After the horrific shooting in in Orlando, the conversation has turned to homophobia—specifically, the homophobia of a man who sees two men kissing, buys an AR-15, goes to a gay nightclub, and killed 49 individuals. But homophobia does not always come with a high capacity rifle—sometimes it comes with lab coats and syringes. As the 53 individuals who were critically injured in the shooting receive medical care, we must come to terms with the anti-gay discrimination that pervades our medical system.
Above the Fold
Time to Brexit the Health Care System?
Can’t. Won’t work. We’re stuck with this. We have to fix it.
But “Brexit” was a great logo/hashtag/campaign meme, with echoes of “Britain, break it, exit” all in one. Falls right off the tongue, it does. And it described fairly exactly the mood behind it, one of breaking, getting out.
So in healthcare? Time to FFSexit — exit the fee for service business model. Nah, doesn’t trip off the tongue. And it has echoes of “sex” and even “sexist.” Next!
Time to ITexit — exit the non-interoprative, non-communicative garbled EHRs and other information systems we have ended up with. Nope, nope. Sounds too much like inviting Texas to re-think this whole annexation thing.
Time to Vexit — exit the volume-based business model. Hmmm, no. Sounds vexatious, vexed.
Time to exit the fragmented, opaque, partial, byzantine, and outright cruel healthcare financing system we have now —FragOpParByzOutCrexit! Sigh.
Wait. Wait. Here’s the core problem of this meme-pondering: We don’t want to “exit” healthcare in any way.
The Great Insurer Fee Disconnect
A message to health insurance CEOs, COOs, and CFOs. I believe there to be a fundamental disconnect between typical health insurer provider reimbursement strategies and the long term good of our healthcare delivery system and its financing.
Let me give you some examples which I know, as a former health insurer COO and CEO, to be true.
- Insurers still pay primary care physicians far less than most specialists. That perhaps was a function of the RBRVS system adopted by Medicare to “measure” the demands of specific physician activities and pay accordingly. Specialist activities were rated higher than primary care activities. They were deemed more complex, often involving surgery and fancy equipment with more training needed, etc. The gap between primary care and specialist reimbursement grew and grew. And what happened? Predictably, the best and brightest are avoiding low paying primary care. Consequences?
- Shortage and aging of primary care physicians who are needed to keep us from requiring the much more expensive specialist and hospital care
- Oversupply of specialists resulting in overuse, because if you build it they will come
- Keeping the focus on sick care, which is what most specialists specialize in, rather than well care
- Devaluing E&M (evaluative and maintenance) activity, which is the heart and soul of the practice of medicine, requiring observation, patient knowledge, and perception
Where’s the Value in MACRA?
The intent of Title I of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) is to improve care quality and reward value. 1 Tying an increasing percent of Medicare fee for service payments to quality or value through alternative payment models such as Accountable Care Organizations (ACOs) is also Department of Health and Human Services Secretary Sylvia Burwell’s goal. 2 However, in the proposed MACRA rule published in May, CMS will measure and score quality and resource use or spending independently. 3 CMS will not measure outcomes in relation to spending. CMS will not measure for value. If value is left unaddressed in the final rule the agency can neither meet MACRA’s goals nor Secretary Burwell’s. CMS cannot also reasonably expect providers to continue to enter into, and succeed under, risk based contacts if they do not know if they are incrementally improving quality or outcomes relative to spending. Continue reading…
The Mischief and the Good In Precision Medicine
When The White House announced their Precision Medicine Initiative last year, they referred to precision medicine as “a new era of medicine,” signaling a shift in focus from a “one-size-fits-all-approach” to individualized care based on the specific characteristics that distinguish one patient from another. While there continues to be immense excitement about its game-changing impact in terms of early diagnoses and targeting specific treatment options, the advancements in technology, which underlie this approach, may not always yield the best medical results. In some cases, low cost approaches, based on sound clinical judgment, are still the better option.
For example, tuberculosis (TB) is an infectious disease that continues to pose global burden with 9.6 million new cases and 1.5 million deaths reported in 2014 alone. The large toll is partly due to lack of effective treatments (particularly for drug-resistant cases) but also due to delays in diagnosis. One might think that precision medicine technology leading to improved diagnosis would be effective at minimizing the related death toll but we shouldn’t automatically assume that. It turns out that sometimes the latest technological advancements can be so sensitive that we detect organisms that are not causing disease.
Understanding the True Costs of ACOs and Medical Homes
One of the privileges of being a managed care advocate is that you never have to discuss the unpleasant question of how much your proposed intervention will cost. Whether your proposed intervention is HMOs, report cards, pay-for-performance, ACOs, “medical homes,” or electronic medical records, you never have to estimate what your bright idea will cost. With this privilege comes another: You are free to criticize doctors and hospitals for being “cost unconscious.”
Over the last decade, CMS has become a proponent of this double standard – cost consciousness for doctors and hospitals and cost unconsciousness for the health policy illuminati
. Beginning with the Physician Group Practice Demonstration, which ran from 2005 to 2010, and running through today’s ACO and “medical home” demos, CMS has assiduously avoided reporting the costs that clinics and hospitals incur to participate in these demos. Jeff Goldsmith and Nathan Kaufman have described CMS’s behavior as “sunny obliviousness to provider economics.” [1]Continue reading…
On THCB
- Does Arnold Schwarzenegger Deserve Better Care Than Our Veterans? by Karen Sibert MD
- The Black List Part II (Features Which Should Be In Every EHR, But For Some Reason Aren’t) by Hayward Zwerling, MD
- An Epidemic of Septicemia? by Al Lewis
- In Silico Medicine by Nicole Van Gronigen, MD
- All Risk is Local by Jeff Goldsmith
- The Team Sport of Diagnosis: A Culture Shift Can Reduce Missed Diagnoses By David Newman-Toker
- Confession of a Liberal by Margalit Gur-Arie
- Confusion over HIPAA Causes Grief in Orlando by Art Caplan & Craig Konnoth
- Men, Women and Health Care Pricing Theory: Speaking Different Languages by Jeanne Pinder
Will Federal Court Back Rules Treating Health Insurance as a Utility, Not a Luxury?
On June 14, 2016 a Federal Court ruled that broadband internet is as essential to American as phones, electricity, water and sewer systems and should be available to all Americans as a utility, rather than a luxury that doesn’t need close government supervision.
In the United States, public utilities are often natural monopolies because the infrastructure required producing and delivering a product such as electricity or water is very expensive to build and maintain. As a result, they are often government monopolies, or if privately owned, the sectors are specially regulated by a public utilities commission which severely limits the profits for the private utility company and the associated costs passed on to consumers of that utility.
There is nothing more essential to the lives and well being of Americans than health insurance and therefore healthcare is the ultimate utility.
Time to Put a Stop to Workplace Bullying
Civility is a system value that improves safety in health care settings. The link between civility, workplace safety and patient care is not a new concept. The 2004 Institute of Medicine report, “Keeping Patients Safe: Transforming the Work Environment of Nurses,” emphasizes the importance of the work environment in which nurses provide care.1 Workplace incivility that is expressed as bullying behavior is at epidemic levels. A recent Occupational Safety and Health Administration (OSHA) report on workplace violence in health care highlights the magnitude of the problem: while 21 percent of registered nurses and nursing students reported being physically assaulted, over 50 percent were verbally abused (a category that included bullying) in a 12-month period. In addition, 12 percent of emergency nurses experienced physical violence, and 59 percent experienced verbal abuse during a seven-day period.2
Workplace bullying (also referred to as lateral or horizontal violence) is repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators.3 Bullying is abusive conduct that takes one or more of the following forms:3
Does Arnold Schwarzenegger Deserve Better Care Than Our Veterans Do?
When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.
When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.
Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.
