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Wednesday, January 29, 2014

"There is no way to survive the coming rise in Medicaid recipients, aging boomers, still-uninsured and underinsured without a lean, efficient organization." - Joe Flower

One of the clearest thinkers in the health care space is Joe Flower. His latest blog post "What about the poor?" is a tour de force. An excerpt:
What can we expect in the coming years?

The Future of Medicaid, the Uninsured and the Underinsured

Medicaid numbers are astonishing if you are not used to them. Even before the projected expansion, at some time during an average year about 72 million people, close to a quarter of all Americans, are on Medicaid. At any given moment, it’s over 50 million. Medicaid is an open-ended program: When more people are eligible, or sick, or have more complex diseases, the states and the federal government pay more. By law, states have to provide certain minimum benefits for certain defined poor populations, such as children, pregnant women, the disabled and the elderly. The only control states have over Medicaid costs is to cut reimbursements and to control utilization by making health care massively inconvenient to access.

The economy. The economy appears to have undergone real structural change. In this new economy a lower proportion of the working age population is able to find work with a living wage or start a sustaining business. Income inequality is still growing, with almost all of the new wealth created in the slowly recovering economy going to those few who are already well off. So we can expect more Medicaid-eligible people every year.

Expansion. In over half the states, Medicaid eligibility has been expanded by the Affordable Care Act (ACA) to include all adults with income below 138 percent of the federal poverty level (FPL). More states will likely accept the expansion. Turning away federal money that would benefit your citizens and pay for thousands of jobs (as studies show) may be ideologically pure, but politically and economically it is a very shaky stance. It will become shakier as people in neighboring states reap the benefits, while yours do not.

Will those newly covered individuals use more health care or less? Contrary to a common assumption, studies show that just getting people covered does not in itself improve their health, and those newly insured patients will likely use the emergency department (ED) 40 percent more than they did when uninsured, unless the system finds some less expensive way to serve their needs. The “system,” in this case, is you.

. The ACA will actually expand the ranks of the underinsured (those whose insurance is weak enough that they will often act as if they are uninsured). The “bronze” plans cover only 60 percent of most expenses; the “silver” only 70 percent, well below the 80 percent typical of corporate plans, with much higher deductibles. The feds also allow, in fact encourage, states to add deductibles and co-pay requirements to Medicaid even for the poorest. And many states that are expanding eligibility are actively cutting reimbursements, narrowing networks and reducing benefits.

Out-of-luck demographics
. At the same time many people, especially in the just pre-Medicare demographic, will not want to accept Medicaid, because they still have some assets, typically equity in a house, that Medicaid would require them to liquidate and “spend down.” In the states that do not expand Medicaid eligibility, the uninsured non-disabled adult below 138 percent of the FPL is just plain out of luck, with no ACA subsidies for insurance, but is still hit with the ACA tax penalty.

So expect still substantial numbers of uninsured — 26 million by 2016 by Congressional Budget Office estimates — as well as growing Medicaid rolls in all states, even those that do not expand eligibility.

? “Deficit hawk” politicians focus on Medicaid because it is growing and open ended. Proposals to reform Medicaid largely would make it into block grants to the states, which Congress could then throttle downward. No proposed reforms contemplate putting more money into Medicaid. Under any reasonably expectable political scenario we can expect ever-narrowing reimbursements.

Health care execs can be forgiven for feeling that they are in some zombie movie, pursued by teeming masses of people with Medicaid coverage, or no coverage at all. But it’s time to stop hiding. It’s time to leave behind the old tactics of divert, dump and deny once and for all, and to push instead for radical new ways of providing health care — good, quality care — to those who can least afford it...
Click the link above. Read the entire piece. I've forwarded it on to Dr. John Toussaint of the ThedaCare Center.

I began this blog nearly four years ago touting the utility of "Lean" right in my first post. See also one of my workflow slide decks (pdf).

apropos of the title of Joe's post, "What about the poor?" recall my prior post When it comes to health, your zip code matters more than your genetic code.”

See also Danielle Ofri's latest:
When Doctors Give Patients Money

Recently a few of my colleagues were sitting together and one asked if any of us had ever given money to a patient. There was an awkward pause, and then the stories starting coming out — a few dollars for a co-pay, or to help a frail patient take a cab instead of a bus; a bag of food or an extra meal. “How could I not,” one doctor said, “when my patient’s immediate need could be solved by the small change in my coat pocket?”

A physician recently wrote in JAMA about giving a patient $30 to help pay for a medication after a two-hour phone battle with the insurance company came to naught. He was cited by his institution for unprofessional behavior, but was also deluged with letters from doctors and nurses who have been in the same position and done the same thing.

We hear daily about “health care costs,” a lumbering behemoth that dominates the news and the economy. But it is the smaller amounts, literally the pocket money, that often has the most profound and palpable effect on the concrete currency of health.

Caregivers on the front lines fully recognize that giving patients a few dollars isn’t ultimately the way to solve the problems of society. But the starkness of our patients’ immediate needs are hard to ignore...
Even though overall health care costs have been falling slightly, and some aspects of the economy appear to be improving, economic realities are playing an increasing role in the day-to-day health of many patients. The dollar amounts in question are usually small — bundled together they would hardly rise to a rounding error of a distant decimal of “health care costs.” The impact, however, is anything but small. Medications skipped, antibiotics delayed, procedures avoided, diet skimped — the morbidities rack up quickly.

A recent study in Health Affairs confirmed what most physicians and nurses see in their daily practice — lack of small amounts of money wreaks outsize damage on health. This particular analysis showed that in low-income neighborhoods there was a 27 percent increase in hospital admission for hypoglycemia, or low blood sugar, at the end of the month compared with the beginning of the month.

This end-of-the-month disparity, unsurprisingly, was not noted in high-income neighborhoods, where households do not run out of money and food at the end of the month...
Yeah. See also
Millions Are Now Realizing They're Too Poor For Obamacare

Thanks to a Supreme Court ruling and staunch Republican resistance, Marc Alphonse, an unemployed 40-year-old Marine veteran who is essentially homeless, cannot get health insurance under Obamacare.

Three years ago, Alphonse learned he has a kidney disorder that will deteriorate into kidney failure, and possibly prove fatal, if left untreated. As it stands now, he suffers from bouts of nausea caused by his dysfunctional kidneys, and he's dogged by an old knee injury that limits his job prospects. He gets by on $400 a month in unemployment benefits, and his family can no longer afford housing in their home city of Miami. Alphonse's 28-year-old wife, Danielle, and three young children are staying with relatives while Alphonse couch surfs.

"I live from family to family until I'm able to get myself situated," he told The Huffington Post.

Alphonse is one of nearly 5 million uninsured Americans caught in a cruel gap that renders some Americans "too poor for Obamacare."

Broken Promise
Obamacare was supposed to make health coverage affordable, or even free, for low-income Americans. The law's official name is the Affordable Care Act. However, the Supreme Court tossed a huge obstacle in the path of that goal in 2012, ruling that the states could opt out of one of Obamacare's crucial provisions: The expansion of Medicaid coverage to anyone making less than 133 percent of the federal poverty level, or about $15,300 a year for a single person. Since the court's ruling, 24 states, including Florida, chose not to expand the program...
Indeed. "What about the poor?"

More to come...

Tuesday, January 28, 2014

"The SOTU is ____________________________."

I'll be watching tonight. Be interesting to see how much time the President devotes to health care.

Am I too cynical? What's your take on the SOTU?

Been a slow Health IT news period lately. I'm seeing a lot of re-reporting of the same few stories, over and over and over.

I'm pretty sure the President will mention "income inequality" during his SOTU. apropos of my recent post When it comes to health, your zip code matters more than your genetic code,”

A 2013 SOTU Wordle

2014 SOTU Wordle


More to come...

Saturday, January 25, 2014

BREAKING: Nevada State Health Information Exchange board votes to cease operations

Above: from yesterday's published meeting agenda.

Sources report that the Nv HIE has voted to cease operations. This effort was started via a $6.1 million ONC cooperative grant concomitant with the passage of Nevada SB43 (pdf).

Questions linger as to what was done with these substantial funds, given that the HIE had barely begun bare-bones operations several years after issuance of the grant.

The HIE website has apparently been taken down.

NOTE: this is not the HealtHIE Nevada HIE, which is the private not-for-profit statewide health information exchange administered by HealthInsight.


I loved this, from NV HIT Coordinator Lynn O'Mara's notice to prospective HIE participants.

Okay. So, can we assume that DHHS has been HIPAA compliant with respect to having named a/the Privacy and Security Official(s)? Who has/have [1] conducted the requisite HIPAA Security Risk Analysis, mitigated any deficiencies, [2] written the requisite Policies and Procedures, and [3] trained all staff for compliance?

The other odd thing here is the request for a BAA document from each applicant provider. You risk having to deal with complying with umpty differing BAA specifications. You should require that all signups use your HIPAA-compliant BAA.

What a waste.


Full story here

Full story here


Dear Bobby,

HealtHIE Nevada would like to address any concerns that may have arisen after it was revealed that the Nevada Health Information Exchange (NV-HIE) will shut down on Feb. 7. We also want to clear up any confusion that may have come as a result of this announcement.

We would like to reassure all of our participants that the decision by the Nevada Health Information Exchange does not impact the operations of our organization. As you know, we are not affiliated with NV-HIE nor do we currently receive state or federal funding to operate. We remain an independent, stakeholder led, private, not-for-profit health information exchange. We have a deliberate sustainability plan in place, and we have positioned ourselves for continued growth and success in the coming years.

HealtHIE Nevada has made strides since its inception. We have grown from a single hospital using our health information exchange system to having every major hospital system in the state participating in our HIE. Our system allows health care providers to access and transmit information in an effective compliant manner.

HealtHIE Nevada remains committed to serving Nevada communities by providing healthcare providers timely access to clinical patient information so they can provide patients with the quality care they deserve. We continue to have conversations with the NV Department of Health and Human Services to find ways we can work together to meet our mutual needs and goals.

We encourage you to actively spread the word that HealtHIE Nevada is not affected by the closure of NV-HIE and remains a vital part of our health care community. HealtHIE Nevada looks forward to continuing to serve as a catalyst for improved health care outcomes in Nevada.

HealtHIE Nevada

More to come...

Tuesday, January 21, 2014

“When it comes to health, your zip code matters more than your genetic code.”


One of my daily blog destinations is The Incidental Economist. A while back I ran across this:
Sometimes health policy can’t be about about health care
A paper in this month’s edition of Health Affairs (gated) provides a stark reminder that many determinants of health lay well outside the boundaries of insurance and health care delivery. Hilary Seligman and her coauthors examined temporal trends in the incidence of hypoglycemia (dangerously low blood sugar, usually associated with diabetes), stratified by income*. They posit a plausible story about the “pay cycle” that develops in households, which is well established in the literature, particularly among low-income individuals . Toward the end of the month, a household’s resources—income, SNAP, Social Security, and/or other benefits—can become exhausted, ostensibly changing food consumption patterns...
Policy wonks have a terrible habit of focusing on insurance and health system design (and here I count myself, because health care financing is the research I find most interesting, so it’s what I write about). This gives short shrift to the “social determinants” of health—upstream factors related to lifestyle, environment, and socioeconomic status—that cannot be corrected by medical interventions. We’re fond of highlighting how much more the United States spends on health services, but an idiosyncrasy that receives less attention is how much less we spend on other social services. For a fuller discussion of that than I can provide, you should see this interview with Lauren Anne Taylor and Elizabeth Bradley, authors of The American Health Care Paradox.

These findings also illustrate the difficulty in finding policy solutions to address health disparities. The authors note that food pantries and soup kitchens already ramp up staffing and resources toward the end of the month. We could explore different ways to distribute existing benefits, but that may have other negative impacts (ie: making it harder to pay rent or bills at the beginning of the month).

Of course, in the political arena, the discussion isn’t framed as “expanded coverage or expanded social policy”. Instead, we’re stuck with polemics about “expanded coverage… or not.”  As complicated as insurance is, we default to it in health policy because it seems the most facile way to confront medical problems. That doesn’t make it the most effective way—but it’s hard to be optimistic about changing the terms of the debate.

*Here, “low-income” is defined as residing within a ZIP code where average income is in the lowest decile of admitted patients in a given year. Everyone not matching this criterion is “high income”.
"...focusing on insurance and health system design." Indeed. PPACA, ACOs, HIX, Health IT, Big Data, Quality Measures, "interoperability," organizational leadership, workflow redesign, etc. All the topics nominally the broad focus of this blog.

But, apropos,

Health policy was once thought to be about little more than the provision and funding of medical care: the social determinants of health were discussed only among academics. This is now changing. While medical care can prolong survival and improve prognosis after some serious diseases, more important for the health of the population as a whole are the social and economic conditions that make people ill and in need of medical care in the first place. Nevertheless, universal access to medical care is clearly one of the social determinants of health.

Why also, in a new publication on the determinants of health, is there nothing about genes? The new discoveries on the human genome are exciting in the promise they hold for advances in the understanding and treatment of specific diseases. But however important individual genetic susceptibilities to disease may be, the common causes of the ill health that affects populations are environmental: they come and go far more quickly than the slow pace of genetic change because they reflect the changes in the way we live. This is why life expectancy has improved so dramatically over recent generations; it is also why some European countries have improved their health while others have not, and it is why health differences between different social groups have widened or narrowed as social and economic conditions have changed.
PDF link here.

Recall my coverage of the stirring Keynote of outgoing Kaiser head George Halvorson back in November at NYeC 2013. George has made the mitigation of health care disparities his next focus of action.

This kind of stuff takes us uncomfortably but unavoidably into socioeconomic theory and the heated partisan politics it generates.

to wit:

Two issues dominated Barack Obama’s first presidential term: healthcare and the economy. Both reflect the tension between the individualism of the Northern herders and the collectivism of the Southern herders. The Patient Protection and Affordable Care Act, also known as Obamacare, established national health insurance in the United States. Liberals praised it, not as a perfect system but as a historic step in the right direction. The United States had finally joined the rest of the modern world in providing basic healthcare to all its citizens. Conservatives— many of them— despise Obamacare, which they regard as a step toward ruinous socialism. The recent healthcare debate has been awash in misinformation,* but amid the lies and half-truths there can be found an honest philosophical disagreement.

At its core, this disagreement, like so many others, is about the tension between individual rights and the (real or alleged) greater good. Universal health insurance requires everyone to buy in, either through an individual purchase of health insurance or through taxes. Conservatives mounted a  legal challenge to Obamacare, culminating in a landmark Supreme Court decision. The Supreme Court upheld Obamacare on the grounds that it’s funded through a combination of voluntary purchases and taxes (which are both constitutional) rather than by the government’s forcing people to buy something (which is arguably not constitutional). But the tax-versus-forced-purchase distinction is really just a legal technicality. The people who hate Obamacare don’t hate it because they believe that it’s funded by forced purchases rather than forced taxes; what they hate is the forcing. Obamacare might not be socialism, but it’s certainly more collectivist than some people care for, restricting individual freedom in the name of the greater good.

During one of the primary debates, journalist Wolf Blitzer had the following exchange with Texas congressman Ron Paul.
BLITZER: A healthy 30-year-old young man has a good job, makes a good living, but decides, you know what? I’m not going to spend $ 200 or $ 300 a month for health insurance because I’m healthy, I don’t need it. But something terrible happens, all of a sudden he needs it. Who’s going to pay if he goes into a coma, for example? Who pays for that?
PAUL: Well, in a society that you accept welfarism and socialism, he expects the government to take care of him.
BLITZER: Well, what do you want?
PAUL: But what he should do is whatever he wants to do, and assume responsibility for himself. My advice to him would have a major medical policy, but not be forced—
BLITZER: But he doesn’t have that. He doesn’t have it, and he needs intensive care for six months. Who pays?
PAUL: That’s what freedom is all about, taking your own risks. This whole idea that you have to prepare and take care of everybody— [applause]
BLITZER: But Congressman, are you saying that society should just let him die?
As Paul prepared his hesitant answer, a chorus of voices from the crowd shouted, “Yeah! Let him die!” These are the Northern herders. Paul couldn’t quite bring himself to agree— or disagree. He said that neighbors, friends, and churches should take care of such a man, implying, but not explicitly stating, that the government should let him die if no one else is willing or able to pay. As you might expect the more Southerly herders disagree.

(Note: In the Parable of the New Pastures, the Southern herders are extreme collectivists, communists, and are thus far to the left of contemporary mainstream liberals, despite frequent accusations to the contrary. Thus, as we discuss contemporary politics, I refer to contemporary liberals as “more Southerly” rather than “Southern.” Contemporary U.S. conservatives, in contrast, resemble more closely their fictional Northern counterparts.)

Along with healthcare, the miserable state of the U.S. economy took center stage during President Obama’s first term. When Obama took office in 2009, the economy was in free fall, thanks to a housing bubble that burst after a decade of inflated growth and a financial sector that placed enormous bets on housing prices. The government did several things in an attempt to stave off complete financial disaster. First, in late 2008, while President Bush was still in office, the federal government bailed out  several of the investment banks at the heart of the crisis.* Later, the Obama administration bailed out the auto industry and extended aid to homeowners facing foreclosure. These measures were opposed, to varying degrees, by Northern herders who argued that the banks, the automakers, and the desperate homeowners should, like Ron Paul’s hypothetical patient, be allowed to “die.” Why, they asked, should American taxpayers have to pay for these people’s poor judgment? The more Southerly herders didn’t especially relish the thought of bailing out irresponsible decision makers, but they argued that these measures were necessary for the greater good, lest their bad choices sink the whole economy. During Obama’s first year, congressional Democrats passed his $ 787 billion stimulus bill, the American Recovery and Reinvestment Act of 2009. This, too, was opposed by Northern herders who favored less government spending and more tax cuts. Better, they said, to put money into the pockets of individuals who can decide for themselves how to spend it.

Related to both healthcare and the economy is the broader issue of economic inequality, which came to the fore in 2011 with the Occupy Wall Street protests. From 1979 to 2007, the incomes of the wealthiest U.S. households skyrocketed, with the top 1 percent enjoying income gains of 275 percent, while the bulk of Americans gained around 40 percent. (The gains at the tippy top, the top 0.1 percent, were even larger, around 400 percent.) These trends inspired the Occupy slogan “We are the 99%,” calling for economic reforms to restore a more egalitarian distribution of wealth and power.

The story of rising income inequality comes in two versions. According to the individualist Northern herders, the winners earned their winnings fair and square, and the losers have no right to complain. “Occupy a Desk!” read the sign of a Wall Street counterprotester. Presidential hopeful Herman Cain called the protesters “un-American,” and the eventual Republican nominee, Mitt Romney, accused them of waging “class warfare.” In September 2012, the liberal magazine Mother Jones dropped one of the biggest bombshells in U.S. electoral history. They posted online a secret recording of Romney in which he described roughly half of the American population as willful government dependents who will never “take personal responsibility and care for their lives.” According to Romney’s infamous speech, the “47 percent” of the population that earns too little to pay income taxes (on top of payroll taxes) deserve no better than what they’ve got.

The more Southerly herders tell a different story. They say that the wealthy have rigged the system in their favor, noting that rich people like Mitt Romney pay taxes at a lower rate than many middle-class workers, thanks to lower tax rates on investment income, myriad tax loopholes, and overseas tax havens. And now, thanks to the Supreme Court’s decision in Citizens United v. Federal Election Commission, which legalized unlimited campaign contributions to “independent” political groups, the rich can use their money to buy elections like never before. These more Southerly herders say that even in the absence of nefarious system rigging, maintaining a just society requires active redistribution of wealth. Otherwise the rich use their advantages to get richer and richer, passing on their advantages to their children, who then begin life with a big head start. Without redistribution of wealth, they say, our society will bifurcate into permanent classes of haves and have-nots...
Thanks to Science Based Medicine for the tip on this book. See Tribalism and Medical Ethics. Economic disparities are sharply in the rise in the U.S., -- increasingly so. 

e.g., consider the maps below regarding two of our major cities, New York and San Francisco.

Darkest shaded areas depict highest income earners. This is a hot topic of late in my Bay Area -- the new Techie Billionaires pricing everyone else out of the city. Resentment has been building; Google private employee commuter buses have been attacked. Twitter headquarters in downtown SF is the site of protests.

Just in (Jan 22):
The tech protests get personal — and ugly
Breaking the rules of a civil society: Activists target a Google engineer at his Berkeley home

On Tuesday, an activist group styling itself the “Counterforce” took the San Francisco Bay Area “protests” against tech-boom-driven gentrification to a new, absurd and potentially dangerous level. They rallied in front of the Berkeley home of Google engineer Anthony Levandowski, ringing his doorbell at 7 a.m. and passing out fliers in his neighborhood that claimed he “develops war robots for the military and builds surveillance infrastructure.”...

From Counterforce’s manifesto:

After previous actions against the Google buses, many critics insisted that the individual Google employees are not to blame. Taking this deeply to heart, we chose to block Anthony Levandowski’s personal commute. We also respectfully disagree with this criticism: We don’t see one action as better than the other. All of Google’s employees should be prevented from getting to work. All surveillance infrastructure should be destroyed. No luxury condos should be built. No one should be displaced…

Below, Park Avenue: money, power and the American dream.

Well worth your time. They use the "Monopoly" game analogy, that exemplar of cutthroat winner-take-all capitialism. Moreover, this PBS documentary asks us to consider what it's like playing the Monopoly game wherein those who acquire the most assets get to repeatedly change the rules while playing, in ways that inure to their benefit.

Is that the state of our nation? One Dollar, One Vote? Is this inexorable? Are we headed for a new Feudalism? 

What will be the upshot for health care? Will our socioeconomic trends neuter the progress resulting from our clinical science and information technology advances?
“When it comes to health, your zip code matters more than your genetic code.”
From Oxfam:

Bringing up such issues invariably begets you the epithets "moocher," "taker," "bleeding heart liberal," "socialist," "commie," etc. -- the tried and true ad hominem strategy for shutting down debate. It has been fashionable of late among "conservatives" to sarcastically cite former President Reagan's jibe that "we fought a war on poverty, and poverty won." Fashionable to demonize the halt, lame, and poor.

See "Richistan"
Nonetheless, the problems wrought by extreme economic disparity are real and will not simply be denied away in pursuit of Wishful Thinking fallacy convenience.

Specifically back to the health care implications:

Veronica’s headache
It was an unseasonably warm spring day in South Central Los Angeles in 2011. I had joined this community clinic three years before and had set about implementing an upstreamist approach. Veronica, a 33-year-old woman, sat in my exam room, her head in her hands. Her otherwise tall and formidable figure was slouched over in pain. This was not the first time she had felt this way. For more than a year, her headaches had come and gone. And each time, the pain would ripple through her life, disrupting her family and work. This episode was no different. She had missed about seven days of work as an office manager at an auto parts dealer in the past month. Veronica’s employer, who was understanding, would see her in pain and insist that she leave early and seek help. But the headaches kept coming, straining her relationships at work. Her home life started to suffer, too. It was hard for her to sleep. She often had to call on her aging mother to care for her two sons when Veronica needed to visit the doctor or simply to rest. At school events and her sons’ after-school activities, Veronica was often unable to focus. Usually a stoic woman, she considered herself unflappable in the face of adversity. But these days, she admitted, she was fatigued and often irritable.

Three weeks earlier, Veronica had gone to a local emergency room to seek relief. After a battery of tests, a doctor prescribed her some pain medications. Then she gave Veronica instructions to return to the emergency room if the pain worsened or persisted. The medicines helped for a short while, but they often left her drowsy and unfocused. The pain persisted. So, following instructions, she returned twice more to a local emergency room. All told, she underwent at least a dozen blood tests, two CT scans, and a spinal tap — a procedure in which a needle is placed in the lower back to collect and test a sample of spinal fluid. But for Veronica, each visit to the emergency room ended the same way: She was told her test results were “normal,” sent home with more pain medication, and advised to seek a primary care physician.

Veronica had already tried that approach. When she had visited primary care clinics for headache flare-ups, her experiences hadn’t inspired much confidence. The doctors and nurses seemed rushed. She heard a lot of talk about tests and short-term medications. One doctor wondered if Veronica was exaggerating her pain simply to get narcotics. Despite multiple visits, she didn’t feel much better. In fact, she told me, that’s why she went to the emergency room in the first place.

When I met Veronica, she was exasperated. A $ 1,200 bill for her first hospital visit had arrived at her home. At work, her boss was growing concerned. Veronica was concerned about losing her job. Without a steady income, she worried about paying the rent, roughly $850 per month. She fought back tears as she described the toll this was taking on her family. 

And she grimaced often. On top of everything else, Veronica was still in pain.

Veronica’s story is far too typical in our health care system. Her experience has become commonplace, not just in low-income neighborhoods but in middle-class and more affluent communities as well. Access to quality care is a problem. And even when care is available, it is often poorly coordinated, expensive, and stressful.

When Veronica came to our clinic, though, we did things slightly differently.

The clerk checked Veronica in. The medical assistant recorded vital signs and collected standard information about her health. This is a typical process for many clinics. But then the medical assistant ran down a simple checklist, asking Veronica a few routine, evidence-based questions about her housing. Veronica indicated that her apartment had some problems with mold, water leaks, and roaches. These answers went into her chart, along with other important data. I briefly reviewed the chart and opened the door to greet her. 

Knowing where Veronica lived made a world of difference. I asked her to tell me more about her home and her headaches. She lived with her sons in a two-bedroom, ground-floor apartment in South Los Angeles, not far from the clinic. Veronica insisted that she kept her home as clean as possible, but persistent leaks had led to chronically damp, moldy conditions and the roach infestation. Her landlord hadn’t helped, and she couldn’t afford to move. As she talked, I followed up with more questions and began a targeted physical exam. Within 15 minutes, I felt pretty confident in my diagnosis: Veronica had migraines related to chronic nasal allergies and sinus congestion. These conditions are often caused or made worse by dampness, mold, roaches, and other markers of substandard housing. I asked about her sons’ health. Her eldest was under a pediatrician’s care for severe asthma, another health problem often related to bad housing. I explained my concerns and prescribed her medicines to help with the symptoms. Then I referred her to a program run by our clinic in partnership with two local organizations to help make her housing healthier. One of the partners was a tenants’ rights advocacy group long active in South Los Angeles. The other was a community development agency that created affordable housing and trained residents to become community health workers.

Within a few days, a community health worker from our clinic visited Veronica. She taught her new techniques for controlling dampness in her home. Then, with the help of our partners, she helped Veronica contact the landlord, this time with a doctor’s note and information about local housing codes that the landlord was obligated to meet.

Veronica came back to the clinic a few months later for a routine follow-up visit. She hadn’t been to the emergency room. Her home was healthier. Her allergies lingered but had improved, and her headaches were gone. Her son’s asthma was less active. Veronica and her family had gotten better.

The current standard of care
To improve Veronica’s headache, the health care system had to address where she lived. Why did Veronica go so long before she got that type of care? Did she have to suffer as long as she did? The great irony is that many of the health care professionals who had cared for her provided what is generally considered adequate care. On each occasion, doctors and nurses initiated a diagnostic workup involving expensive machines and procedures. They prescribed medications to help relieve her pain and instructed her to seek further evaluation if required. Based on what we know about Veronica’s experience, most people, including myself, would not find these clinicians at fault for negligence. In fact, on an individual basis, each clinician’s approach was probably well within the bounds of what we consider the current standard of care.

The problem, of course, is that the current standard of care isn’t working. Instead of addressing the cause of disease, health care in the U.S. has long focused on just treating its symptoms. We fixate on the headache and ignore the home. Once upon a time, interacting with patients in their homes and communities seemed like an obvious, integral part of doctoring. But in the last century or so, the culture of medicine has largely been shaped by an exuberant overemphasis on the biologic and molecular phenomena of disease. Improving the social conditions that shape health has become an afterthought.

And that’s the irony. When clinicians ignore the home — or any of the other factors that shape our health — their treatments often are less effective. In clinics and hospitals across the nation, we repeatedly miss precious opportunities to understand and improve people’s health in the context of their social and physical environments. These opportunities are often obscured by the transactions of pills and bills that have come to define the health care experience for many patients and providers. For patients like Veronica, the medical system fails to reduce suffering because it simply doesn’t collect the right data or equip providers with the right tools to address the factors that shape our health where it begins.

This disconnect is striking, especially when one considers the forces that determine how healthy we are as a society. As the New England Journal of Medicine   reported   in 2007, medical care accounts for only about 10 percent of the variation we see in health outcomes. Consider that statistic from another perspective. Let’s say someone asks you to review all the accumulated science about what determines a society’s health. Next, they give you a menu of interventions and $ 100 in small bills. Based on what you learned from your review of the evidence, you’re given the task to spend that $ 100 in whatever way you want with one purpose in mind: Create the greatest health you can for your population. You’d be wise to spend only about $ 10 of your budget on medical care and spend more on improving social and environmental factors such as substandard housing, job stress, poverty, discrimination, and dangerous neighborhoods — what experts often call the “social determinants of health.”

When we think about what really shapes our health, medical care is just one relatively minor force. Experts often think of five general health-defining forces: genes and biology, behavior, medical services, social environment (the ways in which we relate to each another), and physical environment. The latter two, often referred to together as the social determinants of health, are significantly more powerful drivers of wellness than is medical care. The social determinants are shaped by the power and resources that people have, all of which are influenced by the policy choices we make as a society. These policies, in turn, influence the behaviors and choices you and I make every day. For instance, a growing body of research indicates that how close people live to affordable, healthy food outlets or safe, green parks plays a role in their choices to eat healthily or to exercise.

Where we live and work clearly impacts our health behaviors. And these social and environmental forces are also capable of changing our DNA, literally. Epigenetics, an emerging field of science, examines the link between environmental exposures and the regulation of our genes, especially as they pass from one generation to the next. New discoveries in epigenetics reveal that exposure to toxins, such as chemical pollution or even severe emotional stress, can significantly affect the health and development of individuals and their children. For instance, a   study   reported in the Economist in 2011 showed that children born to mothers who experienced stress and psychological abuse during pregnancy were significantly more likely to have DNA changes that reflected a higher sensitivity to stress hormones compared with children of women who did not suffer abuse.   Stress and abuse, in turn, are most often linked with poverty and other socioeconomic factors.

The nature vs. nurture debate can no longer be viewed as a battle between equals. The impact of nurture — in the form of the social and environmental settings that surround us — is far more powerful than we’ve ever imagined. These are the forces that shape or distort our genes, our behaviors, and the landscape of opportunity in our communities.

The current standard of care often ignores these forces. This lack of attention leads to missed opportunities to effectively alleviate suffering and can sometimes even contribute to more suffering. Think of the costs for Veronica. While bouncing in and out of the health care system, Veronica stacked up major opportunity costs. Instead of spending time at work or with her family, she spent days in a hospital or clinic looking for help. The direct economic costs were just as bad. Just one of her three emergency room visits resulted in a bill roughly equivalent to one month’s rent.
Then, ironically, this experience with the health care system took its own toll on her health. Each time a hospital or a clinic discharged her with nothing more than pain medicine, the system unwittingly sent Veronica — without adequate warning, protection, or tools — back to her home, the place where her illness first started...
Manchanda, Rishi (2013-06-06). The Upstream Doctors: Medical Innovators Track Sickness to Its Source (Kindle Single) (TED Books). TED Conferences. Kindle Edition.


So, what about it? Is this OK? Should society simply permit people to acquire all the material wealth they are capable of amassing? Objectively, is there any such thing as an economically just and sustainable society? He Who Dies With The Most Toys Wins? e.g., Venture Capitalist (and Liberal Kristallnacht Victim of late) Tom Perkins.

He Who Dies With The Most Toys Dies, actually. But...

Below, a common blogosphere sentiment.



Michael Lind of The New America Foundation has written an interesting, nuanced (if somewhat depressing) article just posted at, "The 1 percent wins again: The system’s so fixed that a global class war is only a dream"
[P]urported measures of the global 1 percent that conflate different species of the rich in radically different societies — self-made entrepreneurs, bankers dependent on government bailouts, crony capitalists in autocratic regimes, and members of the political elite in petrostates — are not worth the press releases that tout them. Chinese Communist Party princelings, who owe their manufacturing-based wealth to family connections and corruption, have little or nothing in common with Saudi aristocrats — who in turn came by their wealth by methods different from those used by generals in some military dictatorships who are paid by dictators out of the loot derived from plundering the population. And the minority of the global rich who more or less earned their wealth — by founding a business that provides a good or service that people want to pay for — belong in a separate category altogether from aristocrats who inherited their wealth or kleptocrats who manipulated government connections.

In other words, “inequality” is not a single disease; it is a label for a variety of quite different maladies in different societies, some worse than others.  From this it follows that different kinds of harmful inequality, in different countries, must be subject to different remedies. For example, if you want to combat inequality in China, you should want to abolish the monopoly of political power and much economic wealth by Communist Party officials, who use their control of government and of state-owned enterprises to illicitly enrich themselves and their offspring. In contrast, inequality in the U.S. is driven largely by policies like financial sector bailouts that socialize the costs while privatizing the risks of high-income individuals who work in the FIRE (Finance, Insurance and Real Estate) sector. An appropriate policy agenda for reducing U.S. inequality would bear little resemblance to the anti-inequality agenda in China...
Interesting. Read all of it.

I have a bit of FIRE Sector experience, btw. See my posts "Tranche Warfare" and "The Dukes of Moral Hazard." And, I have long followed the Sisyphean‎ writings of the iconoclastic Bill Black of UMKC's New Economic Perspectives.

Another great read: Graeber's "To have is to owe," precursor to to his excellent book "Debt: the first 5,000 years." I was blessed to read that book before I knew who he is. It is a fine piece of social anthropology scholarship.

Mr. Lind notes that
The idea that cross-national class allegiances will trump cross-class national allegiances has appealed to many on the radical left ever since Marx and Engels called on the workers of the world to unite. It didn’t happen in the 19th century, and it didn’t happen in the 20th century. A global class war won’t happen in the 21st or 22nd or 23rd centuries, either. 
To that point I would just add that the efficacy of technologies for suppression of effective dissent are progressing at least as rapidly as the disparities of income and wealth, if not moreso.

Billionaire Sam Zell Defends Tom Perkins: 'The 1 Percent Work Harder'

When the going gets tough, the rich dudes stick together. Or at least rich dude Sam Zell did in an interview with Bloomberg TV Wednesday.

The billionaire chairman of Equity Group Investments backed up fellow rich guy Tom Perkins, who set off a firestorm when he recently compared the "progressive war on the 1 percent" to Nazi anti-Semitism in a letter to the Wall Street Journal. (He later apologized for using the word "Kristallnacht" but defended the overall "message.")

"I guess my feeling is that he’s right," Zell said when asked by Bloomberg's Betty Liu how he felt about Perkins' stance. "The 1 percent are being pummeled because it’s politically convenient to do so."

Zell then said the problem is that all non-rich are just jealous that they don't have the same work ethic that the country's wealthiest do.

"The problem is that the world and this country should not talk about envy of the 1 percent. It should talk about emulating the 1 percent," he said. "The 1 percent work harder. The 1 percent are much bigger factors in all forms of our society."

Liu countered that the ever-widening gulf between the richest and poorest Americans must make it harder for those living under the poverty line to get ahead, no?

Nah, said Zell.

"Lots of people have come from nowhere and become part of the 1 percent," he said.
5 libertarian oligarchs who made fortunes off the government they want to destroy

The cult of the libertarian-minded ultra-weatlhy would make an intriguing anthropological case study. But it would be a case study with a twist: its research subjects increasingly control our economy, our politics, and even our personal lives.

We’re dealing with a cohort of highly fortunate, highly privileged and highly unaware individuals who have been inappropriately lionized by society. That lionization has led them to believe that their wealth and accomplishments are their own doing, rather than the fruits of collaborative effort – effort which in many cases was only made possible through government support.

But instead of thanking the government and the taxpayers for their good fortune, they’ve allowed their own good press to go to their heads. And they’re biting the hand that feeds them, attempting to shut down the system of taxpayer support and government action which created their world.

Our money-obsessed society gives them far more praise and then they deserve. Our corrupted political system gives them far more influence than we deserve. And, slowly but surely, they are now turning their considerable resources to dismantling government’s role in society...

Tom Perkins doubles down...


IN OTHER NEWS Launches Health Care Reform Implementation Blog has kicked off a new project to track how well the Affordable Care Act is fulfilling its goal of getting Americans insured.

Remaking Health Insurance: The Affordable Care Blog will focus on California, the state with the largest number of uninsured, and move beyond  politics to explore how care is being accessed and how effectively that care is being delivered. Check out our introductory post discussing the scope of the blog.


Just finished listening to Dr. DeSalvo's DC ONC Conference opening keynote via live streaming. I was to have been there, but the blizzard bumped me off my flights.

She will get no shortage of advice and criticism. e.g., from one of THCB resident trolls:

HHS Secretary Sebelius speaks at 10 a.m. EST.



Best audience question of the day thus far was about  EHR (non) readiness to accomodate "football field size" patient genomic data. The entreprenurial / venture capital panel agreed that they are not ready.

Such readiness is likely a long way off. Beyond database and I/O capacity, we are woefully short of people qualified to counsel patients on the upshot of genetic findings. See AJMC Panel: Genetic Testing Should Come With Counseling: American Cancer Society CMO, Supreme Court Plaintiff Warn of Consumer Risks.
Driving down costs makes [genetic] testing more accessible, but the amount of information can overwhelm patients and primary care physicians if experienced genetic counselors are not part of the process, the panelists agreed.
Link (pdf)
What GAO Found
GAO’s fictitious consumers received test results that are misleading and of little or no practical use. For example, GAO’s donors often received disease risk predictions that varied across the four companies, indicating that identical DNA samples yield contradictory results. As shown below, one donor was told that he was at below-average, average, and above-average risk for prostate cancer and hypertension.

GAO’s donors also received DNA-based disease predictions that conflicted with their actual medical conditions—one donor who had a pacemaker implanted 13 years ago to treat an irregular heartbeat was told that he was at decreased risk for developing such a condition. Also, none of the companies could provide GAO’s fictitious African American and Asian donors with complete test results, but did not explicitly disclose this limitation prior to purchase. Further, follow-up consultations offered by three of the companies failed to provide the expert advice that the companies promised. In post-test interviews with GAO, each of the companies claimed that its results were more accurate than the others’. Although the experts GAO spoke with believe that these tests show promise for the future, they agreed that consumers should not rely on any of the results at this time. As one expert said, “the fact that different companies, using the same samples, predict different directions of risk is telling and is important. It shows that we are nowhere near really being able to interpret [such tests].”...


Lot of empty seats. Weather must have impacted attendance. I was scheduled to go, but lost my flights owing to JetBlue overbooking caused by the blizzard.


More to come...

Friday, January 17, 2014

Meaningful Use Stage 2 is off to a bumpy start

As reported on MedPage Today
Few Docs Ready for Stage 2 'Meaningful Use'
Jan 17, 2014, David Pittman, Washington Correspondent, MedPage Today

WASHINGTON -- Roughly one physician in eight has an electronic health record (EHR) system capable of supporting most requirements for Stage 2 of the "meaningful use" program, a government survey found.

Only 13% of office-based physicians reported an intention to participate in the EHR incentive program and had a system meeting 14 of the 17 Stage 2 core objectives, according to a report released this week from the CDC's National Center for Health Statistics (NCHS).

About 56% of all physicians intended to participate in the EHR incentive program but didn't meet the core objectives the NCHS asked about.

"Meaningful use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clinical care...

Over on THCB, Incoming ONC head Dr. Karen DeSalvo tried to put a positive spin on the state of health IT in her recent piece Survey Says: EHR Incentive Program Is on Track. Be interesting to hear what she has to say next week at the ONC Annual Conference in DC.

Below, the typical invective hurled by the anti-HIT trolls, this one from Dr. DeSalvo's post.


Sources tell me that the ONC funded Nevada State HIE (run out of DHHS, not may be about to fail. It won't be the first one, but it will sure be another multi-million dollar waste of taxpayer money.

Speaking of wasting money:


Do providers have the EHRs for Stage 2 Meaningful Use?
Jennifer Bresnick, January 20, 2014

Providers may be lacking one big, basic ingredient for a successful Stage 2 attestation: a certified EHR capable of meeting the Meaningful Use objectives.  The National Center for Health Statistics (NCHS) has released a new data brief that highlights the relatively small number of providers operating on an updated EHR as the industry enters the second stage of the EHR Incentive Programs.

While 69% of office-based physicians reported that they intended to participate in meaningful use during a survey in 2013, only 13% of those providers also had an EHR system capable of supporting 14 of the Stage 2 core and menu objectives.  While this number seems exceedingly low, one should note that the survey was conducted between February and June of 2013, long before the majority of EHR vendors had even finished developing their 2014 ONC certified technology.

However, it is no secret that it’s been an achingly slow process to get the new technology through the testing and verification process.  Tight deadlines and major upgrades are slowing the adoption process for providers who have already spent big bucks on their 2011 systems...

Were I a Medicare EP who began attestation in 2011, I'd have by now collected $38k of the full $44k incentive reimbursement potential (not counting the sequester deduction now applied to the payments), ~86% of the total available. It sure looks to me that the combination of costs for Stage 2 upgrades -- certified software update, workflow alterations, administrative expenses -- may well eclipse any remaining potential reimbursements.

A doc I know responds:


And the hits just keep on coming...
Why specialists don’t like their EHRs

The list of reasons why specialists don’t like their EHRs could go on for pages, but what it really comes down to is this: most EHRs try to satisfy everyone’s needs, an impossible feat in a world with hundreds of medical specialties. Hospitals and primary care practices can sometimes make a one-size-fits-all EHR work, but specialists have a much harder time adjusting to having an EHR as part of their workflow.

A recent Black Book Rankings survey found that specialists are much less happy with their current EHR than family physicians are. However, most physicians place the blame on themselves. The top three reasons for considering a vendor switch all have to do with picking the right EHR:

  1. Solution does not meet the individual needs of the practice, including workflow (80 percent)
  2. The practice did not adequately assess its needs before selecting the original EHR (79 percent)
  3. Design of EHR is not suited for the practice specialty (77 percent)
Moving forward, specialists are taking a lot more care in picking their next EHR, focusing on more than just qualifying for government incentives. According to Black Book, here are the top five “must haves” for a replacement EHR vendor:
  1. Vendor viability (84 percent)
  2. Provider data integration and network data sharing (83 percent)
  3. Demonstrable return on investment (78 percent)
  4. Adoption of mobile devices (75 percent)
  5. HIE support and interoperability
With the EHR market in a constant state of shuffling out the unpopular EHRs, practices are most concerned with an EHR’s past success and future prospects. Practices want proof now, not just promises...

More to come...