The Health Care Blog – Page 771 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Managed Care 2.0

Dec 4, 2010• 8

By MICHAEL TURPIN

“The law of unintended consequences is what happens when a simple system tries to regulate a complex system. The political system is simple, it operates with limited information (rational ignorance), short time horizons, low feedback, and poor and misaligned incentives. Society in contrast is a complex, evolving, high-feedback, incentive-driven system. When a simple system tries to regulate a complex system you often get unintended consequences.” — Stephen Dubner and Steven Levitt, Freakonomics

When The Patient Protection and Affordable Care Act (PPAC) and its companion legislation was ratified by Congress and signed by the President into law, there was a great expectation for sweeping change. Yet, change is a scary proposition for 180M Americans who believe the devil they know (employer based private coverage) is preferred to a government run system.

Seniors are suddenly doing the math and wondering if their beloved Medicare will default on their watch. More than 50% of these same seniors, when polled, shared they do not want a government run healthcare system ——even though Medicare is a government run system. People are confused, angry and wary. Yet PPAC is now law and despite its obvious flaws and potential for unintended consequences, it is unlikely to be repealed or deconstructed. For better or worse, it is the foundation for Managed Care 2.0.

Managed Care 2.0 – Reform is setting the stage for a new era of American healthcare – Managed Care 2.0. In launching this new period anchored by expanded access and insurance market reforms, we are expecting to say farewell to the three decade era of Managed Care 1.0 – a barren stretch of fiscal and social desert marked by spiraling costs, misaligned financial incentives, massive underfunding of Medicare and Medicaid obligations, fraud, over-treatment, public to private cost shifting, historic rates of chronic illness and the slow erosion of employer sponsored healthcare leading to an astounding 40M Americans without insurance.

Where Managed Care 1.0 was a time characterized by consolidation of stakeholders, cost shifting, risk shifting and scorched earth, Darwinian battles on the supply and delivery side, Managed Care 2.0 will begin, as one pundit called it, “ the battle for the soul of medicine”.Continue reading…

Do EHRs Kill People?

Dec 4, 2010• 56

By MARGALIT GUR-ARIE

Back in the times when EHRs were just EMRs, they had a very simple and humble mission. The software was supposed to help providers of health care services better manage their business. EMRs were supposed to help physicians adhere to CMS documentation rules, automate patient flow management and get rid of all the mountains of paper floating around a typical medical office or hospital. It was assumed that EMR software will increase reimbursement rates, streamline workflow and even make the doctor more efficient. After all, every other industry that switched to computerized business management realized bottom line improvements.

Along the way, bolder statements started appearing, mainly from EMR vendors trying to sell their wares. EMRs could also reduce medical errors. The most common argument was for the benefits of replacing the notoriously illegible physician hand writing. Prescription errors would be reduced if only pharmacists and nurses could get a nice legible script. Then came the frequently misplaced paper charts. If the chart resides in the computer, it cannot be misplaced, it is always available to all and it is complete. All the information you need right at your fingertips, regardless of your physical location. It could save lives or at the very least, it could save time. The EMR was nothing more than an electronic chart. One vendor went so far as to create a computerized image of a yellow manila folder with tabbed pockets for various items in the electronic chart.Continue reading…

If I Ruled the World

Dec 4, 2010• 23

By DAVID DRANOVE, PhD

If you study previous attempts to reform healthcare delivery through the private sector, there is one common thread. These attempts all failed because of an absence of proper management information systems. We need integrated electronic health records. And not just to improve medical decision making. We need EHR that can be used for management decision making – for contracting, measuring costs, measuring and rewarding quality; I could go on and on. We are trying to solve management problems in a $2 trillion industry using management information systems that would be an embarrassment in nearly any other sector of the economy.

Of course, the industry has been pushing EHR for decades and there are places where EHR is really first rate. Kaiser is a great example but also a special case because of its thorough vertical integration and long history. And even Kaiser has been unable to replicate itself outside of its core markets. The sad fact is that most providers have little incentive to adopt EHR, and even when they do, they have little incentive to be compatible with other providers. Unfortunately, the network externalities benefit purchasers and consumers a lot more than they benefit providers, so don’t expect the compatibility problem to solve itself.

My proposal is simple. Assemble a panel consisting of medical professionals, managers, and insurers. “Lock them in a room” for 72 hours and tell them to choose from among the many fine existing EHR systems. Tell them they can combine the best features of each if they wish. Once we have settled on an EHR system, give every provider one year to adopt it. If they refuse, deny them Medicare and Medicaid payments. Combine the stick with a carrot – subsidies to providers who have limited financial resources. I believe the total one-time subsidies would be less than $50 billion, a drop in the bucket compared with the size of the system.

The Libertarian Mind

Dec 3, 2010• 9

By RONALD PIES, MD

“It is an eternal obligation toward the human being not to let him suffer from hunger when one has a chance of coming to his assistance.” –Simone Weil

Libertarianism is much in the news these days, as the political divide in the U.S. seems to widen almost before our eyes. Before providing a rough, notional definition of “libertarianism”, I should offer readers some caveats. First, I am not a political scientist, professional philosopher, or economist, though scholars in these fields have offered many pointed critiques of what is loosely called libertarianism (see references). Furthermore, as a psychiatrist, I am trained to diagnose individuals whom I have professionally examined. I am not in the habit of “diagnosing” movements, ideologies, or political groups; indeed, the idea of doing so is clearly outside the purview of medical or psychiatric practice.

Nonetheless, as a lecturer on bioethics and humanities, it is impossible for me to read the platform and proclamations of the Libertarian Party without drawing some tentative conclusions as regards the nature of this movement; its psychological underpinnings; and its ethical implications for the poorest and sickest among us—those sometimes referred to as “the destitute sick.”

I do not propose to “psychoanalyze” particular individuals, or to speculate on the motives of political figures who figure prominently in American politics. And, because the term “libertarian” has such a wide range of meanings, I will focus my attention on the official platform of the Libertarian party, which is very lucidly spelled out in a publicly-available venue (http://www.lp.org/platform). For the most part, I will deal with the Libertarian party’s position on health care and social support systems, while offering some tentative impressions on the “psychology” of libertarian theory.Continue reading…

Blood Test Surprise

Dec 3, 2010• 24

By BRAD WHITE

In the spring of 2005, the sinus infection returned. I awoke severely congested with a pounding forehead and pain around my eyes that grew worse when I bent to tie my shoes. The feeling was familiar. Two years earlier, I had similar symptoms, but was uninsured and endured a miserable week with nothing but over-the-counter medication. Now they were back.

Fortunately, when I started graduate school, my father insisted that I have health insurance. As a healthy 24 year old, I didn’t see the need, but he agreed to foot the bill for a high-deductible insurance policy to cover me in the event of catastrophic illness. Except for four physician office visits subject only to a $35 co-payment, my policy offered no benefits until I spent $3,000 out of my own pocket. With my sinuses throbbing, I knew I needed to use one of those visits. Overwhelmed by the list of “in-network” providers on the insurer’s website, I picked an internist based on convenience—his practice was located in a medical complex near my home.

Arriving for my appointment, I checked in and presented my insurance card to the receptionist. “Your visit today will be $35,” said the woman behind the desk. I was relieved to hear that my coverage was working as promised. A nurse ushered me to an exam room, where the physician promptly entered, half-heartedly listened to my complaint, and confidently asserted that I did not have a sinus infection because I had no fever. I wanted to say “Really? Mind handing me a tissue so that I can show you what’s been coming out of my head?” but resisted the urge. Instead, I clarified that fever or no, I didn’t feel well, and believed my sinuses were the culprit. At this, the internist lost patience. He ordered some lab work and a sinus CT scan to rule out infection, and said that I could have everything done downstairs.Continue reading…

Understanding Medicare Reimbursement?

Dec 2, 2010

By HERBERT MATHEWSON, MD

I opened my “Medicare Summary Notice” from CMS (Centers for Medicare and Medicaid Services) with great anticipation to see the explanation of Medicare benefits for my recent medical care. At last, I might have a chance to understand Medicare reimbursement, an understanding that has to date eluded me both as a pediatrician and a hospital administrator

The ER physician’s bill for both the visit and the suturing of three lacerated fingers was $448.00. Medicare “approved” $163.88 and “paid” $131.10. It also stated that I could be billed the $32.78 difference, but I knew I wouldn’t because “balance billing” is not permitted in Massachusetts. A reminder that even though Medicare is a federal program, its reimbursements and reimbursement rules vary by state, by region, and even by county.

Then I noticed a small “a” in the last column to the right that instructed me to “See Note Section”. On the bottom of page 2 that little “a” in the Note Section told me that “Medicare paid the provider for this claim $197.81” a figure quite different than $131.10. I tried, but could not reach the new figure by adding up any of the other amounts. I had no clue as to where that number came from.

Moving on to the next encounter, a scheduled spinal tap in the Ambulatory Procedure Area of my hospital for a different clinical problem, I was surprised to run into more complexity. The hospital charged $697 for the procedure and $634 for the 6 lab tests done on the spinal fluid for a total hospital charge of $1,331.00. No “approved” amount nor “paid” amount was listed, but then I noticed…again far over to the right, another set of little letters; “b” and “c”. Note “c” on the bottom of the page told me that Medicare paid $388.23. There was no clue what that reimbursement of 29% of charges was actually for.

OK, OK, I know that hospital charges and reimbursement are complicated, so I moved along to the physician’s claim summary information. Surely this will be easier to understand.

FTC Proposes New Safeguards for Online Privacy

Dec 2, 2010• 3

By NAOMI FREUNDLICH

Yesterday the Federal Trade Commission proposed a broad framework for protecting consumer privacy both on the Web and offline. The framework is meant to help guide policymakers in crafting legislation to prevent the tracking and wholesale collection and sale of consumer information that is practiced by large online companies like Google, Mozilla, and Microsoft. Yesterday I wrote about health information “data mining;” (see post here) the collection and sale specifically of web user’s health data, including the conditions they suffer from, medications used and identification information like name, age, gender and even personal doctor. As the FTC notes in its proposal; “The more information that is known about a consumer, the more a company will pay to deliver a precisely-targeted advertisement to him.”

The FTC noted that current privacy efforts by most online companies were inadequate. Some did not alert consumers to the fact that data was being collected in the first place, others provided lengthy and incomprehensible warnings that most Web users ignore and others did offer the chance for individuals to block collection of their personal data, but this action has to be repeated at the beginning of every transaction.

Instead, the FTC framework proposes a “Do Not Track” option that consumers can chose to activate on their browsers. Similar to a “Do Not Call” list that prevents most (but not all) telemarketers from contacting you by phone, the “Do Not Track” option would prevent most data miners from surreptitiously collecting personal information online. The FTC says that the Do Not Call registry currently contains 200 million telephone numbers.

Publicity is Cheap, Privacy is Expensive

Dec 2, 2010• 2

By JOHN HALAMKA, MD

When I was 18 years old, publicity was hard to come by. Media outlets were limited to newspapers with very high editorial standards, television with few channels and very limited news time, and a few high profile news magazines.

My first 15 minutes of fame came in 1981 when I was interviewed by Dan Rather for a CBS Evening News spot on entrepreneurialism in the Silicon Valley. In 1982, I appeared in Newsweek, as a student correspondent at Stanford, writing about religion, politics and the culturally important trends of the day. In 1983, I appeared in US News and World Report in an article about the emerging importance of software.

Today, blogs, wikis, forums, YouTube, Facebook, Twitter, and Google enable fame and publicity without editorial control. Use your phone to take a video of a squirrel doing something amusing and a few minutes later you’ve got publicity and thousands of people watching your work.

The Non-Scalability of Charisma

Dec 1, 2010• 19

By BOB WACHTER, MD

Early on, many social movements depend on a charismatic leader to focus attention, build a burning platform, and inspire people to action. You know when the movement has made it when it no longer needs such a leader for fuel.

The safety and quality movements have picked up tremendous steam over the past decade, but they haven’t yet hit that self-sustaining tipping point. Last week, there were two things that reminded me of this: the announcement of a new leader of the Institute for Healthcare Improvement (IHI), and a doleful JAMA essay by Peter Pronovost.

During the circus that was Don Berwick’s recess appointment to lead the Centers for Medicare & Medicaid Services (CMS), all eyes were trained Inside the Beltway. But 440 miles north, in Cambridge, MA, arguably the most important organization in the quality and safety galaxy needed to get on with its business. On July 8th, IHI announced its choice of Maureen Bisognano to become its new CEO. Maureen is a nurse and former hospital exec who has spent the last 15 years at IHI as Don’s consigliere. She is a terrific person, with boundless energy and great organizational skills – insiders will tell you that she was the reason that IHI’s trains ran on time for the past decade, as Don is the quintessential big picture guy.Continue reading…