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Above the Fold

Washington Post Reports Thousands Waiting On Healthcare.gov Appeals

Feb 2, 2014• 11

By THCBist

More bad news on Healthcare.gov. This from Sunday’s WaPo:

“Tens of thousands of people who discovered that HealthCare.gov made mistakes as they were signing up for a health plan are confronting a new roadblock: The government cannot yet fix the errors. Roughly 22,000 Americans have filed appeals with the government to try to get mistakes corrected, according to internal government data obtained by The Washington Post. They contend that the computer system for the new federal online marketplace charged them too much for health insurance, steered them into the wrong.” insurance program or denied them coverage entirely …”

Not good. The newspaper reports that consumers who call the 1-800 help line “are (being) told that HealthCare.gov’s computer system is not yet allowing federal workers to go into enrollment records and change them, according to individuals inside and outside the government who are familiar with the situation.”

Go read the whole thing.

Why Your A-fib Diagnosis May Not Be as Bad as You Think It Is

Feb 1, 2014• 17

By NORTIN HADLER, MD

With breathtaking speed, atrial fibrillation has gone from “Huh?” to parlance.

“A-fib”, a common cardiac cause of palpitations, is now in the front ranks of evils lurking to smite our well-being. There is no mystery to this transformation. In 2013, the Food and Drug Administration licensed three new drugs to prevent a stroke, the fearful complication of A-fib: apixaban (Eliquis), rivaroxaban (Xarelto) and dibatigatran (Pradaxa).

This unleashed the full might of pharmaceutical marketing: the scientific data for efficacy that convinced the FDA is tortured till it convinced “thought leaders” whose opinions convinced influential journalists. Sales pitches populate print, broadcast and social media. A-fib is now more than a worrisome disease; it is a product line.

Nonetheless, A-fib can be scary for those afflicted. There are lots of choices to make and a lot of confusing, conflictual and counter-intuitive advice to deal with. Troubled by this situation, Mr. X recently sought me out to have a dialogue about his situation.

Mr. X is a 70-year-old business executive who has enjoyed robust good health and is on no prescription drugs. He exercises vigorously and is a consumer of various over the counter treatments purveyed as salutary. Like many “health-wise” Americans, he also takes 80mg of aspirin a day unaware that the benefit is minimal at best and is counterbalanced by a similar magnitude of risk.

A month earlier he had the sudden onset of palpitations, a fluttering in his chest that made him exceedingly anxious and somewhat breathless. He waited an hour before asking his wife to drive him to the local emergency room. By the time he was first seen, another hour passed. The diagnosis of A-fib followed. Another hour passed to find the consulting cardiologists debating whether to convert the A-fib to a normal rhythm by using drugs or an electrical shock.

Before they could decide, Mr X’s heart decided to behave again; he was back in a normal rhythm. It was a frightening experience for Mr. and Mrs. X. He left the ED shaken and shaky.

He also left with a follow-up appointment with a cardiologist who specialized in rhythm disorders and a prescription for a drug that slowed the conduction of electrical impulses initiating in one heart chamber, the right atrium, and traversing the heart. The normal “pacemaker” is a specialized cluster of muscle cells in the right atrium that discharges at regular intervals, initiating a current that causes the heart to contract in the synchronized fashion termed Normal Sinus Rhythm.

In A-fib, for reasons that are poorly understood, multiple pacemakers form in the right atrium leading to chaotic discharging and circular currents in the right atrium. How many of these impulses manage to exit the atrium to traverse the heart depends on the capacity of the conducting tissues; most just stay confined to the atrium causing it to quiver ineffectively.

After Months of Thought Senate Republicans Propose Obamacare Lite

Jan 31, 2014• 2

By Roger Collier

No-one can say any longer that Senate Republicans are entirely deaf to calls to describe how they would replace the much maligned Affordable Care Act.

This week, three senior GOP senators (Orrin Hatch, Tom Coburn, and Richard Burr) announced their proposed Patient Choice, Affordability, Responsibility, and Empowerment (or Patient CARE) Act. Given that each of this group is a heavyweight mainstream Republican and that Senator Coburn is one of the few physicians in the Congress, the draft Act deserves a serious look.

Although the first part of the draft would repeal the ACA, other parts would continue a number of the ACA’s reforms while introducing some changes in attempts to control costs and reduce the numbers of uninsured, creating a kind of Obamacare Lite.

The draft proposes to continue the ACA’s ban on lifetime insurance caps, its coverage of dependents up to the age of 26, and the ACA’s savings in Medicare costs. It also continues, although in a weaker form, the ACA’s subsidies for low-income individuals and the ban on medical underwriting, and allows states to continue to operate insurance exchanges (although without any federal funding).

On the other hand, the three parts of the ACA that have taken the most heat from Republicans – the individual mandate, the Medicare IPAB, and the expansion of Medicaid eligibility – would all be eliminated.

Building for Providers? Proceed with Caution

Jan 31, 2014

By Kim Krueger

"Provider" modeling Google Glass circa 1991

There was a moment, ever so brief, where Google Glass seemed like nothing more than a glorified headband. Admit it. You too saw early users matching their Glass color to their shoes. And if you didn’t, I saw two, which is two too many for the both of us. How Google Glass was going to make a significant impact on the world of Health 2.0 was beyond me until I brushed up on my nineties pop culture with a little help from the boss.

More than twenty years ago, “Terminator 2” had a Google Glass prototype for providers. Of course their “provider” was one extremely fit future “governator” who answers to Arnold, but the glasses were perfect for modern day health care professionals. They were equipped with automatic identification of surroundings, facial recognition, and decision support. In a nutshell, that’s all providers really need, right?

It definitely sounds like the “ideal information system” that Dr. Prentice Tom, Chief Medical Officer of CEP America, described at the Second Annual Silicon Valley Innovation and Technology Summit (hosted by the Northern California HIMSS chapter). His wish list for the perfect piece of tech demanded that it be mobile, have voice recognition, NLP, push relevant information, increase efficiency, and facilitate action and communication over documentation. Problem solved? Not so fast.

The program at the Innovation Summit featured two provider keynotes and two provider-filled panels, which naturally raised some key points surrounding provider and systemic adoption of Health 2.0 technologies. First, thanks to Dr. Tom’s early reference to Google Glass – he did have a giant picture of it onscreen as he described his ideal information system – the event left the distinct impression that providers want Google Glass. No other providers directly referenced Glass, but it became an implied solution for every problem raised thereafter.

Matthew Holt Interviews PlushCare Founder Ryan McQuaid

Jan 31, 2014• 2

By KIM KUEGER

[youtube]http://www.youtube.com/watch?v=HFqF0T1mYPQ#action=share[/youtube]

Ryan McQuaid, former Head of Product for AT&T mHealth and friend of Health 2.0, joined Matthew Holt to discuss the launch of his brand new startup PlushCare. And when we say brand new, we mean as of writing this post, their Indiegogo campaign is a mere 23 hours old. PlushCare combines elements of telehealth and concierge medicine to provide basic health care via phone, email, and video chat for $10 per month. Busy working professionals can use the service to connect with Stanford MDs for same-day diagnosis and treatment of illnesses or injuries. The physicians provide advice, prescribe medicine, and will refer directly to primary care providers and specialists if necessary.

PlushCare removes the hassle of scheduling an in-person doctor visit, and provides the same care at lower costs. In addition, for each individual that purchases PlushCare, the company provides one child a lifetime of immunity to measles. PlushCare is currently accepting a limited number of members via their Indiegogo campaign to validate demand and user test. Several other companies are using a similar model of tech-enabled services, including American Well and Teladoc, but the space is sure to see more activity at the prospect of pushing basic care out of the doctor’s office in a way that is convenient for consumers and increases provider efficiency.

How Clinical Guidelines Can Fail Both Doctors and Patients

Jan 30, 2014• 25

By Robert McNutt, MD & Nortin Hadler, MD

Any confusion over the recent news of cholesterol guidelines in the U.S. is perfectly understandable. On the one hand, the guidelines suggest that nearly half the population should use statins to stave off heart attacks and strokes. On the other, use of the drugs is not with potential side effects and, to many, will offer no substantive benefits. The controversy highlights a problem mired in an outdated way of thinking about health care and the doctor-patient relationship.

Guidelines came about after generations of physicians wanted to bring something more than “opinion and experience” to the patient’s bedside. In the late 1960s legislation for the U.S. Food and Drug Administration was amended to call for a demonstration of efficacy and an assessment of benefits and risk as prerequisite to the licensing of any pharmaceutical. Modern clinical science resulted, first slowly and now with an avalanche of clinical trials, each pouring forth outcome data galore.

The Burden of Clinical Data

Clinicians are expected to stay current with this wealth of information. The modern medical curriculum instructs all budding physicians on how to evaluate the quality and the clinical relevance of all such contributions to the body of clinical science. Because some (or perhaps many) find this exercise overwhelming, there are organizations—many academic and some without any discernible relationships with purveyors that could pose a conflict of interest—that attempt to bundle the information in a fashion that might be relevant to particular physicians or physicians in particular specialties. Some of this bundling is quite systematic, some quite helter-skelter.

Occasionally there is a contribution to the literature that offers an unequivocal advantage for a particular patient group. More often, the bundlers are faced with a heterogeneous literature that often demonstrates little, if any, efficacy. Faced with these circumstances, biostatistics has offered up many a method to impute more value to the literature than is apparent at first blush. The result is that all this bundling adds to an enormous and ever-expanding secondary literature.

What is the clinician to do?

Why Transparency Doesn’t Work.

Jan 30, 2014• 16

By Alexander Chaitoff

The Cleveland Clinic is by far the best provider of cardiac care in the nation. If you have cancer there is no better place to be than Texas. Johns Hopkins is the greatest hospital in the America.

Why? Because US News and World Report suggests as much in its hospital rankings.

But which doctors at the Cleveland Clinic have the highest success rates in aortic valve repair surgeries? What are the standardized mortality rates due to cancer at University of Texas MD Anderson Cancer Center? Why exactly is Johns Hopkins the best?

We don’t have answers to these types of questions because in the United States, unlike in the United Kingdom, data is not readily available to healthcare consumers.

The truth is, the rankings with which most patients are familiar provide users with little. Instead, hospitals are evaluated largely by “reputation” while details that would actually be useful to patients seeking to maximize their healthcare experiences are omitted.

Of course, the lack of data available about US healthcare is not US News and World Report’s fault – it is indicative of a much larger issue. Lacking a centralized healthcare system, patients, news sources, and policy makers are left without the information necessary for proper decision-making.

While the United Kingdom’s National Health Service may have its own issues, one benefit of a system overseen by a single governmental entity is proper data gathering and reporting. If you’re a patient in the United Kingdom, you can look up everything from waiting times for both diagnostic procedures and referral-to-treatment all the way to mortality and outcome data by individual physician.

This is juxtaposed to the US healthcare system, where the best sources of data rely on voluntary reporting of information from one private entity to another.

Besides being riddled with issues, including a lack of standardization and oversight, the availability of data to patients becomes limited, manifesting itself in profit-driven endeavors like US News and World Report or initiatives like The Leap Frog Group that are far less well-known and contain too few indicators to be of real use.

The availability of data in the United Kingdom pays dividends. For example, greater understanding of performance has allowed policy makers to consolidate care centers that perform well and close those that hemorrhage money, cutting costs while improving outcomes. Even at the individual hospital level, the availability of patient data keeps groups on their toes.

Unpacking the Wyden Chronic Care Bill

Jan 30, 2014• 2

By Billy Wynne

As he ascends to the Chair of the Senate Finance Committee, Senator Ron Wyden’s recent proposal to reform Medicare by improving care for the chronically ill has garnered significant attention and support. Its topline goal of incentivizing integration of care for high-risk patients is resonating with stakeholders across the health care continuum.

In light of its momentum and Senator Wyden’s imminently expanding authority over Federal healthcare programs, we thought it wise to take a closer look at his plan – the “Better Care, Lower Cost Act” (BCLA). What we found is more interesting, ambitious and – potentially – complex than the headlines suggest.

In essence, the BCLA would allow providers (and health plans) to form new entities – labeled Better Care Programs (BCPs) – that receive capitated payments for all Medicare-covered services delivered to their enrollees. The initiative would initially focus on regions of the country with disproportionately high rates of chronic illness and only medically complex patients would be allowed to enroll.

There are a variety of medical protocols that BCPs would be required to adopt, including development of personalized chronic care plans for each enrollee.

If you are hearing echoes of the Accountable Care “movement,” then you are in the right concert hall but listening to a very different symphony. While BCPs share some characteristics with ACOs, they would differ in important ways. A limited number of ACOs in Medicare currently take full(ish) financial risk, but all BCPs would do so, with some risk corridors instituted in the first few years.

Unlike most ACO programs, control groups would be established for purposes of measuring BCP performance. Also – and this is pivotal – BCPs would be required to proactively enroll Medicare beneficiaries, while patients are typically passively attributed to ACOs.

By taking a giant step down the shared savings path, which it travels alongside ACO programs, the BCLA further blurs the line between traditional fee for service and managed care. BCPs would actually be compensated in the same manner as Medicare Advantage plans, the private insurance option in Medicare.

Why Didn’t the President Mention the Latest Good News on Health Costs?

Jan 29, 2014• 21

By Leah Binder

President Obama rarely shies away from an opportunity to tout successes in U.S. health care, but in last night’s State of the Union oddly omitted any mention of the new and optimistic report about U.S. health spending from actuaries at the Centers for Medicare and Medicaid Services (CMS).

The finding: from 2009 through 2012, health care spending in the U.S. grew at the slowest rate since the government started collecting this data in the 1960s.

The actuaries found that in 2012 spending “stabilized,” growing by 3.7 percent in 2012, and health care accounted for a slightly smaller percent of GDP than the prior year, 17.2 percent versus 17.3 percent in 2011.

Perhaps an actuarial report proclaiming stable growth doesn’t make for much of an applause line for a State of the Union speech. But for confessed policy wonks like me, it’s as good as a Hollywood blockbuster.

So get out your popcorn, here are five Hollywood moments in the report.

1. Ninja Combat

When the report came out in early January, the Obama administration quickly ascribed the good news to Obamacare. But, lo and behold, the actuaries wielded their slide rules like weapons.

They respectfully disagreed with their president, pointing out that few of the provisions in the health reform law were actually in place during the slow-growth years in question. The actuaries conclude that most of the cost stability results from the economic recovery process.

Given the silence in the State of the Union, they may have been given the last word on the subject.

What About the Poor?

Jan 28, 2014• 9

By Joe Flower

Hospitals need to overhaul their processes so they can help the un- and under-insured stay healthy.

Many people running health care institutions tell me that they have been fighting the fight, learning to be nimble, transforming their cultures, making big changes as the landscape rearranges itself like a really bad day along the San Andreas Fault.

But in comparison with the actual scale of the problems, most of the business models and strategies in health care have been sleeping like overfed dogs. It’s wake-up time in America.

Nowhere is the problem defined more clearly than in this question: How can we deal with the tens of millions of new Medicaid recipients, the tens of millions of still-uninsured poor, and the increasing numbers of the underinsured?

Today’s hospital executives formed their careers around the “volume” question: “How do we get more and better-paying customers into and through our system?”

This is a different era. Most markets do not have enough medical care to go around, between an aging population, expanded Medicaid in 25 states, and expanded numbers of insured in all states.

When there is not enough of what you are selling to go around, operating inefficiently leads to choking on volume. In order to survive under any business model we must get the volume down and the value up.

First: What can we expect in the coming years?

The Future of Medicaid, the Uninsured and the Underinsured

Medicaid numbers are astonishing if you are not used to them. Even before the projected expansion, at some time during an average year about 72 million people, close to a quarter of all Americans, are on Medicaid. At any given moment, it’s over 50 million. Medicaid is an open-ended program:

When more people are eligible, or sick, or have more complex diseases, the states and the federal government pay more.