The Health Care Blog – Page 784 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

PBM Industry Reforms can Reduce Wasteful Health Care Spending, Protect Patient Choice of Pharmacy

Oct 19, 2010• 3

By CSS

American businessman Victor Kiam best described the small business owners’ mindset by declaring, “An entrepreneur assumes the risk and is dedicated and committed to the success of whatever he or she undertakes.” However, external forces can occasionally constrain even the most astute entrepreneur, as is the case with independent community pharmacy owners. These same forces needlessly inflate prescription drug costs for employers and health plan sponsors, while undermining patient choice and health outcomes.

Pharmacy benefit managers (PBMs) are hired by employers, government agencies, health insurance plans and unions to administer prescription drug plans. They morphed over time from simple claim adjudicators to gigantic drug middlemen operating a byzantine drug delivery system that benefits them at the expense of others. They reap windfall profits simply for processing claims and operating mail order pharmacies. In 2009, the three largest PBMs – CVS Caremark (which includes the CVS pharmacy retail chain), Medco Health Solutions, and Express Scripts – made $6.4 billion, $1.1 billion and $776 million respectively in profits. By contrast, independent pharmacies operate off of slim profit margins that are driven by prescription drug reimbursement. Despite the rising cost of many medicines, these rates have been declining for years.

Local pharmacists have a Hobson’s choice: accept onerous, non-negotiable contract terms dictated by PBMs or lose access to both new and long-term patients. When the contracts are signed community pharmacies are dragged into a profit-draining, bureaucratic abyss. If they have the temerity to complain, PBMs can often freely void the contract. U.S. Representatives Anthony Weiner (D-NY) and Jerry Moran (R-KS) introduced H.R. 5234, the PBM Audit Reform and Transparency Act of 2010; a bipartisan-supported bill designed to tackle some of the most egregious practices of the PBM industry. Its passage is a must.

Doctors, Hospitals and the Yankees

Oct 19, 2010• 5

By ROB LAMBERTS, MD

Joe Boyd hated the Yankees.

“Those damn Yankees. Why can’t we beat ‘em?”

Then he got the opportunity to save his beloved Washington Senators by making a deal with the devil – giving up his soul in exchange for being transformed into “Shoeless Joe” to propel his team to win the World Series.

Interesting. I think a lot of doctors are making their deal with the devil. They are looking for a small gain in comparison to a long-term of misery. True, Joe Boyd made out in the end; but that will only happen if someone from Hollywood writes our script.

Here’s the problem: at the core of our problems with healthcare is the total lack of cohesive communication. Doctors have no idea what other doctors have done with a patient. Tests get ordered, medications get changed, procedures, hospitalizations, even surgeries are done without communication to other doctors who would benefit from this information. The conduit of communication is this:

Doctor: “So, how have you been doing over the past few months?”

Patient: “Didn’t you get the notes from the hospital? I was in for two weeks. I had a heart attack and a stroke and now I am in rehab for both of these.”

Doctor: (checks chart uncomfortably) “No, I didn’t hear about it. Why don’t you tell me about it….”

Situations like this happen daily at my office. Patients are started on medications by specialists without my knowledge. Lab tests are done that I have no access to. Huge changes happen in the lives of the patients for whom I have cared for over a decade, and I get nothing. Even consults I order are done without any communication back to me. On the other side of things, my patients are hospitalized without any consideration of the care I have been giving over the past decade. Patients are treated as if their care starts from scratch every time they enter a new venue.

San Francisco 2010: Launch of ShareCare

Oct 18, 2010

By Bianca Grogan

WebMD founder Jeff Arnold launched ShareCare at this year’s Health 2.0. ShareCare recruits industry experts to answer health and wellness questions, providing consumers with the necessary tools to make smart health choices and live healthier lives. ShareCare simplifies the search for health information, allows consumers to find high quality answers from multiple points of view, and drives healthcare to the local level by allowing consumers to hear from physicians close to home. With partners such as Sony, Harpo (Oprah’s production company), Discovery, Dr. Mehmet Oz, and multiple major content providers, the launch of ShareCare has been highly anticipated.

The Health Reform (Almost) Everyone Loves

Oct 18, 2010• 32

By MICHAEL MILLENSON

Come with me to the land of happy health reform. It is a place where Republicans and Democrats find common ground, a place where physicians, hospitals and health insurers sit together as partners, a place where criticism is respectful, not rancorous. It is the world of Accountable Care Organizations (ACOs).

What are ACOs, and why have they escaped the general onslaught of opprobrium from Obamacare opponents?

The term Accountable Care Organization was originated by Elliott Fisher of the Dartmouth Center for the Evaluative Clinical Sciences, picked up by the Medicare Payment Advisory Commission and then enshrined in Section 3022 of the Patient Protection and Affordable Care Act (otherwise known as health care reform). The language is explicitly designed to use financial incentives to change the health care delivery system.

ACOs are defined less by form than by function. A group of physicians, possibly with a hospital, agrees to manage the full spectrum of care for a defined population of at least 5,000 Medicare beneficiaries for a minimum of three years. If the ACO meets certain targets for quality and cost-effectiveness, it gets to keep part of the savings.

HIE Guide for the Perplexed

Oct 18, 2010• 23

By MARGALIT GUR-ARIE

HIE stands for Health Information Exchange. Sometimes the term HIE is used to describe the act of exchanging health information, sometimes HIE is used to describe the infrastructure which enables the exchange to occur and sometimes HIE is used to describe an organization that owns the infrastructure which enables the act of health information exchange. HIE (the act) is supposedly the holy grail of Health Information Technology (HIT) and the enabler of “an EHR for every American by 2014”, which in turn, will bring about better health care at lower costs and, by leveling the playing field, will reduce disparities in care.

The Government, through ONC, has awarded over $547 million to various States to create regional HIE (organizations). The fledgling new State HIEs (the organizations) are busy screening and purchasing HIEs (the platforms) and defining the rules of their local HIE (the act). There are several HIE (platform) vendors, notably Medicity and Axolotl (recently acquired by Ingenix), but even Microsoft and IBM are trying to make inroads into this fairly new market. In a parallel process, ONC is busy defining national standards and regulations for HIE (the act).

There are two basic models for any information exchange and HIE (the act) is no different.

The Centralized Model – All information creators/editors/contributors push their content to a centralized repository, preferably in real time, and all users/readers pull the information on demand from said centralized repository. This is the infamous “database in the sky” which houses every American’s medical records. Conceptually, this is the simplest model to understand. The Government will buy enough hardware to set up clusters upon clusters of databases, define the exact data elements and documents to be stored, assign a national identifier to all of us (physicians too) and finally publish specifications for pushing and pulling data securely. Every EHR vendor and medical information supplier (such as labs and pharmacies) will build the necessary web services and integrate them in their technology and we will all live happily ever after. However, other than the obvious monumental technology challenges involved in maintaining such infrastructure, Americans tend to experience significant discomfort with the concept of Uncle Sam having unfettered access to so much personal information and the obvious privacy issues it raises.

San Francisco 2010: iWantGreatCare Demonstration

Oct 17, 2010• 2

By Bianca Grogan

In the US, a growing number of doctor rating sites offer helpful – and unfortunately sometimes less than helpful – background information on physician performance. Healthgrades, Angie’s List, Vitals.com and a long list of start ups use a range of approaches and methodologies to provide comparative information on physicians, theoretically allowing users to make informed choices between providers, comparison shop for the best prices and avoid doctors with poor track records. In the UK, the independent iWantGreatcare.com takes a different approach, offering a stats driven glimpse into the performance of doctors working for the National Health Service (NHS). We like the site’s clean lines and ease of use, something we can’t always say about all its U.S. based competitors. In this presentation from October’s Health 2.0 Conference in San Francisco, iWantGreatCare’s Managing Director Neil Bacon talks about his firm’s approach and why nearly as many doctors as patients are using the site.

A Prescription For Doctors

Oct 16, 2010• 21

By THOMAS GOETZ

Enough about patients: What is a doctor to do?

In the past few months, since The Decision Tree book came out, I’ve had the privilege to talk with many doctors about the opportunity and challenge of engaging patients in their own health. Some physicians, not surprisingly, have been suspicious, and even hostile to the idea that patients have a role to play. But thankfully, those have been rare exceptions. Most doctors I’ve spent time with have been eager to hear about new tools that might engage their patients, and they’ve been eager to share well-earned advice on where there’s work to be done. It has been a delight and an education to talk about the potential of healthcare with these physicians who are, after all, doing the hard work of providing medical care every day.

A high point in my continuing education came a couple weeks ago, when I was invited to speak at the Minneapolis Heart Institute Foundation‘s Fall Nursing Conference, where I met a number of nurses who are eager to help patients gain some control over their health. A few days later I gave a lecture on patient engagement at the University of Minnesota Medical Center. The invitation came from Dr. David Rothenberger, an esteemed surgeon who has consistently emphasized the importance of innovative thinking in medicine. Dr. Rothenberger also runs a program for physicians with promising leadership potential, and part of my day involved talking with them about the changing nature of clinical medicine, and the challenge of engaging patients in their healthcare.

These were good doctors, deeply motivated to help their patients, and there was scant resistance to the notion of an empowered patient who might seek to engage in their care and treatment. Indeed, they seemed to relish the opportunity to work with such patients.

San Francisco 2010: Regina Holliday Presents her Painting

Oct 15, 2010• 11

By Bianca Grogan

On the last day of the Health 2.0 Fall Conference in San Francisco, October 7-8, 2010, Regina Holliday presented the painting that she worked on for the full two days of the conference. She titled her painting Bridging the Great Divide, in reference to how we communicate, bridge communities, and combine left and right brain thinking.

What’s Your Platform?

Oct 15, 2010• 3

By JONATHAN BUSH

We’ve done some heavy dipping into the world of policy recently. In mid-September, I spent a day in Washington, D.C., with friend and advisor Tom Scully meeting researchers, senators, and a congressman. We heard from “ONCHIT” that “CCHIT”—which, as you know is an “ATCB”—granted us Stage 1 MU! This is great news for me, mostly because some competitors didn’t get it! (How’s that for starting a policy blog with some serious ABCs?!)

I met with some amazingly smart and engaged reporters who now (I think, get called “researchers,” since their newspapers can no longer afford them) work for the Henry J. Kaiser Family Foundation or NPR. They’re the real deal. They needed much less initial grounding in the problems we try to solve than most of the journalists we meet. They had taken on board the assumption that the move toward ACOs means less waste (which it could for some) and can get everybody in the clinical supply chain on one system (which has been seen to work at times).

But none of them appears to have considered the idea that there is a relationship between a healthy integrated health information ecosystem and a health information exchange marketplace. It’s still surprising to me, but precious few people correlate sustainability of any social good with the existence of a healthy marketplace with enough room for flexibility to allow innovation over time. It’s like the single economic condition responsible for ALMOST ALL of the social progress of this nation since inception, but in health care it’s still kind of a new idea.

Hospitalists as Extensivists

Oct 15, 2010• 5

By PAUL LEVY

I had heard something about this, but couldn’t find it. A colleague here finally tracked it down. The story is about Caremore, a California based organization. Hospitalists generally are internal medicine doctors based in the hospital; but here they care for frail elderly members at high risk of hospital admission or readmission in skilled nursing facilities and in outpatient settings both before and after a hospital stay. Here’s an article on the AHRQ Innovations Exchange website.

An excerpt:

A Medicare Advantage plan expanded the role of its employed hospitalists, using them to continue following and caring for recently discharged members until their condition stabilizes, as well as other members at high risk of a hospital admission. Known as “extensivists” and supported by sophisticated information technology (IT) systems, these physicians generally split their time between the hospital, where they round on a small group of members each day, and an outpatient clinic, where they see recently discharged members and other members at high risk of an admission. Once or twice a week, these physicians also see members in SNFs.

The results:

The program reduced readmission rates and has led to low LOS (lengths of stay) and to below-average inpatient utilization in a high-acuity population.

Is this worth considering more broadly? What are the conditions for success? I welcome your thoughts.

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.