Thursday, July 2, 2015

Medical School Hopefuls Grapple With Overhauled Entrance Exam : Shots - Health News

Medical School Hopefuls Grapple With Overhauled Entrance Exam : Shots - Health News : NPR

Prospective medical students MCAT test updated for first time in 20 years.  Major new emphasis on social science students. Meaning of life, quality of life, Humanities weighted more heavily......21st Century Medicine

Wednesday, July 1, 2015

Accountable Care Organizations: The Next IRS

The invention of the ACO is associated primarily with one man – Dr. Elliot Fisher, director of the Center for Health Policy Research at Dartmouth Medical School.

Fisher’s statement that he can invent rules for assigning patients to doctors and doctors to hospitals is no more or less logical or useful than the statement by the inventors of the Kevin Bacon game that they can assign a Kevin Bacon number to virtually any actor.

Elliott Fisher, shown here with Dartmouth Atlas founder Jack Wennberg, is credited with coining the phrase Accountable Care Organization.

By Kip Sullivan, October 2010
The “accountable care organization” (ACO) is the latest fad in American health policy. It remains an unknown concept to the vast majority of the public, including most doctors, but it is all the rage among health policy analysts as well as lawmakers who sit on heath policy committees in Congress and in state legislatures.
Although the assumptions used by ACO proponents to justify ACOs have been around since the dawn of the HMO movement, the ACO label is relatively new. It was invented late in 2006 during a discussion at a public meeting of the Medicare Payment Advisory Commission (Medpac). The seminal article announcing the concept appeared in December 2006. By 2009 the ACO had become so fashionable among congressional Democrats it was mentioned in all three draft health care “reform” bills prepared by Democrats during the first half of 2009 (two of those bills originated in the Senate and one, the Tri-Committee bill, was written in the House). The ACO movement’s crowning achievement to date is the inclusion of ACO provisions in the final “reform” legislation – the Patient Protection and Affordable Care Act (PPACA)
The Affordable Care Act created a new kind of “cooperative” health insurance arrangement heralded by supporters of health reform.  The co-ops were founded on the idealistic belief that community members could band together to create health insurance companies that would be member-driven, service-oriented, and would not have to answer to shareholders or turn a profit. But the 23 co-ops that were created had significant start-up costs, no experiential data upon which to set premiums, generally had to pay extra to lease physician and hospital networks, and had few people in the companies and none on their boards with insurance experience.  The idealism has quickly faded.  After receiving hundreds of millions of dollars in government start-up loans, most co-ops are surviving now on what remains of more than $2 billion in federal “solvency loans” and on the promise of future “shared risk” payments that are likely to produce only a fraction of the revenue co-ops have booked.
The History and Definition of the “Accountable Care Organization”
The definition of “ACO” bears a striking resemblance to the definition and history of “HMO,” a term coined in 1970. As was the case with the HMO, the ACO has been promoted primarily for its alleged value as a cost-cutting tool. Like the HMO concept, the ACO concept is vague and has multiple definitions which vary depending on who you ask. Like the HMO, the ACO is defined as an entity that will be “held accountable” for providing comprehensive health services to a defined population. As was the case with the HMO, “accountability” for cost will allegedly be achieved by shifting some or all of the insurance risk now born by insurance companies and public programs like Medicare to providers, and “accountability” for quality will allegedly be achieved by subjecting providers to report cards. 
The principle difference between HMOs and ACOs, at least for the foreseeable future, will be their size. Whereas HMOs, like most insurance companies, generally have enrollees in the hundreds of thousands, the ACO has so far been defined as having a much smaller number of enrollees, possibly as few as 5,000 (that’s the minimum number of Medicare beneficiaries who must be in an ACO according to PPACA’s Section 3022). The other major difference between HMOs and ACOs, at least for the near term, will be the extent to which they bear insurance risk. Whereas HMOs function like insurance companies (they bear 100 percent of the risk that the premiums they charge will not be enough to cover all necessary services for their enrollees), ACOs will bear little or no insurance risk for the first few years. However, judging from published papers by Elliot Fisher and other proponents of ACOs, proponents want ACOs eventually to bear all insurance risk, just as HMOs have.

By Grace-Marie Turner and Thomas P. Miller Overview     
Portions of this blog were taken from publications from PHNP, Physicians for a National Health Program 

Monday, June 29, 2015

Healtlh Care Collaboration and Kenneth Cohn, M.D.

I received an email at 2:45 AM PDT today.  It was a bit like a knock at the door with a message from an unknown person. "I regret to inform you, your colleague, Kenneth Cohn passed away prematurely at age 64.

Kenneth Cohn M.D.  had this huge data base in his mind, always searching for new data,  and did not need fancy analytics or algorithms to analyze health care.  He took it all in and then revealed 'out of the box' solutions.  He lived in one of the most challenging periods of health care.  It is one of those sea-changes when things happen so fast one is b arely able to adjust to a  change when another even more radical change occurs.

Some of us were swept away by the tsunami of government intrusions, managed care, reduced reimbursements and more. Others went with the flow, ending up higher on the beach, or sucked out to sea to swim for our lives. Kenneth did his  best to keep us afloat......what a battle it was.   He is in a far better place today. I hope he and his family did not suffer too long.

Thanks Ken for all the things you did for us.

In closing  here is the official announcement from Linda O'Brien

In Memoriam

Gary M. Levin M.D.

Saturday, June 27, 2015

Post SCOTUS ruling on the Affordable Care Act

A recent survey (admittedly uncontrolled, and unscientific) reveals several types of reactions to  the SCOTUS ruling on the Affordable Care Act.

1. Apathy
2. Continuing resistance
3. Liberals who equate Obamacare with socialized medicine.

Nothing could be further from the truth.  Apathy amongst providers is growing. Too much energy and time are involved fighting this battle for patients, which detracts time and energy from direct patient care.

Republicans                 Democrats                                

The Republican party has wasted much time and effort attempting to tear down the  Obamacare Wall by removing a tiny  cindereblock from the foundation.

The major problem with Obamacare is not the tax credit issue.

Blindly offering insurance coverage and access by politicians intent upon gaining political influence, and/or election is a great disservice to the American voter.  The internal workings of the American health system are overshadowed by HHS, Medicare, and Medicaid rulings which at times overrule the workings of the private sector.

As recently as 1965 governmental intrusion into health care was minimal.  Over the next 50 years involvement grew exponentially as Americans lined up for their 'entitlements'. As it grew, freedom of choicde gradually eroded.

President Obama now claims the Affordable Care Act is "the law of the land", much like he promised, "If you like your doctor, you can keep your doctor".  The truth is quite the opposite.  This one lie disenchanted any intelligent voter. He lied about that, and about the influence of Jonathan Gruber on the construction of the Affordable Care Act.  Obama lined up with Gruber and his statement about the American Voter being too stupid to  understand the law.

The lingering problem is that many Americans are ignorant how medical care is financed, and the insatiable appetite for  health  care...there is never enough.

In the long run SCOTUS' ruling will not mean much when the law is deconstructed and heavily amended.  It will require intellligent minds who are grounded in patient care and health administration, keeping it paitent and provider centered.

Friday, June 26, 2015

SCOTUS and the Affordable Care Act

As Yogi Berra said, "It ain't over until it's all over"

Any baseball fan can quote this fundamental Yogi Berra-ism. Berra was a famous catcher for the New York Yankees in the 1950s and 60s. I was a diehard Yankee fan during an era when they won  7 straight world  series, a feat yet to be duplicated in the 'modern era'.

it will be along time before ObamaCare and it's influence can be duplicated, nor produce a more disruptive, controversial law.

SCOTUS'  decision is far from ending the dispute about the Affordable Care Act.  Out of desperation the  GOP has focused it's effort to negate the entire law.  This is a fundamental flaw in the game to unravel the law.

Today there are many opinions from health reform pundits and politicians about what the SCOTUS ruling means.

Avik Roy
Forbes, 6/26/15

 “In a statement after the decision, President Obama declared that his signature health law is “here to stay.” But in his remarks, the President knowingly ignored the key concept in the case: that if the challengers had won, not one word of the law called the “Affordable Care Act” would have been changed. On the other hand, if voters elect a Republican President and a Republican Congress in 2016, quite a bit will change.”

Most Americans aren’t signing up for Obamacare
For the people that Obamacare claims to help—those who shop for coverage on their own—an analysis by the Manhattan Institute found that the law increased individual-market premiums by 49 percent in the average county, in its first year alone. Since, then many states are facing additional double-digit rate hikes.

It shows that as a percentage of those eligible for Obamacare’s subsidies, only those near poverty—with incomes between 100 and 150 percent of the Federal Poverty Level—are signing up in large proportion. That’s because for them, taxpayers are subsidizing nearly all of the cost of their coverage. As you go up the income scale, Obamacare’s subsidies aren’t large enough to make up for the law’s steep premium hikes. This is exactly what I and my Manhattan Institute colleagues were concerned about when we first started writing about Obamacare’s “rate shock” problem.

Indeed, the vast bulk of Obamacare’s increase in health insurance “coverage” comes from its expansion of Medicaid. Medicaid is so dysfunctional that it has been shown to have “no significant effect” on health outcomes, relative to having no insurance at all.

Insurers will continue to announce premium hikes, and states will continue to struggle to fund roads and schools, as Medicaid eats up more and more of their budgets. Obamacare will remain unpopular.
And if voters elect a Republican President in 16 months, it will be elected officials—not the Supreme Court—who will be rewriting the law.

Bill Would Force Supreme Court to Enroll in Obamacare

A House Republican on Thursday proposed forcing the Supreme Court justices and their staff to enroll in ObamaCare. ....

(John Lynn) from EMR & HIPAA

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

The Anti-Constitutional Consequences of King v. Burwell

Roberts gets it wrong -- Again from National Review Online

The Affordable Care Act was drafted with extraordinary carelessness given its importance, and conservatives who say that the Obama administration has implemented it contrary to its plain meaning have strong arguments. So opined six justices of the Supreme Court, including its most liberal members, in King v. Burwell. 

Read more at:

Thursday, June 25, 2015

Supreme Court Upholds Obamacare Subsidies, President Says ACA 'Is Here to Stay' - ABC News

Supreme Court Upholds Obamacare Subsidies, President Says ACA 'Is Here to Stay' - 

The Supreme Court today voted 6-3 to uphold subsidies to states who do not operate their own health insurance exchange, thereby strengthening the market place across the United States.

Congress, overwhelmingly Democratic wrote a flawed law, the Affordable Care Act, poorly written and conceived will for the time being remain intact.

The vote is seen as a win for President Obama and the Affordable Care Act, and some say this will insure the survival of the law after 2016.  Republicans remain adamantly opposed to the law.  However Republican Governors can breathe a sigh of relief knowing that their  state constiuents will qualify for federal  subsidies.

The questionable wording is buried in the lengthy 1200 page law, most of which was not read by Congress.  As Nancy Pelosi  predicted, "We won't know what is in it until we pass it"

The wording, "established by the state"  appears ten (10) times in the law, found by this author in the certified text of the Affordable Care Act.

No one seems to have specified this wording in the law. The closest wording found:   (Section 1311)

12 CHANGE.—An eligible individual shall not be treated
13 as a qualified individual under section 1312 eligible
14 for enrollment in a qualified health plan offered
15 through an Exchange established under section 1311. 

Was it congress' intent to obfuscate it's plan to insure all Americans? The Supreme Court's Opinion is "YES"  firmly establishing the Affordable Care Act as the law of the land.


Wednesday, June 24, 2015

Health Information Technology: Are we facing another bubble ?

U.S. Technology Funding -- What's Going On? from a16z

Some are comparing today's hot market in HIT to the Internet bubble of 1999.  However there are some significant differences.

The beauty here is its attempt to understand an organic phenomenon. IMO, it's also useful to look at the underlying drivers of (aka, incentives attributable to) that phenomenon. Today's large, "mature," post-IPO firms (Cisco, Apple, Microsoft, Ellie Mae, Intel, just to name a few) do less of their development in-house and rely more on the startup factories to generate new ideas; then the M&A engine kicks in to liquidate and (hopefully) integrate the new ideas. Sadly, most of these large(r) firms are saddled with un-innovative, un-inspired, un-inspiring, and sadly conventional senior managers, hence old thinking. It's too far a cry from the erstwhile "intra-preneuring" of the 70s and 80s to get to market relevancy, aka traction, while the market is still fertile and competitors sitting on laurels. Thanks for sharing this analysis.