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The ACA at 6 Years: Solid Progress but Cost Issues Remain

Mar 22, 2016• 6

By STEVE FINDLAY

flying cadeucii The Obama Administration this month released final numbers on enrollment for the 2016 coverage year in the health insurance exchanges, as well as overall statistics on coverage gains to date under the Affordable Care Act (ACA).

The numbers emerge as the ACA turns 6 years old this week—on March 23. They were also released just as House Republicans issued their proposed 2017 federal budget. That budget, once again—you guessed it—repeals the ACA. The Republican budget is a counter to the Administration’s budget proposed in February. The release of both triggers the annual bruising battle over funding of the federal government, which again this year could end in prolonged stalemate.

You could be cynical or blasé about the Republicans’ persistent mission to kill the ACA—that is, if you don’t support that mission. But I think this piece of political theater continues to warrant contempt. Why? Because even if a Republican were elected President in November, the law is now technically impossible to gut completely. And Republicans know it.

There are a host of reasons the law cannot be nixed in its entirety, and these deserve more attention and discussion, on THCB and elsewhere, at a later time. In the context of this blog, I’ll just point out the obvious: it would simply be unacceptable (and political suicide) to strip 15 to 20 million people of their coverage. In addition, realistically, any insurance scheme to replace Obamacare would very likely be structured in a similar way—through private-sector insurance companies and plans operating in a regulated marketplace for people without employer-sponsored coverage. That’s why Republicans rarely talk about alternatives to Obamacare in any detail.

ESCOs: The Value of Disease-Specific Accountable Care

Mar 22, 2016

By ALEXANDER MAINOR and MARIETOU OUAYOGODE

flying cadeucii Patients with End Stage Renal Disease (ESRD) constitute a high-cost, high-need population that can greatly benefit from targeted policy initiatives to improve care coordination. In 2010, patients with ESRD made up 1.3% of the Medicare population, but accounted for 7.5% of total Medicare spending, amounting to over $20 billion.¹ Adoption of the accountable care organization (ACO) model for ESRD has the potential to improve care coordination and patient outcomes. Due to complex health needs, patients in this population can require visits to multiple providers with multiple care plans. By bringing these providers together under the same organizational structure, accountable care provides the opportunity to improve quality through coordination. Though just over 1 million ESRD beneficiaries participated in the Pioneer ACO program, to date no direct studies have examined the effect of ACOs on management of ESRD.

What Data Won’t Tell you About Caregiving

Mar 22, 2016

By SONA MEHRING

As I entered CaringBridge through the technology door, the software engineer in me always seeks data to validate the personal experiences of patients, caregivers, family and friends sharing a health journey. So I could hardly wait to dig into the motherlode of facts and figures published in Caregiving in the United States 2015, a major report produced by AARP and the National Alliance for Caregiving.

The numbers were big, with 43.5 million Americans fitting the definition of “caregiver:”

“A person who has provided unpaid care to a relative or friend over the last 12 months that may include helping with personal needs or household chores. It might be managing a person’s finances, arranging for outside services, or visiting regularly to see how they are doing. The person receiving care does not necessarily live with the caregiver.”

Telehealth is Working in Texas. Here’s Why

Mar 21, 2016• 1

By KOFI JONES

Screen Shot 2016-03-23 at 11.14.24 AM

Over the past two years, policy makers across the nation have been actively adopting policies in support of the rapid adoption of telehealth. From states affirming that health insurance plans should appropriately cover care provided through innovative technologies, to Congress contemplating multiple proposals for telehealth expansion within Medicare – telehealth is fast becoming a permanent part of our healthcare ecosystem.

This movement has been most clearly demonstrated by state medical boards. It has been their job to answer the questions: can physicians use technology to extend the reach of their care? Can telehealth be used to create a treatment relationship, and if so, are their limitations to this relationship?

Overwhelmingly, the resounding answer to these questions has been a consistent one – yes, you can use robust telehealth technologies to provide care and the main limitation is simple – uphold the same standard of care. The Federation of State Medical Boards has upheld this concept.

But if you’ve been following this movement, you know there’s a rather large blip on the national map: Texasa state with more than 27 million residents and a clear need for increased access to care – was recently ranked “worst in telehealth” by the National Center for Policy Analysis. The good news: despite restrictive rules and a lawsuit that’s hindering progress, telehealth is working in Texas and changes, they are a coming.

The Antidote to Physician Burnout: A Nine Step Program

Mar 20, 2016• 7

By MARTIN A. SAMUELS, MD

Martin Samuels I have some strategies for preventing “physician burnout.” I am a little over 70 years old and am not experiencing any of the symptoms of “physician burnout.” I do not state this out of any sense of pride, but I have tried to be introspective about this so as to offer some advice as to how to avoid this problem.

My approach is fourfold. I shall begin by reviewing the definition of burnout, and, in particular, physician burnout. Much has been written about this recently, but in order to address the individual issues, it is important that we are using the same definitions. Secondly, I shall review some facts about the reality of American medicine. Third, I shall articulate a paradox between what seems to be an epidemic of physician burnout in the context of the reality of American medicine. Finally, I will offer a nine point set of suggestions, which are meant to help to avoid the symptoms and signs of this syndrome.

Job burnout is not a new idea, and it is not specific to medicine. It has been in the psychology/psychiatry literature for quite a long time. It may be defined as a feeling of emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.

In recent years, many have argued that “burnout” is extremely prevalent; not only in society as a whole but in particular in medicine. It has been said that 50% of physicians have at least one of the three cardinal features: exhaustion, depersonalization and inefficacy. The problem with these kinds of data is that are no adequate controls. It is probably quite common for many people, at some point or another, to experience one or more of these cardinal features. The real question is whether this is more than in a control population and whether they are persistent, rather than transient, symptoms. That information is not available. For these reasons, it is likely that the problem of “burnout” is being exaggerated. Nonetheless the problem undoubtedly does exist in an unknown proportion of physicians.

Health Insights from the Founder of Paypal

Mar 20, 2016• 4

By LYGEIA RICCIARDI

At the annual South by Southwest (SXSW) conference a wide range of industries and creative artists come together to explore transformation through interactive technology. It’s not just healthcare people talking to healthcare people!

One of my favorite presentations this year was by Max Levchin, one of the founders of Paypal. He began by challenging the audience to focus on big problems, Problems That Matter. (I’m presuming the job a guy I shared an Uber with told me about—managing the social media profile of a dog—wouldn’t qualify.)

Levchin highlighted four key trends in business and technology—waves the audience could ride to catalyze meaningful change. Though I was consciously stepping outside of the healthcare track, nearly half of Levchin’s points explicitly referenced opportunities in health and healthcare, while it was easy to draw relevant lessons from the ones that didn’t. Big trends include:

1. Beneficence (AKA “doing good”). Increasingly businesses are providing value and benefit to consumers, even at the expense of higher profit margins. For example, Levchin most recently launched Affirm, a lending service focused on millennials, that specializes in transparency: clearly telling consumers how much they are being charged for financial services. While competitors typically obfuscate their fees (often unbeknownst to consumers), Affirm is in the business of doing well by doing good.

Overoutrage and the Asymmetric Skepticism of Healthcare Journalists

Mar 20, 2016• 17

By SAURABH JHA, MD

flying cadeucii I like healthcare journalists. Some of my best friends are healthcare journalists. I’d rather read Larry Husten on clinical trials than the constipated editorials in peer review journals. Healthcare journalists are an important force against overdiagnosis, overtreatment, overprescription, overdoctoring and overmedicalization. They’re articulate and skeptical. But they seem to have a blind spot – overoutrage.

Overoutrage is excessive moral outrage. Outrage is excessive anger. Anger is excessive emotion. Emotion is excessive anti-reason. Overoutrage is the mother of all overdoing.

Overoutrage is the healthcare journalist’s kryptonite. These skeptical Rotweillers become credulous poodles when they see overoutrage. Overoutrage axiomatically assumes a moral high ground – for the transgression must have been severe for the outrage to occur. Overoutrage is circular reasoning without an exit. Overoutrage is more powerful than any randomized controlled trial. Much of healthcare policy, indeed civic life, is shaped by it.

A recent event highlights this phenomenon very well. NEJM’s national correspondent, Lisa Rosenbaum, wrote about a surgeon’s determined, and widely publicized, advocacy to ban morcellation, a procedure to treat uterine fibroids. Dr. Hooman Noorchashm’s wife, Amy Reed, underwent morcellation to treat uterine fibroids. Unbeknownst, she had uterine cancer, and the morcellation almost certainly worsened the prognosis by spreading the cancer beyond the uterus. Banning morcellation would be a no-brainer except that morcellation has fewer complications than open surgery for fibroids, and that the chances of undiscovered uterine cancer in a woman with fibroids are exceedingly rare.

How the Health Co-Ops Can Meet Their Financial Obligations

Mar 19, 2016

By WILLIAM SNYDER

flying cadeucii A congressional subcommittee held a hearing Thursday to examine the health insurance co-op loan program established by the Affordable Care Act. The program provided $2.4 billion in taxpayer-backed loans as seed money for the co-ops, which are private companies that were originally intended to bring competition, choice, and innovation to the health insurance market. In spite of this seed money, co-ops are off to a rough start. Since their inception just over two years ago, 12 of the original 23 co-ops have closed due to financial concerns. Taxpayers aren’t the only ones at risk of getting left with the tab for the co-ops.

A co-op left doctors and hospitals in Iowa and Nebraska holding over $80 million in unpaid claims when it closed. Worse still, consider that unpaid claims left behind by failed insurance companies are often allocated by state guaranty funds to the surviving insurance companies, who ultimately pass them on to consumers. One way or another, you’re likely to pay for any obligations the co-ops can’t meet. The co-ops’ leaders don’t offer much comfort, either. One co-op CEO recently offered this assessment of the co-ops’ prospects for re-paying their loans: “Will there be a little money left? Yeah, maybe.” Fortunately, the surviving co-ops have an often-overlooked asset they can tap to stay in business and meet their obligations: the recovery rights to their overpayments.

The NFL is Not Big Tobacco: Overdiagnosis and Chronic Traumatic Encephalopathy (CTE)

Mar 18, 2016• 5

By SAURABH JHA,MD

Screen Shot 2016-03-18 at 3.48.30 PM As a general rule, if you keep clobbering a body part it may, in the long run, get damaged. This is hardly rocket science. Soldiers marching long distances can get a stress fracture known as “March fracture.” The brain is no exception. Boxers can get “dementia pugilistica.” This is why we frown upon people who bang their heads against brick walls.

Footballers are at risk of brain damage, specifically a neurodegenerative disease known as chronic traumatic encephalopathy (CTE). CTE was described in a football player by forensic pathologist, Bennet Omalu, who performed an autopsy on Michael Webster, a former Pittsburgh Steeler. Webster died of a heart attack but had a rapid and mysterious cognitive decline. Webster’s brain appeared normal at first. When Omalu used a special technique, he found a protein, known as tau, in the brain.

Omalu’s discovery inspired the movie Concussion in which Will Smith plays the pathologist. The Fresh Prince plays convincingly a god-fearing, soft-spoken but brilliant physician, who is up against incredulous colleagues and the National Football League (NFL). The NFL clearly has a lot to lose from Omalu’s discovery. However, the director’s attempt to emulate The Insider, where big tobacco tailgates the scientist, fails at many levels.

More on Loneliness as a Major Health Risk Factor

Mar 18, 2016

By TOM EMERICK

flying cadeucii One of the myriad reasons wellness programs are not performing well is that all humans have about 100 risk factors, of which obesity, high blood sugar, high blood pressure, and high cholesterol are only four. If those four are in pretty good shape but the other 96 are out of whack, don’t expect good health results.

Further, putting bandages on symptoms of metabolic disease has limitations. Such bandages do not address the root causes of metabolic syndrome. According to Wikipedia:

“Root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. A factor is considered a root cause if removal thereof from the problem-fault-sequence prevents the final undesirable event from recurring; whereas a causal factor is one that affects an event’s outcome, but is not a root cause.Though removing a causal factor can benefit an outcome, it does not prevent its recurrence within certainty.” (Emphasis mine.)

One thing sorely missing from most modern wellness methods is RCA. Unless one deals with RCA in metabolic syndrome it will continue to recur.

Some other huge health risks factors are job misery, terrible marriages, very poor money handling skills, envy, general lack of contentment in life, and loneliness. Another health risk is how far you live from a “dial-911-first-responder”. Yet another is how safe your neighborhood is. I could go on and on. Worksite wellness does nothing to address the vast majority of personal health risks. My book, An Illustrated Guide to Personal Health*, elaborates on such health risks.