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Above the Fold

Assessing the Validity of MACRA’s Risk Adjustment Methods

Jun 14, 2016• 2

By KIP SULLIVAN

flying cadeucii The feedback doctors will receive from CMS under CMS’s proposed MACRA rule will arrive in two forms: Money (more or less of it) and data. Neither form of feedback will be accurate. For that reason, the behavior desired by Congress and CMS – “smarter care” (as CMS puts it) producing lower costs and higher quality – will not materialize.

As I noted in the first installment of this three-part series, the two most important sources of noise in CMS’s feedback will be CMS’s inability to determine which patients “belong” to which doctor (the attribution problem) and its inability to adjust cost and quality scores for factors outside physician control (the risk-adjustment problem). [1] In my first installment I showed that the method of attribution CMS will use is unacceptably sloppy. In this installment I review the risk-adjustment problem and CMS’s irresponsible claim that it can measure physician “merit” even with sample sizes as small as 20 patients.

FUD Part II: The Return of Fear, Uncertainty and Doubt

Jun 13, 2016• 2

By JOHN HALAMKA

John Halamka A Time of Uncertainty …

The upcoming presidential election has everyone spooked – what if Donald Trump is actually elected? What will the transition of administrations, regardless of who is elected mean to healthcare and existing healthcare IT regulations? Will our strategic plans and priorities need to change?

I’ve spoken to many people in government, industry and academia over the past month about the rapid pace of change stakeholders are feeling right now. Here are a few of their observations:

1. In the next year or two there will continue to be consolidation in the healthcare IT industry. Many smaller EHR companies will fold due to declining market share and some established incumbents with older technologies are likely to sell their healthcare IT businesses or reduce their scope.

2. Mergers and acquisitions will continue to accelerate, reducing the number of stand alone community hospitals and practices. The end result is that the market for software supporting midsize hospitals and small group practices is likely to shrink since ACOs/networks/healthcare systems will probably mandate a single centralized EHR solution for the enterprise.

3. Although the election may change the regulatory burden, many incumbent vendors will be spending the next year or two complying with certification demands, reducing their ability to innovate. It’s quite a conundrum. The market is demanding innovative solutions in the short term, but vendors cannot produce them because their development resources have been co-opted by regulatory demands. Thus, vendors may see a reduction in new sales, which will diminish their ability to hire new staff to meet the regulatory demands, putting them even further behind. It reminds of a classic unstable system – beer pong. The more you miss, the more you drink, the more you miss. The more regulation, the fewer new sales, the less ability to deal with regulation.

A Bill You Can Understand: One Page, One Line, One Price

Jun 12, 2016• 6

By FRED GOLDSTEIN and BRIAN KLEPPER

At the recent Health Datapalooza conference, Sylvia Burwell, the HHS Secretary announced a new initiative, A Bill you Can Understand, :

a challenge to encourage health care organizations, designers, developers, digital tech companies and other innovators to design a medical bill that’s simpler, cleaner, and easier for patients to understand, and to improve patients’ experience of the overall medical billing process.

This is a laudable if perhaps slightly misdirected effort.

Why are we looking to create an extra layer of service to explain a very poor function, which will inevitably increase system costs? Because this is healthcare’s typical way of adding more layers and costs to an already bloated system, instead of fixing the underlying problem.

When you buy a car do you receive separate bills for the labor, motor, body, tires, glass, oil and gas, carpet, electronics, air conditioning? I know, there are a few lines – base price, options, transportation fees, dealer fees – but it’s just a few and there are not multiple bills coming from all the components.

Furthermore, this simplification greatly reduces the number of people and systems that a dealer and its suppliers need to staff for the billing and collection process.

What healthcare needs is to simplify and combine the entire billing process and function. We need to bundle pricing that is all-inclusive in advance, just like everything else we buy.

The Opioid Crisis: Nociception, Pain and Suffering

Jun 10, 2016• 6

By MARTIN SAMUELS, MD

flying cadeucii In order to understand the concept of pain and its relationship to the current opioid crisis, it is prudent to review the neurology of pain an why it exists. Several concepts are important to integrate.

Nociception: Nociception is the capacity to sense a potentially tissue damaging (noxious) stimulus. To illustrate this one should place a forefinger in a glass of ice water and determine how long passes until an unpleasant sensation arises. If one performs this experiment in a large group, one can recognize that, although the stimulus is the same (a glass of ice water), the sensation arises at different rates in different people.

In fact, a bell shaped curve will describe the distribution in any population of people. Within 30 seconds almost all will have perceived an unpleasant sensation that is known at pain. Nociception is a very primitive sensation.

It is present in virtually all animals, even those without a brain, such as Aplysia, the sea slug. Though it lacks a brain, it has nerves and ganglia that allow it to sense and move away from a noxious stimulus. Nociception is absolutely essential to our survival and well-being. Without it, one would suffer tissue damage and ultimately death. The human disease, leprosy, is a salient example of an infection that destroys the nerves that are responsible for nociception. That lack of nociception is what causes all of the disfigurement that is characteristic of leprosy. Anyone who has had a dental anesthetic is aware that one can inadvertently bite one’s own lip until the anesthetic wears off.

The Black List: Features Which Should Be In Most EMRs/EHRs (But For Some Reason Aren’t)

Jun 9, 2016• 12

By HAYWARD ZWERLING, MD

flying cadeucii I have been in the health information technology field since 1990 when I began creating ComChart EMR. It was a labor of love which ultimately evolved into a small business. From 2004 until 2012, ComChart EMR had amongst the highest KLAS rating of all EMRs in the small ambulatory care group. From 2011 until 2015, ComChart EMR was certified by the ONC for Meaningful Use Stage I. Unfortunately, the technical requirements arising from Meaningful Use mandates and changes in market conditions required that I stop selling ComChart EMR in 2015.

As a result of the 2.5 decades I spent creating ComChart EMR, I have learned a lot about which features are useful in the exam room and how to design an EMR so that it facilitates the user ability to provide medical care to their patient. As Judy Faulkner, Founder and CEO of Epic said, “Good software is art.” To this, I would add that it is only possible to create a well designed EMR if a practicing physician is intimately involved in both design and programming of the EMR.

Men, Women and Health Care Pricing Theory: Speaking Different Languages

Jun 9, 2016• 20

By JEANNE PINDER

flying cadeucii Men and women in the United States think very differently about health care costs. When I talk about the topic, it’s common for me to see half of my listeners zoning out — the male half. Why? Well, because women make or influence 90 percent of the health care decisions in this country, according to a study by the American Academy of Family Physicians. Of course, men go to the doctor. But they make fewer health care decisions, and they don’t think about pricing the same way women do.

Women are more in touch with health care pricing and more affected by it than men. Women own reproductive health. Women make pediatricians’ appointments and run elder care. Women nag their spouses, be those spouses husbands or wives or none of the above, to get their cholesterol checked, to pick up a prescription, to go to that physical therapy appointment.

So when we talk about shopping for health care, about our business, we’ve grown accustomed to having dudes say “Hm, interesting, can we talk about wearable devices?” or “We have some big data, we’re not really interested in the prices.” At the same time, women tell us how excited they are that we’re attacking opacity in health care pricing.

The Cab Ride

Jun 8, 2016• 7

By ROBERT MCNUTT, MD

flying cadeucii I usually walk from the University of Illinois, campus to Union Station at the end of my workday. But, that day it was raining. So, I hailed a cab. The cab driver was not in a mood to talk so I had time to relax and look around at the traffic. To my right was a recent model Mercedes sedan. I watched it for a moment and then pivoted to peer to the left. An old Toyota Corolla with the rear view mirror attached with duct tape was neck-in-neck slowed on the road with the cab and the Mercedes.

This image struck me; three impressively different cars depicting, perhaps, personal preferences and different opportunities of individuals, despite the differences, were driving on the same road.

So, this piece is about civil rights. Everyone who gets ill deserves the same road to drive on, but presently, some get better, or different roads than others. The “road” in the potentially obscure metaphor is the road that allows every individual the equal and omnipresent rights to information that will allow them to make an informed decision.

The Five Year Plan

Jun 7, 2016• 9

By JOHN HALAMKA

John Halamka When my father died 3 years ago, my comments at his funeral noted that the greatest aspiration any of us can have is to make a difference in the world. My father’s life made a difference.

I’m always self critical and analyzing my own life. I moved to Boston 20 years ago this month. In those 20 years of service to BIDMC, Harvard, numerous federal organizations, international governments, and industry, I’m hopeful that I’ve laid a foundation for 20 more years of trying to make a difference. It’s hard to forecast the best path to have an impact on the healthcare ecosystem, but I can try.

The past 5 years belonged to government – with $34 billion spent on healthcare IT as a result of HITECH, the Meaningful Use program accomplished the goal of moving clinician practices and hospitals from paper to digital systems. Although many challenges remain – improving workflow, enhancing quality/safety, and ensuring usability, the basic platform on which we can build future innovation has been created.

The government will continue to be very a important actor, especially CMS, setting payment policy that will impact the behavior of all stakeholders. However, I believe the era of prescriptive government direction of the IT agenda has ended. Provider organizations are begging for an outcomes focus, instead of a process focus.

Consumer Groups Weigh in on EHRs Under MACRA

Jun 7, 2016• 2

By STEVEN FINDLAY

One of the things that needs to happen as physician payment reform and EHR interoperability (post-meaningful use) evolve under MACRA is this: CMS and ONC need to promote, measure and significantly enhance consumers’ access to their health information and/or interaction with EHRs.

Stated another way: after spending $30 billion to compel the adoption of EHRs, the federal government needs to get its act together to assure that consumers and patients are directly—and not just indirectly—benefiting. That was, after all, part of the original vision way back in the George W. Bush administration. Simply stated: Electronically stored and continually updated information and records on you should be available to you. And without a lot of trouble. Continue reading…

Fame and Fentanyl

Jun 7, 2016• 1

By KAREN SIBERT, MD

flying cadeucii A fentanyl overdose led to the recent death of musician and singer Prince, according to the medical examiner’s report released June 2. The drug seems likely to become as notorious as propofol did after the death of Michael Jackson in 2009.

For all of us in anesthesiology who’ve been using fentanyl as a perfectly respectable anesthetic medication and pain reliever for as long as we can remember, it’s startling to see it become the cause of rising numbers of deaths from overdose. Fentanyl is a potent medication, useful in the operating room to cover the intense but short-lived stimulation of surgery. The onset of action is very fast, and the time that the drug effect lasts is relatively brief.

But fentanyl was never intended for casual use. Fentanyl is many times more potent than morphine; 100 micrograms, or 0.1 mg, of IV fentanyl is roughly equivalent to 10 mg of IV morphine. In March, the LA Times reported that 28 overdoses — six of them fatal — occurred in Sacramento over the course of just one week. The victims had taken pills that resembled Norco, a common pain reliever, but in fact the pills were laced with fentanyl. Even tiny amounts were enough to be lethal.

Like all opioids, fentanyl reduces the drive to breathe, and after a large enough dose a patient will stop breathing entirely. In addition to its effect on respiratory drive, fentanyl may also produce rigidity of the muscles in the chest and abdomen, severe enough to hamper attempts to ventilate or perform CPR.