The Health Care Blog – Page 757 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Laboratories of Democracy

Jan 23, 2011• 4

By MERRILL GOOZNER

If “Obamacare” was a federal takeover of health care, states failed to get the memo.

The House Republicans and three Democrats who voted to “repeal and replace” it with something that provides “lower health care premiums through increased competition and choice” might want to take a look at Utah. Its new internet-based insurance exchange was designed by free-market advocates.

It provides small businesses, individuals and even some large employers with access to competitive insurance plans. The state’s Republican leadership, aided by Michael Leavitt, the state’s former governor and secretary of Health and Human Services in the Bush administration, believes their exchange “could be a national model for market-based health care reform.”

Closer to where they go to work every day, the “repeal and replacers” in Washington might also want to follow onrushing events in Virginia, whose state attorney general sued to void the individual mandate in the national law. Last month, using a $1 million planning grant from the federal government, the state’s Republican secretary of health Bill Hazel, an orthopedic surgeon, issued a “Virginia Health Reform Initiative” that outlined the state’s vision of reform under the federal Affordable Care Act.

It’s centerpiece? The proposal, which was introduced in both houses of the state legislature this month with bipartisan support, calls for setting up a health care insurance exchange that will “try to promote effective competition” within the state, said Len Nichols, a professor of health policy at George Mason University, who consulted with Hazel in coming up with the proposal. Virginia desperately needs some competition since one carrier – Anthem Blue Cross Blue Shield – currently controls over 60 percent of the market, Nichols said.

Job Post: THCB Editorial

Jan 23, 2011

THCB is looking for talented interns to assist with editorial, research and web production tasks as our web site undergoes a major expansion. Perfect for a grad or med student with an interest in journalism, public policy, and/or the business of health care.

ACOs and Community Hubs of Wellness & Health

Jan 23, 2011• 18

By KENT BOTTLES, MD

Hospitals are going to change. What worked in the past will not work in the future. The passage of the federal health care reform law and the inevitable transition from fee for service to global payments is changing the rules of the hospital game. Hospitals will have to make do with less financial support from both government and private payers and at the same time deliver higher quality health care with measurably better outcomes. Hospitals will take care of fewer and fewer patients as care continues to migrate to the outpatient setting, the home, and wherever citizens live carrying their smart phones. The development of Accountable Care Organizations (ACOs) to receive and distribute these global payments will affect hospitals whether they decide to take a leadership role or a wait and see attitude. There will be winners and losers among hospitals; there will be fewer hospitals in America in ten years than there are today in 2011.

Hospitals that survive this transformation of the health care delivery and payment system will become the community hub of wellness and health (CHWH) that citizens turn to in a time of rapid and chaotic change. Becoming a CHWH will require hospitals to expand their services and expertise well beyond the traditional role of an acute care facility. It will also require hospitals to embrace social media and disruptive digital tools that are now available to help care for a defined population living in the community. Hospitals will have to forge a new culture or their ACOs will fail, no matter how sophisticated and expensive their legal structures and physician integration plans become.

Hospital leadership seems ill prepared for this transformation in mission. Robert Naldi, the CFO of Maimonides Hospital in Borough Park, Brooklyn, is not alone when he says, “I don’t spend a lot of time thinking about global issues. When I hear Medicare is being cut six billion dollars over the next ten years, Medicaid cut four billion dollars the next, that ten billion dollars doesn’t change what I do on a Thursday morning…. I don’t spend any energy forecasting the next three or four years, because I don’t think anyone can do that. We’re lucky if we forecast the next six months, things change so rapidly. I just don’t waste time on it.” (http://ow.ly/3Dlxp)

The End of the World as We Know It

Jan 23, 2011• 9

By PAUL LEVY

One aspect of religious dogma that has entered the medical world is that fee-for-service pricing of medical services is bad and should be replaced by a capitated, or global, arrangement that establishes an annual budget for care for different risk groups of patients. Like other religious beliefs, this is often offered without rigorous analytic support. Some insurance companies are particularly pleased with this approach because it shifts risk from insurers to providers and makes it easier for the insurers to create budgets and price their products.

Don’t get me wrong. This may be the right way to go, but the topic is worth more time and discussion than it has received.

It may be illustrative to think about other sectors of our economy and see which of them are characterized by global payments. Not many. Sure, there are products like cellular phone service that are sold in monthly fixed dollar amounts. But that is because it is a high fixed-cost product, where the marginal cost of additional phone calls is essentially zero. Fixed prices offer revenue stability to the vendor and a way to recover those fixed costs.

But most other goods and services in our economy are sold on a piece-work basis. Think of groceries, automobiles, electricity, gasoline, televisions, and clothing. Why is fee-for-service pricing appropriate for these? Or, in economists’ terms, why does such pricing lead to a reasonably efficient solution? The answers are pretty straightforward. Other markets are characterized by open entry and exit and by transparent information concerning quality, value, and pricing. Consumers can make more or less knowledgeable choices based on that publicly available information. New firms enter the market when they see an opportunity. Successful firms grow. Other firms fail.

A Family Physician’s EMR Experience

Jan 22, 2011• 9

By SULTAN RAHAMAN, MD

I have always looked at technology for opportunities to improve the quality of care and the efficiency of my family practice. For instance, nearly 20 years ago I started using speech recognition software to dictate all my patient notes. This eliminated the high cost of transcription and turnaround time too. However since introducing an Electronic Medical Records system (EMR) in my office about 7 months ago the quality of care and the efficiency of my practice have vastly improved. EMR immediately brings many benefits to mind. There is an obvious decrease in paper use. Even faxes such as physician correspondence and reports are now received in a digital file which can be saved to the patient’s record without printing. Prescription refill requests from pharmacies are now received, reviewed and filled electronically. Most of my patient lab test results too are now received electronically, reviewed and then saved into the patient’s record, again without printing. But perhaps one overlooked major advantage of EMR is that data is now more commonly stored on a server offsite on the internet, “the cloud” which provides tremendous advantages.

Over the years I have covered my solo family practice 24/7, essentially 12 months a year. Even when I took a brief vacation or extended weekend out of town I relied heavily on cellular phone and hospitalists for coverage. This has mostly worked well over the years except that when I returned to the office I was confronted with tall stacks of charts waiting for messages to be signed off, reports and specialist correspondence to be reviewed. In fact over the years my brief vacations have been mostly work deferred. I paid for it with extra work when I returned to the office.

Massachusetts, Utah, or Nothing: How States Should Address Exchanges

Jan 22, 2011• 2

By JOHN GRAHAM

PPACA prescribes states’ “flexibility” in structuring exchanges. Libertarian and conservative policy analysts have criticized Massachusetts’ bloated and intrusive Commonwealth Connector, the country’s first pre-Obamacare exchange. Some, however, have pointed to the Utah Health Exchange, re-launching next year, as a more consumer-friendly alternative. According to this line, even states opposed to Obamacare should go forth and establish Utah-type exchanges, which will blunt the worst effects of Obamacare.

These grounds for collaboration, unfortunately, do not survive careful scrutiny. In the pre-Obamacare world, exchanges were suggested as a way to get around the major government failure in American health care: Congress’s grant of monopoly control of our pre-tax health dollars to our employers.

The Utah Health Exchange allows spouses to aggregate defined contributions from different employers. For example, suppose a husband’s employer contributes $300 per month to the exchange for health insurance. His wife works for another employer which does the same. The household has $600 to spend on a family policy that they, not their employers, choose. The husband and wife can then decide to which of their employers they wish to affiliate, satisfying federal regulations for group coverage. That sounds pretty good. However, this “premium aggregator” has not yet been tested. It goes into effect this month, for members who applied via open enrollment at the end of last year.

Is the Culture Finally Shifting?

Jan 22, 2011• 5

By DAVE deBronkhart

Thanks to friend Kavita Patel for pointing out this sign of shifting winds, in this week’s Time online: Googling Symptoms Helps Patients and Doctors. It’s a watershed moment, because the last physician column I saw on this was the unpleasant 2007 When the Patient is a Googler, by Scott Haig MD.

It drove me up a wall, because the title suggested Googling was the problem, when the story was actually about a nightmare patient who was just plain rude. To brand “googlers” as wack jobs was imprecise at best. I responded with one of my first posts here, March 2008: When the Patient is a Yahoo.

Shortly after, our Alan Greene, physician c0-chair of SPM and co-founder of DrGreene.com, posted here about the article, with links to coverage in Salon.com. He summed up our status:

We live in a time of rapid tectonic shifts in what it means to be a doctor and what it means to be a patient. I’m not surprised that there are clashes of ideology and practice. Our labyrinthine, barnacle-encrusted healthcare system resists change. So do our social structures that have lasted for millennia.

But already many e-patients and many e-doctors are actively enjoying a new way of relating, rooted in mutual respect and open access to health information.

There was so much blog discussion that Dr. Haig led a physician roundtable, How to deal with the digitally empowered patient, reported in Orthopedics Today. Haig cited that twenty major blogs hosted lengthy discussion of his “When the Patient” article. (John Grohol posted here about the roundtable.)

For ‘Liberating the NHS’ Read ‘Dismantling the NHS’

Jan 22, 2011• 3

By CLIVE PEEDELL

The NHS white paper is the government’s roadmap for a market based healthcare system, which is designed to encourage increasing roles for the private and third sectors, whilst diminishing the role of the public sector in the England. The NHS is going to be dismantled by using the market forces of ‘creative destruction’. This will have profound effects on the medical profession with attacks on T+Cs, pensions, medical training, professionalism. More importantly, the knock on effects for patient care will be devastating.

The key policy levers enabling this to happen are:

1. The purchaser provider split, with GP commissioning consortia taking the leading role on the purchaser side of the divide.

2. Patient Choice.

3. Competition between a plurality of ‘any willing providers’.

4. Payment by Results with price competition.

5. Patient held budgets.

6. Foundation trusts becoming social enterprises and the abolition of the cap on their private income.

These policies are mutually reinforcing and this is how they will work:

GPs will be formed into GP consortia and will control 80% (£80bn) of the NHS budget to buy in services for their patients from a variety of providers (including FTs, private hospitals and third sector organisations) competing against each other in competitive healthcare market. Market competition will be enforced by applying EU competition law and overseen by the economic regulator, Monitor, as well as the new National Commissioning Board. Money will follow the patients via the Payment by Results (PbR) system. This has traditionally been a fixed pricing system, but the tariffs will now be opened up to price competition (I’ll come back to this).

Geomancy, Haruspex and Contextual Discovery

Jan 21, 2011

By ALEX EPSTEIN

What if your internet interface knew what you wanted – before you even knew you wanted anything?

Would it help or hurt?

Would you wind up doing things you didn’t want to, simply because of suggestion?

Would you give in to digital peer pressure?

If an alternative is presented as THE solution does it become a self-fulfilling prophecy?

Is the future knowable?

The question becomes relevant because “contextual discovery” is leaving the realm of nice to have and entering the realm of on the verge.

Using a witches brew of past searches, personal attributes, GPS coordinates, and chicken bones, a search engine company thinks it can provide answers for me, before I even know the question.

In other words, it can tell me my future.

Now, I have always hated the idea that statisticians and data miners could predict my behavior.

I am an individual with fee-will living in the land of the free. Hell, I don’t even know what I am going to do tonight, let alone where my synapses will take me in the next 10 seconds.

Yet, I guess I am, in aggregate, totally predictable.

Health Bill Sets Out Details of Cameron Plan to Reform NHS

Jan 21, 2011• 2

By MIKE BROAD

The controversial Health and Social Care Bill has been published, paving the way for GPs to control 80% of the NHS budget from 2013.

Unions warn the plans are the first step towards privatising the health service, while the health select committee said the way they have been rushed in has taken the NHS by “surprise”.

But the government argues the changes will improve care and accountability.

The plans will lead to the scrapping of PCTs and SHAs, GPs taking responsibility for commissioning and a greater role for private and voluntary sector providers in delivering services.

Health Secretary Andrew Lansley said: “In order to meet rising need in the future, we need to make changes. We need to take steps to improve health outcomes, bringing them up to the standards of the best international healthcare systems, and to bring down the NHS money spent on bureaucracy.

“This legislation will deliver changes that will improve outcomes for patients and save the NHS £1.7 billion every year – money that will be reinvested into services for patients.”

The BMA described the Bill as a massive gamble.