The Health Care Blog – Page 559 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Good Doctor’s Mind Map

May 30, 2013• 14

By Rob Lamberts, MD

This, apparently, is a map of my mind. It’s a little shocking to find out that my mind looks like a sea creature, a bug, or perhaps a vegetable. Actually, “Rob’s mind” and “vegetable” are often used in the same sentence.

Someone suggested to me that I may benefit from mind mapping. I don’t know how to describe it, but I think spatially; I see things abstractly as if I am pulling up from the ground and getting an aerial view of things. I write that way, I solve problems that way, I even play music that way. Maybe it’s tapping on the right side of the brain that is about nuances or about how things relate to other things in proximity or direction. Like I said: it’s hard to describe.

Anyhow, I was thinking about task-management with my patients, wondering what’s the best way to think about it and what is the best design for a system helping with this. Task management is perhaps the most important thing in health care that’s never talked about. Maybe that’s because it makes doctors feel less special, reducing our “magical” knowledge and “miracle” cures to algorithms and checklists. Personally, I take great comfort in systems because they assure me I am not going to forget important things (like setting a reminder to take the trash out on Sunday and Wednesday nights).

The Independent Purchase Decision Support Test

May 30, 2013• 3

By Adrian Gropper, MD

It’s a busy time in Washington, DC. June 3 marks the Datapalooza and begins a week of cheering and reflection on the success of federal initiatives designed to improve health while reducing cost. This year, the big claim is “information following patients” – a combination of federal Stage 2 Meaningful Use regulations, federal Health Information Exchange guidelines and federal open pricing data policies. We’re surely beyond 1,000 pages of federal initiatives around health data and the policy fog seems to be getting thicker every day. The Independent Purchase Decision Support Test is my beacon for whether we’re headed in the right direction.

Here’s a quote from the Meaningful Use Implementation Guidelines to Assure Security and Interoperability just released by ONC:

“In effect, HISPs are creating “islands of automation using a common standard.” This will hamper information following patients where they seek care―including across organizational and vendor boundaries―to support care coordination and Meaningful Use Stage 2 requirements.”

How will “information following patients” improve health while reducing cost?

It all depends on where the patient goes to get what. Not surprisingly, federal Accountable Care Organizations and related accountable quality contracts with private payers are exactly about where the patient goes too. The difference between these health reform innovations and the old managed care approach is supposed to be the patient’s ability to choose where to go for a healthcare service. Will Stage 2 and the new federal health information exchange implementation guidelines actually lead to effective patient engagement or is it time to “reboot” the HITECH incentives as some have suggested?

The Independent Purchase Decision Support Test cuts through the techno-jargon and paternalistic framing and goes straight to the heart of the policies that influence the physician-patient decisions to drive health care quality and cost. This the essence of patient engagement and the place where the money in healthcare is actually spent.

Letting the Data Speak: On Refusing Medicaid Expansion

May 29, 2013• 20

By Frank de Libero

Robert Pear wrote in the Times that the refusal by “states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance…[1]” Indeed, the refusals will do that, as well as worsen what instead should be remedied. In the following I present a graph of two chronic diseases over the 50 states. Those states which have opted out of the Medicaid expansion are identified. Additionally each state’s poverty rate is indicated. The take-away is that populations in greater need are being further disadvantaged. A conjecture is presented as to why.

Please understand that refusal to expand Medicaid is not about state expenditures. Over the ten years, 2013-2022, every state would gain far more than it would spend for expansion [2]. Were all states to opt-in, the total ROI for the states combined would be almost 10,000% ($8 billion state expenditures in return for $800 billion federal).

Empirically health is associated with income, so if you’re poor you’ll likely have worse health. Also it’s well known that chronic conditions are often comorbid, that if you have a chronic disease, you probably have more than one. Additionally, chronic disease is a major contributor to total health care costs. Continue reading…

Rate Shock and Awe in California

May 28, 2013• 18

By Robert Laszewski

I have to say I was surprised with the press reports last week that there wasn’t “rate shock” in California when the California exchange offered preliminary information about their new plans and rates.

At least one prominent health actuarial group had predicted a 30% baseline increase in costs for California’s new health insurance exchange plans under the Affordable Care Act (ObamaCare”).

As the director of the California exchange put it, “These rates are way below the worst-case gloom-and-doom scenarios we have heard.”

But a few days later there is lots more information coming out and it would appear we have a case of apples to oranges to grapefruit. And, we have a pretty good case of rate shock.

First, the exchange officials pointed out that we have to be careful to compare apples to apples when looking at 2013 rates and comparing them to the 2014 exchange rates because the 2014 exchange plans have far more generous benefits.

Yes we do, particularly when the California exchange forces us to give up our apple and buy a more expensive orange.

One of the reasons health insurance in the exchange will cost a lot more in most states is because the new health law outlaws many of the existing plans now being offered and requires only those much richer plans to be sold.

Are people going to get more coverage for their money? Yes. Do they want more coverage if the premium costs for those plans is a lot higher? Likely yes if taxpayers are paying for most of it. If not, clearly they didn’t want to pay for it before. Come January, lots of California consumers in the small group and individual market are going to get a letter from their existing insurer telling them their current plan is no longer available and the cost of the new required plans will be a lot more.

Simply, the new law is taking plan design choices away instead of letting the consumer decide what is good for them. Does that matter in California?

7 Burning Questions on Marijuana Legalization

May 28, 2013• 11

By Beau Kilmer

Believe me, I’ve heard all the pot jokes, and some of them are true. Public support for legalizing marijuana use is at an all-time high. Some state-level marijuana laws are going up in smoke. And yes, Washington and Colorado are embarking on a historic joint venture.

Puns aside, discussions about marijuana legalization are getting serious. In November, voters in Colorado and Washington made the unprecedented decision to allow commercial production, distribution and possession of marijuana for nonmedical purposes. Not even the Netherlands goes that far.

Policymakers in both states are confronting some new and tricky issues that have never been addressed. For them, and for anyone else thinking about changing their pot laws, here are seven key decision areas that will shape the costs and benefits of marijuana legalization:

1. Production. Where will legal pot be grown — outdoors on commercial farms, inside in confined growing spaces, or somewhere in between? RAND research has found that legalizing marijuana could make it dramatically cheaper to produce — first because producers will no longer have to operate covertly, and second because suppliers won’t need to be compensated for running the risks of getting arrested or assaulted. After lawmakers decide how it will be grown, production costs will be shaped by the number of producers and other regulations such as product testing.

2. Profit motive. If there is a commercial pot industry, businesses will have strong incentives to create and maintain the heavy users who use most of the pot. To get a sense of what this could look like, look no further than the alcohol and tobacco industries, which have found ingenious ways to hook and reel in heavy users. So will private companies be allowed to enter the pot market, or will states limit it to home producers, non-profit groups or cooperatives? If a state insisted on having a monopoly on pot production, it could rake in a decent amount revenue — but for now, that possibility seems far off in the United States since marijuana remains illegal under federal law.

3. Promotion. Will states try to limit or counter advertisements in the communities and stores that sell marijuana? U.S. jurisprudence against curtailing what’s known as “commercial free speech” could make it tough to regulate the promotion of pot. While a state monopoly system could help control promotion, those advertisements you see for state lotteries should give you pause.

Announcing the Novartis Thalassemia App Challenge

May 28, 2013

By Graeme Ossey

Health 2.0 is excited to announce the launch of the Novartis Thalassemia App Challenge sponsored by Novartis Oncology. There is a critical need to develop an innovative app solution that assists Thalassemia patients and their families in managing the disease, including monitoring/tracking of key parameters, treatment/medication adherence and recording of daily personal facts.

Thalassemia is a diverse family of genetic disorders affecting red blood cell production, causing anemia and consequently, patients suffer significant complications.¹ Thalassemia can range from milder types to severe cases that start in infancy and require regular blood transfusions for patient survival.² Clinical complications can vary by type of thalassemia, and patients also may develop iron overload as a consequence of the disease or because of extra iron absorbed from blood transfusions.³ Most patients with thalassemia are of South and Southeast Asian, Mediterranean or Middle Eastern origin, with immigration broadening the global prevalence.⁴

How UCSF Is Solving the Quality, Cost and Value Equation

May 27, 2013• 11

By Bob Wachter, MD

I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. “The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.

“What exactly were you trying to do before?” some have asked, in that wonderful way that smart students blend naiveté with blinding insight.

It is pretty amazing that healthcare has been insulated from the business pressures that everybody from Yahoo! to my father’s garment business have experienced since the days of Adam Smith. We experienced a bit of this pressure in the mid-1990s, when pundits declared healthcare inflation “unsustainable” (sound familiar?) and we invented managed care to slay it. We know how that story ended – the public and professional backlash against HMOs defanged the managed care tiger to the point that it could barely produce a “meow.” The backlash was followed by a 15-year run during which efforts to slash healthcare costs have been remarkably meager.

That run has ended.

Luckily, while we’ve been let off the hook on cost-reduction, we’ve not been given a free pass on improvement. Beginning with the Institute of Medicine reports on safety (2000) and quality (2001), we have been under growing pressure to improve the numerator of the value equation: patient safety, quality of care, and patient satisfaction. Particularly for those of us who work in hospitals, we now feel this pressure from many angles: from accreditors (more vigorous and unannounced Joint Commission inspections, residency duty hour limits), transparency (Medicare’s Hospital Compare), comparative measurement (HealthGrades, Leapfrog, Consumer Reports and many other hospital rankings), and, most recently, payment policies (no pay for “never events,” penalties for readmissions, value-based purchasing, and “Meaningful Use” standards for IT).

These initiatives have created an increasingly robust business case to improve. Hospitals everywhere have responded with new resources, committees, ways of analyzing data, educational programs, computer systems, and more.

7. Task a single entity with defining standards for measuring and reporting quality and cost data.

May 27, 2013

By Berenson, Pronovost & Krumholz

There is a plethora of health care quality data being pushed out to the public, yet no rules to assure the accuracy of what is being presented publicly. The health care industry lacks standards for how valid a quality measure should be before it is used in public reporting or pay-for-performance initiatives, although some standards have been proposed.

The NQF does a good job of reviewing and approving proposed measures presented to it, but lacks the authority to establish definitive quantitative standards that would apply broadly to purveyors of performance measures. However, as discussed earlier, many information brokers publically report provider performance without transparency and without meeting basic validity standards. Indeed, even CMS, which helps support NQF financially, has adopted measures for the Physician Quality Reporting System that have not undergone NQF review and approval. Congress now is considering “SGR repeal,” or sustainable growth rate legislation, that would have CMS work directly with specialty societies to develop measures and measurement standards, presumably without requiring NQF review and approval [30].

Without industry standards, payers, policy makers, and providers often become embroiled in a tug-of-war; with payers and policy-makers asserting that existing measures are good enough, and providers arguing they are not. Most often, neither side has data on how good the contested measures actually are. Most importantly, the public lacks valid information about quality, especially outcomes, and costs.

Indeed, most quality measurement efforts struggle to find measures that are scientifically sound yet feasible to implement with the limited resources available. Unfortunately, too often feasibility trumps sound science. In the absence of valid measures, bias in estimating the quality of care provided will likely increase in proportion to the risks and rewards associated with performance. The result is that the focus of health care organizations may change from improving care to “looking good” to attract business. Further, conscientious efforts to reduce measurement burden have significantly compromised the validity of many quality measures, making some nearly meaningless, or even misleading. Unfortunately, measurement bias often remains invisible because of limited reporting of data collection methods that produce the published results. In short, the measurement of quality in health care is neither standardized nor consistently accurate and reliable.

6. Invest in the basic science of measurement development and applications.

May 27, 2013

By Berenson, Pronovost & Krumholz

The unfortunate reality is that there is no body of expertise with responsibility for addressing the science of performance measurement. The National Quality Forum (NQF) comes closest, and while it addresses some scientific issues when deciding whether to endorse a proposed measure, NQF is not mandated to explore broader issues to advance the science of measure development, nor does it have the financial support or structure to do so.

An infrastructure is needed to gain national consensus on: what to measure, how to define the measures, how to collect the data and survey for events, what is the accuracy of EHRs as a source of performance, the cost-effectiveness of various measures, how to reduce the costs of data collection, how to define thresholds for measures regarding their accuracy, and how to prioritize the measures collected (informed by the relative value of the information collected and the costs of data collection).

Despite this broad research agenda, there is little research funding to advance the basic science of performance measurement. Given the anticipated broad use of measures throughout the health system, funding can be a public/private partnership modeled after the Patient-Centered Outcomes Research Institute or a federally-funded initiative, perhaps centered at AHRQ. Given budgetary constraints, finding the funding to support the science of measurement will be a challenge. Yet, the costs of misapplication of measures and incorrect judgments about performance are substantial.

5. Use measurement to promote the concept of the rapid-learning health care system.

May 27, 2013

By Berenson, Pronovost & Krumholz

Initiatives to promote performance measurement need to be accompanied by support to improve care. Quality measure data should not only be technically correct, but should be organized such that their dissemination is a resource to aid in quality improvement activities. As such, quality measurement should be viewed as just one component of a learning health care system that also includes advancing the science of quality improvement, building providers’ capacity to improve care, transparently reporting performance, and creating formal accountability systems.

There are several strategies to make quality measure data more actionable for quality improvement purposes. For example, for publicly reported outcome measures, CMS provides hospitals with lists of the patients who are included in the calculation. Since the outcomes may occur outside the hospital for mortality and for readmissions that are at other hospitals, this information is often beyond what the hospitals already have available to them. These data give providers the ability to investigate care provided to individual patients, which in turn can support a variety of quality improvement efforts.