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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?”

Re-Engineering Health Care For Safety and Cost Savings

Dec 15, 2013• 1

By Peter Pronovost, MD

Despite spending $800 billion on technology last year, health care productivity is flat and preventable patient harm remains the third leading cause of death in the U.S.

One reason is that health care is grossly under-engineered: medical devices don’t talk to each other, treatments are not specified and ensured, and outcomes are largely assumed rather than measured.

Other industries rely much less on heroism by individuals and more on designing safe systems and using technology to support work. Today a pilot’s cockpit is much simpler than 30 years ago; it is far more error-proof, and built-in defenses enhance safety. By comparison, hospital intensive care units, which contain anywhere from 50 to 100 pieces of separate electronic equipment, appear unchanged.

Changing this will require unprecedented collaboration between health care’s many stakeholders. That’s one reason why this fall the Armstrong Institute and the World Health Organization convened health care leaders, consumers, providers, regulators and private-industry partners to discuss such topics as how to design safer systems at the Forum on Emerging Topics in Patient Safety held in Baltimore.

One effort to design safer systems at Johns Hopkins is Project Emerge. Supported by a $9.4 million grant from the Gordon and Betty Moore Foundation, Emerge is tapping into the wisdom of a diverse team of engineers, nurses, doctors, bioethicists, and patients and family members — 18 disciplines in all from across Johns Hopkins University— to design safer care in ICUs.

Data Points: More Backroom Chaos and Low State Numbers

Dec 13, 2013• 56

By Robert Laszewski

Shifting Millennial Attitudes on Obamacare December 2013.
Harvard Institute of Politics. Dec 4th, 2013. Poll

A few observations after 10 weeks of Obamacare implementation.

The Obama administration released the first two months enrollment figures this week. With HealthCare.gov still struggling in November, the enrollment of 137,000 people in the 36 states was expected. The main event for the federal exchanges will play out in December now that most people can navigate it

What I found notable in the report was the lack of robust enrollment in the states. In states where the exchange has been running at least adequately for many weeks now, the enrollment numbers are far from what I would have expected.

California enrolled 107,000 people in private plans in the first two months. But California has cancelled 800,000 current individual health plans effective January 1––all of whom have to buy a new plan by January 1 or become uninsured. The only place those who are subsidy eligible can get a subsidized plan is in the California exchange.

It’s Doctors versus Hospitals Over Meaningful Use

Dec 12, 2013• 23

By Adrian Gropper, MD

The Massachusetts Medical Society may be the first to notice that Meaningful Use EHR mandates favor large providers and technology vendors. Control over the Nationwide Health Information Network sets the stage for how physicians refer, receive decision support, report quality, and interact with patients. State health information exchanges and policy makers are caught in the cross-fire over health records interoperability. Are the federal regulations over Stage 2 being manipulated to put physicians and the public at a disadvantage?

On Dec. 7, the Massachusetts Medical Society took what might be the first formal action in the nation. A resolution stating:

“That the Massachusetts Medical Society advocate for a more open, affordable process to meet technology mandates imposed by regulations and mandates; e.g., that all Direct secure email systems, mandated by Meaningful Use stage 2, including health information exchanges and electronic health record systems, allow a licensed physician to designate any specified Direct recipient or sender without interference from any institution, electronic health record vendor, or intermediary transport agent.”

Scott Mace’s column Direct Protocol May Favor Large Providers and Vendors is the first to report on this unusual move by a professional society. Full disclosure: I’m a member of the MMS and the initiator of what became this resolution.

Meaningful Use is intended to support health reform by promoting interoperability and innovation in health service delivery. The Affordable Care Act, Obamacare, is fundamentally a free-enterprise model without single payer or even a public option. Obamacare depends on the market for eventual cost controls and sustainability. Meaningful Use is regulation designed to enable market-driven health reform by reducing interoperability barriers.

Although Meaningful Use regulations have already handed out $17 Billion to drive “voluntary” adoption of interoperable electronic health records, meaningful interoperability is still elusive. Meanwhile, the doctors are chafing about Meaningful Use intrusions and policymakers worry that the regulations will actually increase costs.

November’s Numbers: Sorry. They’re Not Good. They’re Bad. Awful, Actually ..

Dec 12, 2013• 18

By SETH J. CHANDLER

The federal government announced yesterday that 137,204 people have selected a healthcare plan through the federal Exchange as of November 30, 2013. The number is an increase over the 29,794 who had done so by the end of October, a month during which the website portal for enrollment, healthcare.gov, was in disarray.

The government reports that 258,497 have now selected a plan through one of the state Exchanges, making a total of 364,682 enrolled. Asked by reporters whether the Obama administration stands by its estimate that 7 million will enroll in individual plans sold on the various Exchanges by March 31, 2013, the day necessary to do so in order to avoid a tax penalty, Michael Hash, director of the office of health reform in the federal Health and Human Services Department, said that they were “on track, and we will reach the total that we thought.”

The pace of enrollment announced by the federal government today is inconsistent with the claim that its 7 million goal will be achieved. The claim rests on hopes of two surges, one taking place over the next 12 days before the December 23, 2013, deadline for coverage starting January 1, 2014 and a second surge taking place as we approach the end of March at which point, if coverage has not been obtained, many Americans will be hit with a tax penalty.

The magnitude of the surge required strains credulity. A scenario in which most of those who wanted coverage have already applied and in which the pace of enrollment stays the same or even sags for lengthy periods as we go forward would appear almost as likely. Plus, it seems unlikely that there will be major enrollment between December 23, 2013, the first deadline, and March 23, 2014, the second deadline. If someone wanted coverage, they would try to get it earlier. What does applying in the middle of February accomplish? Moreover, if, given the unpredictability of human behavior, the surge actually materialized, it might well strain the government’s computer systems.

A Small Paper Problem: The Health Exchanges Face An Avalanche of Paper Applications

Dec 12, 2013• 1

By CHARLES ORNSTEIN

When HealthCare.gov and some state-run insurance marketplaces ran into trouble with their websites in October and November, they urged consumers to submit paper applications for coverage.

Now, it’s time to process all that paper. And with the deadline to enroll in health plans less than two weeks away, there’s growing concern that some of these applications won’t be processed in time.

The Associated Press reported last week that federal officials are now advising navigators—groups paid to assist consumers with enrollment—not to use paper applications anymore, if they can help it.

“We received guidance from the feds recommending that folks apply online as opposed to paper,” said Mike Claffey, spokesman for the Illinois Department of Insurance.

After a conference call earlier this week with federal health officials, Illinois health officials sent a memo Thursday to their roughly 1,600 navigators saying there is no way to complete marketplace enrollment through a paper application. The memo, which Claffey said was based on guidance from federal officials, said paper applications should be used only if other means aren’t available.

Federal health officials also discussed the issue during a conference call Wednesday with navigators and certified counselors in several states.

“They’ve said do not use paper applications because they won’t be able to process them anywhere near in time,” said John Foley, attorney and certified counselor for Legal Aid Society of Palm Beach County, who was on the call.

According to an enrollment report released Wednesday by the U.S. Department of Health and Human Services, about 83 percent of the 1.8 million applications completed between Oct. 1-Nov. 30 were filled out online; the rest were on paper. The online figure was higher, 91 percent, in the 14 states running their own health exchanges, compared to 80 percent for Healthcare.gov, which processes enrollments for the other 36 states. But even outside the federal exchange, paper is proving to be a problem.

The New Tools: What 21st Century Education Can Teach Us

Dec 11, 2013• 19

By VOLANDES, KENNEDY, DAVIS, GILLICK & Paasche-Orlow

The educational world is becoming flat.

A quiet revolution is underway in the way teachers and students interact using recorded lectures, YouTube, and the internet. In 2004, financial analyst turned online educator Sal Khan began tutoring his niece in math using an online drawing program. As he uploaded these lectures to YouTube, their popularity grew into a social phenomenon.

Today, Khan Academy has provided over 240 million online lessons around the world in over 4000 topics. Stanford, MIT, and other universities now offer massive open online courses (MOOCs) by top professors to all comers. In fact, Harvard Business School no longer offers an introductory accounting class due to the availability of an exceptional online course from Brigham Young University. With high-quality content readily available online, the student-teacher dynamic is changing. Students are expecting excellent instruction and teachers are expecting students to be increasingly knowledgeable about subjects from online viewing. These reciprocal heightened expectations have the potential to create a more dynamic and interactive classroom experience.

These innovations can also transform patient education by bringing patients into the circle of learning. Patients already leverage YouTube and other online sources for health purposes. For example, PatientsLikeMe was started in 2004 by the family and friends of Stephen Heywood who had been diagnosed with amyotrophic lateral sclerosis. This online community helps connect patients with other similarly affected patients and aims to educate patients about the illness experience and potential treatment options. This encourages patients to think synergistically about complex problems such as outcomes, decision-making and ethics. Today, PatientsLikeMe covers more than 1200 health conditions with over 100,000 members.

Given these broad ranging developments, we need to rethink the patient–doctor encounter. The typical encounter follows the traditional pedagogic paradigm of “banking” – in which the teacher, who has the power and the knowledge, seeks to deposit knowledge assets into the learner’s bank (1). Unfortunately, though this approach induces passivity and disempowerment it is the dominant mode of patient education. Instead, imagine encounters where patients are prepared to engage in shared decision-making, allowing the office visit to center on activities that promote patient-centeredness and engagement such as confirming patient comprehension, ascertaining values, and establishing goals.

Resisting the Rush to Judgement On the Affordable Care Act

Dec 9, 2013• 47

By David Blumenthal, MD

A full, fair reckoning of the impact of the Affordable Care Act (ACA) will take years. In an earlier blog post, we outlined some of the measures—such as reductions in rates of uninsurance and underinsurance and trends in health care costs and quality—by which the law should be judged and the time frames over which those judgments should be made.

In the mean time, however, the rush to reckoning seems irresistible. These interim conclusions could prove as faulty as the ACA websites, but they should at least be informed by the best information available. As of this writing, this is what we know about the major shortcomings and accomplishments of the ACA.

KEY SHORTCOMINGS:

Poor management of the launch of the federal website, HealthCare.gov. The reasons for this failure are still emerging, but are likely multiple: management failures by the Obama administration, poor performance by its contractors, design flaws in the legislation itself, the decision by so many states not to run their own websites, a toxic political environment, and other factors.
Poor messaging by the President. In retrospect, President Obama should have prepared the public better for the inevitability that some Americans would be left worse off by the law because of higher insurance prices or the need to switch health plans.
Failure to prepare fully in advance for adverse impacts of the implementation of the ACA. There may have been more such preparation than meets the eye but if, for example, the administration had anticipated that private health plans might be cancelled, the policy response could have been waiting on the shelf. Instead, there was a last-minute scramble under the media spotlight.

KEY ACCOMPLISHMENTS:

Provision of health insurance to: 7.8 million young Americans covered under a parent’s health plan who likely would not have been able to do so prior to the law’s passage, including 3 million who were previously uninsured; more than 200,000 Americans covered through state marketplaces as of November 25, 2013; and 26,794 covered through the federal marketplace as of November 2, 2013.

Probably Illegal and Unquestionably Stupid: Covered California’s Release of Personal Health Information.

Dec 9, 2013• 10

By SETH J. CHANDLER

The Los Angeles Times has reported that Covered California, the largest state’s health insurance exchange under the Affordable Care Act, has started releasing to insurance agents throughout the state the names and contact information of tens of thousands of persons who started an application using the state’s online system but failed to complete it.

The Covered California director Peter Lee acknowledges the practice but says that the outreach program still complies with privacy laws and was reviewed by the exchange’s legal counsel. “I can see a lot of people will be comforted and relieved at getting the help they need to navigate a confusing process,” explained Lee.

I am hardly as confident as Covered California’s lawyers apparently were that this practice was legal.

The law requires that disclosures to third parties be necessary and I do not see why Covered California could not have contacted non-completers directly and ask them if they wanted help from an insurance agent rather than disclosing their identity to insurance agents. But even if the practice could be said to be borderline legal, it is difficult to imagine a practice more likely to sabotage enrollment efforts in California — and, since California’s interpretation could be precedent for other states — elsewhere.

For every person unable to complete their application online in California and who will, with the comforting help provided by insurance agents, now want to complete it, there are likely 10 who will be turned off by the cavalier attitude towards privacy exhibited by this government agency. Beyond a violation of ACA privacy safeguards, the action is either a sign of desperation about enrollment figures, even in a state that boasts of its success such as Peter Lee’s California, or monumental stupidity.

If California wanted to create an adverse selection death spiral, it would be difficult to be more effective than, without notice or consent, releasing personally identifiable information to insurance agents.

Mandela’s AIDS Legacy of Silence and Courage

Dec 9, 2013• 1

By Arthur Caplan

Even the greatest among us can stumble.

As the world mourns the passing of Nelson Mandela, it is important to look at the one area where the iconic former president of South Africa slipped — AIDS. The most outstanding moral figure of our age did not do what was needed as HIV began to destroy the country he loved. But his actions after he realized his failures are an important part of his legacy.

South Africa is beset with the worst epidemic of HIV in the world. According to the United Nations, out of a South African population of just over 51 million, 6.1 million of its citizens were infected with HIV in 2012, including 410,000 children under the age of 14. An estimated 240,000 South Africans died in 2012 from AIDS. There are 2.5 million children orphaned because of the disease. The grim social, economic and medical toll AIDS has exacted on Mandela’s country is almost beyond description.

In 1990, when Mandela was released from a 27-year prison sentence, the rate of HIV infection among adult South Africans was less than 1 percent. When the anti-apartheid activist was elected president four years later, AIDS was on it way to being an out-of-control plague, with infection rates doubling every year. In 1998, the rate of HIV infection among adults in South Africa was almost 13 percent, with 2.9 million people HIV positive.

Mandela and his party were more or less indifferent to AIDS throughout his five-year tenure. There were other huge challenges in rebuilding the new post-apartheid nation — but the indifference was not just a matter of priorities. Mandela and his party did not want to admit they had a problem.

Why they did not take prompt action to slow the epidemic’s spread is not clear. Perhaps Mandela and his people — like United States President Ronald Reagan and his administration in the 1980s — found the disease and its modes of transmission too repellent to acknowledge. Maybe they did not want to tarnish the new state with a problem that at the time carried so much stigma and shame.