Following my cynicism about the Braly WSJ interview, not only have they been called out by the Secretary of HHS, but now they’re really in trouble. The Mommybloggers are after them…
Above the Fold
DNADirect bought by Medco: Consumer genomic counselling goes mainstream?
Ryan Phelan started DNADirect to expand the power of genetic testing to everyone, using the Web. She’s been ploughing a tough furrow but been making some real progress in the last few years, including getting an investment from Lemhi Ventures and working with Humana to provide genetic testing to its members (and the utilization management going along with it), to go along with their initial DTC approach.
Late last week DNADirect was purchased by Medco. I spoke with Ryan and Robert Epstein, Chief Medical Officer of Medco to get just a taste of what this will mean for the future of DNA testing within Medco.
Here's the interview.
Gawande’s “Checklist Manifesto”
By BOB WACHTER, MD
Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.
In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.
Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there’s no such worry here: Atul’s passion for patients and humility are so obvious that one never questions his methods or motives.
EHR Redux
It’s time to revive the discussion of electronic health record software in light of the new federal regulations that define criteria for meaningful use and also set criteria for the EHR technologies that must be implemented by doctors and hospitals in order for them to become, and be paid for being, “meaningful users of certified EHR technology.”
While most of the public commentary so far has been directed to the NPRM on meaningful use, the real news here relates to the de-construction of EHRs that is described in the interim final rule covering EHR standards and implementation specifications. Of course, the NPRM and IFR are by design tightly linked. But the NPRM on meaningful use is primarily a set of instructions for doctors and hospitals about how to participate in the incentive payment programs established statutorily under ARRA/HITECH. The rule on EHR technology certification criteria, on the other hand, is a playbook intended for vendors and developers who want to qualify their products to meet the expected demand by meaningful users in those programs.Continue reading…
How to Get Enough Votes in the Senate
When Hillary Clinton was running for President, she set forth a more modest agenda for health care reform than her competitor, Barack Obama. Maybe she understood better, based on her experience, how difficult it is to get a comprehensive bill through Congress in this field.
What is possible now that the President has lost the 60-vote majority in the Senate? I think the thing to remember is that he was having trouble even holding together the 60 votes he used to have. He had to agree to an assortment of give-aways — to Nebraska, to Louisiana, to the labor unions — to get the votes he needed. In part, that proved to be the undoing, as Massachusetts voters watched this sausage being made and sent a message through the election of Scott Brown that they didn’t like what they had been seeing.
Now, it may be that the Republicans will act to kill anything that might come along. I don’t think so. I think they are willing to be part of a bill, but it has to be a bill for which they can claim credit among their constituencies. What might it be?
Insurance reform: People, irrespective of party and political leanings, despise the practices of insurance companies that limit or take away coverage. The use of pre-existing conditions to deny coverage, lifetime limits of coverage, and rescission of policies are nasty and unfair. These practices remain as sources of insecurity among Americans, even those with insurance. There should be near-universal support to change them.
Tort reform: I think that most people feel that, while people should have a right to sue for medical malpractice, the process that exists today is inefficient and arbitrary for both plaintiffs and defendants. Any doctor will tell you that fear of such suits also leads to the practice of defensive medicine, driving up costs for all of society. Tort reform does not require limitations on payments. It could be accomplished with the establishment of specialized courts and procedures that would add greater certainty to outcomes and reduce the tensions and abuses associated with the system. This should not be a partisan issue.
Payment reform: Nobody likes the results of a system that systematically underpays primary care doctors and leads them to a life of 18-minute appointments and a role as triage doctors, a way station to referrals to higher paid specialists. If Congress were to order Medicare and state Medicaid plans to take the lead in establishing reimbursement rates for PCPs that reflected their value to families and patients, we would be on the way to a more rational system of care. Likewise, if physicians were paid for care delivered by telephone and electronically, millions of unnecessary and time-consuming office visits could be eliminated. If these steps were taken for Medicare and Medicaid, private insurers would follow.
Transparency: A national mandate for public disclosure of the rates paid by insurers to providers would help drive greater rationality in payment methodologies in the states. Disclosure of clinical outcomes in clinically important arenas would provide impetus to improvement in patient safety and quality. How can this be a partisan issue?
Now what about access? I fear that expansion of insurance coverage is the third rail in this debate. Why? Because it requires revenue to support the subsidies that would be required, and tax increases are really hard to achieve. The President made this issue more radioactive than necessary by proclaiming at the start that you could get access, choice, and lower costs all in one neatly wrapped package. Everybody in the field knew that you could not. This then resulted in sleight-of-hand revenue measures that became the undoing of the bill as Christmas tree ornaments were added to undo the effect on particular states or interest groups.
As I have stated here, a fair approach to generate the revenues for expanded access is to eliminate or reduce the pre-tax treatment of insurance premiums. Doing so would use the progressive income tax system in a way that would apply a larger percentage of these costs to more wealthy people. Could this approach gain a bi-partisan consensus? It could not gain support even among the Democratic majority, so I am guessing not. And the Republicans seem to express no interest at all in mandates for greater access. Maybe we have to accept as a reality the idea that expanded access is a casualty in this debate. I hope not, but I don’t yet see an answer to this that can get 50 votes, much less 60.
Government to Account For More Than Half of Healthcare Spending
Amid all the gloomy numbers in the latest government projections for health care spending, one statistic stands out: Public sector involvement in health care this year will surpass private sector spending for the first time in U.S. history.
The actual projections show it will only reach 49.3% of $2.57 trillion, but that assumes Congress won’t throw more money at physicians at the end of this month when previously legislated cutbacks in Medicare pay are slated to go into effect. Congress can’t pass health care reform, but spending more on physicians (mean salary for cardiologists and radiologists in 2009 was over $400,000) has unusual bipartisan support.
What’s driving the growing public role is no mystery. With unemployment at 10 percent and underemployment widespread, millions of Americans have lost employer-based coverage and now must rely on public sector programs. Even where people remain employed, their firms can no longer afford skyrocketing premiums and thus are abandoning or cutting back on coverage.
And there’s no end in sight to those trends, even with an improving economy. Health care spending, which surged to 17.3% of gross domestic product in 2009 from 16.2 percent in 2008, the largest single jump in the history of government recordkeeping, is slated to rise to 19.3% in 2019, a year when the public sector will account for 51.9% of the $4.49 trillion health care economy. And that’s without paying physicians more.
Here’s another way to look at it: In 2019, U.S. government agencies at the state and federal level ALONE will spend 10% of GDP on health. That’s a greater share of economic activity than many other highly industrialized nations that insure everyone, yet the U.S. will still have one in six or seven people without any coverage at all at some point during the year.
Why Calculators Are the Future of Healthcare
Want to know the future of medicine and healthcare in one sentence?
For my money, it goes like this: The real opportunity in healthcare is to combine our personal data with the huge amount of general biomedical and public health research, in order to create customized information that’s specific to our person and our circumstance. We need relevance, and the right information at the right time will help us make better choices for prevention, helping us stay healthier longer, it’ll help us navigate diagnosis, letting us select screening tests that are useful and not unnecessarily fearful, and it’ll let us make better decisions on care and treatment – when we’re trying to choose among various treatments to find our way back to health.
It’s in the last category – care and treatment – that I wrote a recent post at the Huffington Post about one man’s story with prostate cancer. Tom Neville got a diagnosis and then had to struggle to find information to help him make sense of what to do. Ultimately, he chose surgery, but the difficulty of the choice led him to create Soar Biodynamics, a company that offers decision-making support for men assessing their prostate health.Continue reading…
Wellpoint’s wasted opportunity
Sometimes with something so egregious gets written that, even if it’s in the Wall Street Journal, you have to notice it. Angela Braly, the CEO of Wellpoint—compensation a hair under $10m in 2009—ought to be happy, even though Joseph Rago in the WSJ is surprised about that. It looks like the health reform bill which put much of Wellpoint’s highly profitable individual and small group business at risk is dead, and this week Wellpoint started putting up rates between 35% and 80% in the California market (where it’s Anthem Blue Cross).
But the WSJ quotes her as calling health reform a “wasted opportunity”. Funnily enough Wellpoint and the trade association it funds, AHIP, were on both sides of the debate. Pushing Congress to give it 30 million more customers as part of the bill, and then surreptitiously funding the Chamber of Commerce to oppose health reform (and putting pressure on the Blue Dogs, and the DINOs in the Senate) when some of the terms of the House Bill started to look less favorable (85% Med loss ratios limits among them).
I’d had some semi-decent hopes for Braly and her team.
The Point of Health 2.0. Yes There is One
By MATTHEW HOLT
The (not huge) world of Health 2.0, participatory medicine and ePatients has been fretting itself about a comment Susannah Fox (all hail) elevated into a post called “What’s the Point of Health 2.0”.
Here’s an excerpt from the comment from DarthMed,
The remaining 95% of “patients” out there are not motivated to become informed, or invest the time/energy/money in using any of these tools. These are the folks that know that fast food isn’t healthy, but are just too tired to choose differently. Some (emphasis on some) will do a standard Google search when they receive a new diagnosis at best. Yet these are the folks – often folks with multiple chronic (often preventable) health problems, many overweight, on multiple medications, sometimes social problems – that have the real issue that needs fixing.
So we can all sit and perfect the tools for a few folks that never needed them anyway, or we can recognize that the kinds of solutions required for healthcare in the US today have nothing to do with fancy IT, or prioritization on search engines, and everything to do with low-tech, unsexy approaches toward grass-roots public health. Sorry to be the voice of reality guys.Continue reading…
Plan B
With word that the House is likely to take up the repeal of the health insurance industry anti-trust exemption it is now clear the Democratic leadership has begun Plan B.
It is also clear that this is much more a part of a political Kabuki dance then any substantive effort at even piecemeal health care reform.
The House probably has the votes to pass the repeal. The Senate does not. I doubt that even all of the 59 Senate Democrats will vote for it if and when it does come up on the floor of the Senate.
The base of the Democratic Party, as well as many “progressive” Dems in the House and Senate, are rabidly mad about not being able to ram their health care bill through. That is why you continue to hear all of the talk about reconciliation options even though there is no chance such a scheme would pass either the House or Senate.
But what to do? The apparent answer is to bring up a few smaller health care bills the Democratic leadership views as popular back home and expect the Republicans will vote against them. Right now health care is a big negative issue for the Dems given the unpopularity of their effort to date. But if they can be seen trying to pass a few smaller measures “we can all agree on” only to be thwarted by Republican opposition their hope is they can turn the table on this issue to their advantage—well before they get to November.>
Interesting politics but no hope for any real progress while these games play out.
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When the Democrats say they believe they can still pass a health care bill are they bluffing? That’s my opinion.
Here is a first rate story from Politico on their options and the dismal political reality each faces.
