PatientsLikeMe has, since before we first featured them at Health 2.0 in 2007, been the patient online community continually pushing the boundaries for patients with rare diseases. It started with MS, ALS and Parkinson’s and slowly moved towards mental health. And along the way PLM developed some of the most unique reporting tools both for patients and for third party (read: pharma) researchers. However, it always stayed away from the really big disease categories, like diabetes. No longer. As of today anyone can start a community for any condition at PatientsLikeMe. As of right now there are 182 patients with type 2 diabetes. Of course this is minuscule compared to Diabetic Connect or dLife, but given PLM’s reputation and press coverage, the gloves are well off in the patient community contest.
Above the Fold
The Massachusetts Mistake
By ROGER COLLIER
A year after the passage of health care reform, fewer than half of Americans support it, a similar percentage believe that it has already been found unconstitutional or soon will be, health care costs are continuing to rise far faster than the CPI, and the Republican Party has seized on the issue as a sure election winner.
The Obama administration and congressional Democrats, now thoroughly on the defensive, are clearly surprised at the public and political reaction. But should they be? This post—on the reliance on Massachusetts as a model—is the first of three that will look at some of the miscalculations—and sheer bad luck—that have helped to undermine reform. When Governor Mitt Romney signed Massachusetts’ reform bill into law in 2006, it was widely regarded as a bipartisan political triumph, and one that was supported by the public and by most of the state’s insurers and providers. Massachusetts would be the first state to require virtually all legal residents to have coverage (with tax penalties imposed on those not complying), while providing subsidies for lower-income individuals not eligible for government programs, as well as to implement a state-administered brokerage function (the Connector) to allow competitive selection of health plans. By the fall of 2008, as congressional efforts to design national health care reform moved into overdrive with the election of Barack Obama, the Massachusetts legislation was widely regarded as a success. Public reactions were generally positive, the numbers of uninsured had fallen, and there had been no dramatic increase in costs. It was scarcely surprising that the Massachusetts model emerged from the field of competing proposals as the favorite of most Democratic lawmakers.
Unfortunately, the elected officials in Washington DC failed to recognize that Massachusetts was an exceptional state in terms of health care. Even before the state’s reform bill was enacted, the percentage of uninsured was very low. It was also a socially very liberal state, far more likely than most to support reform efforts (in fact, Massachusetts had passed, but then revoked, a slightly different version of health care reform a dozen years earlier). And, of course, the economy was still in its boom period when the new law was passed. Massachusetts had other advantages that would not transfer to national reform. As a small state, with only a small percentage of the population likely to be directly affected by reform, implementation could be much faster—less than a year for most provisions of the state’s new law. Continue reading…
The RUC’s Defense
By BRIAN KLEPPER
On Wednesday, 47 American medical specialty societies sent Rep. Jim McDermott (D-WA) a letter, with copies to all members of Congress, containing a detailed defense of the American Medical Association’s (AMA’s) Relative Value Scale Update Committee’s (RUC). For 20 years, the RUC has exclusively advised the Centers for Medicare and Medicaid Services (CMS) on physician procedure valuation and reimbursement. On its face, the letter responds to a seemingly minor piece of legislation introduced by Rep. McDermott, H.R. 1256, the Medicare Physician Payment Transparency and Assessment Act, that would require CMS to use processes outside the RUC to verify the RUC’s recommendations on medical services values.
Conspicuously absent from the letter’s signatures were the nation’s three main primary care societies: the American Academy of Family Physicians (AAFP) – which has formally endorsed Mr. McDermott’s bill – the American College of Physicians (ACP) and the American Academy of Pediatrics (AAP). Last week, the New Jersey Academy of Family Physicians sent a letter to its parent organization, AAFP, “strongly encouraging” it to quit the RUC. It is as though the long-compromised primary care physician community, that makes up one third of American physician and handles half of our office visits, is suddenly mobilizing.
The medical societies’ letter is more than a response to just Rep. McDermott’s bill. It also responds to the primary care physician community’s stirrings. Marshaling the influence and discipline of a medical establishment obviously distressed by the prospect of having its economic franchise disrupted, it was the third public defense of the RUC in a little more than a week, following a column on Kaiser Health News by the RUC’s Chair, Barbara Levy MD, and a letter this past Tuesday to Rep. McDermott by AMA CEO Michael Maves. After 20 years of easily-validated intentional obscurity – ask virtually any room of physicians what the RUC is and watch the majority’s blank responses – this open activity favoring the RUC is unprecedented.
The letter is also obviously orchestrated, using many of the same tactics and arguments that Drs. Levy and Maves employed in their defenses. It carefully avoids talking about the abysmal real world consequences of the RUC’s historical approach. It ignores the dramatic under-valuing of primary care, the plummeting rates of medical students choosing primary care, the over-valuing and over-utilization of a wide variety of specialty procedures, and the inherent incentive for the RUC to focus on under-valued rather than over-valued procedures.
Instead, it obfuscates. To counter the McDermott proposal that CMS should use means other than the RUC to assess the RUC’s recommendations, the letter argues that past efforts to use contractors have failed. Therefore, it is senseless to go down this path again.Continue reading…
Sekou & Steve: When Does Death Begin?
This was sensational when I saw it live at TEDMED and it’s even more amazing second time around. Sekou & Steve do 18 minutes of beat poetry & intensity–“we know when life ends, but when does death begin!
Ponzi Schemes
By JOHN GOODMAN
Jack Lew is lucky he isn’t in prison. Were he representing a private pension fund and if he made the sort of statements he made in USA Today the other day, he might well be sharing a cell with Bernie Madoff.
So who is Jack Lew? And what did he say?
Lew is the Director of the federal Office of Management and Budget. About Social Security, he wrote: “Taxes are placed in a trust fund dedicated to paying benefits owed to current and future beneficiaries. When more taxes are collected than are needed to pay benefits, funds are converted to Treasury bonds — backed with the full faith and credit of the U.S. government.” As a result of these investments, the Social Security trust fund will be able “to pay full benefits for the next 26 years.” Not only is this preposterous, Charles Krauthammer called it a “breathtaking fraud.”
Before dissecting Lew, let’s consider why Bernie Madoff is in the hoosegow. Madoff told investors he was investing their funds in real assets, when in fact he was not. He secretly used their funds for personal consumption and to pay off other investors. Either figuratively or imaginatively, Madoff wrote IOUs to himself, all backed by the full faith and credit of Bernie Madoff. Maybe in the beginning he fully intended to pay off. But that’s beside the point. Inducing people to give you money with this sort of lie is criminal fraud. It’s against the law.
Like most government-sponsored retirement programs in the world today, our Social Security system is pay-as-you-go. All payroll tax revenues are spent — the very minute, the very hour, the very day they are received by the U.S. Treasury. Most of these revenues are spent on benefits for current retirees. Any additional amount is spent in other ways.
But there is no funding of future benefits. No money is being stashed away in bank vaults. No investments are made in real assets.Continue reading…
Why CMIOs Matter, and Why We Hired One
By JONATHAN BUSH
On Monday morning, April 4, we were proud to announce that Dr. Todd Rothenhaus has come onboard here at athenahealth to serve in the role of chief medical information officer, or CMIO. It’s a new position and we’re excited he’s joined us. Among many other tasks he’ll take on, he’ll be working on various product development and physician advocacy initiatives.
So now that we’ve got one on the payroll…you might ask: what exactly is a CMIO? And why do we now have one at athenahealth?
I have always known, at a gut level, that from a sales perspective, CMIOs are more important for us to engage with early in the sales process than a traditional CIO (no offense Halamka, I still wanna be friends). In fact, we became major sponsors of CMIO magazine long before I truly appreciated the role of a CMIO!
The CMIO is almost always a doctor, but a doctor in an executive position responsible for managing the health information in a medical organization. They lead implementation of EMR and other health information technology systems. And it seems there is a Lorax element to most. Remember that Dr. Seuss favorite? Well, in the way that the Lorax speaks for the trees, the CMIOs I know speak for the other docs in their organization where management of information is concerned.Continue reading…
The evolution of THCB
It’s been a couple of months since we moved THCB to WordPress and added the channels you see at the top. As you may have noticed there have been some teething troubles, and for all its power WordPress does have some problems. We’re still working on fixing the right hand columns. However, we’re able to do some things that we couldn’t before–including this little mini-blog microbrew that allows me (Matthew) to write little pieces that I like without having to write enough for a whole post. WordPress also does much better on spam trapping;I literally just went through 1,000 spam comments and only 3 were false positives. If youve had problems posting comments try taking OUT any links (that tends to trigger the spam filter).
But overall you can expect more and better from THCB in the coming weeks…and we’ll be keeping you updated.
Video Collage: KP Center for Total Health
This week I spent quite a bit of time at the very new and very fancy Kaiser Permanente Center for Total Health in Washington DC. It’s next door to a very large medical office building (110+ docs) in which KP is showcasing its current integrated care model, and how far its come in its mid-Atlantic region. The Center is a pretty fascinating place–part tech and idea showcase and part meeting room. Certainly no other health care organization that I’m aware of has spent so much on a place designed to stimulate the imagination and enhance conversation–under the nose of the folks on Capitol Hill. I won’t get into here whether this is how money should be spent in health care but on balance I’m a fan. (FD KP is a sponsor of the Health 2.0 Conference I co-run). Instead I want to try to give you a feel for the place, and why it fits their vision and what it’s trying to demonstrate.
I took a tour with some colleague journo/blogger types led by the always expressive Robbie Pearl (CEO of the Permanente Groups in N Cal and now DC too–the airlines thank him!) and with Phil Fasano, CIO of the whole organization. Robbie is not shy in voicing his opinions (as you’ll see) and Phil occasionally trots out the voice of caution to reel in Robbie’s vision a tad. It was great fun.
What was also fun was the cocktail party at the grand opening. There I met three of my favorite DC-based ladies in health: Deven McGraw, Regina Holliday & Cindy Throop. So we’ll start with that fun video, and then there’s a whole lot more from the tour of the center after the jump. All these videos are pretty short.
After that fun and games, lets head to the tour. This is a series of videos of me and a few others testing out the displays, and listening to Pearl & Fasano, as well as asking them a couple of pointed questions.
But I’ll take the tour in order….after a quick thanks to Holly Potter, Danielle Cass, Ravi Poorsina & center boss Julie Norris who with a ton of their colleagues worked their butts off keeping hundreds of visitors informed and entertained.
First up, Robbie Pearl on the current state of the KP.org health record and why we shouldn’t have to put up with less; what he called the 19th century state of medicine. And I can assure that is on display in my wife’s OBGYN office every time I visit.Continue reading…
Time for Toto to Pull the Curtain Away from Patient-Centered Medical Homes
Patient-Centered Medical Homes in statewide populations have unstoppable momentum and major constituencies in support of them, so valid analysis of their outcomes is probably as futile as it will be unwelcome. However, the math speaks for itself, at least in the mother of all statewide medical homes, North Carolina Medicaid’s Community Care Access Model.
I write this after having analyzed the actual data from this project’s outcomes report, rather than the stated conclusion of the report, a conclusion that continues to be cited in support of the many states considering or implementing medical home models for their Medicaid populations.
The conclusion makes North Carolina looks like a huge win for PCMH: $300-million in reported savings. However, readers should have (but largely didn’t) observe a number of curiosities about the data in support of that conclusion:
(1) Every element of resource use declined. People have to be getting their care from somewhere, but inpatient, ER, outpatient, physician, drug, and other expenses somehow all declined vs. trend.
(2) The decline in physician practice expense is especially counterintuitive: Why are the doctors so supportive if they are working harder but making less money?
(3) Even though somehow savings were shown in physician expense, per capita doctor visits did indeed increase. More concerning was that specialist visits –which are supposed to decline in a PCMH model – also increased.
(4) Inpatient expense fell 47%. This was achieved despite the fact that all the AHRQ’s “Ambulatory Care –Sensitive Conditions” total to about 20% of admissions in most populations.
(5) The evaluators (William M. Mercer) are on record as saying that “choice [emphasis mine] of trend has a large impact on estimates of financial savings.” Perhaps it is possible that Mercer, having given themselves this latitude, “chose” a trend that would make the study look good.
Those observations merely suggest that the study was done wrong. But one other “finding” invalidates the entire study: the 54% reduction in spending on babies under one year of age, accounting for the majority of the entire $300-milllion in spending. (Any nontrivial savings whatsoever in this category should have raised eyebrows since PCMH is mostly about managing chronically ill patients.) The components of spending in that category include physician expense, which should rise since doctors get paid more to be more accessible, and drug expense, which should rise for the same reason. This means that the entire 54% savings across the category must be concentrated in neonatal expense. Since neonatal expense is about half of total spending in the age category, it would have to decline by a mathematically impossible 100%+ in order for the category to average a 54% reduction.Continue reading…
Why We Still Kill Patients
By
A recent front-page article [1] in the New York Times conveyed grim news about patient safety. The first large-scale study [2] of hospital safety in a decade concluded that care has not gotten significantly safer since the Institute of Medicine’s 1999 estimate [3] of up to 98,000 preventable deaths and 1 million preventable injuries annually.
What for me struck a particularly jarring note was not just the absence of improvement, but the reluctance of the health care leaders interviewed to speak candidly about why progress has been so slow. Instead, they offered nostrums about the need to “do more” or opined that “openness” or better “coordination” would somehow turn the tide.
But tucked in the actual study’s conclusions section, between bland boilerplate about “further study” and a “refocusing of resources,” some carefully worded candor cautiously peeked through: “[T]he absence of large-scale improvement is not evidence that current efforts to improve safety are futile,” wrote Christopher Landrigan and colleagues in the Nov. 25 New England Journal of Medicine. “On the contrary, data have shown that focused efforts to reduce discrete harms, such as nosocomial infections and surgical complications, can significantly improve safety.”
In plain language, we know how to prevent many of these patient deaths, but we don’t. That makes, “Why?” a lot tougher question.
