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Above the Fold

The Republican Landslide and the Affordable Care Act

Nov 3, 2010• 39

By GLENN LAFFEL, MD

After their resounding triumph in yesterday’s midterm elections, House Republicans will likely act on their promise to repeal the Affordable Care Act, the health reform bill President Obama signed into law last March.

Their efforts could be blocked by the Democratically controlled Senate or, if necessary, by a veto from the Big O himself. But the Boehners might still get the final say, since they have the power to halt appropriations funding for large swaths of the law.

These realities have health-industry groups, some of whom vigorously supported Democratic efforts to pass the law, cozying-up to the GOP like a Snuggie on a cold winter night.

Private insurers want Congress to nix that $70 billion tax that will be levied against them beginning in 2014. They’d also like lawmakers to permit them to widen the rating bands which cap the amount of money they can charge older enrollees.

Insurers and providers want Congress to add a tort reform rider to the law, preferably one that protects physicians against malpractice lawsuits if they adhere to best practice guidelines. Drug companies want to kill the proposed Independent Payment Advisory Board, whose job it is supposed to be to control the rate of growth in Medicare spending. The Board’s recommendations would, after all, likely include reduced federal spending on prescription drugs which is very bad for their business.

Yet these same groups are worried sick that Republicans might go too far in their zeal to repeal the deal. The baby in the bathwater for these trade groups is the individual mandate: a provision in the law that requires most Americans to carry health insurance.

Laying on of the Hands

Nov 3, 2010• 8

By HERBERT MATHEWSON, MD

It appears that except for physical therapists, masseuses, and priests no one lays on the hands anymore. Certainly contemporarily trained physicians do not.

Recently I went to my local ER because a 2-day old pain in my back “due to a strained muscle” from a gym work-out was now, at 11:00 PM, causing me to be quite short of breath and unable to lie down. The ER reception desk was empty and, as the sign instructed, we picked up the phone and announced our presence. An ER nurse came out, signed me in, registering me as a new patient, escorted me back to a cubicle, recorded my vital signs, took a short history, listened to my chest (“A few crackles there in your back”), started an IV, ordered an EKG and a chest x-ray, and drew a whole bunch of bloods, one tube of which revealed that I was probably having pulmonary emboli (clots to my lungs). The CT scan confirmed the diagnosis of “multiple bilateral pulmonary emboli”.

Then I saw my first doctor. While standing at the bottom of the bed juggling a clipboard that was barely controlling various colored sheets of paper, she took a short history, listened to my chest (“A few crackles there in your right posterior chest”), told me that the CT scan was positive, and that the admitting hospitalist would come to see me soon. The nurse explained that the ER doc was busy with a very sick patient being transferred into town.

The admitting hospitalist was a true gentleman. He even sounded like a gentleman with his clipped British accent and Eastern Indian last name. He took a longer history, listened to my heart and lungs (“A few crackles on the right side there”) and outlined what was to happen next; a stay in hospital for three days at least, immediate anticoagulation, and tomorrow an ultrasound of the legs and an echocardiogram looking for a source of the clots. He explained things very clearly, was reassuring, and answered my questions succinctly and thoroughly. I felt that I was in good hands, …but I was a little uneasy that no one had done a complete, or even a semi-complete, physical exam.

What has happened to all that we were taught in second year Physical Diagnosis?

Can we get physicians to use modular apps?

Nov 3, 2010• 4

By MATTHEW HOLT

Health 2.0 is best known for (and started with) consumers using online tools, search, communities and other services. But over the last year or two we’ve seen more and more SaaS-based and modular tools developed aimed at physicians and their offices. At the same time of course the Feds have promised (but not quite started yet) to lay out up to $36 billion to put EMRs into doctors’ offices.

The problem is that most physicians practice as independent small businesses, and almost all the progress in mainstream EMR adoption has been in larger enterprises–particularly the VA using Vista and many larger provider systems (e.g. Kaiser) using Epic and a few other larger client-server based systems. But smaller businesses outside of health care are using a whole range of SaaS-based services to run their operations. For example, at Health 2.0 we use Highrise for customer tracking, Google Docs for records, Gmail for sharing information, Skype for communication, Surveymonkey for attendee surveys, Mailchimp for marketing emails, and several others.

Can physician offices use a parallel set of modular applications to run their various business and clinical processes? I believe that they can and will. But the problem is how to get the message out? So I was pretty interested to find that Sanofi Aventis is trying to reach physicians about these issues via a site called iPractice. They asked (and commissioned) me to write something about the topic. So I’ve described seven modular Health 2.0 tools for physicians. You can read my article here

Dismantling the Cottage Industry

Nov 2, 2010• 33

By MARGALIT GUR-ARIE

Last week I went to see a doctor about an EHR. Dr. Greene (not his real name) is a typical solo primary care physician in a typical small town in the typical middle of nowhere. Four hours from the closest airport and miles and miles of winding roads, cow pastures and corn fields away from medical centers of excellence. Dr. Greene is in his late fifties and has been practicing medicine for over thirty years in the same location. He works six days per week and missed “two and a half” days of work since he hung his shingle up and never missed a Rotary Club luncheon. Dr. Greene is planning on practicing for ten more years and now, he wants to go electronic.

Dr. Greene’s practice is located in a small and spotless one-story building with large windows and an open floor plan. We sat down at a white laminate round table in the kitchen during his lunch break. His wife of many years is his office manager and the only other employee is a nurse who doubles as front office receptionist. His shortest appointment is for 30 minutes and new patients, who are scheduled for 1 hour, come at the end of the day just in case it takes longer than planned. His notes, written on special gold colored paper in nicely rounded cursive font, are concise and neatly organized by visit date. Like most doctors who use paper charts, he doesn’t code his visits. He checks diagnoses and procedures on a sparse super-bill devoid of any numbers. His wife and office manager takes it from there and all his claims go out electronically every day.

Contemplating Safety While Lying Down

Nov 2, 2010• 3

By JESSIE GRUMAN, PhD

I write about what it takes for us — whether we are sick or well — to find and make good use of health care today.

At the end of September I was hospitalized for surgery to remove a tumor in my stomach. Below is one in a series of five observations about my experiences since then.

“You have to get out of this hospital – it’s a dangerous place,” each of my physician friends exclaimed when they came to visit me during my recent stay after surgery for stomach cancer.

Jeez! I know! Prior to my operation, I was more preoccupied by the possibility of medical errors than of the operation itself or the pain it might cause. What if they take out my kidney instead of my stomach? Or leave a sponge in there? Or over-hydrate me so I drown? What if one of my many overnight vitals-taking-shot-givers infects me with MRSA?

The human imagination has wondrous capacities, especially when fueled by true stories of harm people have experienced due to medical errors. I read closely the IOM report To Err is Human: Building a Safer Health System ; I am horrified by the medical errors experienced by Sue Sheridan and impressed by her leadership of Consumers Advancing Patient Safety and Diane Pinakiewicz’s at the National Patient Safety Foundation to raise awareness about the dangers patients face due to carelessness and lack of system-level controls.

Mike Barber, GE Healthymagination

Nov 2, 2010• 1

By Matthew Holt

Last week thanks to the munificence of the RWJ Pioneer Fund (thanks Steve, Paul & team!), I spent a few days at the TEDMED conference in the Hotel Del Coronado near San Diego (famous for its role pretending to be a Florida hotel in the best Marilyn Monroe movie, Some Like it Hot).

While I was there I caught up with Mike Barber, VP of Healthymagination–GE’s current big play in the health care space, which combines its work in imaging, diagnostics, IT and much more.

This effort is clearly coming into focus now, and Mike gave a nice talk about it at TEDMED. He also discussed the new join venture GE has in the area of pathology with University of Pittsburgh Medical Center called Omnyx. I spoke with Mike and raised a few points about the validity and future of imaging (including one part of the future he pulled from his pocket), consumer health, and the EMR world. Gene Cartwright, CEO of Omnyx, makes a quick appearance here too. This is 10 minutes worth seeing to find out what the world’s biggest industrial conglomerate is up to in the world of health care.

Privacy Paradigms: From Consent to Reciprocal Transparency

Nov 1, 2010• 2

By FRANK PASQUALE, JD

Computational innovation may improve health care by creating stores of data vastly superior to those used by traditional medical research. But before patients and providers “buy in,” they need to know that medical privacy will be respected. We’re a long way from assuring that, but new ideas about the proper distribution and control of data might help build confidence in the system.

William Pewen’s post “Breach Notice: The Struggle for Medical Records Security Continues” is an excellent rundown of recent controversies in the field of electronic medical records (EMR) and health information technology (HIT). As he notes,

Many in Washington have the view that the Health Insurance Portability and Accountability Act (HIPAA) functions as a protective regulatory mechanism in medicine, yet its implementation actually opened the door to compromising the principle of research consent, and in fact codified the use of personal medical data in a wide range of business practices under the guise of permitted “health care operations.” Many patients are not presented with a HIPAA notice but instead are asked to sign a combined notice and waiver that adds consents for a variety of business activities designed to benefit the provider, not the patient. In this climate, patients have been outraged to receive solicitations for purchases ranging from drugs to burial plots, while at the same time receiving care which is too often uncoordinated and unsafe. It is no wonder that many Americans take a circumspect view of health IT.

Privacy law’s consent paradigm means that, generally speaking, data dissemination is not deemed an invasion of privacy if it is consented to. The consent paradigm requires individuals to decide whether or not, at any given time, they wish to protect their privacy. Some of the brightest minds in cyberlaw have focused on innovation designed to enable such self-protection. For instance, interdisciplinary research groups have proposed “personal data vaults” to manage the emanations of sensor networks. Jonathan Zittrain’s article on “privication” proposed that the same technologies used by copyright holders to monitor or stop dissemination of works could be adopted by patients concerned about the unauthorized spread of health information.Continue reading…

Companies Clearly Won’t Stop Hiking Health Care Coverage Premiums

Nov 1, 2010• 6

By STEPHEN KRUPA

As employees participate in open enrollment for their company’s health insurance enrollment next year, it’s clear they should make a point of participating in their employer’s enrollment information meetings, not merely pick last year’s coverage. Partly because of the implementation of President Obama’s health care overhaul plan, U.S. workers are expected to pay average premiums of $2,200 in 2011 – an increase of 12.5 percent, the biggest in four years, according to human resources consulting firm Hewitt Associates.

Increases in health care premiums are certain to continue increasing in coming years at double-digit rates, with inflation further exacerbated by the entry of 32 million uninsured Americans into the healthcare system. This will speed the transformation of insurers from underwriters of medical risk to managers of medical risk, a process inevitably accompanied by higher prices.

Annual healthcare inflation — and hence baseline premiums — have been rising 8-12 percent annually for two decades, and there is no reason to expect this to change anytime soon. It could actually increase as provisions of healthcare reform – such as the mandated removal of pre-existing conditions – become law. Some of these provisions, such as the elimination of a dollar amount of health benefits in a given year and the fact that children can now stay on a parent’s health plan until age 26, help explain the likely spike in health insurance premiums next year.

Job Post: Home and Community Based Services (HCBS) Policy Director

Nov 1, 2010• 1

Organization: The Service Employees International Union (SEIU)

Location: Washington, D.C.

The Service Employees International Union (SEIU) is seeking a talented and forward-thinking individual for the position of HCBS Policy Manager. This is a senior-level position within SEIU Healthcare, one of the union’s three operating divisions, and will report to the Home Care Director. The HCBS Policy Manager will have lead-level responsibility for the following:

Providing overall leadership to SEIU’s policy work in the area of home and community based services (HCBS)
Cultivating and maintaining relationships with allied organizations, academic policy experts, government policy-makers and other stakeholders in order to achieve program goals and to drive joint work
Conducting research and policy analysis and developing legislative and regulatory proposals
Developing policy white papers & other written documents for both internal and external audiences
Collaborating with our government affairs staff on lobbying and federal legislative priority-setting
Serving as a resource on long-term care issues for other SEIU staff in DC and in our local union affiliates

The focus of the work is on influencing policy-making at the federal level, though intermittent support of state-level efforts is also part of the job.

PPACA Premium Subsidies: The Government Is Here to Help You!

Nov 1, 2010• 2

By ROGER COLLIER

If anyone ever doubted the extent to which Congressional committees could turn good intentions into a bureaucratic nightmare, they need only to look at PPACA’s premium subsidy provisions and their potential impact on insurance exchanges.

PPACA offers premium and enrollee cost-sharing subsidies for lower-income people not eligible for Medicaid or SCHIP as one of the three key components—along with liberalizing Medicaid income restrictions and requiring everyone to have coverage—of reform’s attempt to solve the affordability problem that’s led to fifty million Americans being uninsured.

How will the subsidy process work? It takes up 25 pages of the final reform legislation, so the following is a vastly simplified description. It’s also one that assumes that the final regulations will not deviate significantly from the law itself.

First, anyone wishing to be eligible for a subsidy must submit an application to an exchange. The application must include all information necessary to determine if the applicant is eligible for Medicaid or SCHIP, as well as for the PPACA subsidies. (Massachusetts’ Connector—the prototype exchange—requires a 12-page page form to convey this information.)