The Health Care Blog – Page 524 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

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.

* Patients Not Included

Oct 25, 2013• 22

By LESLIE KERNISAN, MD

A few weeks ago, I went for the first time to Stanford’s Medicine X conference. It’s billed as a conference that brings a “broad, academic approach to understanding emerging technologies with the potential to improve health and advance the practice of medicine.”

Well, I went, I saw, and I even briefly presented (in a workshop on using patient-generated data).

And I am now writing to tell you about the most important innovations that I learned about at Medicine X (MedX).

They were not the new digital health technologies, even though we heard about many interesting new tools, systems, and apps at the conference, and I do believe that leveraging technology will result in remarkable changes in healthcare.

Nor were they related to social media, ehealth, or telehealth, even though all of these are rapidly growing and evolving, and will surely play important roles in the healthcare landscape of the future.

No. The most remarkable innovations at MedX related to the conference itself, which was unlike any other academic conference I’ve been to. Specifically, the most important innovations were:

Patients present to tell their stories, both on stage and in more casual conversational settings such as meals.
Patient participation in brainstorming healthcare solutions and in presenting new technologies. MedX also has an ePatient Advisors group to help with the overall conference planning.

These innovations, along with frequent use of storytelling techniques, video, and music, packed a powerful punch. It all kept me feeling engaged and inspired during the event, and left me wishing that more academic conferences were like this.

These innovations point the way to much better academic conferences. Here’s why:

The power of patient presence

I wasn’t surprised to see lots of patients at Medicine X, because I knew that the conference has an e-patient scholars program, and that many patients would be presenting. I also knew that the director of MedX, Dr. Larry Chu, is a member of the Society of Participatory Medicine. (Disclosure: I’ve been a member of SPM since last December.)

I was, on the other hand, surprised by how powerful it was to have patients on stage telling their stories.

How could it make such a difference? I am, after all, a practicing physician who spends a lot of time thinking about the healthcare experience of older adults and their caregivers.

But it did make a difference. I found myself feeling more empathetic, and focused on the patient and family perspective. And I felt more inspired to do better as a physician and as a healthcare problem-solver.

In short, having patients tell their stories helped me engage with the conference presentations in a more attentive and meaningful way.

Now, some will surely be tempted to wave this off as a gauzy touchy-feely experience that is peculiar to the fruit-cakes of the Bay Area; a nice conference touch that isn’t materially important to the purpose of an academic conference.

Sorry. Saturated Fat is Bad For You. Or More Accurately — It’s Complicated. Let’s Review the Evidence…

Oct 25, 2013• 8

By David Katz, MD

A commentary in the current issue of the British Medical Journal (BMJ) suggests that saturated fat is not really so bad after all. The article has the media buzzing, with headlines exonerating saturated fat sprouting like mushrooms throughout cyberspace and print media alike. My most recent Google search of “saturated fat” limited to news retrieved 20,000 sites.

Since the new paper is just a commentary — one doc’s opinion — and not a new study, and since this opinion has been asserted many times already, I’m not sure I really get the reaction. But hey, I just work here. Let’s deal with it.

Is it, in fact, time to absolve saturated fat? No, it’s not. But then again, it was never time to demonize it in the first place. I will lay out my case that we are ill-served to think of saturated fat as either scapegoat or martyred saint.

1) Ancel Keys was never really wrong.

The case against saturated fat, its implication in the development of atherosclerosis, inflammation, and chronic diseases, notably heart disease, involves a vast expanse of research over many years by thousands of researchers around the world. But dealing with all of that in this column would be a terrible bother, so let’s just blame it all on Ancel Keys. Keys was certainly among the first to emphasize the association between saturated fat intake and heart disease.

The temptation to absolve saturated fat comes along with a temptation to indict Dr. Keys of crimes against dinner. But, Ancel Keys, while perhaps not quite right, was never really wrong.

Keys looked at rates of disease around the world and correctly noted that heart disease was more common in societies that ate more meat and dairy. His mistake may have been to look past that dietary pattern for the “active ingredient” in it, which led to the convictions of dietary cholesterol, saturated fat, and to a lesser extent overall dietary fat.

There’s much that could be said about this. Whole columns could be written about dietary cholesterol, dietary fat, and saturated fat and ways we went wrong. In fact, I — along with innumerable others — have written just such columns. Simply click the inserted links.

The 834 Problem

Oct 25, 2013• 12

By Robert Laszewski

You have probably already heard that Obamacare has as many backroom problems as problems with the front end consumer web enrollment portal.

Insurance companies participating in the new health insurance exchanges are receiving detailed enrollment information for each of the very few people who have successfully enrolled through the 36 federally run health insurance exchanges.

But the problem is that this enrollment is coming from the government with a very high rate of errors––way beyond anything they can handle manually once the real enrollment volume comes in.

So long as each insurance company is receiving only 10 or 20 enrollments a day––that is what they are receiving now––the high error rate enrollments can be fixed with lots of hands-on effort. If the Obama administration fixes the consumer portal before fixing the 834 problem, the insurance companies could begin receiving thousands of enrollments with high error rates every day.

That would bring the insurance company information technology departments to their knees. It would mean lots of new policyholders could have problems getting their bank accounts properly debited, their claims held up, or health care providers refusing to treat them because they aren’t on the list of covered people.

So this is a very big deal.

An 834 transaction is a technical term for exactly how enrollment information is exchanged, in this case, between the federal government and the health insurance companies.

The 834 transaction represents a computer “benefit enrollment and maintenance document.” It is commonly used by employers, unions, government plan sponsors (Medicare Part D, for example), and insurance marketing organizations to enroll members in a health benefit plan. This current version developed out of the 1996 Health Insurance Portability and Accountability Act (HIPAA). So, it has been around for many years.

This process is where the federal government’s backroom has come off the rails and is in need of an urgent fix.

Round One of the Obamacare Exchange Hearings. Angry Republicans 6 Contractors 0.

Oct 24, 2013• 7

By Charles Ornstein

Today’s House Energy and Commerce Committee hearing/grilling of the contractors behind Healthcare.gov brought a lot of defenses and fingerpointing, but little clarity of when the website will be fixed.

Still, here are some of the more-memorable quotes. The sources are below each.

“I will not yield to this monkey court,” Rep. Frank Pallone (D-N.J.) said when Republican lawmakers tried to talk about online privacy fears. -Politico

“This is not about blame. It’s about accountability,” said Rep. Fred Upton (R., Mich.), chairman of the House Energy and Commerce Committee. “We still don’t know the real picture, as the administration appears allergic to transparency.” – WSJ.com

“CMS [the Centers for Medicare and Medicaid Services] had the ultimate decision to go live or not go live,” said Cheryl Campbell, senior vice president of CGI Federal, the lead federal contractor on the project. “At CGI we were not in position to make that decision. We were there to support the client. It’s not our position to tell clients whether to go live or not go live.” — Washington Post

“Amazon and eBay don’t crash the week before Christmas,” said Rep. Anna Eshoo of California, a Democrat. “ProFlowers doesn’t crash on Valentine’s Day.” – NBC News

“Three weeks after the Web site went live, we are still hearing reports of significant problems. These problems need to be fixed, and they need to be fixed fast,” said Representative Diana DeGette, Democrat of Colorado. -New York Times

“We understand the frustration many people have felt since healthcare.gov was launched. We have been and remain accountable for the performance of our tools and our work product,” said Andrew Slavitt, the group executive vice president for Optum/QSSI, a contractor on the project. – ABC News

Meanwhile, HHS officials may be regretting their decision to give Healthcare.gov visitors the ability to post comments to the site. ProPublica reporters reviewed over 500 comments posted at https://www.healthcare.gov/connect/.

A sampling:

Wrongly Listed As Jailed

“Website said my wife and I were ineligible due to current incarceration. We have never been arrested in our lives, both 63!!!!!!!!!!!!!!!!!!!!!!!,” Fred wrote on Oct. 21.

Health Problems Made Worse

“I have a pre-existing condition …. a-fib…..and actually had an attack after getting frustrated with this confusing mess,” Bill wrote on Oct. 22. (A-fib refers to atrial fibrillation, an abnormal heartbeat.)

Daughter is Not a Daughter Anymore

“I am having difficulty with my account,” Joanna wrote on Oct. 22. “It appears that my daughter was added twice so that I now have two daughters with the same name and social security number. I am unable to delete one of them. Also, the drop down menu that relates to what relationship someone is to another is faulty. I choose that my husband is the father of our daughter and that my daughter is a dependant [sic] to me and my husband. What it actually shows though is that my daughter is a stepdaughter to her father and that my daughter is now both my husband and I’s parent. “