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Thursday, August 29, 2013

"Medical High School"? What?

Not kidding. I'm relocating from Las Vegas to the Bay Area. My wife works in Walnut Creek. Been a hassle for the past 5 years, this now-concluding "Virgin America Marriage" (and back to a real one). We're selling our Las Vegas house. The truck will be here on Sept. 13th.

Found a great, spacious place to lease out in Antioch ("Good Antioch," as the locals say, the south side). I can even bring my digital baby grand! Only about 17 miles or so from Cheryl's office, no freeways to contend with.

Looks like a "Bubble-icious" area to me, in light of the surplus of relatively inexpensive rents out that way. I'm gonna pay half what I'd have paid in Walnut Creek proper. This had to be one of those locales that got quickly built up all shiny and new and was subsequently populated by a lot of incautious buyers who took out pricey ARM loans and bought high, only to crash unceremoniously and painfully back to earth when the economy tanked about 5 years ago (my fav acronym of the era is the "NINJA Loan" -- No Income, No Job, or Assets).

So, I'm surfing the ZIP 94531 area on Google Map last night, zooming in and out, scrolling up and down, panning left and right, when I run across this maybe a mile away from our new digs: "Dozier-Libbey Medical High School." What?

Indeed. Wow.

They call it a "pathway school." Below, sort of their Mission/Vision Statement.

What's not to love? Get to 'em early. I've reached out to this school to offer to be a volunteer in any appropriate manner they might see fit to use me. I bet the kids that go to this school are really bright, really teachable. I'll have the schedule flexibility.

We'll see. They're probably wondering "who the heck is this guy?"

How nice. This is an idea that should spread nationwide, in light of the severe and growing need for astute people in every aspect of health care.

apropos, my Rolling Stone email newsletter popped into my inbox a little bit ago, and had a link to this:
Jerry Brown's Tough-Love California Miracle
The 75-year-old governor rescued the Golden State from financial ruin - and is reshaping a national progressive agenda

...Just two years ago, the idea that California could be a global model for anything was laughable. When Brown took office, the state was staggered by double-digit unemployment, a $26 billion deficit and an accumulated "wall of debt" topping $35 billion. California was a punch line for Republican politicos – a cautionary tale, they said, of the fate that awaits the nation should it embrace Left Coast-style economic, social and environmental liberalism. On the campaign trail in 2012, Mitt Romney joked that "America is going to become like Greece, or like Spain, or Italy, or like . . . California."...

he California that Brown inherited on his return to office appeared to be an insolvent, ungovernable mess. California's finances have been out of wack since the late 1970s, when right-wing, anti-tax activists passed Prop 13, a constitutional cap on property taxes that also requires a two-thirds supermajority vote to raise any tax through the state legislature. Moreover, it was a Republican, Arnold Schwarzenegger, who hastened the recent fiscal calamity by slashing California's vehicle license fee. Promising to cut the "car tax" keyed Schwarzenegger's victory over the hapless Democrat Gray Davis in the recall election of 2003. But it also blew a $4 billion annual hole in the budget that Schwarzenegger simply papered over with bond debt.

When the Great Recession struck and the state's credit rating collapsed, California was in a bind: Its budget shortfall was too massive to resolve with cuts alone. But the state's intransigent minority of Republican lawmakers refused to raise revenues. Making matters worse, in the same 2010 election that returned Brown to office, Californians tied his hands by approving another hard-line anti-tax proposition that reclassified many state fees as "taxes" and even made closing tax loopholes subject to supermajority rules...

Curbing climate pollution is just one way Brown is working to breathe new life into the ambitious agenda President Obama pursued in his first term. The nation's most populous state is also leading the country in the implementation of Obamacare – providing a critical test case that a model pioneered in Massachusetts can work, at scale, in a massively diverse state where nearly one in four residents lacks health coverage. "It's not too much to say that the success or failure of California will determine the fate of the legislation going forward," says Tanden, who helped craft Obamacare as a senior administration adviser. "I believe it will be a success – they're way ahead of everyone."

In June, Brown signed legislation adopting Obamacare's generously subsidized expansion of Medicaid to the working poor. Ever budget-conscious, Brown had been wary of the "big costs" and "big unknowns" of growing a program that already accounts for 20 percent of the state's general fund. But unlike GOP governors – such as Perry in Texas – who have rejected the program out of hand, Brown pragmatically embraced the challenge and the opportunity to cover 1.4 million state residents. "We're going to move with commitment," Brown said, "because I do believe people do need decent health care."

California also made headlines this spring when it unveiled sample rates for individuals in its new insurance exchange, which will serve up to another 5 million residents. Many had predicted sticker shock as premiums adjusted to cover Obamacare's expanded benefits. Instead, the increases were modest and plans affordable. Even before federal subsidies, 25-year-olds can get coverage for $141 a month; 40-year-olds for $219. The system is working, health advocates say, because California used its bargaining power to force insurers to offer uniform products and compete on price. "We held insurers' feet to the fire," bragged Peter Lee, the governor's executive director for California's insurance exchange...

Having waged and won his 2012 ballot initiative by focusing on education funding, Brown is now transforming how that money gets spent. The governor's new budget begins by restoring school districts to their pre-recession funding. But it targets additional spending for districts with high concentrations of at-risk learners. "A child in a family making $20,000 a year or speaking a language different from English requires more help," Brown said, pitching the plan to the legislature. "Equal treatment for children in unequal situations is not justice." Of the state's 6 million public schoolchildren, 3 million come from homes that don't speak English. Two million live in poverty. Under the new formula, per-pupil funding in Fresno – a city in the agricultural Central Valley, where 92 percent of students are disadvantaged – will nearly double by 2020 to more than $12,000.

U.S. Secretary of Education Arne Duncan and Brown have clashed on policy in the past, with Brown decrying federal testing regimes that force students to regurgitate "quiz bits of information." But in June, Duncan praised Brown's "real courage" for implementing a reform that may sound like "common sense" but – given how America's schools have historically been funded – "is actually revolutionary."...
I'm glad to be "coming home" to California after 45 years. I was born in NY, raised in NJ and first came to CA in 1966, and then lived in North Beach San Francisco in 1967-68. I have never felt so at home anywhere else (I'm gonna be a BART-ridin' fool; oh! the reading I'm gonna get done).

Yeah, the state has huge problems. So what? See "How Jerry Brown Scared California Straight" and "Jerry Brown's Political Reboot."

On the topic of medical education, the latest lament over at
The Trojan Horse called Integrative Medicine arrives at another medical school
Posted by Scott Gavura on August 29, 2013
Medicine is a collaborative practice. Hospitals are the best example, where dozens of different health professionals work cooperatively, sharing responsibilities for patient care. Teamwork is essential, and that’s why health professionals obtain a large part of their education on the job, in teaching (academic) hospitals. The only way that all of these different professions are able to work together effectively is that their foundations are based on an important, yet simple, principle. All of us have education and training grounded in basic scientific principles of medicine. Biochemistry, pharmacology, physiology – we all work from within the same framework. As a pharmacist, my role might include working with physicians and nurses to manage and monitor medication use. A team approach is only possible when you’re working from the same playbook, and with the same aim. And in medicine, that playbook is science.

That’s why “integrative” medicine frightens me so much. Integrative medicine is a tactic embedding complementary and alternative medical practices into conventional medical care. Imagine “integrating” a practitioner into the health system that doesn’t accept germ theory. Or basic disease definitions. Or the effectiveness of vaccines. Or even basic biochemistry – perhaps they believe in treatments that restore the body’s “vital force” or manipulate some sort of “energy fields”. Instead of relying on objective signs and symptoms, they base treatments on pre-scientific beliefs, long discarded from medicine. There may be entirely different treatment goals, which are potentially antagonistic to the scientific standard. Imagine a hospital or academic setting where this occurs, and the potential impact on the quality of care that is delivered...
"There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is “Eastern” or “Western,” is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. We recognize that there are vastly different types of practitioners and proponents of the various forms of alternative medicine and conventional medicine, and that there are vast differences in the skills, capabilities, and beliefs of individuals within them and the nature of their actual practices. Moreover, the economic and political forces in these fields are large and increasingly complex and have the capability for being highly contentious. Nonetheless, as believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy." - Phil B. Fontanarosa & George D. Lundberd "Alternative Medicine Meets Science, JAMA
...In the science-based, reality-based world, there is no yang that needs to be fortified, just as there is no such thing as a yin deficiency. Yet your licensed TCM practitioner can sell you horny goat weed which is Health Canada approved to treat your forgetfulness and cold lower back. And if the University of Toronto is successful with its new Centre for Complementary and Integrative Medicine, this type of material may soon be “integrated” into its medical and pharmacy education. The entire concept is absurd...

Moves to embed CAM into academic settings start with the assumption that “integrative medicine” is a good thing, in the absence of any data to show that is the case. Based on the information that does exist, it’s reasonable to assume that increasing the levels of “integrative” medicine at the University of Toronto will reduce and compromise the quality of medical and pharmacy education, and ultimately, the quality of care offered to patients. It’s sadly ironic that the University of Toronto, with a medical school lauded by Abraham Flexner in 1910, is now turning its back on those qualities, 103 years later.
 At Dozier-Libbey Medical High School, an emphasis on "science" is touted.

Would controversies pertaining to "integrative medicine" be a topic for senior "Medical Ethics"?


Just in, from The NY Times:

Ugh. My grandson Keenan is now a sophomore at St. Olaf College. He plays football. Loves it. Loves to hit and be hit. We worry about brain damage.


A doctor takes up the Fred Trotter challenge. "Why re-invent the EMR wheel? ... Here’s my answer to that question"
What medical records offer: High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.
What I need: No focus on billing codes, instead a focus on workflow.
What medical records offer: Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information.
What I need: Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.
What medical records offer: Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)
What I need: Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.
What medical records offer: Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.
What I need: A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.
What medical records offer: Organization of information is not a high priority, as physicians are not reimbursed for organized records. The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.
What I need: Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial. The goal is to put the most important information up front and to give easy access to the details sought.  I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.
What medical records offer: Top priority is paid to billing workflow, with second billing given to in-office patient management.  The least attention is given to clinical workflows for patients outside of the office.
What I need: My priorities are 180 degrees from this. My top priority is keeping people outside of the office healthy and happy. which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records.  Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out.  Billing is almost a non-issue, as it is very simple in my system.
What medical records offer: Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office.  For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient.  This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”
What I need: Task management is near to the top. I am focused on coming up with a care plan for each patient and making sure the patient understands that plan.  The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health.  So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”
What medical records offer: Mobile communication is becoming more available, but it is very much system centric., meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.
What I need: My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.  I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application).  I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible.  In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.
What medical records offer: Payment for health services generally depends on two things: a problem being treated and a procedure code and are therefore the focus of the record system.  Problem lists are in the record, not primarily because they help with care, but to allow billing for services.
What I need: I believe we should focus far more on reducing risk factors than on treating “problems.” My goal is to avoid problems and do fewer procedures when and where at all possible.  Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided.  If this happens, I will have less procedures, a fact that will make both me and my patients happy.
What medical records offer: Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business. It allows physicians to give good care despite the system that rewards them for bad care.
What I need: The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system. The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch.  Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.
Dr. Rob is a good guy. I follow his blog posts routinely. He recently went "direct pay" -- cash subscribers. No 3rd party billing (the still-principal focus beef against mainstream EMRs, i.e. "ONC certified" EMRs).


Aug 29 (Reuters) - Aetna Inc has decided not to sell insurance on New York's individual health insurance exchange, which is being created under President Barack Obama's healthcare reform law, the fifth state where it has reversed course in recent weeks.

The third-largest U.S. health insurer has said it is seeking to limit its exposure to the risks of providing health plans to America's uninsured, but did not give details about its decision to pull out of specific markets.

"We believe it is critical that our plans not only be competitive, but also financially viable, in order to meet the long-term needs of the exchanges in which we choose to participate. On New York, as a result of our analysis, we reluctantly came to the conclusion to withdraw," Aetna spokeswoman Cynthia Michener said...
Wonder how this will affect NY's newly approved "Oscar" HIX (if at all)?


An interesting aspect of packing up to move after being in Vegas for 21 years is running into long-forgotten items, such as papers and reports written long ago. The snip below is from a series of reports I wrote 20 years ago during my first HealthInsight tenure (then called "Nevada Peer Review") based on analyses of what were then called "HCFA data" -- basically large file dumps of Medicare claims data that included HIC numbers, demographic info, facility IDs, Attending IDs, admit and discharge dates, discharge destinations, admitting dx, principal dx, secondary dx's, px/tx codes, DRGs, etc.

A hot topic in those days was the "30-day readmit," patients discharged and then re-admitted to an acute care facility within 30 days -- a possible marker for poor quality care.

(The data were crunched and graphics rendered in Stata.)

20 years later, a priority topic for HHS/CMS study and improvement action under the PPACA "pay-for-performance" initiatives (P4P)? The ever-so-persistent "30 Day Readmission."

Maybe this time, given the significantly increased availability of EHR-borne clinical data supplanting claims data, we'll finally make some headway.

PDF scan copy of these ancien reports here (~18 mb. I omitted the voluminous tables).


Bloomberg has an interesting interactive presentation up:
Bloomberg ranked countries based on the efficiency of their health-care systems.

Each country was ranked on three criteria: life expectancy (weighted 60%), relative per capita cost of health care (30%); and absolute per capita cost of health care (10%). Countries were scored on each criterion and the scores were weighted and summed to obtain their efficiency scores. Relative cost is health cost per capita as a percentage of GDP per capita. Absolute cost is total health expenditure, which covers preventive and curative health services, family planning, nutrition activities and emergency aid. Included were countries with populations of at least five million, GDP per capita of at least $5,000 and life expectancy of at least 70 years.
I snipped out the top and bottom 10.

Not sure yet how I feel about these summary proxies for "efficiency." Do what degree do they reflect "quality"? And, if we define "value" as "Quality/Cost," can we get there from these data?



I just downloaded this from O'Reilly (free with registration).

...[D]ata and predictive analytics have driven ever deeper in­ sight into user behavior such that companies like Google, Facebook, Twitter, and LinkedIn are fundamentally data companies. And data isn’t just transforming the consumer Internet. It is transforming fi­ nance, design, and manufacturing—and perhaps most importantly, health care. How is data science transforming health care? There are many ways in which health care is changing, and needs to change. We’re focusing on one particular issue: the problem Wanamaker de­ scribed when talking about his advertising. How do you make sure you’re spending money effectively? Is it possible to know what will work in advance?

Too often, when doctors order a treatment, whether it’s surgery or an over-the-counter medication, they are applying a “standard of care” treatment or some variation that is based on their own intuition, ef­fectively hoping for the best. The sad truth of medicine is that we don’t always understand the relationship between treatments and out­ comes. We have studies to show that various treatments will work more often than placebos; but, like Wanamaker, we know that much of our medicine doesn’t work for half of our patients, we just don’t know which half. At least, not in advance. One of data science’s many promises is that, if we can collect enough data about medical treat­ments and use that data effectively, we’ll be able to predict more ac­curately which treatments will be effective for which patient, and which treatments won’t.

A better understanding of the relationship between treatments, out­ comes, and patients will have a huge impact on the practice of medi­cine in the United States. Health care is expensive. The U.S. spends over $2.6 trillion on health care every year, an amount that consti­tutes a serious fiscal burden for government, businesses, and our so­ciety as a whole. These costs include over $600 billion of unex­plained variations in treatments: treatments that cause no differ­ences in outcomes, or even make the patient’s condition worse. We have reached a point at which our need to understand treatment ef­fectiveness has become vital—to the health care system and to the health and sustainability of the economy overall.

Why do we believe that data science has the potential to revolution­ize health care? After all, the medical industry has had data for gen­erations: clinical studies, insurance data, hospital records. But the health care industry is now awash in data in a way that it has never been before: from biological data such as gene expression, next-generation DNA sequence data, proteomics, and metabolomics, to clinical data and health outcomes data contained in ever more preva­lent electronic health records (EHRs) and longitudinal drug and med­ical claims. We have entered a new era in which we can work on massive datasets effectively, combining data from clinical trials and direct observation by practicing physicians (the records generated by our $2.6 trillion of medical expense). When we combine data with the resources needed to work on the data, we can start asking the impor­tant questions, the Wanamaker questions, about what treatments work and for whom.

The opportunities are huge: for entrepreneurs and data scientists looking to put their skills to work disrupting a large market, for re­ searchers trying to make sense out of the flood of data they are now generating, and for existing companies (including health insurance companies, biotech, pharmaceutical, and medical device companies, hospitals and other care providers) that are looking to remake their businesses for the coming world of outcome-based payment models...
Yeah, to be sure. But, still, I worry about naive and slovenly analytics of "Big Data."

More to come...

Monday, August 26, 2013

Health IT down the drain

Billions wasted on fruitless bid to create paperless vet health records

By Hannah Winston, News 21

The Department of Veterans Affairs and the Department of Defense spent at least $1.3 billion during the last four years trying unsuccessfully to develop a single electronic health-records system between the two departments — leaving veterans’ disability claims piling up in paper files, a News21 investigation shows.

This does not include billions of dollars wasted during the last three decades, including $2 billion spent on a failed upgrade to the DOD’s existing electronic health-records system.
For a veteran in the disability claims process, these records are critical: They include DOD service and health records needed by the VA to decide veterans’ disability ratings and the compensation they will receive for their injuries.

Although Congress repeatedly has demanded an “integrated” and “interoperable” electronic health-records system, neither the DOD nor the VA is able to completely access the other’s electronic records. Meanwhile, each has spent hundreds of millions of dollars on upgrades to its information technology and on attempts to improve interoperability between their systems.

At a July congressional hearing, Rep. Jeff Miller, R-Fla., said he was disappointed and frustrated.  “The only thing interoperable we get are the litany of excuses flying across both departments every year as to why it has taken so long to get this done,” said Miller, the chairman of the Veterans Affairs Committee...

But wait! There's more!
Behemoth breach sounds alarm for 4M
Advocate Health reports second biggest HIPAA breach ever
DOWNERS GROVE, IL | August 26, 2013

Advocate Health System announced that the theft occurred at one of its Advocate Medical Group administrative building in Park Ridge, Ill. on July 15. Patient names, addresses, dates of birth, Social Security numbers and clinical information – including physician, medical diagnoses, medical record numbers and health insurance data — were all contained on the computers, officials say.

Health system officials have contacted local law enforcement to investigate the incident but have been unable to locate the computers.

"We deeply regret that this incident has occurred," wrote Kevin McCune, MD, chief medical officer of Advocate Medical Group, in an Aug. 23 letter mailed to affected patients. "In order to prevent such an incident from reoccurring, we have enhanced our security measures and are conducting a thorough review of our policies and procedures."...
"...we have enhanced our security measures and are conducting a thorough review of our policies and procedures"?

Really? After the fact? Seriously? To determine, say, whether they were HIPAA Omnibus-compliant one month out of the deadline?

How much actual healthcare money has to be foregone in the service of all this incompetence?


Republican hardliners are pushing GOP senators to sign a stunt "pledge" to "defund Obamacare."

Well, I screen-scraped the current status tally off their website and droped it into Excel.

There are 47 GOP Senators. 14 have signed, 9 have stated that they will not, and 24 are tiptoeing past the graveyard.

Boys, you don't have the votes, and are not going to get them. The House is all Sound and Fury, Signifying Nothing. Without a 60 vote Senate supermajority, the "defund" effort is finished before it starts.

While this circus will surely continue until September 30th, you are not going to succeed. "Government shutdown / federal debt default" prospects notwithstanding.

What they're really after is your money. To "sign the petition" you have to give a name and email address. I signed in as "Barack Obama" (I can't believe they don't screen this out).

Which takes you straight to their donation page.

Fleecing the rubes. Talk about money down the drain. My August 20th take on "Defunding ObamaCare" here.

More to come...

Friday, August 23, 2013

Are you ready to board the Omnibus?

One month from today (Sept 23rd) you will have to be able to demonstrate that you are in compliance with HIPAA as amended by ARRA/HITECH.

Will you be able to prove compliance with, most notably, 45 CFR 164.308(a) et seq for protection of ePHI? Implementation of things like
  • Administrative safeguards;
  • Technical safeguards;
  • Physical safeguards;
  • Written coherent and comprehensive policies and procedures;
  • Staff HIPAA training records;
  • Publication and dissemination of revised patient privacy practices;
  • Breach notification procedure;
  • Patient ePHI data request procedure;
  • Omnibus-compliant Business Associates Agreements (BAA).
And so on. Buying some E-Z boilerplate stuff from a HIPAA huckster vendor isn't going to cut it. Buying their E-Z No-Problem one-day online assessment questionnaire service isn't going to cut it. Assurances from some EHR vendor that "We've Covered This One For You" isn't going to cut it.

Maybe you're banking on not getting audited, at least until after you've had time to cobble this annoying stuff together post hoc.

Maybe. Maybe not. post hoc isn't going to cut it. That would be fraud.

HIPAA Hunting Season is about to commence in earnest. I wrote a prior HIPAA post in May of 2012, btw.

More to come...

Tuesday, August 20, 2013

HIX Update: here come the Oscars

New York is again in the Health IT news, HIX-related specifically (Health Insurance Exchanges).
Say Hi To Oscar: The New Kid That May Change Health Insurance
Forbes, Pharma and Healthcare 8/19/13, Nicole Fisher & Scott Liebman, Contributors

In five weeks from now, the Patient Protection and Affordable Care Act mandates the opening of health insurance exchanges around the country. At that time New Yorkers will be introduced to an innovative way of thinking about health care: Oscar. Three friends, and technology entrepreneurs, teamed up to do something that has been inconceivable to date—create a start-up health insurance company to take on conventional health insurers on the NY exchange. Oscar co-founders, Josh Kushner, Kevin Nazemi and Mario Schlosser, plan to change the health insurance industry through technological interfaces, telemedicine and real transparency. Their goal is to redesign insurance to be geared toward the user experience, to make patients seek out their insurer before their doctor.

Americans do not usually think of health insurance as an intimate part of the care process. When sick, individuals do not call their insurance company for care or support. The health insurance industry is considered confusing, at best. The ACA however, presents an opportunity for the reformation of health insurance as we know it, not because of its disappearance, but by making it an integral part of receiving quality care. According to one co-founder, “We want consumers to feel like they have a doctor in the family.” That family doctor he speaks of is Oscar.

Oscar will have one plan in each of the ACAs metal-tiered categories, and additional plan options for the Bronze and Silver tiers. Although Oscar will have some of the familiar pillars of the health care industry like co-pays and deductibles for in-person visits, it introduces new elements like free telemedicine, free generic drugs and online price comparisons. Oscar health insurance will pioneer “a consumer experience, not a processor of claims,” explained Nazemi, with the goal of simply guiding individuals through the complex health system in an integrative and safe way...
...Currently, the Oscar site is merely a welcome page and a list of open positions within the company. But, on October 1st, the site will be fully functioning, possibly putting other sites and insurers to shame. It is certain, given its creative employee background, that the feel and design of Oscar will be more user friendly than the state-based or federal sites.

According to Schlosser, the idea for consumer usage is to have a site where, “like Google, you can come use Oscar. You can type in your issue and we will help you find the best solution.” He explained that the entire experience will be interactive.

When asked about their role or faith in the success of the ACA, the team commented that, “the ACA is a catalyst for what we’re doing.” And the creators hope that Oscar will become a catalyst for the rest of the health insurance industry to be more transparent. They claim Oscar will set the stage for new expectations and behaviors by consumers, and that people already know they deserve more from their health care system.

Whatever the success of Oscar in the early stages of the exchange market in New York, one thing is for certain; Oscar has the potential to cause much needed disruption to health insurance and health care.
Should be interesting. Full article link here. More below, from The Washington Post.

Can three technologists, $40 million, and Obamacare change health insurance forever?
By Ezra Klein,  July 26 at 11:19 am

On Jan. 1, 2014, the federal government will begin subsidizing millions of people’s health insurance purchases through Obamacare. “At that point,” warned Byron York, an influential conservative columnist with the Washington Examiner, “the Republican mantra of total repeal will become obsolete.”

Three years after the law passed, one year after the U.S. Supreme Court upheld it, and nine months after Republicans lost the election that might have allowed them to repeal it, the Washington conversation is still about Republicans’ rearguard actions to undermine the Affordable Care Act and profit politically from the damage.

But in a cavernous room in New York’s SoHo district, a group of entrepreneurs is working to render the entire Washington conversation over Obamacare obsolete. There, Obamacare is no longer a political controversy: It’s a business opportunity. And a trio of young technologists have raised $40 million to take advantage of it...

The palpable (and candidly expressed) anxiety of the intransigent, uncompromising Right goes to their fear that, once the HIX process ensues and smooths out, voters may well in the aggregate come to like the PPACA tolerably well; they will be able to obtain health insurance coverage heretofore out of reach owing to income, age, and pre-existing conditions (including those latent in the genes), etc. They'll have become "addicted" to "dependency" on the federal government.

So, increasingly, we have to endure the maudlin Boehnerista/Ted CruzControl brinksmanship comprised of the threat to "shut the government down" on October 1st should the President and congressional Democrats fail to agree to the "defunding of ObamaCare" (principally meaning at this point scuttling the linchpin nacsent HIX rollout). GOP mouthpieces are all over the media trying to spin things as Obama "wanting to" shut down the federal government (and default on the federal debt).

08/21 NEWS SNIPPET: Sen. Ted Cruz (R-Texas) faced some unexpected guests at his Obamacare town hall on Tuesday night, enduring a line of hecklers multiple times during his speech.

Video footage from NBC News shows protesters shouting "USA! USA! USA!" The Washington Post reports that he also received chants of “you have health care, we should too!”...
My reaction to the "Defund" demand, posted far and wide.
I thought President Obama -- the Constitutional Law Professor, recall? -- gave a weak reply to the reporter who asked him during his pre-vacation Presser if HE was prepared to let the government shut down on October 1st. Well, that's blatantly false framing. Here's all you need to know about it, from the Constitution:

The Congress shall have power to lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defense and general welfare of the United States; but all duties, imposts and excises shall be uniform throughout the United States;

To borrow money on the credit of the United States;

To make all laws which shall be necessary and proper for carrying into execution the foregoing powers, and all other powers vested by this Constitution in the government of the United States, or in any department or officer thereof.

The validity of the public debt of the United States, authorized by law, including debts incurred for payment of pensions and bounties for services in suppressing insurrection or rebellion, shall not be questioned.

The Congress shall have power to enforce, by appropriate legislation, the provisions of this article.

That's it. There's nothing else pertaining to passing laws and funding the federal government.

NOWHERE in the Constitution is the President authorized to [1] borrow money to run the nation and/or [2] repeal or "defund "his own law" (the Affordable Care Act). The authority to pass, amend, or repeal laws (and/or to borrow money or enact taxes to appropriate funds) is SOLELY the responsibility of Congress.

Congress has the power to override any Presidential veto should it become necessary. That is how it works. Should Congress fail to uphold the national debt as required, those voting to let the government go into default and shut things down will be in explicit violation of their Oaths of office and the Constitution and should be removed from office.

Don't fall for the jive. I know this is all largely brinksmanship posturing in the service of kissing the angry butts of the recess Town Hall Meeting mouth-breather ignoramuses (a significant percentage of them on Medicare and Social Security) who can't even spell "Civics Lesson," but this could all go terribly wrong. It's way past time to stand up to these morons. This threat to shut down the federal government and default on the debt unless Obama agrees to the defunding of the PPACA amounts to extortion. Recall the Oath to defend the nation from all enemies, "foreign or domestic"? These congressional extortionists fall clearly into the latter category. And they need to be loudly and unrelentingly called out on it. Thus far this is not really happening; the public in the aggregate has no clue as to the clarity and severity of the situation.

The President needs to get his act together and point out forcefully just where the responsibility lies on this issue. This pre-adolescent foot-stomping anti-governance nihilism has gone way too far. President Obama needs to make things clear both to the public and to the small handful of actual adults on The Hill.

I urge you all to write your senators and congressmen/women and tell them to Cut the Crap. And write the White House to urge the President to clearly state what OUGHT be obvious.
Now, it ought be clear (but probably isn't) that federal debt default (patently unconstitutional) and federal shutdown (arguably constitutional, notwithstanding its shoot-yourself-in-the-foot stupidity) might well be separate issues. Congress could authorize payment of existing debt (consistent with Amendment XIV) while refusing to allocate funding for ongoing federal operations.

DeMint: Republicans who oppose Defund Obamacare ‘need to be replaced
By Aaron Blake, Washington Post, August 20

Former senator Jim DeMint (R-S.C.) said in an interview broadcast Tuesday that congressional Republicans who oppose the Defund Obamacare effort “should be replaced.”

“I’m not as interested in the political futures of folks who think they might lose a showdown with the president,” DeMint said at a Monday town hall hosted by Heritage Action, the political arm of the Heritage Foundation, which DeMint leads.

DeMint later told NPR: “I think (President Obama) knows that Republicans are afraid, and if they are, they need to be replaced.”

The Defund Obamacare movement seeks to get Republicans to commit to not voting to fund the government if Obamacare is included in that funding.

But several GOP senators have balked at the proposal, not wanting to risk a government shutdown that could be blamed on Republicans...

Obviously, the risk calculation concern here is obviously one of GOP-directed "blame" with Legs that might translate into further erosion of Republican control of Congress -- perhaps even loss of control. But, "risk calculations" apparently do not seem to enter into the minds of the nihilistic Defund/Shutdown/Default cohort. They want crisis, calamity even. Their look-ahead political worldview extends no further than the first week of October 2013.

OK, What does any of the foregoing have to do with Health IT?

Do I really have to explain it?


 By Caren Bohan

WASHINGTON, Aug 21 (Reuters) - U.S. Republican lawmakers, who staunchly oppose President Barack Obama's signature healthcare law, are considering using a fall showdown over the country's borrowing limit as leverage to try to delay the law's implementation.

The idea is gaining traction among Republican leaders in the House of Representatives, aides said on Wednesday. An aide to House Majority Leader Eric Cantor said the debt limit is a "good leverage point" to try to force some action on the healthcare law known as "Obamacare."

"There are plenty of discussions ongoing but no decisions at this point," said another leadership aide.

Republicans are weighing the tactic as an alternative to another approach that would involve denying funding for the law and threatening a possible government shutdown.

The push to deny funding for Obamacare has the backing of some prominent Republican senators, including Ted Cruz of Texas and Marco Rubio of Florida.

But many Republicans in both the House and the Senate oppose the shutdown strategy, viewing it as a reckless move that is bound to fail. Many worry the gambit would cause a backlash against their party ahead of the 2014 congressional elections.

When lawmakers return on Sept. 9 from their five-week summer recess, they will face two fall deadlines. If Congress does not pass a measure by Oct. 1 to keep federal agencies funded, the government will shut down.

Another standoff looms in late October or early November when lawmakers must pass an increase in the U.S. debt limit or face a default on the country's debt...
Yep. Tactical political "leverage," or extortion via threat of a dangerous unconstitutional act?

While I'm editorializing: This photo below is from a metastasizing stunt called "Overpasses for Impeachment."

I might have to call this "child abuse." We used to teach our children to respect American government and our legal system. Now we use them as props in the service of sedition.

"States will be required to check in with the federal hub for applicants’ immigration status, income level, etc. The federal hub is being built and rolled out at the same time that states are designing the rules for how their marketplaces will speak to and integrate with it. Again, it’s a bit like remodeling an airplane mid-flight."
From "In the Eleventh Hour," The Health Care Blog.

Twitter hashtag #HCUX

Top 10 Healthcare Usability Myths Debunked
Myth #1 Clinicians are Uncomfortable with Technology and just need more training
Fact: Current HIT systems often don’t fit the way end users think and work

Myth #2 Put it all on 1 screen to make it easier to use

Fact: Developers need to understand workflows and tasks to know what information is needed

Myth #3 Whoever has the Most features wins
Fact: Vet your current feature set. Less may be more

Myth #4 If they like it on the desktop, they’ll love it on mobile
Fact: Context and tasks matter more

Myth #5 If we allow clinicians to customize their screens they will be satisfied
Fact: Develop information architecture for users’ workflow

Myth #6 Usability is subjective
Fact: There are many types of usability measures (performance, cognitive, perceptions, motivation, costs, risk management etc.)

Myth #7 Usability = Only Pretty & Friendly
Fact: Usability = Patient Safety

Myth #8 Usability Stifles Innovation
Fact: Usability drives innovation. Got iphone?

Myth #9 Usability is the Vendor Responsibility
Fact: Usability is a joint responsibility

Myth #10 Meaningful Use Stage 2 is another year away
Fact: Start preparing now---usability takes time

More to come...

Thursday, August 15, 2013

"Start Spreading The News..."

Mana Health wins contract to design patient portal for New Yorkers
August 15, 2013

New York eHealth Collaborative held a design challenge earlier this year to spark some ideas and discussion on how to execute some of the goals of the patient portal for its statewide health information network. Mana Health, a digital health startup that won the competition, has now got a contract to design it, according to a press release.

One of the biggest challenges companies encountered was how best to bridge the gap between patient needs and health literacy. Mana Health’s design balancing important information with big colorful graphics is aimed at increasing patient engagement...
Interesting. Having been born on Long Island and raised in northern New Jersey, I follow regional developments routinely, developments in Health IT in particular. NYeC has a good rep as a leader.

Nice consumer-facing look to this product.
It's gonna have to be usable, stable, nimble, and secure. And, "sustainable." -- i.e., who pays? We shall see. I wish them the best.


Michigan doctor held on $9 million bond for misdiagnosing cancer patients in Medicare scam
Oncologist Farid Fata allegedly scammed $35 million from Medicare for giving unnecessary chemotherapy to patients who didn't need it and diagnosing cancer when patients didn't have it. The scheme took place over a two-year period.
[NY Daily News] An oncologist accused of intentionally misdiagnosing cancer patients to scam Medicare in Detroit had his bond set at $9 million by a federal judge...

Fata, who owns Michigan Hematology Oncology Centers, is accused of giving unnecessary chemotherapy to patients who didn't need it and diagnosing cancer when it wasn't apparent.

According to the complaint, Fata defrauded federally funded Medicare out of about $35 million over a two-year period.

He was arrested on Tuesday and taken to Wayne County Jail in Detroit, and federal agents raided his multiple offices in the Detroit area.

They also seized his medical records as they build a case against him.

Robert D. Foley, III, the FBI special agent in charge, said in a news release, "Violating a patient's trust and placing them at risk through fraudulent abuse of our nation's health care system is deplorable and a crime which the FBI takes most seriously."

The FBI remains committed to the arrest and prosecution of those who commit health fraud, he said.

According to ABC News, Angela Swantek, an oncology nurse who spent time at one of Fata's clinics, said she had first complained to investigators about his alleged wrongdoings in 2010.
"I don't know how he's gotten away with it for this long," she told ABC News...
We've been gumshoeing Medicare billing records for decades. We of late have "RACs" -- Recovery Audit Contractors -- for this sort of thing, but, could we expand this into "clinical forensics," perhaps using SOAP dx/tx fraud screening algorithms that probe HIT records and kick out suspect findings for expert "chart review," much of which could be done remotely by forensically trained telecommuting docs?

If this guy is convicted, he deserves a special place in Hell.


Just got notified of my press credential  approval for the 2013 Health 2.0 Conference.

The 2012 conference in San Francisco was great fun: e.g., as I covered here, here, here, and here. This year I'll be living in the Bay Area. My Vegas house is now under sales contract and is in Due Diligence, and we just put in an application for a leased house close to Cheryl's office in Walnut Creek.


From a current AthenaHealth white paper, the Physician Sentiment Index:

Lots of unhappiness in the Physicians' world these days. Dubiety and despair at every turn it seems. "ObamaCare" sux. All proposed payment reform models suck. Decreasing physician autonomy and reimbursements suck. Increasing regulation sux. Health IT sux...

e.g., from The Health Care Blog:

What, if anything, can be done that might garner the sustainable traction of consensus? One thoughtful proffer here:

A Blueprint for a More Effective, Physician-Directed Health System
Research funded by The Physicians Foundation, Jeff Goldsmith, Ph.D. May 2013

As it moves inexorably toward implementation, it is becoming clear that health reform, as envisioned in the Affordable Care Act of 2010, will not fix our health system. While providing coverage for perhaps 30 million Americans represents progress, fundamental flaws in the legacy health payment and care systems will result in squandering a lot of the new funding without improving Americans’ health.

The US healthcare system has been changing rapidly in anticipation of health reform. Specifically, it has been consolidating into regional hospital monopolies that are narrowing patients’ choices and driving up the price of healthcare to patients, businesses and health insurers. Hospital systems are also using their enhanced bargaining leverage with health plans and the resultant cash flow to absorb their physician communities, locking down healthcare markets. Further, in most American communities, two or fewer health insurers control half or more of the health insurance market. Patients and their physicians find themselves marginalized in an increasingly corporate and uncompetitive healthcare marketplace.

The central questions in health reform are how to obtain better value for the healthcare dollar and how to engage patients more effectively in improving their own health. Because they are the pivotal contact point for patients and their families, physicians can play a decisive role in achieving both better health for patients and a more effective health system overall – by helping patients manage their health risks and by finding the most cost-effective solutions to patients’ health problems when intervention is required. If patients and physicians are submerged in vast bureaucracies, however, that potential will never be realized...
Physicians have a crucial role to play not only in reforming the care system, but also in creating cost and quality accountability in the care system. Physician care remains a bargain compared to institutional alternatives. And because they know where the waste is in the system and how to avoid it, physicians can play a key role in organizing the most cost-effective care when patients need it.

Physicians wishing an alternative future to becoming employees or civil servants will need to do three things:

  1. Achieve the Mass and Scale to Organize Care More Effectively and Lower Costs
  2. Develop New Care Models that Better Meet Patients’ Needs
  3. Assume More Risk and Responsibility for Managing the Cost of Care
In order for these things to happen, public financing programs and private health plans must forge new working relationships with physicians – as well as simplify their financial relationships with physicians to support these new models and encourage better teamwork in care provision.    Physicians are the key to a more efficient, humane and effective US healthcare system.
Full paper here (pdf). I'll finish reading it prior to commenting further.

apropos of the issue:

The accompanying editorial by Ezekiel Emanuel and Andrew Steinmatz calls the current national debate about healthcare an “all hands on deck” moment in medical history. They wonder whether doctors will assume responsibility and step in to captain the ship, or stand aside, and let others navigate the future of healthcare while they swab the deck.

Only one-third of doctors in the survey felt that they themselves had a major responsibility for reducing costs. The news media jumped on this as doctors simply blaming others. But looking at it from a more human perspective may explain this seemingly callous response.

We doctors train in the scientific method and subscribe to evidence-based medicine. We calculate risk profiles and cite placebo-controlled studies. But we are not nearly as rational as we like to tell ourselves, or our patients. Past experiences, gut instincts, and emotional contradictions factor in just as much hard data, especially when we try to figure out how to steer the listing ocean liner that is our health care system today.

For the average practicing physician, the major goal of any given day is simply to stay afloat. The typical 15-minute office visit is rarely enough time to fully address the clinical needs of patients with multiple chronic illnesses, and the onerous documentation demands of electronic medical records ensure that doctors spend most of that visit interacting with the computer rather than with the patient.

 Many of these documentation requirements are, of course, important.. As a primary care internist, I wholeheartedly support the idea that we should be asking our patients about domestic violence, depression, and pain levels, that we should be on the lookout for barriers to communication, that we should be documenting efforts in patient education, that we should be rigorous about age-appropriate screening tests, that we should print and review the medication list at every visit.

But there are so many requirements—and the list keeps growing—that there’s hardly time in that 15-minute visit to talk to the patient about their actual medical conditions, let alone do a thorough...

More to come...