The Health Care Blog – Page 526 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Healthcare.com Would Have Worked Better

Oct 20, 2013• 21

By J.D. Kleinke

Is this any way to build a railroad?

By now you’ve heard that the “Obamacare exchanges” did not launch on October 1 so much as stumble out into public view, barely able to crawl.

Three weeks later, the federal version — “healthcare.gov,” which is actually the same exchange re-deployed 36 times in 36 states — is still barely able to crawl. By contrast, most of the 15 exchanges operated by individual states and the District of Columbia are working more or less fine, for varying reasons we will explore in a moment.

Why the epic fail for healthcare.gov, estimated to have generated a health insurance enrollment rate of less than one-half of one percent among nearly 10 million visitors? Information technologists have identified lunk-headed flaws in its overall design, while pointing to the way the Federal government rolled it out, all at once, all across the nation — as if it were a campaign commercial and not one of the most complex undertakings in the history of e-commerce.

Which would be for good reason: the federal exchange is a campaign commercial, one the Administration had no choice but to broadcast after its opponents went to war on every front against implementation of the Affordable Care Act.

The architects of the ACA expected that states would build their own exchanges. The federal exchange was supposed to be a failsafe — a fallback for a few straggler states unable to build their own in time for the October 1 launch. For the rest, healthcare.gov was supposed to do two things: point people to their state’s exchange; and handle the very complicated task of querying tax and other federal databases to verify people’s eligibility.

Instead, it found itself saddled with the entire e-commerce job for 36 refusenik states.

If Gun Violence is a Health Epidemic, Can We Quarantine It Like a Virus?

Oct 20, 2013• 4

By Mike R. Weisser

At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.

But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.

It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.

Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.

So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.

And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?

Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.

Should the Obamacare Exchanges Be Shut Down?

Oct 19, 2013• 36

By Robert Laszewski

My sense is that the biggest reason Obamacare is now in trouble is because of the top-secret way in which the administration has handled the rollout. If they had developed the computer system in a transparent way, the marketplace would have told them long ago this would not work.

No one outside the inner circle at the Department of Health and Human Services has any idea what’s really going on behind the Wizard’s curtain. Hasn’t for months. Doesn’t now.

So any technical advice any of us could give would be, to say the least, uninformed.

If I were on the inside, and it were up to me, the first thing I would do is bring in a group of heavyweight information technology experts to tell me just what was really going on. The administration cannot trust the people who have been working on this because they told them to launch this mess on October 1 and almost three weeks in there has been no improvement on the website or in the backroom––they no longer have credibility.

I would ask those experts to very quickly answer three questions:

Can this thing be fixed on the fly––as the administration appears to be trying to do?
If it can’t be fixed on the fly––and three weeks into this that sure looks doubtful––then can it be taken down for one or two months with a high degree of confidence it can be brought back up in time to enroll people sooner rather than later?
If the first two options are not possible, just how long will the computer system have to be shutdown before Obamacare can be launched in a way that there can be confidence it will work smoothly?

Then I would take their advice.

The Great Coronary Angioplasty Debate: Giving Patients the Right to Speak

Oct 19, 2013• 2

By Nortin Hadler, MD

Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”

The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.

I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.

I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.

So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.

There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).

State Surveillance Endangers the Affordable Care Act: A Case Study

Oct 18, 2013• 10

By Adrian Gropper, MD

… and a call to action. This case study is based on my meeting with the Center for Health Information and Analysis (CHIA) in my home state. CHIA is an all payers claims database, a massive collection of diagnoses, locations, dates and prices for all of your health services across all of your providers and insurers. Whether it’s claims or health records, almost every state and many private clearing houses are setting up to monitor you.

Your information can be used by business to manipulate prices for maximum profit, or by you to inform your choice of health insurance plans and health care providers.

Unfortunately, business can get your information but you can’t. This reflects an industry strategy to obstruct the market-based features of the Affordable Care Act. I hope you will take this case study, edit it, and file it with the Attorney General and Governor in your state to ask for your data as a consumer protection issue. That’s what I’m about to do.

My state is #1! Go Massachusetts! My state is #1 in health care costs. It’s also #1 in implementing a health insurance exchange (Romneycare 2006) and a leader in state surveillance with the 2012 cost containment law known as Chapter 224. Chapter 224 mandates various state surveillance mechanisms including a health information exchange that monitors encounters and an all payer claims database called “the center”.

The cost containment law also includes some consumer protections. Line 1909 states:

“To the maximum extent feasible, the center shall also make data available to health care consumers, on a timely basis and in an easily readable and understandable format, data on health care services they have personally received.”

Although the state surveillance is in place, and the price fixing that keeps us #1 is ongoing, the consumer protection part of the law is not implemented. So, I took the opportunity to meet with the executive director of CHIA and their chief legal counsel and get the scoop on why the state is not following the law. To paraphrase their explanation: “It’s too hard.”

Why PCORI Should Be Very Wary of Studying Medical Devices

Oct 18, 2013• 7

By Peter Ubel, MD

In the New York Times on Thursday, October 17, Topher Spiro wrote an important op-ed expressing why we need to hold onto the medical device tax that helps pay for parts of the Affordable Care Act. Spiro backs up his argument by pointing out how profitable the device industry is. To his argument I would also add the fact that this will provide the industry with more paying customers. Certainly it can afford to pay the taxes.

But I diverge from Spiro on a proposal he floated near the end of his piece:

“To complement these efforts, the new Patient-Centered Outcomes Research Institute [PCORI], a non-governmental body created by the Affordable Care Act, should pay for research that compares the effectiveness of devices so physicians can make informed choices. (Three years into its existence, the institute has initiated few, if any, studies of medical devices.”

Listen to me PCORI. Don’t follow this advice, unless you plan not to survive to celebrate your fourth birthday.

Consider what happened to the Agency for Healthcare Policy Research (AHCPR), when it tried to help physicians figure out the best way to treat low back pain. AHCPR was created as a stand-alone research institute, akin to the NIH, but one that would focus not on the basic science of treating disease, but instead on evaluating how well existing treatments worked.

A Pragmatic Fix for Healthcare.gov & the HIXs

Oct 18, 2013• 24

By MATTHEW HOLT

By now even those of us who originally thought that we were seeing minor teething troubles are no longer deluding ourselves. Healthcare.gov, the federal health insurance exchanges (HIXs), and many of the state HIXs are in deep trouble.

One summary of many articles about this is up at ProPublica. But now that the House Republicans have stopped trying to destroy the country and themselves, attention will turn quickly to this problem, and–much worse–beyond the politics, there is now only eight or so weeks to get ready for actual enrollments for Jan 1, once you take out Thanksgiving and the Christmas holiday. Getting ten or twenty million new customers on board, not to mention the small businesses who want to move from their current insurance onto the exchanges, seems like an impossible task.

But, if we can muster the will, there may be a solution. (And yes, I want it to work, faut de mieux). Quietly last summer two private online insurance brokers, eHealth which runs the eHealthInsurance.com site, and GetInsured, struck deals with HHS which allowed them to enroll individuals in plans that qualify for the mandate under the ACA, and more importantly, connect with the “Health Exchange Data Hub” that figures out whether the enrollee qualifies for a subsidy (theoretically by connecting to the IRS).

That part of the transaction, though, could be done by attestation and dealt with later. In other words, someone buying health insurance could state what their income will be in 2014 (or was in 2013) and if it ends up varying dramatically on their 1040 then in 2015 they will pay or receive the difference. Essentially this is something all Americans recognize–the IRS asks you for more or gives you a tax refund well after the fact, and H&R Block and their competitors make a business of giving you the refund right away (and of course charge you for the privilege).

That is important because what seems to be crippling the HIXs right now is not the back end, it’s the front end. (Go to this Reddit thread for lots more deeply technical conversation about that). Showing people options, comparing plans, setting up accounts–that’s all standard web stuff and most of the HIXs can’t do it. Those private brokers have both smoothly done this for years and at least the two I mentioned have built comparative tools for the new insurance plans. (Both were demoed at Health 2.0 on October 1).

So why can’t we put prominent links to eHealthInsurance.com and GetInsured on the Healthcare.gov site and move people over there? Continue reading…

My Personal Affordable Care Act–A Manifesto

Oct 17, 2013• 43

By Vik Khanna

The Founding Fathers had one. Karl Marx had one. Bertrand Russell and Albert Einstein had one. And, now I have one: a manifesto, declaring my intent to live my life with as little interaction as possible with the US health care system by doing what the Affordable Care Act (ACA) tells me by omission I do not need to do: take responsibility for myself.

This is my Personal Affordable Care Act.

My manifesto is an algorithm for thriving in spite of the government’s naked and absurd attempt to define health as something that begins in the clinic. My goal is to make myself and my family as scarce as possible within the health care system.

The ACA is a collective solution to the mass failure of individual will. Our transformation into an information culture actually worsened the malady. We are so conditioned to success at the speed of a search engine that, like the person who aspires to retire early, but refuses to save, we’ve forgotten to manage the fundamentals.

First, that every healthy lifestyle decision you make today, from diet and exercise to outlook and mood, requires thought and an exertion of will. Even in the age of Google, volition matters, and choosing not just wisely, but strategically, is an option available to most people.

Second, despite revolutionary democratization of medical information, we still don’t do our homework. Americans visit physicians 3 times per year on average, and the number one reason for the visits is “cough.” Really? You need to go to the doctor for a cough? Unless you have a fever, chest discomfort, bloody sputum, or the cough lasts for weeks and keeps you up at night, it is almost certainly viral or related to an allergen and self-limited.

The Federal Shutdown is Over. The Health Care Fight is Just Getting Started. Here’s What May Happen Next…

Oct 17, 2013• 2

By Dan Diamond

Social security numbers allegedly passed around in clear sight. Page after page of unworkable code. And no clarity on when it will all be fixed.

Just another day of trying to log in to healthcare.gov.

Two weeks after its launch, the federal health insurance exchange is a “failure,” says the Washington Post‘s Ezra Klein. Some officials deserve to be fired, according to Robert Gibbs, who until February 2011 was one of President Obama’s closest advisers.

And those are the Affordable Care Act’s supporters.

Even the president conceded on Tuesday that healthcare.gov had “way more glitches than I think are acceptable.”

Those glitches could take months — or even years — to fix, according to reports. But there’s a key deadline looming: Jan. 1, 2014, when the ACA’s individual mandate takes effect.

Under the mandate, millions of Americans who were expected to use the exchanges to obtain health insurance will face fines if they haven’t purchased coverage by Feb. 15, raising the question of whether the mandate or other Obamacare provisions should be postponed — an uncomfortable position for an administration already trying to implement a politically divisive law.

But at this late date, what parts of the ACA can legally be delayed?

“In a sense, all of it,” Timothy Jost, a Washington & Lee law professor, told me. But “there’d be a high political price to pay. And delay could result in litigation.”

Jost was among several experts who spoke with me about the health insurance exchanges’ bumpy rollout, the ripple effects for the mandate and other provisions, and what it could all mean for implementing the ACA.

What Agencies Can and Can’t Do
When considering a delay to Obamacare, it’s important to understand the difference between statutory and discretionary deadlines.

For example, the ACA’s language directly calls for many mandatory deadlines — like rolling out the individual mandate or implementing a slew of insurance market reforms on Jan. 1, 2014.

But the agencies also have had considerable leeway on how they’ve chosen to apply the law — like choosing an Oct. 1 launch date for the exchanges, a deadline that retrospectively seems ambitious.

Knocking on Health 2.0’s Door

Oct 16, 2013• 29

By Leslie Kernisan, MD

I recently attended the flagship Health 2.0 conference for the first time.

To avoid driving in traffic, I commuted via Caltrain, and while commuting, I read Katy Butler’s book “Knocking on Heaven’s Door.”

Brief synopsis: healthy active well-educated older parents, father suddenly suffers serious stroke, goes on to live another six years of progressive decline and dementia, life likely extended by cardiologist putting in pacemaker, spouse and daughter struggle with caregiving and perversities of healthcare system, how can we do better? See original NYT magazine article here.

(Although the book is subtitled “The Path to a Better Way of Death,” it’s definitely not just about dying. It’s about the fuzzy years leading up to dying, which generally don’t feel like a definite end-of-life situation to the families and clinicians involved.)

The contrast between the world in the book — an eloquent description of the health, life, and healthcare struggles that most older adults eventually endure — and the world of Health 2.0’s innovations and solutions was a bit striking.

I found myself walking around the conference, thinking “How would this help a family like the Butlers? How would this help their clinicians better meet their needs?”

The answer, generally, was unclear. At Health 2.0, as at many digital health events, there is a strong bias toward things like wellness, healthy lifestyles, prevention, big data analytics, and making patients the CEOs of their own health.

Oh and, there was also the Nokia XPrize Sensing Challenge, because making biochemical diagnostics cheap, mobile, and available to consumers is not only going to change the world, but according to the XPrize rep I spoke to, it will solve many of the problems I currently have in caring for frail elders and their families.

(In truth it would be nice if I could check certain labs easily during a housecall, and the global health implications are huge. But enabling more biochemical measurements on my aging patients is not super high on my priority list.)