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

Loser Pays

Dec 19, 2010• 7

By RICHARD REECE, MD

Tort reform is a hot-button issue among physicians. It distorts the practice of medicine by compelling doctors to order tests, the lack of which, might be used against them. It makes each patient a potential enemy. It forces doctors to spend time in extensive documentation. It imposes extensive, often unnecessary, costs on the health system. And it received little attention in the new health reform law, other than being kicked down the road through a demonstration project, which will further delay the need for further action.

Well, Texas acted on tort reform back in 2003-2005, and the fruits of that reform have since become apparent. A WSJ editorial on December 15 , which I shall quote listed these benefits.

“This Texas upgrade would build on reforms in 2003 and 2005 that have vastly improved the legal climate in what has not coincidentally become the country’s best state for job creation. Texas rewrote everything from class-action certification to product liability. One success was rationalizing the asbestos-silica litigation scam. Another was an overhaul of medical malpractice laws, ending the practice of venue shopping for friendly judges and putting a $250,000 cap on noneconomic damages like pain and suffering.”

“Before the reform, Texas was a kind of holy place on the tort bar pilgrimage. Now it’s a Mecca for doctors, especially the emergency physicians, obstetricians and surgical specialists who elsewhere can face blue-sky malpractice premiums.

Between the Cracks

Dec 18, 2010• 5

By KELLY CHERAMY

Between the cracks is a frightening place to be.

During the course of trying to improve our family’s financial stability, my husband and I were blind-sided by one hidden detail: We’d face $10,000 in costs to continue my husband’s serious medical treatment because we found ourselves unexpectedly without coverage for 30 days.

This was money we simply did not have. We had been prepared to foot the full bill for good health insurance, but that wasn’t even an option, thanks to the circumstances of our career transitions and my husband’s health.

I was leaving my job of 10 years to begin a satisfying new position that came with excellent health care coverage. It was a beneficial move that would offset my husband’s impending loss of insurance as his employer downsized and prepared to go out of business. We knew the end result, but we didn’t know the timing. It just so happened that his coverage ended the same month that I began my new job, leaving a gap of one month before my new coverage would begin.

With this routine employment-benefits formality before us, we knew we’d have to purchase coverage. We had hoped to buy a Cadillac COBRA plan, given the circumstances that require very expensive care. But we learned that an out-of-business employer is not obligated to offer COBRA, and our plan to continue the same level of coverage at our expense was not available.

Health 2.0 San Francisco – Tim O’Reilly Keynote

Dec 17, 2010• 7

By THCB STAFF

How are Web 2.0 technologies changing healthcare? What are the implications of trends like cloud-based computing for major healthcare players like pharma companies and large health systems? What about mobile computing? What are the practical implications for providers? What can healthcare providers learn from like dominant Web 2.o players like Google? Silicon Valley legend Tim O’Reilly (The Web 2.0 conference, O’Reilly publishing) gives an overview in this keynote from this years Health 2.0 conference in San Francisco in October.

Using An App to Confront Your Metastatic Melanoma

Dec 17, 2010• 4

By GEORGE D. LUNDBERG, MD

If you or anyone else you know has had a malignant melanoma, you and that other person, and your respective physicians, should click http://therapy.collabrx.com to access the Targeted Therapy Finder–Melanoma (ttf-melanoma). It is free and does not require registration.

Collabrx of Palo Alto has developed this first of its kind application (app) under the leadership of noted internet entrepreneur and melanoma survivor Marty Tenenbaum.

The app is based upon the science of the original Melanoma Molecular Disease Model (MMDM) in Cancer Commons built by David Fisher and Keith Flaherty of Harvard Medical School and Smruti Vidwans and colleagues on our staff.

Over decades, medicine has developed a comprehensive approach to diagnosing, grading, and staging malignant melanoma and many physicians follow that knowledge to deliver treatment at the “standard of care”. Thus, of the 70 000 melanomas diagnosed in the USA each year, approximately 90% are cured, mostly by surgery. The problem comes with those 7000 per year that progress “beyond standard of care”. Most of these patients have metastases to organs far from the site of the primary melanoma and its related lymph nodes. This clinical circumstance has long been considered hopeless for most patients, since no therapy has been consistently successful.

Goodman’s Law

Dec 17, 2010• 13

By JOHN C. GOODMAN, PhD

The other day I ran across five items of interest:

1. A news article about Medicare paying $800 to rent a wheelchair that could have been purchased outright for $350;

2. An article in The Atlantic arguing that the United States spends more on renal dialysis and gets worse results than other countries because of the nonsensical way we pay for dialysis;

3. A Uwe Reinhardt explanation of how Medicare pays hospitals (via an approving pointer from Austin Frakt) along with Uwe’s defense of the system; but nonetheless linking to

4. A Reinhardt Health Affairs interview with former CMS director Tom Scully who opines that “Medicare is a dumb payer;” and

5. A Reinhardt explanation of how Medicare pays doctors (7,000 physician tasks, each with a price that varies for every city, town and hamlet in the land), along with a challenge to readers to come up with a better way.

Okay. I accept the challenge.

I sometimes wonder if health economists actually understand how other markets work. Let’s try a thought experiment. Suppose you ran a business that purchased lots of wheelchairs and you had the misfortune of paying the way Medicare pays. What do you think would happen?

The minute your presence in the market was generally known — probably before the first wheelchair was even delivered — you would be visited by a rival vendor offering to meet your needs for, say, two-thirds of what you were paying. Then another rival would offer to top that — say, cutting your costs in half… and before long the cost of the wheelchair to you would be a fraction of what it started out to be. This is how normal, sensible people function in typical markets, day in and day out.

Thoughts on the PCAST Report

Dec 17, 2010• 4

By MARGALIT GUR-ARIE

The President’s Council of Advisors on Science and Technology (PCAST) released a report this month ambitiously titled “REALIZING THE FULL POTENTIAL OF HEALTH INFORMATION TECHNOLOGY TO IMPROVE HEALTHCARE FOR AMERICANS: THE PATH FORWARD”, complete with current state of HIT analysis and authoritative recommendations to ONC, CMS and HHS on how to proceed going forward. Initially, I skimmed through the 90 pages of the report and very much liked what I saw. PCAST is recommending a federated model for health information, with medical records stored where they are created and a comprehensive view aggregated on the fly on an as-needed basis by authorized users, including patients and their families. PCAST is urging ONC to significantly accelerate efforts in this direction. Perfect. And then I took a deeper dive into the details of the report, and disappointingly came across a series of misconceptions and questionable assumptions surrounding what is basically a very good, albeit expensive, strategy.

The State of Affairs

The classic opening to all HIT reports seems to be the obligatory comparison to “other industries”: “Information technology, along with associated managerial and organizational changes, has brought substantial productivity gains to manufacturing, retailing, and many other industries. Healthcare is poised to make a similar transition, but some basic changes in approach are needed to realize the potential of healthcare IT”. While this is true, we should also recognize that medicine is very different than other “industries” in that it lacks 100% repeatable processes. For example, the entire process of manufacturing, packaging, ordering, delivering, stocking and selling a box of Fruit Loops is exactly the same for every single Fruit Loops box. Automation of such process is easy. Unfortunately, people are not very similar to Fruit Loops boxes, and paradoxically, the lack of appeal and utility of current EHRs is in large part due to EHR designers thinking about Fruit Loops instead of the many ways in which people express Severity or Location.

Will Avatars, Robots, and Video Games Replace Doctors?

Dec 16, 2010• 10

By KENT BOTTLES, MD

I have never met Dr. Joseph C. Kvedar of Partners HealthCare’s Center for Connected Health, Susannah Fox of Pew Research Center’s Internet and American Life Project, or Professor Andy Clark of Edinburgh University face to face in the real world. And yet they have all profoundly changed the way I think about health care’s most vexing problem: how are we going to take care of all these Baby Boomers who are starting to retire and get sick?

Kvedar nicely summarizes this supply and demand problem on one slide in a talk I watched on YouTube; he notes that there are currently 24 million Americans with diabetes, and the rate is increasing 8% every year. One in three Americans over 20 years old have hypertension, and Kvedar wonders where we are going to get all the doctors to care for these patients. His answer is we need to form trusting relationships with technology in a process he terms Emotional Automation. (http://e-patients.net/index.php?s=fox)

I had never heard of Kvedar or the Center for Connected Health until I saw a Fox twitter link to her blog post about robots, enchanted objects, and networks. (http://e-patients.net/index.php?s=fox) Fox and I follow each other on Twitter, so I read her blog, which included the embedded YouTube video of Kvedar speaking about Emotional Automation. In a way Fox is also responsible for me knowing about Professor Clark’s views on “embodied cognition” and “the extended mind.” One Sunday Fox noted in a tweet that my habit of aggregating the health care news every morning at 5:30 AM was helpful to her and the rest of my twitter tribe. That one pat on the back encouraged me months later to scour the New York Times blogs where I found Professor Clark’s Opinionator blog titled “Out of Our Brains.”

Will ACO IT Models Be Walled Gardens or Open Platforms?

Dec 16, 2010• 5

By VINCE KURATIS, JD

Will ACO (accountable care organization) IT models be walled gardens or open platforms? i.e., will ACO IT platforms focus on exchanging information within the provider network of the ACO, or will they also be able to exchange information with providers outside the ACO network? (If the question still isn’t clear, click here for a further explanation.).

One POV: ACO’s Will Need Open IT Platforms

Mike Cummens, M.D., associate chief medical information officer at 750-physician Marshfield Clinic in Wisconsin, is quoted in a recent article in Healthcare Informatics. Dr. Cummens argues for an open ACO IT approach:

There will be an emphasis on transfer-of-care summaries and how to facilitate information sharing across the full continuum of care, he said. “For instance, you will have to work into care management plans the notification of home health agencies,” Cummens added. “In an ACO model, you will have to have methods in place to communicate all this information to providers who are not part of your own organization. People will have an option to see providers outside an ACO, so you will need to be able to transfer care summaries and discharge summaries outside the ACO.”

Also, because patient involvement is a key part of ACOs, the IT infrastructure will have to support patients signing off on their care plans and document their progress toward reaching goals, he noted. That will involve some type of self-management tools and personal health record access to their own data.

Cummens noted that the patient-centered medical home is geared toward an individual practice, and meaningful use metrics are geared toward providers, but ACOs will require managing data across enterprises. “When we visualize this and realize we are dealing with multiple electronic health records, the infrastructure for ACOs really has to ride on top of that,” he said. He sees the need for a new type of system, probably outside the EHR, that can bridge organizations, allow for risk assessment and analytics and reach down into tools for day-to-day management. That’s a tall order.

High Stakes Health Reform ‚Äì Employers: In or Out?

Dec 15, 2010

By MICHAEL TURPIN

It‚Äôs high noon for private healthcare. Over the last decade, large, medium and small employers that procure and manage over $1T of private healthcare spend for an estimated 180M Americans have been engaged in an expensive game of Texas Hold ‚ÄòEm ‚Äì – wagering with and against a continuum of stakeholders that all seem to possess more powerful hands. As providers consolidate, insurers retrench and the government wrestles with obligations of an uncontrolled fee for service Medicare, the costs of staying at the final table are taking its toll.

To many veteran observers, it appears that employers may be on the brink of folding their cards. As finance and HR professionals consider the table stakes and costs to remain in the game, the Affordable Care Act (ACA) has suddenly provided a potential golden opportunity to step away from a fifty year obligation without incurring onerous near term financial consequences.

As individuals and small business have continued to lapse into the ranks of the uninsured, those small and mid-sized businesses choosing to continue to offer health insurance are coming to the realization that the Affordable Care Act will not result in the moderating of double digit medical trends. In the near term, some contend costs will continue to rise by much as 25-40% before the launch of 2014‚Äôs guarantee issue health exchanges.

Larger employers are already cynical to whether reform will actually work for them or against them. Bigger firms and collectively bargained plans are beginning to understand that if small and mid-sized employers drop out of offering private healthcare, the decline of employer plans will leave them as the sole remaining source for private insurance cost shifting. As the cards are turned, the outcomes are far from certain ‚Äì – and as we have come to discover, business hates uncertainty.