into oblivion Paul Ryan and the many others who wouldn’t support him. And he might of course self-immolate as he tries to manage his business, his relationship with Russia and his soon to be launched TV network–while actually having to be President.

But if he’s going to end Obamacare, Trump is going to have to worry about two things. First, he has said that he wants to repeal it but is going to make sure everyone can buy health insurance, even if they have preconditions. When the middle aged white working class who voted for Trump discover that their Medicaid and their health insurance goes away, and that insurers wont sell them insurance if they’re not a good risk, they might be unhappy.

Second, the other people who are going to be unhappy are the health care industry stakeholders. Health care is a series of complex legislative and market interactions. As a consequence of the ACA, most health insurers, providers and even pharma or device companies have made huge changes to their business strategy. Those business strategies and investment are now six years old. Like Wall Street and corporate America, Trump is going to make the health care establishment deeply uncomfortable. The question is, once big pharma, insurers and providers lean on the Administration, will anything actually change, or will we see the route towards value-based care continue?

Not only that, but the sea-change that is just starting in the shift from FFS to value-based payments from Medicare & CMS is underway because the country can’t afford continued health care cost growth. That remains the same. Eventually that reality will impinge even on a Trump administration.

So what happens next? Well it’s amateur hour and we’ve all failed to predict it thus far, so it’ll be tough to do it now. But health care will be a sideshow.

Oh, and time to repeal the frigging electoral college.

Death and Readmissions

Nov 8, 2016• 4

By ANISH KOKA, MD

Eugene’s wife is on the phone. She has been taking care of Eugene for 41 years. I supposedly take care of his heart, weakened by two prior heart attacks. I say supposedly because his wife does all the heavy lifting. She makes sure he takes his medications when he should. She watches his weight every day and occasionally administers an extra dose of diuretic when his weight climbs more than a few pounds in a day. And perhaps most importantly, she calls me when Eugene’s in the hospital and things seem wrong to her. This is one of those phone calls. They were in the ER, Eugene hadn’t been responding to his diuretic as he normally does, and his breathing seemed more labored to her. The ER physician wanted to send them home – she was hoping I would weigh in. Not surprisingly, she was right, Eugene needed to come into the hospital. I used to be surprised when the ER wouldn’t call me for complex cardiac patient having an acute cardiac problem. Not any more.

There is a clear culture shift that is obvious to those who have spent any time in the ER over the past ten years. Low risk patients used to be managed and discharged from the ER, and higher risk patients were quickly admitted to the hospital for management by specialists. This used to be a source of tremendous friction with the ER in my younger years, as I would try to explain to ER physicians that every single chest pain in a patient with known coronary disease did not deserve admission. I seldom have this conversation with the ER anymore. What changed?

Prescription For Patient Safety With Health IT: More Time With the Patient, and Less Distraction

Nov 7, 2016• 11

By TOM LANG, MD

Recent government incentives have gone a long way toward bringing digitization to healthcare, with particular benefits seen in the PACS/ digital radiology areas and digitally archiving data for better access. A 2016 AMA survey (1) has shown that the biggest desires for physicians from digital health are increasing patient safety and improving work efficiency.

I would like to propose that the most important aspects of patient safety are as follows:

clinical workers (that is, doctors, nurses and other members of the caregiving team) need to maximize their time ‘at the bedside’
clinical workers need to maximize their communication and interaction within the patient care team to optimize patient care

clinical workers need to minimize distractions from the two activities above.

Health IT systems need a complete overhaul, guided by these principles, in order to optimize patient safety with its use. One way to look at health IT from a clinical perspective is to break it down into 2 pieces: data aggregation (that is, the ‘anytime, anywhere access’ to digitized health information) and data entry: the time and distraction from patient care that data entry tasks require for clinical workers. The big wins so far with health IT has been with the former, the big problems with the latter.

Trump and the “Public Option”

Nov 7, 2016• 3

By KIP SULLIVAN, JD

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Jacob Hacker, the godfather of the “public option,” and Donald Trump have much in common. They both think the solution to high health care costs is more competition within the insurance industry. They both acknowledge that the insurance industry is highly concentrated, and yet for reasons they don’t disclose they both think it’s possible for new insurance companies to break into such a highly concentrated industry. The only difference between their theories of competition is that Trump wants insurance companies to create insurance companies from scratch, while Hacker wants the government to create insurance companies from scratch.

In my last post , I criticized Hacker for not explaining how the “public option” (PO) will come into existence. All Hacker can say is the PO will be “like Medicare.” Hacker and other PO proponents don’t tell us how the PO will become “like Medicare.” We are simply supposed to believe the PO will leap into existence and, when it does, it will be big like Medicare and enjoy Medicare’s low overhead and payment rates. [1]

Trump’s “explanation” is just as empty. He simply asserts that insurance companies in one state will open shop in other states if the regulations in some states are reduced. [2] Here is how Trump “explained” his proposal during the second presidential debate on October 19: “We have to get rid of the lines around the state, artificial lines, where we stop insurance companies from coming in and competing, because they want – and President Obama and whoever was working on it – they want to leave those lines, because that gives the insurance companies essentially monopolies….”

An Ad Page In the NEJM and the Future of Cancer Care

Nov 4, 2016

By MARC HERANT, MD

I am not sure how many docs still do this, but I still read the actual hard copy of my New England Journal of Medicine, and that means I flip past ad pages with smiling grandfathers playing with grandchildren thanks to supercalifragilistic products on my way to scholarly papers with tables and figures. But this time, I stopped in puzzlement when I came across an ad from Intermountain.

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Intermountain is a health system based in Utah, highly respected for its sound approach to quality and cost control[1], but not broadly well known for cancer care in the way of centers like Dana Farber or Sloan Kettering. Digging further by going to the website uncovers the actual offering which is a streamlined 5 step process:

Send tumor sample
Deep sequencing of 96 key cancer genes
Genomic data analysis
Tumor board makes a treatment recommendation
Facilitated procurement of the relevant cancer drugs

Turn-around time is about two weeks, fast enough to wait for the information before starting a regimen.

Dear (Quite Possibly) President Trump

Nov 3, 2016• 33

By MARGALIT GUR-ARIE

Even the most ardent of Obamacare supporters are now forced to admit that the law has hit a rough patch this year. The opposition to Obamacare is positively gloating with self-congratulatory “I told you so” assessments of the supposedly dire situation. Defenders of the cause are counteracting with the customary deluge of charts and graphs to prove unequivocally that Obamacare is actually turning out better than they expected. Integrity and honesty being in short supply on both sides of this quandary, chances are excellent that no matter what happens next, the American people will lose big time, unless….

How the “Public Option” Became Just Another Fuzzy Buzzword

Nov 2, 2016• 4

By KIP SULLIVAN, JD

In an earlier post, I criticized managed care proponents for promoting concepts defined only by the aspirations of their proponents. HMO, ACO, “medical home,” and “patient-centered this and that” are examples.

The “public option” (PO) is the latest example of a buzzword defined only by the aspirations of its proponents. The PO, first introduced to the public a decade ago by Jacob Hacker, Democratic presidential candidates and advocates of what would become the Affordable Care Act, has been revived by Democrats over the last five months. [1] Hacker, Hillary Clinton, Barack Obama and others say a PO would reduce premium inflation. But they refuse to define the PO, which makes it impossible to determine whether it could survive, much less reduce premium inflation. It’s not even clear whether proponents are proposing a PO open to all Americans or just to those who shop on the state exchanges established by the Affordable Care Act. The best they can do is say the PO will be “like Medicare.” That’s not a definition. That’s an aspiration.

A Shout Out to Our Corporate Supporters

Nov 2, 2016

By THCB STAFF

THCB would not be possible without the generous support of our corporate supporters. Today’s shout out goes out to the good people at HealthCatalyst, one of our favorite Health IT companies. Visit the HealthCatalyst Knowledge Center for great tutorials, walk-throughs and explainers on value-based care and the Affordable Care Act. You’ll also find online sessions like this week’s highly useful MACRA FAQ.

The MACRA FAQ

Nov 2, 2016

By THCB STAFF

Speaking of frequently asked questions, THCB will be collecting yours this fall going into the New Year. Send us (or tweet) your questions about MACRA, value-based care and payment reform and we’ll publish them. While much of our coverage of payment reform centers on the big picture issues around the Affordable Care Act, the what-ifs and the whys and why nots, our readers also want practical advice and insight on how best to manage the transition to this important new payment model.

If you’ve had an experience with an early ACO you’d like to tell us about, feel free to write. You can also post your comments in this place. Be sure to include your organizational affiliation if you’d like credit for your ideas, although anonymous contributions will be accepted as always. To get started, you can check out the online session on MACRA Frequently Asked Questions here. Come back to THCB for posts in the weeks to come.

Disrupting Deductibles: An Innovative Approach to HDHPs

Nov 2, 2016• 10

By RYAN MARLING

screen-shot-2016-11-02-at-7-01-57-am Health plan deductibles are on the rise in a big way. Deductibles, or the amount of money members must pay out-of-pocket before their health plans kick in, have soared a whopping 63% over the last five years. This is compared to the modest 19% growth in health plan premiums during the same time period. Rising deductibles represent a shift in who is being exposed to financial risk in healthcare. The burden of the spiraling healthcare cost problem in the United States is being shifted away from insurers and employers and more and more upon the shoulders of individuals and families in the form of out-of-pocket payments.

Insurers construct deductibles into their health plans as tools to prevent members from spending more on healthcare than they truly need. They reason that if members have ‘skin in the game,’ they will prudently shop around for reasonably priced healthcare providers, and not purchase more healthcare goods and services than necessary. Continue reading…