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Bringing Nurses Into the Cost Containment Discussion

Jul 15, 2013• 9

By September Wallingford, RN

Why are nurses not usually integrated into the cost containment discussion? Why have we not been invited to the table? Likely, it is because we don’t have the power to order (or discontinue) tests, labs, or medications, all of which are major factors in the rising costs of care. Even so, a nursing perspective can be important and should be considered when doctors make treatment decisions.

For example, I recently treated a patient who had undergone abdominal surgery. Despite uncomplicated post-operative days 1 and 2, on day 3, he developed nausea, vomiting, and an increasingly distended abdomen. I administered intravenous anti-nausea medications, along with back rubs and cool cloths on his forehead. None of the treatments worked. While waiting for the doctor, I sat with the patient and spoke to him about the possibility of receiving a nasogastric tube to alleviate his symptoms. Given an understanding of the process, the patient agreed to this possibility and I paged the doctor once again. The doctor eventually placed the nasogastric tube, the tube was connected to suction, and out came a liter of gastric contents.

I then noticed that the doctor had put in an order for an abdominal x-ray to “check nasogastric tube placement.” Seeing this, I initiated a conversation with the doctor to discuss the patient’s symptomatic improvement as well as his current state of exhaustion. I assured the doctor that nurses would be at the patient’s bedside to monitor for signs and symptoms of tube malfunction. As a result, the doctor cancelled the x-ray, which not only eliminated an unnecessary test for the patient, but also reduced the cost associated with his care.
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The Affordable Care Act and the Death of Personal Responsibility

Jul 14, 2013• 126

By Vik Khanna

I was a chubby kid, which brought with it all manner of slights, both real and imagined. My predicament was worsened because I came from an immigrant family, and my father was tormented by unrelenting and untreated bipolar disease. When he was lucid, however, he taught essential lessons that neither he nor I knew at the time would become my life’s cornerstone: don’t trust the professions too much; advance your own cause through limitless learning; and, use exercise — all forms of it — as an irreplaceable lever for personal betterment. My dad may have been out of it more often than not, but he swam, did calisthenics, played tennis, and boxed, and he walked vigorously right up until the end of his life. I saw, I learned, I did (and still do).

Imagine, then, my chagrin at how the Affordable Care Act (ACA) effectively shears away the concept of personal responsibility and mastery of lifelong wellness skills from the pursuit of actual health. It was a huge missed opportunity to teach Americans about what’s first in the line of responsibility for good health.

Instead, the ACA’s philosophical foundation ignores the power that individuals have to impact their personal health trajectory, and it compels Americans to accept lifelong roles as patients in a system that many of them not only don’t want any part of but that they distrust and don’t understand. It is exactly the opposite result that something called “health” reform should have produced.

As the Debate Over Obamacare Implementation Rages, a Success on the IT Front

Jul 12, 2013• 34

By Ashish Jha, MD

Just a little over four years ago, President Obama, in his inaugural address, challenged us as a nation to “wield technology’s wonders to raise health care’s quality and lower its costs.” This was an awe-inspiring, “we will go to the moon” moment for the healthcare delivery system. But the next thought that ran through the minds of so many of us who work on health IT issues was this: how were we going to get there?

We were essentially starting from scratch. Less than 1 in 10 hospitals had an electronic health record, and for ambulatory care physicians, the numbers weren’t much better – about 1 in 6 had an EHR. Hospitals and physicians reported an array of challenges that were holding them back. No nation our size with a healthcare system as complex as ours had even come close to universal EHR use. Yet, the President was calling for this by just 2014.

And it was clear why. The promise of EHRs was enormous and we knew that paper-based records were a disaster. They lead to lots of errors and a lot of waste. I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR. In the weeks that followed Obama’s inaugural address, the U.S. Congress passed, and the President signed the Health Information Technology for Economic and Clinical Health Act, which contained a series of incentives and tools to drive adoption and “meaningful use” of EHRs. None of us knew whether the policy tools just handed to the Obama administration were going to be enough to climb the mountain to universal EHR use. We were starting at sea level and had a long climb ahead.
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How Digital Technology is Transforming Value in Health Care

Jul 11, 2013

By Robin Friedlander, MD

Health 2.0 has collaborated with UC Berkeley’s Haas School of Business to offer a first of its kind executive education course to be held this October 3rd-5th in Berkeley, California.

How Digital Technology is transforming Value in Health Care is a three-day course for health care leaders and executives in health IT who will benefit from expert instruction, critical analysis, and high-level discussion around this rapidly changing and exponentially growing area. Digital technology impacts nearly all aspects of health care today, and yet so much of this technology is new to those at the front lines of improving care delivery, be they on the payor side, provider side or service side.

Professors including Bob Rogers PhD, chief data scientist at Apixio, Ann O’Leary, chief expert on the organization and financing of the health care system at Berkeley School of Law, and Jaspal Sandhu PhD, systemic innovation expert, will cover topics including big data, policy and regulatory issues in health IT, and patient-centered design.

The Health 2.0-Berkeley course is part of a larger initiative, Health 2.0 EDU, which is a response to widespread demand for a targeted, learning objectives-driven, and comprehensive education program for the health care and health IT communities. EDU brings draws upon Health 2.0’s seven year history of curating and presenting excellent content as well as its worldwide network of leaders in health care technology. Health 2.0 EDU also offers online courses and workshops through a new virtual learning center.

For those who plan to come to the Health 2.0 Fall Conference, registration for the Health 2.0-Berkeley course grants you a 50% discount for the conference ticket. Space is limited – you can register early here.

Robin Friedlander, MD is the senior director of consumer and academic programs at Health 2.0.

The GOP’s Endless War on Obamacare-and the White House Delay

Jul 11, 2013• 177

By Robert Reich

The official reason given by the Administration for delaying, by one year, the Affordable Care Act’s mandate that employers with more than 50 full-time workers provide insurance coverage or face fines, is that employers need more time to implement it. The unofficial reason has more to do with the Republicans’ incessant efforts to bulldoze the law.

Soon after the GOP lost its fight against Obamacare in Congress, it began warring against the new legislation in the courts, rounding up and backstopping litigants all the way up to the Supreme Court. Meanwhile, House Republicans have refused to appropriate enough funds to implement the Act, and have held a continuing series of votes to repeal it. Republican-led states have also done what they can to undermine Obamacare, refusing to set up their own health exchanges, and turning down federal money to expand Medicaid.

The GOP’s gleeful reaction to the announced delay confirms Republicans will make repeal a campaign issue in the 2014 midterm elections, which probably contributed to the White House decision to postpone the employer mandate until after the midterms. “The fact remains that Obamacare needs to be repealed,” said Senate Republican leader Mitch McConnell, on hearing news of the delay.

The Father of Microlending Takes on U.S. Health Costs

Jul 11, 2013• 2

By Malorye Allison Branca

What can a microlending bank in Bangladesh teach us about trimming healthcare costs in New York City? Perhaps much more than we think.

Nobel Peace Prize-winning economist Muhammad Yunus founded Grameen Bank, revolutionizing the fight against poverty by handing out “micro” loans of less than $30 to Bangladeshi women during the mid 1970s. He went on to spread microfinance around the world, including to Queen’s, New York, where the flagship Grameen America office serves 12,000 women.

Now, he’s piloting a breakthrough health program aimed at dramatically cutting costs while improving the health of those borrowers in Queens. It’s a tall order, given that these women are mainly immigrants, single working mothers, and living on $20,000 a year or less.

What’s more, the program is designed to become self-sustaining. The borrowers will pay for some of the services from the start. Over time, their payments will cover more of the costs. That, Yunus argues, is the only way programs for the poor can be long lasting and deliver the quality of service people want. Even the wealthiest nations, Yunus says, are starting to realize that their “free” health systems are still too expensive to pay for.

Healthcare insiders will be incredulous. How in the world will the priciest healthcare system serve people living below poverty without relying mainly on charity? Yunus answers that question, and explains why he’s going into health care in the first place, in a recent Financial Times op-ed [i].

In his work with the world’s poor, Yunus has been continually rankled by the fact that health care costs are such a burden to so many and are continually rising. For the poor, health costs are an especially serious threat, because even small bills can cause financial ruin. To someone living on $25 per day, for example, a $300 prescription represents weeks of food and transportation.
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Health Insurance Exchange Subsidies–Another Warning Sign???

Jul 11, 2013• 12

By Robert Laszewski

Come October millions of people will be applying for tens of billions of dollars in federal health insurance premium subsidies on the honor system.

On the Friday after the Fourth of July––when the administration apparently hoped no one would be paying attention––the Obama administration dropped 606 pages of regulations. Buried inside was the news that that insurance exchanges can ignore any personal income information they get from the Federal Data Hub during 2014 if it conflicts with “attestations” made by individuals.

That came three days after the administration announced it was putting the employer mandate on hold––and therefore not requiring detailed information from employers regarding the health plans they offer to their workers. The administration said the delay was because of the burden the reporting put on employers. But, was the administration ready to handle the data?

Because there will be no employer reporting in 2014, the administration also said in the Friday regs that the new health insurance exchanges “may accept the applicants attestation regarding enrollment in eligible employer-sponsored plan…without verification.” Given the incredibly complex “ObamaCare” 60%/9.5% employer benefit eligibility rule, that will be a challenge for most citizens.

But here’s the biggest deal in the new “ObamaCare” regulation: The exchanges are to rely upon the applicant’s statement regarding their income the vast majority of the time. Instead of requiring proof of their income, as had been expected when the Federal Data Hub couldn’t verify someone’s representation, the exchanges will only do a formal check on a “statistically valid sample” of applications.”

For those not part of this “statistically valid sample,” “the Exchange may accept the attestation of projected annual household income without any further verification.”

Apparently, millions of people will receive tens of billions of federal premium subsidy dollars “without any further verification.”

It would appear that the administration is going to rely upon subsequent 2014 tax filings, made in early 2015, to reconcile what it paid people compared to what they were actually eligible for.

That presents some big issues.

Caveat Online Health Information Emptor?

Jul 10, 2013• 11

By Brian Ahier

Patients who search on free health-related websites for information related to a medical condition may have the health information they provide leaked to third party tracking entities through code on those websites, according to a research letter by Marco D. Huesch, M.B.B.S., Ph.D., of the University of Southern California, Los Angeles.

The research letter was recently published in JAMA Internal Medicine entitled “Privacy Threats When Seeking Online Health Information” and looked at how 20 health-related websites track visitors, ranging from the sites of the National Institutes of Health to the health news section of The New York Times online. Thirteen of the sites had at least one potentially worrisome tracker, according to the analysis performed by Dr. Huesch.

He also found evidence that health search terms he tried — herpes, cancer and depression — were shared by seven sites with outside companies. According to the paper:

“A patient who searches on a “free” health-related website for information related to “herpes” should be able to assume that the inquiry is anonymous. If not anonymous, the information knowingly or unknowingly disclosed by the patient should not be divulged to others.
Unfortunately, neither assumption may be true. Anonymity is threatened by the visible Internet address of the patient’s computer or the often unique configuration of the patient’s web browser. Confidentiality is threatened by the leakage of information to third parties through code on websites (eg, iframes, conversion pixels, social media plug-ins) or implanted on patients’ computers (eg, cookies, beacons).”

Dr. Huesch says that he was inspired to investigate this area by the archive of coverage on the topic by The Wall Street Journal on how the technology and market for your online information work. The most recent piece in this series is on Facebook privacy settings and some of the risks associated with “Graph Search.” This entire series is very good and worth the read.

Getting Obamacare’s Messaging Right

Jul 10, 2013• 4

By Les Funtleyder

Recently, there was a bit of a dust-up over whether it was appropriate for the Secretary of Health and Human Services (HHS) to engage the National Football League (NFL) to help HHS with the process of drumming-up enrollment for health insurance exchanges. In the end, the NFL and other sports leagues decided they were not going to be involved fearing the appearance of taking political sides.

In our view HHS is better off with this outcome. To our way of thinking the exercise would not have delivered the desired results and would have left individuals confused and created a political distraction. At the heart of most public health communication plans are three main functions: create a message, deliver the message and get people to act on the message (many variations: example, example, and example). The HHS/NFL combo would likely have failed the test: What exactly does someone who catches a football for a living say that would make the uninsured purchase insurance on an exchange? While it’s easy to single out HHS and the administration, the opposition party also thinks messaging alone will solve all of its ills but that is far from correct assumption in our view.

In terms of creating a message, our first instinct would be to recommend a governmental agency like the FCC but for healthcare. We would call it something like the clinical communications clarification committee (CCCC). However, given recent concerns about “Orwellian” government information gathering, perhaps a more open-source, crowd-sourced approach to communicating may be more readily accepted. What we have in mind is a something like Pubmed meets Wikipedia where the information is readily available, credible, and based on updated facts. Inevitably something like this would need to be proctored to keep unreliable information out. Many crowd-sourced communities do a good job of self-policing but it couldn’t hurt to have an adult watching just in case.

Assuming we can create information (the message) in a way that is understandable and credible, how to transmit this information (the medium) becomes the next challenge. While we are pretty sure the “wired generation” who wear body monitoring devices are getting the “right” information via mobile devices, the web etc., we think that more important populations that are not technologically savvy may be missing out. Dual-eligibles for example, who are major drivers of cost and poor outcomes in the system, are not in our view, easily able to access useful information via high-tech gadgetry.

British Petroleum’s Wellness Program is Spewing Invalidity

Jul 10, 2013• 28

By Al Lewis & Vik Khanna

A critical observation in Cracking Health Costs is you need not “challenge the data” to invalidate claims that wellness saves money. Instead, you can simply read the data as presented. You’ll find it usually invalidates itself.

Nowhere is that more true than in a study published this month by Mercer, Staywell and British Petroleum (“BP America”) in the Journal of Occupational and Environmental Medicine (JOEM). As we’ll demonstrate, the results completely contradict Staywell’s own statements, and are also mathematically impossible. Indeed, Mercer was a wise partner choice by BP America because their validations are often unconstrained by the limits of possibility. For instance, they validated massive savings both for infants in a North Carolina Medicaid program that did not enroll infants, and for a Georgia Medicaid disease management program that did not manage diseases, at least according to the FBI.

Along those lines, let’s see what happens when one compares the JOEM conclusion — that the Staywell wellness program for BP America achieved almost $20,000,000 in savings on 20,343 BP participants after only two short years – to the limits of possibility.

It turns out this overall savings claim of $1,000/person would require completely wiping out wellness-sensitive medical events (heart attacks, diabetes events etc.) not just on those 20,000+ people, but also on perhaps 40,000 of their closest friends. The authors elected not to disclose the change in wellness-sensitive medical events across the entire eligible population, perhaps because they were embarrassed by the size of the decline, if indeed those events declined at all.