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Three Words That Health Care Should Stop Using: Insurance, Market, and Quality (Part 2 of 2)

Posted on August 23, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous part of this article ripped apart the use of the words “insurance” and “market” to characterize healthcare. Not let’s turn to another concept even more fundamental to our thinking about care.

Quality

The final element of this three-card Monte is the slippery notion of quality. Health care is often compared to the airlines (when we’re not being compared to the Cheesecake Factory), an exercise guaranteed to make health care look bad. Airlines and restaurants offer relatively homogeneous experiences to all their clients and can easily determine whether their service succeeded or failed. Even at a mechanical level, the airlines have been able to quantify safety.

Endless organizations such as the National Association for Healthcare Quality (NAHQ) and the Agency for Healthcare Research and Quality (AHRQ) collect quality measures, and CMS has tried strenuously to include quality measures in Meaningful Use and the new MACRA program. We actually have not a dearth of quality measures, but a surfeit. Doctors feel overwhelmed with these measures. They are difficult to collect, and we don’t know how to combine them to create easy reports that patients can act on. There is a difference between completing a successful surgery, caring for things such as pain and infection prevention after surgery, and creating a follow-up plan that minimizes the chance of readmission. All those things (and many more) are elements of quality.

Worst of all, despite efforts to rank patients by their conditions and risk, hospitals repeatedly warn that quality measures underestimate risky patients and therefore penalize the hospitals that do the most difficult and important work–caring for the sickest. Many hospitals are throwing away donor organs instead of doing transplants, because the organs are slightly inferior and therefore might contribute to lower quality ratings–even if the patients are desperate to give them a try.

The concept of quality in health care thus needs a fresh look, and probably a different term. The first, simple thing we can do is remove patient ratings from assessments of quality. The patient knows whether the nurse smiled at her or whether she was discharged promptly, but can’t tell how good the actual treatment was after the event. One nurse has suggested that staff turnover is a better indication of hospital quality than patient satisfaction surveys. Given our fascination with airline quality, it’s worth noting that the airline industry separates safety ratings from passenger experience. The health care industry can similarly leverage patient ratings to denote clients’ satisfaction, but that’s separate from quality.

As for the safety and effectiveness of treatment, we could try a fairer rating system, such as one that explicitly balances risk and reward. Agencies would have to take the effort to understand all the elements of differences in patients that contribute to risk, and make sure they are tallied. Perhaps we could learn how to assess the success of each treatment in relation to the condition in which the patient entered the office. Even better, we could try to assess longitudinal results instead evaluating each office visit or hospital admission in isolation.

These are complex activities, but we have lots of data and powerful tools to analyze it. Together with a focus on changing behavior and environments, we should be able to make a real difference in quality–and I mean quality of life. Is there anything an ordinary member of the health professions can do till then? Well, try issuing Bronx cheers and catcalls at any meeting or conference presentation where someone uses one of the three misleading terms.

Three Words That Health Care Should Stop Using: Insurance, Market, and Quality (Part 1 of 2)

Posted on August 22, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Reading the daily papers, I have gotten increasingly frustrated at the misunderstandings that journalists and the public bring to the debates of over health expansion, costs, and reform. But you can’t blame them–our own industry has created the confusion by misusing terms and concepts that work in other places but not in health. Worse still, the health care industry has let policy-makers embed the incorrect impressions into laws and regulations.

So in this article I’ll promote the long process of correcting the public’s impressions of health care–by purging three dangerous words from health care vocabulary.

Insurance

The health care insurance industry looks like no other insurance industry in the world. When we think of insurance, we think of paying semi-annually into a fund we hope we never need to use. But perhaps every twenty years or so, we suffer damage to our car, our house, or our business, and the insurance kicks in. That may have been true for health care 70 years ago, when you wouldn’t see the doctor unless you fell into a pit or came down with some illness they likely couldn’t cure anyway. The insurance model is totally unsuited for health care today.

The Affordable Care Act made some symbolic gestures toward a recognition that modern health care should embrace prevention and wellness. For instance, it eliminated copays for preventative visits. The insurance companies took that wording very literally: if you dare to bring up an actual medical problem during your preventative visit, they charge you a copay. Yet the “preventative” part of the visit usually consists of a lecture to stop smoking and go on the Mediterranean diet.

Effective wellness programs jettison the notion of insurance (although patients need separate insurance for catastrophic problems). They keep in regular contact with clients, provide coaching, and sometimes use intelligent digital interventions such as described by Dr. Joseph Kvedar in The Internet of Healthy Things (which I reviewed shortly after its release). There are scattered indications that these programs do their job. As they spread, the system set up to deal with catastrophic health events will have to adapt and take a modest role within a behavioral health model.

The term “insurance” is so widely applied to our healh funding model that we can’t make it go away. Perhaps we should put the word in quotation marks wherever it must be used.

Market

This term is less ubiquitous than “insurance” but may be even more harmful. Numerous commenters have pointed out the difference between health care and actual markets:

  • In a market, you can walk away and refuse to pay for a good that is too expensive. If the price of beef goes through the roof, you can switch to beans (and probably should, for your own health). So the best time to argue with someone who promotes a health care market may be right after he’s fallen from a ladder and is clutching at his leg in agony. Ask him, “Do you feel you can walk away from an offer of health care?” Cruel, but a lesson he won’t forget.

  • A market serves people who can afford it. It’s hard to find a stylish hair dresser in a poor neighborhood because no one can pay $200 for a cut. But here’s the rub: the people who need health care the most can’t afford it. Someone with serious mental or physical problems is less likely to find work or be able to attend a college with health insurance. Parents of seriously ill children have to take time off from work to care for them. And so on. It’s what economists–who have trouble discarding the market way of thinking–call a market failure.

  • In a market, you know what you’re going to pay for a service and what your options are. Enough said.

  • In a market, you can evaluate the quality of a service and judge (at least in retrospect) whether it was worth the cost. I’ll deal with quality in the next section.

The misconception of health care as a market came to a head in the implementation of the Affordable Care Act. Presumably, millions of “young invincibles” were avoiding health insurance because of the cost. The individual mandate, combined with affordable plans on health care exchanges, would bring them flooding into the insurance system, lowering costs for everyone and balancing the burden created by the many sick people who we knew would join. And yet now we have stubbornly rising health care rates, deductibles, and caps, along with new costs in the states where Medicaid expanded Where did this all fall apart?

Part of the problem is certainly the recession, which caused incomes to decline or stagnate and exacerbated people’s health care needs. Also, there was a pent-up need for treatment among people who had lacked health insurance and avoided treatment for some time. This comes through in a study of prescription medication use. Furthermore, people don’t change habits overnight: many continue to over-rely on the emergency room (perhaps because of a shortage of primary care providers).

But there’s another unanticipated factor: the “young invincibles” actually start using health care once they get access to it. An analysis showed that mental health needs among the young are much higher than expected. In particular, they suffer widely from depression and anxiety, which is entirely reasonable given the state of our world. (I know that these conditions are connected to genetics and biology, but environment must also play a role.)

Ultimately, until we get behavioral health in place for everybody, health care costs will continue to rise and we won’t realize the promise of near-universal coverage. Many health care activists–especially during the recent political primary season–call for a single-payer system, which certainly would introduce many efficiencies. But it doesn’t solve the problems of chronic conditions and unhealthy lifestyles–that will require policy action on levels ranging from improvements in air cleanliness to new opportunities for isolated individuals to socialize. Meanwhile, we still have to look at the notion of quality in tomorrow’s post.

How Precision Medicine Can Save More Lives and Waste Less Money (Part 2 of 2)

Posted on August 10, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article looked at how little help we get from genetic testing. Admittedly, when treatments have been associated with genetic factors, testing has often been the difference between life and death. Sometimes doctors can hone in with laser accuracy on a treatment that works for someone because a genetic test shows that he or she will respond to that treatment. Hopefully, the number of treatments that we can associate with tests will grow over time.

So genetics holds promise, but behavioral and environmental data are what we can use right now. One sees stories in the trade press all the time such as these:

These studies usually depend on straightforward combinations of data that are easy to get, either from the health care system (clinical or billing data) or from the patient (reports of medication adherence, pain level, etc.).

And we’ve only scratched the surface of the data available to us. Fitness devices, sensors in our neighborhoods, and other input will give us much more. We can also find new applications for data: for instance, to determine whether one institution is overprescribing certain high-cost drugs, or whether an asthma victim is using an inhaler too often, meaning the medication isn’t strong enough. We know that social factors, notably poverty (LGBTQ status is not mentioned in the article, but is another a huge contributor to negative health outcomes, due to discrimination and clinician ignorance) must be incorporated into models for diagnosis, prediction, and care.

President Obama promises that Precision Medicine features both genetics and personal information. One million volunteers are sought for DNA samples and information on age, race, income, education, sexual orientation, and gender identity.

There are other issues that critics have brought up with the Precision Medicine initiative. For instance, its focus on cure instead of prevention weakens its value for long-term public health improvements. We must also remember the large chasm between knowing what’s good for you and doing it. People don’t change notoriously unhealthy behaviors, such as smoking, even when told they are at increased risk. Some experts think people shouldn’t be told their DNA results.

Meanwhile, those genetic database can be used against you. But let’s consider our context, once again, in order to assess the situation responsibly. The data is being mined by police, but it’s probably not very useful because the DNA segments collected are different from what the police are looking for. Behavioral data, if abused, is probably more damning than genetic data.

Just as there are powerful economic forces biasing us toward genetics, social and political considerations weigh against behavioral and environmental data. We all know the weaknesses in the government’s dietary guidelines, heavily skewed by the food industry. And the water disaster in Flint, Michigan showed how cowardice and resistance by the guardians of public health to admitting changes raised the costs in public health measures. Industry lobbying and bureaucratic inertia work together to undermine the simplest and most effective ways of improving health. But let’s get behavioral and environmental measures on the right track before splurging on genetic testing.

How Precision Medicine Can Save More Lives and Waste Less Money (Part 1 of 2)

Posted on August 9, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

We all have by now seen the hype around the Obama Administration’s high-profile Precision Medicine Initiative and the related Cancer Moonshot, both of which plan to cull behavioral and genomic data on huge numbers of people in a secure manner for health research. Major companies have rushed to take advantage of the funds and spotlight what these initiatives offer. I think they’re a good idea so long as they focus on behavioral and environmental factors. (Scandalously, the Moonshot avoids environmental factors, which are probably the strongest contributors to cancer) . What I see is an unadvised over-emphasis on the genetic aspect of health analytics. This can be seen in announcements health IT vendors, incubators, and the trade press.

I can see why the big analytics firms are excited about increasing the health care field’s reliance on genomics: that’s where the big bucks are. Sequencing (especially full sequencing) is still expensive, despite dramatic cost reductions over the past decade. And after sequencing, analysis requires highly specialized expertise that relatively few firms possess. I wouldn’t say that genomics is the F-35 of health care, but is definitely an expensive path to our ultimate goals: reducing the incidence of disease and improving life quality.

Genomics offer incredible promise, but we’re still waiting to see just how it will help us. The problems that testing turns up, such as Huntington’s, usually lack solutions. One study states, “Despite the success of genome-wide association and whole-exome and whole-genome sequencing (WES/WGS) studies in revealing the DNA variants that underlie the genetic basis of disease, the development of effective treatments for most diseases has remained a challenge.” Another says, “Despite much progress in defining the genetic basis of asthma and atopy [predisposition to getting asthma] in the last decade, further research is required.”

When we think about the value of knowing a gene or a genetic deviation, we are asking: “How much does this help predict the likelihood that I’ll get the disease, or that a particular treatment will work on me?” The most impressive “yes” is probably in this regard to the famous BRCA1 and BRCA2 genes. If you are unlucky enough to have certain mutations of these gene, you have a 70% lifetime risk for developing breast or ovarian cancer. This is why testing for the gene is so popular (as well as contentious from an intellectual property standpoint), and why so may women act on the results.

However–this is my key point–only a small percentage of women who get these cancers have these genetic mutations. Most are not helped by testing for the genes, and a negative result on such a test gives them only a slight extra feeling of relief that they might not get cancer. Still, because the incidence of cancer is so high among the unfortunate women with the mutations, testing is worthwhile. Most of the time, though, testing is not worth much, because the genetic component of the disease is small in relation to lifestyle choices, environmental factors, or other things we might know nothing about.

So, although it’s hard enough already to say with any assurance that a particular gene or combination of genes is associated with a disease, it’s even harder to say that testing will make a big difference. Maybe, as with breast or ovarian cancer, a lot of people will get the disease for reasons unrelated to the gene.

In short, several factors go into determining the value of testing: how often a positive test guarantees a result, how often a negative test guarantees a result, how common the disease is, and more. Is there some way to wrap all these factors up into a single number? Yes, there is: it’s called the odds ratio. The higher an odds ratio, the more helpful (using all the criteria I mentioned) an association is between gene and disease, or gene and treatment. For instance, one study found that certain genes have a significant association with asthma. But the odds ratios were modest: 3.203 and 5.328. One would want something an order of magnitude higher to show running a test for the genes would have a really strong value.

This reality check can explain why doctors don’t tend to recommend genetic testing. Many sense that the tests can’t help or aren’t good at predicting most things.

The next section of this article will turn to behavioral and environmental factors.

How Will the Coming Election Year Impact Healthcare IT?

Posted on November 10, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It seems like the Presidential election should be closer since we’ve been hearing about possible Presidential candidates for the past year. However, we still have a whole year before the next Presidential election. Does anyone else think we’re going to be tired of this process a year from now? (But I digress)

In past years, there was certainly a lot to talk about when it comes to the impact a new president would have on healthcare IT. However, I don’t think that this presidential election will be the same. I think that’s true for healthcare in general as well.

On the healthcare IT side, meaningful use has basically run its course. Sure, Jeb Bush has asked to eliminate meaningful use and government mandates and penalties for EHR use. Although, John Halamka and Marc Probst have both recently asked for the same. We’ve written previously about how getting rid of meaningful use wouldn’t do much of anything to alter the current course of EHR and healthcare IT. It just wouldn’t change much of anything.

What could a presidential candidate do to impact healthcare IT? I really don’t see them having an interest in doing much of anything to impact the current course of healthcare IT. If you think otherwise, I’d love to hear why.

On the healthcare side of things we might see more changes. Certainly the topic of healthcare costing the US too much money is a very big an important topic for the president. However, I think Obamacare and those healthcare reform efforts are too far gone to be able to really go back and change them now. Sure, we could see some changes here and there, but I think it’s too late for a new President to really drastically change what’s already been done.

Related to this is the move away from fee for service to a value based reimbursement environment. Would any President condone this direction? Would any President advocate for a return to the old fee for service environment? I don’t see it happening. As many people have told me, the shift to value based care has left the building. There’s no coming back. Could they modify the approach and some of the details. Certainly! However, they’re not likely going to change the trajectory.

Long story short, I’m not sure any Presidential candidate will do anything that will drastically impact healthcare IT and healthcare as we know it. Sure there will be some tweaks that will have some impact, but nothing major like Obamacare or the HITECH Act.

Do you agree or disagree? I always love to hear other perspectives.

Fun Friday Healthcare Humor

Posted on November 6, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It’s Friday and I came across this cartoon which is funny and sad at the same time (the best kind of humor). However, I think it reflects the major challenge and a lot of the discontent many feel towards health care today.
The advances in Health-Care seems to be putting some distance between the doctor and patient.

I recently asked some people where all this physician discontent is going to lead. They didn’t have a good answer and I don’t either.

Since it’s Friday, I thought this graphic was worth sharing as well:
Friday Doctor Humor

Thanks to all the hundreds of thousands of doctors who work hard every day and don’t mail it in because it’s Friday, a weekend, late at night, etc etc. You’re true heroes.

Beyond the Buzz: The Myths and Realities of Consumer and Patient Engagement

Posted on September 29, 2015 I Written By

The following is a guest blog post by Peter Edelstein, MD, is the Chief Medical Officer at Elsevier.
Peter Edelstein, MD
Today’s healthcare reform world is filled with buzzwords.  “Population Health Management.”  “Value-Based Care.”  “Patient Engagement.”  I am in no way suggesting that these topics do not play critical roles if we are to realize the enormous potential of healthcare reform.  However, if you ask ten people to define any one of these buzzwords, you’ll receive twelve different definitions.  And in a world of threatening reimbursement penalties and expanding healthcare legislation, the sooner that we come to some consensus on the basic meaning of these terms, the sooner we can understand the associated myths and realities.

Relative to the patient population (that is, the general population), the population of providers (doctors, nurses, and other clinicians) represents a fairly homogeneous and small group to target with initial reform efforts.  In addition, we are all painfully aware of the unacceptable number of preventable deaths and complications which occur at the hands of providers each and every day.  Thus reform legislation has first focused on reducing variability, elevating quality, and controlling the cost of care delivery through programs focused on providers (hospitals and healthcare systems, as well as the physicians, nurses, other clinicians who work in such institutions). 

Again, this makes sense as a starting point.  That said, to believe that we will achieve our ultimate goals of evolving into a system dominated by preventative care and outpatient and home health maintenance (leaving hospitals to serve only those whose chronic conditions can no longer be controlled in the outpatient setting) solely by changing how providers deliver care is a myth of epic proportions.  Far-and-away our greatest opportunity to shift our population’s health from reactive, acute, and expensive to proactive, preventative, and cost-efficient is by directly engaging and educating and empowering the general population of patients and future patients themselves. 

This perspective is based on two major realities.  First, studies (as well as our own experience) confirms that even individuals with chronic conditions spend on average only a handful of hours annually in front of a professional care provider.  (How many hours did you or your spouse spend under the direct care of a provider in the previous twelve months?  For the overwhelming majority of you, the answer is less than a couple.)  Second, patients who demonstrate interest in and ownership of their health have better clinical outcomes and reduced costs of care.  In a nutshell, people spend virtually all of their lives away from doctors, nurses, and hospitals, and as with virtually any complex processes, those who are more involved and knowledgeable have better outcomes.

Now we come up against another reality:  limited resources.  Hospitals and healthcare systems have limited staff and finances, and Patient Engagement often draws the short straw when competing with electronic health records, computerized order sets, and other provider-specific support solutions.  But, as I’ve suggested, de-prioritizing Patient Engagement as “less important” or “less impactful” is a myth which greatly limits our potential to increase the value (elevate quality/reduce costs) of healthcare delivery.  Thus, the most important first step for healthcare stakeholders to accept is the reality that assigning resources to Patient Engagement must be as great a priority (if not greater) as allocating staff and money to products and solutions which target only traditional providers.

Once healthcare leaders accept the critical importance of Patient Engagement, they again have to consider their limited resources.  It is another common and perilous myth when trying to allocate resources and develop and implement Patient Engagement strategies to consider all patients within a healthcare system’s catchment area as a homogeneous population.  The reality here is that not all individuals have the same potential for or barriers to becoming engaged patients.  And understanding with which patient subpopulations you can get “the most bang for your buck” is a necessity which is often overlooked. 

For example, any of us who have directly cared for a large cohort of patients knows that there are some individuals (comprising a patient subpopulation) who simply have no intention of ever lifting a finger to care for themselves.  I think about the roughly 50% of Americans with chronic conditions who fail to take their medications as prescribed.  Or the diabetics who simply cannot be troubled with checking their blood sugars.  Every provider can immediately call to mind dozens of patients who, understanding how to better their own health, simply refuse to do so.  The reality is that as in all areas of life, there are simply some people who just will not engage, be accountable, take ownership.  To waste valuable resources trying to engage this patient subpopulation is foolish, disillusioning for staff, and wasteful, and it is best to quickly identify these individuals and accept that all you can do is provide reactive care when they become ill.

A second and large patient subpopulation is well worth the resources and efforts to engage.  These are the folks with limited literacy and numeracy skills.  Multiple studies have demonstrated the inverse relationship between literacy and healthcare outcomes.  Thus, assigning resources to clearly engage and educate these individuals so that they have the knowledge and understanding necessary to engage is worthwhile.

The third large patient subpopulation worth targeting is comprised of people whose upbringing or culture serves as a barrier to engagement.  Perhaps the largest of these cohorts is elderly Americans, many of whom were raised never to question a physician or ask for clarification.  Such patients are unable to engage because they refuse to address their lack of understanding of recommendations for their self care.  Another large faction are those who were raised in cultures (often outside of the United States) where, as with elderly Americans, the provider is God, never to be questioned.  Thus, these folks don’t really understand what they can do to improve their health, and they refuse to ask for further clarification.

The reality for these two large patient subpopulations is that the appropriate use of resources to understand and directly address the obstacles to true engagement and education can result in great successes.

In the end, our ability to achieve truly dramatic and impactful healthcare reform depends to a great extent on engaging and educating the patients of today and tomorrow.  Appreciating this reality, and understanding the realities related to identifying patient subpopulations which can truly be engaged and educated is the best approach to achieving successful reform.

About Peter Edelstein, MD
Peter Edelstein, MD, is the Chief Medical Officer at Elsevier. Edelstein is board certified by the American College of Surgeons and the American Society of Colon and Rectal Surgery. He has more than 35 years of experience practicing medicine and in healthcare administration. Edelstein was in private practice for several years before serving on the surgical faculty at Stanford University, where he focused on gastrointestinal, oncologic and trauma surgery. He then spent more than a decade as an executive in the Silicon Valley medical device industry. Edelstein’s most recent role was as Chief Medical Officer for the healthcare business at LexisNexis Risk Solutions, a Reed Elsevier company. He is also the author of the recently published book, ‘Own Your Cancer: A Take-Charge Guide for the Recently Diagnosed & Those Who Love Them’.

The Post SGR Replacement World – An SGR Infographic

Posted on July 13, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been regularly blogging about the changes from a fee for service world to a new value based reimbursement world and everything that’s involved in that. I think it’s a key change that’s happening in healthcare that’s going to drive everyone to do things differently. This is particularly true as a healthcare IT vendor.

With that in mind, I found this history of Medicare SGR patches quite interesting. Understanding the past is a great way to take a look at where we’re heading in the future.
SGR Timeline and Move to MIPS and MACRA

King v Burwell Decision Teaches Sad Lesson in Law Making

Posted on June 25, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In case you’re living under a hole (in the healthcare world we call that in the middle of an EHR implementation), the Supreme Court ruled on King v Burwell today. You can read the 47 page document here if you’re interested in the details of the decision. If you’ve ever read a Scalia decision or dissent, then you’ll know what to expect in his dissenting comments.

The reality is that the decision essentially made it a non-event. If they’d decided the other direction, then there would be a lot of scrambling to mitigate the damage of having all the federal health exchanges not be subsidized. That didn’t happen and so ACA (Obamacare) will continue on as before.

I won’t dive into the good and bad of ACA or the efforts to keep it around or get rid of it here. However, the one big takeaway I have from reading the SCOTUS decision is that the law making process is really awful. At one point in the decision they even reference a quote that “we need to pass the law to see what’s in it” which I’m told is a common phrase in Washington. The decision also commented on how the law was poorly crafted because it wasn’t put through the regular congressional procedures.

I understand that the US government has hundreds of years of overhead that they’re dealing with when making laws. A lot of the procedures likely play a critical role in the law making process. However, I feel that the law making process has accrued so much complexity that it makes everything a challenge.

In the tech world we call this situation “technical debt.” Over time as you’re programming a piece of software, you accrue so much technical debt that making changes on the existing code base becomes really expensive. The solution in the software world is often to recode the software from scratch. It’s almost like declaring bankruptcy and starting from scratch.

The SCOTUS decision highlights to me how much legislative debt our government has accrued in their processes. Unfortunately, they can’t declare bankruptcy and start over without the debt. That’s just not feasible or reasonable.

Since I live in the healthcare IT world, we’ve seen a lot of this “debt” impact legislation like meaningful use. We’re going to see more of it around value based reimbursement and ACOs as the healthcare payment world evolves. Government involvement is a reality in healthcare for many reasons including the government being one of the biggest healthcare “customers.” There can be a lot of benefits that come from government involvement, but there can also be a lot of challenges and loopholes that can snag you. That’s the lesson I’m taking from the King v Burwell decision.

Does Federal Health Data Warehouse Pose Privacy Risk?

Posted on June 23, 2015 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Not too long ago, few consumers were aware of the threat data thieves posed to their privacy, and far fewer had even an inkling of how vulnerable many large commercial databases would turn out to be.

But as consumer health data has gone digital — and average people have become more aware of the extent to which data breaches can affect their lives — they’ve grown more worried, and for good reason. As a series of spectacular data breaches within health plans has illustrated, both their medical and personal data might be at risk, with potentially devastating consequences if that data gets into the wrong hands.

Considering that these concerns are not only common, but pretty valid, federal authorities who have collected information on millions of HealthCare.gov insurance customers need to be sure that they’re above reproach. Unfortunately, this doesn’t seem to be the case.

According to an Associated Press story, the administration is storing all of the HealthCare.gov data in a perpetual central repository known as MIDAS. MIDAS data includes a lot of sensitive information, including Social Security numbers, birth dates, addresses and financial accounts.  If stolen, this data could provide a springboard for countless case of identity or even medical identity theft, both of which have emerged as perhaps the iconic crimes of 21st century life.

Both the immensity of the database and a failure to plan for destruction of old records are raising the hackles of privacy advocates. They definitely aren’t comfortable with the ten-year storage period recommended by the National Archives.

An Obama Administration rep told the AP that MIDAS meets or exceeds federal security and privacy standards, by which I assume he largely meant HIPAA regs. But it’s reasonable to wonder how long the federal government can protect its massive data store, particularly if commercial entities like Anthem — who arguably have more to lose — can’t protect their beneficiaries’ data from break-ins. True, MIDAS is also operated by a private concern, government technology contractor CACI, but the workflow has to impacted by the fact that CMS owns the data.

Meanwhile, growing privacy breach questions are driven by reasonable concerns, especially those outlined by the GAO, which noted last year that MIDAS went live without an in-depth assessment of privacy risks posed by the system.

Another key point made by the AP report (which did a very good job on this topic, by the way, somewhat to my surprise) is that MIDAS’ mission has evolved from a facility for running analytics on the data to a central clearinghouse for data sharing between CMS and health insurance companies and state Medicaid organizations. And we all know that with mission creep can come feature creep; with feature creep comes greater and greater potential for security holes that are passed over and left to be found by intruders.

Now, private healthcare organizations will still be managing the bulk of consumer medical data for the near future. And they have many vulnerabilities that are left unpatched, as recent events have emphasized. But in the near term, it seems like a good idea to hold the federal government’s feet to the fire. The last thing we need is a giant loss of consumer confidence generated by a giant government data exposure.