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Above the Fold

The Swing to the Right: The Election and Its Effects On Health Reform

Nov 6, 2010• 31

By DAVID HARLOW

Like Tom Friedman, who lampooned some of this year’s unreasonable campaign rhetoric in a recent column, I too would be in favor of reality-based political campaigns … but that seemed to be too much to ask for this year. Instead of truth, we now have truthiness. The joke news shows (and their joke political rallies) seemed to be more popular than the evening news. (I wish Jon Stewart and his 200,000 fans on the Washington Mall last weekend had stayed home, canvassing for their candidates of choice.) Fact-checkers told us that many political ads this season were in the “barely true” or “pants on fire” zones according to the Truth-O-Meter. But in the end, the buzzwords seem to have worked their magic, and many “insiders” are out, and “outsiders” are in. The angry and the impatient on the campaign trail have, in some cases, adopted the line from the movie Network: “I’m mad as hell, and I’m not going to take this any more,” perhaps forgetting that while that line garnered the Howard Beale character strong ratings, network bosses arranged for his on-air assassination when his ratings fell.

The Utopia tune at the top of this post, “Swing to the Right,” comes to you from the Ronald Reagan era, and perhaps we are seeing the generational swing of the pendulum back to the right. It does seem to happen every 30 years or so … but don’t blame me — I’m from Massachusetts (home to a Democratic sweep this Election Night).

The last two years have seen a tremendous amount of change in Washington. The question of the moment, of course, is: How will the election results affect implementation of health care reform?

The short answer is that even having sustained the losses that they have, the Democrats in Congress will be able to sustain a Presidential veto of any GOP anti-health reform initiative. The 2012 election may well determine the ultimate course of health reform. If the GOP gains further ground in two years, then implementation may be that much more difficult to accomplish.

Money and Healthcare Reform

Nov 5, 2010• 24

By JANE ORIENT, MD

Congress handed the Congressional Budget Office (CBO) some assumptions, the computers came up with the mix of adjustments needed to give a magic number under $1 trillion in 10 years, and the “Affordable Care Act” (ACA) emerged.

The “affordable” trillion apparently means net additional federal government expenditures, with the Treasury envisioned as one big pot of liquid gold. All the revenue gets mixed in, and the financial engineers turn the valves to direct the outgo. Less will go into some channels (“savings”), and more into others.

Numbers are thrown about—but where’s a spreadsheet of the money flows? The President couldn’t exercise a line-item veto even if he had one because there aren’t any line items. For example, how can you budget for each of the new bureaucracies if you don’t even know exactly how many there are (159—more or less)? And are they counted in the $1 trillion cost?

Swamp Creature

Nov 5, 2010• 10

By JEFF GOLDSMITH

Many people forget that before Washington DC was our nation’s capital, it was a pestilential swamp, whose few hardy residents regularly succumbed to tropical diseases like malaria. It was virtually uninhabitable in the summer (some say it still is), and like Houston and New Orleans, really began to boom only after the advent of affordable air conditioning. It is also a political swamp, infested with lobbyists and special interests, and Washington “lifers” – commentators, political operatives, consultants, intellectuals and bureaucrats who outlive increasingly fragile Presidential administrations. The electorate despises Washington, and sends waves of “outsiders” (e.g. ordinary Americans) to drain the swamp.

Though President Obama signed it into law in March, the new Affordable Care Act of 2010 is a swamp creature. Written by an exhausted Congress, half beast, half plant, the ACA is a seething, octopus-like tangle of well meaning but opaque government projects intended to expand health coverage and fix the health system’s numerous problems. Far more than “insurance reform”, it sprawls over and touches virtually every corner of our $2.5 trillion health system, bringing change, uncertainty and a ton of taxpayer dollars. It also has sunk its taproots deep into the national treasury and extends its feeding tentacles to an obese and hungry industry that already claims 17% of the national wealth.

A new wave of Republicans are about to hit town, fired up by their stunning mid-term election victory and control over the House of Representatives. One of their campaign pledges is to kill the swamp creature. They will shortly charge off into the swamp to try and kill it, like the British army tried to kill Francis Marion. In doing so, they expose themselves to a whole bunch of hidden hazards, including the beast itself. Handled thoughtlessly, the Republican campaign against health reform could damage the party’s prospects in 2012, even if the economy continues to sputter.

From Progressive to Zombie Legislation after Midterms?

Nov 4, 2010• 4

By RICHARD REECE, MD

This is a guess as to what the midterms, a political setback for supporters of the Affordable Care Act (ACA), might mean for health reform. Exit polls indicate 58% of voters opposed the ACA, and cracks are beginning to show among progressives that implementation of the reform law will be difficult and fraught with political obstacles. During the campaign, Democrats fled from endorsing the health reform law, most of those supporting it lost, and Republicans will soon be holding hearings seeking to expunge or changes many of its provisions.

These cracks are beginning to show in the New England Journal of Medicine, long an echo chamber among supporters of Obamacare. Almost to the person, contributors to the “Perspective” section of the New England Journal of Medicinehave hued to the Obama health reform line, namely that the Affordable Care Act is a step in the right direction, that all will be well if only we follow its provisions to the letter, and that its implementation is inevitable and is needed to correct deficiencies in our health system.

In the October 28 NEJM issue, Henry Aaron, PhD, of the liberal Brookings Institute in Washington, D.C. sounds the alarm and breaks out of the chamber by saying, in effect, “Hey! Maybe this thing we call ACA isn’t going to work after all.”

He breaks ranks with conventional progressive wisdom by opening admitting the ACA may fail “The Midterm Elections– High Stakes for Health Policy.”

Eric Dishman talks about Intel in health

Nov 4, 2010• 2

By Matthew Holt

Eric Dishman has been working with a big team at Intel on the use of technology to help seniors and patients age in place. It’s been a long-ish road for Eric but in the last few years his extensive work on the anthropology of aging is starting to bear fruit in terms of products from the chip giant, including a new-ish joint-venture with GE. I talked with Eric and got some brief overviews of some of the products at last week’s TEDMED conference.

Patient Engagement on the Med-Surg Floor

Nov 4, 2010• 1

By JESSIE GRUMAN, PhD

Three times a day, as though responding to some signal audible only to the generously medicated, we rise from our beds to join the slow procession around the perimeter of the unit. Like slumped, disheveled royalty, each of us blearily leads our retinue of anxious loved ones who push our IV poles, bear sweaters to ward off the harsh air conditioning and hover to prevent stumbles. Some make eye contact. Few talk. Each of us is absorbed in our suffering and our longing to return to our bed.

I find this experience strangely moving.

Despite the nausea, dizziness and enough mind-altering drugs to fell a horse, so many of us fight our way to consciousness, creakily right ourselves and step out of our rooms to join the others. At that moment we are able to say “I’ll do the one thing they say might help me get better,” taking one painstaking step after the next – the height of our ambition meets the limits of our abilities – to resume the life we left behind when we entered the hospital.

This is one glimpse of what it means to be engaged in our health care.

Jessie Gruman, PhD, is the founder and president of the Washington, DC -based Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. She blogs regularly on thePrepared Patient Forum.

The EMR Cage Match Results

Nov 4, 2010

By JONATHAN BUSH

It turns out, there was no cage at the experimental debate earlier in October between me and Girish Kumar Navani of eClinicalWorks. And Girish was wearing a shirt…and no mask.

These, plus other anticlimaxes, sent our PR guy John Hallock into a deep, week-long depression.

“He could have gone for the jugular! Why didn’t he go for the jugular?!?”

This was all he said for days.

The truth is that it’s hard to get too snippy with a guy who has built such an awesome company—WITHOUT VENTURE CAPITAL! It’s just an incredible accomplishment. That, combined with his incredible intuition around software design, made him a guy I really wanted to hear from…rather than jump on.

Also though, I heard Girish start to say words that for most plain ol’ software company leaders are “un-sayable.” He said he wanted to host for his clients. He said he wanted to maintain their data for them. As a private company, I think Girish is in the best place to go the rest of the way. Why not insist that all ECW clients get on a shared instance? Why not start to take on some of the functions that cause so much frustration (34% of new athenaClinicals clients are actually frustrated software-based EMR clients!) These acts would destroy ECWs profits for a few years but they would emerge a genuine candidate for national HIT backbone, along with athenahealth.

We need that…a lot more than we need more versions of software.

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School.

The Electronic Medical Home

Nov 4, 2010• 4

By JOHN HALAMKA, MD

In previous blog posts, I’ve mentioned an idea deserves its own dedicated post.

Over the weekend, I keynoted the eClinicalWorks National User’s Conference in Florida. One of the attendees emailed me the following question:

“I have a number of questions regarding certain types of patient-level data that might cause us problems in the future of HIE. No one, to date, has been able to answer these and I thought I might ask you.

The first, and easiest, is how we we going to handle the following situation:

1) I am seen in Boston as a child and my mother says that I am allergic to Penicillin (or pick your drug of choice). The nurse-practitioner asks a few questions of my mother, who isn’t terribly forthcoming with information but insists that I am allergic. While he/she has reservations, they record it as an allergy in their eclinicalworks EMR. It goes to the Massachusetts HIE.

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?