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Unpacking the Ingenix Settlement

Jan 14, 2009• 12

By ROBERT LASZEWSKI

Earlier this week, New York Attorney General Andrew Cuomo announced a "victory" in his battle with the insurance industry over how out-of-network physician claims are paid. Cuomo had argued that the industry’s use of its out-of-network "customary and reasonable" database "defrauded" consumers and he sued the database’s manager, United Health’s Ingenix, over the controversy.

In a February 2008 post I said, "In a few months, we will hear that Ingenix paid a big fine and agreed to fix something (that no one will understand) and Cuomo will have another notch in his belt."

Here’s how the settlement will work: Ingenix will pay $50 million to
set up an independent not-for-profit to operate the customary and
reasonable database. The industry gets to continue determining what
customary and reasonable
physician charges are through this non-profit and just exactly how they
do it will continue to be done by systems gurus the way systems gurus
do things–pretty much in a "black box." While an undetermined
university will operate the system, the industry, who will finance it,
will presumably have a great deal of input into
it. The industry’s use of the database will be more defensible since
one of its own is no longer arguably directly controlling the entity.

Health 2.0 Will Benefit from Obama’s HIT Stimulus

Jan 14, 2009• 8

By Peter Schmidt

The Obama team is talking very seriously about including health information technology in his “main street” stimulus package. While I generally agree with the predictions of doom and gloom for providers saddled with the burden of data entry, this creates a potentially huge opportunity for Health 2.0.

As very publicly warned in this forum and others, a stimulus package focused entirely on existing EMR/HER technology would not only offer no proven health benefits (Linder, et al. Arch Intern Med. 2007) but also would financially harm clinical practice. Kaiser Permanente’s Hawaiian experiment with EMR added approximately an hour a day of data entry work per physician (Scott et al., BMJ 2005).

This impact will fall disproportionately on primary care.

Disruptive Physician Behavior: Fact vs. Frenzy

Jan 14, 2009• 12

By Alan Rosenstein, MD

The Joint Commission has recently proposed in its 2009 Accreditation Standards that hospitals develop and implement a Code of Conduct policy and provide appropriate education and processes that address disruptive behaviors.

Many think the decision is long overdue, while others have expressed concern that it was just another way for administration to weed out physicians who are openly vocal in expressing contrary views to administrative policies and decisions.

Disruptive behaviors include any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment. Unfortunately, they’re all too common in the health care arena, and they affect staff morale as well as patient safety.

My top 10 rules for Email Triage

Jan 14, 2009• 3

By John Halamka

I
receive over 600 email messages each day (with virtually no Spam, so
they are all legitimate) and respond to most via Blackberry. How do I
triage 600 messages? I use these 10 rules to mentally score each email:

1.
E-mail marked with a “high importance” exclamation point must pass the
“cry wolf” test. Is the sender a habitual “high importance” e-mailer?
Are these e-mails actually important? If not, the sender’s emails lose
points.

2. I give points to high-priority people: my senior management, my direct reports, my family members and my key customers.

3. I do the same for high-priority subjects: critical staff issues, health issues and major financial issues.

4.
I rate email based on the contents of the “To,” “cc” and “bcc” fields.
If I am the only person in the To field, the e-mail gets points. If I
am in the To field with a dozen other people, it’s neutral. If I’m only
cc’d, it loses points. A bcc loses a lot of points, since I believe
email should always be transparent. E-mail should not be used as a
weapon.

5. I penalize email with emotional words, capital letters or anything less than civil language.

Tone deaf git of the month award

Jan 14, 2009• 33

By Matthew Holt

I’m always amused to see Ivy league professors with tenured appointments and gold-plated group health insurance explaining how the individual market for health insurance works pretty well for, well, quite a few of the well people in it. But this award is not for Mark Pauly.

Today there’s a long piece in the Wash. Post (essentially paid for and scripted by Kaiser Family Foundation—which may be the future model of health care journalism). In it, we see this paragraph:

Experts define the underinsured as those forced to spend at least 10 percent of their income on health care, excluding premiums. But the nonprofit Center for Studying Health System Change found recently that financial pressures on families increase sharply when out-of-pocket spending on medical bills exceeds 2.5 percent of family income. New York’s Commonwealth Fund has reported that 72 million adults under age 65 had problems paying medical bills or were paying off medical debt in 2007, up from 58 million in 2005. Many had insurance, and 39 percent said they had exhausted their savings paying for health care.

Yup, even people with insurance are in real trouble. Two days ago I met a woman in her early 20s who faces 3 more years paying off extra bills from emergency ankle surgery 2 years ago. And yes she had insurance–just not very good insurance.

And so we have around 25% of adults having problems paying medical debts. And of course that’s a 2007 number—in other words pre-recession. So in order to be “balanced,” they get a quote from a resident member of the loony right. And for our tone deaf git of the month award we select this wonderful piece of empathy.

Economist Thomas P. Miller of the American Enterprise Institute, a conservative Washington think tank, said he believes the problem of medical debt has been exaggerated and is a symptom of the broader economic crisis. The solution, he said, should not be "to kill people with kindness" by requiring an overly expansive and expensive benefits package that could "preempt the use of resources for other purposes."

In other words, screw you poor people, you’re on your own and the system works fine.

Confessions of a Cultural Anthropologist: The Cause and Cure of High Health Costs

Jan 13, 2009• 15

By RICHARD REECE

Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students’ choices are dictated by the desire to maximize income and minimize work time.

Pamela Hartzband, MD, and Jerome Goodman, MD
“Money and the Changing Culture of Medicine”
New England Journal of Medicine, 1/08/09

I have a confession to make. I think the cause of high American health costs is straightforward, but it is not simple. It is American culture in general and the physician culture in particular. There is nothing wrong with this, and I point no fingers.

The Way We Are
It is our culture. It is the way we are, the way we’ve been for 232 years. It is our distrust of government and high taxes. It is our want to be free to choose. It is our belief in for equality of opportunity for access to the latest and best of care.

It is the notion, stemming from frontier days and conquering of the West, that action speaks louder than words, that if you do something specifically, it is better than doing nothing generically. “Don’t do nothing, do something,” as the saying goes.Continue reading…

The anti-Dimitriy!

Jan 13, 2009• 15

By Matthew Holt

Certain people have accused Health 2.0 of being a bubble. Others of us have responded that it’s not. I don’t think either side in that argument has claimed that health care needs a bubble. But Forbes columnist Sramana Mitra thinks that a tech bubble in health care would be a great thing. In particular it would produce many more AthenaHealths and PatientsLikeMes

Certainly a provocative read!

New NRC Report Finds “Health Care IT Chasm,” Seeks New Course Toward Quality Improvement and Cost Savings

Jan 12, 2009• 20

By DAVID C. KIBBE

Like the Institute of Medicine’s (IOM) 2001 counterpart report, “Crossing the Quality Chasm,” a new report from the National Research Council of the National Academies is complex, full of new ideas assembled from multiple disciplines, and is likely to have seminal importance in framing public policy from now on. “Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions” was released last Friday, January 9, 2009 in draft, but there is so much to comment on that I think it’s wise to begin with a quote from the committee that sums up the central conclusion:

In short, the nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade. In the quality domain, various improvement efforts have failed to improve health care outcomes, and sometimes even done more harm than good. Similarly, based on an examination of the multiple sources of evidence described above and viewing them through the lens of the committee’s judgment, the committee believes that the nation faces the same risk with health care IT—that current efforts aimed at the nationwide deployment of health care IT will not be sufficient to achieve the vision of 21st century health care, and may even set back the cause if these efforts continue wholly without change from their present course. Success in this regard will require greater emphasis on the goal of improving health care by providing cognitive support for health care providers and even for patients and family caregivers on the part of computer science and health/biomedical informatics researchers. Vendors, health care organizations, and government, too, will also have to pay greater attention to cognitive support. This point is the central conclusion articulated in this report. (emphasis added)

It would be difficult to find a more sober indictment of US health care IT policy and implementation over the past decade than what is contained here.

Free Trade and Free Antibiotics

Jan 12, 2009• 3

By MICHAEL MILLENSON

The next time you visit your doctor with a case of the sniffles, he may want to inquire about your position on the North American Free Trade Agreement before deciding whether to reach for his prescription pad.

A recent article by the Charlemagne columnist of The Economist points out a strong correlation among those European nations whose populations believe that globalization offers an opportunity for economic growth and the data on consumption of antibiotics. The article notes:

Rather like trade protection, the popping of an antibiotic offers false comfort to individuals. In an anonymous 2008 survey, Greek pediatricians said that 85 percent of patients demanded antibiotics for children with the common cold virus. As with political debates over free trade, some people appear to suffer from a corrosive lack of trust when the authorities tell them that they are demanding the wrong thing. Even when told that antibiotics cannot fight viruses, 65 percent of Greek parents in the survey insisted they did until their doctors gave in.

Commentology

Jan 12, 2009• 1

Dr. Rodney Hornblake of Boston wrote us an email wondering if the Obama administration’s much- ballyhooed plans for Health IT investment may actually be slowing technology investment over the short term.

"My partners and I have put on hold our planned implementation of e Clinical Works. Scheduled for February the project is now on hold. The reason? Obama’s emphasis on healthcare IT as an “economic stimulus”. If we invest now we are likely to miss tax credits or other incentives."

Michael Millenson had this to say in response to David Kibbe’s posting this morning on last Friday’s Health IT report from the National Research Council of the National Academies.

"The tunnel vision of the IT community is unintentionally shown by the comparison of the IT gap to the "quality chasm." That demonstrates a fundamental misunderstanding. The quality chasm is a gap between the care we have and the care we should have. Health IT, by contrast, is a critical tool in closing that gap — but it is only that, a tool. Just like telephones or, for that matter, file folders."

Rick was among the readers who commented on Dr. Val’s posting on Sanjay Gupta’s potential nomnination as Surgeon General …

"Dr. Gupta, while serving as a war correspondent for CNN in Iraq,
performed five emergency brain surgeries in the field. I don’t know if
that counts for military experience, but anyone at the Pentagon who
overlooks it ought to be reminded — though I expect Dr. Gupta would be
too polite to do so.

Frankly, it sounds like Dr. Jones’ anonymous source has a case of
the sour grapes, resentful at getting passed over by someone with more
star power, or at least, is close to people who are."

Meanwhile, skeptic writes:

"The director of public health for Los Angeles County (Jonathan Fielding
MD) or his New York City counterpart would be far better candidates for
Surgeon General. Both have experience running large organizations and
noteworthy accomplishments, along with excellent PR skills."