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Above the Fold

Questions for Secretary Sebelius

Oct 30, 2013• 5

By Charles Ornstein

Health and Human Services Secretary Kathleen Sebelius will testify before the House Energy and Commerce Committee this morning. Her testimony comes the week after Healthcare.gov contractors testified before the same committee and a day after the head of the Centers for Medicare and Medicaid Services testified before a different House committee.

Here’s what you need to know.

1. Where to watch the hearing, which began at 9 a.m. EST:

Live coverage via C-SPAN.

2. Read Sebelius’ prepared testimony. Politico calls it more of the same:

Sebelius’s eight pages of prepared testimony for the House Energy and Commerce Committee matches nearly word-for-word testimony delivered by CMS Administrator Marilyn Tavenner to Ways and Means on Tuesday.

In both written statements, the officials acknowledge that the website hasn’t met expectations but say the administration is taking major steps to improve it.

Neither testimony includes an apology for the bungled launch—but Tavenner verbally apologized at the hearing Tuesday morning.

Clay Johnson (@cjoh), who advocates for open source information in the federal government, annotated the testimony on Rap Genius, with questions and comments.

3. Get familiar with the background. Sebelius gave an interview to CNN’s Sanjay Gupta last week in which she had this memorable exchange:

Gupta: The president did say that he was angry about this. I mean do you know when he first knew that there was a problem?

Sebelius: Well, I think it became clear fairly early on. The first couple of days, that —

Gupta: So not before that, though? Not before October 1st?

Sebelius: No, sir.

Gupta: There was no concern at that point here in the White House or at HHS?

Sebelius: I think that we talked about having — testing, going forward. And if we had an ideal situation and could have built the product in, you know, a five-year period of time, we probably would have taken five years. But we didn’t have five years. And certainly Americans who rely on health coverage didn’t have five years for us to wait. We wanted to make sure we made good on this final implementation of the law.

And, again, people can sign up. The call center is open for business. We’ve had 1,100,000 calls. We’ve had 19 million people visit the Web site, 500,000 accounts created. And people are shopping every day. So people are signing up and there’s help in neighborhoods around the country, that people can have a one-on-one visit with a trained navigator and figure out how to sign up. So people are able to sign up.

I wondered at the time if Sebelius’ answer left a little wiggle room. I expect Republicans on the committee will pursue this.

4. Digest media reports. You can definitely expect that Sebelius will be asked about a CNN report yesterday that Healthcare.gov’s lead contractor warned the administrator well before the Oct. 1 launch of major problems. Read the documents.

CNBC suggests these six questions for her:

—What did you know, when did you know it, and who told you?

—Did you ever consider not launching Oct. 1?

—Why has no one been fired?

—What does all this cost?

—What contingency plans do you have?

—What are the enrollment numbers?

TPM offers what it calls seven legitimate questions for her.

And the Washington Post says that “the embattled secretary of health and human services will submit to a quintessential station of the Washington deathwatch.” Gotta love Washington.

Charles Ornstein is a senior reporter at ProPublica and past president of AHCJ. An earlier version of this post originally appeared on his tumblr, Healthy buzz.

Mr. President, I Like My Health Insurance. I’d Like to Keep It. Can You Please Help Me Out?

Oct 29, 2013• 79

By Robert Laszewski

How many times have I talked about rate shock, the millions of people who would be getting cancellation letters from their current health plan, and the problem of people having to put up with more narrow networks?

And, how many times have those predictions been met by push back and spin: Today’s policies are just junk and people will be better off finding lower cost health insurance under Obamacare.

I have been in this business for 40 years. I know junk health insurance when I see it and I know “Cadillac” health insurance when I see it.

Right now I have “Cadillac” health insurance. I can access every provider in the national Blue Cross network––about every doc and hospital in America––without a referral and without higher deductibles and co-pays. I value that given my travels and my belief that who your provider is makes a big difference. Want to go to Mayo? No problem. Want to go to the Cleveland Clinic? No problem. Need to get to Queens in Honolulu? No problem.

So, I get this letter from my health plan. It says I can’t keep my current coverage because my plan isn’t good enough under Obamacare rules. It tells me to go to the exchange or their website and pick a new plan before January 1 or I will lose coverage.

First, the best I can get in a Blue Cross network plan are HMOs or HMO/Point-of-Service plans. In the core network those plans offer, I would have to go to fewer providers than I can go to now in the MD/DC/VA market. And, the core network has no providers beyond my area. I can go to the broader Blues network but only if I pay another big deductible for out-of-network coverage.

I Give Up

Oct 28, 2013• 23

By TONY JEWELL

Since October 1, I have logged on to various websites across the Internet to book three flights, make hotel reservations in four cities, buy a pair of boots, some t-shirts and a set of nifty retro Mason jars.

What I haven’t bought: health insurance through healthcare.gov.

Nor have I tried, even after being able to (finally) create an account and see the prices on specific plans offered here in South Jersey, after weeks of frustration.

Here’s why: Given my family’s initial experience in setting up an account and the horror stories that continue to pour out day by day, we simply have no faith that the system will work if we attempt to sign up. And, given the bungling to date, we are not confident our insurance will be there January 1 – even if we are able to Whac-A-Mole our way through the registration process.

Think about it this way: If you really need to get to Miami, would you attempt to buy a plane ticket on a sketchy site that may or may not sell you a ticket that may or may not be waiting for you for a plane that may or may not be there when you get to the airport on the travel day?

Of course not. Nor are we comfortable relying on healthcare.gov, 1-800 numbers, navigators or parchment to sign up for health insurance through the federal exchange at this point.

So, You Need Knee Replacement Surgery…

Oct 28, 2013• 2

The Health 2.0 Developer Challenge team recently caught up with the 1st place winner of the RWJF Hospital Price Transparency Challenge (Static Visualization Category), Imaginary Office. Their winning submission, lead by Esther Chak and Mary-Jo Valentino, is an excellent visualization of recently released CMS charge data that helps consumers make a more informed decision when choosing a hospital to receive knee surgery.

Check out what they built and the thought process behind creating the winning submission!

HT: Tell us about Imaginary Office and your larger mission.

Imaginary Office (IO): Imaginary Office is a collaborative graphic design and communications studio founded by the two of us, Mary-Jo Valentino and Esther Chak. We design and develop print and web media for clients who need to communicate complex content — for example, the science behind ocean conservation, the feeling of a piece of classical music, or the effectiveness of public schools. We have been lucky to work with clients whose missions we support, from sustainable seafood, to clean water, to arts education.

HT: Why did you choose to participate in the RWJF Hospital Price Transparency Static Visualization Challenge?

IO: Our motivation to clarify some aspect of the healthcare or health insurance experience stems from a medical emergency that Mary-Jo had a few years ago. It was a wake-up call to both of us to take healthcare and insurance coverage more seriously. But, it’s not easy to understand—for us or for anyone, really.

As self-employed designers we had been following the healthcare reform journalism pretty closely. We clicked through many online articles and eventually stumbled upon a mention of the RWJF Challenge. That was the catalyst to realize an infographic that we had kept in the back of our minds since Mary-Jo’s medical emergency. The RWJF Challenge gave us an opportunity to develop the idea and share the outcome with an audience.

The Opening Act

Oct 28, 2013• 31

By David Dranove & Craig Garthwaite

That past month of debate over the botched launch of the health care exchanges has brought the programming geeks, and their hired mouthpieces, out in the open to defend the indefensible. As painful as this has been for so many Americans, we cannot help but be amused to hear so many commentators doing their best impression of Captain Renault and expressing their shock that the federal procurement system could have produced such an outcome. Of course, most of this is a sideshow, the opening act to an even more serious drama in the making.

Let us be clear from the outset, the rollout of Healthcare.gov is an embarrassment. However, this only becomes a real problem if it dissuades enough people who were already marginal customers with respect to their purchase of health insurance on the exchanges to simply pay the penalty and avoid the hassle of staring at a computer screen, waiting on hold for hours, or refusing to try again once the geeks get this all sorted out.

While the self-appointed technology experts on both sides of the aisle have been debating the causes of the web site debacle, attention has been diverted away from the necessarily frank discussions we must have about the real potential benefits and looming costs of the exchanges.

In a valiant attempt to steer the conversation towards the benefits of the ACA, President Obama held a rose garden press event where he repeatedly claimed that the health insurance on the exchanges is good product. But as is all too often the case, the President talked about the benefits and side stepped the difficult conversation about the costs.

At least he is half right. If they can ever fix the web sites, people with pre-existing conditions who shop on the exchanges will gain access to insurance at a more affordable price. Enrollees may save thousands of dollars. But let’s not kid ourselves.

The exchanges do not reduce the cost of medical care; they only change who pays for it. And we all know who that is.

Should Sebelius Resign?

Oct 27, 2013• 16

By John Hudak

As Congress begins investigations into the Affordable Care Act rollout and the healthcare.gov flaws, Republicans are calling for resignations as far up as the Secretary of Health and Human Services. The logic goes: if managerial issues were behind failures to test the website component of the federal health care exchange, we need new management.

That concern is a valid one. In the private sector and often times in the public sector, when misakes happen—particularly in an area critical to the executive’s interests—heads roll.

Yet, Kathleen Sebelius will stay, and Republicans have no one to blame but themselves.

Why is this? In an ironic twist of fate the Republican Party’s obsession with filibustering, delaying, or holding executive branch nominations will finally have negative consequences for the GOP instead of the president.

Over the past several years, Republicans in Congress had refused to confirm a director of the Consumer Financial Protection Bureau because they did not like the law that authorized the agency. They refused to confirm nominees to the National Labor Relations Board because of opposition to unions. They put a hold on the chairman of the Federal Communications Commission for fear he may require more transparency in campaign activity. The examples go on.

Why, then, would President Obama remove Secretary Sebelius and nominate a replacement? The HHS Secretary oversees the implementation of the Affordable Care Act. And GOP opposition to CFPB or NLRB or FCC pales in comparison to the visceral and existential contempt the party feels toward Obamacare. Given such opposition, the president would be foolish to make such a change in HHS leadership.

Through Google Glass, Maybe

Oct 27, 2013• 3

By H. James Wilson

Everybody is hopping on the wearables bandwagon. Since the publication of my HBR article on wearables, I’ve been asked a number of follow-up questions from executives, tech analysts, and most especially from entrepreneurs.
Though the questions vary, they generally fall into three buckets.

“Aren’t Head-up Displays (HUDs) like Google Glass where the market is going?”

No. Not necessarily. Pricey (and for now, socially awkward-looking) HUDs will likely be a sliver of the nearly half-billion units that will ship by 2018. By comparison, most other types of wearables will be relatively cheap, and as socially unobtrusive as a ring or wristband.

No doubt, there will be well-defined segments of HUD wearers. For instance, emergency first responders and many disabled people will immediately benefit from additional contextual information the tools display that enhance safety and the ability to navigate tricky situations. The more you consider real data and use-cases, the more you see wearables’ potential to support humanistic aspirations.

However, as I suggest in my HBR piece, we should vigorously question the ethics and effectiveness of any “asymmetrical” uses of HUDs. The presumption that a Google Glass wearer has a right to ascertain information from others who haven’t opted in isn’t necessarily socially acceptable. (HBR editor Scott Berinato calls Glass wearers who point their devices at others who haven’t opted in “glassholes”). It may not even be legal. In the work place, any use absolutely must be accompanied by clearly stated benefits to the employee (not just the employer) and ensure her data privacy. Otherwise, it’s Orwellian.

Aren’t wearables basically just a hands-free PC or smartphone?

Some wearables are indeed the next stage in the evolution from PCs to smartphones to tablets. Samsung’s watch, for example, tethers to its phone and lets you take and receive calls and texts. But many others tools and applications, such as the one I describe below, are discontinuous. They support radically new ways to improve work and society. The opportunity in the discontinuous space is probably bigger, and certainly some of the killer apps for wearables haven’t even been conjured yet. Something will take us by surprise.

GOP’s Oddest Obamacare Rejection: “Patient-Centered Healthcare”

Oct 27, 2013• 15

By Michael L. Millenson

The reason that Republicans shut down the federal government, it turns out, was to “restore patient-centered healthcare in America.”

Huh?

As the lead author of a policy paper entitled, “Will the Affordable Care Act Move Patient-Centeredness to Center Stage?” I admit to a certain guilty thrill when I read this precise demand coming as the climax of a letter sent by 80 hard-right representatives to House Speaker John Boehner (R-OH). You don’t get much more “center stage” than shutting off the federal money spigot, which is what the letter – discussed in a recent article in The New Yorker – threatened unless the ACA was defunded.

Having said that, patient-centeredness was a truly odd choice to occupy a central role in the conservative casus belli that ended up disrupting the entire U.S. economy until the right wing finally caved.

To begin with, the term is a minor piece of jargon likely to draw blank stares from pretty much the entire American public. Even for us health policy mavens, the GOP letter linking James Madison on the redress of grievances to defunding Obamacare to a “restoration” of patient-centeredness required major mental gymnastics.

Then there’s the unintentional linguistic irony. The term “patient-centered medicine” originated after World War II with a psychoanalyst who urged physicians to relate to patients as people with physical and psychological needs, not just a bundle of symptoms. “Patient-centered care” further defined itself as exploring “patients’ needs and concerns as patients themselves define them,” according to a book by the Picker/Commonwealth Program for Patient-Centered Care, which coined the term in 1987. Patient-centered care was adopted as a “goal” by the Institute of Medicine, which added its own definition, in 2001.

But here’s where the irony kicks in. Obamacare opponents assert that the ACA undermines the traditional doctor-patient relationship – although I suspect that being able to pay your doctor because you have health insurance actually improves it quite a bit.

Yet in calling for “patient-centered healthcare” instead of the more common “patient-centered care” or even patient-centered medicine, conservatives unwittingly abandoned doctor-patient language in favor of business-speak.

Making Health Addictive

Oct 26, 2013• 3

By Joseph Kvedar, MD

I first posed the question, “Could Mobile Health Become Addictive?” on August 20^th. Since then I’ve done more thinking and I’m warming to the concept.

To start with, addiction is a word laden with negative meaning. When we hear the word, we think of opiates, street drugs, cigarettes, or possibly gambling. In fact, Wikipedia defines addiction as, “the continued repetition of a behavior despite adverse consequences.” So, with that definition as backdrop, is there any way health can really be addictive? Probably not.

What I’m really talking about is the juxtaposition of motivational health messaging with some other addictive behavior, specifically checking your smartphone.

New evidence shows that people are in love with these devices, checking them more than 100 times per day! I’ve heard people are tapping in 110, even 150 times a day. Of course this varies, but let’s face it, we check our smartphones a lot and it’s hard to stop. A somewhat disturbing video makes the case well. It’s easy to build a case that smartphones are addictive.

Recent research shows that checking your phone results in a small release of the neurochemical dopamine. Dopamine release has long been associated with ingestion of addictive substances such as heroin and tobacco. In fact, once the pattern of ingestion and dopamine release is established, even thinking about the ingestion triggers the dopamine release, the biochemical explanation for cravings.

For this post and a series to follow, I choose not to question whether this compulsive relationship with smartphones is good or bad, but simply to acknowledge that it is common, almost universal among smartphone users and to ask if we can exploit it as tool to improve your health.

What’s Next for Healthcare.gov?

Oct 25, 2013• 12

By Aneesh Chopra

The launch of HealthCare.gov certainly didn’t go as planned. Due to technical errors, millions of Americans were sent to the functional equivalent of a waiting room before they could enter the shopping portion of the site.

Historically, projects of such complexity and demand have encountered early problems yet still often achieve great success. While much of the commentary has focused on coding problems, the site still has the potential to spur innovation — be it public or private — that will result in quality improvement and lower costs.

For context, the HealthCare.gov site is merely the front door to an incredibly complex technological undertaking tasked with organizing insurance plans, assessing program eligibility, facilitating consumer enrollment, managing financial services, and providing all of the associated customer support.

An estimated 19 million people visited the site through Sunday, and many did so at the same time; at peak periods, there were five times as many simultaneous visitors as had been expected. In rapid response to that surge, the HealthCare.gov team tried to restrict the number of visitors to the area of the site where they could establish accounts and begin shopping.

Naturally, this was not ideal, but it was preferable to the alternative.

When Internet entrepreneurs prepare to launch a new service, they tend to anticipate two scenarios. The first, and worst, is that nobody visits. The other is that too many people do.

Rise of a new platform

Drawing from my experience as CTO in President Barack Obama’s first term, we overcame initial technical challenges in popular programs such as “Cash for Clunkers” or the Post-9/11 GI Bill of Rights for veterans through an analysis of the root cause problems — and a systematic plan to address them.

I’m confident that the HealthCare.gov team will similarly fix the technology with the help of experienced technical talent – in and out of government – to work through its punch list. The site should continue to improve in the weeks ahead, building toward Dec. 15.

But the real story, likely to play out over the coming months, will be its rise as a new platform for innovation – one that will lead to the creation of new private sector services to improve our nation’s health.