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In Defense of Narrow Networks

• 27

By David Dranove & Craig Garthwaite

It wasn’t long ago that the newly established health exchanges were being celebrated. Before the ongoing website catastrophe, politicians and policymakers were lauding the low premiums in these new health insurance market places. On September 24, President Obama said, “And the premiums are significantly lower than what they were able to previously get … California — it’s about 33 percent lower. In my home state of Illinois, they just announced it’s about 25 percent lower.”

How times have changed! Even supporters of the exchanges have rightly criticized the technical problems that have prevented millions of Americans from signing up. However, many critics are also complaining about the large number of health plan offerings with “narrow networks” of physicians that enrollees can visit for medical services. The Missouri Health Advocacy Alliance expressed “major concern” when Anthem excluded BJC HealthCare from its narrow network. Seattle Children’s Hospital, which was excluded from several exchange plans, has sued the Washington State Office of Insurance for “failing to ensure adequate network coverage.”

Criticism of narrow networks is misguided and counterproductive. As we explain below, narrow networks will be of little consequence to most of the individuals who sign up for the exchanges, and the elimination of narrow networks could eliminate our single best opportunity to harness market forces to reduce costs and improve quality. Indeed, narrow networks are largely responsible for the low premiums that were being celebrated just one month ago.

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So, What Exactly Is a Health Insurance Exchange Anyway???

• 24

By David Williams


I’m a health care expert who follows health reform closely, so when I’m confused about something I know most people are.

When Massachusetts passed the universal coverage law in 2006 I didn’t understand exactly what the Connector was supposed to do. If they had called it a health insurance store or marketplace or comparison site I would have grasped the concept better. Once it’s explained it’s obvious, but why use the word “connector” in the first place?

The federal Affordable Care Act makes matters even worse. It calls these things health insurance “exchanges.”

That word has the wrong connotations. When I hear the word “exchange” I think of a stock exchange. That’s not somewhere I go to buy or compare products or services to use. Others think of “exchange” as what they do when they made a purchase that was the wrong size or received a gift they didn’t like.

Even for health wonks that fully grasp the concept, the word “exchange” is confusing, because the term is also used in the context of health information exchanges, which are used to exchange clinical data. I often hear people asking about the impact of the “exchange” –without specifying “insurance exchange” or “information exchange,” and I have to ask them which they mean.

There’s a simple solution to this: let’s dump the word “exchange” and use a term that’s more understandable and appropriate. How about:

  • Store
  • Marketplace
  • Comparison site
  • Supermarket

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma, biotech, and medical devices. Formerly with BCG and LEK. He writes regularly at Health Business Blog, where this post first appeared.

Obamacare’s Fiscal Cliff

• 10

By John Goodman

Did you notice that in the standoff over the fiscal cliff, all the discussion was about the Bush tax cuts? Which ones would be made permanent? And for whom? There was no discussion about the ObamaCare tax increases. I think that was a huge tactical mistake on the part of the Republicans.

Over and over again, President Obama claimed he was trying to protect the middle class from higher taxes. It was a claim that went unchallenged ― by the Republicans and by the mainstream media.

Yet five of the tax increases Americans are facing this month are new taxes created under the Affordable Care Act (ObamaCare). Three of the five will hit people who are solidly middle class.

Next year, things will get worse. The new tax on health insurance is about as regressive as a tax can be. It will total $100 billion over the next 10 years and very little of that amount will be paid by anyone who can be called “rich.”

  • The health insurance tax will fall on private sector Medicaid plans, which have about 70% of all Medicaid enrollees.
  • The tax will fall on Medicare Advantage plans whose enrollees have below average incomes and are disproportionately minority.
  • The tax will hit every small business and every individual who buys insurance in the commercial market place.
  • The tax will not fall on self-insured plans whose enrollees include the highest paid workers and the highest paid CEOs.

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The Chart-Eating Virus, Me Too Software and Other Emerging Digital Threats

• 12

By David Shaywitz, MD

The ability to gather, analyze, and distribute information broadly is one of the great strengths of digital health, perhaps the most significant short-term opportunity to positively impact medical practice. Yet, the exact same technology also carries a set of intimately-associated liabilities, dangers we must recognize and respect if we are to do more good than harm.

Consider these three examples:

  • Last week, a study from Case Western reported that at least 20% of the information in most physician progress notes was copy-and-pasted from previous notes. As recently discussed at kevinmd.com and elsewhere, this process can adversely affect patient care in a number of ways, and there’s actually an emerging literature devoted to the study of “copy-paste” errors in EMRs. The ease with which information can be transferred can lead to the rapid propagation of erroneous information – a phenomenon we used to call a “chart virus.” In essence, this is simply another example of consecrating information without first appropriately analyzing it (e.g. by asking the patient, when this is possible).
  • At a recent health conference, a speaker noted that a key flaw with most electronic medical record (EMR) platforms is that they are “automating broken processes.” Rather than use the arrival of new technology to think carefully, and from the ground up, about the problems that need to be solved, most EMRs simply digitally reify what already exists. Not only does this perpetuate (and usual exacerbate) notoriously byzantine operational practices and leave many users explicitly complaining they are worse off than before, but it also misses the chance to offer conceptually original approaches that profoundly improve workflow and enhance user experience.

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Set My People Free

• 7

By Margalit Gur-Arie

Somewhere between the 20th century Bank ATM and the 25th century Tricorder, lays the EMR that we should have today.

Somewhere between the government-designed Meaningful Use EMR and the Holographic doctor in Star Trek, there should be a long stretch of disposable trial-and-error cycles of technology, changing and morphing from good to better to magical. For this to happen, we must release the EMR from its balls and chains. We must release the EMR from its life sentence in the salt mines of reimbursement, and understand that EMRs cannot, and will not, and should not, be held responsible for fixing the financial and physical health of the entire nation. In other words, lighten up folks …

A patient’s medical record contains all sorts of things, most of which diminish in importance as time goes by. Roughly speaking, a medical record contains quantifiable data (numbers), Boolean data (positive/negative), images (sometimes), and lots of plain, and not so plain, English (in the US).

The proliferation of prose and medical abbreviations in the medical record has been attacked a very long time ago by the World Health Organization (WHO), which gave us the International Classification of Disease (fondly known as ICD), attaching a code to each disease. With roots in the 19th century and with explicit rationale of facilitating international statistical research and public health, the codification of disease introduced the concept that caring for an individual patient should also be viewed as a global learning experience for humanity at large. Medicine was always a personal service, but medicine was also a science, and as long as those growing the science were not far removed from those delivering the service, both could symbiotically coexist.

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What the Story of a Famous Little White Pill Says About How Medical Research Works

• 5

By John H. Schumann, MD

Twenty-five years ago this month, the New England Journal of Medicine published a special report on something that’s become medical gospel:

Aspirin.

That’s right. Not as in “take two and call me in the morning,” but in the realm of the randomized double-blinded placebo-controlled trial. Or what we generally consider the gold standard of evidence in medical research.

If you’ve often heard that bit of jargon but always wondered why it’s so exalted, break it down:

  • randomized: the assignment of the treatment (aspirin) or placebo (‘inert’ sugar pill) is not given in any planned sequence.
  • double-blinded: neither the researchers nor the subjects know who is taking what (everything is coded so that analysts can find out at the end).
  • placebo-controlled: the study compares the treatment against placebo to see if it’s helpful or harmful.

Even though acetylsalicylic acid’s properties as a pain reliever and fever reducer had been known in the time of Hippocrates, it was in 1899 that Bayer first patented and marketed what came to be known as aspirin worldwide.

A mere 89 years later, researchers from the “Physicians Health Study” did something unusual. Citing aspirin’s “extreme beneficial effects on non-fatal and fatal myocardial infarction”–doctor speak for heart attacks–the study’s Data Monitoring Board recommended terminating the aspirin portion of the study early (the study also was looking at the effects of beta-carotene). In other words, the benefit in preventing heart attacks was so clear at 5 years instead of the planned 12 years of study that it was deemed unethical to continue blinding participants or using placebo.

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Heroes and Villains

• 11

By Rob Lamberts, MD

“Lance Armstrong is a bad guy who has done some very good things.”

These are the words of a sports radio personality I listened to yesterday. He was obviously commenting on the confession (to my pal Oprah) by Armstrong about his use of performance enhancing drugs. The sportscaster, along with many I heard talk on the subject, were not as upset by the fact that Armstrong used the banned substances, or his lies on the subject, but the way he went after anyone who accused him of what turned out to be the truth. Armstrong used his position of fame and power, along with his significant wealth, to attack the credibility of people in both the media and in the courtroom. The phrase, “he destroyed people’s lives” has been used frequently when describing his reaction to accusations.

It’s a horrible thing he did, and shows an incredibly self-centered man who thought the world should bend to his whim. It’s more proof to the adage: absolute power corrupts absolutely.

But simply dismissing Lance as a cad or a horrible person would be far easier if not for the other side of his life. In his public battle against cancer, he inspired many facing that disease to not give up their battle. Even for those who eventually lost, the encouragement many got from Armstrong’s story was significant. On top of that, the Livestrong foundation did much to raise money and awareness for cancer and for other significant health issues. This foundation exists because of the heroic story of Lance’s successful battle to beat cancer, as well as his subsequent cycling victories. Whatever the lies he told in the process, he did beat cancer and he did win the Tour de France multiple times.

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Health Expert Insight for 2013: Jeff Goldsmith and Charlie Baker

• 5

By Alexandra Drane

We talk to people every day about the barriers, fears, and motivations they have around their health, and often have the luxury of funneling the insights we learn back into the larger healthcare ecosystem. So here’s a doozy:  recent Eliza survey data (from October 2012) suggests that 82% of people say they would like their health plan more if they were more proactive about covered health care benefits … and two-thirds of people believe that their health plan is not telling them enough about what’s going on with healthcare reform and how it will impact their care in the coming years.

Based on this data, we wanted to dig a bit deeper into what exactly we can tell people to expect on that front. So we engaged Jeff Goldsmith and Charlie Baker in a conversation on everything from whether or not the Affordable Care Act is implementable (2:50) to the readiness of state and federal exchanges (5:00) to how employers will be stepping up to fill in critical health components (10:15) to the impact of increasing consolidation (15:00) to how the physician realm can keep a semblance of competitive tension in the provider networks (25:25).

And finally, we asked them the question we should all be asking ourselves:  will the care you are going to get in 2015 be better than the care you got in 2009? [40:41]

Click here to listen to the Podcast.

The good news is that many of these trends can be addressed through strategies like a stronger consumer-focused angle; higher-touch yet lower-cost communication between healthcare organizations and the people they serve; and a deeper understanding of how to proactively encourage health in both traditional (preventive health) and not-so-traditional (patient advocacy) ways. All eminently doable, right?

So listen, learn, and enjoy… and most importantly, stay ferociously committed to a healthier 2013 for all of us.

Alexandra Drane is the Chief Visionary Officer of Eliza.

Connecting Medical Devices and Their Makers

• 7

By Peter Pronovost, MD

Today, an intensive care unit patient room contains anywhere from 50 to 100 pieces of medical equipment made by dozens of manufacturers, and these products rarely, if ever, talk to one another. This means that clinicians must painstakingly review and piece together information from individual devices—for instance, to make a diagnosis of sepsis or to recognize that a patient’s condition is plummeting. Such a system leaves too much room for error and requires clinicians to be heroes, rising above the flawed environment that they work in. We need a heath care system that partners with patients, their families and others to eliminate all harms, optimize patient outcomes and experience and reduce waste. Technology must enable clinicians to help achieve those goals. Technology could do so much more if it focused on achieving these goals and worked backwards from there.

This week marks a step that holds tremendous promise for patients and clinicians. On Monday the Masimo Foundation hosted the Patient Safety Science & Technology Summit in Laguna Niguel, California, an inaugural event to convene hospital administrators, medical technology companies, patient advocates and clinicians to identify solutions to some of today’s most pressing patient safety issues. In response to a call made by keynote speaker former President Bill Clinton, the leaders of nine leading medical device companies pledged to open their systems and share their data.

Lack of interoperability between medical devices plays no small role in the 200,000 American deaths caused by preventable patient harm each year, such as in the case of 11-year-old Leah Coufal. After undergoing elective surgery, Leah received narcotics intended to ease her pain.

When Leah received too much medication, it suppressed her breathing, eventually causing it to stop altogether. Had she been monitored, a device could have alerted clinicians when Leah’s breathing slowed to a dangerous level.

But as we know, clinicians are busy and unfortunately don’t always respond to alarms from bedside machines. If a machine measuring her breathing had been linked with the device delivering her medication, it could have automatically stopped the drugs from infusing into her blue, oxygen-deprived veins.

All of this is possible today; technology is not a barrier. Until now, the only thing that’s stood in the way is a lack of leadership and a lack of willingness for device manufacturers to cooperate.

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Welcome to Healthcare IT Live!

[youtube width=”475″ height=”300″]http://www.youtube.com/watch?v=9-2EkxSHPIg[/youtube]

This time the camera was turned on THCB’s Matthew Holt. Tim Cook of Healthcare IT Live! interviewed Matthew for the web show, which takes place weekly on Google+ Hangouts. Click for a list of the show’s upcoming guests.

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