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Above the Fold

Analyzing A Crucial Battle In The Legal War Over Health Reform

Jun 10, 2011• 10

By TIMOTHY JOST

For a lawyer, the argument of Florida v. the Department of Health and Human Services before a three judge panel of the Eleventh Circuit Federal Court of Appeals on Wednesday, June 8, was a beauty to behold. (For a non-lawyer it was probably tedious, repetitive, and much too long). Three active and very well-prepared judges spent two and a half hours grilling three very talented lawyers about intricacies of health policy and constitutional law, rarely allowing the lawyers time to finish a thought before interrupting with yet another question.

This is arguably the most important of the many Affordable Care Act (ACA) challenges currently pending in the courts. The plaintiffs include over half of the states, as well as the National Federation of Independent Businesses (NFIB) and two individual plaintiffs. It is one of only two cases in which a part of the ACA has been held unconstitutional (out of over thirty cases that have been filed), and it is the only case in which the lower court struck down the entire statute as unconstitutional. Thirty-six amicus briefs were submitted to the appellate court, including briefs filed by professional and provider organizations, members of Congress, states and state legislators (on both sides), Nobel Prize winning economists, law professors, disease and consumer organizations, and just about every conservative advocacy group in the country.

The attorneys. The importance of the case is underlined by the fact that the federal government was represented by Acting Solicitor General Neal Katyal, while the states were represented by Paul Clement, Solicitor General under the Bush administration, perhaps the first time two solicitor generals have squared off against each other in a court of appeals argument. (The NFIB was represented by a third well-known lawyer, Michael Carvin).

Quality Like Beauty Is In the Eye Of The Beholder

Jun 10, 2011• 8

By HUMPHREY TAYLOR

For as long as I can remember we have told ourselves that the health care priorities of the American people are access, cost and quality. However there was never a consensus as to what exactly we meant by quality, let alone how to measure it, or pay for it. The truth is that there are many ways of defining quality and our research shows that different players define quality very differently. Patients, physicians , employers, insurers, the I.O.M, hospital managers, drug companies, the NCQA, public health experts, demographers and policy wonks all focus on different indicators of quality. Clearly quality, like beauty, is in the eye of the beholder.

Patients tend to define quality as meaning affordable access to almost everything. Naturally they care about the outcomes of their own care. They tend to believe that more care is better than less. The demeanor and bedside manner of doctors and nurses, being treated with respect and courtesy, are important. They often judge hospitals the way they judge hotels; good food and a nice atrium make a difference. As Ian Morrison has written “good quality is being in a waiting room with people who have more money than you”.

The Institute of Medicine has equated quality with the avoidance of medical errors (adverse events) and patient safety , and the pursuit of ways to improve these.

Most Employers tend to equate quality with having happy , uncomplaining employees at the lowest possible cost. A minority of progressive employers , such as those who participate in the NBGH and PBGH meetings, also focus on “value” and the use of sticks and carrots to influence the behavior of their employees and pay for performance incentives to influence providers.

“But they are different.” Not!

Jun 10, 2011• 1

By PAUL LEVY

Whenever I talk about the spectacular work Brent James and his colleagues have done with process improvement at Intermountain Health, someone says, “But they are different.” These comments are often based on prejudice. It reminds me of the folks in the US automobile industry who initially said of Toyota’s use of Lean principles, “It will never work in America. Those Japanese are different. They are so much more compliant than Americans.” Then, those competitors discovered that Toyota factories in the US, with American workers, also effectively used Lean. And ate their lunch.

What do they say about IH? They talk about the homogeneity of the population in Utah, meaning that there is a predominantly Mormon population. They subtly suggest that Mormons are somehow more complaint with regard to health care treatment, have fewer health problems, or that the doctors are more likely to follow orders, or something equally foolish. Here’s the more accurate description:

The IH network of twenty-three hospitals and 160 clinics provides more than half of all health care delivered in the region. Intermountain’s hospitals range from critical-access facilities in rural areas to large, urban teaching hospitals. Although Intermountain has an employed physician group and a health insurance plan, the majority of its care is performed by independent, community-based physicians and is paid for by government and commercial payers.

No Magic Pill to Cure Poor Medication Adherence

Jun 9, 2011• 7

By JESSIE GRUMAN

You are sick with something-or-other and your doctor writes you a prescription for a medication. She briefly tells you what it’s for and how to take it. You go to the pharmacy, pick up the medication, go home and follow the instructions, right? I mean, how hard could it be?

Pretty hard, it appears. Between 20 percent to 80 percent of us – differing by disease and drug – don’t seem to be able to do it.

There are, of course, many reasons we aren’t. Drugs are sometimes too pricey, so we don’t fill the prescription. Or we buy them and then apply our ingenuity to making them last longer by splitting pills and otherwise experimenting with the dosage.

Some drugs have to be taken at specific times or under specific conditions, posing little challenge when you are taking only one. But it can be devilishly difficult to coordinate the green pill half an hour before breakfast, the yellow ones on an empty stomach four times a day and the orange one with a snack between meals. It’s complicated; we don’t understand. We’re busy; we forget. We’re sick; it’s confusing.

Some drugs produce uncomfortable side effects while others set off an allergic reaction. Every single day, we have to decide if the promised outcomes are worth the discomfort.Continue reading…

It’s THCB’s Health Wonk Review

Jun 9, 2011• 1

By Matthew Holt

It’s Thursday morning. Fresh off the digital presses. It’s finally here. THCB (after a long absence) is back hosting Health Wonk Review….

Health IT Dept

We start close to home with huge news for THCB’s sister organization Health 2.0. (FD-Matthew Holt THCB’s Founder is also Co-Chairman at Health 2.0). And the news is that the world has gone crazy for Challenges, and that HHS and ONC (they of the billions for EMRs) are joining in, and funding a huge series of challenges for tech innovation in health care. Over at Health 2.0 News Matthew and Health 2.0 CEO Indu Subaiya explain Heath 2.0’s role in Investing In Innovation or i2.

And if that wasn’t enough, the entire health data wonk world is descending physically or virtually on Rockville, MD this morning for the Data-Palooza inspired by HHS’ CTO Todd Park. If you don’t know about Todd you should read this great profile by Simon Owens in The Atlantic. But THCB published Todd’s piece about the Data-Palooza (or more formally the Health Data Initiative Forum) a fraction ahead of the HHS blog, so we’re linking to it here. It includes information about what, who and how you can see it live–and if you care about health and tech and data, how can you miss it?

Of course, i2 and HDI is not all that’s been announced in tech this week. Inspired by Steve Jobs’ iCloud keynote this week in San Francisco, Dr. Jaan Sidorov at the Disease Management Care Blog ponders the healthcare potential of Apple’s ballyhooed mobile operating system.

Despite the boom over the past few years in new technologies and services targeting healthcare, many new services are not doing as well as the experts have predicted. (Note LOTS more HWR below the jump)

HIT Trends Summary for May 2011

Jun 9, 2011• 1

By MICHAEL LAKE

This is a summary of the HIT Trends report for May 2011. You can get the current issue or subscribe here.

E-prescribing scale and innovation. Surescripts reports dramatic growth for e-prescribing with a third of office-based physicians on its network and 20% of all scripts now going electronically to pharmacies and mail order. Yet formulary and prescription history data are underutilized by practices. This according to a study by Center for Studying Health System Change who finds that while most physicians have access to formularies and about half to medication histories, many don’t utilize it because they don’t see the value or systems are too cumbersome. However, there continues to be innovation in this area. CVS Caremark is piloting electronic prior authorization and Medco released a consumer pharmacy app for Verizon phones that alerts consumers to lower cost alternatives that Medco hopes will be discussed with prescribers. This is a terrific model for supporting the provider-patient dialog around medications. The key is the personalization to the member’s specific benefit information and the application’s ease of use. Perhaps these innovations can help address the utilization issues.

EHR market dynamics. There is also market growth and adoption of EMRs. According to report by Kalorama Research it’s a $15.7B U.S. market in 2010 with predicted market growth of 18%-20% per year for the next two years. California Health Care Foundation is reporting that over half of California’s primary care physicians using an EHR, and of the largest practices, adoption is over 80%. EHR is increasingly a global issue with new reports on the European experience highlighting that 81% of hospitals there have electronic patient records. This is a comprehensive European study of 909 hospitals in 30 countries. Larger public and university hospitals are more advanced than smaller private ones. Nordic countries are leading. Individual spider-charts give readers a summary at-a-glance. Still all is not rosy. England’s National Audit Office reports its National Health Service EHR project is failing.

Online Communities & Attrition from Health Intervention Programs

Jun 9, 2011• 1

By GLENN LAFFEL, MD

Provider-centric, face-to-face health intervention programs that help people quit smoking, lose weight and increase activity levels have been shown to work, but they are expensive, don’t scale, and inconvenient. By contrast, Internet-based programs with similar goals can be disseminated widely and inexpensively, and can be accessed by consumers at a convenient time and place.

Although many of the latter programs have been shown in clinical trial settings to be efficacious, attempts to commercialize them have been plagued by attrition. People stop using the programs because they lose motivation, can’t find the time, or become frustrated by clunky interfaces and data entry requirements.

In one study for example, only 26% of participants in a randomized trial of a free physical activity website dropped out of the study before it was completed, whereas 67% of registered open access users dropped out during the same course of time. The open access users also spent less time on the site.

The lower attrition rate in the trial was likely driven by the emotional, cognitive and logistic support provided by trial personnel. It follows that the commercial success of online health intervention programs hinges on their ability to support users in the same way as trained personnel do in clinical trial settings.

Health 2.0 will be running challenges & scanning innovation for ONC

Jun 9, 2011

By Indu Subaiya & Matthew Holt

We’re delighted to tell the Health 2.0 Community that all of your great work in the Health 2.0 Developer Challenge has received tremendous backing of the highest order. Today HHS confirmed officially that ONC is getting into the challenges business, and–working with our partner Capital Consulting Corporation–Health 2.0 will be managing a $5m 2 year program called Investing in Innovation or i2.

There are lots more details in the press release from HHS, but expect to soon hear from us about many more public sector challenges across the board in information technology in health with some considerably larger prizes than we’ve seen in the 22 challenges we’ve already managed.

We are incredibly excited about both our role in working with ONC and the opportunity that this gives all the innovators in the Health 2.0 community. Please keep your eyes open for both more private sector challenges, and major announcements about HHS challenges starting in July. And of course we’ll be saying more about this at the Health Data Initiative Forum on Thursday.

In addition Health 2.0 (and our Health 2.0 Advisors’ service) will be working on a contract for HHS/ONC to track and scan the overall level of innovation in health technology. Please stay tuned as we’ll be releasing more information about our scanning and advisory work in the near future, or you can of course **@********on.com“>contact us directly.

The Unbridgeable Gap between Left and Right on Health Reform

Jun 8, 2011• 57

By JEFF GOLDSMITH

Though thoroughly smothered under 2900 pages of well meaning but poorly focused, expert-driven “good works”, the core of the Affordable Care Act was providing 30 million people subsidized health insurance coverage. As the country continues to decide how it feels about this monumental legislation, a major ideological divide persists over whether the aggressive coverage expansion in health reform was really needed or not.

Far from “selling itself,” as a overconfident White House aide suggested it would back on March 23, 2010, health reform remains strikingly unpopular. Only 37% of the public thinks the country will be better off as a result of health reform, and only 28% think their families will be better off, according to the May Kaiser Family Foundation tracking poll. There is a stark partisan divide over health reform. While 72% of Democrats have a favorable opinion of health reform, a substantial minority believes the bill could have done more (covered more people, provided a public option or path to single payer). Alternatively, 74% of Republicans have an unfavorable opinion of health reform; the same percentage favors repeal. Independents tend to break toward the Republican view of the bill (49% unfavorable vs. 35% favorable). Those opposed feel more intensely about health reform than those in favor.

The Ryan House Budget for 2012 zeroes out all new spending for health reform (while keeping ACA’s Medicare cuts, devoting them to deficit reduction!). The conservative narrative is that the problem of the uninsured was liberal mythology, not meriting major new spending. In the blogosphere, an analysis surfaced suggesting that the real uninsured problem is only about 4 million people. This apparently originated in a Heritage Foundation blog posting from late August, 2009. Other conservative analysts charitably suggest there may be as many as ten to twelve million uninsured worthy of federal help. To take care of this smaller number, you do not need a major coverage expansion, but merely to apply the familiar market oriented remedies: selling insurance across state lines, high deductible health plans, malpractice reform, high risk pools, etc.

Defining Quality in the Health Insurance Industry

Jun 8, 2011• 19

By VIPAN NIKORE, MD

My patient, whom I’ll call Jane, had a neurologic disorder that prevented her from emptying her bladder properly. She required a permanent urinary foley catheter to help her urinate. Jane landed back at the hospital with yet another urinary tract infection – her third in one month. She had pus draining from her catheter and was infected with a multi-drug resistant strain of the bacteria Proteus. Our lab ran tests (sensitivities) to determine which antibiotics would be required to eradicate the infection, and it turned out the only oral drug that could destroy the infection was fosfomycin. Giving her fosfomycin would allow her to avoid intravenous antibiotics and be treated at home. This would prevent a lengthy expensive hospital stay. Thank goodness for fosfomycin, I thought.

One problem though: The insurance company wouldn’t pay for her 3 day fosfomycin prescription. It took several calls by our case manager and senior resident physician before, finally, the insurance company agreed to pay. And even then the insurance company decided to place a restriction on her purchasing of fosfomycin — they only allowed her to purchase only one dosage at a time. Did I mention that her neurological disorder prevented her from walking? Yes, a lady from a low-income area of Cleveland who cannot walk was required to find her way to the pharmacy three times in order to eradicate a dangerous infection. Was this just cruel, or was I missing something here?

We had to delay discharge two days, which was troublesome for Jane. Plus, the cost for two more nights in the hospital negated any savings that the insurance company gained by refusing to pay for her medicine. The time lost by our team members on the phone arguing with insurance companies easily could have been spent providing care to other patients. I’m struggling to find the winner in this equation!