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FUD Part II: The Return of Fear, Uncertainty and Doubt

The Healthcare Blog - Mon, 06/13/2016 - 13:16

A Time of Uncertainty …

The upcoming presidential election has everyone spooked  – what if Donald Trump is actually elected?  What will the transition of administrations, regardless of who is elected mean to healthcare and existing healthcare IT regulations?   Will our strategic plans and priorities need to change?

I’ve spoken to many people in government, industry and academia over the past month about the rapid pace of change stakeholders are feeling right now.   Here are a few of their observations:

1.  In the next year or two there will continue to be consolidation  in the healthcare IT industry.    Many smaller EHR companies will fold due to declining market share and some established incumbents with older technologies are likely to sell their healthcare IT businesses or reduce their scope.

2.  Mergers and acquisitions will continue to accelerate, reducing the number of stand alone community hospitals and practices.   The end result is that the market for software supporting midsize hospitals and small group practices is likely to shrink since ACOs/networks/healthcare systems will probably mandate a single centralized EHR solution for the enterprise.

3.  Although the election may change the regulatory burden, many incumbent vendors will be spending the next year or two complying with certification demands, reducing their ability to innovate.     It’s quite a conundrum.  The market is demanding innovative solutions in the short term, but vendors cannot produce them because their development resources have been co-opted by regulatory demands.    Thus, vendors may see a reduction in new sales, which will diminish their ability to hire new staff to meet the regulatory demands, putting them even further behind.   It reminds of a classic unstable system – beer pong.  The more you miss, the more you drink, the more you miss.   The more regulation, the fewer new sales, the less ability to deal with regulation.

4.  The capacity of hospitals to pay large sums for EHR implementation and operation will be reduced as margins shrink during the fee for service transition to value-based payment.  Vendors will be pressured to offer cloud hosted subscription models with standard configurations that are less resource intensive.    Customization will be less attractive than a good enough platform that is affordable and highly usable.

5.  As I wrote about last week, innovation is likely to come from one of two areas – smaller/agile companies that are not yet overwhelmed with regulatory burden or companies on the edges of the healthcare IT industry such as Apple, Google, and Amazon.     It’s hard to predict the winners.   There was a flurry of small startups in 2014-2015, but in 2016 we’re seeing them close/sell/merge.  The pace of new startups has slowed.

What kind of innovation do we need?  I have a “top challenges” list that includes

*A master patient identifier for the country
*A provider directory for the country
*A consent registry/record locator service for the country
*A customer relationship management platform that supports care management
*A groupware communication tool for healthcare
*A set of security solutions that makes two factor authentication/endpoint encryption easier
*A mobile platform for patient/family engagement that provides usability and high value transactions to the consumer
*A telehealth/telemedicine platform that supports documentation/billing in the cloud
*An interoperability platform that leverages cloud technologies to seamlessly provide clinicians with the information they need when their need it
*An analytics platform that notifies/alerts clinicians when something needs to be done – providing wisdom, not just a flood of data.

I’m increasingly on the lookout  for organizations which will address these challenges during the uncertain 24 months ahead.    The advantage of being at Beth Israel Deaconess is that I can draw on all sectors – payers, providers, patients, established industry and startups to aquire potential solutions.    Situational awareness and agility are a must for the months ahead.  I’m keeping my running shoes on!

John Halamka is the CIO at Beth Israel Deaconess Medical Center.



Categories: OIG Advisory Opinions

Medical Billing and Coding for Small Private Practices in the US

Medical Coding News - Mon, 06/13/2016 - 11:14

Medical billing and coding companies in the US are gaining popularity with their efficient services. Small private practices and clinics that want to minimize claim denials and rejections and ensure proper reimbursement should seek the services of efficient medical billing service providers. Value-Added Services of US Medical Billing Services If you have a small private […]

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Categories: Healthcare News

A Bill You Can Understand: One Page, One Line, One Price

The Healthcare Blog - Sun, 06/12/2016 - 11:21

At the recent Health Datapalooza conferenceSylvia Burwell, the HHS Secretary announced a new initiative, A Bill you Can Understand, :

a challenge to encourage health care organizations, designers, developers, digital tech companies and other innovators to design a medical bill that’s simpler, cleaner, and easier for patients to understand, and to improve patients’ experience of the overall medical billing process.

This is a laudable if perhaps slightly misdirected effort.

Why are we looking to create an extra layer of service to explain a very poor function, which will inevitably increase system costs? Because this is healthcare’s typical way of adding more layers and costs to an already bloated system, instead of fixing the underlying problem.

When you buy a car do you receive separate bills for the labor, motor, body, tires, glass, oil and gas, carpet, electronics, air conditioning?  I know, there are a few lines – base price, options, transportation fees, dealer fees – but it’s just a few and there are not multiple bills coming from all the components.

Furthermore, this simplification greatly reduces the number of people and systems that a dealer and its suppliers need to staff for the billing and collection process.

What healthcare needs is to simplify and combine the entire billing process and function. We need to bundle pricing that is all-inclusive in advance, just like everything else we buy.

It’s really not that hard. For an example we can look no further than a nearby offshore facility, Health City Cayman Islands.  I wrote about this hospital before, but the gist is they offer surgery services for a number of specialties with a price that’s all-inclusive:

There are no surprises, it’s all in and you know before you go how much it is. Here’s an example of a bill for a major joint replacement.  One Page, One Line, One Price. Now what could be more simple than that?

We applaud HHS for trying to help all of us who have to deal with billing in the current health care system. But the simple solution is more effective, efficient, and transparent published pricing that creates competition and lowers costs.

Brian Klepper is a consultant based in Florida. Fred Goldstein is the CEO of Accountable Health! 

Categories: OIG Advisory Opinions

The State of ICD-10 Implementation: Calm, and Qualms

Medical Coding News - Sat, 06/11/2016 - 09:26

Now at almost the 9-month mark, the implementation of the new ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) diagnostic codes by physician practices resembles a calm, glassy stretch of ocean broken by a solitary shark fin. Yes, there is calm. By almost all accounts, the switch from the old ICD-9 […]

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Categories: Healthcare News

The Opioid Crisis: Nociception, Pain and Suffering

The Healthcare Blog - Fri, 06/10/2016 - 09:50

In order to understand the concept of pain and its relationship to the current opioid crisis, it is prudent to review the neurology of pain an why it exists.  Several concepts are important to integrate.

Nociception:  Nociception is the capacity to sense a potentially tissue damaging (noxious) stimulus.  To illustrate this one should place a forefinger in a glass of ice water and determine how long passes until an unpleasant sensation arises.  If one performs this experiment in a large group, one can recognize that, although the stimulus is the same (a glass of ice water), the sensation arises at different rates in different people. 

In fact, a bell shaped curve will describe the distribution in any population of people.  Within 30 seconds almost all will have perceived an unpleasant sensation that is known at pain.  Nociception is a very primitive sensation. 

It is present in virtually all animals, even those without a brain, such as Aplysia, the sea slug.  Though it lacks a brain, it has nerves  and ganglia that allow it to sense and move away from a noxious stimulus.  Nociception is absolutely essential to our survival and well-being.  Without it, one would suffer tissue damage and ultimately death.  The human disease, leprosy, is a salient example of an infection that destroys the nerves that are responsible for nociception.  That lack of nociception is what causes all of the disfigurement that is characteristic of leprosy.  Anyone who has had a dental anesthetic is aware that one can inadvertently bite one’s own lip until the anesthetic wears off.

Controlling Nociception:  Why is it that a noxious stimulus ‘”wears off?”  Why does the unpleasant sensation not go on forever?  A system has evolved that is designed to turn off the nociceptive system.  This signal arises in the brain and releases a chemical that turns off the nociceptive impulses just after they enter the central nervous system.  This chemical is one of two small peptides, known as enkephalins, which bind to opioid receptors.  Because these are made in one’s own nervous system they are known as endogenous opioids.  Thus opioids are natural substances that are critical for controlling nociception so that the pain does not last beyond its use, which is to signal the presence of noxious stimuli.  Opioids are widespread in nature.  Many centuries ago, human being learned that there was something in poppies that relieved pain.  That substance was an opioid.  All natural and synthetic opioids have a very similar chemical structure and they all work by turning off the nociceptive system.  Those that come from sources outisde of one’s own nervous system are termed exogenous opioids. 

Pain:  Pain is discomfort caused by injury.  It is a phenomenon that arises in a part of the brain known as the thalamus, a cluster of nuclei in the center of the head (the centrencephalon).  The thalamus is the way station for virtually all sensation coming from the outside world, whether noxious or not.  Examples of non-noxious stimuli would be sounds, visions, touch, and vibration sense; in other words anything that is not potentially tissue damaging.  The only exception is the sense of smell, a system so old and so primitive that it does not have a thalamic connection; rather it has direct access to the higher parts of the brain, the limbic cortex.  The thalamus is constantly weighing the amount of noxious vs non-noxious information coming from the surrounding world.  When noxious stimuli exceed non-noxious ones, pain is the sensation experienced.  Pain allows one to consciously recognize that there is a potentially tissue damaging stimulus in the environment.  As such it is critical to health and even survival.  Pain that lasts beyond the experience of nociception has sometimes been called chronic pain, though it is better to think of it as a form of suffering.

Suffering:  Suffering is the experience of undergoing pain, hardship or distress.  Note that pain is only one of the causes of suffering.  Some others might be: war, poverty, marital discord, mental illness, work dissatisfaction, anxiety and depression, just to name a few. Suffering is a complex phenomenon that requires a high level brain.  We believe, but cannot prove, that Aplysia does not suffer though it clearly has nociception.

Phenomena common to the use of many drugs:  Several phenomena occur with drug use.

Tachyphylaxis is said to occur when increasing doses of a drug no longer produce greater effects.  Amphetamines, such as the street drug methamphetamine or many diet drugs, have this characteristic.  Tachyphylaxis occurs when the mechanism of a drug is the release of a preformed substance (e.g. catecholamines) from nerve endings.  When that substance is depleted, additional drug can have no incremental effect.  In other words, tachyphylaxis is sudden tolerance that is not dose dependent. 

Tolerance means that, over time, increasing doses of the drug are required to produce a equivalent effect.  Opioids (eg codeine, morphine, oxycodone), alcohol and benzodiazepines (eg diazepam, lorazepam) have this characteristic.  When there is tolerance, the person will experience symptoms and signs of withdrawal when the dose of the drug is reduced or it is discontinued.  Tolerance is due to reduced number or sensitivity of drug receptors effected by exposure to the drug.  Everyone who uses a drug of this type will develop some degree of tolerance and withdrawal.

Addiction implies a craving or obsession.  Everyone is familiar with the obsession phenomenon as we all occasionally experience an “ear worm” meaning a tune that one cannot get out of one’s mind.  Obsessions, which are thoughts, may lead to acts (compulsions) that relieve the obsession, though often only temporarily.  Addictions do not only refer to drugs, but can be seen in other forms such as sex addictions or gambling addictions.  Drug addiction means that the person becomes obsessed with the drug and spends inordinate amount of effort and time in attempts to obtain it, even including illegal and dangerous activities.  The system in the brain that leads to addiction uses a different chemical, dopamine, the substance that is depleted in Parkinson Disease.  In the course of replacing dopamine to treat Parkinson Disease, some patients acquire obsessions, such as gambling problems.  Thus it is important to realize that addiction can be due to tolerance and withdrawal but not necessarily so.  People vary with respect to how susceptible they are to obsessiveness and addiction.  Just as we can demonstrate the variation in the experience of pain after putting one’s finger in a glass of ice water, one can prove that a bell shaped curve describes the tendency in a population of people to develop addictions.  This tendency is probably at least partially genetically determined and thus tends to run in families, though common experience also is a characteristic of familial relationships.  It is likely that genetic and epigenetic factors are at play.

The essential problem:  The essential problem underlying the opioid societal issue is that various forms of suffering are being routinely treated as if they were pain due to nociception.  It is important to remember that opioids are meant to reduce pain due to noxious stimuli; not for the relief of suffering caused by any number of other factors.  When we became physicians we all took an oath to reduce suffering.  We did not promise to remove pain and nociception, both of which are critical to good health and indeed survival.  Opioids have their very important place, but it is their side-effects that cause the deaths in people who are using them to treat their suffering, including suffering caused by chronic pain.  Recall the scene from the Wizard of Oz where Dorothy and her friends come across a field of poppies, which put them to sleep.  As a side effect, opioids can cause coma and stop breathing, thus causing death.  They also may stimulate the dopamine reward system, leading to addiction. 

It is thus critically important for the medical and lay communities to understand the proper place for opioids.  Put simply, exogenous opioids are needed when the noxious stimulus is sufficiently intense that endogenous opioids are not adequate.  A long bone fracture would be a good example.  Bone metastates might be another.  In both circumstances the longevity of the pain will be time-limited.  In the case of the fracture, immobilization and healing will be the end point.  In the case of bone metastases, radiotherapy or the end of life might mark the end point.   When endogenous opioids are not adequate to relieve a time-limited pain, exogenous opioids are the treatment and doctors must prescribe them.   Simply legislating limits on opioid prescribing does not address the essential problem.   It is more important to acknowledge and deal with the causes of human suffering (i.e. pain, hardship and distress) from poverty, war, abuse, depression, and anxiety with techniques that are meant for this purpose; not with the use of a class of drugs that is only meant for reducing pain from noxious stimuli.  Reducing suffering is much more complex and challenging than relieving pain.  It requires time, empathy and wisdom.  Machines do not possess the necessary attributes to relieve suffering.  Only people have those attributes.  The opioid epidemic is a symptom of our society’s overreliance on machines and drugs.  Staring at a computer and prescribing drugs, no matter how electronically sophisticated, is not medicine.  The word patient is derived from the Greek meaning one who suffers.  Medicine is all about relief of suffering.  Only people can provide that poultice.

Categories: OIG Advisory Opinions

CMS’s Final Rule on Medicaid Managed Care

Medical Coding News - Fri, 06/10/2016 - 06:42

On April 21, 2016, the Centers for Medicare & Medicaid Services (CMS) issued final regulations that revise and significantly strengthen existing Medicaid managed care rules. In keeping with states’ increasingly heavy reliance on managed care programs to deliver services to Medicaid beneficiaries, including many with complex care needs, the regulatory framework and new requirements established […]

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Categories: Healthcare News

Texas Lawmakers Study Regulations on Surprise Medical Bills

Medical Coding News - Thu, 06/09/2016 - 06:27

Even though they may have health insurance, growing numbers of Texas consumers are getting unexpected bills from doctors not in the consumers’ health care network. A public policy group told state legislators recently that consumers need more protection from surprise medical bills, particularly those arising from emergency room visits. Stacey Pogue, a senior policy analyst […]

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Categories: Healthcare News