Deadlines and Health Wonks

Today is the deadline for open enrollment under the Affordable Care Act. All the reports I’ve heard have suggested that Americans are excellent procrastinators. After the dust settles, we’ll see how many people enrolled in a private insurance plan or Medicaid through the exchanges. Then we can hear both sides argue over whether it has been a success or a failure. It should be fun.

In the meantime, Chris Fleming, who maintains the Health Affairs blog, hosted the latest version of the Health Wonk Review. Wright on Health’s own Shirie Gale was featured this time around. Her post is great, as are all the others. Go check it out here.

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Can She Make a Cherry Pie, Billy Boy?

My parents have always made their own bread, a skill I have never been able to master.  The other day my dad was showing off this beautiful loaf of bread he had made, and I asked him how he did it.  He said “I don’t know.  I followed the recipe and then added more flour until it looked right.”  Huh.  So the recipe was wrong?  “Well, not really.  It just needed more flour.”

As I was reading our dear leader Brad Wright’s policy wonk piece from March 12 I clicked on John Goodman’s piece on personalized medicine and it occurred to me that my father’s approach to bread baking is a good analogy for how doctors confront protocols and guidelines.  Goodman has a great blog, by the way, over at the National Center for Policy Analysis.

Let’s start with the recipe itself.  You think you want to make, say, a pie.  You don’t know what kind of pie, just “pie”.  But you’re an experienced baker, you’ve been baking for 20 years.  You look in the index and find the directions for “pie”.  You follow the directions exactly.  You end up with something that looks like pie.  But it’s not quite right, it doesn’t fit exactly.  There’s no filling.  You haven’t decided how to personalize the pie, make it yours.  According to our analogy, the baker is the doctor.  He’s very experienced, and has been practicing medicine for a long time.  He sees a patient whom he decides has, say, diabetes.  He looks in the index of his protocol manual, as he has been told to do by the administrators of his EMR, and follows the directions for “diabetes” exactly.  But the patient doesn’t get better.  The doctor hasn’t found out what kind of person his patient with diabetes is, so he can tailor the recommendations to the patient, that is, he can personalize it.

To extend the analogy, say this baker makes his pie according to the directions but because of his experience, knows a few ingredients are missing, so he adds them.  Like my dad, an experienced bread-maker, adding flour.  The results are much better, and he is able to charge more for his superior bread.  But the doctor does this for his diabetes patient, and the patient’s insurance company calls him saying it won’t pay for the added items.  They aren’t in the recipe.

Now someone comes to the baker and says: “Baker I ate your pie and I got sick.  What did you put in it?”  The baker replies that he followed the recipe, but when pressed admits he added a few things, but nothing that could make the pie-eater sick.  The pie-eater doesn’t believe him but the worst that he does is no longer buy pie from the baker.  The patient comes to the doctor and says: “Doctor I did what you said but I got sick.  What did you do?”  The doctor says he followed protocol, but when pressed admits he added a few things, but only things that would improve the patient’s care.  Doctor is sued for 10 million dollars.  Conversely, a person buys a pie and says to the baker: “This pie tastes terrible.  What happened?”  And the baker answers that someone got sick from a pie he made with additions, even though it wasn’t his fault, so now he just follows the recipe.  The patient says to the doctor:  “This treatment isn’t working for me, what happened?”  And the doctor says:  “I got sued for personalizing care, so now I just follow protocol.”

Tired of this analogy?  Me too.  Here is the problem with cook-book medicine.  You’ll come out with something that looks like quality care, but doesn’t really satisfy anyone.  It’s nice to have guidelines, so you know in general how things are done by other doctors and experts in the field, but if you don’t have the freedom to use judgement gained by experience to adjust care to the patient at hand, the end product doesn’t work.  I guess my point in all this is that quality care cannot be legislated and measured with strict guidelines.  Quality health care is like good pie; you know it when you see it, and you leave it to the professionals.

 

Health Wonk Review: Mud Season Edition

I moved around a lot when I was really young, but for the most part, I grew up in southeast Georgia–that’s the place that I’ll always identify as home. So, the last few years, first in Rhode Island, and now in Iowa, have taken some getting used to weather-wise. This year, winter has been especially brutal. But as I write this, I am sitting in my house with the windows open. Sure, it is supposed to snow tomorrow, but today it got up to 60 degrees. We have moved our clocks forward, leading to longer sunlit evenings, and I feel the promise of Spring approaching. For now, though, it’s mud season. All of the snow that has blanketed the ground since December has finally melted–quickly–leading to a sloppy mess. To be frank, the world of health policy is not that different. Things can change quickly, and they can certainly get messy. Thus, this mud season edition of the Health Wonk Review is presented with the understanding that while things might be a bit of a mess right now, there is hope on the horizon.

As the snow melts, we’re also nearing the end of open enrollment under the ACA. The latest numbers suggest that the Obama Administration is going to miss its target. I suppose the problem with setting goals is that you can fail to meet them. Louise at the Colorado Health Insurance Insider suggests that it might have been more efficient to spread open enrollment across the whole year. As long as that policy doesn’t extend to frozen precipitation, I’m intrigued.

Likewise, much ado–replete with mudslinging–has been made of Obamacare’s early going: Are enough people signing up? Are they the right types of people in the right proportions? Is it working? These are all excellent questions, but as Joe Paduda points out at Managed Care Matters, they aren’t the most important questions. Those, he contends, are what is happening to health plan prices and quality, and he is encouraged by what he sees at this early stage.

In that spirit, perhaps it will help if health care providers heed the advice of the Healthcare Talent Transformation blog’s Jonena Relth, who urges them to rediscover the adrenaline rush they first felt when they began treating patients. By encouraging use of portals and other patient-engaging technologies, she believes that our nation’s health care system can be the best in the world. On his Health Policy Blog, John Goodman also advocates for personalized medicine over protocols.

When it comes to Obamacare, there’s a lot to wade through, but our bloggers are on it. Hank Stern of InsureBlog examines the disturbing story of a vet caught up in an Obamacare tragedy and asks: What does a 1944 French existentialist play have to do with health care in modern America? Anthony Wright of the Health Access Blog takes a close look at President Obama’s appearance on Zach Galifianakis’ “Between Two Ferns” and in the process of fact-checking the video, dismantles the myth of the “young invincibles.” Also not afraid to fact-check is Linda Bergthold who, writing for healthinsurance.org, explains why rumors about the threat of Obamacare to your employer-sponsored health plan shouldn’t be keeping you up at night.

When the snow piles up, you need a shovel. When the disinformation around the ACA piles up, you need Maggie Mahar to help set the record straight. In “How a CBS Video About an Obamacare ‘Victim’ Misled Millions,” Maggie finds that neither the woman being interviewed, nor the reporters and producers involved in creating the piece seemed to understand some basic elements of the ACA thanks to the fog of disinformation that reform’s opponents have generated. It’s a terrific read–even if a bit unsettling.

Seemingly like the arrival of Spring, implementation of the ACA has also been delayed on more than one occasion. Delay of the employer mandate has gotten a lot of attention, but now there’s a push to delay the individual mandate too. At the Healthcare Lighthouse, Billy Wynne discusses how the House’s decision to pair the bipartisan doc fix policy with delay of the individual mandate is a death knell for permanent SGR repeal in the near term. Also on the subject of payment reform, the Health Affairs blog presents a post from Suzanne Delbanco, executive director of Catalyst for Payment Reform. Suzanne looks at the track record and potential of pay-for-performance and finds that the evidence on whether pay-for-performance models improve quality and affordability is mixed at best.

Mud season is typically referred to in New England (although trust me when I say it applies to the Midwest!), so it’s worth looking at the state that was doing Obamacare before Obama was President: Massachusetts. At the Health Business Blog, David Williams is running a series of interviews about health policy with all of the Massachusetts gubernatorial candidates. He shares with us his interview with well-known health quality advocate and gubernatorial candidate Don Berwick, who says as Governor, he’d pursue a single-payer system and work to implement the Triple Aim.

As we slog along, let’s not forget about other health care providers, like dentists and the hygienists that assist them. As the ACA is implemented, we’re hearing a lot about the use of midlevel providers to meet increases in demand, while helping to control costs. Well, the Healthcare Economist, Jason Shafrin, finds that this principle holds true in dental care as well. When hygienists’ scope of practice is limited, meaning dentists are left to do some less advanced tasks such as cleanings, the net result is approximately a 12% increase in many dental care costs.

The muck and mire is especially thick when you look at conflicts of interest in health care, as our good friend Roy Poses does regularly at the Health Care Renewal blog. This time around, he’s writing about a policy that actually condones keeping conflicts of interest a secret and the implications this may have had in a separate controversial case. Read both of his posts here and here. And, while we’re at it, Tom Lynch of Workers’ Comp Insider tells us all about a hospital that has been bribing politicians and providing doctors with kickbacks for referring patients for surgery.

Finally, for those of you still stuck inside for a few more weeks, I highly recommend checking out a new resource from Jared Rhoads. Healthpolicy.tv is a source for the most interesting health policy videos from around the web. Perhaps most importantly, it aims to elevate the debate by including views from all across the political spectrum. See? I told you that mud season foreshadowed better days ahead. Well, that’s it for this edition of the Health Wonk Review. Next up to host is Chris Fleming at the Health Affairs blog.

 

Is It True

My dear friend Paul Ryan, who has his eyes firmly glued on the white house, recently released a 200-page report with lots of figures and references and ibid’s claiming that all the anti-poverty programs run by the government are worse than useless and should all be scrapped.  He’s got some ideas on why people are poor:  they come from or create broken homes.  They have no education.  They don’t work.  They work part-time.  They receive medicaid.  Wait, what?  Here’s what the report claims:

“Medicaid coverage has little effect on patients’ health,” the report says, adding that it imposes an “implicit tax on beneficiaries,” “crowds out private insurance” and “increases the likelihood of receiving welfare benefits.”

Is this true?

There are a lot of references listed at the bottom of the page.  Let’s look at some of them.

1. The Medicaid and CHIP Payment and Access Commission. Children on medicaid or CHIP are more likely than privately insured or uninsured children to be in fair or poor health…and to have more problems like asthma, ADHD, autism, etc.  Well, yeah.  Medicaid helps poor people.  Poor people often have poorer health.  That doesn’t mean that medicaid causes poorer health.

Oh, and I love this one.  Adults younger than 65 who are enrolled in Medicaid are sicker than those who are privately insured or uninsured.  That’s because you have to be disabled to get on Medicaid if you are younger than 65!

2. A study out of Stanford by Baker and Royalty: Medicaid Policy, Physician Behavior, and Health Care for Low Income Population.  Medicaid patients are more likely to be treated in hospitals or public clinics than in private physician’s offices.  OK, that’s true. Medicaid pays 70% or so of what Medicare pays, which is way less than what private insurers pay.   Baker and Royalty assert that this is not an efficient source of care.  But it’s the cheapest.  One could argue that if reimbursement was better more patients would get treated by private physicians.  Assuming that really is better.

3. The Oregon Health Insurance Experiment.  Medicaid patients use more health care than uninsured patients.  Well, duh.  What, the goal is to keep people from using health care at all?  If that were the case we’d be spending all our money on promoting exercise and salads, not invading countries.  And the report chooses to ignore the rest of the story, which is that the medicaid patients also had lower out-of-pocket expenses, lower medical debt, and better physical and mental health.

4. The Oregon Health Insurance Experiment II.  Medicaid coverage does little to improve people’s health.  That’s because health care does not improve people’s health.  People do.  Poor people have fewer options for healthy lifestyle choices.  Mr. Ryan’s report also plays down the rest of the story, which is that having medicaid also increased the use of preventive services and eliminated out-of-pocket catastrophic debt.  Which is what insurance is supposed to do.

5. Rachel Rapaport Kelz in an article entitled Morbidity and Mortality of Colorectal Carcinoma Surgery differs by Insurance Status.  Medicaid patients are more likely to get sick during their hospital stay.  This is another entry in the duh category.  This is not because they have Medicaid.  It’s because they are poor.  And because they are poor, they have fewer healthy lifestyle options.  Because they have fewer healthy lifestyle options, they’re sicker.  Put them in the hospital, they’re sure to get sicker yet.

How about that “implicit tax?”

6. The Interaction of Public and Private Insurance: Medicaid and the Long-Term Care Insurance Market, by Brown and Finklestein.  “The premiums that one might have paid for existing private policies go to pay for benefits that would have otherwise been provided by Medicaid.”  I have no idea what that means.

And finally, the topper:  Being on Medicaid increases the likelihood of receiving welfare benefits.

7. Moffit and Wolfe: The Effect of the Medicaid Program on Welfare Participation and Labor Supply.  A rise in medicaid benefits increases the likelihood that a person is on AFDC (welfare) and decreases the likelihood that the person has a job.  Somebody needs to explain cause and effect to Moffit and Wolfe.

This is all to say that Medicaid does not cause anyone to be poor, be on welfare, have poor health, etc.  Medicaid is a health insurance program for the poor.  Being poor therefore increases the likelihood that you’ll be on Medicaid.  It’s not a great system and the care isn’t that good, but it’s not a failed program.  The war on poverty may indeed be lost, but not because of Medicaid.  It’s being lost in spite of Medicaid.

 

American Heart Association Launches Accelerator To Find Internal Game Changers

Accelerator programs and incubators are growing rapidly in number within the health care industry, with most replicating standard tech incubator models. But one organization has worked to redefine what an accelerator program can look like in the health space by joining one of the country’s largest and most influential associations in its landmark effort to court healthcare innovation. Dr. Ross Tonkens, a cardiologist and Chief Medical Officer in Cary, North Carolina has directed the creation of the Science and Technology Accelerator Program inside the American Heart Association (AHA), that targets and supports ground-breaking ideas from residents to senior clinicians.

Breaking The Mold

Although the AHA is most well known for its Heart Walks, Heart Ball and various awareness efforts such as the Go Red campaign, with a growing accelerator program, the Association could soon be known for changing how health associations and organizations think about growing overall impact. Not only do new ideas, technologies, and products improve the branding and public relations of an association, but it also leads to innovation that improves cost-effective practices, patient experience and standards of care.

According to Dr. Donald Lloyd-Jones, Senior Associate Dean for Clinical and Translational Research at Northwestern University, “When the prevalence of atrial fibrillation is presently estimated between 2.5-6 million Americans, but also estimated to be 6-16 million by the end of 2015, we know invention and innovation are needed.”

The AHA’s 2020 Impact Goals are to reduce deaths from cardiovascular disease and stroke by 20% as well as improve cardiovascular health of all American’s by 20%. Lloyd-Jones said the kind of disruption and change necessary to make these goals achievable will have to come from newer and more effective ideas and products through the Accelerator program in addition to continued research funding.

Dr. Lloyd-Jones set the tone of the AHA’s “Get Pumped” efforts by highlighting that, “continuing to fund research efforts will ensure tomorrow’s health and science discoveries make it from bench to bedside.”

Dr. Tonkens adds that investments through the Accelerator program can encourage industry and venture capital interests to “pick up the baton and carry it to the finish line after we fund proof of concept clinical research.”

Funding

Presently, the AHA is the second largest funder of cardiovascular research after the federal government. AHA has spent over $3.5 billion in supporting basic science research, and continues to do so. The Accelerator on the other hand is focused on identifying the game changers that can be propelled to market as quickly as possible, and helping the industry and investors feel confident in having a lower amount of risk on innovative products.

While AHA gave an estimated  $134 million last fiscal year in research, the AHA Science and Technology Accelerator Program is independent. To date it has not collected money directly from AHA, but instead, relies solely on donations directed to the Accelerator through awareness and fundraising efforts.

While this can make funding difficult, it also means any return on investment by the Accelerator is used to drive game changers into the market faster; the gift that keeps on giving.

Challenging The Status Quo

The Accelerator program not only invests money, but also expertise in areas such as scientific research, regulatory issues, intellectual property and commercialization strategies. This is done to ensure that all ideas are solicited, vetted and implemented to the best of their abilities, even those from younger individuals in the AHA that may not have yet been granted government funding or published in journals.

At the Heart Innovation Forum in Chicago last October, Jill Seidman of Healthbox agreed. During a panel discussion on accelerating discovery to patient experience she examined to audience that it was ideal for Chicago to host the AHA Forum because it was on the forefront of young innovation. She explained that, “bridging academic medical centers (AMCs) with community centers and clinics is imperative to improving outcomes, and Chicago has more AMC and medical schools than any other region in the United States.”

Dr. Tonkens message was clear at that same Forum. He said that like Healthbox, the Science and Technology Accelerator within AHA could fund – and has – great ideas. As he put it, “small amounts of money can dramatically improve life expectancy and decrease death from heart attack and stroke when leveraged by the global expertise in science, medicine, IP, regulatory and commercialization strategies which AHA is uniquely capable of bringing to bear.

American Heart Month And Beyond

As February closes out National Heart Month it is important for American’s to think about the implications of the country’s most detrimental health condition, heart disease. As a nation we have a long way to go to improve overall outcomes as they pertain to cardiovascular health, and especially those of our minority populations.

Through initiatives that range from the new Get Pumped phone app to high-end fundraisers to advocacy campaigns, the AHA is working hard on its outreach, educational, and public policy efforts. “Funding research and encouraging technological innovation is critically important,” said AHA Illinois Government Relations Director Alex Meixner, “but we also work with stakeholders ranging from hospitals to local, state, and federal governments to ensure that today’s scientific breakthroughs become tomorrow’s universal standards of care.”

Further, the status quo must be disrupted, and must be met with acceptance by veteran clinicians. Although current best practices exist for a reason, there cannot be progress using older methods to care for our aging and changing population.