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Would Repealing the ACA Violate International Law?

The Healthcare Blog - Fri, 04/28/2017 - 11:11

Barely one month after a stinging and stunning legislative defeat, President Donald Trump has committed to revising the AHCA and potentially resubmitting it for Congressional approval.

In addition to Democrats and widespread popular opinion against ACA repeal, the AHCA may face another obstacle – international law.

This week the Washington Post’s Dana Milbank reported that the United Nations Office of the High Commission on Human Rights forwarded a four-page letter to the Acting Secretary of State, Thomas A. Shannon, to express the Commission’s “serious concern” that the US was in danger of violating its obligations under international law if the U.S. ratified legislation repealing the ACA.

The letter authored by Dainius Puras, a Lithuanian with the somewhat remarkable title of UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, argues that repealing core elements of the ACA would negatively impact almost 30 million Americans’ right to the “highest attainable standards of physical and mental health”, particularly those in moderate and low income brackets and those suffering from poverty or social exclusion.

While we in the United States debate whether health care is a right or a privilege, Puras cites U.S. international treaty obligations as authorities for why health care is a right. In particular, he argues that Article 25 of the Universal Declaration of Human Rights (UDHR), a Declaration which the US voted for and had a key role in developing, clearly “establishes everyone’s right to a standard of living adequate for the health and well-being, including food, medical care and necessary social services”

He further cites other similar provisions in international treaties, conventions and UN Committee comments including Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) (signed but not ratified by the U.S.), article 5(e) the International Convention on the Elimination of All Forms of Racial Discrimination and General Comment No. 14 of the Committee on Economic, Social and Cultural Rights as proof of states’ obligation for a “progressive realization of the right to health” for all.

The letter concludes by asking the Trump administration to respond to four questions:

Not surprisingly, the Trump  administration has failed to respond.  According to Milbank, the letter was leaked to Congressional Democrats by a DHHS employee.

Does this mean that President Trump, or members of his administration, will be dragged before international courts?  No.  The UDHR is declaration by the UN General Assembly and doesn’t legally bind member-states, the U.S. never ratified and acceded to the ICESCR and while the U.S. has ratified the ICEAFRD, it does not recognize article 22 which provides that disputes be referred to the International Court of Justice.  President Trump can therefore probably rest easy in knowing that the long arm of the law is actually relatively short – at least in an international context.

But while public international law suffers from problems of applicability and enforceability, it still holds considerable political and moral authority in the international realm and helps provide a common aspirational foundation for UN member-states.  In the past, the U.S. has been a champion of key international legal instruments advanced by the UN and, in fact, the U.S. Department of State , still states that two of its key human rights goals are to:

•    Hold governments accountable to their obligations under universal human rights norms and international human rights instruments; and
•    Assist efforts to reform and strengthen the institutional capacity of the Office of the UN High Commissioner for Human Rights and the UN Commission on Human Rights.

Although the President may not be a fan of the UN, even he recently expressed that it has “huge potential. ”  Part of that potential is realized when the UN can compel states in meeting treaty obligations for the purposes of working towards a common goal of peace, security and prosperity.

For this reason, the U.S. should bolster the UN by addressing its concerns about possible contravention of international law.  This relatively simple approach may ensure that the U.S. can leverage the UN in securing its long-term interests in other areas.

This is not the first time the US has been in conflict with UN efforts to safeguard human health.  Readers of THCB will recall from my the February 7 post, “Hell Is A Very Small Place: Voices From Solitary Confinement,” the UN Special Rapporteur on Torture, Juan E. Mendez, noted in 2011 that solitary confinement, that in the US isolates prisoners for decades, be limited to no more than 15 days and be absolutely prohibited for those with mental disabilities and juveniles.

Categories: OIG Advisory Opinions

Can Interactive Group Therapy Boost Productivity in Medicine?

The Healthcare Blog - Thu, 04/27/2017 - 15:02

Imagine attending private lectures and taking all your college exams in your professors’ offices individually, one-on-one. Your instructors lecture you, then pepper you with questions, grading your answers and recording your scores. This is not unlike traditional physician visits. Contrast this to attending classroom lectures and taking online multiple choice exams where a computer algorithm or Scantron tallies your answers and calculates your grade. Classroom instruction with standardized testing is much more efficient that private tutoring. Hundreds of students can learn and take their online exams simultaneously. What if medical productivity could be similarly improved?

Inefficient Physician Communication. When you visit your doctor you are engaging in what’s known as synchronous communication. You queue up in a waiting room and later both you and your doctor meet one-on-one in an exam room (at the same time). You may spend five minutes talking to a nurse and then 10 minutes talking to a doctor. A survey found with waiting and travel time, the whole process takes patients about three hours, on average. Furthermore, many doctors see only about 20 to 25 patients a day. The amount of information conveyed during an office visit is limited — as is the amount of information patients retain. Doctors also must take notes and update medical records during the exam. Fiddling with electronic health records further reduces the amount of useful information exchanged during a 10-minute encounter while your doctor hunts for pull-down menus. The way medicine is practiced is inherently labor intensive, not to mention inconvenient for patients.

Synchronous telemedicine is where you call your doctor or he/she calls back and you talk one-on-one. That may be a little more convenient for patients, but it’s still labor intensive. Asynchronous telemedicine is like email (or snail mail for that matter). You email your doctor or call your doctor and leave a message. Your doctor replies via email or by leaving voicemail. Asynchronous communication doesn’t require both parties to be present at the same time to communicate, but the information flow back and forth can be slow and inhibited compared to talking.

Medical Automation. Mercatus scholar, Robert Graboyes, writes about Lemonaid Health, a type of asynchronous telemedicine on steroids. (Lemonaid Health charges a flat $15 for a prescription for handful of common ailments.) He explains some medical services require one-on-one time (think an initial visit for a diagnosis), while others can be quickly performed through a series of interactive processes. The latter are scalable; aided by a computer algorithm, one doctor could oversee the care of many times more patients than possible if limited to one-on-one office visits.

Now for a thought experiment: imagine logging-in on your doctor’s office website, then being examined by answering questions from an interactive menu. The website algorithm then generates a treatment plan based on your responses for a chronic disease like, say, diabetes. Your doctor could review the results and approve your treatment plan, order prescriptions and maybe insert some specific advice much more quickly than using the traditional synchronous communication (office visit) model. At least in theory, a doctor performing the cursory evaluation of the automated treatment plan could be located anywhere in the world.

Computer-aided diagnostic tools for physicians already exists. Most mammograms are initially read by computer algorithms, highlighting areas where there may be problems or uncertain indications for a radiologist to interpret. An alternative method requires two different radiologists to validate individual interpretations. One radiologist using one computer is more efficient than two redundant radiologists using no computer.

Strength in Numbers. Now let me expand on Bob Graboyes’ discussion. Numerous diseases have support groups, where people suffering with the same disease or condition shares stories and exchange information on symptoms, treatments, doctors and so on. Nowadays most support groups are online. Members may never actually meet in person, yet benefit tremendously from interacting with others. Not only can people exchange ideas, the discussion thread is archived online for others to read and learn from long after the initial exchange occurred.

Group therapy is therapy sessions provided to educate a group of patients rather than each individually. It is most common in environments where sharing the experience of others with similar conditions is beneficial or peer pressure is needed to improve outcomes. Overweight people have group therapy: it’s called Weight Watchers. Addicts have group therapy: it’s called Alcoholics Anonymous or Narcotics Anonymous. People with mental health conditions used to have group therapy (simply called, group therapy). Think back to the old Bob Newhart Show in the 1970s. Half a dozen comically-neurotic characters, with a garden variety of mental health issues like depression, anxiety or phobias, would all arrive for a group session at a scheduled time. They would sit around for an hour and each take turns sharing their neuroses while validating each other’s feelings.

I actually attended a group therapy session of sorts the other day. My dog’s veterinary behaviorist charges $150 an hour to evaluate canine behavior problems. Initial evaluations take about two hours. The veterinarian periodically sponsors group sessions where dog owners can come as a group and listen to a presentation on some aspect of dog behavior. The events last about two hours and admission is only $15. Dog owners can learn more from these $15 seminars than most could afford to pay the vet one-on-one.

Interactive Group Therapy. Now imagine rather than a diabetes online support group open to the public, members are enrolled in an exclusive telemedicine group therapy program. Members could share a name or nickname and discuss or message other members privately. However, most interactions would be shared among the entire group. Doctors would monitor the group’s interactions and correct bad information. A physician or nurse practitioner could check metrics that are entered on a periodic basis (weight, blood glucose, activity levels, medications taken, etc.). Based on the inputs and interactions, physicians would review the automated treatment plans, update the medical record and prescribe medications electronically. People who don’t participate might be contacted by others in the group, a nurse or the computer system. Such a system could upload some metrics (e.g. weight and blood glucose levels) using Bluetooth. Members could share recipes, eating habits, exercise regimens and generally support each other’s efforts — all while under medical supervision.

Interactive group therapy could easily work in a Direct Primary Care practice to replace in-person routine physicals and wellness visits. I could sign up with my doctor alongside a thousand other guys. We could watch our doctor’s YouTube videos on wellness, the importance of maintaining proper weight, blood pressure, cholesterol and so on. We could routinely upload information on weight, blood pressure and any concerns we have. Our physician could follow up if needed for a nominal fee. Perhaps once or twice a year we could have blood drawn to check cholesterol, hormones, liver kidney, etc. Any readings out of the normal range would alert the doctor, who could call in a prescription or call us in for a one-on-one evaluation.

Categories: OIG Advisory Opinions

GuideWell Wants Your Opinion: Deadline Tomorrow!

The Healthcare Blog - Thu, 04/27/2017 - 11:19

It goes without saying that a cancer diagnosis is daunting, terrifying and can be completely life-altering. With approximately 40 percent of men and women being diagnosed at some pointduring their lifetimes. cancer changes a survivor’s life from one-minute daily activities to grand life decisions. GuideWell Innovation is committed to

bringing great minds together to facilitate and transform new ideas into solutions, helping to jumpstart the path to better health. With the launch of the GuideWell Cancer Challenge this past February, GuideWell is harnessing the strength of collaboration to help support cancer patients and survivors with concierge services to support the wide range of needs of living with cancer.

The challenge deadline is nearly here, but it’s not too late to make your mark. We want to hear from you! Simply register or log in to the challenge website to submit an idea for a service, share insights about living with cancer, or view ideas submitted by others. You can then VOTE or COMMENT on any submitted idea. And get this—you don’t even have to submit an idea to be eligible for a prize! Just by providing your thoughts and insight on a submission you can enter the competition for cash prizes ranging from $1,000 to $5,000.

The challenge has received unique ideas addressing various cancer patient needs and promoting vital support for people living with cancer. On March 30, we hosted a webinar answering key questions about how to get involved (view it here). Submissions thus far include a wide range of services and insights including app and web-based platforms designed to monitor and identify cancer diagnoses and support for finding treatment and nutrition information.

The deadline to participate in the challenge is TOMORROW, Friday, April 28, 2017. The GuideWell Innovation steering committee will then begin to review and evaluate all submissions and comments. If we bring our minds together we can work to mitigate the issues and improve the experience of living with cancer. With just one click, you can help make a difference in the lives of those who live, and will live with cancer.

Chelsea Polaniecki is a Program Manager at Catalyst @ Health 2.0.

Categories: OIG Advisory Opinions

The Return of the Angry Granny State

The Healthcare Blog - Wed, 04/26/2017 - 14:44

Texas should call itself The Granny State. That’s because it’s a nanny state in which the public officials who run the place have the values of a tea-totaling, Bible-thumping biddy who knows how God wants everyone to live and can’t resist telling them. No buying liquor on Sundays when people are supposed to be at church. No gambling ever. No whacky-weed for medicinal uses or recreation, even in the privacy of one’s home. No gay marriage, preferably no gays, and no transgender folk deciding which restrooms to use. And, of course, no sex, sex education, birth control, or abortions. Women should have sex only in marriage and then only to reproduce, and those who get pregnant must carry their babies to term, regardless of the consequences for themselves or anyone else.

These religion-inspired policies have served Texans poorly. The state’s maternal mortality rate nearly doubled in just two years after Texas cut its budget for family planning by two-thirds and eliminated funding for Planned Parenthood clinics. It’s now the worst in the developed world, not just in the US. Texas ranks 8th from the bottom in the frequency of STDs and has the 5th highest teen pregnancy rate too. Its 35 births per 1,000 girls aged 15-19 are nearly double the national average. Meanwhile, Colorado and other states have achieved miraculous reductions in teen pregnancy rates and abortion rates by providing young women with long-acting contraceptives, like implants and IUDs. If Texas is following God’s plan, then God’s plan is a bust.

Now Granny is once again sticking her nose where it doesn’t belong. Currently before the Texas legislature is Senate Bill 25, which would eliminate the wrongful birth cause of action that the Texas Supreme Court recognized four decades ago in Jacobs v. Theimer. The facts were as follows. While traveling, Dortha Jacobs became ill. Upon returning home, she consulted a physician, Dr. Louis Theimer, who discovered that she was newly pregnant. Fearing that the illness was rubella—also known as the German measles—Jacobs asked Dr. Theimer if there was reason for concern. Rubella can injure a gestating fetus severely. Dr. Theimer told her not to worry, but he did so without performing an available diagnostic test. In fact, the disease was rubella and the child “was born with defects of brain, speech, sight, hearing, kidneys, and urinary tract,” among others. The medical expenses were extraordinary.

The Jacobs sued for medical malpractice. In defense, Dr. Theimer argued that his mistake could not have harmed them. When Mrs. Jacobs became pregnant, the US Supreme Court hadn’t yet decided Roe v. Wade and abortion was illegal in Texas for all purposes except to save the life of the mother. Because the baby’s defects did not endanger Mrs. Jacobs, Dr. Theimer contended that abortion wasn’t an option for her. She’d have had to deliver the baby even if he had identified her illness correctly. Therefore, she and her husband would also have had to bear the infant’s medical costs.

The Texas Supreme Court disagreed. Abortion was illegal in Texas, it reasoned, but the procedure was lawful elsewhere. Consequently, Dr. Theimer had to give the Jacobs the information they needed to choose among their available options, including the option of having an abortion performed in another state. By misdiagnosing the illness, he therefore caused their loss and was on the hook for the extraordinary medical costs. (To be clear, Dr. Theimer was not responsible for costs the couple would have borne in the course of raising a healthy child. A healthy child is regarded as a gain, not a loss, even when a pregnancy is unwanted.)

SB 25 would eliminate the wrongful birth cause of action by making it impermissible for anyone to recover damages by claiming that they would have terminated a pregnancy instead of carrying a baby to term. The bill provides that “[a] cause of action may not arise, and damages may not be awarded, on behalf of any person, based on the claim that but for the act or omission of another, a person would not have been permitted to have been born alive but would have been aborted.” Had the bill been law in 1975, the Jacobs would not have been able to argue that, but for Dr. Theimer’s negligence, they would have aborted the baby. They’d have had to pay for all the surgeries and other treatments the child needed, expenses that, today, would into the millions.

SB 25, which offers parents in the Jacobs’ position no financial help at all, has already passed the Texas Senate and seems bound to pass the House. Its success is assured because, politically, it is a two-fer. Texas’ Republican lawmakers are eager to free doctors from financial responsibility for medical errors and to advance the Christian right’s anti-abortion agenda. SB 25 does both.

The bill will cause problems, though, first and foremost because it allows medical providers to make errors with impunity. Given the frequency with which mistakes occur, Texas’ leaders should be strengthening the incentives providers have to exercise reasonable care, not emasculating the state’s already-weakened malpractice liability system.


The wording of SB 25 is also too broad. Suppose that a woman with a defective uterus becomes pregnant, that her ob-gyn negligently fails to identify the defect, that late in the pregnancy her uterus ruptures, and that the woman dies or is severely injured. If SB 25 becomes law, neither the mother nor her survivors will be able to recover from the ob-gyn. Their claim would be that, but for the doctor’s mistake, the mother would have protected herself by aborting the fetus instead of carrying the baby to term—precisely the claim that SB 25 would forbid. The bill would thus eliminate civil liability for negligence committed in the one context where abortion has always been lawful in Texas—to protect the life of the mother.


There’s no need for the bill either. In 2003, Texas eliminated the possibility of excessive damage awards in medical malpractice cases by capping patients’ damages. Both the number of malpractice claims and physicians’ insurance premiums are at historic lows. Wrongful birth cases are rare too. Although the available data do not quantify them precisely, a study by The Doctors Company finds that most malpractice claims against obstetricians involve delays in treatment of fetal distress or improper performance of vaginal delivery. Wrongful birth claims are brought too infrequently to have their own category.


SB 25’s supporters are offering two types of argument in support of the proposal. One is the worn-out assertion that the bill will attract doctors by making Texas a safer place for them to practice. Texas is already one of the most doctor-friendly states in the US—Emergency Physicians Monthly ranks it among the top four—and the assertion that tort reform brings doctors into the state has been thoroughly disproven. Texas’ leaders should be ashamed of themselves for repeating this falsehood.

Another argument is that wrongful birth lawsuits insult disabled persons by telling them that they would have been aborted had their parents known of their impairments. This is an example of good intentions gone astray. In all lawsuits, parties say unpleasant things about others. Plaintiffs accuse defendants of neglecting duties, committing frauds, breaking agreements, and being dishonest. Defendants accuse plaintiffs of spouting falsehoods, exaggerating injuries, and being responsible for their own losses. One wishes that civil justice could be delivered with fewer insults, but it is a blood sport and always will be. The main point, though, is that parents of children borne with serious defects need resources. Only with those in hand can they love their children and provide for them too. When the choice is between a dignitary loss and the money with which to pay for life’s necessities, the decision is easy, even if it is also made with regret.


Charles Silver is a professor at the University of Texas School of Law and a co-author of After Obamacare: Making American Health Care Better and Cheaper (forthcoming 2018).

Categories: OIG Advisory Opinions

The Fairy Tale of a Non-Profit Hospital

The Healthcare Blog - Tue, 04/25/2017 - 11:04

Nonprofit hospitals have higher profit margins than most for-profit hospitals after accounting for their tax obligations.  3900 (62%) of U.S. Hospitals are non-profit and therefore tax-exempt: they pay no property tax, no federal or state income tax, and no sales tax.  An article published in Health Affairs found seven of the nation’s 10 most profitable hospitals were of the non-profit variety, each earning more than $163 million from patient care services. Revoking their property tax-exempt status for not functioning as a charitable entity could return billions in healthcare dollars to local government, communities, and citizens, struggling to afford quality health care.

The idea of exempting nonprofits from paying taxes in the first place is based on the belief these entities provide charity for the underserved and underinsured who would otherwise require the government to lend a helping hand.  As the percentage of uninsured declines as a result of the ACA, the justification for tax exempt status is being called into question.

Many nonprofit hospitals calculate their charitable care by using something known as “charge master” pricing; exorbitant, non-negotiated prices which are inflated many times higher than what private insurance or Medicare would pay.  This allows facilities to overstate their provision of “charity care,” calculated as revenue loss by the hospital in exchange for their lucrative tax exemptions. In a patient evaluated with chest pain, the allowable for Medicare is $3600; however, in an uninsured patient, the hospital may “write-off” an inflated $25,600 in uncompensated costs, which is 8 times higher than actual cost of care provided.  Nonprofit hospitals should be required to meet a higher standard by providing true (non-inflated) charity care.

A study, conducted by Zack Cooper (Yale), Stuart Craig (University of Pennsylvania), Martin Gaynor (Carnegie Mellon), and John Van Reenen (London School of Economics), evaluated the way nonprofit hospitals charge.  “Not-for-profit hospitals don’t price any less aggressively than for-profits. We subsidize not-for-profits to the tune of $30 billion annually, in the form of tax exemptions, and we have to ask what that money is getting us,” says Cooper, co-author of the study.

So what is the tax exemption getting us if not to “real” charity care for those in need?  A significant amount of nonprofit hospital revenue is being spent on executive salaries and benefit packages, reinvestment in new state-of-the-art facilities, and expanded healthcare services for those who can afford it.

According to Becker’s Hospital Review in 2012, the combined compensation of the top executives at the 25 most profitable non-profit hospitals totaled almost $58 million. The highest paid nonprofit hospital CEO in the nation is Jeffrey Romoff, at the University of Pittsburgh Medical Center (UPMC.)  An article in The Pittsburgh Post Gazette found his 2015 compensation was $6.43 million dollars; he has topped $6 million for the last four years, plus notable perks, such as access to a private chef, chauffeur, and a jet.  Additionally, the Gazette found 31 UPMC executives and physicians earned at least $1 million in 2015, six of whom received more than $2 million each.

In 2013, Pittsburgh Mayor Luke Ravenstahl unsuccessfully sued UPMC to collect more taxes on the grounds his city was losing $20 million annually as a result of the tax exemptions.  CBS News aired a segment after investigating the financial details.  UPMC brought in $948 million in profit over the 2 year period 2011-2012, while providing a mere 2% of its budget in charity care, and yet was saving $200 million after tax exemption. Imagine what that could pay for in the way of healthcare for the poor, disabled, and elderly, not to mention the funding for teachers, police officers, and firefighters?

The idea nonprofit hospitals should be paying property taxes has been gaining traction ever since.  In 2015, a New Jersey judge ruled that Morristown Medical Center should be responsible for paying property taxes because it acted more like a for-profit organization than one devoted to the provision of charity care.  He said, “modern nonprofit hospitals are essentially legal fictions;” kind of like a modern day fairy tale.  Ultimately, Morristown Medical Center reached an amicable agreement with the city to pay $1 million in the way of taxes, but multiple cities have followed suit, challenging the tax exempt status of nonprofit hospitals in the state.

Illinois is the latest battleground for the property tax exemption controversy.  A 2009 report by the Center for Tax and Budget Accountability found the property tax exemptions for 47 Chicago-area nonprofit hospitals were worth $279 million. In Illinois, a charity was originally defined as an organization generating revenue from donations and providing services to those in need.   In 2010, the Illinois Supreme Court ruled Provena Covenant Medical Center was not entitled to a property tax exemption because they were not a charity, as most of their revenue was generated from fees for service.

In 2012, the Illinois Hospital Association lobbied hard to expand the definition of charity in state law.  The state legislature passed a provision—buried in the Medicaid Reform Bill 2194– allowing property tax exemptions for hospitals providing charity care in the equivalent amount to their tax liability.  Medicaid reimbursements, considerably lower than private insurance payments, were allowed to count toward the “charity care” tabulation.

The Carle Foundation Hospital is the 10th most profitable hospital in the nation, according to the May 2013 article in Health Affairs.  They filed a request to have a property tax exemption after the controversial 2012 law was enacted.  The City of Urbana argued Carle had revenues approaching $2 billion annually, functioned more as a for-profit organization than nonprofit, and caused the city to lose $6.3 million in property taxes, necessitating a rate increase for other city properties as a result.  Last year, the 4th District Appellate Court ruled the 2012 state law unconstitutional.

Dissatisfied with the outcome, Carle Foundation Hospital appealed to the Illinois Supreme Court.  On March 23, 2017 the Supreme Court of Illinois vacated the ruling of the Appellate Court, but would not consider constitutionality of the 2012 law; Carle will be entitled to the property tax exemption for now.  The Supreme Court recommended reconsideration in the lower courts as to the question of constitutionality, so the debate remains ongoing.

The days of charitable establishments singularly devoted to comforting and caring for the poor and suffering are long gone.  Most nonprofit hospitals are vast profit machines bearing little resemblance to the charitable organizations of the past.  By reinvesting in state-of-the-art facilities with unnecessary “bells and whistles,” nonprofits are currently dominating city landscapes, becoming the largest local employers, and bringing in more revenue than the cities in which they are located.
By sidestepping property tax payments to the county or city in which nonprofit hospitals reside, they are shifting the financial burden for essential services and infrastructure onto the backs of individual citizens and small business owners, who should not bear the costs alone.  Stricter criteria should be applied to determine whether a hospital meets a “charity care threshold” in order to retain the lucrative nonprofit designation.  This is a vital step toward ensuring cities and counties collect adequate revenue for developed land, while ensuring vulnerable populations have somewhere to go when in need of healthcare, which is rapidly becoming unaffordable for us all.

Categories: OIG Advisory Opinions

Why Medical Necessity Continues to Be a Top Priority

Medical Coding News - Tue, 04/25/2017 - 07:44

Medical necessity is an important issue. Just review the definition of medical necessity: “a legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.” So, what does that really mean? A few years ago, I was preparing to speak at a national conference with […]

The post Why Medical Necessity Continues to Be a Top Priority appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

BTG buys Oncoverse–Amanda Goltz explains all

The Healthcare Blog - Mon, 04/24/2017 - 18:42

Amanda Goltz is a massive ball of energy in the world of digital health. For the past 2 years she’s been working for English pharma company BTG. But how does a pharma company get involved in health tech without wasting everyone’s time, and what exactly are they trying to do? Amanda certainly has both opinions and a plan. Today part of that plan became official with the purchase of Oncoverse, a cancer management program BTG has been working on with Wanda and Dignity Health. I spoke to her Monday morning my time to find out more (and yes, if you wait to the end, there is both a job “offer” and I have my own BBC Live home office moment!)

Categories: OIG Advisory Opinions

The Sad Myth of the Direct to Consumer Startup

The Healthcare Blog - Mon, 04/24/2017 - 10:55

Last week I had a startup entrepreneur come to me with an idea about how to “pivot” his company strategy. The company, which had begun as a medical device company but couldn’t quite find it’s market, was considering re-emerging as a consumer-focused digital medical device company in an adjacent market. The idea was to create a device to measure a serious medical condition and market it to consumers directly. Their plan was to target mothers who would be paranoid enough to spend money on medical devices to diagnose an issue in their children.

Imagine my heavy sigh.

Ever the heart-breaker, I had to tell this person that this strategy did not make any sense to me. As his target market representative du jour, I mentioned that there is no world in which I would trust myself to diagnose a major medical problem. Rather, if I even suspected a hangnail I would rush my precious princess straight to the doctor, do not pass Go, do not pay iTunes fees.

In fact, as I sat there explaining this psychology, I could not think of one single digital health company addressing a major medical condition that had successfully created a company by selling directly to consumers. If I am missing one, please do let me know in the comments section below. Please remember I am talking about companies that sell directly to consumers, not to physicians. And I am also talking about companies that address real, hardcore medical conditions, not fitness and not beauty. People will spend all kinds of money on fitness and beauty products even knowing full well they will make them neither fit nor beautiful. But medical products? Not so much. Insurance is supposed to pay for that. Or at least that’s what most consumers think.

Yes, there are some consumer-direct digital health companies that have had minor successes in the market, but none that have been able to achieve any size at all and certainly none that were able to deliver on venture capital return goals, even reasonable ones. And here’s why: if someone has a major medical problem they sure as hell don’t trust themselves to diagnose and treat it; they want their doctor involved, and appropriately so. Consumers might use a digital health medical device type product if their physician recommends it, but buy it off the shelf on their own without physician prescription or recommendation? Nope.

I have written about this issue before (consumer willingness to purchase medical products) and have seen my Digital Health, Destiny and Doritos article literally circle the globe. I think it’s because I talk about guacamole in the article. Everyone loves guacamole. If you don’t like guacamole, I have a digital diagnostic product to sell you that will determine your mental fitness to visit California, where guacamole consumption is mandatory.

So this is a cautionary tale for entrepreneurs, whose passion for their work is always so admirable but who don’t always think through this consumer issue to its logical conclusion (doom). And all too often, when I break their hearts by telling them what I know is the truth, they get even more committed to proving me wrong. I have broken more hearts than George Thorogood. I am pretty sure I’m not through yet.

I love this quote from George Santayana and even have it hanging on the wall of my office decorating a Road Runner & Wile E. Coyote animation piece, “Fanaticism consists of redoubling your effort when you have forgotten your aim.” Way too many entrepreneurs are way too committed to their vision of minting rational and engaged healthcare consumers when they should be thinking about how to influence those who influence consumers instead. And in case you needed further amplification on this issue: the cost of direct to consumer marketing is beyond the realm of nearly every healthcare-focused venture fund’s checkbook limit.

If I had a dollar for every entrepreneur to whom I said, “Dear God, please don’t rely on a direct to consumer strategy or you are doomed” and who later came back to me and said, “you were right.” I wouldn’t have to work anymore. In fact, this may be my new business model. Download my new app and receive a small electric shock whenever you think about going direct to consumer. I know you will thank me. That will be $1.

Categories: OIG Advisory Opinions

Healthcare Hotbed for Fraud Cases

Medical Coding News - Mon, 04/24/2017 - 09:18

While it might surprise some folks that five Modesto doctors are among those facing fraud charges in a $40 million medical billing and kickback case based in Southern California, it shouldn’t surprise anyone that there was yet another medical fraud case. Wherever there is money, you’ll find people or institutions are that ripe for defrauding, […]

The post Healthcare Hotbed for Fraud Cases appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

Finding Care Can Be Easy; Check Out The RWJF Choosing Care Challenge Finalists

The Healthcare Blog - Mon, 04/24/2017 - 09:05

How would you get to an unfamiliar destination without Google Maps, Waze, a GPS or even an old school map? Now how about your health care– how do you determine which road to take when you need local, reliable and affordable services? It can be tough to find the right care, but the RWJF Choosing Care Challenge is changing the game. In Phase I of the challenge, over 60 teams submitted seamless solutions to help patients find the care and services that fit their needs. Each team’s solution simplifies the journey to address the crucial need for personalized and accessible health care.

The challenge judges were particularly impressed with the solutions of: Stroll Health, Project Helix, A Moment Team, Luma Health and Transcendent Endeavors. Named the Phase I Finalists, each of these teams will receive $5,000 to further their tech development for Phase II of the challenge. These solutions include:

Stroll Health (@StrollHealth) helps health providers send patients directly to a local imaging center that fits their needs. Stroll delivers a convenient easy-to-use platform providing automatic referrals, prior authorization and real-time scheduling.

Project Helix (@kcdigitaldrive) utilizes a chatbot within a mobile application to walk patients through the steps of a doctor’s care recommendations. Transparency and accessibility are key in Project Helix’s technology, as the team connects with the patient each step of the way with text notifications and API data tailoring results to the patient’s needs.

Moment (@momentdesign) created “Orderly,” which has three key features: 1) patients receive up-to-date lists of preferred specialists, imaging labs and pharmacies, 2) patients can view data such as cost, coverage and location, and 3) patients can schedule next steps through provided contact information and online booking tools.

Luma Health (@Lumahealthhq) uses text message updates to connect patients with a pharmacy, imaging center or specialist as soon as they step out of an appointment. Luma’s secure chatbot collects basic information to fully understand health care needs. Once the information is collected, a phone call from a specified provider will then be initiated directing them to their choice of preferred care.

Transcendent Endeavors (@TransEndeavors) introduces “Pooled,” a web-based platform designed to collect patient demographics to be used in a patient pool. Healthcare providers can then compete, or bid, to offer the lowest price for their services. With this solution, patients can follow a bidding process to compare price and location of services to get the most out of their care experience.

Amongst the many innovative and comprehensive submissions, the judges also recognized the following five teams as honorable mentions:

  • Emrify’s (@emrify) mobile app empowers patients to document their care and discover follow-up resources to improve outcomes.
  • Markit Medical (@MarkitMedical) pinpoints a patient’s needs and identifies follow-up care at the moment when it’s most actionable for the patient.
  • Team Anakalypsi uses a Facebook chatbot to communicate with patients on a more personal level.
  • Doctible (@doctible) leverages a patient referral systems to deliver an easy-to-use experience for patients and providers.
  • HonestHealth’s (@honestHealth) consumer-focused portal on acts as a baseline to locate and acquire imaging lab services and specialists, affordable coverage options and in-network referrals.

In Phase II, three of the five finalists will be selected as winners and granted prize funding to continue to develop their tech-enabled solutions. The third place winner will receive $10,000, followed by the second place winner with $15,000, and first place will be awarded the grand prize of $50,000.  For further updates on the Phase II winners of the RWJF Choosing Care Challenge and other programs, subscribe to the Catalyst @ Health 2.0 Newsletter, and follow @catalyst_h20 on Twitter.

Chelsea Polaniecki is a Program Manager at Catalyst @ Health 2.0.

Categories: OIG Advisory Opinions

If I Had More Time, I Would Have Written a Shorter Blog Post

The Healthcare Blog - Sun, 04/23/2017 - 14:57

I don’t know why, but even as a young person I never could make sense of the saying, “seeing is believing”. Seeing, vision, is nothing more than a data collection instrument, not an arbiter of insight. I saw my wife frown at me the other day, for example, after I claimed to have washed the dishes so thoroughly that no spot of grease could be left behind. I have made this claim before and been incorrect, so the frown, the data, triggered an anticipation of being rebuffed. However, nothing of that sort followed. I asked, Why the frown?” She responded, “I just cut my finger”. The frown was obvious, the cause unclear. I believed I was about to be reprimanded and missed the chance to notice her accident.  This story suggests that a truer aphorism might be, instead, then, that “believing is seeing”.

These comments about bias in interpretation of data are not new. Consider the condition of “hindsight bias”; once we know, we change our minds to show how correct we now can be. How about, “confirmation bias”; since we believe we know the diagnosis we find information to justify that diagnosis, eschewing contrary data. Counselors tell us all that if you change your mind, you change your life.

But changing our minds is not that easy, and, in medical care, it is extremely difficult because of deeply held beliefs that shape the ideas, which shape the actions, which produce the consequences of costly, wasteful care.  So, let’s examine some beliefs:

If we believe that the young and well must pay through the nose to assure care for the sick, we will continue to design profitable margins into plans, and make sure inequality in those plans fulfill our beliefs. Right (sarcasm), my son and daughters should pay to make sure my 82 year old relative gets 2 CT scans, 2 MRIs, 1 PET scan, and 3 months of chemotherapy for an metastatic non treatable cancer; the treatment that finally contributes to her end from an infection during a nadir in counts.

If we believe that economics and profit matter in medicine and that medical care is a good employment system, we will continue to let economists and governments intrude in medical care. We will keep adding people to the mix of delivering wasteful care. Specialists will proliferate, physicians and nurses will proliferate, and integrative medicine groups will proliferate to bill the unsuspecting.

If we believe we can determine what is best for patients with averaged out, small-randomized trials conducted with patients who we have no idea where they came from, we will continue to produce inferior trials and not advance the science of letting individuals have information to make informed choices.

If we believe in population health we will continue to disparage the lives of individuals who are not at the mean. We will continue to aggregate into groups rather than take full advantage of the singular, cottage industry needed to provide time and space for a doc and patient to become informed about care.

If we believe that physicians know best about decisions we will continue to let physicians drive costly care to even newer highs. (See my aunts care above, and then multiply by thousands of daily decisions).

If we believe that malpractice insurance somehow protects more than harms, we will see decisions promulgated by physicians in specious attempts to protect themselves.

If we believe we need “guidelines” to bulldoze care decisions over unsuspecting physicians and patients, we will unduly continue to underwrite the economic interests of suppliers of medicines, tests, and procedures.

If we believe that money matters, as much or more than best care for people who are ill, we will see TV and radio adds targeted to unsuspecting people proliferate.

If we believe only physicians can judge the veracity of medical information we will continue to see cults of organ based physicians continue to grow. Biomedical journals will sprout to produce the weakest of seeds, as good and bad information will carry the same fermentation weights. Since patients cannot presently sift the wheat from the chaff, contrary data will destroy confidence and trust.

If we believe physicians are more important than patients, we will see the development of guilds and gilded unions to advocate for physicians and the system rather than patients.

The title of this piece is based on a well-known saying. I did not put the title in quotes, as we really don’t know who wrote it, but, who we think wrote it, did not say it this way (Blaise Pascal, according to a superficial, non-expertise based search for the quote). Its value, in my view, is that it embodies a contrary notion; we expect the end of the sentence to be 180 degrees opposite. This sort of twist is used in comedy, sarcasm and irony. But, it also suggests that sometimes what we believe is just the opposite of what is true.

This is why what we believe is paramount and penultimate to forward thinking. What we believe spawns our ideas; I think it is time for medical care to change what it believes”

Categories: OIG Advisory Opinions

Why Science is Mistrusted

The Healthcare Blog - Sat, 04/22/2017 - 15:23

Recently, the Harvard Chan School of Public Health, in their press release, reported about the effect of surgical checklists in South Carolina. The release was titled, “South Carolina hospitals see major drop in post-surgical deaths with nation’s first proven statewide Surgical Safety Checklist Program.”

The Health News Review, for which I review, grades coverage of research in the media. Based on their objective criteria, the Harvard press release would not score highly.

The title exudes certainty – “nation’s first proven.” The study, not being a randomized controlled trial (RCT), though suggests that checklists are effective, far from proves it. At least one study failed to show that surgical checklists improve outcomes.

The press release’s opening line is “South Carolina saw a 22 percent reduction in deaths.” It reports relative risk reduction (RRR). Reporting RRR is now considered a cardinal sin in healthcare journalism, because RRR inflates therapeutic optimism by making the intervention sound more efficacious than it is.

A good press release gives the reader the whole picture of competing evidence, particularly where there’s controversy. The press release mentioned one other study which showed an even higher mortality benefit of surgical checklists.

The press release goes onto say,

“Adoption of a safe surgery checklist has been demonstrated to reduce deaths in controlled research studies since 2009. But the ability to produce improved outcomes at large scale has remained questioned.”

In other words, the science is settled. But there is no mention of the Canadian study which failed to show surgical checklists improve outcomes. The reader is lulled into a false sense of certainty about the benefits of surgical checklists.

If this was a press release for a statin, or device, which, ironically, subjects itself to greater methodological rigor, it would have been taken to task. Yet, no one batted an eyelid about the press release about surgical checklists. Why does a sensational press release about an inferior quality study about surgical checklists not induce the same ire as a sensational press release about an RCT of a drug or device?

Future anthropologists might better answer this question. I’m not an anthropologist, let alone a future anthropologist. But I will speculate. In our rational age, we’re still indefatigably prejudiced, self-righteous creatures. Witnessing pharma make big bucks on false therapeutic optimism gets under our skin. Money corrupts. Nothing else quite corrupts to the same degree, we believe.

The proponents of surgical checklists don’t make money off checklists. That the proponents of checklists might advance their academic careers despite the therapeutic optimism of checklists doesn’t perturb. The nobility of their intent – they wish to make surgery safer – shields them from the scathing scrutiny reserved for drug and device industries.

It’s not easily apparent that the advocates of checklist might have the “this is my bright idea” bias. In this regard, the reaction of Atul Gawande, the author of Checklist Manifesto, who is self-evidently a true believer of checklists, to the Canadian study is instructive. He “wished the Ontario study was better.” He felt the study was underpowered and the implementation of checklists was weak.

When you don’t like the results of a study, the next step is to find weaknesses in the study design. The astute reader will note that I’ve done exactly what I’m accusing Gawande of doing. Guilty as charged. I have my biases. And there is no way to determine if one’s search for methodological weaknesses in a study is actuated by intrigue or bias. But my point isn’t whether surgical checklists work or not. My question is why do we not see the same skepticism for surgical checklists, and other policy measures, that we see for drugs and devices.

Of course, there are differences between checklists and drugs. Simple checklists cost nearly nothing to implement. If you’re wrong about the efficacy of a drug, that could be costly. If you’ve overestimated the efficacy of a surgical checklist, that’s no big deal.

But the differential standards, as justified as they may be, may lead to a deep mistrust of science and of dabblers in science. A casual observer, unfamiliar with epistemic nuances, may suspect that ideology is at play. The observer may see, in the sliding scale of methodological rigor, blatant double standards. The observer may lose faith in statistics seeing that it can be fine-tuned, like the thermostat of a shower, to prove and disprove what we wish proven or disproven.

When Anne Case and Angus Deaton showed that middle class white men were not reaping the mortality benefits of other demographics, the demolition of their analysis was swift.


In a sense, this is good because science needs refutation. But would their study have inspired the same statistical scrutiny if it had shown that Hispanic or South Asian men were dying sooner than white men? Skepticism loses credibility if seen to be applied selectively. And if we can’t trust skeptics, who can we trust?

Statisticians can debunk or defend a study using their deep knowledge of statistics by selectively highlighting the strengths and weaknesses of a study – no study design is perfect. The degree to which the weaknesses of a study can be exposed, is arbitrary – there’s no normative frame. Thus, statisticians have become the new lawyers. I wonder how long before we have a “right to a statistician.”

The ideologue with a deep knowledge of statistics is the most dangerous ideologue. The ideologue who claims God or history is on their side is easy to identify. The ideologue who claims to have science, which really means statistical technique, on their side is more difficult to identify and refute. Few have deep enough knowledge of statistics to call BS on the callers of BS. The result is that people mistrust science.

Science has become a substitute for morality. It has become a weapon to fight social injustice (whatever that term means), to reduce inequality, to mock incompatible world views. This is a blow for both science and morality. Historically, our species never resorted to science to do the right thing. Slavery was bad because it was morally bad. The Civil Rights Movement was right because it was morally right. The suffragettes were on the right side of history, not because an academic proved the net benefits of women voting in an election (p <0.0005), by analyzing a secondary database. The suffragettes were right because they were morally right. India’s freedom struggle was not initiated by a macroeconomic analysis, but because independence was morally right. If your moral intuitions can’t tell you that same sex marriage should be permitted, I doubt any scientific analysis will convince you.

It may be morally right to be politically correct. Then we should say so, and keep science away from political correctness. Science loses most credibility when seen to selectively address the favored social injustices of the time. It is not fashionable in elite circles to be perturbed by the plight of the working class white man. In this circle, which I sometimes frequent, a physician seeping with social justice from every pore, once said that it was imperative that we developed a vaccine for malaria, because the Africans have suffered enough from imperialism. He was right and wrong. He was right that a malaria vaccine will reduce the suffering of Africans tremendously, and that it was imperative that it be developed. But he was wrong. The vaccine is no more, or no less, important because of the history of the African continent. Alexander Fleming didn’t discover penicillin because he wanted to fight capitalists.

We may discourage reporting RRR for drugs and devices to curb therapeutic optimism and encourage reporting RRR for surgical checklists to encourage compliance. This is understandable, because how we frame a message, and reporting relative risk reduction is just a way of framing, depends on what we wish to achieve. But here lies another problem. Note, science is not informing us what to do. We’ve already decided what we want to do. Science is helping us implement, helping us engineer, helping us design, not a bridge, not a spacecraft, not a computer, but ourselves and society. This was once the dominion of religion. That this is now the dominion of science is ironic. But more troubling than irony is that science is no longer value-neutral. And when science ceases to be value-neutral, science ceases to be science.

(Saurabh Jha MD is a contributing editor to THCB. He can be reached on Twitter @RogueRad)

Categories: OIG Advisory Opinions

When Practices are Too Cautious about HIPAA

Medical Coding News - Sat, 04/22/2017 - 05:00

Many providers have the belief that HIPAA should be treated like well-regarded advice from your mom: It’s better to be safe than sorry. But that mentality is not always the way to go. Sometimes, practices can be too cautious with HIPAA. There’s a difference between ensuring protected health information (PHI) doesn’t fall in the wrong […]

The post When Practices are Too Cautious about HIPAA appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

ICD-10 Diagnosis Codes That Identify Weeks Gestation of Pregnancy

Medical Coding News - Fri, 04/21/2017 - 09:01

ICD-10 Diagnosis Codes that identify weeks gestation of pregnancy and birth weight requirement when billing a delivery CPT Procedure Code Effective for Dates of Service beginning January 1, 2017, and thereafter, Medicaid required a Weeks Gestation of Pregnancy Diagnosis Code and a birth weight on delivery claims billed on an UB-04 or CMS 1500 Claim […]

The post ICD-10 Diagnosis Codes That Identify Weeks Gestation of Pregnancy appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

Reform & Improve

The Healthcare Blog - Thu, 04/20/2017 - 16:30

With the failure of the Republican’s American Health Care Act (AHCA), what’s next? Congressional Republicans face the ugly choice of admitting defeat and funding the Affordable Care Act (ACA), including the cost-sharing reductions (CSRs) that they have tied up in federal court, de-funding the ACA and likely being blamed for its demise, or compromising with Democrats to improve it. In all likelihood, the next set of moves will focus on avoiding/shifting blame for the imminent crisis of health plan withdrawals that failure to fund CSRs would precipitate.

But the long-term problems with the ACA should be addressed: How to sustain health plan competition? How to simplify a nearly incomprehensible medical financing scheme? How to cover more of the uninsured? How to win enough moderate Republican support to de-escalate partisan wars over the ACA? Sooner or later, Congress needs to consider serious compromise proposals for improving the ACA.

So, what might they consider?

Were a bargain on improving the ACA to be struck, Democrats would insist that it ensure full federal funding and maintain goals related to covering most Americans. Taxes will be the “sticking point” for many Republicans, but not all: Senators Cassidy & Collins’ Patient Freedom Act (PFA) retains 95% of current funding.) On the other hand, the price of support from moderate Republicans probably includes making substantial changes that borrow heavily from the best ideas in the AHCA and the PFA. The approach proposed below does both.

I propose three goals for a bipartisan effort to “reform and improve” the ACA:

  • Stabilize the individual market and risk pool, long-term
  • Simplify the ACA and de-regulate its marketplaces, so the private sector can support them
  • Cover substantially more of the uninsured, without increasing federal spending per enrollee

Stabilize the market

The core element of this proposal is an alternative to the ACA’s method for making coverage affordable. The ACA tries to do so via a complex formula for tax credits that depends on projecting a household’s income next year – which is literally impossible to do with any credibility – so that eligible applicants pay a progressively scaled percentage of their income toward the second lowest cost silver plan (SLCSP).

As an alternative to this complex formula, let’s borrow from the AHCA and PFA, which I will refer to collectively, as “Republican,” but with one major modification that is crucial to my proposal: below, say, 300% of the federal poverty level (FPL), all eligible subscribers get advance premium tax credits (APTCs) amounting to 100% of the full premium of the most basic benchmark plan available to them i.e., the lowest-priced bronze plan in their zip code. Here is a simple, bronze, high-deductible health plan (HDHP) that might serve as this national benchmark plan:

60% AV level:                    Individual           Family (2+)

Annual deductible           $5,000                   $10,000

Coinsurance                       20%                        20%

Max. OOP                           $6,600                   $13,200

Free preventive services (zero deductible first)

PCP Office visits with $25 copayment (zero deductible first)

How much would the proposed tax credit — 100% of the premium for the benchmark bronze plan – cost, relative to the ACA’s current APTCs? Because of its lower actuarial value, premiums for the proposed benchmark bronze plan should average about 85% of the premium for the second lowest priced silver plan (SLCSP). For those who received APTCs under the ACA, they averaged 72% of the gross premiums for SLCSP prior to the large premium increases of 2017.   (ASPE, Health Insurance Marketplace 2015)

Because the current ACA formula holds eligible enrollees harmless for year-to-year premium changes, in effect increasing APTCs as average SLCSP premiums increase, the large premium hikes of 2017 (averaging 22%) actually increased the level of APTCs relative to gross premiums: adjusting the 72% for large premium increases in 2017, APTCs should now average about 77% of gross premiums for SLCSPs [1-(.28/1.22) = .77]. And for those under 300% FPL, the percentage of gross premium for silver plans covered by APTCs should be even higher than 77%. Hence, I estimate that the premium for the lowest cost bronze plan – 85% of SLCSP – would only slightly exceed the today’s average APTC for a household between 100% and 300% FPL.

Beyond 300% FPL, which approximates median U.S. income, APTCs would phase out in large steps, such as 2/3rds of the full credit from 301-400% FPL, and 1/3rd the full credit from 401-500% FPL.

The focus on HDHPs is right out of the Republican policy book. The critical difference is that, by definition, APTCs would suffice to make the benchmark plan “free” for most of the uninsured. This offers three huge advantages:

  1. “Free” is literally the most powerful word in sales and marketing, and most of the uninsured should opt for coverage;”
  2. It works reasonably well even without the individual mandate, thereby undercutting much of the popular opposition to the ACA; and
  3. Having a free plan makes auto-assignment practical, so that when the uninsured land in ERs, apply for other benefits, or fail to renew coverage, they can be auto-assigned.

However, if 70% actuarial value in the ACA benchmark plan was considered skimpy coverage for those earning below 250% FPL – hence the addition of CSRs — then 60% actuarial value is even thinner coverage. Fortunately, there is a far simpler and more efficient method than CSRs to reduce cost-sharing. (CSRs must be “fronted” to the enrollee by health plans, and then retroactively claimed by carriers from the IRS. And because they are available only to silver plan enrollees on marketplaces, hundreds of thousands, if not millions, of marketplace enrollees forego them, often inadvertently.)

Adapting a third Republican policy preference, it would be far simpler, more equitable and easier to fund Health Reimbursement Arrangements (HRAs) than CSRs. Exchanges (public or private), brokers, and/or carriers could establish HRAs on behalf of each enrolled household under, say, 400% FPL, to be funded by a tax credit. A reasonable funding level for those below 300% FPL might be the full deductible on the benchmark bronze design, so that they would be responsible only for the 20% coinsurance payments, and then half that deductible (from 300% to 400% FPL). Like CSRs, HRAs are only expended as services are used — unused funds would revert to the IRS. But unlike CSRs, the HRA can bear a certain degree of retroactive funding, which is very helpful when administering credits tied to a household’s projected MAGI.  This feature allows HRA funding to be tied directly into tax filings, including real MAGI calculation, for the plan year.

A fourth, important change to the ACA, taken from Republican bills, would reduce average premium levels overall, an important goal of Republican proposals. The ACA’s maximum premium range of 3-to-1, under which a 21-year old cannot be charged less than one-third as much as a 64-year-old, over-charges younger relative to older adults, and raises the average cost of coverage for all enrollees. The average medical cost of someone in their 20’s is about 1/5th of someone in their 60’s. By discouraging enrollment of the healthiest age group, this cross-subsidy from young to old makes the risk pool older and sicker in the aggregate, and thereby raises the average premium (index=1) around which the age range of rates are constructed.

While 5-to-1 strikes some sensibilities as an unfair burden on older Americans, covering the full premium of the benchmark plan for lower-income enrollees of all ages, as is proposed, largely negates the affordability and fairness arguments. Also, this is not a zero-sum game: by adding more young adults to the risk pool, a 5-to-1 age-rating band would reduce the average premium, perhaps enough that covering the full premium of the benchmark up to 300% FPL would cost less than today’s average APTC.

In addition to the four major changes described above, Republicans have proposed a series of small steps to stabilize the individual market, which should be adopted. For example, strictly enforcing the restrictions on off-season enrollment, so that Special Enrollment Periods are not “abused” by those who wait until they get sick to buy coverage. (See Oliver Wyman, “Special Enrollment Periods and the Non-Group, ACA-Compliant Market”.) Other common-sense underwriting practices include shortening the annual open enrollment window, reducing the 90-day grace period for lapsed premium payment, and reinstituting a federal-state funded stop-loss program for very high cost cases.

Finally, without an individual mandate, we need to encourage the maintenance of coverage and protection of the risk pool from those who jump in when they need services. Even if free to those below 300% FPL, those above 500% would pay full premiums. There are many ways to protect the risk pool from this sort of adverse selection, but the AHCA’s 30% surcharge strikes me as counter-productive – a penalty for enrolling. I prefer a conventional, commercial underwriting approach: a 6-month waiting period for covering pre-existing conditions for those who have not maintained continuous coverage.

Simplify the ACA & Reduce Market Regulations

ACA marketplaces depend upon the active participation of private health plans. So, let’s reduce all but necessary requirements on health plans that offer products in the direct market: one standard bronze plan (the benchmark plan) would have to be offered by any issuer that intends to offer health plans that qualify for a tax credit. This would help consumers make apples-to-apples shopping comparisons for the “benchmark” plan, and would likely intensify competition in terms of price, network breadth and service, rather than often mystifying benefit twists. Beyond that, qualified issuers should be required to offer richer benefits of their own design, including at least one at a reasonably rich level, such as 80% actuarial value. Although not full federal de-regulation, this proposal accords with Republican’s efforts to return insurance regulation to the states and flexibility to the markets.

Under the construct described above, eligibility determination for APTCs would be greatly simplified: legal residence, age, household size, and zip code would be required, as is the case with the ACA and the AHCA. However, instead of determining APTCs based on exact income projections, there are a few steps that most filers can understand and the IRS can readily assess: 100% – 300% FPL, 301-400% FPL, and 401-500% FPL.

HRAs are controversial, but are recommended here primarily as an administratively feasible cost-sharing mechanism that ties directly to annual tax filings. It also readily accommodates financial rewards for healthy patient behaviors, such as engagement with chronic disease management, and prudent consumer behavior, such as shopping for best value.

An important Republican innovation is to divorce eligibility determination from plan shopping. The IRS would administer the tax credits, and allow brokers and exchanges (public or private) to organize plan shopping. Or the consumer could buy directly from a health plan. The federal government is already working on a solution – Eligibility Verification as a Service (EVaaS) — to enable private entities at the point of shopping to understand the applicant’s net premium (after APTCs). This approach reduces the public costs of operating exchanges – or the surcharge on premiums that fund those public costs — and unleashes the private sector to locate, message and sell to the uninsured.

With sincere respect for the tremendous efforts made to date by state-based marketplaces, direct-to-consumer marketing is not generally considered a core strength of the public sector. Allowing a range of commercial (and public) web-based entities to market qualified health plans could add substantially to enrollment. (Private options, such as Softheon, eHealth, and Getinsured either did not exist or were far less robust when the ACA was drafted.)

Borrowing again from Republicans, over/under payments by IRS would be fully reconciled on each year’s tax filing and fully recoverable from filers. Indeed, given the simplification of calculating APTCs and the substitute of HRA for CSR, the IRS could rely on self-attestation for estimating the current year’s household income, using past filings as a check.

Any reform of the ACA should clear out the dead wood: eliminate both the small employer marketplace and the ACA’s convoluted 2-year tax incentive for very small employers (<25 FTEs) of low-wage workers to provide group coverage. Neither program has attracted significant use. By now, even ACA supporters can probably identify at least another half dozen special programs and pieces of the ACA which have simply failed – COOPs being the most spectacular of them – so let’s sunset them.

Increase enrollment

The ACA still falls short of its primary goal, to cover 95% of Americans. We could meet this goal with a few changes to Medicaid eligibility and qualified health plans that might attract a coalition of Democrats and center-right Republicans.

First, since expanding Medicaid eligibility to 133% FPL has not attracted voluntary participation by 19 states, let’s lower the bar. Why not let the remaining states choose to expand eligibility to 100% FPL, or cap the higher federal funding for all states at 100% FPL? With bipartisan reform, most of the holdout states are likely to raise their income-eligibility standard to 100% FPL, thereby rapidly boosting enrollment and filling in the awkward hole between those who earn too much for Medicaid and too little for APTCs. This one change would reduce the number of uninsured Americans by millions!

Second, one of the advantages of a zero-premium benchmark plan is that it virtually sells itself, even without a mandate. However, we can go even farther. We should make auto-assignment to the “zero-premium” benchmark plan the default option, and force eligible tax-filers to make a choice if they prefer to go bare. The ACA now covers only about 60% of APTC-eligible uninsured Americans. The combination of zero-premium coverage and auto-assignment might be so powerful that we end up covering a lot more of the uninsured without the individual mandate than with it!

Political Prospects

Coverage is all about the money. My rough estimate is that APTC costs per enrollee would be comparable to the existing ACA, but this proposal contains plenty of variables that can be adjusted to make a 10-year budget impact comparable to the ACA’s:

  1. The cost/savings of the option to expand Medicaid eligibility to 100% fpl
  2. The income cut-off for full APTCs (300% fpl)
  3. The step-function for phasing out APTCs (to 500% fpl)
  4. The level of HRA funding;
  5. The income cut-off for full HRA funding
  6. The step function for phasing out HRA funding
  7. The start-date for capping employers’ contributions to ESI

Of course, there are strong arguments against cutting costs for these variables, as any savings to federal outlays will also reduce the number of subsidized enrollees and/or generosity of coverage. The one essential element of this proposal which cannot be altered to meet budget requirements is maintaining a free benchmark plan for lower-income households.

Admittedly, the likelihood of Republicans joining Democrats to improve the ACA any time soon seem modest. But the intermediate-term perils of inaction are also considerable: without any substantive action on the ACA, congressional Republicans look foolish entering the 2018 election cycle; with Republicans already attacking each other over tax reform, the President needs a legislation he can claim credit for; and Democrats need to improve and de-escalate the rhetoric around their landmark reform.

Jon Kingsdale, Ph.D., teaches health policy at Boston and Brown universities. He founded the Massachusetts Health Connector (marketplace) and consults with CMS and a dozen states on the ACA.

Categories: OIG Advisory Opinions

A Modest Health Care Economics Experiment to Fight Rising Costs

The Healthcare Blog - Thu, 04/20/2017 - 10:24

Healthcare providers, medical institutions, local pharmacies and pharmaceutical companies generally set the price of their products/services well above the payment they expect to receive from all insurers. These healthcare vendors set their fee schedule at 150%, 200% or 1,000% of the maximum payment they expect to receive from their most generous payor.

Here in Massachusetts, when a healthcare product or service is consumed and the patient has health insurance, the vendor submits a bill to the insurance company who specifies the “allowed fee,” which is considerably less than the “billed fee,” and the vendor “writes off” the balance of the  “billed fee” from their books.

For example, I recently had some blood tests done at Quest Diagnostics. Quest Diagnostics sent a bill to my insurance company for $660. The “allowed payment” was $110, so Quest wrote-off $550 and the “allowed payment” of $110 was divided between me and my insurance company.

In my practice, where the fee schedule is created by my hospital, the “billed fee” for a level 3 follow-up office visit is about $230. The actual payment received from various insurance companies range from $62 to $164.

The “cash price” for many medications at a patient’s local pharmacy is also far above the amount the pharmacy expects to receive from any insurance company. For example, the cash price for Viagra is about $60/pill but the agreed reimbursement rate, between the local pharmacy and the insurance company, is about $10/pill. The same is true for many other medicines.

As the healthcare vendors’ fee schedules do not closely mimic the actual “competitive market rates,” patients who have either no health insurance or poor quality health insurance are required to pay outlandish medical bills. In this regard,  “capitalism” has failed to bring down the price of healthcare services.

In August 2012, Massachusetts created the Health Policy Commission, which set a targeted maximum rate of rise of healthcare spending in Massachusetts. The Commission was to cajole healthcare providers into staying within this limit. In 2015 the Bill seemed to have some effect as the rise in healthcare spending dropped from 4.2% (2014) to 3.9% (2015), although it was greater than the targeted rate of rise of 3.65%. Some argued that this data was proof that the law was having its intended effect as the Massachusetts rate of rise of healthcare spending was lower than the national average (4.9%), lower than the prior year and statistically close to the allowed limit.

I believe that the existing exorbitant (and market disconnected) fee schedules in the Massachusetts healthcare market may be one reason why this law has not been as effective as its designers had hoped.  Although there are restrictions which specify how fast the cost of healthcare spending can rise for a medical group/vendor, the fee schedule for specific services/products is so far above the payments received in the prior year that it will take decades before the “billed fee” schedule closely approximates the “allowed payment” fees set by the insurance companies. This huge disparity between the “billed fee” and “allowed payment” will make it more likely that healthcare spending will continue to rise more rapidly than permitted by the Massachusetts Health Policy Commission.

One way to mitigate the rising healthcare spending in Massachusetts might be to prohibit providers of healthcare services/products from setting their fee schedule higher then say 3.65% above the maximum payment they had received from an insurance company in the previous calendar year.

While some will argue that this flies in the face of capitalism, nobody will argue that the cost of healthcare spending is out of control and we must stem the rise in healthcare spending long before it consumes the entire discretionary Federal budget, bankrupts the public and makes our products fiscally noncompetitive around the world. Thus, this restriction on “fee schedules” might be a “healthcare economic experiment” we want to consider trying in a few in states.

Categories: OIG Advisory Opinions

OB Coding: Delivering Accurate Coding Remains a Challenge

Medical Coding News - Thu, 04/20/2017 - 07:13

To quote Robert F. Kennedy, “There are those that look at things the way they are, and ask ‘why?’ I dream of things that never were, and ask ‘why not?’” Coders are experts at scanning provider documentation and assigning codes. My approach to chart review is to try to piece together what actually happened during […]

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Categories: Healthcare News

CMS Told To Crack Down On Improper Medicaid Payments

Medical Coding News - Wed, 04/19/2017 - 11:04

The Centers for Medicare & Medicaid Services needs to step up its involvement in states’ Medicaid integrity programs in order to strengthen oversight and identify overpayments, according to a new federal watchdog report. CMS oversees how states run their Medicaid integrity programs and supports fraud-fighting efforts through reviews, training and hiring contractors to audit providers. […]

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Categories: Healthcare News

Health 2.0 has something important to tell you

The Healthcare Blog - Wed, 04/19/2017 - 04:30

Important news about my day job at Health 2.0 from my partner Indu Subaiya and me! You can also see the press release here and watch a video discussion with HIMSS CEO Steve LieberMatthew Holt

Indu and Matthew are excited to announce that after 10 years of convening the Health 2.0 community through our events and programs around the world, our conference company has found a new home and a partner who will help us exponentially expand our reach and impact. Effective immediately, we are joining forces with HIMSS and will be established as a new Health 2.0 business unit within the enterprise that includes HIMSS North America, HIMSS Analytics, HIMSS Media, HIMSS Europe, HIMSS AsiaPacific and the Personal Connected Health Alliance.

Health 2.0 and HIMSS share a single mission, to improve health outcomes by leveraging the best that technology has to offer. While terms change through the years, that common end goal hasn’t and won’t moving forward.

Our integration with HIMSS is a transformative opportunity to bring the knowledge and expertise from Health 2.0’s global network of entrepreneurs, developers and end-users together with that of clinicians, IT professionals, health care executives, policy leaders and other stakeholders to make a sustainable difference.

We are at a critical inflection point in the evolution of the health technology industry. Exciting advances in data science and AI, precision medicine and genomics, sensors and hardware to name just a few, coupled with the increased rate of adoption of digital health technologies by health care providers, payers, life science companies and communities require a level of collaboration like never before.

And yet, start-ups face barriers to access and distribution while large organizations face challenges in vetting and selecting new technology partners. Working with HIMSS, we will be able to create even more vibrant formats for interaction and more efficient mechanisms for innovation to spread throughout the healthcare system.

Countries around the world want to share models and best practices, to import and export health technology innovation while growing their own markets and their market reach globally. Working with HIMSS, we will be able to combine and expand our global footprint to be better ambassadors as well.

Indu will join HIMSS as executive vice president for the newly established Health 2.0 business unit and continue to co-host Health 2.0’s Annual Fall and Wintertech conferences with Matthew, while he will be our globe-trotting ambassador and continue to host and develop our international business.

Since 1961, HIMSS has focused on its vision of improving health and healthcare with the best use of information technology. Now, more than 55 years later, it continues on this path to improve the quality and affordability of, and access to, healthcare.

Health 2.0 was born from a need for consumers to take charge of their health using new technology frameworks that disintermediated access to health information and services. Over the past 10 years the Health 2.0 community has spawned an ecosystem of companies that helped bridge the gap between the institutional world of care delivery. We were bound to meet in the middle.

As with all great partnership journeys, we know this is not an ending, but a beginning.  When it comes to technology, there will always be a new frontier. It’s going to take all of us to explore that frontier together and to translate new ideas into the industry standard. We need both the foundation and the means to continually experiment to make good on our mission to leverage the best technology has to offer in helping us live healthier lives.

Onwards and together,

Indu & Matthew

Indu Subaiya is Co-Chairman & CEO of Health 2.0, and Matthew Holt is Co-Chairman of Health 2.0

Categories: OIG Advisory Opinions

CMS Updates ICD-10 Quality Measures, More from C&M Meeting

Medical Coding News - Tue, 04/18/2017 - 12:31

The Centers for Medicare and Medicaid Services (CMS) has released an update to the ICD-10 and Quality Measures website. The home page covers ambulatory surgical centers, hospital inpatient and outpatient, Centers for Disease Control (CDC) and National Healthcare Safety Network (NHSN) Surgical Site Infections (SSI) Measures, CMS outcome and payment measures, Agency for Healthcare and […]

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Categories: Healthcare News