By RYAN MARLING

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…

By ANISH KOKA, MD

I was asked to see an unfortunate elderly man – Harry – one afternoon.  He had multiple coronary stents placed for coronary disease over the course of the last ten years, and after presenting with difficulty speaking, was found to have a brain tumor.  The neurosurgeon was hoping I could provide some reassurance about how healthy his heart was to undergo an operation.  An assessment revealed him to be high risk for a coronary event, and I had a lengthy discussion with the surgical team, and the patient, who elected to proceed with the surgery.  Three hours after the surgery, the nurse practitioner taking care of the patient messaged me to tell me his heart rate was slow – ‘in the 30’s’.  I was driving to another hospital, and when stopped, messaged back asking for an electrocardiogram to be sent to me. A quick glance at the image on my screen had me turning around.  There are three major arteries that feed the heart. One of Harry’s arteries had closed off.

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By DAVID INTROCASO

It’s not that we do not know that Medicaid and Medicare fraud is rampant.  A 2012 estimate by the former CMS administrator, Donald Berwick, estimated the amount at $100 billion annually.  Nor are we unaware, that drug companies routinely pay massive fines for illegal business practices: eight firms have paid in sum over $11.2 billion in civil and criminal fines since 2010.  Beyond these issues what is possibly most disturbing about the numerous inter-related health and human services issues “The Poverty Industry” raises is Professor Hatcher’s detailed discussion of how state human service agencies, in partnership with private contractors, have monetized poverty or turned vulnerable populations into a source of state revenue.  As Hatcher says in his introduction, states are, “strip-mining billions in federal aid and other funds from impoverished families, abused and neglected children and the disabled and elderly poor. ” 

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By NIRAN AL-AGBA,MD

By STEVEN FINDLAY

OK.  Yes, this is bad.  The Obama administration is being disingenuous if it tries to spin it any other way.   And, as has been clear for several months, this hands Hillary a “nasty” issue (pun intended). 

The “this,” of course, is the administration’s announcement on Oct. 24—after weeks of speculation and anticipation—that premiums in the exchanges will rise by an average 22% for 2017 coverage (if both state- and federally-run exchanges are included in the count.)

Despite the fact that tax subsidies will significantly soften the blow for the vast majority of people buying health insurance in the exchanges, millions of families will still be adversely affected.  

Specifically, about 2 million people who will buy coverage through the exchanges in 2017 will not get subsidies because their incomes are too high.  You could argue: hey, they can afford it.  But it’s still a pretty big hit when your monthly premium goes from $500 a month to $625.   Continue reading…

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…

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.

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