The Health Care Blog – Page 691 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

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The Affordable Care Act Supreme Court Petitions: Issues And Implications

Sep 29, 2011• 2

By TIMOTHY JOST

Wednesday, September 28 was a busy day at the Supreme Court clerk’s office.

It had been widely expected that there would be a major pleading filed with the clerk in an Affordable Care Act challenge, as the response of the United States to a certiorari petition in the Sixth Circuit’s Thomas More case, which had upheld the ACA as constitutional, was due. A cert. petition asks the Supreme Court to exercise its discretion to review the decision of a lower court, and the losing plaintiffs in Thomas More had requested the Supreme Court to reverse that decision and find that Congress had no authority under the Commerce Clause of the Constitution to adopt the ACA’s minimum coverage requirement.

The Justice Department did file a response in that case, but very late in the day. Earlier in the day, to the surprise of most observers, three certiorari petitions were filed, asking the Court to review thedecision of the Eleventh Circuit Court of Appeals in the Florida case, which had held the minimum coverage requirement to be unconstitutional. The Eleventh Circuit upheld several other rulings of the lower court finding other parts of the ACA to be constitutional, and had reversed the decision of the lower court striking down the entire ACA as being not “severable” from the minimum coverage requirement.

Late in the morning on the 28^th, the National Federation of Independent Business and two individuals, plaintiffs in the Eleventh Circuit case filed a cert. petition, asking the Supreme Court to reverse the decision of the Eleventh Circuit refusing to hold the entire ACA to be unconstitutional. An hour or so later, the twenty-six states that are plaintiffs in the Eleventh Circuit case filed their own cert. petition asking the Court to strike down the entire ACA, but also asking the court to reverse the appellate court’s decision upholding the constitutionality of the ACA’s Medicaid expansions and of the employer mandate as applied to the states.

Mandate On Its Way To the Supreme Court?

Sep 29, 2011• 4

By ROGER COLLIER

It may have looked like a non-event, but it was a significant one.

Monday September 26 was the last day on which the Obama administration could ask the Eleventh Circuit Court of Appeals to reconsider its three-judge panel’s ruling that the Affordable Care Act’s individual mandate was unconstitutional. The fact that the Justice Department took no action almost certainly means that its intent is to ask the Supreme Court to decide the issue.

The administration’s thinking was most likely dependent on three factors. First, given that the full Eleventh Circuit is considered even more conservative than the three-judge panel that struck down the mandate, the only advantage of a second hearing would have been to delay consideration by the Supreme Court. Against this was presumably factored the political risk of a further well-publicized rejection of the mandate providing additional ammunition for opponents of reform.

Second, the administration may still be able to delay a Supreme Court decision either by filing its request for a hearing at the last possible moment in November, or even by asking for a filing extension—something that the Court might be willing to consider, given the potential impact of a decision in the middle of a presidential election.

Top-Down vs. Bottom-Up

Sep 28, 2011• 2

By BOB WACHTER, MD

In my last post, I discussed the role of physicians in patient safety in the US and UK. Today, I’m going widen the lens to consider how the culture and structure of the two healthcare systems have influenced their safety efforts. What I’ve discovered since arriving in London in June has surprised me, and helped me understand what has and hasn’t worked in America.

Before I arrived here, I assumed that the UK had a major advantage when it came to improving patient safety and quality. After all, a single-payer system means less chaos and fragmentation—one payer, one regulator; no muss, no fuss. But this can be more curse than blessing, because it creates a tendency to favor top-down solutions that—as we keep learning in patient safety—simply don’t work very well.

To understand why, let’s start with a short riff on complexity, one of the hottest topics in healthcare policy.

Complexity R Us

Complexity theory is the branch of management thinking that holds that large organizations don’t operate like predictable and static machines, in which Inputs A and B predictably lead to Result C. Rather, organizations operate as “complex adaptive systems,” with unpredictability and non-linearity the rule, not the exception. It’s more Italy (without the wild parties) than Switzerland.

Complexity theory divides decisions and problems into three general categories: simple, complicated, and complex. Simple problems are ones in which the inputs and outputs are known; they can be managed by following a recipe or a set of rules. Baking a cake is a simple problem; so is choosing the right antibiotics to treat pneumonia. Complicated problems involve substantial uncertainties: the solutions may not be known, but they are potentially knowable. An example is designing a rocket ship to fly to the moon—if you were working for NASA in 1962 and heard President Kennedy declare a moon landing as a national goal, you probably believed it was not going to be easy but, with enough brainpower and resources, it could be achieved. Finally, complex problems are often likened to raising a child. While we may have a general sense of what works, the actual formula for success is, alas, unknowable (if you’re not a parent, trust me on this).

The Key to Improving Our Health? Look Beyond Health Care.

Sep 28, 2011• 3

By AARON WERNHAM, MD

The United States spent $2.5 trillion on health care in 2009, more per capita than any other nation. Yet our country is ranked 32nd in the world in life expectancy, and rates of conditions such as diabetes and obesity have increased dramatically in recent years.

If we hope to address spiraling medical costs and improve the health of all Americans, we need to begin focusing on the policies — in fields such as transportation, energy, education and agriculture — that shape the world outside the doctor’s office.

But how? Policymakers are already juggling shrinking budgets, crumbling infrastructure and competing priorities. A recently released report from the National Research Council offers a solution. The study, “A Framework and Guidance for Health Impact Assessment,” points out that good health is determined by more than money spent on the health care system. An NRC committee on health impact assessments, of which I am a member, took an in-depth look at why they are needed.

Similar to the way a Congressional Budget Office score predicts the fiscal impact of a proposed policy, an HIA identifies the likely effect on health of a decision in another field, such as building a major roadway, revitalizing a neighborhood or developing energy or agricultural policy. HIAs can help decision-makers identify unintended risks, reduce unnecessary costs and leverage opportunities to improve the health of their communities.

As a doctor, I’ve often cared for diabetics who struggle to follow exercise recommendations because there’s nowhere nearby that’s safe to exercise. I’ve seen patients with frequent asthma attacks exacerbated by living in housing with mold and poor ventilation. I’ve given diet advice to parents of overweight children, only to find that they live in a neighborhood with no grocery store for miles and eat school lunches that should but often don’t meet current nutrition guidance.Continue reading…

Too Much Responsibility/Not Enough

Sep 27, 2011• 16

By ROBERT LASZEWSKI

The Health Leadership Council (HLC), a coalition of CEOs from many of the leading health care companies, has created a list of Medicare reform recommendations for the Super Committee tasked with finding at least $1.2 trillion in budget savings.

As we begin the national debate over what to do about Medicare’s unsustainable costs, I will suggest that the HLC proposal gives us one, of what will have to be many, outlines for discussion.

Their recommendations include:

Creating a new Medicare Exchange, beginning in 2018, where beneficiaries would have the choice of private Medicare plans as well as the traditional Medicare plan. The HLC proposal would be a defined contribution program much like the Republican Ryan plan but would differ from Paul Ryan’s in a couple of key ways. First, in the HLC proposal traditional Medicare would continue to be one of the options. Second, the annual increase in the beneficiary support premium would be more generous—the HLC is proposing an annual premium support increase equal to GDP plus 1%.
Gradually increasing the Medicare eligibility age from 65 to 67—starting in 2014.
Reforming Medicare’s cost sharing structure by increasing deductibles and co-pays as well as requiring high-income beneficiaries to pay the full cost of Medicare Part B.
Implementing medical liability reform including a cap on non-economic damages, a one-year statute of limitations, and a “fair share” provision that would limit damages commensurate with responsibility for the injury.

The Challenge of ICD10 Adoption

Sep 25, 2011• 15

By JOHN HALAMKA

On October 1, 2013, the entire US healthcare system will shift from ICD9 to ICD10. It will be one of the largest, most expensive and riskiest transitions that healthcare CIOs will experience in their careers, affecting every clinical and financial system.

It’s a kind of Y2k for healthcare.

Most large provider and payer organizations, have a ICD10 project budget of $50-100 million, which is interesting because the ICD10 final rule estimated the cost as .03% of revenue. For BIDMC, that would be about $450,000. Our project budget estimates are about ten times that.

CMS and HHS have significant reasons for wanting to move forward with ICD10 including

1) easier detection of fraud and abuse given the granularity of ICD10 i.e. having 3 comminuted distal radius fractures of your right arm within 3 weeks would be unlikely
2) more detailed quality reporting
3) administrative data will contain more clinical detail enabling more refined reimbursement

Large healthcare organizations have already been working hard on ICD10, so they have sunk costs and a fixed run rate for their project management office. At this point, any extension of the deadline would cost them more.

Most small to medium healthcare organizations are desperate. They are consumed with meaningful use, 5010, e-prescribing, healthcare reform, and compliance. They have no bandwidth or resources to execute a massive ICD10 project over the next 2 years.

The Power in What We Most Fear

Sep 25, 2011• 2

By JOE FLOWER

There is fire in the valley and smoke in the mountains. A plague is on the land and danger is afoot. That may be — maybe — the good news.

Health care is more unstable than it has been at any time in living memory. That’s pretty scary, but that instability may turn out to be its most important asset in this moment, as the whole industry becomes open to profound change.

As long as I can remember, thoughtful analysts have been saying, “We need to do this differently. This is not working.” In this century, the voices became louder and more insistent, and they spread. But health care has been very slow to evolve in any fundamental way. Even health care reform, when it came through extraordinary political pain and maneuver, was more a way to bolster business as usual, a way to shore up revenue streams and patch holes in the fee-for-service business model, than it was any fundamental restructuring.

Now the ground under our feet is liquefying.

Educating the Health 2.0 Workforce

Sep 25, 2011• 1

By Charles Friedman & Wil Yu

As any new field of human activity evolves into something important, its original participants are drawn to it from a range of other fields and bring to it a wide range of backgrounds and experiences. For example, the original computer scientists were not schooled in computer science. The field didn’t exist when they were in school. The first generation of computer scientists were mathematicians, engineers, philosophers, among other things, who came together around shared interests in a set of challenging and important problems.

As computer science matured and proved its worth, however, something inevitable happened. Programs specifically to educate the next generation of computer scientists began to develop, and a range of questions arose about how best prepare them—how to combine math, engineering, philosophy into a new interdisciplinary program of studies.

Exploration of how to train its next generation gives shape to a new field, stimulates further growth and innovation, and ensures that that the next generation will be large enough to support a thriving enterprise. So it is with Health 2.0—a new field that has attracted an eclectic group of energetic pioneers and is beginning to mature. It’s time to think about the next generation.Continue reading…