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The Road to Wellville: Pilots and Demos?

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By ROGER COLLIER

As might be expected of reform legislation, the Patient Protection and Affordable Care Act places a lot of emphasis on innovation. Reasonably enough, most of the potential changes—at least in Medicare—are to be preceded by pilot or demonstration projects designed to test their feasibility. In fact, according to one health care blogger with time on his hands, PPACA includes no less than 312 mentions of demonstrations and 80 mentions of pilots.

Just how important are all these pilots and demos? Harvard’s David Cutler, who served as a key advisor to the Obama administration in developing the reform strategy, clearly believes they are vital. Writing in the June Health Affairs, he stresses the need for rapid implementation of the pilots and demonstrations in order to help achieve eventual savings of “enormous amounts of money while simultaneously improving the quality of care.”

How realistic are Professor Cutler’s expectations?

CMS’ Medicare chronic care demonstrations provide some clues. With data showing that the costliest 25 percent of beneficiaries account for 85 percent of total Medicare spending and that 75 percent of the high-cost beneficiaries have one or more major chronic conditions, the demonstrations were expected to show big benefits from care coordination—the major theme of PPACA’s proposed demos.

The outcomes were decidedly discouraging, as noted by MedPac’s 2009 report to Congress:

“Results suggest that some of these programs may have modest effects on the quality of care and mixed impacts on Medicare costs, with most programs costing Medicare more than would have been spent had they not been implemented….In almost all cases, the cost to Medicare of the intervention exceeded the savings generated by reduced use of inpatient hospitalizations and other medical services.”

Continue reading…

Unhealthy Skepticism

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By JOHN MOOREJohn Moore

There remains an unhealthy level of skepticism in the market as to whether or not consumers will use a personal health record (PHR). While a certain level of skepticism is healthy in any market, the level to which it is laid towards PHRs is unwarranted and likely more a function of ignorance then malicious intent. Following is a brief PHR case study that provides validity to the mantra that a patient who is provided access to their personal health information (PHI) via a PHR can become a more engaged patient in self-managing their health. What is particularly striking about this story is that it is does not take place in middle-class America, where many have targeted their PHR initiatives, but rather among the urban poor.

Last week, I met with Dr. Nunlee-Bland, Director of  Howard University Hospital’s (HUH) Diabetes Treatment Center, who graciously provided the context and content for this remarkable story.

Empowering the Urban Poor to Self-Manage Their Diabetes:

In 2008, HUH received a grant from the Dept of Health, DC to launch a diabetes treatment program primarily targeting urban poor. As part of this grant, HUH launched a PHR initiative creating a patient portal using NoMoreClipboard (NMC), linking NMC to their clinical diabetes EHR, CliniPro from NuMedics. The PHR provides patients with access to their problem list, vitals (height, weight, blood pressure, BMI), medication lists, basic lab results, A1C results (can be charted for track and trend) and basic demographic information. While Dr. Nunlee-Bland stated that HUH has no reason not to provide patients with full access to all PHI, they have purposely kept the PHR simple and focused on the treatment of diabetes.

Continue reading…

Massachusetts has the best health care in America?

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By PAUL LEVYPaul Levy

A well regarded local hospital administrator last week said, “There is lots of evidence that Massachusetts health care is the best in the country.”

The context was a discussion in which it was pointed out that health care costs in Massachusetts are above the national average, even adjusted for wage differences. The statement was made to suggest that it is worth paying a bit more if what we actually get is better.

I was taken aback. I have never seen any evidence to support this conclusion. Would anyone care to offer quantitative support for the proposition — or against it?

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

The HIT Parade

By LISA SUENNEN

The Cleveland Clinic recently published an annual Top 10 list of what their leadership believes to be the most significant advances in medicine in each of the last five years.  In 2007-2008 all of the items on the top 10 lists were either medical devices, clinical diagnostics,pharmaceutical or biotech products.  These sectors were basically the Beatles of medicine, while healthcare information technology was more like the indie group Florence + the Machine:  intriguing, but not likely to be called out on the Billboard Top 10 (or make Cleveland’s own Rock and Roll Hall of Fame) in the immediate future.

Interestingly, healthcare information technology (HIT) applications began to sneak their way onto the Cleveland Clinic Top 10 list over the last two years.  In 2009-2010 HIT barely made it, coming in at number 10 in both years.  In contrast to all previous years, however, there it was.  HIT had made it to the list representing 10% of what one of the nation’s most prestigious medical institutions calls the most significant up-and-coming technologies that can have the biggest impact on health care.  In 2011 HIT was number 6 with a bullet, moving HIT well up the Top 10 list.

I think it is fair to say that most people in the know about the healthcare field agree that the strategic application of HIT is essential to moving the quality, efficiency and efficacy of our healthcare system forward.  However, it is particularly gratifying to see an organization such as the Cleveland Clinic broadening their view of what constitutes the most profound developments in our healthcare system.

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The Road to Repeal?

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By RICHARD REECE, MD

Emboldened by their victory in the Midterms, many Republicans are calling for repeal of the Patient Protection and  Affordable Care Act (PPACA). How likely is it that we’ll see changes any time soon?  Probably not very.  More cautious observers are expressing reservations about the prospect of any reversal in the near term.

Paul Ryan, R-Wisconsin, one of the Republican young guns, says, “You can’t fully replace this law until you have a new President and a better Senate. And that’s probably 2013, but that’s before the law fully kicks in on 2014.”

Michael Tanner, a senior fellow at the conservative Cato Institute, is more straightforward,”Repealing Obama care is just not going to happen while Obama is in office.”

In the meantime, expect the following events to play out over the next two years.

1. House Republicans will vote overwhelmingly to repeal Obama care, with modest Democratic support from those elected who opposed Obamacare.

2. Harry Reid, Senate Democratic leader, will refuse to bring the House repeal up for a Senate vote.

3. President Obama will insist, as he already has, that it is foolish to “relitigate” a law which he regards as set in legislative, historic, and ideological concrete.

4. They will call upon Kathleen Sibelius, Secretary of Health and Human Services, to explain why costs have risen sharply since passage and why so many insurers and businesses have dropped coverage.

5. They will summon Doctor Donald Berwick, Administrator for the Centers of Medicare and Medicaid Services, to explain his views and to justify why he should be reseated following his recess appointment.

6. They will seek to repeal the reform the provision calling for submitting of 1099 forms for every $600 of business expenditures – a possible item of compromise.

Continue reading…

Paper Is Good … Pass It On

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By ALEX EPSTEINPicture 1

I nearly dropped my spoon into my fibery breakfast cereal last Sunday, because as I was reading the  paper, I noticed a a full page ad that read in part…

“It’s Easier to Learn on Paper”

Seems a Paper Company – called Domtar, has been taking out full page ads in the New York Times Magazine, among others, to tell the world – words go better with paper.

I was reading about the virtues of paper, in a paper, printed on paper. A paper trifecta.

Another of their claims: Reading on Paper is 10-30% faster than reading online, plus reviewing notes and highlights is significantly more effective.

Now I don’t know if any of that stuff is really true.  Or if it is the dying gasp of a dying medium.

Speaking of dying, did the guys who made papyrus tell the authors of the Dead Sea Scrolls that the scrolls would be an easier read if read on their vegetable based medium rather than the animal medium of parchment?

I remember way back when I was a kid growing up Brooklyn, and my teachers at P.S. 241 put our class on the subway for a class trip to visit the Gray Lady herself. That was when she still printed on West 43rd Street (and you wondered why it’s called Times Square – duh!).

And they gave us a tour and showed us the whole process – from the city room to the banks of men typing the stories on gargantuan machines that molded type out of lead – to the printing presses to the trucks.

Anyhow, I wonder whether the Linotype Operators union was telling its people then…words go better with lead?

Now people actually have to remind us – Paper is Good??

Continue reading…

Top 10 Developments That Give Me Hope About Future of Health Care

By KENT BOTTLES, MD

Tomorrow I will be giving a keynote address for the American Institute of CPAs conference in Las Vegas (http://ow.ly/37mD9). At first they wanted an overview of federal health care reform and what the future holds for US hospitals and doctors. Latter, they called back and said we want a more hopeful message about the future of American medicine and health care. Do you have any hope?

So I got to thinking about what makes me hopeful about our industry’s future? I came up with 10 developments I am very excited about.
1. Shared Decision Making and Slow Medicine
2. Computer Simulation (Think David Eddy’s Archimedes)
3. Video games for professional instruction, lifestyle changes, drug adherence
4. Patient social networking sites (Think PatientsLikeMe and DiabetesMine)
5. Smart phones and health care apps including EMRs
6. Patient generated research (Think CureTogether)
7. Reverse innovation (Think GE)
8. PHRs
9. Doctors being replaced by online information from a patient like me for health information
10. Twitter and Facebook.
The AICPA folks would only give me an hour for the keynote so I am going to talk mostly about numbers 1 and 2, but all of these developments give me hope for the future.
Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his new blog, Kent Bottles Private Views.

Does This ACO Thing Really Mean We Need to be ‘Accountable’?

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By VINCE KURATISKuratis, JD

Last month The American College of Physicians (ACP) released a well-reasoned and thorough position paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices.

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

At this time, implementation of the above principles within care coordination agreements represents an aspiration goal…

The care coordination agreements should be viewed solely as a means of specifying a set of expected working procedures agreed upon by the collaborating practices toward the goals of improved communication and care coordination — they are not legally enforceable agreements between the practices. [emphasis of “solely” is in the original document, not added]

Translation:

Don’t expect to hold us accountable….and don’t expect to be able to sue us if we don’t get it right

Vince Kuraitis, JD, MBA is a health care consultant and primary author of the e-CareManagement blog where this post first appeared.

Alzheimer’s Disease: The $20 Trillion Enemy We Must Not Forget

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By LISA SUENNEN Picture 12

In the last several weeks I lost my phone (recovered), my iPod (gone) and even a piece of jewelry (I am pretty sure the cat is guilty).  I was at the airport when I couldn’t remember where I parked my car for long enough to wonder if I actually did drive myself there.  (Don’t judge me; I know you do it too.)

All of us are prone to losing objects and forgetting appointments and struggling for that word on the tip of our tongue that we definitely should know.  Sometimes we even forget the names of people who live in our house just for a second; admit it: how many times have you called your child by the dog’s name?

Those momentary lapses of memory can be amusing or frustrating, but they usually don’t slow us down much.  We laugh it off and say, “wow, I must be getting old” and move on to the next task.  An op-ed I read recently in the NY Times, however, made me realize we don’t long have the luxury of humor when it comes to this issue.

Authored by Supreme Court justice Sandra Day O’Connor (ret.), Nobel Laureate neurologist Dr. Stanley Prusiner and Age Wave expert Ken Dychtwald, and entitled The Age of Alzheimer’s, the article pointed out these astonishing facts:

Starting on Jan. 1, our 79-million-strong baby boom generation will be turning 65 at the rate of one every eight seconds. That means more than 10,000 people per day, or more than four million per year, for the next 19 years facing an increased risk of Alzheimer’s. Although the symptoms of this disease and other forms of dementia seldom appear before middle age, the likelihood of their appearance doubles every five years after age 65. Among people over 85 (the fastest-growing segment of the American population), dementia afflicts one in two. It is estimated that 13.5 million Americans will be stricken with Alzheimer’s by 2050 – up from five million today.Continue reading…

Suzanne Delbanco on the new Catalyst for Payment Reform

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By MATTHEW HOLT

Catalyst for Payment Reform is a new organization set up by several large employers. The organization’s goal is to pay for health care differently, and make sure that those employers run ahead of any Medicare payment reform coming down the track. Suzanne Delbanco, formerly of Leapfrrog, is now the first Executive Director and Founder of the new organization. Last week I interviewed her about what the organization is going to do, what employers care about, and (despite decades of employers being simple price takers in health care) why this time it’s going to be different.

Keep watching to the very end to see the great view from Suzanne’s office!

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