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Above the Fold

Liberty Mutual: A Blow to Health Care Transparency

Mar 4, 2016

By CHARLES ORNSTEIN

Charles Ornstein The U.S. Supreme Court dealt a blow this week to nascent efforts to track the quality and cost of health care, ruling that a 1974 law precludes states from requiring that every health care claim involving their residents be submitted to a massive database.

The arguments were arcane, but the effect is clear: We’re a long way off from having a true picture of the country’s health care spending, especially differences in the way hospitals treat patients and doctors practice medicine.

It also means that, for the time being at least, we’ll remain heavily reliant on data being released by Medicare, the federal health insurance program for the elderly and disabled, to study variations in health care. ProPublica has used Medicare data to study differences in medication prescribing, surgeons’ complication rates and use of services by doctors, but it’s still not clear that Medicare is representative of all health care in the country.

The court’s decision involves a case from Vermont, one of 18 states that created so-called all-payer claims databases. Vermont’s law called for health insurers, health providers, medical facilities and government agencies to report data on health care costs, prices, quality and use of services to the state. That included employers who pay the costs of their workers’ treatments themselves, and not through an insurance contract. (Self insurance is common for large companies.)

But Liberty Mutual Insurance Co. objected, saying the Employee Retirement Income Security Act of 1974, or ERISA, prevents states from imposing such a requirement on self-funded plans. The idea is that companies that have operations across the country shouldn’t be subjected to 50 different state laws, but instead should only have to abide by rules from one agency, namely the U.S. Department of Labor.

Mr.Trump’s Proposal for the Sale of Health Insurance Across State Lines

Mar 3, 2016• 6

By JIM PURCELL

Donald Trump’s website has a position paper entitled “Healthcare Reform To Make America Great Again.” And some of his suggested reforms make sense. However, the question of the moment involves Item 2:

“Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.”

This is not by any means a new proposal. Despite being supported by most Republican Presidential candidates, it has lingered around for decades without going anywhere. And for good reason.

The driving argument is that this would permit increased competition amongst insurers which would lower premiums. While it is true that competition might increase, it is highly doubtful that the result would be lower premiums, and there are considerable consumer protection concerns as well.

Homo Ex Machina

Mar 3, 2016

By ASIF DHAR, MD

flying cadeucii ‘Temet Nosce’ or know thyself.

This is what The Oracle tells Neo when they first meet in The Matrix. Who we are and how we learn is a combination of our biology and our personal experiences. The plasticity of our minds and our genes make us individual persons in the world. Our individual mind and experiences are hard to offset. Sometimes we make decisions counter to our long-term wants because the wiring of our minds and our conditioned responses. Often it seems as if we are a slave to our desires and incapable of realizing our long-term goals. Would knowing myself better help me make better decisions?

Let me give you an example. As someone who has struggled with my weight, I would like nothing more than to make only healthy, evidence-based decisions when it comes to diet and exercise. But sometimes I don’t. A few months ago, I decided I needed to tip the scales in my battle against my desires. I downloaded a weight loss app, started counting steps and continued a lifelong practice of mindfulness, all in an effort to override those short-term desires and work toward my long-term goals. And I, like Oprah, lost 26 pounds over several months (both of us eating bread)!

Most of us struggle in one way or another with some sort of addiction, desire, impulse or emotion — by just being human — and understand all too well what it means to be enslaved to the biological machine. The awesome thing is now we seem to have digital tools to help set us free.

While walking (miles according to fitness tracker) at the HIMSS16 conference, something dawned on me. Many of the enterprise health IT software solutions that I saw at the conference and have spent most of my professional life with would do little to help me with obesity and to prevent me from developing diabetes. They are very helpful if I end up sick in a hospital but have little to do with preventing me from getting there. The consumer-centric technology counting my steps or my mobile solution helping me become aware of what I am eating might just do it.

The Meme-ifcation of Health Care

Mar 3, 2016• 18

By YEVGENIY FEYMAN

flying cadeucii Why can’t we have nice things? As a self-anointed health policy wonk, I find myself asking this question many times. It seems that every potentially transformative (to use a tired cliché) health care trend must eventually go through a process I’ll call “meme-ification.” And I’ll preface by saying that this applies across the political spectrum.

Take the hobby horse of many progressive reformers – single payer. If you’ve spent any time immersed in health care policy, you’ve probably heard it all: every other advanced country does it, insurance companies (and profits) are evil, health care can’t be a for-profit (evil) industry etcetera.

Of course, if you’ve spent any time immersed in health care policy you probably also understand that attempting to extrapolate lessons from the U.K. (relatively homogeneous, over 250 people per square kilometer, and about 1 homicide per 100,000) to the U.S. (about as diverse as you can imagine, about 35 people per square kilometer, and nearly five homicides per 100,000) is at best, an uphill battle.

What Trump’s Plan to Negotiate With Pharma Should Tell Us

Mar 3, 2016• 9

By JK WALL

Screen Shot 2016-01-31 at 3.58.55 PM

Donald Trump’s proposal to allow the federal Medicare program to negotiate prices with drug companies should be a wake-up call for the pharmaceutical industry.

Trump is leading in the polls for the Republican nomination and is even drawing the support of Tea Party conservatives who, just a year or two ago, never would have supported a candidate endorsing such strong government intervention into a private-sector industry.

Characteristically, Trump didn’t give a lot of detail about his plans. He claimed $300 billion in savings per year (about 10 times more than is realistic). But that doesn’t matter. If the leading GOP presidential candidate—a man who has proved masterful at reading the public mood and playing to it—has signed on to this idea, it proves that change has come.

I know that many veterans of the pharmaceutical industry think they have seen this horror movie before and know how it ends. There have been several past public furors over the price of prescription drugs, and each one gradually faded without major disruption for drugmakers. But this time feels different.

Not Quite DOA: Why Reports of the Demise of the President’s Budget May be Exaggerated

Mar 2, 2016

By CECI CONNOLLY

Ceci Connolly Anyone who has spent a few years in Washington knows the federal budget dance: President stands behind podium with a fancy seal and flags and unveils a giant tome. The next morning newspapers declare the tome DOA, Dead on Arrival. And we all return to regularly scheduled programming.

This year was no exception. Even the White House seemed to acknowledge the fact by releasing the 182-page blueprint on the same day as the Iowa caucuses with Donald Trump, Bernie Sanders and Ted Cruz grabbing the headlines.

But budget nuggets have a way of seeping into the policy fabric and eventually taking hold. Legislative staff scrub the document for ideas, not to mention numbers. Candidates steal liberally, adding favorites to their rhetorical arsenal. Eventually, some of those candidates become lawmakers, cabinet secretaries and even president. So the ideas live on.

Happily, President Obama chose his final budget proposal to draw attention to the inexplicable, indefensible rise in drug prices in this country. Our nonprofit, provider-sponsored plans know better than most the clinical value of so many of today’s medications. At ACHP, we have the privilege of partnering with organizations that are in pursuit of the 4Rs – the Right patients receive the Right treatments at the Right time for the Right price. From Capital Health Plan’s Center for Chronic Care, which reduces health costs for the entire community by providing concierge-type care for the sickest one percent of Capital members, to Group Health Cooperative of South Central Wisconsin’s pioneering initiative embedding pharmacists in primary care clinics to track patients who may need additional treatment management, ACHP members are working to ensure patients always receive the medications they need.

Omar Hussein, CEO Imprivata

Mar 2, 2016

By MATTHEW HOLT

This is the first of a series of interviews I’m doing at the behemoth HIMSS conference. They will hopefully give you a quick overview of the companies, and give you a sense of where the system is going.

First up, grabbed in the corridor is a quick interview with Omar Hussain, CEO of widely used data security company Imprivata. (They incidentally had a rocking party last night, and in case you were wondering this interview was filmed before not at the party!)

https://youtu.be/DX5JJHjZvfM

EMR Data show: The ACA has Improved Access to Care for Low-Income Patients

Mar 2, 2016

By JOSH GRAY

As Barack Obama’s presidency draws to a close, we anticipate growing discussion of his legacy. Much of that discussion will focus on the Affordable Care Act (ACA), his signature legislative accomplishment. The legislation is complex and in some cases ineffective and cumbersome. It can be argued, for example, that the complexity of the ACA favors the same high-cost, legacy health care players that the bill was designed to address.

But one of the major goals of the ACA was to provide more accessible, more dignified, and more effective health care to the poor. And in this respect, we believe that the Affordable Care Act – at least in those states that have elected to expand Medicaid – has been a success.

Our perspective on health care reform comes from ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth to study the impact of health care reform. We have just released our latest report, The Effects of the Affordable Care Act through 2015, which focuses on the impacts of insurance coverage expansion for patients and providers, with an emphasis on primary care. This report analyzes data from 21,900 health care providers on athenahealth’s network for at least five years. These physicians, who serve communities across the nation, are broadly representative of the country as a whole (please refer to the Appendix of the latest report). This allows us to compare physician practice before and after the coverage expansion provisions went into effect in 2014.

In June 2012, the Supreme Court ruled in “National Federation of Independent Business (NFIB) v. Sebelius” that states could choose whether or not to expand Medicaid eligibility. Although the federal government would cover the full cost of coverage expansion through 2016 and gradually decreasing to 90 percent of it thereafter, about half of the states declined to provide expanded Medicaid access to low income people. Since that time, six of those states have changed course and made Medicaid available to more of their residents.

In those states that agreed to loosen Medicaid eligibility requirements, there was no guarantee that the law would improve health care access for low income people. Because Medicaid payment levels are much lower than commercial rates, some observers were concerned that physicians would not open their schedules to see more Medicaid patients. And when patients did come in for care, no one knew whether they would form ongoing relationships with physicians or merely receive one-off care for acute or symptomatic issues.

Building Virtual Kaisers: Transcending Healthcare’s Tower of Babel

Mar 1, 2016

By GARY MENDOZA

The Tower of Babel Twenty years ago this month, California created an organizational architecture for integrated delivery systems taking global capitation—the restricted Knox-Keene (RKK) license.

At its creation, I envisioned the RKK as a pathway to virtual Kaisers.

This post distills the RKK’s guideposts for provider organizations on that pathway.

It also summarizes a straightforward path to transcend the biggest barrier to fluid, integrated care—healthcare’s Tower of Babel.

Organizational architecture for full risk. Many provider organizations do a very good job delivering patient care; very few have the systems or experience to effectively administer benefit arrangements.

Taking full risk for patient care requires both.

RKK provider organizations meet all Knox-Keene standards governing the provision of healthcare services, including requirements to provide continuity of care, assure timely access to healthcare services and separate medical decisions from fiscal management.

Without a strong financial footing, provider systems taking full risk put their patients at risk for care disruptions. RKK licensees must maintain a minimum net worth and assure that incurred-but-not-reported claims are reflected in the organization’s books and records.

Licensees also need grievance systems to address patient and non-contracting provider complaints.