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Above the Fold

Attacks on IPAB Gather Strength—And Waste Energy?

Aug 16, 2011• 3

By ROGER COLLIER

The Washington Post reports that the Affordable Care Act’s Independent Payment Advisory Board, intended to constrain Medicare spending increases, is under increasing pressure from Republicans, health care lobbyists—and a significant number of Democrats.

As specified by the ACA, the IPAB will consist of fifteen health care “experts” to be appointed by the president and confirmed by the Senate, with authority to make cuts to Medicare if spending exceeds specified targets, starting in 2015. Congress could overrule the panel, but only by mustering a super-majority in the Senate or by creating an alternate plan to save the same amount.

The ACA imposes narrow limits on the IPAB. By law it cannot ration care, cut benefits, change eligibility rules, or raise revenue by increasing beneficiary premiums or cost-sharing, nor can it—until 2020—reduce payments to hospitals. This means that the brunt of any IPAB-proposed savings will fall on physicians and drug and medical device companies.

mHealth – Potentially Valuable, But Not Ready For Primetime

Aug 15, 2011• 11

By TED DRISCOLL

mHealth – otherwise known as mobile healthcare – sounds like just what the doctor ordered to help make healthcare delivery cheaper and more effective. And since the Internet today essentially resides in everybody’s pocket, it would seem as though it’s ready to be implemented. But we have what amounts to a “last-three-feet” problem. So I’m not sure mHealth is ready for primetime, mostly because I don’t think our conventional healthcare system is ready or capable of embracing it.

The goal is to have patients wirelessly send appropriate clinical information to their healthcare providers in a timely manner. This would save time-consuming trips to the doctor on their part and, for doctors, ultimately make it easier to retrieve key patient clinical data. Such a system could detect events just before they happen and allow early critical intervention. The problem is that at this point this is just a goal, not reality.

I have looked at a half dozen startups in this space but haven’t made a commitment to fund any of them. In many cases, their technology looks promising, but it isn’t clear how the company would actually generate consistent revenue. Would the healthcare system reimburse mHealth? Would the doctor know how to interpret the flood of real-time data? Would our system drown under a deluge of alerts, many of which resolve naturally? There is a wealth of questions around these issues.Continue reading…

Why the 11th Circuit’s Opinion on Health Care Reform Self-Destructs

Aug 14, 2011• 85

By MARK HALL

Like a tragic literary figure, the 11^th Circuit’s opinion declaring the individual mandate unconstitutional is doomed to failure by its own internal contradictions. What follows is a series of quotes directly from the opinion, paired to show how desperately the majority twisted logic in order to find its path to a unsupportable conclusion:

1. On the key necessary and proper argument, the court obfuscated as follows:

The government’s argument derives from a Commerce Clause doctrine of recent [1995] vintage: . . . the “essential part of a larger regulation of economic activity” language in Lopez. . . . Raich [is the] the only instance in which a statute has been sustained by the larger regulatory scheme doctrine.

HOWEVER, the court was well aware that

The Supreme Court’s most definitive statement of the Necessary and Proper Clause’s function remains Chief Justice Marshall’s articulation in McCulloch v.Maryland: 17 U.S. (4 Wheat.) 316, 421 (1819).

In Obamacare Case, Constitution Is Victor

Aug 14, 2011• 12

By ILYA SHAPIRO

Today is a great day for liberty. By striking down the individual mandate, the Eleventh Circuit has reaffirmed that the Constitution places limits on the federal government’s power. Congress can do a great many things under modern constitutional jurisprudence, but, as the court concludes, “what Congress cannot do under the Commerce Clause is mandate that individuals enter into contracts with private insurance companies for the purchase of an expensive product from the time they are born until the time they die.” Indeed, just because Congress can regulate the health insurance industry does not mean it can also require people to buy that industry’s products.

One of the striking things about today’s ruling is that, for the first time in one of these cases, a Democrat-appointed judge, Frank Hull, has ruled against the government. Just as the Sixth Circuit Judge Jeffrey Sutton made waves by being the first Republican appointee to rule in the government’s favor, today’s 300-page ruling shows that the constitutional issues raised by the healthcare reform—and especially the individual mandate—are complex, serious, and non-ideological.

Supporters of limited constitutional government need to temper their celebrations—just as they wisely tempered their sorrows after the last ruling—because we must all now realize that this will not end until the Supreme Court rules. Nevertheless, today’s decision gives hope to those who believe that there are some things beyond the government’s reach and that the judiciary cannot abdicate its duty to hold Congress’s feet to the constitutional fire.

Ilya Shapiro is a senior fellow in constitutional studies at the Cato Institute and editor-in-chief of the Cato Supreme Court Review.

This post first appeared at Cato@Liberty – Cato Institute Blog.

Healthcare is Different

Aug 14, 2011• 79

By JOHN HALAMKA, MD

I’m often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.

Many clinicians say that healthcare is different.

I’m going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.

Here’s an inventory of the issues

1. Flow of funds – Hospitals and professionals are seldom paid by their customer. Payment usually comes from an intermediary such as the government or insurance payer. Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.

The July Effect

Aug 13, 2011• 1

By BOB WACHTER, MD

“Don’t get sick in July!” We’ve all heard patients and family members say this – part declaration, part wishful thinking – in reference to the perceived summertime risks of teaching hospitals. When I hear it, I usually respond with comforting bromides like “robust supervision” and “cream of the crop.” But deep down, if I had the choice of entering a teaching hospital in July and April, I’d choose the latter.

This preference comes partly from my recollections of my own training experience. The day before I began my residency at UCSF, my entire intern class gathered to meet our new bosses. We were on pins and needles – laughing at jokes that weren’t really funny, suspiciously eyeing our colleagues, whose admission to the program (unlike our own) could not be explained by clerical error. The chief of service, Greg Fitz, a brilliant gastroenterologist with a disarming “aw shucks” manner and a Southern drawl (he’s now Dean at UT Southwestern), stood to address us.

“I know you’re all nervous,” he said, catching our collective mental drift. “But don’t worry. If we can turn bread mold into penicillin, we can turn you guys into doctors.”

I was only partly reassured.

The next day, I began my internship on the wards at San Francisco General Hospital. I picked up the service from a graduating intern. His sign out to me was pithy. “Sucker!” he shouted gleefully, as he jammed his beeper into my abdomen like a football. Panicked, I managed to survive my first few weeks on the wards without killing any patients.

The True Measures of a “Good Doctor”

Aug 12, 2011• 23

By CHRISTOPHER J. WHITE, MD, FSCAI

Measuring patient outcomes is one way to determine how “good” a doctor is – but it is far from the only way. In our obsession with measuring performance, we seem to have forgotten that.

In medicine we measure a lot of things. We measure procedure times, length of stay in the hospital, complication rates. As a chief of cardiology, I’m involved in measuring a wide range of metrics, from how quickly the patient receives treatment (door-to-balloon time) to major adverse cardiac event (MACE) rates, and numerous other measurements. The medical field has spent the last decade developing metrics to assess quality of health care, and certainly these measures have value.

But by themselves, these metrics are inadequate to answer the patient’s most essential question, “Do I have a good doctor?”

We seldom measure whether a doctor is available after hours when their patient has a concern. We seldom measure doctors’ ethics or whether they are able to meet the emotional needs of a patient. We seldom measure a doctor’s willingness to refer a patient to another physician if that person can better meet the patient’s needs. Yet to a patient, these things can be every bit as important as outcomes.

Most health care professionals know a “good doctor” when they encounter one. Being a good doctor is not the same as a career achievement award such as being named a “master clinician.” Often we recognize “good doctors” among younger physicians-in-training, or junior faculty members, as well as some, but not all, senior faculty members. Patients can identify “good doctors” without ever knowing what they scored on their Board exams.

Let’s Hope ACOs Aren’t Our Last, Best Chance for Delivery System Reform

Aug 11, 2011• 1

By DAVID E. WILLIAMS

After reading the July edition of Health Affairs, I’m concerned about the impact of Accountable Care Organizations (ACOs) on cost trends in the US health care system.

In The Accountable Care Organization: Whatever Its Growing Pains, The Concept Is Too Vitally Important To Fail, Francis Crosson of the Kaiser Permanente Institute for Health Policy plays down the various criticisms of ACOs (that they may stifle innovation, unleash a torrent of regulation, and rely too heavily on fee for service payment methodologies) and argues that we need to help them succeed because there are no good alternatives. If not,

both public and private payers will probably be forced into across-the-board reductions in payment rates to providers, because the state of the economy will require cost reductions, and there will be no other obvious course to pursue. Reductions in quality and access may follow…

But the emergence of ACOs is driving hospitals to consolidate, buying other hospitals and physicians practices.

Reduce Antibiotic Resistance: Get Your Flu Vaccine

Aug 11, 2011• 4

By LAURI HICKS, DO, SEEMA JAIN, MD, & RAMANAN LAXMINARAYAN

A study published in the July issue of Infection Control and Hospital Epidemiology shows that antibiotic prescriptions tend to spike during flu season, even though influenza is caused by a virus and cannot be treated with antibiotics.

Some of these antibiotic prescriptions are justified – bacterial pneumonia, which must be treated with antibiotics, is also common during the winter months. And getting the flu puts you at higher risk for developing complications from secondary infections, including bacterial pneumonia.

Yet some people suffering from the flu virus alone may demand–and get–an antibiotic even though viral infections do not respond to antibiotic treatment.

According to Extending the Cure, a nonprofit project funded by the Robert Wood Johnson Foundation’s Pioneer Portfolio, between 500,000 to one million antibiotic prescriptions are filled each year during flu season for patients who have the flu and no bacterial illness.

Why should we care about how many antibiotics are prescribed?

When antibiotics are overused or inappropriately used, bacteria can develop antibiotic resistance, or the ability to withstand antibiotic treatment, making bacterial infections difficult to treat. Antibiotic resistance can develop quickly. Today’s antibiotics – the wonder drugs that transformed modern medicine – are used so commonly that we face the prospect of a future with a multitude of resistant bacteria and a shelf full of ineffective drugs.

From EHR to HIE and Back

Aug 11, 2011

By MARGALIT GUR-ARIE

According to the latest count, there are 255 Health Information Exchange (HIE) organizations across the country, which amounts to an average of 5 in each State. If you are a practicing physician and have an EHR, chances are someone already knocked on your door offering to connect your practice to the local HIE for a small fee. If you don’t have an EHR, you may have had offers to access an HIE web portal, or maybe an HIE supplied EHR Lite, allowing you to at the very least view clinical data from other sources. Perhaps for free. If you are the proud owner of one of the full-featured EHRs, you may wonder what an HIE can do for you that your EHR is not already doing, and whether that service is worth your hard earned money.

In theory, a top-shelf EHR should be able to connect your practice to multiple facilities and allow you to exchange information to the best of all participants’ abilities. Granted most EHRs are still working on some of the connections, particularly to local facilities, but all in all, an EHR should be able to eventually provide for all your connectivity needs as shown in Figure 1. Note that for some types of connections, your EHR vendor can use a clearinghouse or portal approach to simplify and reduce costs of connectivity. For example, you don’t need a separate interface for each pharmacy – you use Surescripts as the clearinghouse and let them worry about it. You also don’t need an individual connection to each patient’s home – you communicate with all of them through one portal. With the exception of Surescripts pharmacy connectivity and a small number of reference labs, each connection, or interface, is costing you a pretty penny, and the more local the connection, the longer it takes to build.