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Above the Fold

Independent Decision Support at the Point-of-Care for Both Patients and Physicians

May 13, 2016• 9

By ADRIAN GROPPER, MD

flying cadeucii “We did not spend $35 Billion to create 5 data silos.” This was said by Vice President Biden at the beginning of Datapalooza on Monday and repeated by CMS’s Andy Slavitt on Tuesday. On Wednesday, at the Privacy and Security Datapalooza at HHS, I proposed a very simple definition of electronic health record (EHR) interoperability as the ability for patients and physicians to access independent decision support at the point of care regardless of what EHR system was being used.

Over the three days of Datapalooza, I talked to both advocates and officials about data blocking. In my opinion, current work on FHIR and HEART is not going to make a big dent in data blocking and would not enable independent decision support at the point of care. The reasons are:

A Free Market Repudiation of Evidence-Based Medicine

May 13, 2016• 14

By MICHEL ACCAD, MD

Michel Accad In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.” I am grateful for his interest in my work and for the the kind compliment that he extended in his article. Having also become familiar with his fine writing, I return it with all sincerity. I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices: “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.” Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged. I have been trying to sink that baby for a number of years now, attacking it from a variety of angles. I have made a special plea in favor of small data and I have even questioned the intellectual sanity of EBM. On the question of the coexistence between EBM and clinical judgment, I have been decidedly intolerant, relegating EBM to second class citizen status. In other words, I’m an unapologetic EBM-denialist which, as I found out yesterday on Twitter, puts me in the same category as climate change skeptics.

Hillary’s Pivot Left on Healthcare

May 13, 2016• 10

By INDUSTRY MOLE

Is Hillary Clinton really moving to the left on healthcare, as the NY Times and many others have asserted, pushed by continued pressure from Bernie Sanders to endorse the public option? It is a strange claim. First of all, her campaign’s explicit support of the Public Option goes back to at least February, when her site was updated with language backing it, and which seems essentially identical to the language the campaign uses today. She hasn’t moved left in the last three months due to the lingering strength of the Sanders campaign.

Has she changed at all from previous years? There isn’t any indication of that, either. If anything, her plans today are scaled back from her 2008 presidential campaign, in which the public option, based on Medicare, figured prominently.

Datapalooza: MACRA, EHR Reform and Working with Doctors – Not Against Them

May 12, 2016• 11

BY ANDY SLAVITT

Screen Shot 2016-05-12 at 8.45.31 AM There’s a bit of a checklist for speaking at Datapalooza. Thank Niall. Mention Todd Park. Remark at how big the event has gotten compared to last year. Recap how much progress has been made. Refer to yourself as a “data geek” . Also, have in my notes “Good not to follow Farzad or Aneesh” . Perhaps even make some news with an announcement or grant or contest. Several of my colleagues did this and I share their excitement.

But I’m not going to make news. Instead, I’m going to relay a bit of my personal experience with health care innovation and technology as my goal is to leave this job with nothing really left unsaid. Twitter, by the way, seems to be helping with that.

Lately, we’ve been contemplating a significant transformation of the Medicare program by implementing the bi-partisan MACRA legislation. Legislation to make a wholesale change in the Medicare payment system to pay for quality. This has caused me to begin an obsession with the plight of independent physicians, knowing as we all do that if we don’t invest in primary care, we’ll invest double or triple when people get unnecessarily sick. And as a steward of programs where people with the lowest incomes and in the most remote locations get care, I know that without access, it will be people that can afford it the least that suffer first and most.

Making Sense of MACRA

May 12, 2016

By THCB STAFF for HEALTH CATALYST WEBINARS

Health Catalyst Flame The healthcare transformation from fee for service to fee for outcomes just got an adrenaline shot in the arm April 27th when the Department of Health and Human Services surprised many in the market by announcing a Quality Payment Program, a proposed set of new rules to take effect in 2019.

While the dust is yet to settle from the momentous thud of the 962-page proposal that was dropped seven days ago, Bobbi Brown, Health Catalyst Vice President of Financial Engagement, has a head start in understanding the ramifications of this proposal with more than 30 years working across the largest and most complex healthcare organizations.

Get answers to questions like:

What does this mean for you?
How will it impact your payments?
What should you be doing today to prepare?
With quality as a key component to payment, how will it be measured?

Learn more about this important webinar for THCB readers here.

The Rise of the Chief Cognitive Officer

May 12, 2016• 3

By DAN HOUSMAN

Cogito potestas est (Thinking & learning is power)

Screen Shot 2016-05-12 at 1.06.57 PM

In a recent blog post titled ‘A computer that allows the doctor to be more human’ Toby Cosgrove, the CEO of the Cleveland Clinic stated “It may sound odd, but technology like Watson will make healthcare less robotic and more human.” The reasoning behind putting an AI through a version of medical school is that human physicians can’t possibly read and process the exponentially growing volumes of clinical trials, medical journals, and individual cases available in the digital domain. A computer that digests them can transform them into useful support options for care of a patient. Furthermore humans can’t be a part of every case and learn from every physician. But by combining a human with the capacity of a computer as a physician’s assistant, physicians can focus on the many things that they are uniquely able to do in the complex domain of medicine. This includes the critical conversations with patients and their families.

The Tangled Hospital-Physician Relationship

May 11, 2016• 8

By GOLDSMITH, KAUFMAN and BURNS

flying cadeucii Together, hospital and physician services account for more than half of national health spending. In its 2014 National Health Expenditures estimates, the Centers for Medicare and Medicaid Services’ actuaries make the hospital (nearly $1 trillion) and physician practice (nearly $600 billion) sectors appear to be independent and non-overlapping. This is an optical illusion. Hospitals and physicians are, in day-to-day practice, hopelessly intertwined.

And while power appears to be shifting from physicians to hospitals with the increasing salaried employment of physicians, appearances can be deceiving. This post discusses the economic power balance between hospitals and physician communities, and the policy levers that influence this complex relationship — a relationship that is evolving in a way that could increase financial pressures on both hospitals and the American health system.

Physicians and hospitals must intimately collaborate or care does not get delivered. At the same time, hospitals and physicians directly compete in surgery, imaging, and other ambulatory services. In this relationship of simultaneous competition and interdependency, the borderline between hospitals and physicians is fraught both with economic conflict and moral/legal risk.

A Hayekian Defense of Evidence-Based Medicine

May 11, 2016• 5

BY ANDREW FOY, MD

It’s a lousy Saturday morning in Southeastern Pennsylvania. The 100-mile bike ride I had scheduled, the first century of the year, was cancelled at 5 AM due to inclement weather. I’ve been scanning my Twitter feed ever since.

I only joined Twitter yesterday, so I’m a bit obsessed at this point. The synapses in my prefrontal cortex are getting fresh hits of dopamine every time I land on another exciting science/political story, journal article, or blog that’s been tweeted about. Yes, I’m a nerd.

Through Twitter, I was introduced to Michel Accad less than 24 hours ago. He’s a cardiologist, philosopher, writer, and creator of the blog “Alert and Oriented”. Over last evening and this morning, I read most of his blog articles as well as a few research papers he has authored. In short, I think he’s a fantastic writer and very intelligent guy but I have to take issue with a recent piece titled “The devolution of evidence-based medicine”. In it, he praises Anish Koka’s recent article on this site titled, “In defense of small data”. I know Anish personally; he is brilliant and paradoxically, he positively covered my own research using big data in another recent article.

More Than Adequate

May 11, 2016

By KOFI JONES

CMS recently unveiled a massive regulatory overhaul of Medicaid managed care requirements. Despite the fact that it’s being called a “mega-reg,” and taking some heat for its 1400+ page size, there’s certainly some interesting reading contained within, particularly for the telehealth community.

It’s all about network adequacy standards.

Health plans are regulated by states or CMS and measured based on their ability to demonstrate the adequacy of their in-network providers. How many are there? What’s the availability by specialty? Do consumers understand which providers are in-network? What does access look like in terms of wait times and distance? Answering these questions are the key to meeting the standard.

A Comprehensive Strategy For Primary Care Payment Reform in Medicine

May 10, 2016• 16

By MOSTASHARI, KOCHER and McCLELLAN

farzad_mostashari Strengthening primary care has been a core goal of health care payment reform over the past several years. Primary care physicians are the cornerstone of the health care delivery, directing billions of dollars of follow-on care. With better support, the models presume, primary care doctors could guide their patients toward a better health, direct them to the right care when needed, and in so doing, bring down unnecessary medical costs. Moreover, especially if coupled with payment reforms that can support better coordination with specialist practices, these reforms can provide an alternative to health system employment and health care consolidation, thus buoying competition in local markets.

The most recent effort toward this goal lies at the heart of the recently announced Comprehensive Primary Care Plus (CPC+) program. This program doubles down on the kinds of “medical home” payment and delivery reforms that were the hallmarks of previous Medicare initiatives, most notably the Comprehensive Primary Care Initiative, which in its first two years showed significant improvements in some dimensions of quality – but so far has generally failed to show reductions in overall costs significant enough to offset the per-member per-month (PMPM) payments to primary care practices to support their reforms. While some medical home payment reforms have shown both savings and outcome improvements, overall results have been mixed particularly in Medicare, with the result that the CMS actuaries have not yet “certified” any such medical home model as leading to overall spending reductions.