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Above the Fold

Essential Health Benefits: The Secretary’s Joystick

Jun 23, 2011• 3

By Robert Graboyes

Beginning in 2014, the Patient Protection and Affordable Care Act (PPACA) hands the Secretary of the U.S. Department of Health and Human Services a joystick – the Essential Health Benefits (EHB) package – with the potential to rocket small-business health insurance premiums skyward. EHB is the menu of goods and services that must be covered under all exchange-purchased insurance plans and non-grandfathered small-group and individual insurance plans. By vesting one set of hands with control over EHB, small business faces permanent administrative uncertainty. At the same time, the brunt of EHB appears largely to bypass big business, unions, and governments.

The EHB requirements apply to policies purchased both in exchanges and in non-exchange small-group or individual markets. In the small-group and individual markets, annual or lifetime coverage limits on all EHB items are forbidden. And plans must have an actuarial value (AV) of at least 60 percent, meaning the plan’s total reimbursements must be at least 60 percent of the total qualifying health care costs incurred.

Section 1302 empowers the Secretary of HHS to define EHB, but gives little specificity beyond requiring that EHB include 10 general categories (e.g., ambulatory patient services) and “the items and services covered within the categories;” the Secretary is to also assure that EHB includes “benefits typically covered” by a “typical employer plan.” The meaning of these words in quotation marks is left to the Secretary (and future Secretaries) to define and redefine. The fluid definitions and concentrated discretion mean uncertainty, which carries a financial cost for small business.
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A New Hope? (…But What About That Pesky Death Star?)

Jun 22, 2011• 10

By MICHAEL PAINTER, MD

Picture a version of the Star Wars opening crawl:

A long time ago in a galaxy far, far away…. It is a period of enormous change and worry. The challenges are great. The status quo of poor health care quality and crushingly high costs is bearing down on the people—but that enemy is also under attack. A growing band of folk from all parts of the galaxy are attempting to bring every imaginable force—technology, market, government, people power—to the cause. No one’s certain how it will all turn out…

Now, cue ominously Darth Vader’s imperial march theme… (Fade out).

Earlier this month, I participated in the 2011 HHS/IOM Health Data Initiative Forum and self-styled “Data-Palooza”. It was exciting. Lots of dynamic leaders attended —from the government, the software development world and other industries—lots of Twitterati—social media personalities. The place buzzed, literally. (It was just missing the Tatooine bar music.)

I couldn’t help but flash back to last year’s markedly more freshman, inaugural meeting and compare. The differences one year later were striking—even startling at times. The obvious progress could make one pretty hopeful. The vision of creating tools that use previously moribund federal (and other) data in unique ways to solve real problems is already bearing some remarkable fruit.

During the “Data-Palooza” plenary session, a parade of app developers demonstrated technology that mines and harnesses data for very cool, practical purposes. High points: PatientsLikeMe; Asthmapolis; and Multistate Foodborne Disease Outbreak Investigation System (catchy name…). The whiz bang, jaw dropping technology of these, and other, examples was impressive. Last year, one really had to suspend to imagine how all this talk might actually have a major impact. This year it could seem as if the vision isn’t keeping up with the technology. In fact, perhaps we should be bolder, much bolder.

But, then, the enormity of the challenge brings one right back down to Earth—or rather—Endor.

Getting More Startups Focused on Health

Jun 21, 2011• 11

By MISSY KRASNER

Could it be true? Is venture funding on the mend after it’s collapse in 2008? Some would say that the amount of capital invested is on the rise, and new funding streams are providing an excellent opportunity for startups to start getting funded again. But is this also true for health or healthcare startups? After leaving Google recently, I have been spending time talking to various startups and VC firms that are interested in health and healthcare apps. I am encouraged by what I see.

There seems to be a handful of seed accelerators and government initiatives focused on stimulating innovation in the consumer and provider health tech space. New incubators like Rock Health and Startup Health, an arm of the Startup America Partnership are trying to encourage attention to this vertical. Other cool platforms such as the Quantified Self movement, ONC’s Investing in Innovations (i2) Initiative, and this week’s impending announcement of the SMArt (Substitutable Medical Apps, Reusable Technologies) Challenge Apps are creating some fresh buzz. But what I find even more interesting is that broader tech accelerators like YCombinator, and 500 Startups are also starting to fund some health startups (checkout drchrono.com and Evoz).

While I am making my rounds, I cannot help but make a shameless plug for some of my ex Googler friends at 500 Startups. In case you have not heard of them yet, 500 Startups is a $40 million Super Angel investment fund that was founded by former PayPal executive, Dave McClure and Christine Tsai, former Google Marketing pro who ran Google I/O. They provide early-stage seed funding ($10K to $250K) and have over 140 experienced startup mentors around the world that help with product design and data and customer acquisition. 500 Startups holds a series of events on all kinds of things relating to startup success. In fact, check out the event they are hosting this Saturday, June 25th from 1-6pm called “‘Design a Healthy Startup: Prevent Burn Out.” This event will feature 500 Startup founders and entrepreneurs from HealthTap, EcoFactor, Google, Facebook and Zynga. Demos from cool new startups in the wellness space like Dojo, Habit Labs, and FitSquid, will also be presenting. Read more about the event or sign up to attend this Saturday.

Missy Krasner spent several years helping getting Google Health off the ground, and before that was David Brailer’s right-hand woman at ONC.

Setting The Record Straight On Drug Shortages

Jun 21, 2011• 7

By TED SLAFSKY

John Goodman of the National Center for Policy Analysis (NCPA) says in a recent blog entry that the Public Health Service 340B drug discount program is part of a “web of [federal] regulations that are preventing life saving drugs from reaching the patients who need them.” More specifically, he says that the program, which provides discounted drugs to safety-net institutions such as hospitals and clinics that treat large numbers of indigent patients, is “contributing” to severe prescription drug shortages.

His essay, however, offers no factual support for its claim that the 340B program is somehow causing shortages. His entire case against 340B drug discounts rests upon his belief that “when prices are kept artificially low, shortages develop.”

Last month, the Pharmaceutical Research and Manufacturers of America (PhRMA) issued a statement on drug shortages and their causes. Citing the Food and Drug Administration (FDA) and other experts, the industry group says shortages can occur

for any number of reasons ranging from natural disasters; shifts in clinical practices; wholesaler and pharmacy inventory practices; raw material shortages; changes in hospital and pharmacy contractual relationships with suppliers and wholesalers that can cause fluctuations in the availability of certain products; adherence to FDA-mandated distribution protocols, which can impact patients’ timely access to medicines; individual company decisions to discontinue specific medicines; and manufacturing challenges.

The absence of any mention of 340B, or of government limits on drug prices more generally, is noteworthy given that PhRMA is not very fond of such programs.

Seriously, Some Consensus About Health Care

Jun 21, 2011• 10

By GREGORY MANKIW

We are entering the season of polarization. With various Republicans vying to replace Barack Obama, the president eager to keep his job, and both the House and the Senate up for grabs, candidates from both sides of the aisle will spend the next year and a half stressing their differences.

But beneath this veneer of partisanship lie a few fundamental agreements. Consider health care, which will be at the center of the political debate. Here are four aspects of the issue in which Republicans and Democrats have stumbled into consensus.

THE VALUE OF COMPETITION Representative Paul D. Ryan, Republican of Wisconsin, has attracted much attention with his plan to reform Medicare. He proposes replacing the current fee-for-service program, in which the government picks up the bill for medical expenses, with a “premium-support” system in which seniors use federal dollars to choose among competing private insurance plans.

Democratic critics of the plan suggest that enacting it would be akin to pushing Grandma over a cliff. But they rarely point out that the premium-support model is in some ways similar to the system set up under President Obama’s health care law. If choosing among competing private plans on a government-regulated exchange is a good idea for someone at age 50, why is it so horrific for someone who is 70?

Republicans, meanwhile, are eager to repeal Obamacare and so are also reluctant to point out its parallels with Ryancare. We can take heart, however, in the kernel of agreement about the value of private competition.

Lessons Learned from my Uncle’s Sacrifice

Jun 20, 2011• 6

By JOHN MAA, MD

My uncle’s tale illustrates the fundamentally American tragedy of experiencing financial and medical catastrophes simultaneously, and having to choose between rationing one’s own care or depleting precious financial resources for potentially lifesaving treatment that could as well be futile.

From my perspective as a surgeon, an additional tragedy is that my uncle never got the chance to know his cause of death with certainty. There is a small chance (approximately 5 percent) that his jaundice arose from a benign or treatable condition such as lymphoma, an autoimmune process, or another noncancerous condition, and that if he had received full treatment he would be alive and well today. But a diagnostic surgery would likely have added $100,000 to his final medical costs. Thus my uncle weighed the odds and rationed his own care to preserve his daughters’ inheritance for their future benefit.

To answer the question I posed at the end of the previous article, I do not believe that my uncle was treated fairly by the system. Sadly, he was just a few years too young to receive Medicare benefits, despite having paid into the system for decades. I was especially struck by the feedback about my uncle’s story from readers in France, Poland, Canada, Cyprus, and other countries with universal health care who were stunned to read of the dreadful timing in this desperate situation.

Death by Regulation

Jun 20, 2011• 2

By JOHN GOODMAN

“How many of you have not been able to get a drug you needed to properly deliver anesthesia to a patient?” I asked.

Every hand in the room went up.

“How did that affect your patients?” I asked. “Two of our patients died,” one woman answered.

I was speaking to a group of nurse anesthetists, enrolled in a business management program at Marshall University in West Virginia. I wish I could say their experience is unusual. It isn’t.

About 90 percent of all the anesthesiologists in the country report they are experiencing a shortage of at least one anesthetic. Drug shortages are also endangering cancer patients, heart attack victims, accident survivors and a host of other ill people. The vast majority involve injectable medications used mostly by medical centers, in emergency rooms, ICUs and cancer wards. Currently, there are about 246 drugs that are in short supply and, as the chart shows, the number has been growing for some time.

So what’s going on?

Fulfilling the PROMISe

Jun 20, 2011• 1

By MARGALIT GUR-ARIE

A brand new EMR is being rolled out in a midsize hospital. The EMR is exclusively based on touchscreen technology, with devices strategically placed on the floor. It provides concurrent access to medical records for all team members (physicians, nurses, pharmacists, radiologists, dieticians, secretaries) wherever they may be. Patients are also accessing the EMR. They enter their own histories and describe symptoms in detail through the same touchscreen devices. This patient-centered EMR, built by a team of clinicians and technologists working together, is taking a huge step forward in Clinical Decision Support (CDS). Physicians are not only shown differential diagnoses based on what patients and other team members entered into the system, but are also presented with individualized care plans, possible side effects, dosage recommendations and drug-drug-interaction alerts, all referencing evidence available in medical literature. Longitudinal records, test results and narratives are available by problem and by patient, and the response time is never more than half a second between the thousands of screens available. The place is Vermont, and the year is 1970.

Half a century ago, when work on this EMR was taking place, Healthcare IT was on the cutting edge of technology. The Problem Oriented Medical Information System (PROMIS), the brainchild of Dr. Lawrence Weed, was pushing the envelope on every technology from hardware to operating systems, to network communications, database design and programming languages. By the time this government funded project was finally shut down, the PROMIS team dealt with such issues as mass storage, federated or single database, high availability, human interface design and networking between geographically dispersed locations. It will take several decades for the rest of the world to catch up with Dr. Weed’s, now defunct, innovation and produce something like IBM’s Watson software package, which is yet to be adapted and tested in health care. Somewhere, somehow, we took a wrong turn in Healthcare IT, and it wasn’t the much maligned billing influence, since PROMIS from day one, attempted to integrate billing in its software, with no ill effects.

Rads are Good For You. Take Twice as Many.

Jun 20, 2011• 2

By PAUL LEVY

Dear Mrs. Smith, I am writing to inform you that we exposed your body to an unnecessary level of radiation during your visit to our hospital. Oh, by the way, that was two years ago. We don’t intend to do anything about this for you. Also, we have known about this problem for a long time, and we don’t expect to change our procedures for future patients. Just wanted you to know. Yours in delivering the best health care in the world, Chief of Radiology and CEO. (Jointly signed.)

That’s the essence of this article by Walt Bogdanich and Jo Craven McGinty in the New York Times. Here are excerpts:

Long after questions were first raised about the overuse of powerful CT scans, hundreds of hospitals across the country needlessly exposed patients to radiation by scanning their chests twice on the same day, according to federal records and interviews with researchers.

Double scans expose patients to extra radiation while heaping millions of dollars in extra costs on an already overburdened Medicare program. A single CT scan of the chest is equal to about 350 standard chest X-rays, so two scans are twice that amount.

Health Data Discovery Contest at CureTogether

Jun 19, 2011

By Alexandra Carmichael

If the fine folks at Health 2.0 are any indication, contests seem to be the best way to spark innovation these days. CureTogether is throwing another contest into the mix this summer:

The Health Data Discovery Contest

Over the past 3 years, CureTogether has gathered millions of patient-reported data points on symptoms and treatments for over 500 conditions. Now it’s time to test on a larger scale how well CureTogether data represents the general population. Do they match up or not?

So we’re running a contest to tap the most brilliant stats minds out there. Challenge our dataset! See whether or not it holds up to existing research studies. Why? You’ll be helping to demonstrate the effectiveness of online platforms for medical discovery, and ultimately helping to reduce global suffering.

There are cash prizes, and the deadline to join the contest is June 29, 2011.Continue reading…