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Make the Technology Disappear

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By HILARY HATCH, PhD

When Esther Dyson asked me to participate in a panel at the Louisville Innovation Summit called “Real-world Care Technologies for Medicaid/Medicare Recipients That Institutions Actually Deploy”  next week, I could hear the frustration in her voice in the name of the panel. “Make something useful that people will actually use.”

I stumbled on the word “technology.” What if we said, “real-world care solutions for Medicaid/Medicare recipients that institutions actually deploy.” Is there a difference? Yes. A solution solves a problem. How we solve a problem shouldn’t be the focus.

I think our customers would say, “if you have to do it with technology, fine.” They are not excited about technology. Who can blame them? In health care, technology has created real-world unhappiness, implementation complexity, low morale and a poor user experience for patients and care providers. To our buyer, technology invokes extra steps on the way to getting the problem solved: IT implementation backlogs, security review, and anxiety about data stewardship.

It would be best if the solution was apparent and the technology disappeared.

Which reminds me of this story:

The architect hired to re-design a famous museum pitched his designs to the Board of Trustees as follows: He said, “If you give me enough money, I’ll design you a beautiful building. If you give me more, I’ll make it disappear.” What a seduction!

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Underuse is Rampant, But Overuse is All We Talk About

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By KIP SULLIVAN, JD

This is my fourth in a series of imaginary lectures on remedial health policy for President Obama. My goal is to convince Obama that he relied on the wrong people for health policy advice. I am focusing on three people in particular: Elliott Fisher and his colleagues at the Dartmouth Institute, Peter Orszag, and Atul Gawande.

In my first comment , I criticized Obama for clinging to the belief that the Affordable Care Act has already reduced health care inflation and will continue to do so in the future. I devoted my second comment  to explaining how influential the Dartmouth Institute has been. In my last comment I set forth the reasons why the Dartmouth group’s influence has declined since approximately 2010. 

I devote this comment to a review of some of the evidence that indicates underuse (the failure of the health care system to deliver necessary care) is more prevalent than overuse. Knowing that fact is useful not just for understanding my criticism of Obama but for understanding how flimsy the justification is for accountable care organizations and other managed care nostrums. I have only enough space here to introduce you to the best of the under- and overuse literature. I believe it will be enough to convince you that underuse is more common than overuse. Once you comprehend that fact, you’ll also comprehend that it is neither logical or ethical to base health policy on the assumption that overuse is the only form of inappropriate use we must address. If we view underuse as an equally serious problem, then it makes no sense to promulgate managed care notions (such as shifting insurance risk to doctors) designed to address overuse.

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Building Better Metrics:  Patient-Driven Metrics

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By NIRAN AL-AGBA, MD

Recently I wrote about empowerment and the importance of letting patients make their own health care decisions.  Our job is to make sure patients are given information and then allowed to choose the best option for them. Maybe we should even embolden patients; give them confidence and encourage them to take more control. Physicians tend to feel more comfortable advising according to the “standard of care” and we struggle handing over the reins when we believe we “know” the safest path to take. 

Every time I talk about building better metrics, I emphasize the significance of evaluating something physicians can change or control.  The intent behind measuring patient satisfaction was likely to increase patient autonomy, however, as with many things; the devil was in the details.  It turns out chasing higher patient satisfaction scores can result in higher costs and increased mortality.  Overall, the most satisfied patients were more likely to be admitted to the hospital and total health-care costs were 9% higher. Most strikingly, for every 100 people who died over a four year period in the least satisfied group, 126 people died in the most satisfied group.  At least they died happy and satisfied right? That notion can be difficult for some physicians to accept but might be more important than we realize.   

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There’s a Story Behind the “Craziest Thing in the World”

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By STEVE FINDLAY

screen-shot-2016-10-04-at-12-39-26-pmIs he on or off message — or what?  We are taking about Bill Clinton, who said in a speech today/yesterday that small business folks and individuals were “getting killed” by Obamacare….with “premiums doubled and their coverage cut in half.”  

“The people who are getting killed in this deal are the small businesspeople and individuals who make just a little too much to get in on these subsidies,” Clinton said. He added that for many people, Obamacare’s changes have meant “their premiums doubled and their coverage [was] cut in half.”

Ouch.  But then he went on to say that one solution is to allow Americans to buy into Medicare, as Hillary has proposed.   We’re not sure if she’d be pissed or pleased with these remarks.  Perhaps not bad to let Bill signal her awareness that things with the exchanges are not good, and that she might be open to bigger changes in the program than she’s owned up to so far.

ColoradoCare by the Numbers

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By ROGER COLLIER

screen-shot-2016-10-04-at-10-16-06-amWhen Vermont Governor Peter Shumlin dropped his support for Green Mountain Care a year and a half ago, it looked like single-payer healthcare in the United States might have taken a fatal blow.

But no! A couple of thousand miles away, in Colorado, a new single-payer proposal is on the November ballot and might even pass. 

ColoradoCare would put in place a quasi-state-administered health plan covering almost every resident of the state. Paid for by a “premium tax” on businesses and individuals, it would provide a wide range of benefits for residents not covered by any federal government program (but including those now enrolled through ACA insurance exchanges). It also would pay for Medicaid services at the same rates as other residents and provide supplemental Medicare coverage.

ColoradoCare’s proposed coverage is remarkably generous, with no deductibles and with zero copays for most primary care, but—predictably—the ballot measure to create the program faces strong opposition from insurers and most business owners.

What’s likely to happen? A June poll showed strong support, but the insurance industry is now funding a barrage of negative publicity. Support for the ballot measure may also be eroded by the announced opposition of Colorado’s Democratic governor, and by a Colorado Health Institute analysis indicating that revenues would likely be insufficient to cover costs.

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Holier Than Thou Doctors

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BY JIM PURCELL

flying cadeuciiI can recall it like yesterday.  It was 2004, and I had become the CEO of Blue Cross & Blue Shield of Rhode Island.  I was in the middle of my annual physical with my long-standing primary care physician, Dr. Richard Reiter (true).  Dick Reiter is my age and is an old school doc.  He caught my cancer before it got too serious, and had been yelling at me about things like cholesterol, stress, and exercise for years.

During a lull in the exam, I turned to him and asked, “Dick, I’m the CEO of Blue Cross.  What do I need to know?”  He paused, looking down.  Then his cheek started to twitch.  I actually saw him lose his temper for the first time in 25 plus years.  “Jim, you want straight?  What the bleep are you doing to us?  A monkey can do a colonoscopy and yet they make four times what we primary care doctors make.  What you are doing is a disgrace.”  He was some pissed!!

I then had lunch with Dr. Al Puerini, a highly regarded PCP of 30 years with a full practice.  I asked him how much he netted before taxes, and when he told me, I was appalled.  He made some aside about it not being about the money, but it IS in part about the money.  He also told me about how difficult it was to recruit new PCPs in RI.

Those two encounters started me down my path of alarm about the future of primary care.  Rhode Island is a small (40×30 mile, one million population) microcosm of the country.  While we have our accents and quirks, and people still think we’re overrun by the mafia, we’re not all that much different.  Just wicked smaller.  Our PCP population was aging and shrinking rapidly.  The best and brightest from Brown Med School and others of its ilk were decidedly not swarming into primary care.  Practices could not recruit new members.  We were, and still are, in a crisis that is nation-wide.

And it didn’t stop with just the poor PCP reimbursement.  PCPs cannot survive financially without untoward volume.  This has all sorts of negative consequences.  Moreover, on the totem pole of respect, PCPs do not seem to rank high for reasons that I simply cannot fathom.  It seems that the more “miracle machines” a physician uses, the more respect he or she gets.  While the poor PCP does what we in the billing world refer to as “E&M” (Evaluative and Maintenance).  The look-you-in-the-eye, known-you-for-years sort of thing.  In other words, taking basic tests and extrapolating health trajectories.  Wading into gray areas.  Knowing the patient and her family, and making informed prognoses.  All difficult stuff.  Not something that shows up on an LED screen.  Ahhhh….judgment and perspective.

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Burning Out on Employee Burnout

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BY HANS DUVEFELT, MD

Today I attended a very entertaining and inspiring seminar, and yet I left it with a sick feeling in the pit of my stomach.

Bryan Sexton, a national authority on health worker burnout and patient safety, made a convincing case for the importance of addressing burnout. Staff burnout causes surgical complications, medication errors and even hospital deaths. And burnout affects roughly half of all healthcare employees.

But his solution, which I was invited to substantiate by participating in Duke University’s latest NIH sponsored study, was a series of educational videos and daily SMS reminders prompting followup activities to reinforce six lessons. These lessons had titles like “Gratitude” and “3 Good things”; smartphone Buddhism, I told my wife over dinner. I qualified my statement by admitting that the six lessons from Duke could make us all better providers and better human beings. In fact, my own writing sometimes serves the purpose of focusing my attention away from the frustrations and distractions in medicine and toward those aspects of my patient interactions that enrich, humble or awe me.

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Is the FDA Sleeping With the Enemy?

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By SAURABH JHA, MD

flying cadeuciiPublishing in the BMJ, Vinay Prasad, an oncologist and healthcare’s leading evidence-based iconoclast, found that over half of medical reviewers who leave the FDA work for device and pharmaceutical industries. Prasad’s findings created disquiet amongst purists of various stripes. The media was shocked and tried shocking people by showing how shocked it was. The Lown Institute, which has been fighting physician conflict-of-interest (COI) with industry, seemed exasperated that yet another COI has emerged. Even pro-industry observers were upset by Prasad’s data-driven insinuation that a career in the FDA seems, for many, a means to a career in industry.

The reactions show deep inconsistency and a tangled-web of moral confusion which pervades healthcare. Let me start with the obvious. If nothing is inherently wrong with physician-industry relationship, and I side with the amoralists, then it scant matters that for some physicians the FDA is a stepping stone to industry. I’ll be more explicit: it is illogical to encourage physician-industry relationship and be upset when this relationship is consummated.

Conversely, if you believe the FDA is a force for public good (FWIW, I’m decidedly on the fence), then you should be happy when an FDA reviewer consults for a pharmaceutical company, particularly if you also believe that industry is not a force for public good. If you believe there’s inherent virtue in regulations, that the assessment of safety and efficacy of a new drug is a science that is as beautiful as religion, then why be upset when a regulator shows industry how to satisfy regulators? The FDA sets standards to save us from rapacious capitalists, and some FDA reviewers show rapacious capitalists how to meet the standards which keep us safe. By valuing medical reviewers for the FDA, industry signals that they value satisfying regulators. Am I alone in I failing to see a problem? Would the Church of the Latter Day Saints object to their members moving to Wall Street to proselytize investment bankers, or to Hollywood to preach prudence?

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ACO Performance Year Three: What Happened and What Does It Mean?

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By DAVID INTROCASO

Since Accountable Care Organizations (ACOs) are CMS’s largest pay for performance model delivering care to over 7.5 million beneficiaries, each August Medicare policy analysts await CMS’s press release summarizing ACO financial and quality performance for the previous year.  This past August 25, CMS announced 2015 results.  Like performance year one (2013) and two (2014), performance year three again produced marginal results.  Largely because, inexplicably, CMS is not evaluating the ACO program, once again analysts are left to decipher what performance results mean for the program, how success was achieved and what ACO performance means in context of the agency’s overall efforts at lowering Medicare spending growth.   

Summary of 2015 Performance Results

In CMS’s August 25th press releases, the agency noted 120 out of 392 2015 ACOs earned share savings. 1  CMS also releases annually a data file summarizing ACO participants, participation track, number of assigned beneficiaries, financial benchmark and quality measurement data.  Based on the data file, of 392 ACOs, 115 ACOs earned shared savings, 114 in Track 1 and one in Track 2, or 29% of all ACOs. 2  This compares to 26% in 2014. 3  Of the remaining 276 ACOs, one ACO earned shared savings but did not meet their quality performance standard, 86 ACOs produced savings but did not exceed their Minimum Loss Ratio (MLR) and 95 received reimbursements beyond their benchmark and fell within their negative MLR. The worst performing ACOs were the 95, or 24%, that received reimbursements that exceeded their negative MLR.  Had this last group not been in Track 1 they would have owed CMS half of their above benchmark reimbursements.  As in 2014 earned shared savings was highly concentrated.  Ten of the 115 successful ACOs earned $220 million in shared savings, or more than one-third of total $645 million in shared savings payments. 

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The Letter of Recommendation: A Two Way Legal Instrument

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By VARUN SETHI, MD

Letters of recommendation (LORs) are a common part of the job application. Employers rely on them to help choose new hires. Many physicians have written reference letters for their peers and trainees. It is important to appreciate that LOR is a legal instrument that holds not only the applicant accountable but also the writer. It is a signed document that is retained in the employee’s files and its origin can be traced.

I will describe the case of a physician group which was successfully sued for writing an inaccurate reference letter for a former colleague. Litigation involving inaccurate and misleading references in the broader employment arena will be discussed to highlight the nature of liability in LORs.

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