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Mental Health Parity and the Affordable Care Act

Nov 11, 2013• 5

By David Dranove & Craig Garthwaite

The Obama administration announced on Friday that it will require parity for mental health insurance coverage. That means that health insurers must apply the same copayments, deductibles, and visit limits to mental healthcare as they do for physical health care treatment. Call it fair, call it political, but please don’t call it a good economic or health policy.

The story about how this is fair, or at least politically popular goes something like this: Health insurers are evil and powerful firms that can and will do whatever they want. On the other hand, patients with mental health problems are politically weak and must be protected from the powerful insurers that have no interest in taking care of them.

In this story, the Obama administration rides in on its white stallion and rights the wrongs being perpetrated by the villainous insurance companies. All we need is a damsel in distress, an evil step-mother, and a catchy tune and Disney will sign the movie rights.

The problem with this simplistic story line is that you can replace “mental health” with nearly any other condition and the story would sound just as plausible.

Sorry. If You Want The ACA to Work, You’re Going to Have To Actually Make People Buy Insurance

Nov 10, 2013• 35

By THCBist

A THCB reader in New York writes in with this timely observation:

“If you want everyone to be able to get insurance, everyone has to actually have insurance.

Most people agree that one shouldn’t be denied insurance because of illness and pre-existing conditions. This is probably the least controversial aspect of healthcare reform. The problem is, you can’t insist that insurance companies sell to all comers at reasonable rates unless you also guarantee a sufficiently large risk pool that includes the healthy as well as the sick.

If you don’t see to it that the healthy sign up, people will go without insurance until they get sick, and the pool of the insured will become so costly that premiums will quickly spiral out of control.

So, to make sure everyone CAN get insurance, everyone MUST get insurance.

This isn’t a moral or political stance, it’s not something you can choose to believe in, it’s basic economics.

The problem with the ACA’s approach to ensuring universal coverage is that the incentives for the healthy to sign up are too weak.
The healthy who decide not to purchase insurance will have to pay a penalty, but that penalty will usually be substantially lower than the price of insurance. Perversely, this weakened approach to ensuring universal coverage could make things worse than they are today. How?

Today, if I’m healthy and uninsured, I know that if I develop a serious illness, I won’t be able to get coverage. At all. This is an incentive for me to go out and spend the money on insurance. Once the ACA is in full force, if I decide that I would rather pay the (cheaper) penalty than buy insurance, I have the security that should I become sick, assuming it’s not a super emergency, I will be able to get insurance to cover future costs, since policies will have to be offered to all. This security blanket for those who choose to remain uninsured is a major problem.”

A Plan B For Healthcare.gov?

Nov 10, 2013• 28

By ROBERT LASZEWSKI

It is now becoming clear that the Obama administration will not have Health.care.gov fixed by December 1 so hundreds of thousands, or perhaps millions, of people will be able to smoothly enroll by January 1.

Why do I say that? Look at this from the administration spokesperson’s daily Healthcare.gov progress report on Friday:

Essentially what is happening is people [those working on the fixes] are going through the entire process. As we have fixed certain pieces of functionality, like the account creation process, we’re seeing volume go further down the application. We’re identifying new issues that we need to be in a position to troubleshoot.

Does that sound like the kind of report you would expect if they were on track to fix this in less than three weeks? Their biggest problem is that they admittedly don’t know what they don’t know.

The spokesperson also reiterated the administration intends to have Obamacare’s computer system “functioning smoothly for the vast majority of users” by the end of the month.

It’s time for the Obama administration to get real.

It takes months to properly test a complex data system like this. Two things are obvious:

When they launched on October 1, very little of the testing had been completed.
They are now in the midst of that many months long testing and fixing period. It is clear they don’t have a few weeks of work left; they have months of work left.Continue reading…

The Art Of The Apology: What Not To Say When Things Go Wrong

Nov 10, 2013• 6

By TONY JEWELL

There were two high-profile apologies in the news this week — by the Leader of the Free World and by a Man Who Makes Yoga Pants.

Neither was well executed and neither was well received.

Let’s start with President Obama, who offered his belated apology on the rollout of the federal health exchange at the heart of the Affordable Care Act. After more than five weeks of shifting stories, blame and timelines, the president sat down with Chuck Todd to say “I’m sorry” for repeatedly saying some variation of, “If you like your health plan, you can keep it. Period.”

Sort of.

“I am sorry that they are finding themselves in this situation based on assurances they got from me,” he told NBC News. “We’ve got to work hard to make sure that they know we hear them and we are going to do everything we can to deal with folks who find themselves in a tough position as a consequence of this.”

Critics quickly and loudly objected to the president’s use of passive voice — and the fact that he claimed people found themselves with cancelled plans “based on assurances they got from me.” They pointed out that it wasn’t the assurances that cancelled the plans; it was the way Obama’s administration wrote the regulations that required insurance companies to cancel the plans.

In short, Obama didn’t own the cause of the pain. He only apologized for the “assurances” (which, by almost all accounts, are better known as “lies”).

Now, the Man Who Makes Yoga Pants.

Lululemon founder Chip Wilson got in hot water for blaming women’s bodies for well-publicized problems with his company’s yoga clothes, including see-through pants and pilling:

“Even our small sizes would fit an extra large, it’s really about the rubbing through the thighs, how much pressure is there … over a period of time, and how much they use it,” he said.

Well, then.

This, of course, led to a predictable backlash — particularly on the company’s Facebook page, where women shared their views of the company and Wilson’s basically saying “You’re too fat to wear our clothes.”

Information Asymmetry – The Politics of Health IT Policy

Nov 9, 2013• 21

By ADRIAN GROPPER, MD

Let’s recognize Healthcare.gov as the dawn of mass patient engagement – and applaud it. Before this website, patients were along for the ride. Employers choose most of the insurance benefits, hospital web portals are an afterthought, and getting anything done with an insurance company, for both doctors and patients, means a phone call and paper. Can you imagine going online to find out the actual cost and buy anything? All that changed with Healthcare.gov.

Information is valuable and not evenly distributed. The haves are immensely valuable corporations. The have nots are patients and doctors. Welcome to the world of health IT politics where the rich get richer ($20 Billion of “incentives” have caused massive health IT consolidation and a hidden health surveillance state) and the poor get frustrated (talk to an independent physician about their EHR or to a patient trying to access her own health records).

Information asymmetry drives $1 Trillion waste of our $2.7 Trillion health care cost. That waste is about $3,000 per year per citizen.

The politics of health IT policy are not left vs. right but institution vs. individual. Politicians and regulators alike are now scrambling to understand the role of health IT policy in that $3,000 annual waste per citizen.

The asymmetry that drives health IT policy is easy to understand when you consider that health IT is sold to corporations. As physicians and patients, we do not prescribe or buy information technology and we are paying the price through a total lack of price and quality transparency.

UCSF’s Wikipedia Experiment: Should Med Students Get Credit For Curating Medical Information Online?

Nov 8, 2013• 11

By JOHN SCHUMANN, MD

You’re a loyal THCB reader. You have a symptom. You Google it. One of the first three hits will be an entry about the symptom or an associated condition on Wikipedia.

As an informed lay person, you wonder, “How accurate is Wikipedia for medical information?”

You’ve always been a little skeptical of Wikipedia, but over the years you’ve found it more and more reliable for celebrity tidbits (e.g. “How old is Jane Lynch?” or “What was the name of that guy in “Crash?”) and sports trivia (“How many Super Bowls have the Minnesota Vikings lost?”).

In fact, it’s become quite useful for understanding geopolitics, ancient and recent history, and helping explain science topics (Higgs Boson, anyone?).

So why not medicine?

We in academic medicine look down our noses at Wikipedia. “Show us original texts,” we harrumph. “Where does the original data come from?” we ask our residents and students.

Just like high schoolers and college kids are warned NOT to use Wikipedia as a research tool, medical professors hold the site lowly in regard to seriousness of purpose.

Well, it’s time to accept reality.

We all use it, whether we admit it or not. Some of us a lot. The good news is, Wikipedia’s going to get even better in the medical realm.

Hospital Exec Pay: If P4P is Good Enough for Doctors, Why Not the CEO?

Nov 8, 2013• 28

By Ashish Jha, MD

In my previous blog, I made the argument that whatever strategy we use to improve care in hospitals will not be implemented and executed well without proper focus by hospital leadership. So, it is in this context, that we recently published some pretty disappointing findings that are worth reflecting on.

We examined the pay of CEOs across U.S. hospitals and found that some CEOs got paid a lot more than others. This was not surprising. CEOs of larger, urban, teaching hospitals get paid a lot more than CEOs of small, rural, non-teaching institutions. But the disappointment was around quality: we found no relationship between a hospital’s quality performance and the pay of the CEO. Holding size, teaching, and other factors constant, what was the pay of CEOs of hospitals with high mortality rates?

About the same as CEOs of hospitals with low mortality rates. What about other quality measures? Most of them didn’t really seem to matter, with the exception of patient experience, which correlated nicely with CEO compensation. It seems that when setting CEO compensation, patient outcomes are not a big part of the discussion. How could this be, and why does it matter?

How you set incentives for senior managers says a lot about your priorities. Boards generally set the salary for their CEOs and they clearly reward patient satisfaction scores. That’s good. They also seem to reward the things that build hospital reputations: having the latest technology such as a PET scanner or academic status. But are boards rewarding CEOs based on mortality rates or adherence to basic quality metrics? Not so much. Why not? I’ve spoken to a lot of board chairpersons over the years and the answer is not that they don’t care. Most boards want to reward quality and believe that they do.

The problem is that most board members lack sufficient expertise on quality metrics and can’t decipher, from the large number of quality metrics, which ones are important (like mortality rates) and which ones are not. Hamstrung, they focus on satisfaction but also end up rewarding things that feel like proxies for quality, such as having the latest technology. And here’s the part that’s frustrating – our national efforts on quality measurement and improvement are not helping. We seem to have done very little to prioritize what’s really important, and shine a light on them.

So what do we do to move forward? Some states have started requiring that boards undergo training in quality. Medicare, as a condition of participation, could certainly require that boards (or at least some members thereof) show a degree of expertise with quality. I like these ideas but worry that training programs would themselves be of variable quality, and for some boards it would become an onerous requirement without achieving real gains in expertise.

Of course, if we really want to help boards be more effective and engage healthcare leaders, the biggest thing that we could do is actually reward hospitals, in a meaningful way, based on quality. Yes, we have the value-based purchasing program, and it is well-intentioned. But, as I’ve written before, it has several big problems. First and foremost: the incentives are very weak and there is little reason to believe it will have a meaningful impact on patient outcomes. Second, the measures are diffuse – we have too many of them, some of which matter (mortality) and many which don’t in the absence of the appropriate clinical context (checking the ejection fraction on a heart failure patient). It’s hard for hospital boards to really get a clear signal on what matters if they aren’t seeing it clearly and consistently from national leaders on quality.

Hyperdiagnosis: The Wellness Industry Doubles Down on Overdiagnosis

Nov 7, 2013• 46

By AL LEWIS and VIK KHANNA

By now we are all familiar with the concept of overdiagnosis, where “we” is defined as “the readers of THCB and a few other people whose healthcare literacy is high enough to know when not to seek testing and/or when not to automatically believe the test results.”

The rest of the country hasn’t gotten the memo that, quite counter-intuitively, many suspected clinical problems should simply be left alone. Many insignificant conditions get overdiagnosed and subsequently overtreated, at considerable cost to the health plans and risk to the patient.

For more information on that we refer you to the book Overdiagnosed. The thesis of that book is that insured Americans are far more likely to be harmed by too much care than too little.

Rather than use its resources and influence with human resources departments to mitigate overdiagnosis, most workplace wellness companies have opted for the reverse, taking overdiagnosis to a level which, were they physicians billing the government for this work, could cost them their licenses and possibly their freedom. Instead, they win awards for it.

We call this new plateau of clinical unreality “hyperdiagnosis,” and it is the wellness industry’s bread-and-butter. It differs from overdiagnosis four ways: It is pre-emptive. It is either negligently inaccurate or purposefully deceptive. It is powered by pay-or-play forfeitures. The final hallmark of hyperdiagnosis is braggadocio – wellness companies love to announce how many sick people they find in their screens.

1. Pre-Emptive

Most cases of overdiagnosis start at the doctor’s office, when a patient arrives to join the physician in a generally good faith search for a solution to a manifest problem. The patient comes in need of testing. By contrast, in hyperdiagnosis, there is neither a qualified medical professional providing adult supervision nor good faith. The testing comes in need of patients, via annual workplace screening of up to seventy different lab values. Testing for large numbers of abnormalities on large numbers of people guarantees large numbers of “findings,” clinically significant or not. It is a shell game that the wellness vendor cannot lose.

2.Inaccurate or Deceptive

Most of these findings turn out to be clinically insignificant, no surprise given that the US Preventive Services Task Force recommends annual screening only for blood pressure, because otherwise the potential harms of screening outweigh the benefits. The wellness industry knows this, and they also know that the book Seeking Sickness: Medical Screening and the Misguided Hunt for Diseasedemolishes their highly profitable screening business model. (We are not cherry-picking titles here—there is no book Hey, I Have a Good Idea: Let’s Hunt for Disease.) And yet most wellness programs require annual screens to avoid a financial forfeiture. This includes the four programs covered on THCB this year — CVS, Nebraska, British Petroleum, and Penn State.

Those four programs and most others also obsess with annual preventive doctor visits. Like screening, though, annual “preventive” visits on balance cause more harm than good, according to academic and lay reports. The wellness industry knows this as well. We have posted it on their LinkedIn groups, and presumably they have also access to Google. They addressed the data by banning us from their groups.

3. Pay-or-play forfeitures

Because of the lack of value, the inconvenience, and privacy concerns, most employees would not submit to a workplace screen if left to their own devices. The wellness industry and their corporate customers “solve” that problem by tying large sums of money annually — $600 for hourly workers at CVS, $1200 at Penn State and $521 on average – to participation in these schemes. Yet participation rates are still low. At Penn State, for example, less than half of all employees got screened despite the large penalty.

Posts of Note: The 2013 Harvard Business School Cyberposium

Nov 7, 2013

By Grant Ho

This past weekend, I attended Cyberposium at Harvard Business School where I was invited to speak on the Healthcare Technology panel. Cyberposium is one of the largest MBA student-run tech conferences in the country and typically gets around 1,000 attendees — students, industry professionals, press, and VCs. This year was no different.

The atmosphere was buzzing. There’s always a certain energy at these events, and when you’re surrounded by individuals who are passionate about innovation and the curiosity and sense of possibility that come with it, it’s an exciting place to be.

The morning’s keynote featured Bill Clerico, CEO of WePay (a competitor to PayPal in the online payments space). Bill told us about his motivations for starting WePay, their journey to raise $20M, and how he and his team worked relentlessly to scale the organization.

His two big takeaways on what it takes to be a successful entrepreneur, especially if you’re just starting out: 1) you have to be scrappy and 2) you have to have maniacal focus on the customer (both when you acquire and service them). I couldn’t agree more. Personally, it was a reminder that as we grow bigger at CareCloud, we can never lose sight of our entrepreneurial roots.

After the keynote, I headed off to the Healthcare Technology panel. On the panel, I was joined by HCIT folks from Activate Networks, athenahealth, HealthTap, and Operating Analytics. Our panel was moderated by Zen Chu, serial healthcare entrepreneur and founder of MIT’s H@cking Medicine program (who earlier in the day, told me about a startup he recently invested in called Figure1 — think of it as a Pinterest for doctors).

The 50-minute discussion focused on the future of healthcare, from the impact of reform to emerging business models and trends in HCIT investing. As I think back on the panel and dozens of conversations throughout the day, a few things stood out:

1) Big data’s a big deal: Our panel immediately jumped into big data, with one of the more interesting discussions around what’s needed to reach the promised land called population health. For me, it’s about starting with a platform that can easily house both patient and claims data. You can’t have one or the other, you need both – especially as providers take more financial risk for care delivery.

More critically, as you build analytics on top of that, the platform needs to be scalable, have enough horsepower to aggregate and analyze all the information, and is interoperable so you can bring in new data sets from different sources (think genomics or the quantified self). The combination of storing administrative, financial, and clinical data in a powerful, cloud-based system is what we have at CareCloud today and in my view, is a critical enabler for big data going forward.

2) Selling to doctors is hard: During the panel, an audience member (a new HCIT entrepreneur) asked what’s the best way to sell to doctors. As a marketer, we work to connect with practices every day – helping them navigate through the pain of declining reimbursements, while easing their struggle with poorly designed HCIT. In my view, it’s a twofold solution.

First, it’s having a simple, flexible business model like SaaS-based pricing that makes finances easier on practices. Secondly, it’s developing products with “design thinking” from the start. You can build all the Meaningful Use features into your EHR, but if you’re making the doctor’s life harder and she can’t go home to see her family, you’ve failed. Usability has always been an obsession with us at CareCloud, and that’s why I’m so encouraged by the great work of our product teams, led by Edwin Miller, to make the fastest, most user-friendly HCIT solutions out there.

3) Engaging patients is even harder: Throughout the day, there was a lot of buzz about wearable devices like FitBit, mobile health apps like Ginger.io, and physician networks like HealthTap. While the growth of these tools is exciting, it made me realize how siloed all data is and how hard it will be to get patients to take action (I, for one, don’t walk an extra mile when Jawbone Up tells me I’ve hit less than 10,000 steps on any day).

Perhaps it’s linking all this disparate data into a patient portal so it reaches doctors and EHRs, incentivizing doctors on care planning (not just care delivery), or simply having patients pay a greater share of their healthcare spend. However, in my view, a combination of integration and incentives are required to reduce the physician/patient asymmetry.

How Many Patients Did We Hurt Last Month? Learning (But Not Too Much) From The Best Hospitals

Nov 6, 2013• 23

By ASHISH JHA, MD

I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.

He told me how a few months ago, soon after returning to Boston from a trip to China, he had started feeling short of breath. When his cardiologist convinced him to be evaluated, he found himself at the Beth Israel Deaconess Medical Center (BIDMC), arriving in the ER late one evening. He was triaged within minutes, had an EKG within 15 minutes, at which time comparisons were made to previous EKGs. After ruling out a heart attack, his ER physicians quickly ordered a CT Angiogram.

That test, completed within an hour of his initial arrival to the ER, revealed the reason for his shortness of breath: he had a large saddle pulmonary embolus. He was started immediately on IV heparin and sent quickly to the ICU, experiencing essentially no delay in care. He spent three days there and reports receiving care that was attentive, expert, and consistently of the highest quality. Even after discharge, he received two nursing visits at home to ensure he was doing OK. In discussing his experience, he repeatedly emphasized the fantastic communication and teamwork that he witnessed. Weeks after discharge, he continues to get better and feels the benefits of the excellent care he received.

This is the story we all hope for. And when I heard it, I have to say that I wasn’t surprised. There’s something about the BIDMC that’s unusual. Of the 4,500 hospitals that report their mortality rates to Medicare’s Hospital Compare website, only 22 (less than 0.5%) have better than predicted mortality rates for all three reported conditions: heart attack, congestive heart failure, and pneumonia. And, we know that the combined performance on these three conditions is remarkably good at predicting hospital-wide outcomes, including outcomes for pulmonary embolism.

If you are a patient and care deeply about good outcomes, BIDMC seems to be a good place for you.

So what’s so special about them? What do they do that’s different? I don’t know, specifically, all of their tactics, but I have some guesses about what seems to differentiate high performing institutions from the rest. And in a word, it’s leadership. BIDMC has had two CEOs over the past few years, and both of them have been unusually committed to achieving high quality care. That commitment translates into real activities that make a big difference. Let me divert us with a story of what this might actually mean.

A few years ago, I was working on a strategy for improving the quality and safety of VA healthcare. As part of this effort, I called up senior quality leaders of major healthcare organizations across the nation. One call is particularly memorable. Because I promised anonymity, I will not name names but this clinical leader was very clear about his responsibility: every month, he met with his CEO, who began the meetings with three simple questions: “How many patients did we hurt last month? How many patients did we fail to help? And did we do better than the month before?”

The CEO and the entire hospital took responsibility for every preventable injury and death that occurred and the culture of the place was focused on one thing: getting better. When I looked them up on Hospital Compare, they too had excellent outcomes and they regularly get “A” ratings for patient safety from the Leapfrog Group.