The Health Care Blog – Page 560 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

A Health Insurance Exchange That Won’t Be a “Train Wreck”

May 1, 2013• 3

By Robert Laszewski

Every week, I get an email from the Maryland Health Connection––the state run health insurance exchange.
Maryland is one of a minority of states that are building their own Affordable Care Act (“ObamaCare”) exchange.

You can go to their site and sign up for these weekly updates.

Let me suggest that Maryland is an example of what an on-track and well organized effort looks like for any exchange hoping to be ready to enroll people on October 1––and ensure that they will be covered should they walk into a doctor’s office on January 1, 2014.

Maryland is simply ticking through all of the key milestones they must meet. The latest release reviewed its efforts to launch the connector program (those who will assist people in signing up), the status of the carrier filings (Maryland Blue Cross has filed for an average increase of 25% for individual coverage warning young people could pay as much as 150% more), the timelines for carrier submissions of coverage packages, and they outlined their third party administration program to be able to launch the small business choice (SHOP) option––unlike the federal exchange Maryland will have the SHOP option.

For Hospitals On the Edge, HIT Is the Tipping Point

May 1, 2013• 3

By Edmund Billings, MD

“No aspect of health IT entails as much uncertainty as the magnitude of its potential benefits.”

A few years into the Meaningful Use program, it seems this quote from a 2008 Congressional Budget Office report entitled “Evidence on the Costs and Benefits of Health Information Technology” may have been written with the assistance of a crystal ball.

Fast forward to 2013.

“Just from reading a week’s worth of news, it’s obvious that we don’t really know whether healthcare IT is better or worse off than before [Meaningful Use incentives],” popular blogger and health IT observer Mr. HIStalk wrote earlier this year.

So, perhaps RAND was hypnotized by Cerner funding when they created their rosy prognosis (hearken back, if you will, to 2005 and the projected $81 billion in annual healthcare savings). Maybe they were just plain wrong and the most recent RAND report stands as a tacit mea culpa.

Either way, we’re left with hypotheses that, while not incontrovertible, are gaining traction:

Health IT benefits will manifest gradually over an extended timeframe.
Those benefits will not quickly morph into reduced costs, if they ever do.
Because of 1 and 2, investing in a hugely expensive electronic health record system is potentially risky.

How risky? Without question, massive health IT expense and the predominant proprietary IT model are threats to a hospital or health system’s financial viability, to its solvency.

We’re seeing some examples even now.

The Cost of Dementia: Who Will Pay?

Apr 30, 2013• 9

By Michael D. Hurd

Dementia is a chronic disease of aging that robs people of cognitive function, leaving them unable to tend to even the most basic activities of living. But demented persons can live for many years, incurring long-term care bills that can leave surviving spouses impoverished and estates depleted.

In a study published recently in the New England Journal of Medicine, my colleagues and I reported that the total costs of paying for care for seniors with dementia in the United States are expected to more than double by 2040. Medicaid pays these costs for the poor, and some people have private insurance. But for large numbers of elderly Americans, dementia brings not only human suffering but financial ruin as well.

Designing and building a program to protect Americans from the cost of dementia care is a daunting and expensive task, one that probably cannot be accomplished without the help of the federal government. The federal government has broad experience in creating health safety nets and has been expressing concern over the state of the nation’s long-term care systems for some time now. If Congress and the administration need a reason to act, our numbers on costs can provide it.

Currently, some 15 percent of Americans 71 or older have dementia. That is about 3.8 million people; a large number to be sure, but one that will pale by comparison to the 9.1 million expected to be suffering from the disease by 2040.

Our report, The Monetary Costs of Dementia in the United States, estimated that in 2010 Americans spent $109 billion for dementia care purchased in the market place, like nursing home stays. Factoring in the costs of informal care—provided by family members or others outside of institutional settings—the total cost of caring for dementia patients grew to between $159 billion and $215 billion.

A Call For a New Model For Generalist-Specialist Information Exchange

Apr 29, 2013• 7

By Bob Wachter, MD

Everybody hates curbside consults – the informal, “Hey, Joe, how would you treat asymptomatic pyuria in my 80-year-old nursing home patient?”-type questions that dominate those Doctor’s Lounge conversations that aren’t about sports, Wall Street, or ObamaCare. Consultants hate being asked clinical questions out of context; they know that they may give incorrect advice if the underlying facts and assumptions aren’t right (the old garbage in, garbage out phenomenon). They also don’t enjoy giving away their time and intellectual capital for free. Risk managers hate curbside consults because they sometimes figure into the pathogenesis of a lawsuit, such as when a hospitalist or ER doctor acts after receiving (non-documented) curbside guidance and things go sideways.

There is some evidence to support this antipathy. A recent study published in the Journal of Hospital Medicine examined 47 curbside consultations by hospitalists, in which formal consults by different hospitalists (unaware of the details of the curbside encounter) were performed soon thereafter. Conducted by a team of researchers from the University of Colorado, the study found that the information given to the curbside consultant was incomplete or inaccurate roughly half the time, and that management advice offered via the two forms of consultation differed 60 percent of the time. (In those cases in which the consultant was given inaccurate or incomplete information, the advice differed more than 90 percent of the time!) This is not the first warning about the dangers of such consults (see also here and here), and it won’t be the last.

The Electronic Medical Record and the Patient Narrative

Apr 28, 2013• 15

By Rob Lamberts, MD

It’s been a long time since I wrote a post. My life, you see, is incredibly dull and boring. There has been so little to write about that I’ve been at a loss.

No, actually that’s a load of crap. It’s become a fantasy of mine to have such boredom. In reality, my life is as un-boring as it could be. It’s like the part of a story where everything is in flux, where little decisions have huge consequences, and where the inflection point between a comedy and tragedy is located.

So how’s my new practice going? In some ways things are going about as well as they could. My patients are amazed when I answer their emails or (even more surprisingly) answer the phone. ”Hello, this is Dr. Lamberts,” I say. This usually results in a long pause, followed by a confused and timid voice saying something like, “well…uh…I was expecting to get Jamie.” Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem. It’s amazingly efficient to answer the phone.

Financially, the practice has been in the black since the first month, and continues to grow, albeit slowly. The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine. It’s also not that I am so busy at 250 patients that growth is difficult. In truth, when we aren’t rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse. In that sense I’ve proved concept: that it’s not unreasonable to think I can handle 500, and even 1000 patients with the proper support staff and system in place.

Which brings us to the area of conflict, the crisis point of this story: the system I have in place. The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently.

The ACO Failure Hypothesis: Likely But Not Inevitable

Apr 28, 2013• 14

By LES FUNTLEYDER

We recently participated in a program at Columbia Business School’s Healthcare Program on whether ACOs (Accountable Care Organizations) will fail. For those of you that don’t know, ACOs are one of the structures promulgated by PPACA (aka Obamacare) designed to encourage better cost control and quality improvement in the healthcare system.

The current zeitgeist among the commentariat is that ACOs will fail (examples: here and here). We think the reason for the one-sided nature of the question is that those of us who lived through the healthcare upheaval in the early and mid “90s” saw first hand the failure of PHOs, PPMs and IDNs (and all of the other acronyms now relegated to the dustbin of history). When ACOs are touted as a saving grace for the system, you can almost hear the collective groan of the industry veterans.

Ever the contrarian, however, we took the side of the debate that said ACOs will NOT fail. The premise of our argument was that since we already have a good idea of why the structure will fail, we can, a priori, fix the shortcomings, and though likely, ACO failure is not inevitable.

There is an extensive list of why list of why ACOs will fail. We put them into four general buckets.

Infrastructure: The system has mis-allocated resources so we have too many of some things and not enough of others leading to inefficiencies.

Technological/telecommunication: For a number reasons the healthcare system has not adopted technology as fast as other industries.

Cultural: Providers are habituated to fee-for-service payment mechanisms and patients aren’t likely to change their own healthcare behaviors.

Inertia: The well known system problems (e.g. asymmetry of information, the Pareto nature of patient demand, unexplained variation of care, counterproductive incentives) have been around forever and are difficult to overcome.

Because we spend most of our time identifying private healthcare companies with investment potential, we often get a view into what is happening in the entrepreneurial space under the punditry radar.

Why You Probably Have a Lot Less to Fear From the Latest Superbug Than You Think

Apr 28, 2013• 2

By COLIN SON, MD

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such.

Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

Earth to Washington: Repeal the Sequester

Apr 27, 2013• 1

By Robert Reich

Economic forecasters exist to make astrologers look good. Most had forecast growth of at least 3 percent (on an annualized basis) in the first quarter. But we learned just recently (in the Commerce Department’s report) it grew only 2.5 percent.

That’s better than the 2 percent growth last year and the slowdown at the end of the year. But it’s still cause for serious concern.

First, consumers won’t keep up the spending.Their savings rate fell sharply — from 4.7% in the last quarter of 2012 to 2.6% from January through March.

Add in March’s dismal employment report, the lowest percentage of working-age adults in jobs since 1979, and January’s hike in payroll taxes, and consumer spending will almost certainly drop.

Median household incomes continues to decline, adjusted for inflation. Another report out today showed consumer confidence fell in April.

Ryan the Redistributionist

Apr 26, 2013

By Robert Reich

Who is going to end up making all the money in the end if Obamacare continues to be in place?” Republican National Committee chairman Reince Priebus growled Monday on Sean Hannity’s Fox News show. “It’s going to be the big corporations, right? And who gets screwed? The middle class.”

The Republican Party makeover is breathtaking. Now, suddenly, instead of accusing Democrats of being “redistributionists,” the GOP is posing as defender of the middle class against corporate America — and it’s doing so by proposing to do away with the most progressive piece of legislation in well over a decade.

Paul Ryan’s new budget purportedly gets about 40 percent of its $4.6 trillion in spending cuts over ten years by repealing Obamacare, but Ryan’s budget document doesn’t mention that such a repeal would also lower taxes on corporations and the wealthy that foot Obamacare’s bill.

Caution: Wellness Programs May Be Hazardous to Your Health

Apr 26, 2013• 19

By Al Lewis

The exponential growth in wellness programs indicates that Corporate America believes that medicalizing the workplace, through paying employees to participate in health risk assessments (“HRAs”) and biometric screens, will reduce healthcare spending.

It won’t. As shown in my book Why Nobody Believes the Numbers and subsequent analyses, the publicly reported outcomes data of these programs are made up—often to a laughable degree, starting with the fictional Safeway wellness success story that inspired the original Affordable Care Act wellness emphasis. None of this should be a surprise: in addition to HRAs and blood draws, wellness programs urge employees to go to the doctor, even though most preventive care costs more than it saves. So workplace medicalization saves no money – indeed, it probably increases direct costs with these extra doctor visits – but all this medicalization at least should make a company’s workforce healthier.

Except when it doesn’t — and harms employees instead, which happens altogether too often.

Yes, you read that right. While some health risk assessments just nag/remind employees to do the obvious — quit smoking, exercise more, avoid junk food and buckle their seat belts — many other HRAs and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.