By LEONARD D’AVOLIO

I was walking with colleagues debating the merits of the latest round of healthcare payment reforms when we came across the ultimate symbol of American entrepreneurialism.  A young girl had set up a lemonade stand with a sign marketing 25 cents a cup.

“I’ll take one” I declared and was impressed with how confidently the young entrepreneur announced my total.  As I settled my tab my colleague stated that he too would like a cup of lemonade and was willing to pay 30 cents.  Except, he would pay half now and the other half would arrive after the cup was emptied, assuming a list of 8 pre-determined criteria were met.  Before he could finish explaining the 30 possible criteria from which she could choose, the third companion announced his thirst.  He would buy lemonade for two of the three of us!  For this, he would offer a dollar.  The catch was that two of us would receive all the lemonade we required for this flat rate.  She eyed each of us up and down carefully, gauging our potential lemonade intake and asked which two were to be covered?  To which my colleague answered, “you will not know until you sign the contract.”

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By TAMARA ST. CLAIRE

Consumers know that their primary care doctors don’t talk to their specialists, who don’t talk to their pharmacists, who don’t talk to their insurance providers. The rise of consumerism in healthcare may be in its infancy, but according to research recently released by Xerox, a full 64% of consumers wish their pharmacist, healthcare provider, and insurance company were more connected regarding their health.

Consider your most recent travel experience. You probably used a website like Expedia.com to look up flights, hotels, and even rental cars. With all the relevant information displayed conveniently (and often beautifully) side-by-side, you were probably able to make an informed decision and instantly book the exact travel package that suited your needs.

Now imagine your most recent healthcare experience. Scheduling the appointment was probably a painful logistical balancing act, accompanied by terrible hold music. You likely had to find and present an insurance card, possibly even filling out another set of insurance forms and a health history for the thousandth time.

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By ROGER COLLIER

Dear Mrs. Clinton –

It’s probably good politics to suggest making Medicare available to some under 65s , just when Congressional Republicans are proposing to increase the Medicare eligibility age. Sometimes, though, good politics doesn’t produce good policy.

Medicare may be well-regarded by most Americans, but the program has four huge weaknesses that need to be fixed before considering any expansion.

Here’s what’s wrong.

Medicare is absurdly, insanely overcomplicated.  When Medicare was created in 1965, it consisted of just two components, Part A hospital care and Part B physician and other care, with the split made only to gain AMA support for the legislation. Fast forward to 2016: we now also have Part C (Medicare Advantage), Part D (prescription drug), and seven versions of dual Medicare-Medicaid eligibility (in turn dependent on 50-plus states’ and territories’ own Medicaid regulations). And that’s all before the thousands of pages regulating payments to providers. The complexity provides a lot of jobs for bureaucrats and consultants, but does little for beneficiaries.

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By CAITLIN BREANNE SMITH

What if I told you that tobacco use, poor diet, lack of activity and toxic agents are not the main causes of death in the United States, as conventionally accepted?

With ever-rising healthcare costs combining with often ineffective strategies to combat suffering from preventable diseases, researchers have increasingly dedicated a particular focus on identifying ways to optimize our ephemeral resources. They are finding that the true or underlying causes of death can be linked to the economic and social circumstances of the individual, such as her or his income, education and social connectedness.

The historically accepted morbidity and mortality factors are often actions and behaviors that are driven by socio-economic factors. Identifying and addressing the root causes of these tangled health webs is recognized as the most advanced methodology to create the highest impact at the lowest cost.

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By NIRAN AL-AGBA

Earlier this week , physicians in small private practices and rural areas breathed a collective sigh of relief.  There is a possibility the implementation of changes to physician reimbursement (known as MACRA) could be delayed.  Thank you, Mr. Slavitt, for listening.  I am grateful to Orrin Hatch (R-UT) and Ron Wyden (D-OR) for keeping our rural needs in mind.  We have a window of opportunity for rural health care to survive but we must communicate our needs as physicians and patients’ loud and clear.

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By KARL STRAUB

The path to consistent, quality patient care progression sounds simple enough:

1. Set and meet accurate length of stay targets based on appropriate DRGs—begin with an end in mind and proactively manage toward that end.

2. Focus unit care teams on clear, appropriate care progression plans for all patients.

But admissions processes often do not capture and disseminate an appropriate target length of stay and DRG in a way that informs expectations for treatment and documentation. Thus caregivers face challenges choosing appropriate goals for managing patient progression so that everyone is working toward that goal. The resulting delays in care prolong length of stay, increase costs, frustrate patients and caregivers, and increase the possibility of preventable harm. Inconsistent care progression can also increase readmissions, as divergence from appropriate and timely care plans increases the risk that the need for treatment will reoccur.Continue reading…

BY PETER PRONOVOST, MD

How would you react if you sent your sputtering car to the auto mechanic, and they stopped trying to diagnose the problem after 15 minutes? You would probably revolt if they told you that your time was up and gave back the keys.

Yet in medicine, it’s common for practices to schedule patient visits in 15-minute increments — often for established patients with less complex needs. Physicians face pressure to mind the clock while they examine you.

That’s not to say that your physician “clocks out” as soon as your 1 p.m. appointment hits 1:15, or that all appointments last that long. What it does mean is that patients and doctors may be deprived of the opportunity for more meaningful discussions about the underlying causes of their problems and plans to improve them. A woman in her 50s who presents with high blood pressure and obesity might need medicine. But a longer conversation about the stresses of being the primary caregiver to her father, who has Alzheimer’s, could help provide strategies to help her look after herself.

When you see a new patient every quarter hour, there is often scant time to get to these root causes, to make accurate diagnoses, and develop the best treatment plans. And there is the danger that you miss a major diagnosis altogether.

The 15-minute appointment arose not out of evidence that it improves patient outcomes but out of production pressures — both the need to meet patient demand and to see enough patients to stay profitable.

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By JIM PURCELL

On July 11, 2016, the Journal of the American Medical Association published an article written by Barack Obama, JD.  The JD (juris doctor) part reflects the fact that the author graduated from law school.  Listed among the article’s purposes is to “recommend actions that could improve the health care system.”  One of those recommended actions is “introducing a public plan option in areas lacking individual market competition.”  While the President devoted only a small portion of his article to the public option, this is what he wrote:

“Some parts of the country have struggled with limited insurance market competition for many years, which is one reason that, in the original debate over health reform, Congress considered and I supported including a Medicare-like public plan. Public programs like Medicare often deliver care more cost-effectively by curtailing administrative overhead and securing better prices from providers.  The public plan did not make it into the final legislation. Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited. Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government. ” (Emphasis added)

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By JOHN HALAMKA, MD

Would you buy an iPhone if the only apps that ran on it were written by Apple? Maybe, but the functionality would not be very diverse.

The same can be said of EHRs. Athena, Cerner, Epic, Meditech, and self developed EHRs such as BIDMC’s webOMR are purpose-built transaction engines for capturing data. However, it is impossible for any single vendor to provide all the innovation required by the marketplace to support new models of care I’m a strong believer in the concept of third party modules that layer on top of traditional EHRs in the same way that apps run in the iPhone ecosystem.

There are 3 such companies doing important care coordination work in Massachusetts and we’re expecting a wide rollout of their cloud hosted modules that tightly couple with EHRs, but are not authored by EHR companies.

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By  ANISH KOKA, MD

Vatsal Thakkar, a psychiatrist, recently wrote of the perks doctors are afforded in everyone’s favorite instrument of social justice – the New York Times. Dr. Thakkar speaks effectively and correctly about a broken health care system navigated best by pulling the ‘doctor’ card. Some on the progressive left have seized on this blatant disregard for egalitarianism as yet another example of a broken healthcare system, despite the fact that a two tiered system is exactly what they have been building over the last eight years.

To be clear, there has always been special treatment accorded fellow doctors and nurses – it has just become more obvious as the gulf between the haves and the have nots in health care has grown.  Make no mistake – this is absolutely a function of multiple strategies that have created winners and losers in the healthcare space.  The problem, of course, is that patients and physicians have ended up on the losing side of this equation.

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