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#Gchat Medicine?

Google just announced that they are piloting a specific health focused service for Helpouts which apparently is a fully HIPAA-compliant system that allows patients to receive telemedicine from clinical providers.  They are currently partnering with One Medical Group, an “experience-focused” medical practice, which allows patients to “request a Helpout, and typically speak with a physician within 20 minutes. It’s recommended for people with cold and flu symptoms, rashes, or simple infections.”

I love the idea of medicine finally moving away from the clinic and towards a digital future, and in our health system we are currently exploring ways that we can deliver telemedicine to our patients with diabetes.  But to do this effectively, we have to understand the elements needed for a health visit.

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Trying To Make Sense of the Covered California Numbers

I’ve read a number of reports in recent days gushing over the progress Covered California is making leading the nation in signing up people for Obamacare.

But, I am having trouble understanding how the numbers should make anyone gush with enthusiasm.

Covered California, the state health insurance exchange, has a goal of enrolling 500,000 to 700,000 subsidy eligible Californians by March 31, 2014.

Covered California just announced that it would proceed with its original plan to cancel 1.1 million existing individual policies (their estimate)––80% of them by December 31. Covered California also just said that 510,000 of them would qualify for a subsidy.

The only place a Californian can buy a policy with a subsidy is on the Covered California state exchange.

So, it would certainly seem that the only way those 510,000 people can continue their coverage and get a subsidy is to sign-up on the California health insurance exchange––80% of them by December 23.

So, if only the canceled policyholders who are subsidy eligible replace their canceled policies Covered California will make the lower end of its entire 2014 enrollment goal. Doesn’t sound like much of a stretch goal for them.

Besides the 1.1 million who have lost their policies because of cancellation, Covered California has estimated that 5.3 million Californians are uninsured and eligible to purchase coverage on the state exchange––about half with subsidies.

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How Will My Subsidy Be Paid?

A THCB reader writes in:

“I understand that part of the population will qualify for subsidies and others will not.

What I do not understand, nor do I think that those getting subsidies understand, is how will the monthly cost be paid.

For example (this is made up), the insurance I am quoted costs $1,200 per month, however, I qualify for a $500 per month subsidy.  When I pay the bill each month do I pay $1,200 or $700.   My understanding is that the ACA is showing people the Net cost with the subsidy applied.   I would assume that one would pay the full amount and hope to get the subsidy as a refund when taxes are filed.

Unfortunately, I can not afford to pay $1,200 per month up front and am unable to wait to file taxes and hope to get the refund in a timely manner.  Those that get subsidies are most likely lower paid, already struggling to make ends meet, and will be unable to pay the up front value.  How does the ACA work regarding paying the monthly costs?  What happens if a person is audited?  Does it delay their subsidy?

What happens if refunds are late?  How are people supposed to pay their bills if they are counting on the subsidy in their refund?

If those that do receive subsidies have to pay the entire cost up front, then this will turn into a very big cash flow issue for them.   Is this how the program works?  If the ACA Website is showing the net cost with the subsidy applied, however, does not clearly state that you pay the full cost up front and receive the subsidy with your tax refund, then I find that to be very shady advertising.”

Is Opposition to Obamacare Racist?

It is pretty easy to be against Obamacare these days.

The federal government can’t come up with a working website to help people buy health insurance. The President misled people about whether they could hold onto their old insurance plans. And come next tax day, the least popular provision of the Affordable Care Act – the individual mandate – will be implemented for the first time.

Lost amidst all this controversy is the very strong likelihood that once Obamacare is fully implemented, and the disastrous healthcare.gov website is functioning properly, the law will mean health insurance for millions of previously uninsured Americans.

And the people most likely to benefit from this law, according to a recent study, are blacks and Hispanics who not only have higher rates of uninsurance, but also frequently demonstrate greater need for medical care.

Which raises a question: is it racist to oppose the Obamacare efforts to increase health insurance in the United States?
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A Tale of Two IT Procurements

Recently, the President of the United States, the most powerful person on earth, the man whose finger rests on the nuclear button, struck a bold blow for . . . procurement reform?

“There are a whole range of things that we’re going to need to do once we get [the Affordable Care Act (ACA) rollout] fixed—to talk about federal procurement when it comes to IT and how that’s organized,” the president said on November 4, speaking to a group of donors and supporters.

People are clamoring for heads to roll, and the president is talking about what just could be the geekiest, most obscure topic ever to clog a federal bureaucrat’s inbox. Procurement reform? Has he gone off the deep end?

Well, not really. Among the causes of healthcare.gov’s difficulties, the federal process for purchasing goods and services could rank right up there with toxic politics, lack of funding for ACA implementation, and management goofs. Let me explain why, from personal experience.

From 2009 to 2011, I served as National Coordinator for Health Information Technology. My job was to implement the HITECH ACT, which aims to create a nationwide, interoperable, private, and secure electronic health information system. As national coordinator I had to lead a lot of federal contracts.

This is how that went.

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New California Numbers Show Disproportionate Enrollment by Those Over 55

California has frequently been cited as an early Affordable Care Act success story with enrollment coming at least closer to projected numbers than in other states. This week’s release of information from Covered California, the state entity organizing enrollment there, shows a mixed picture about the likelihood that the ACA will become a stable source of non-discriminatory relatively inexpensive health insurance in the nation’s most populous state.

A highlight from the report is that 79,891 have at least gotten as far as selecting a plan since enrollment opened on October 1, 2013.  That’s better than any other state and better — at least as of the last report — of all the other states combined using the healthcare.gov portal.

And, because, contrary to the wishes of California Insurance Commissioner Dave Jones, Covered California has decided not to permit those with recently enrolled in underwritten individual health insurance to “uncancel” policies that do not provide Essential Health Benefits, there is the potential to add more people to the Exchange pools than would otherwise be possible.

Additional good news: the pace of enrollment has picked up over the past two weeks.

Still, to date, the 79,891 who have at least selected a plan are only 6% of the 1.3 million that the federal government projected California would enroll through 2014. And the web site in California appears to be working acceptably.

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What Is the Difference Between On-Exchange and Off-Exchange Policies?

A THCB reader from Colorado writes in:

“I am an individual health insurance purchaser in Colorado. I know I need to buy my policy through the Colorado exchange if I want to get a possible subsidy. I am not likely to be eligible for a subsidy, however, and I found that it’s also possible to buy policies “off” the exchange. I briefly looked at some of those policies and found similar premiums, copays, and deductibles to policies “on” the exchange. I assume the “off-exchange” policies must also be as ACA-compliant as the exchange policies. 

Given all these similarities, what is the DIFFERENCE between “on”-exchange and “off”-exchange policies?

In the ACA, what purpose do the two categories serve?”

Radiologist: Thou Shalt Disclaim by Law

There is an old joke. What’s a radiologist’s favorite plant? The hedge.

Radiologists are famous for equivocating, or hedging.

“Pneumonia can’t be excluded, clinically correlate”. Or “probably a nutrient canal but a fracture can’t be excluded with absolute certainty, correlate with point tenderness”.

Disclaiming is satisfying neither for the radiologist nor the referring physician. It confuses rather than clarifies. So one wonders why legislators have decided to codify this singularly unclinical practice in the Breast Density Law.

The law requires radiologists to inform women that they have dense breasts on mammograms. So far so good.

The law then mandates that radiologists tell women with dense breast that they may still harbor a cancer and that further tests may be necessary.

You may quibble whether this disclaimer is an invitation or commandment for more tests, or just shared decision-making, the healthcare equivalent of consumer choice.

But it’s hard to see why any woman would forego supplementary tests such as breast ultrasound, magnetic resonance imaging and 3 D mammogram, or all three, when their anxiety level is driven off the scale.

What piece of incontrovertible evidence inspired this law, you ask?

Perhaps a multi-center trial run over 10-15 years that randomized women with dense breasts to (a) mammograms plus additional screening and (b) screening mammograms alone, show that additional screening saves lives, not just find lots of small inconsequential cancers.

No. The law was instigated by a heart-rending anecdote, which avalanched into the “breast density awareness” movement, cloaked by an element of scientific plausibility: women with dense breasts may have a higher incidence of cancer; a conjecture of considerable controversy.

Wasn’t  the Affordable Care Act (ACA) supposed to usher an era of rational policy-making, guided by p values, statistics not anecdotes?

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The Real Reason You May Not Be Able to Keep Your Doctor Under the New Healthcare Law


Here is what the President said at the American Medical Association Meeting in July, 2009––and likely lots more times:

“No matter how we reform health care, we will keep this promise: If you like your doctor, you will keep your doctor. Period. If you like your health care plan, your will keep your health plan. Period. No one will take it away. No matter what. My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.”

We have all heard this repeated many times before in recent weeks. But with the front-page story in the Washington Post yesterday, “Health Insurers Limit Choices to Keep Costs Down,” it’s as if somebody rang a new bell this time focused on the “you will keep your doctor” part.

It’s not like we haven’t been talking about more narrow networks becoming a staple of the new health insurance exchanges.

It is as if some of this stuff is just starting to sink in.

Why the limited networks?

In the old health insurance market, insurers competed for business through price and plan design. Network size has historically been a minor factor with consumers and employer plan sponsors expecting to be able to use about any doctor or hospital, especially those with the best reputations.

But with the Affordable Care Act, health plans lost two of their historically big plan pricing variables; medical underwriting and plan design.

Under Obamacare, insurers can no longer underwrite, or exclude people, to keep the cost of their individual market health insurance plans down––a good thing.

Under Obamacare, insurers can no longer offer a wide variety of health insurance products in the individual health market––a good thing when it gets rid of the worst of the health plans out there but not such a good thing when it gets rid of the many policies people could choose and have liked and are now mad about losing. Now, all health plans have to fit into four strict boxes: Bronze, Silver, Gold, and Platinum. And, these boxes can only differ by out-of-pocket costs––not benefits.

So, if a health plan can no longer vary its benefit choices, how can it distinguish itself on price?

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The ePrognosis App: How Calculating Life Expectancy Can Influence Healthcare Decision-Making

Last month an intriguing new decision support app launched, created by experts in geriatrics and palliative care. It’s meant to help with an important primary care issue: cancer screening in older adults.

Have you ever asked yourself, when considering cancer screening for an older adult, whether the likely harms outweigh the likely benefits?

Maybe you have, maybe you haven’t. The sentence above, after all, is a bit of wonky formulation for the following underlying questions:

  • How long is this person likely to live, given age and health situation?
  • Given this person’s prognosis, does cancer screening make sense?

The first question seems like one that could easily occur to a person — whether that be a patient, a family member, or a clinician – although I suspect it doesn’t occur to people perhaps as often as it should.

As for the second question, I’m not sure how often it pops up in people’s minds, although it’s certainly very important to consider, given what we now know about the frequent harms of cancer screening in the elderly, and usually less frequent benefits.

Furthermore, there is abundant evidence that “inappropriate” cancer screening remains common. “Inappropriate” meaning the screening of people who are so unwell and/or old that they’re unlikely to live long enough to benefit from screening.

For instance, one astounding study found that 25% of physicians said they’d order colon cancer screening for an 80 year old with inoperable lung cancer. So it’s clear that improving the decision-making around cancer screening would help improve healthcare safety, quality, and value.

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