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The Healthcare Blog - Wed, 02/10/2016 - 19:46
Seth Sternberg was a founder at instant message service Meebo, which was acquired by Google in 2012, and like many tech guys he’s next decided to try to change the health care experience. But unlike many others the aspect he wanted to change was the in home caregiving market, following a bad experience with his own mother. Honor came out from under wraps last year, raised $20m, and is currently operating in Los Angeles and San Francisco. It’s not only a market place where you can hire caregivers for a loved one, but it also allows the client, whether they be the person receiving the care or their loved one–that daughter out of town–to manage the process end to end including booking and paying, and allows the caregiver to report on what they are doing, and follow a careplan.
But beyond that Sternberg is on a mission to “professionalize” the caregivers by not only increasing their pay, but accurately matching them to client needs, and increasing their control over their own situation. To that end Honor recently backed off the Uber independent contractor model and made its caregivers full employees (with stock options!). Very interesting guy with an interesting model. Here’s the interview:
Categories: OIG Advisory Opinions
Medical Coding News - Wed, 02/10/2016 - 07:15
We have a code! The Zika virus has continued to generate national headlines. During this past week, it was announced that Zika can be transmitted through sexual contact as well as infected mosquitos. Eleven states have reported travel-associated Zika virus cases, meaning that the virus was contracted while traveling in the known countries in which […]
Categories: Healthcare News
The Healthcare Blog - Wed, 02/10/2016 - 07:07
Twenty years ago as a newly trained oncologist, I faced the same challenge that many cancer patients and their families do as they try to figure out where to turn when my mother was diagnosed with ductal carcinoma in situ– or pre breast cancer. Her surgeon, who had come highly recommended by her family doctor,told her she needed to have a lymph node dissection, which can result in lifelong disability due to lymphedema or swelling of the arm. As an oncologist, I knew it was not recommended for ductal carcinoma in situ, but she resisted my suggestion to get a second opinion. Despite the fact that I—her daughter—am an oncologist, her first thought was, “I can’t go against what my family doctor told me to do.”
It is still not part of our general culture to question physicians and, in a sense, to discuss health care options. Many patients are shell shocked by a cancer diagnosis and don’t think beyond what they are immediately told to do or where they are told to go for treatment. Some highly motivated patients dig deeper to research their options for cancer treatment, but these motivated patients are still a minority.
California is now leading the way in publically reporting cancer surgery volume to make it easier for patients, as well as health care professionals, to access and compare information on the frequency of surgeries at different hospitals. I participated in the Advisory Group, informing an effort funded by the California HealthCare Foundation,to make cancer surgery volume data available for the first time for 341 California hospitals on www.CalQualityCare.org. Accompanying the release of these data is a new report, Safety in Numbers: Cancer Surgeries in California Hospitals,highlighting important findings about the frequency of surgeries by hospital for 11 types of cancer for which there is an association between low hospital volume of surgeries and increased mortality and complications.
While more research is needed to analyze and understand the linkage, this new access point facilitates conversation between patients and doctors as well as between health plans and hospitals. The new data identifies important areas to research and helps health plans to enter into dialogue with hospitals where low volume surgeries occur.
The idea of establishing thresholds — or minimum frequencies — for cancer surgeries is complex, but most of us can agree that a red flag goes up when a hospital is only performing a surgery once or twice a year. It is important for hospital administrators to ask why this occurs and consider referring patients to higher volume facilities. In some cases, an emergency surgery took place, but Safety in Numbers illustrates that low volume cancer surgeries are much more prevalent than many of us realized.
In fact, almost 75% of California hospitals performed surgery for one of the 11 types of cancer only one or two times in 2014. Most patients—between 60% and 81% depending on the cancer type—who had surgery at a hospital performing a low number of those surgeries in 2014 were within 50 miles of a hospital performing higher volumes.
Anthem health plans,in concert with the Blue Cross Blue Shield Association, have developed Centers of Excellence for rare and complex cancers. Anthem health plansassign case managers to patients with serious medical conditions to help those facing tough decisions find a qualified hospital specializing in their condition.The goal of Anthem health plans is to direct members to the Centers of Excellence, made available online. We already encourage consumers to have surgery at facilities experienced with their specialized condition and our case managers are trained in discussing the Centers for Excellence and assisting members in getting second opinions.
A key challenge is getting information into the hands of consumers quickly enough – they need to understand their options when they are making the decision about where to have surgery. Members often engage with case managers after surgery has occurred and as they continue in their treatment. As we explore ways to get important information about cancer treatment options upstream to consumers, efforts like this by the California HealthCare Foundation can help raise awareness.
Safety in Numbers provides both the evidence and the data to start including volume as a criteria in our Centers of Excellence research. While the centers have focused more broadly on different types of cancer, we can use these data as a basis and may start to focus on the outcome-surgery volume link. It is and will, however, continue to be difficult to identify specific thresholds as a criteria to determine treatment options. There are many factors contributing to patients’ options, such as the distance they may need to travel to different hospitals – though our health plans do cover such travel expenses.
While Safety in Numbers raises important questions about whether the medical community should establish thresholds for complex cancer surgeries, health plans can look for ways to move the dialogue with hospitals, physicians and patients. We must also look at what else high performing teams are doing that other hospitals can replicate, as there will always be many factors influencing surgery outcomes. It makes sense to avoid surgery altogether when possible. For example, combined treatment with chemotherapy and radiation has the same long-term survival as surgery for esophageal cancer. As we move to make available data on surgical outcomes, we need to make sure patients have the full range of treatment options presented to them so that they can make the best choice given their own life circumstances and preferences.
As research and understanding about surgery volume continues, it would be helpful for health plans to have access to measures linking surgery volumes to outcomes that are established by medical associations, such as the American College of Surgeons.Continuing research on surgery volume-outcome linkages, leveraging the new data now available on cancer surgery volume in California, and promoting dialogue on this issue will, ultimately, benefit patients and health care systems.
Jennifer Malin, MD, PhD, is Staff Vice President, Clinical Strategy at Anthem, Inc.
Categories: OIG Advisory Opinions
The Healthcare Blog - Tue, 02/09/2016 - 10:52
This weekend the NYTimes published an editorial titled Give Up Your Data to Cure Disease. When we will stop seeing mindless memes and tropes that cures and innovation require the destruction of the most important human and civil right in Democracies, the right to privacy? In practical terms privacy means the right of control over personal information, with rare exceptions like saving a life.
Why aren’t government and industry interested in win-win solutions? Privacy and research for cures are not mutually exclusive.
How is it that government and the healthcare industry have zero comprehension that the right to determine uses of personal information is fundamental to the practice of Medicine, and an absolute requirement for trust between two people?
Why do the data broker and healthcare industries have so little interest in computer science and great technologies that enable research without compromising privacy?
Today healthcare “innovation” means using technology for spying, collecting, and selling intimate data about our minds and bodies.
This global business model exploits and harms the population of every nation. Today no nation has a map that tracks the millions of hidden data bases where health information is collected and used, inaccessible and unaccountable to us. How can we weigh risks when we don’t know where our data are held or how data are used? See www.theDataMap.org .
Medicine was always based on a relationship of two, a doctor and patient. Doctors earn trust by protecting patients’ sensitive information, so patients will share intimacies and speak freely about symptoms. How can anyone trust millions of companies holding data bases and selling personal health data? The world’s largest data information, services, and technology company has longitudinal profiles of 500 million people. The corporation’s IPO describes buying and trading health data with 100,000 health data suppliers covering 780,000 daily health data feeds.
Current commercial “innovation” targets eliminating human and civil rights to privacy—by design. Inevitably patient trust in health professionals, hospitals, research, technology, and government is destroyed. So millions of patients act to protect privacy by hiding health information, and delaying or avoiding treatment for serious conditions like cancer, depression, and sexually transmitted diseases. Do we want electronic health records systems that drive patients away from effective treatment?
Instead commercial innovation could use technology to ensure and protect human and civil rights, and put people in charge of their data. Millions of patients will agree to enabling research queries, ensuring research they care about and privacy. This ‘New Deal on Data’ model will be equally profitable for major corporations, while benefitting individuals and supporting Democracy. See: http://civics.com/NewDealOnData/
Current technology products and IT services were designed for totalitarian government and corporate surveillance, exploiting and controlling humans by destroying fundamental human and civil rights to determine who can use personal information. Surveillance enables 1) deeper more intrusive data collection and aggregation, 2) deeper, more extensive individual profiling for hidden discrimination and data sales , 3) costly new services, treatment, and products that grant corporations and governments ‘rights’ more power than the rights of humans.
We can choose technology to strengthen individual autonomy and agency, which is also a revenue-generating engine to support Democratic governments, institutions, and corporations. Shouldn’t we choose technology that ensures and protects human rights and values, and enables massive research with patient consent?
Why do surveillance technologies used by enemies of the state have any place in the modern practice of Medicine and healthcare? Like Democracy, the purpose of Medicine and healthcare systems is to serve individuals and respect human and civil rights.
The current business model of the Internet and the world’s largest tech corporations is the collection, aggregation, and exploitation of personally identifiable information. But the downside for humans ranges from preventing trust in relationships, to secret discrimination, to imprisonment and death. Entrenched, global monopolies don’t want change, but their business models must be replaced. And people everywhere will demand it.
Governments and businesses may actually have to treat people like people, not like data on the IoT. 90% of data is human data. Technology systems that serve human needs for privacy will be just as lucrative as current exploitive data surveillance and collection technologies, but everyone wins.
Are calls for “cures” and “innovation” that use surveillance technology to collect intimate personal health information being disguised as sheep?
Categories: OIG Advisory Opinions
Medical Coding News - Tue, 02/09/2016 - 08:56
ICD-10 went into effect Oct. 1, 2015 and, so far, everything seems to be going pretty well. There are a few areas, however, that continue to give clinical documentation improvement (CDI) specialists and coders headaches. One of these problems is Acute Myocardial Infarction (AMI) documentation. In ICD-10 there is a demand for increased specificity – […]
The post Putting a Halt to ICD-10 AMI Documentation Obstacles appeared first on MedicalCodingNews.Org.
Categories: Healthcare News
The Healthcare Blog - Mon, 02/08/2016 - 14:16
Nick Augustinos was at Healtheon (later WebMD) in the early days, then at Carescience with David Brailer, and later was senior in the health care teams at Cisco and Cardinal. Given Nick isn’t as young as some health tech startup guys and did OK back in the day, you might wonder why he’d leave the cushy corporate world and take on the supervising adult role at a startup.
But he just did, with Aver–an analytics company focusing on incorporating incentives and quality improvement in bundled care. Last month it raised $13.6m in a series B and I had a quick chat with Nick to find out what Aver was up to.
Categories: OIG Advisory Opinions
Medical Coding News - Mon, 02/08/2016 - 09:29
As it was billed and touted, ICD-10-CM/PCS gives medical personnel vastly expanded powers of specificity when diagnosing diseases and other health issues. Yet that greatly enhanced specificity comes with a price tag—a transition period that some observers believed could be messy and disruptive. Login to Read More
Categories: Healthcare News
The Healthcare Blog - Mon, 02/08/2016 - 05:18
Last week I told you of my admiration for Dr. Mona Hanna-Attisha, the Michigan pediatrician and epidemiologist whose strong research and advocacy was able to finally bring a shining light to the problem of lead in the water supply of Flint.
Continuing with a theme, I now bring you the story of Dr. Adriana Melo of Campina Grande, Brazil.
Dr. Melo is an OB-GYN who subspecializes in Maternal-Fetal Medicine (MFM), the branch of obstetrics that deals with high-risk pregnancies.
She lives and works in northeast Brazil, which is less populous and more economically challenged than the southern, more well-known parts of the country (including Rio de Janeiro and Sao Paulo).
Dr. Melo noted an uptick in the number of fetuses with small heads on ultrasound — which is the main tool used by MFM doctors to diagnose babies in utero.
How much of an uptick? A rough look at the statistics shows ONE HUNDRED times the ‘normal’ rate of babies born with microcephaly, the medical name for the condition.
Dr. Melo had a suspicion that the mothers giving birth to these babies all had a common trait: they’d all told her that they’d had the characteristic rash associated with the mosquito-borne Zika virus.
When she tested the mothers for evidence of the Zika virus in their blood, the tests were negative. Not deterred, she convinced public health authorities to test the amniotic fluid of mothers carrying microcephalic fetuses. And indeed a strong correlation was found between exposure to Zika and microcephaly.
It’s this story of a doctor in a somewhat out-of-the-way place using her clinical insight to ‘prove’ a correlation which I find inspiring.
Dr. Melo could have been content to merely diagnose and treat these poor mothers and babies, perhaps simply ‘reporting up’ her findings on the increase in microcephaly. Instead, she decided to push against the inertia of daily medical practice because what she was seeing really bothered her — and as a mother of young children herself, she felt the urge to get to the bottom of the new trend.
If you follow health news, you no doubt have heard a lot about the Zika virus in the last few weeks, including warnings from both the CDC and the World Health Organization. As is often the case with warnings from these organizations, a certain amount of panic ensues — such as women in Latin America feeling that they’re being told not to get pregnant, for example.
I want to make it very clear that though there is a STRONG ASSOCIATION between the rise in cases of Zika in the tropics of the Western Hemisphere and a concurrent rise in babies born with microcephaly, we must remember: Correlation does not equal causation. The public health agencies issuing travel and birth control warnings, while sounding dire, are making best guesses for us all to minimize our chances of harm. But drowned out in the response is the fact that we don’t yet know for certain that Zika is the cause of microcephaly. That work is ongoing.
For example, many experts think something else may be the cause — perhaps the use of dangerous pesticides in Brazil (that are banned elsewhere). That also sounds plausible since pesticides are used to “control the mosquito vector.” It’s entirely possible that microcephaly is occurring because of a chemical effect.
For now, we must wait and hope that science can show us the true cause of the uptick in microcephaly.
I also think it’s important to remind ourselves of two things about Zika virus: We’ve known about it since the 1940s, when it was discovered in Africa — so though if feels new, it’s really not. Secondly, at least for non-pregnant people, it only appears to cause mild flu-like symptoms and be a self-limited illness (not more than a few days at most).
My advice: Better to save your anxiety for the never-ending Presidential race.
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 02/06/2016 - 22:30
“The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.” —William Arthur Ward
Looking confidently past the skeletons of drowned state and federal healthcare experiments, America’s health insurance exchanges set sail in January 2014. Disregarding the rough seas ahead, healthcare reform pundits and legislators applauded the Affordable Care Act’s signature public expansion vehicle as an impenetrable solution for achieving affordable coverage and competition.
Less than two years later, the exchanges are taking on water.
In November, United Healthcare lowered earnings projections, a move driven primarily by its hesitancy to commit to enrolling new exchange members until risks are better understood. While other insurers were quick to reassure investors that the public exchange market remains a viable means for organic growth, a low-pressure system of doubt is already building over the nascent public exchanges.
Initial enrollment projections for 2016 are fewer than 10 million members—about half of the 20 million target estimated by the Congressional Budget Office. In their rush to expand coverage to the uninsured and under insured, many public officials and industry neophytes failed to consult with those who have firsthand experience with the difficulties of underwriting those who are obtaining insurance for the first time.
Enrollment projections for 2016 are fewer than 10 million members—about half the Congressional Budget Office target of 20 million.
The rush to participate in public exchanges has attracted inexperienced players seeking a piece of a $300 billion premium opportunity.
Investors want desperately to believe healthcare is ripe for transformational disruption.
Rush to Judgment
The rush to participate in public exchanges has launched a flotilla of inexperienced players all seeking to get a piece of what many have described as a $300 billion premium opportunity. The reassurance of a functional distribution system of consumer purchasing portals, reinsurance dollars to hedge against adverse selection and penalties for failure to purchase insurance seemed to signal a sure thing. Public exchanges would foster new competition, prune excessive insurer margins and eliminate self-serving industry practices that have left an ever expanding number of Americans uninsured—many of whom were working for small businesses that simply could not afford to cover employees.
It is indeed an irrational time. Consider Oscar Health Insurance, a commercial and public exchange insurer with a market cap exceeding $1.5 billion. While Oscar lost close to $30 million in 2014 and has only 40,000 members, it boasts a valuation multiple above the nation’s largest insurers. It seems that investors want desperately to believe that healthcare is ripe for transformational disruption—think self-service health apps that can capture the hearts and minds of millennials and Gen Xers.
While these are innovative, consumer-friendly solutions, most of their target consumers either don’t buy insurance or don’t consume many of the services that currently drive costs (e.g., specialty drugs or hospital inpatient services for chronic conditions and other illnesses endemic to older populations). The fact is, money and resources are pouring into this newly expanded market of potential insureds, yet many of them are sick or low-income people who are less likely to engage or adopt the technology—unless it comes with a cheap policy.
Ovid once said, “The man who has experienced shipwreck shudders even at a calm sea.” Indeed, national insurers who still bore the scars of past expansion experiments were nervous about the exchanges. They counseled caution and slow going, even as newcomers eagerly entered the marketplace, casting aside these warnings—and 20,000 pages of unread legislation.
Many were buoyed by reassurances from the U.S. Department of Health and Human Services that any losses arising from adverse selection and uneven enrollment would be reimbursed by the 3Rs—risk adjustment, reinsurance and risk corridors.
But they underestimated the complexities and unintended consequences associated with administering and enrolling an entire segment of our society that had not been participating in commercial or public health insurance systems. The actuarial results in 2014 were sobering—more than $250 billion in losses against a paltry $300 million in excess profits. As of November 2015, Health and Human Services can refund only 12% of the 2014 losses to underperforming plans. And an increasing number of new entrant co-op healthcare plans are in bankruptcy or in dire financial straits.
So what went wrong?
Affordability and Access
Both the federal and state-based exchanges were immediately riddled with administrative hassles and consumer access problems. The embarrassing miscues and failures of healthcare.gov were ameliorated only when federal officials turned to industry-based specialists at Optum to assist them in repairing their flawed technology and process. In that same period of time, we have witnessed spectacular failures in more than half of the state-run exchanges.
We have also seen a marked increase in public exchange health premiums—in some cases well above the 10% increase benchmark that HHS established as “egregious.” These price increases discourage reenrollments. In fact, the largest public exchange participant, Anthem, recently reported an 8% decline in 2016 reenrollments. In a market driven by two simple axioms—affordability and access—many have failed.
One wonders if the architects of the S.S. Affordable Care Act have ever left shore. Few seem to understand traditional commercial underwriting or the volatility wrought by such a highly regulated file-and-approve rating process. File-and-approve pricing requires insurers to submit rates for approval well ahead of effective dates of coverage—often with little visibility of the risk attributable to the members currently enrolled.
Under the law, the actual time lag between when a carrier sets an annual premium for a specific product and the period in which claims reveal the true underlying risk is hopelessly out of step. Exchange insurers have essentially less than one month to assess the risk profile for their Jan. 1, 2015, enrollees before submitting 2016 rates for approval. To quote one insurance CEO, “ACA regs put you two years out of sync with the reality of the economics of the business.”
Insurers must now either build in excessive margins to hedge against adverse selection, which leads to less competitive premiums, or take the risk and hope the reinsurance pools and risk corridors will make them whole.
Carolina Journal Online recently reported: “Health insurers across the country are experiencing massive losses despite healthy inflows of federal cash. The scope of the problem varies by state. But the problem is essentially national. It stems from the very architecture of the ACA, which offers too heavy a subsidy for some customers and then attempts to spread that cost over too narrow a set of other ones.”
As if the legislation is not difficult enough to manage, Health and Human Services is violating basic rules of risk selection for the sake of garnering maximum membership. The agency is allowing applicants to apply after open enrollment periods have concluded, which is tantamount to allowing people with houses on fire to purchase property coverage. Insurers have determined that the loss ratio on “special enrollment” membership is a full 15 points worse than the traditional open enrollment risk pools.
Jumping Financial Guardrails
Take, for example, the state of New York. When it established its minimum loss ratio of 75% for small business, it promised to use the excesses of those insurers that achieved lower loss ratios to reimburse insurers who lost money. Aside from the obvious misguided incentives this created for some insurers to under-price, it quickly resulted in few carriers actually experiencing medical loss ratios below 75%. The state quickly determined there would not be enough excess premiums available to compensate those who experienced higher loss ratios—leading to industry exits and higher rate increases.
Future attempts to cover New York’s uninsured occurred through Healthy NY, which offers comprehensive health insurance to small businesses. But even though it was supported by risk corridors and risk reimbursement, Healthy NY failed to offset losses incurred by underperforming insurers. And in some cases, the losses did not come from bad risk selection.
The law also provides a misguided incentive for new entrants to compete without adequately resolving obvious shortcomings, such as inferior network discount contracts with providers, limited medical management and, in some cases, aggressive pricing to win new members. When these firms finally sobered to the fact they would not be made whole for losses, that there were no excess dollars available to pay them, these same insurers either failed or left the market.
The Affordable Care Act uses risk adjustment, risk corridors and reinsurance to help insurers weather the first few years of uncertain demand arising out of newly covered uninsureds. The risk corridor program, which expires in December 2016, is failing. According to one industry observer, “The legislation suggests that HHS will try to make these insurers whole, (yet) a conservative Congress is not likely to appropriate more dollars to prop up underperforming insurers. The result would be catastrophic, as it would prevent the natural selection of a free market from eliminating its poorest performers.”
The observer went on: “Despite administration claims that incoming payments from profitable insurers would cover losses from unprofitable ones, the risk corridor program shortfall exceeded $2.5 billion in 2014. Insurers with lower-than-anticipated claims owed about $360 million, and insurers with higher-than-anticipated claims requested about $2.9 billion from the program.”
Failed pricing is now manifesting itself in 2016 exchange pricing. Consider a sampling of the following states:
- CareFirst of Maryland: 34% increase for its PPO plan, 27% for its HMO
- North Carolina: 26% increase from Blues
- Oregon: 25.6% increase from largest market share insurer
- BCBS of Tennessee: 36.3% increase
- Georgia: 19% average increase
- Iowa: 43% increase
- Kansas: The increase could be as high as 38%.
Adverse Selection Is Real
The Kaiser Foundation estimates that “65% of individuals expected to purchase health insurance through the Exchange, transition from being uninsured…. (More than) one third of individuals expected to enroll in the Exchange have gone more than two years without a checkup (37%), nearly two in five did not have a usual source of care (39%), and more than a quarter had no interaction with the healthcare delivery system during the year at all (29%). The findings on access barriers indicate … these Exchange enrollees may have a large pent-up need for medical care once they gain insurance. It will be important to monitor whether individuals who gain insurance coverage through the Exchanges continue to have difficulty accessing care and whether there are adequate primary care providers to address their healthcare needs.”
Despite federal and state reports that suggest there is an adequate demographic spread of young, middle-aged and older Americans accessing care, adverse selection will continue to reign supreme. It’s logical to assume those who sign up for care are more likely to consume it than those who choose to pay a penalty. With less than one quarter of the target uninsured population likely to sign up, a fiscal storm is brewing.
Beginning of the End?
The concerns over the viability of public exchanges are real and legitimate. Insurance underperformance, the government’s commitment to make losing parties whole, dramatic spikes in healthcare costs (such as those for specialty drugs) and the potential for Congress to repeal the Cadillac tax provision, which was expected to raise up to $120 billion over 10 years, are bringing to bear the full weight of the legislation. And we fear the ship is sinking.
As far as exchanges go, we could be in a temporary period of enrollment attrition and risk pool deterioration. And this expansion experiment may not be salvaged without more congressional funding and enabling intervention. If that is the case, Congressional Budget Office estimates of a $140 billion surplus in 10 years will be obliterated, and yet another entitlement program will further accelerate our deficit and rising public debt.
But the news is not all bad. Survival is possible on the public exchanges, but it will take stamina to weather early storms and execute across a wide range of stakeholders. Anyone taking risk must have the following:
- A trusted brand that resonates with consumers
- Access to capital to withstand the lower margins of heavily regulated public exchanges
- The ability to serve as a nexus to aggregate lives
- The ability to manage risk
- A clinical footprint wide enough to serve a target population
- The ability to change patient behavior.
But perhaps the most important attributes of anyone playing the exchange game are emotional intelligence and the ability to achieve a collaborative culture across stakeholders often working at cross purposes. Healthcare delivery is fundamentally changing, and this type of transformation requires a strong and united crew to succeed.
Michael Turpin is frequent speaker, writer and practicing benefits consultant across a 27 year career that spanned assignments in the US and in Europe. He served as the northeast regional CEO for United Healthcare and Oxford Health from 2005-2008 and is currently Executive Vice President for Benefits for the New York based broker, USI insurance Services. He blogs regularly at Usturpin’s Blog.
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 02/06/2016 - 22:08
Leonard Kish talks to Douglas Fridsma, President and CEO at American Medical Informatics Association, about his work in the Office of the National Coordinator for Health Information Technology, or ONC, and the barriers to implementing MIPS in the most useful and transparent way. In order to communicate the data, of course, we’ll need informatics; but how will that work? And which comes first, policy or technology?
Leonard Kish: When you first began your studies in medical informatics, was there a sense that the field was a science?
Doug Fridsma: After working on the Standards of Interoperability Framework for the National Cancer Institute – which was essentially crowdsourced, I engaged government, research and other pharmaceutical companies and standards organizations to basically come up with what that standard should be – I had an opportunity to go out to the University of Arizona and ASU. Ted Shortliffe, who had been my mentor at Stanford, had just been appointed to be the Dean of the new medical school at the University of Arizona.
Fundamentally what physicians do is information management. The thought we had was, if we really wanted to change the way we use technology in medicine, then one of the biggest ways we can make an impact is to train medical students to engage in and to learn this information, then we can actually start to develop the physicians of the 21st Century.
It was a great opportunity to get in on the ground floor with a blank slate, so there could be there was a new effort to include informatics and information management into the training.
As I started working on developing the curriculum at ASU, we approached informatics from a new angle. If you want to teach someone about pharmacology, and you want them to prescribe medication, you need to teach them pathophysiology, pharmacology, and basically all of the basic sciences. You don’t teach them how to write a prescription – that’s not the first thing you do. You certainly don’t have the pharmaceutical companies come in and teach how to write good prescriptions. ˇhe way information technology was being taught at the time was just that. You would bring in the big vendors, who would spend a week teaching medical students how to use their system and then reaping the rewards.
We had to figure out if there was a way to educate the students with the basic sciences about how to represent and use information, why to collect it in certain ways (and not in others), how you collect it is often times determined by how it will be used afterwards. It was a very interesting set of activities and much of that work is continuing even today.
LK: Teaching the actual care delivery, which health IT is a part, hasn’t until recently been a part of medical curriculum, and still only at a few medical schools so far. Now that we’re focusing economic attention on value and outcomes, you see a little more of it.
DF: I think we have to change the way to document care delivery. We use something called the SOAP Note (Subjective, Objective, Assessment, Plan) as an outline of how medical information is captured by physicians and others. The problem is that none of those talk about outcomes.
We talk about the subjective complaints, objective tests, physical exams and given that information, what is our assessment of what’s going on? And then we describe a plan of what we want to do. But, nowhere the approach to documentation do we capture what the outcome is. The next time you as a patient are seen, you talk to your medical provider about your subjective, objective, assessment and plan. But no one ever just asks the patient, “Did those medications work for you?”
As we think about value-based purchasing and quality measurement, we go through these conniptions to infer what the quality and outcome was, whereas sometimes, maybe we just need to ask the patient or have the doctor record what the outcome was. I think that there needs to be fundamental changes in medical school curriculums just for us to make outcome assessments happen.
LK: We work with a telemedicine company and your description of SOAP falls into our conversations. We talk about going from event-based encounters where a plan has to be made, versus a really longitudinal perspective. Information technology is just beginning to allow us to track a patient day in and day out, and this shift necessitates interoperability.
Interoperability is becoming an unusually hot political topic. Perhaps because of the high tech industry; some of it coming out of 21st Century Cures, the bill making it through the health committee; and some of it is with the Precision Medicine Initiative. There seems to be recognition that for medicine to move forward, it’s based on the availability of information. In your opinion, what’s going on there?
DF: I’ve tried to maintain for the last six years a consistent definition of what interoperability is. The first thing I can describe is what interoperability is not. It is not a state of utopia in which there is this information liquidity. You will hear this all the time: we want ubiquitous information, and free-flow, data liquidity and all those things.
But interoperability is not that state of the world. Interoperability is defined operationally. I use one of the definitions by the IEEE folks. The best version is that interoperability has two parts: the first part of the ability of two or more systems to exchange information and the second one – the one we usually overlook – is the ability of the systems to use the information that has been exchanged. It’s about exchange and use.
The example is that I use a Mac and you use a PC. I use my mail program and set up an e-mail and send it to you. We can exchange information if you open up Outlook and open my message. We’ve exchanged information. But, if I wrote my e-mail in German and you only speak French, then we’ve exchanged information but there’s nothing you can do with that information… unless you translate it.
The question is: have we had true interoperability? We’ve had exchange, but not really interoperability. The reason why I like the definition of exchange and use is that, when someone says, “I’m so upset, my system is not interoperable,” my first question can be, “What do you want it to do?”
Interoperability cannot be achieved in the abstract. It can only be achieved, given a definition, in the concrete. Interoperability is the exchange and use forces us to ask ourselves “what do we want to try to accomplish?”
When I was seeing patients at Mayo Clinic, I often worked in their Urgent Care Center. I saw a lot of folks that had been seen the night before, perhaps in the emergency room, and they just needed follow up.
Frequently, they’d come to me and have this yellow carbon copy that was written with a felt tipped marker, where the notes didn’t come through as well as they could have. I’m trying to look at this yellow sheet of paper to determine what medications they’re on, what tests they got, what were the results of the test, and it’s all scribbled at 3 o’clock in the morning and I can’t really read any of it.
If I had an electronic copy of that in my inbox, even if it was a scanned image of the original one, I’d have interoperability because I’d be able to exchange the information and use it for the purposes of understanding what happened that night before.
On the other hand, if my goal is to have that document and any new medications that they had been prescribed automatically incorporated that into my electronic health record, I wouldn’t have interoperability for that function.
Interoperability for legibility is different from interoperability for long-term care. If we have “exchange” and “use”, then it’s the “use” part that really defines what interoperability is.
LK: Where can we go from here in terms of the baseline of interoperability? I perceive there is a base level of frustration in the industry at large: how one hospital on one system can get basic information to another system. What are the best measures to figure out whether it’s about “uses” or about something else? How can we assess the quality of our interoperability?
DF: Healthcare is what I would term an “ultra large-scale system,” and a report that the Department of Defense did back in 2006 is illuminating. What do you do when you have a billion lines of code that all have to work together and seamlessly exchange information across these systems? The report was focused on communication and navigation and other kinds of systems, but does a good job of articulating the characteristics of a large scale system.
We need to frame the question. If you frame it as “we need to build some giant architecture that makes this all work,” you’re going to end up with AOL and not the World Wide Web. If you frame it around achieving a policy, like lower costs or higher quality outcomes, technology can help you get to that policy.
I think you need to think more strategically, realizing you are building an ecosystem, not a product. The large scale approach frames the problem better, accepting that we’re never going to centralize medical informatics; it’s always going to be decentralized.
The World Wide Web, which is probably the best example of a successful ultra large scale system, breaks down the technology into a fundamental stack of building blocks. One of our biggest challenges is that we haven’t thought strategically about how we create a set of fundamental building blocks so that the next use case can actually leverage what has been done instead of starting over with new approaches.
It’s sort of like those early telephone systems where they had all the cords and you had to pull the cord to connect it to the right connection. It becomes tremendously complicated because everything is a one-to-one connection; scaling becomes unmanageable.
Whereas, if as with the World Wide Web, you create individual packets to be routed and transferred, you can have set of standards rather than these one-off solutions.
LK: It seems like the lack of interoperability is in some ways used as a strategic advantage. So how do we get from this insular or institution-based perspective of interoperability to a global perspective? Does it have to be a legislative solution? And how do we communicate and bridge to the consumer (which may actually be key to decentralized thinking)?
DF: There are three fundamental things we need to turn the ship in a better direction. The first step is I think we need to focus on those fundamental building blocks; for how we represent meaning, how we structure information, how we transport it, and how we secure it. Those four things are really just an API.
But unless we think about what those fundamental building blocks are, even if we develop APIs, we’re still going to be in the situation with the switchboard and the cords. The building blocks are the first goal, and one of the pieces that’s missing is “how do we represent granular data” because most of our exchange right now is document centric.
We need to move from document-centric to data-centric exchange. We need to have a way to represent data at a granular level because that’s how we’re going to be able to calculate quality measures, that’s how we’re going to do decision support, and a lot of the other sophisticated computable things that we need to do.
The second thing we need to realize is that it’s very likely that we’re going to develop ecosystems with a high degree of interoperability within the ecosystems and a low degree between the ecosystems. It’s like smart phones or computers: some people have iPhones, others have Androids; some people use PC’s, some Macs, and some people use Linux.
APIs can be really helpful within an ecosystem but can be challenging between ecosystems. We don’t require that Android works on iPhones or vice versa, but it’s really useful to have ways of exchanging information between those things so that if I’ve got a PC and I’ve got my iPhone, I can still move music back and forth because there’s this thing called an mp3 or an mp4.
I think in healthcare we need that granular data that will help us develop good APIs and clinical decision support, but I need to be able to move from the Android system to the Microsoft system if I need to. To me, that is having the ability for a patient to have a full extract in a computable, maybe not interoperable, but computable format that they could take from their Cerner System and move to their Epic system or take from Epic and move to NexGen system.
HIPAA allows that to happen but there’s been a lot of pushback and defenders would rather say “well we’re not going to give patients the entire extract, we’re going to give them access to selected information in an API that we develop.” The issue with that it’s then the vendors who get to decide what information they share and what information they won’t. That creates an establishment of those ecosystems and sort of locks them in.
If you can create a way of having granular data for these things like clinical decision support and quality measurement and the like, and the ability for patients to have a full extract of their information and actually move information between ecosystems, not entirely interoperable but at least computable, it makes it possible that things like precision medicine can be supported.
Precision medicine is about discovery of new associations and new ways that you can relate genetic information to behavioral and environmental and medical information. API’s presuppose that you know precisely what information you need to share. Precision medicine says, “We don’t even know what we’re looking for.” So we need to have a way to have all the data accessible, to move between ecosystems and to be available for discover for science.
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 02/06/2016 - 15:15
- The Search For the Elixir of Life by Tom Emerick
- Physician Burnout is an Epidemic by Anees Chagpar
- Biden’s Moon Shot and the 21st Century Cures Bill by Steven Findlay
- The Secrets of Cancer Survivors by James Salwitz, MD
- Iowa is Voting on Health Care Tonight by Marglait Gur Arie
- What Trump’s Plan to Negotiate With Pharma Should Tell Us by JK Wall
- There Is Nothing Free About the Health Care Free Market by Nortin M Hadler, MD
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 02/06/2016 - 09:17
I am on the 2016 TEDMED speaker review committee/research scholar i.e. I am among the group of people who will be reviewing potential speakers for this year’s event.
If you know someone (does not have to be an MD or PhD) who is doing great work in medicine, public health and policy or education (any aspect of healthcare including basic science research) and would be interested in giving such a talk, please nominate them here. It is a short form which needs their bio and pitch for a talk, also a speaking sample in public domain (i.e. YouTube or Vimeo) if available but not a necessity.
A little background about their nomination process: “There is no deadline to nominate a speaker, and we accept nominations year-round. Typically, we consider about 10,000 nominations for about ~50 spots on our stage, and are nearly done with the speaker selection process for this year. However, if we receive your nomination after we have completed the selection process, we will keep it in our database for future years.”
This year, the conference is from Nov 30 – Dec 2, 2016 in Palm Springs, California.
Feel free to forward this to your friends/colleagues and if you have more questions, email me directly at firstname.lastname@example.org
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 02/06/2016 - 02:19
Lawmakers in Washington are gearing up to pass major, far-reaching legislation on drug approval and cancer research. This is a good thing in the main but—no surprise here—Republicans and Democrats differ on approach and details, and things are already getting messy.
This makes the proposed legislation very risky. It could all implode in an election year, but momentum is building fast and both parties have something to gain by passage.
This blog is a primer on what’s happening. Future posts will track the legislation’s progress and delve into some of the issues at stake. Comments are invited.
As you’ve no doubt heard, the White House—with Joe Biden in the lead—has proposed a “moon shot” on cancer research. The administration is expected to propose, in its FY 2017 budget request, $755 million in funding for the initiative, with $195 million of that earmarked for the National Institutes of Health (NIH) and around $75 for the FDA.
Importantly—and you’ll see why below—under the budget deal agreed to in December for FY2016, NIH’s budget was already boosted by $2 billion, with $264 million going to the National Cancer Institute. That was an unprecedented 6% boost after many years of minor or no increases. (A promise of an additional $9 billion for NIH over the next 5 years was also made.)
Among the major goals of the moon shot initiative, according to the White House: launch and complete clinical trials for up to 20 kinds of cancer in as many as 20,000 patients by 2020, with a focus on advancing breakthroughs in immunotherapy—by all accounts the most promising area of cancer research at the moment.
Researchers are already lining up to capitalize. On January 12, a group of leading researchers and drug companies, including Amgen and Celgene, launched “The National Immunotherapy Coalition: Cancer MoonShot 2020.” The stated aim: accelerate the potential of combination immunotherapy as the next generation standard of care in cancer patients.
Meanwhile, lawmakers in Congress are processing a bill dubbed “The 21st Century Cures Act.” (I’ll abbreviate as “Cures.”) It was written by Republicans and emerged from the House Energy and Commerce Committee led by Rep. Fred Upton (R-Mich.). The bill, in a nutshell, gives FDA a batch of new tools to expedite the approval process for new drugs and medical devices. One of those tools would allow the FDA to approve new drugs based on a wider range of research results than is the case now.
The House passed the Cures bill in July, with bipartisan support. Notably, however, support from Democrats came almost entirely from a provision in the bill that increased NIH funding by $2 billion. Most Dems were worried about the FDA provisions but strategized that the Senate would very likely modify those anyway—hence the bill got their vote.
As referenced above, that $2 billion increase for NIH was “borrowed” from the bill in the 2016 federal budget agreement, which became law in December. That served to undermine support for the Cures bill in the Senate, and some thought it might be dead—if not forever at least until after the election.
Then along came moon shot. It appears to have reenergized chances for the Cures bill. Upton and other Republicans are doing everything in their power to leverage moon shot to gain Senate passage. The White House—or more precisely Biden—has signaled a willingness to go along with that. But Republicans in the Senate now say they plan to chop the bill up rather than pass a single piece of comprehensive legislation.
The Republicans move reportedly blindsided Democrats and threw the process into chaos, with Democrats suspicious of Republicans’ motives (again, nothing new about that). Democrats have also stated clearly—led by Patty Murray of Washington state, the ranking Democrat on the Senate Health, Education, Labor, and Pensions (HELP) committee—that they will not support the Cures bill without the additional funding for NIH and FDA that the White House is now calling for, and over multiple years.
Meanwhile, Sen. Lamar Alexander (R-Tenn.), chairman of the HELP committee, has said that breaking the legislation into parts allows the committee to agree on the least controversial parts first and then figure out the rest.
On yet another and separate track is the President’s Precision Medicine Initiative, launched in 2015. It’s been funded to the tune of $200 million so far, with more likely to be proposed in the 2017 White House budget request. In the White House’s words the initiative is “a bold new research effort to revolutionize how we improve health and treat disease….that takes into account individual differences in people’s genes, environments, and lifestyles.”
All these initiatives are related, of course. And it is a positive development that policymakers are focused on increasing the funding of and improving medical research and new ways to treat disease. But buried in the Cures Act, the cancer moon shot, and the precision medicine initiative are some poorly conceived ideas and unrealistic assumptions.
For example, the House version of Cures has been roundly criticized for creating a possible end run around the gold standard for drug approvals: controlled clinical trials. And the cancer moon shot has spurred jeers in some high-level corners of medical research for being overly optimistic about the pace of scientific progress against what is a highly complex constellation of 100 or so different diseases.
Those issues and more will be the subject of future blogs.
Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology.
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 02/06/2016 - 01:02
Disclaimer: I have never had cancer. Therefore, at the most basic level, I do not have the right to pontificate about dealing with the dread disease.
Rather, I have been the servant and support of those that struggle with cancer. I thought it might be of some assistance to share my observations from the other side of the bed rail. Perhaps, their secrets of survival may help you.
1. Cancer is a team sport; do not do this alone. Never show up to an important appointment by yourself. You are dealing with a physical impairment, as well as a complex mental challenge, at the same time that you are frightened and do not feel well. Have someone with you to listen, ask, take notes and simply carry your things. This is true not only during treatment, but at home. Accept support. Build a team. Work together to fight this awful thing.
2. In the same way, whether you like it or not, a family goes through this together. Those that love you, also “get cancer.” Working together helps everyone deal with the affects of the disease. You are not a burden. You reap what you sow.
3. Nonetheless, it is also important to get time for yourself. You need grounding time; quiet moments to heal. Take a deep breath; rebuild. If your family does not understand the importance of “me time,” show them this note.
4. Be on time for your appointments, tests and treatments. This is my own hang-up, but being on time is part of being organized and I have noted that the patients that are punctual are organized and those that are organized do better.
5. Be whiney. Really, complain a lot. Tell your doctors what is happening. Take notes. Email. Call. Will the doctor give you his cell number? Do not ignore a fever for five days, crawl into the doctor’s office, and say, “By the way, I feel terrible.” That will result in the doctor saying, “By the way, time to go to the hospital.” This is why women make better patients then men; malignant macho.
6. Get in shape. Before cancer. During cancer. After cancer. The more physically active, the better your body can fight illness and the less side effects you will have. Exercise not only prevents recurrence, but allows more rapid recovery. Walk. Row. Swim. Bike. Sex. Do not be a dead blob.
7. Taking the exercise theme a step further, I have seen that those that do “alternative exercise” seem to do better. Yoga, Tai Chi, Pilates, Jazzercise, kickboxing, Recki, and a host of others seem to have remarkable benefits. Acupuncture, acupressure, Shiatsu, Jin Shin Do and chiropractic techniques rejuvenate many of these same patients. Stretch your comfort zone.
8. Be on time for your appointments, tests and treatments. This is my own hang-up, but being on time is part of being organized and I have noted that the patients that are punctual are organized and those that are organized do better.Be whinny. Really, complain a lot. Tell your doctors what is happening. Take notes. Email. Call. Will the doctor give you his cell number? Do not ignore a fever for five days, crawl into the doctor’s office, and say, “By the way, I feel terrible.” That will result in the doctor saying, “By the way, time to go to the hospital.” This is why women make better patients then men; malignant macho.
9. No, I do not believe in vitamins. I have never seen them help. The data is poor and I can think of no reason that a pile of chemicals thrown into a tablet in some mad scientist’s lab, can improve on the body’s natural nutritional intelligence. The body knows what it wants and expects to receive vitamins in the balanced form of food. If it tastes bad, the body does not want it. If it tastes good, your body is broadcasting a need. Eat lots of fruits, vegetables. Limited red meat. Hydrate, hydrate, hydrate, hydrate, hydrate. Did I mention the importance of hydration?
10. Do not smoke. Stop immediately. To be clear, if you have cancer and continue to smoke you are wasting your time and money visiting a doctor. You are screwed. Stop. Patients who continue to smoke, die.
11. Limited alcohol. Note, I did not say none…1-2 drinks a week, seems to be OK. However, the 96 year-old who consumes two scotches a day is exceedingly rare.
12. Understand your disease and therapy. It is your body, your life; you have to be in control. I love doctors, some of my best friends are doctors, but they are only teachers and guides. If you are going to get the best care, it will be the care that you think and understand to be best. Ask questions… lots of questions … create lists. Your doctor does not mind, because it focuses the conversation.
12. In the Internet era, it is easy to build a baseline of knowledge. However, take anything you read online with a grain of salt. It is general knowledge, not personal prescription. The Internet can be a scary place, so use it only as a place to start. Ask your doctor.
13.Find ways to deal with the stress. Family is the start, but support groups, counseling, hobbies, short trips, reading, writing, Facebook, can help the cure. Emotional suffering can drain you and make it hard to go on. Talk to your friends, family and doctor about alternatives. The most “successful” patients achieve emotional balance.
14.Joke. Tease. Humor is a powerful weapon against despair and depression. Watch comedies. Read funny books. Joke with your caregivers. This is no more arbitrary than oxygen.
15.Sob. Scream. Fight. Break things. Yell. Bitch. Get really pissed off. Shout now, apologize later. Purge the pain that is trying to eat you up. Let it out. “F**k this s**t.”
16. Did I mention laughter?
17. Recognize that your life has changed.Permanently. Cancer is like other major transitions in life … graduation, marriage, kids. It is just one you did not want … like divorce, flood, losing your job. Work to understand the new you.
18. Recognize that life is the same. You are still you. The things you love (or hate), your view of life, the things most important, are the same. When the chaos settles, in the moments of quiet, you are still there.
19. I do not understand this one, but pets definitely have healing powers. I am not certain what it is about a sad-eyed dog or a purring ball of fur that gives solace. My mother had two cancers. Her cat, Linda, used to bring in dead birds when she was weak in bed. Somehow, that motivated her to get up and going again.
20. Make sure your doctors are communicating with each other. In the best of all possible worlds, they would do this without your prodding. However, you must play secretary; bring back and forth notes and records. Confirm they are talking to each other. Like I said, this is a team sport and it is vital that your professional caregivers function as a team. The most “successful” patients track records and the interactions of everyone involved in their care.
21. Get a second opinion. Or third. Fourth? The worst thing that can happen is that everyone will learn something. Your doctors do not mind. If they do, they probably should not be your doctors.
22. Care about your appearance. Stay groomed and clean. Dress nicely. As they say, the cloths make the man … or woman … and a well-clothed patient is a healthy patient.
23. Try to leave the cancer and the treatment in the doctor’s office. This is very hard to do, but as much as you can compartmentalize the disease, leave the burden somewhere else, the better balanced your life.
24. Attack… attack … attack. Successful patients and doctors know that persistence works. Uncover every stone. Destroy every disease. Be realistic, do not ruin your life with worthless toxic therapy, but consider every chance to kill cancer.On the other, other hand, stay involved with day-to-day life. We are social beings. Go to weddings, picnics and holiday events. Children’s soccer games mend better than antibiotics. Yes, it can be discouraging that you are too weak to dance, and frustrating to use a wheelchair in an airport (although the airlines are great about it, just call ahead). It is hard when you are at the Thanksgiving table and cannot eat. It is much worse, even dangerous, not to show up at all.
25. Do not crawl into a corner and become a cancer patient. In your body, somewhere, is the growth called cancer, but that disease is not you. You are not cancer. You are a wonderful, powerful, intelligent, important, loving and magical being. Do not sit and wait for the disease to go away.
26. Live. Love. Life.
James Salwitz is an oncologist based in New Jersey.
Categories: OIG Advisory Opinions
The Healthcare Blog - Fri, 02/05/2016 - 20:47
Those of you dismayed at the dearth of recent interviews of notable health tech startups on THCB will be glad to hear I have several in the can and will be putting them up starting with Amino today. And the rest of you can move along….
David Vivero made his money at a company matching renters to apartments that ended up part of Zillow. That was too easy, so now he’s decided to match people up with the right doctor. Amino came out of stealth late last year with about $20m in funding and it has acquired large data sets (including being one of the few with official access to all CMS physician data) and some complex ways to match patients to doctors–the primary one being doctors near you that have seen a lot of patients like you. Why are they in a market that already has several well known & well funded players like Vitals, Healthgrades, Better Doctor and more? David told me that and more in this interview.
Categories: OIG Advisory Opinions
Medical Coding News - Fri, 02/05/2016 - 09:04
Unreliable provider communication leaves patients vulnerable to expensive and potentially harmful medical errors, delays the medical billing process, and distorts quality of care. Login to Read More
The post How Provider Interaction Reduces Claims Reimbursement Waste appeared first on MedicalCodingNews.Org.
Categories: Healthcare News
The Healthcare Blog - Fri, 02/05/2016 - 03:58
There is a disease sweeping the nation that has significant consequences for every person living in this country, even if they never contract it directly. And despite its lethality, there is precious little being done about it. It’s called physician burnout, and it affects all of us.
Doctors, on average, spend at least eight years in college, followed by years of postgraduate training during which time they work 80 hours a week. They graduate with a mountain of debt, face the constant fear of malpractice litigation, and are burdened by incessant demands to see more patients in less time with more administrative paperwork. On top of which, there’s compassion fatigue – helping the sick, the injured and the dying is rewarding no doubt, but often emotionally draining. All of this leads to physician burnout.
More than any other profession, doctors face burnout, and the rates have been increasing. A recent study by researchers at the Mayo Clinic found that the number of physicians suffering from burnout is 54%, up from 45% in 2011. And physicians are more than twice as likely to commit suicide than non-physicians; every year, 400 doctors in this country take their own lives.
Why should you care? Because the emotional health of doctors has a direct effect on the broader public. There are a plethora of stories of physicians who describe the chilling consequences of their depression. One surgeon wrote in a recent blog, “my depression…was exacerbated by work. I clearly wasn’t performing to the best of my abilities, and my patient complications and complaints were increasing. A patient died from a post-operative bleed. Would I have managed it better if I wasn’t suffering myself? (When I spoke to the patient’s wife, as he lay dying 20 feet away, she asked me if I was OK.)” Burnout causes a lack of clarity in thinking leading to medical mistakes. “Given the extensive evidence that burnout among physicians has effects on quality of care, patient satisfaction, turnover, and patient safety, these findings have important implications for society at large,” researchers from Mayo Clinic told Forbes.
But it’s not just that doctors who are burned out are more likely to make errors – they’re also more prone to biases noted a recent report. And, it’s clear that bias clouds judgment and causes physicians to treat certain patients differently than others. “Physicians who are burned out, stressed and generally frustrated over near-term crises or long-term concerns are more likely to react negatively to patients,” said a recent study.
Beyond medical errors and poor patient interactions, physician wellbeing also affects access to care. A recent Physicians’ Foundation survey found that 44% of physicians were planning on reducing patient access by either cutting back on patient load, working part time, closing their practice to new patients or retiring. Physicians are getting tired of the “turnstyle” medicine they are being forced to practice – seeing more patients in less time – rather than building the relationships that inspired them to enter the profession. Increasingly, however, the physician-patient relationship is being supplanted by the economic demands of a medical machine. While some have tried to fight back with efforts to unionize, others simply retire or find alternate careers. Such erosion of the profession, especially when coupled with an expected doctor shortage over the coming decades due to fewer trainees, has the potential to seriously impede access to care.
As physicians, we have the humbling privilege of caring for the sick, the weak and the injured. We spend years perfecting our skills in diagnosis and treatment so much so that the idea that we may be suffering ourselves is difficult to accept. We can no longer afford to ignore the fact that burnout affects not only ourselves and our families, but our patients as well.
This is not an issue physicians can address alone. Indeed, a concerted effort is required across all stakeholders. Hospitals must work to foster environments where the economic demands of a viable enterprise are balanced against the need for a happy and healthy physician workforce. Policy makers must consider the ramifications of increasing administrative burdens and reducing reimbursements which only serve to fuel physician fatigue. As a society, we need to ensure we look after the professionals we entrust with our health. When over half of all physicians are burned out and the trend is continuing to rise, there is a silent healthcare epidemic in this country that needs to be addressed. How long can we continue to ignore what is becoming a “critical condition”?
Anees Chagpar is a Yale associate professor of surgery and Director of The Breast Center — Smilow Cancer Hospital at Yale-New Haven.
Categories: OIG Advisory Opinions
The Healthcare Blog - Thu, 02/04/2016 - 12:15
Here’s the executive summary: Most disease and health spending is age-related. As we age we get infirmities ranging from dementia to cancer to vascular disease. Nothing can prevent aging. Period. For millennia mankind has been been on a futile search to prevent aging.
Search for the Elusive Elixir of Life
For 3500 or more years mankind has been searching for the mythological Elixir of Life, the fountain of youth, the philosophers stone, pool of nectar, etc, that will defeat aging and extend life, if not achieve immortality.
According to Wiki, “The elixir of life, also known as the elixir of immortality and sometimes equated with the philosopher’s stone, is a mythical potion that, when drunk from a certain cup at a certain time, supposedly grants the drinker eternal life and/or eternal youth.”
All around the globe from 400 BCE alchemists, from India to China to Europe, were seeking the elixir of life. Many thought gold was an essential ingredient of such an elixir.
The Fountain of Youth, also known as the water of life, was part of the search for the elixir of life. That search was in full throttle during the crusades, and was carried to the New World by Spanish explorers, the most famous of whom was Ponce De Leon in the 1500’s. Even the Mayans had legends about waters of eternal youth.
The search for the elixir of life didn’t end there.
In the 19th century in the US many believed that bathing in special springs had healing powers. During that era people flocked to Eureka Springs, Hot Springs, Healing Springs, and many many more. So called healing spas are still very popular today.
“Snake oil” salesmen were peddling various cure-alls and panaceas into the 20th century. A search on the internet will reveal a large number of “promising” balms and salves, some of which actually worked for minor scrapes and burns.
If you’re over 60 or so you may recall Carters Little Liver Pills. It was advertised to treat biliousness and other ailments. The FTC made them drop the word liver from the name. Carters Little Pills are still sold but as a laxative.
If you watched the Lawrence Welk show, you saw ads for Serutan, which is “natures” spelled backwards. It’s a “vegetable hydrogel”.
Today the search for an elixir of life, by various names, is still in high gear and salesmen for that notion are abundant today.
People today are still pursuing the same version of living longer and healthier lives by pursuing a mix of vitamins, supplements, wellness, incentives, education, exams, tests, etc., that will push the time of their death out a few years.
But, alas, the human body and its organs simply wear out over time. No insurance plan, wellness plan, patient education program, or prevention combination, can defeat the inevitable. As we age our bodies just wear out. For example, the reason brain aneurysms and strokes occur in the elderly is that blood vessels get thinner and more fragile with age. The same applies to other vascular diseases. Joint diseases are common as we age. Why? Joints just wear out over time. Dementia is usually related to aging. The list goes on and on.
Companies are paying huge dollars to elixir of life promoters today when all the facts show it just doesn’t work as advertised. Such companies’ intentions are good, even noble, but doomed to fail. Lesson: whatever you want and seek, someone will find away to sell it to you.
We are all going to have a mortal illness someday unless we die sooner from something else like an auto accident. My grandfather died at age 99. Every organ in his body was failing. His kidneys were failing, as was his vascular system, his brain, and his liver, etc. Why? He simply outlived his body. I’ve known a number of good people who in the end died a miserable terrible death after years in nursing homes. I wouldn’t wish that on my worst enemy.
Another factor driving up costs in the US has been the creation of the emergency phone number system of dialing 911 and having a life-saving trained team show up at your door in few minutes. The dial 911 system saves live no doubt, but there have been unintended health cost consequences too. If one survives a heart attack the average cost is about $250k. Because of the 911 phone system some 80 year olds are surviving three heart attacks in 9 months just to die from the fourth one, adding $750k to their last 12 months. Now they are even putting ventricular assist devices to keep people like that alive for one more day at a cost of $900k.
I’m not making a comment on the morality of deferring and elderly person’s death for 9 months at a cost of $750k to $2M. But we need to have an adult conversation in American about how we are going to pay for all this. By any measurement Medicare and Social Security are both totally unsustainable unless huge changes are made that will impact everyone. Beware of proposed changes that promote intergenerational rivalries.
This chart shows death rates by age (source WIKI). When people hit about age 50 the death and sickness rates begin to skyrocket.
This chart shows leading causes of death (source WIKI). See the strong correlation to aging and heart disease. People are simply outliving their hearts and blood vessels. In 1900 people rarely died of heart disease because they didn’t live long enough to develop chronic conditions. Most of the chronic diseases we worry about are simply a consequence of aging. They are irreversible. Like the Hydra of Greek mythology, if you defeat one chronic condition, three others will pop up in its place.
The third chart shows health spending by age (source Incidental Economist), again correlating disease to aging. That will always be that way until someone comes up with a way to prevent aging or finds an “elixir of life”. That chart also illustrates the massive wasteful spending on end-of-life care in the US compared to peer countries.
People in born in the US today can expect to die along a bell curve centering on age 80. If we all do everything we can possibly do to be healthier for all of our lives there will be slightly fewer deaths around ages 78 or 79. (A great source of information on This topic is Nortin Hadler’s The Last Well Person: How to Stay Well Despite the Health-Care System available on Amazon.)
In any case if you are able to add a year to your life it will be added to the end of your life. For most people that will mean another year in a nursing home, in assisted living, or as an invalid at home. (For a Washington Post article on just how nasty nursing homes can be click here. Again, I would not wish that on my worst enemy.) People sometimes tell me about someone who was more or less healthy and independent at age 90. For every person like that there are a hundred in nursing homes or dementia units.
Most people retiring today don’t have enough in savings to support themselves for more than a few years, let alone enough to pay for assisted living and/or nursing homes when they are elderly and frail. Medicaid nursing home budgets are likewise unsustainable. Don’t count on that. For many people living a year or two longer will simply mean being a burden to your children for another year or two, both financially and emotionally.
What about your children’s lives? Do you really want them to have to look after you well into their 60’s. At that age they should be concentrating on their own welfare.
As people age into their 80’s and 90’s, many become demanding in an irrational way. Some people age 55 and up are relieved when their elderly parents pass away, but often with feelings of guilt. Most people have witnessed this in their own families.
Someday researchers may discover a way to delay the effects of aging. Personally I believe such is the province of science fiction. If that ever happens, God help us. That would be very destructive to mankind.
Imagine our world populated by a billion or more centenarians. Imagine a nation with an average age of 65. Imagine yourself at age 90 with a 120 year old parent or two. Who will look after whom? Will 70 year old children or their 45 year old children be able to look after and support such parents, grandparents, and great grandparents? The news from Asia is that many young people are no longer willing to support their centenarian parents or grandparents today, let alone great-grandparents.
What should we all do then? Simple. Spend less time wringing your hands over which illness will get you in the end, rather make the most of the time you have. Worry will never add a day to your life.
The Romans had a blessing: May you live well and die suddenly.
Tom Emerick is the President of Emerick Consulting, LLC, and Partner and Chief Strategy Officer with Laurus Strategies, a Chicago-based consulting firm, and co-founder of Edison Health.
Categories: OIG Advisory Opinions
Medical Coding News - Thu, 02/04/2016 - 09:03
“Upcoding” means reporting a higher-level service or procedure or a more complex diagnosis, than is supported by medical necessity, medical facts, or the provider’s documentation. For example, reporting a diagnosis of chronic bronchitis if the patient has acute bronchitis qualifies as upcoding, as would billing a level 5 evaluation and management (E&M) service (e.g., 99215) […]
Categories: Healthcare News
The Healthcare Blog - Thu, 02/04/2016 - 01:00
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Categories: OIG Advisory Opinions