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Above the Fold

Sense and Sensibility on Hypertension

Dec 19, 2013• 17

By Vik Khanna & Al Lewis

Every now and then even blind squirrels find acorns. The medical care industry, which long ago abandoned sensible fiscal and therapeutic restraint in the quest for new patients, finally treats us to a revised hypertension guideline that thoughtful people can conclude makes a great deal of sense. It is even based on evidence, or actually the lack of it, which is itself a startling admission of reality from an industry that dances around truth with a nimble sophistry envied by even the most mendacious politicians.

The hypertension guidelines are a sharp departure from last month’s cholesterol guidelines, produced by a supposedly equally august panel of “thought leaders” who gave us guidelines that seemed to channel the The Talking Heads quite literally. John P. Ioannidis, along with Nortin Hadler, easily one of the two or three most important physician thinkers of this or any generation, wrote that the cholesterol guideline will be either…”one of the greatest achievements or one of the worst disasters of medical history.”

If you haven’t read the hypertension guidelines, here is a useful summary:

we treat too many people today;
we rely too much on drugs for things that drugs cannot fix;
treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
if we are really going to improve cardiovascular health, which is strongly implicated not just in stroke, heart disease, and kidney disease, but also cognitive health, people are going to have to change behaviors because there aren’t enough pills on the planet to fix what ails us.

Cognitive health is an especially useful guidepost, because contrary to popular myth, it isn’t something that mysteriously disappears in nonagenarians. The seemingly age-related decline is more likely the manifestation of damage done by a lifetime of incremental harms. Isn’t it edifying to have scientists catch up to our moms?

The new guidelines leave us a redefinition of high blood pressure: greater than 150/90, except in cases where a comorbidity compels pursuit of 140/90 or lower to prevent end-organ damage. This has implications not just for medical care but for workplace wellness, which obsesses with hypertension when it is not obsessing with cholesterol and glucose.

The hypertension guidelines yank away from workplace wellness vendors yet another reason to fine or otherwise antagonize employees who don’t show up at health fairs. The progression of hypertension is strongly related to aging, and healthy aging is the most reliable bulwark against premature stroke, heart attack, kidney failure, or dementia. Unless workplace wellness vendors plan to follow people into retirement, which is when the overwhelming majority of heart attack, stroke, and dementia occurs, there is no logical reason to ask any employee what his or her blood pressure or deign to tell them how to address it.

What We Don’t Know Can Hurt Us

Dec 18, 2013• 32

By David Dranove & Craig Garthwaite

As the health insurance exchanges find their footing and potentially millions of Americans gain access to insurance, this may be a good time to step back and take a longer term view of the ACA. When you get down to it, expanding health insurance coverage was the easiest and least controversial part of health reform. There is no shortage of ways to expand health coverage and almost any credible health reform proposal would have done the job, provided enough money was thrown at the problem.

In designing the ACA, perhaps as a result of political pressure, President Obama opted for a combination of heavily subsidized individual insurance exchanges and generous expansions of Medicaid. Freed from political constraints, he might have instead pushed for the single payer system that many of his most ardent supporters desired. Republicans inclined to expand coverage (at least one of us is proof that unlike the unicorn these do exist) might have pushed for a pure voucher program that harnessed market forces.

All of these options would expand coverage to the degree that policymakers were willing to fund them. So while we congratulate the President for his political success (we doubt the other options could have made it through Congress), it is a simplistic mistake to evaluate the implementation of the ACA by counting the numbers of uninsured or waiting for the monthly updates on the enrollment figures from the exchanges website. Any regulator with a big enough purse can, in the fullness of time, expand access. Frankly, that’s the “easy” part of healthcare reform.

But what about the other elements of the so-called “triple aim” of health reform: cost and quality? You see, while we agree that liberal, moderate, and conservative health reforms can all improve coverage, they each will have very different effects on the other important outcomes. Consider for example the oft-discussed “Medicare for all”; i.e. a single payer system. This would increase access without the messiness of the exchanges. It would also allow the government to flex its monopsonistic muscles and quickly reduce costs – though likely at the expense of quality. In contrast, relying on markets may not reduce costs in the short run, and may not necessarily reward real quality (though it has a better short than single payer in this regard).

Evaluating health reform in the context of the “Triple Aim” is important, but even that approach is not nearly enough. There is a broad consensus among that technological change is the most important long run driver of cost and quality. It follows that the most important element of health reform is its impact on technological change.

To understand how technological change affects all of us, consider the profound impact of the top ten medical advances in the last ten years, as listed by CNN:

1. Sequencing the human genome
2. Stem cell research
3. HIV cocktails
4. Targeted cancer therapies.
5. Laparoscopic surgery

A Shout Out For Our Sponsors

Dec 18, 2013

THCB Editorial Communiques

THCB is produced at our editorial offices in San Francisco and at satellite offices in Atlanta, Los Angeles and Boston. Our work would not be possible without the support of our readers and our generous corporate underwriters. This week’s coverage is brought to you by The ThinkWellPoint American Resident Project.

We’d like to thank WellPoint for their support.

You can read the press release on the THCB-WellPoint partnership here. We invite you to visit the American Resident Project as a way of showing your support for the work we do here at THCB. We think you’ll enjoy following the posts by the inaugural class of bloggers.

As part of our work with the American Resident Project, THCB will be featuring a series of guest posts by young doctors, residents and med students. If you match that general description and would like to be featured on the national stage as a THCB blogger, drop us an email introducing yourself and submit a 300-450 word blog post for us to consider.

We’re particularly interested in posts on the future of medical education, design, innovation, the doctor-patient relationship and your own experiences so far in your career in clinical medicine. Submissions should be provided either as a shared Google drive doc (preferred) or a Word or Pages attachment (less preferred, but still acceptable.) If you’re providing a Google doc, you’ll want to share with editor at thehealthcareblog dot com. If you have one, you can include a head shot (we tend to prefer casual Facebook to staged departmental photo. ) We may or may not use the photo you provide. Should we decide to run your post, you’ll also need a three line bio telling us about yourself. Give us about a week to review your submission.

If you live in the San Francisco Bay area or in Los Angeles, we are also looking for interns. Drop us a line if you think you might be interested in getting involved.

Does ICD-10 Pilot Forecast a Perfect Storm for Healthcare?

Dec 17, 2013• 51

By Edmund Billings, MD

Let me concede from the outset that, in this blog post, I lean toward the negative—dire predictions, worst-case scenarios, a bit of doom and gloom, etc.

But I ask you, oh gentle, patient reader, how could I not?

Let’s go to the satellite. You can see warm air from a low-pressure system (Meaningful Use Stage 2, not changed dramatically by the one-year extension) collide with cool, dry air from a high-pressure area (the turmoil of Obamacare) and tropical hurricane moisture (ICD-10). Tell me you don’t see the Perfect Storm yourself.

And here we sit in our little fishing boat, waiting for the mighty ocean to consume us.

Overly dramatic? Certainly, but still not wholly inappropriate, I will argue.

Consider a recent report on the HIMSS/WEDI ICD-10 National Pilot Program collaborative that was created to, “…minimize the guess work related to ICD-10 testing and to learn best practices from early adopter organizations.”

Designed to ascertain the realities of the entire healthcare system adopting and using ICD-10, this pilot included an education and adoption program for all participants, followed by a set of “waves” in which diagnoses for the 100-200 most common medical conditions were actually coded and submitted using ICD-10.

The end-to-end testing approach …

…would encompass a number of medical test cases that mirror actual processing, including situations with multiple “hops” or “steps” between providers, clearinghouses, and health plans; the identification of high-risk medical test cases to help prioritize testing; the identification of available testing partners; and key reporting and sharing of test results. The test environment must mirror production.

And how did this pilot testing go? (Cue dark, foreboding music here …)

The average accuracy was in the 60 percent range with low scores around 30 percent. Yes, some medical scenarios had nearly 100 percent accuracy, which is great. But very low accuracy accompanied a number of very common conditions. Not so great.

Registration is Open for HxRefactored 2014!

Dec 17, 2013

Meetings

A new kind of conference is on the horizon and tickets are available for purchase! Take advantage of the $699 discounted ticket only available until January 1. Sign up at hxrefactored.com.

Through inspirational talks, practical how-to sessions, collaborative design and API workshops, and on-site challenges, designers and developers will gather at this conference to swap ideas and techniques on how to improve the health experience.

Health 2.0’s Co-Founders, Matthew Holt and Indu Subaiya, and Mad*Pow’s Chief Experience Officer, Amy Cueva, are thrilled. Holt and Subaiya say that “HxRefactored is going to empower developers and designers with the skills they need to make big changes to the health care system. We are excited about hosting this event in the emerging health tech hub of NYC and we couldn’t be more fortunate to be partnering with one of the best design firms in the country.” Cueva echoed those sentiments, “We’re so proud to be continuing the legacy of the HxD conference now partnering with Health 2.0 to involve the developer community.”

HxRefactored is sure to be one of the highlight events of the year, so join us on May 13th and 14th at the New York Marriott at the Brooklyn Bridge and get ready for a conference unlike any you’ve seen before.

Overcharged 38000% !!!

Dec 17, 2013• 80

By THCBist

Pretty Grumpy in NC writes in :

I am writing this letter as a complaint about medical charges from Wake Forest Baptist Medical Center, which I think is excessive.

I would like to point out that I got excellent care during my stay at Wake Forest Baptist Medical Center. I am questioning charges in total of $763.50. I received my bill for my hospital stay for surgery on June 10, 2013. I noticed a charge categorized as “Cast Room” of $763.50. I called the billing department and asked for an itemized bill.

I received the itemized bill and discovered that the “Cast Room” bill was really a daily charge of $254.50 for “Basic Frame with trapeze”. I called about this charge and learned that it was the bar above the bed attached to foot of bed to the head of the bed along with a trapeze handle. This item is used to help get up out of bed.

I think these charges are excessive.

I contacted a local home health equipment company to see what the charge would be if I rented this piece of equipment, and they told me the same item is $20 per month! This just seems unbelievable that a hospital can charge over 38000% above the price I can get this equipment for my home.

We Should Be Getting More Data On The Affordable Care Act

Dec 16, 2013• 4

By SETH J. CHANDLER

The Obama administration released critical data last week on the aggregate levels of enrollment in the various individual Exchanges. Most of the journalistic and blogospheric effort in the aftermath has been in trending: do these numbers portend a massive leap forward in Exchange enrollment such that there can be some confidence that the Affordable Care Act will in fact work?

Might this alternatively be some sort of temporary surge that is both too little and too late? All of this analysis is completely fine; I’ve engaged in it myself. But there are other issues that should be examined.

Here are five questions, mostly about data, I’d like to see other journalists or bloggers start to pursue. I’m doing some of it myself, but I would love company.

1. What is the distribution of enrollment among the various metal tiers?

If a lot of people are purchasing the gold and platinum plans, that is a sign that the people signing up have poor health and do not want to pay higher deductibles. This is particularly true if the same pattern exists among the enrollees receiving income-based subsidies: they, after all, are mostly purchasing gold and platinum because they need it, not because it easily accommodates their budget. If, on the other hand, the distribution is weighted towards the bronze and silver plans, that is some evidence that the people signing up may not be coming as disproportionately from the low or middle expense range.

Unless one’s funds are very limited, it does not make sense for someone who knows they will have high medical expenses to purchase a bronze plan. Disproportionate purchase of gold and platinum policies heightens the potential for adverse selection problems to the extent insurers believed the federal government’s models, which assumed only mild “induced demand” for such policies.

Journalists should also continue pressing at the state and federal level for information on age distribution of enrollees; I can see no legitimate reason to withhold it.

We Need a New Word. We Can Do Better Than “Concierge Medicine” Can’t We?

Dec 16, 2013• 21

By Leslie Kernisan, MD

What should we call it, when doctors decide to not accept with insurance and instead require patients to pay them directly for a healthcare service?

We should call it what it is: direct-pay. As in, patients pay their provider directly.

But most of the world, it seems, calls it concierge.

This is a bit of a problem. Clarity of thought, after all, often stems from clarity in language and word choices.

Now that a growing number of providers are choosing to not accept insurance, or are supplementing insurance payments with annual fees (this too, has been called concierge), we need to be able to have clear, serious, and meaningful conversations about what this means and where healthcare, especially primary care, might be going.

(Disclosure: I’m one of those physicians who has decided to not accept insurance, at least for the time being. I have my reasons.)

The term “concierge medicine” interferes with this conversation. It’s overly broad, freighted with overtones, and allows us to conflate all kinds of aspects of healthcare that would be best considered separately. These include:

How expensive is the care? Concierge has been used to refer to practices that charge primary care subscription fees ranging from $30/month to $25,000/year.
How does the pay structure correspond to service? Although a “monthly subscription = all the care you want” model is common, we also find fee-for-visit and fee-for-time. And then some practices charge patients both an annual or monthly retainer, plus fee-for-service.
Is insurance still accepted? According to Wikipedia, concierge medicine includes practices which accept insurance and charge an additional annual fee to cover extra services. Fees at One Medical in SF are $149/yr; at GreenField Health, they range from $120-$756 per year, depending on one’s age. At MDVIP, the membership fee starts at $1500/year.
What kind of access to the team and to the personal physician is provided? Some practices promise to give patients the doctor’s cell phone number and invite them to call at any hour. Larger practices seem usually offer 24/7 access to the team. Probably few practices are like my consultative practice, which offers good response time during business hours but no after-hours or weekend coverage.
How individualized is the care? How participatory is it? This is a tricky one, but I think it’s important to at least consider, given everyone’s recent interest in things like personalized care, patient-centered care, person-centered care, and participatory medicine. Just about all the practices labeled “concierge” do offer a more satisfactory patient experience. Whether this equates to individualized care in a way that is meaningful (i.e. correlates to better health outcomes or a better match of care to the patient’s situation/values/preferences) is another story.

In general, it seems to me that the term “concierge medicine” right now is being applied for a few different purposes.

The Doc Fix Is Real

Dec 16, 2013• 4

By Billy Wynne

Congress just had an uncharacteristically big week – with significant implications for healthcare policy. It flew by fast and furious, so here we pause to unpack the most significant developments and what they teach us about the future.

1. The Permanent Doc Fix Effort is Real. You have to hand it to the committees of jurisdiction, they have kept their heads down and plugged away all year at permanently repealing the broken Sustainable Growth Rate (SGR) formula that dictates Medicare payments to doctors. They’ve floated new payment methodologies, added policy addressing the package of “extenders” that perennially travels with the “doc fix,” and now all three have successfully completed bipartisan mark-ups of their respective approaches. Furthermore, the three month SGR patch that was included in the budget deal is an implicit endorsement by congressional leadership that there’s actually a chance this could happen in the first quarter of next year.

The next step is to identify savings to pay the roughly $150 billion price tag, which has always of course been the biggest rub. That process is going to take center stage early next year in a “Super Committee-lite” process of negotiating various potential cuts to healthcare programs. The cynics are still betting against it, but we’re closer than we’ve ever been before to replacing the 15+ year-old SGR.

2. The Long-Term Care Hospital Sector Will Never be the Same. In a lesser-noticed component of the three month doc fix patch alluded to above, Congress eliminated the payment differential for LTCHs (pronounced el taks) and regular inpatient hospitals for patients who do not meet clinical complexity criteria. What began as an esoteric exemption for a small handful of hospitals in the early 1980’s and grew to a $6 billion Medicare benefit annually is now going to start to plateau.

The market liked the change, paradoxically, because it was gentler than some bean counters had recommended and gave plenty of time (four years) for sophisticated companies to adjust. But the hot LTCH business just got some pretty cold water poured on it.

3. The Budget Deal Helps Healthcare Programs. The Murray-Ryan agreement to set spending levels for the next two years alleviated some of the impact of the sequester on discretionary spending programs like those at the FDA, NIH and HRSA. This means that funding for new product approvals, clinical research, workforce development programs and some primary care services will be modestly improved in 2014 and 2015.

The Republican Dilemma

Dec 15, 2013• 27

By ROGER COLLIER

What a difference a few weeks make. Just as Republicans were desperately trying to extricate themselves from the fiasco of tying budget passage and debt ceiling legislation to repeal of the Affordable Care Act, the White House came to their rescue with its disastrous healthcare.gov start-up.

It’s now looking like the most egregious healthcare.gov glitches will be fixed by year-end, but with enough problems remaining in 2014 to continue to provide fodder for conservative (and other) critics. Unfortunately for the administration, just as the technical bugs are ironed out the spotlight will move to other aspects of Obamacare.

Premiums are going to take a jump next year, reflecting the lower than projected enrollment by the young and healthy (thanks in part to the healthcare.gov fiasco and the confusion created by Presidential and Congressional attempts to allow non-compliant plans to be extended). There’s a good chance of wholesale cancellations, too, as some insurers take a long look at the unhealthy business they’ve acquired and decide to abandon the exchange market. And it’s almost a given that every other increase in premiums or cut in coverage or cancellation of insurance will be blamed on the upheaval of the Affordable Care Act.

It’s enough to make gleeful Republican leaders believe in the Tooth Fairy.

But will the Tooth Fairy continue to deliver, notably in the Congressional midterms in 2014 and the Presidential election in 2016? The public attention span is notoriously short, and while the current chaos may influence the 2014 midterms, by 2016 the healthcare.gov disaster is likely to be a fading memory. Barack Obama won’t be running for reelection, so harping on the present White House’s incompetence will have limited impact. And while the eventual imposition of IRS fines on those still without coverage will certainly generate a new round of outrage–even assuming the IRS gets the calculations right–Hilary Clinton, or whoever the Democratic candidate turns out to be, will reasonably be able to ask “So where was the Republicans’ better idea?”