The Health Care Blog – Page 472 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Doctors vs. Zombies

Jul 16, 2014• 11

By ROB LAMBERTS , MD

My life changed dramatically 18 months ago when I started my new practice. The biggest change personally was a dramatic drop in my income as I built a new business using a model that is fairly new. That’s a tough thing to do with four kids, three of whom were in college last fall. OK, that’s a stupid thing to do, but my stupidity has already been well-established.

Yet even if the income stayed identical to what I earned before the switch, the change in my professional life would have been nearly as dramatic.

I am no longer focused only on patients in my office.
I am no longer focused on ICD and CPT codes.
Saving patients money has become one of my top priorities.
I feel like my patients trust me more, and see me as an ally.
Patients accept my recommendations for less care (avoiding unnecessary testing and unnecessary medications) much easier.
I focus far more on preventing problems or keeping them small.
I laugh with my patients far more.
I no longer feel like a Zombie at the end of the day (and I no longer eat brains)

Circulation: The Nineties Called. They Want Their Wellness Policy Back

Jul 15, 2014• 22

By AL LEWIS and VIK KHANNA

Last year, we soundly criticized the American Heart Association (AHA) on this blog for its proposal to lower the thresholds for treating cholesterol and getting larger numbers of Americans to swallow statins. We also exposed wellness vendor StayWell, for its mathematically impossible claims of success in British Petroleum’s wellness program. Proving that great minds aren’t the only ones that think alike, StayWell and the AHA have now joined forces. Specifically, the AHA invited the CEO of StayWell, Paul Terry, Ph.D., to help write its workplace wellness policy statement, sort of like Enron inviting Bernie Madoff to help design its financial plan. You don’t learn of this fox-in-the-henhouse conflict of interest unless you read the table on the penultimate page of text.

Naturally, Mr. Terry parlayed this windfall to StayWell’s advantage. The statement: “currently available studies indicate that employers can achieve a positive ROI through wellness” is footnoted to two studies authored by: Paul Terry, along with other Staywell executives. One wonders how a StayWell executive writing policy for the AHA based partly on StayWell’s own articles passes the AHA’s own test of “making every effort to avoid actual or potential conflicts of interest that may arise as a result of an outside relationship.”

How did this conflict of interest get by the peer reviewers? Look at the list of peer reviewers. Prominent among them is Ron Goetzel. Readers of THCB may recall Mr. Goetzel not just from his central role in the Penn State debacle, but also from the ”The Strange Case of the C. Everett Koop Award,” in which it was documented that his committee gave the ironically named award to a sponsor of the award (without disclosing that conflict), even though that sponsor had admitted lying about saving the lives of 514 cancer victims, who, as luck would have it, didn’t have cancer. (The sponsor, Health Fitness Corporation, a division of the equally ironically named Trustmark, has won the Koop award several times, thus proving the cost-effectiveness of their sponsorship.)

If this litany were not enough to dismiss the policy statement forthwith, there is small matter of the actual policy itself, a full employment act for wellness vendors and cardiologists alike, advocating more screening of more employees more often, while ignoring more self-evident facts than Sergeant Schultz. Specifically, they cherry-picked the available literature, continuing to cite the old “Harvard study” whose lead author has now walked it back three times. Except that they didn’t call it the “old Harvard study,” but rather a “recent [italics ours] meta-analysis,” despite the fact it was submitted for publication in 2009, and the average year of the analyses in the study was 2004. Some studies began in the 1990s and were able to use sleight-of-hand to “show savings” despite presumably — in accordance with the conventional wisdom of the era — getting people to eat more carbohydrates and less fat. No wonder Soeren Mattke of RAND Corporation dismissed the Harvard data as archaic in his interview with CoHealth radio in February 2014.

EMR Data Shows Medicaid Gap Widening Between Expansion and Non-Expansion States

Jul 14, 2014• 12

By IYUE SUNG and JOSH GRAY

In measuring the effects of health insurance coverage expansion as part of our ACAView initiative with Robert Wood Johnson Foundation (RWJF), an important factor to consider is state policy towards Medicaid expansion.

The intention of the Affordable Care Act (ACA) was to expand coverage through two mechanisms: 1) People with moderate incomes could gain coverage through the exchanges, often encouraged by subsidies; and 2) those with lower incomes could gain coverage through an expansion of Medicaid eligibility to include groups that had not traditionally qualified for Medicaid.

For many years, states had widely varying Medicaid eligibility rules, with some states covering only women and their children in need of public aid and low-income people with disabilities. Other states had expanded eligibility to include people at income levels higher than the federal poverty level.

Given the differing Medicaid expansion decisions among states, we examined our data on visits to primary care physicians (PCPs) separately for states with and without Medicaid expansion.

Figure 1 shows proportions of visits between January 2012 and May 2014 for four groups of adults (18-64): uninsured individuals in Medicaid-expansion states; uninsured individuals in non-Medicaid expansion states; Medicaid beneficiaries in expansion states; and Medicaid beneficiaries in non-expansion states.

Two observations are worth noting:

ACA coverage expansion appears to be widening a pre-existing gap between states that have elected to pursue Medicaid expansion and those that have not. Providers in the Medicaid-expansion states were already seeing higher proportions of Medicaid beneficiaries in 2013. For example, in December of 2013, 12.3% of 18-64 year- old visits to PCPs in expansion states were from Medicaid beneficiaries, compared with 5.9% in non-expansions states, a 6.4 percentage point differential. By May 2013, that difference had expanded to a 9.3 percentage point differential, as the percent of Medicaid visits increased in Medicaid expansion states but held constant in non-expansion states.
The proportion of uninsured fell in both categories, from 4.5% to 3.3% in expansion states and 7.0% to 5.8% in non-expansion states (figures for January through May for both years, respectively).

Screen Shot 2014-07-14 at 5.08.56 PM

Figure 2 expands the Medicaid payer mix analysis to other specialties.

In Medicaid expansion states, all four specialty types showed a substantial increase in the proportion of visits by Medicaid beneficiaries. In contrast, in non-Medicaid expansion states, the proportion of visits by Medicaid beneficiaries decreased for all four specialty groups.

As a result of these changes, by early 2014 PCPs, surgeons, and other specialists in expansion states saw two to three times more adult Medicaid patients (in proportional terms) than in non-expansion states (for example, 15.6% versus 6.3% for PCPs; 11.6% versus 3.1% for surgeons).

For OB-GYN, the ratio between the proportion of visits by Medicaid beneficiaries in the expansion and non-expansion states is much smaller, 19.4% versus 13.4%. This may reflect more generous Medicaid eligibility in non-expansion states for pregnant women compared to other adults.

As we monitor these metrics, a few questions will be of particular interest:

Where will the increase in Medicaid volumes in expansion states level off?
To what extent is the increase in Medicaid visits driven by established patients who were previously uninsured?
What are the effects of increased Medicaid volumes on medical practices?

We will attempt to address these (and other) complex issues throughout the year.

For a better understanding of our goals, methodology, data sample size, and full findings since the inception of the ACAView series, please read our first report, “First Observations Around the Affordable Care Act.”

The Misuse of Meaningful Use, Part II

Jul 13, 2014• 27

By HAYWARD ZWERLING, MD

As a result of the determined efforts by Massachusett’s politicians, businesses, health insurance companies, hospitals, individual physicians and the Massachusetts Medical Society, nearly 100% of patients in Massachusetts now have health insurance. This is something all the healthcare players in Massachusetts can be proud of, and “universal insurance” enjoys broad public support here in Massachusetts

In an attempt to improve healthcare quality and reduce cost, Massachusetts is moving away from the “fee-for-service” system and replacing it with “physician groups” which contract with insurance companies. Most of these contracts include financial incentive/disincentive clauses about “quality” and “cost.” As a result, in Massachusetts, it is now almost impossible for a solo practitioner to obtain a contract directly with one of the state’s largest insurance companies. Almost all contracts are mediated through a local physician organization, such as an IPA, PHO or ACO.

As a result, health insurance companies now have much greater influence over the Massachusetts healthcare industry. These large insurance companies define the terms of the contract and can tell the small or medium-sized hospitals/physician contracting group their contract is a “take it or leave it” proposition. Needless to say, it is impossible for any small or medium-sized hospital/physician contracting group to refuse to accept the insurance contract when their financial viability is predicated on having access to the insurance company’s patient panel.

Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.

There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value.

Recently, The Office of the National Coordinator for Health Information Technology (HHS) asked the RAND corporation to review all EMR data. RAND created the “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities”

Can Amazon Dominate In Insurance, Too?

Jul 13, 2014

By Sathyanarayanan Sethuraman

In January 2013, LIMRA reported that 90% of industry executives it had surveyed believe that insurance companies will continue to form strategic alliances with “non-traditional organizations” to expand distribution. The example cited was MetLife’s trial alliance with 200 Wal-Mart stores. Then Accenture’s “Customer-Driven Innovation Survey” found that more than two-thirds of customers would consider purchasing home, auto and life insurance from businesses other than insurers—23% were open to purchasing from online service providers like Amazon or Google (which acquired auto insurance aggregator BeatThatQuote.com way back in 2011 in the UK).

Amazon has proven leadership as an e-commerce distributor, while Google is seen primarily as an information organization, so I would like to elaborate exclusively on the compelling reasons for insurers and Amazon to create a distribution model to match ever-evolving customer demands.

Customer demands

Every information source and every analyst report on insurance in the recent past points to changes in customer’s preferences. Generation X, Generation Y and Millennials prefer doing business with companies that provide:

Convenience of on-demand buying and self-service, predominantly through digital channels such as web and mobile.
Personalization of product and service delivery, including helping the customer choose the right product.
Building trust through transparency in pricing, simplified products and clear articulation of benefits.

So, insurers must innovate in personalizing products, providing transparency in the value of products and services and demonstrating excellence in on-demand distribution. Innovation must also touch “moments of truth” such as claims and policy changes. It is also critical that the distribution lifecycle should be an iterative process to consistently review the value of benefits and help customers fine tune the products and services they purchase.

Missing the Forest For the Granularity

Jul 11, 2014• 42

By NORTIN HADLER, MD

European health care systems are already awash in “big data.” The United States is rushing to catch up, although clumsily thanks to the need to corral a century’s worth of heterogeneity. To avoid confounding the chaos further, the United States is postponing the adoption of the ICD-10 classification system. Hence, it will be some time before American “big data” can be put to the task of defining accuracy, costs and effectiveness of individual tests and treatments with the exquisite analytics that are already being employed in Europe. From my perspective as a clinician and clinical educator, of all the many failings of the American “health care” system, the ability to massage “big data” in this fashion is least pressing. I am no Luddite – but I am cautious if not skeptical when “big data” intrudes into the patient-doctor relationship.

The driver for all this is the notion that “health care” can be brought to heel with a “systems approach.”

This was first advocated by Lucien Leape in the context of patient safety and reiterated in “To Err is Human,” the influential document published by the National Academies Press in 2000. This is an approach that borrows heavily from the work of W. Edwards Deming and later Bill Smith. Deming (1900-1993) was an engineer who earned a PhD in physics at Yale. The aftermath of World War II found him on General Douglas MacArthur’s staff offering lessons in statistical process control to Japanese business leaders. He continued to do so as a consultant for much of his later life and is considered the genius behind the Japanese industrial resurgence. The principal underlying Deming’s approach is that focusing on quality increases productivity and thereby reduces cost; focusing on cost does the opposite. Bill Smith was also an engineer who honed this approach for Motorola Corporation with a methodology he introduced in 1987. The principal of Smith’s “six sigma” approach is that all aspects of production, even output, could be reduced to quantifiable data allowing the manufacturer to have complete control of the process. Such control allows for collective effort and teamwork to achieve the quality goals. These landmark achievements in industrial engineering have been widely adopted in industry having been championed by giants such as Jack Welch of GE. No doubt they can result in improvement in the quality and profitability of myriad products from jet engines to cell phones. Every product is the same, every product well designed and built, and every product profitable.

Microsoft Ventures Tel Aviv Is Looking For Startups

Jul 11, 2014

By Paul Ehrlich, M.D., Scott Boyle, and Hanan Lavy

In the past century, medicine has gone from a largely unscientific trade where noxious drugs were given to patients to purge them of unknown toxins to a science where we have the technology to decode the human genome and peer into the deepest recesses of our anatomy non-invasively. We have learned so much and generated massive amounts of data relevant to the understanding and care of the human body.

Globally, we spend enormous sums on healthcare, but we are not necessarily getting any healthier. In 2012, U.S. healthcare spending was $2.8 trillion, or roughly 18% of GDP[1]. Compare this with the global average of 10.2%, the EU at 10.1% or The Netherlands, the developed country with the second highest per capita spending of 12.4%. Despite the scientific advances and extraordinary spending, access to the best, most effective care is far from ubiquitous.

Healthcare, like any other industry, is driven by motivators. While government and regulatory pressures drive many behaviors in medicine, financial considerations are also important drivers When healthcare reimbursement works on a fee-for-service system in which providers are compensated for each service they provide, the incentives do not necessarily promote the most efficient and cost-effective options. Rather, the incentives encourage the delivery of “more” healthcare. But we don’t necessarily need “more” – we need “smarter.” More adds costs. Smarter solves problems.

The Cost-Response Curve

Jul 11, 2014• 9

By LEONARD KISH and KEVIN O’BRIEN, MD

“Drugs don’t work in people who don’t take them.” C. Everett Koop, former US Surgeon General

Cost-based non-adherence, like any lack of medication adherence, leads to further complications and hospitalizations that could have been prevented. CMS appears to have recognized this when they announced that a new ACO measures on whether “providers have educated patients about the cost of medications” in the 2015 fee schedule. Cost and quality conversations between doctors and patients are becoming a cornerstone to value-based care.

The most expensive drugs are the ones that the patient never takes. Nearly one third of prescriptions go unfilled. When patients cannot afford a medication, and only discover the price or out-of-pocket cost at the prescription counter, it’s a big risk to long-term outcomes.

“It has been well established that a lack of affordability can drive a lack of adherence to a course of medications. Patients who do not take their medications cost the U.S. healthcare system an estimated $300 billion in avoidable medical spending annually due to poorer health, more frequent hospitalizations and a higher risk of mortality”, according to The Center for Health Value Innovation and the Network for Health Value in Innovation.

A lack of medication adherence drives further costs for the system and suffering for patients. Estimates are that more than a third of medicine-related hospitalizations happen because people did not take medicine as directed, leading to over 125,000 deaths.

Medication non-adherence, of course, can have many reasons: side effects, difficulty in administering the drug, and others, but there is clear evidence that cost is a factor driving non-adherence. 27% of Americans did not fulfill a prescription due to financial hardship in 2012 according to a Kaiser Family Survey. As copays, deductibles and out-of-pocket expenses go up, so, likely, will non-adherence, and value-based care, and value-based benefits must understand the costs related to non-adherence.

Healthcare Reform Even the Tea Party Could Support

Jul 9, 2014• 56

By BLAKE ASHBY

The Affordable Care Act (ACA) is the law of the land, and nothing the Tea Party does is likely to lead to its repeal. But the ACA can be amended to make it less objectionable, and it wouldn’t be that hard. We just need to modify it to allow Tea Partiers (and others) to form their own healthcare groups.

All insurance, including healthcare insurance, works by forming risk pools. The members of the pool contribute to a pool of money which is then used to pay the claims by the members. Most participants pay in more than they use. In healthcare most people pay more money into the pool than the cost of the care they receive. A few people receive far more care than they pay for.

For risk pools to work, boundaries have to be drawn around what is paid for by the risk pool. As an example car insurance policies place a limit on how much they will pay for any one accident. It’s nice to think that as a rich country we don’t have to draw boundaries around healthcare, that we should be able to pay for any possible medical treatment, but we can’t. We already spend almost twice as much on healthcare as other nations and if costs keep increasing eventually it will bankrupt our country.

Many people blame private insurance companies for our expensive healthcare system, but insurers actually have very little to do with rising costs. Instead advancing medical technology is the primary cause. Our for-profit medical technology industry has made amazing advances in treatment and care that have allowed us to save people that used to die. But its primary goal is still profit. Every year the industry comes up with new procedures or refinements. Most provide only incremental improvements in care but they all come with a higher price tag. Every year the industry spends billions of dollars – yes, billions – successfully encouraging doctors to recommend the new procedures. And it’s about to get much, much worse. There is a flood of new treatments and targeted drugs getting ready to hit the market. Some will undoubtedly be true advances, but all are likely to cost tens and even hundreds of thousands of dollars per treatment.

Google Co-Founders: “Thanks, But No Thanks”

Jul 8, 2014• 13

By DAVID SHAYWITZ, MD

At his yearly CEO summit, noted VC Vinod Khosla spoke with Google co-founders Sergey Brin and Larry Page (file under “King, Good To Be The”).

Towards the end of a wide-ranging conversation that encompassed driverless cars, flying wind turbines, and high-altitude balloons providing internet access, Khosla began to ask about health.

Specifically, Khosla wondered whether they could “imagine Google becoming a health company? Maybe a larger business than the search business or the media business?”

Their response, surprisingly, was basically, “no.” While glucose-sensing contact lenses might be “very cool,” in the words of Larry Page, Brin notes that,

“Generally, health is just so heavily regulated. It’s just a painful business to be in. It’s just not necessarily how I want to spend my time. Even though we do have some health projects, and we’ll be doing that to a certain extent. But I think the regulatory burden in the U.S. is so high that think it would dissuade a lot of entrepreneurs.”

Adds Page,

“We have Calico, obviously, we did that with Art Levinson, which is pretty independent effort. Focuses on health and longevity. I’m really excited about that. I am really excited about the possibility of data also, to improve health. But that’s– I think what Sergey’s saying, it’s so heavily regulated. It’s a difficult area. I can give you an example. Imagine you had the ability to search people’s medical records in the U.S.. Any medical researcher can do it. Maybe they have the names removed. Maybe when the medical researcher searches your data, you get to see which researcher searched it and why. I imagine that would save 10,000 lives in the first year. Just that. That’s almost impossible to do because of HIPAA. I do worry that we regulate ourselves out of some really great possibilities that are certainly on the data-mining end.”

Khosla then asked a question about a use case involving one of my favorite portfolio companies of his, Ginger.io, related to the monitoring of a patient’s psychiatric state.

Responded Page, “I was talking to them about that last night. It was cool.”

That pretty much captures Brin and Page’s view of healthcare – fun to work on a few “cool” projects, but beyond that, the regulatory challenges are just too great to warrant serious investment.