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Saturday, June 29, 2013

Tales of the Zombie Apocalypse !


Alternate title:  How it only took 4 years to turn me into a zombie !!


By now you realize your medical education did not fully prepare you for life as a doctor

Our friend and colleague Zdogg was honored at a recent TEDMED presentation. His rap has made a mark in social media with a long list of YouTube videos.

Most physicians and providers need a dose of his hip hop and rap.

I share his video with you….there is not much more I can add.

Thank you Z   TEDMED will never be the same….

The Happy MD, are you out there"?


Friday, June 28, 2013

The Affordable Care Act, or IRS Tax Code 101


The Affordable Care Act is not really about Health Reform. It is about restructuring health service revenue cycles and the business of health payments. It also requires significant amendment to the IRS tax codes.

There is much more about IRS involvement than the ACA individual mandated insurance coverage. The extend of the change will be outlined below, one  the most intrusive is under ‘Collecting Information” and forms a close inter-relationship between IRS and HHS.  Little has been disclosed about this connection either by the HHS, CMS, nor media outlets.

Health Reform actually takes place with mandated change specified in the ACA and a second law, (much less known)

Through a series of manipulations, robbing Peter to pay Paul a series of tax increases take place up front and additional premiums will fund some of the later ACA implementation.

Further burdens include significant increased taxes, and major modifications to the IRS Tax Code, and the immediate secondary impact of increased tax reporting, administration, legal and accounting fees.


Charitable Hospital Tax:

Codification of the “Economic Substance Doctrine”:

Black liquor” tax hike:

Tax on Innovator Drug Companies

Blue Cross/Blue Shield Tax Hike

Tax on Indoor Tanning Services:

Medicine Cabinet Tax:

HSA Withdrawal Tax Hike:

Surtax on Investment Income:

Hike in Medicare Payroll Tax:

Tax Hike in Medicare Payroll Tax

High Medical Bills Tax

Flexible Spending Account Cap

Retiree Rx Drug Coverage Tax Hike:

Compensation Limit:


Individual Mandate Tax

Employer Mandate Tax

Tax on Health Insurers

Excise Tax on Health Insurance

Distributing subsidies

Early Retiree Subsidy

Nonprofit Tax Exemption

Reinsurance Tax Exemption

State Exchange Tax Credit

Cost-Sharing Subsidy

Small Business Tax Credit:

Small Business Tax Exclusion

Indian Tribe Tax Exclusion:

Therapeutic Discovery Tax Credit:

Adoption Tax Credit:

Tax Exclusion for Dependent Coverage:

Advance Tax Credit and Cost-Sharing Reductions:

Health Care Services Loan Tax Exemption:

Collecting Information

  1. State Exchange Information Reporting:

  2. Exchange Participation Requirement:

  3. Taxpayer Information Disclosure

  4. Insurance Provider Information Reporting:

  5. Large Employer Information Reporting:

  6. Medicare Beneficiary Information Disclosure:

Enforcing compliance

Health Plan Penalty:

New Group Plan Penalty

Group Plan Compensation Discrimination Prohibition

Nonprofit Indicator System:

Small Business Exemption for Cafeteria Plans:

Corporate Tax Advance

Credit to Ryan Ellis and Americans for Tax Reform for their research on this list.

1. “Patient Protection and Affordable Care Act: IRS Should Expand Its Strategic Approach to Implementation.”  Government Accountability Office, June 2011.

The GAO report list 47 new IRS powers in Obama Care, but one has been repealed since the report was issued – the employee voucher requirement.  It would have required employers to provide free choice vouchers to certain employees who contribute over 8 percent but less than 9.8 percent of their household income to the employer’s insurance plan.  The voucher could have been used by employees to purchase health insurance though an exchange.


Wednesday, June 26, 2013

Truthiness in Health Care


serenityzz11Contributed by Rob Lambert MD

This post is going to be a compilation of quotes from physicians who are far more articulate than I am, and who are also still in the trenches of the battle between providers, and CMS.  Sadly the very organization that was formed to insure health care to seniors (and others) has been corrupted by unknown forces (ie, too numerous to mention.

I can only sit here in my ‘lofty position’ either at the top or the bottom of the system.

My main advantage is I no longer have to look at my checkbook and decide what to pay first, or if at all. 

IRS, State Franchise Board, Payroll (probably the most important since my staff depends upon this for their very survival) (God bless them they must be more motivated (or in a self survival mode) than I ever was. Include also my accountant, attorneys, consultants, HIT vendors, Membership dues to 5 or six professional societies, including three separate medical society dues, County, State and the AMA. State Licensing fees ( a total rip off, outmoded, obsolete, underfunded )(our state fees are supposed to pay to run these organizaions)…However that money is probably been sequestered or is going to pay off some bonds to build a road.

Medical Staff dues (for three hospitals)  Malpractice premiums, property and liability, worker compensation premiums.

That is enough about me ,  on to some other thoughts from those in the trenches.

Rob Lamberts is one of those innovative leaders in practice management he was into EMRs and HIT long before the dawn of medicine by the byte. Now he is breaking new ground in direct pay revenue cycle. However that is a misnomer since there is no ‘cycle’  People actually pay at the door, in return for a substantial discount due to the decrease in overhead of not using IT, nor billing services, nor being at the mercy and whim of CMS and countless other insurance companies whose prime goal (despite the glowing marketing press releases) is to deny payment. This requires multiple billing cycle and more overhead.


Rob Lambert

“I’m Rob and I am a recovering doctor.  Yeah, I am recovering…doing a lot better, actually.  Things are tough, but they are a lot better since I left my destructive relationship with Medicare, Medicaid, and insurance companies.  I’ve had to learn how to manage my own money (now that I can’t count on them to bail me out any more), but things are looking a lot better.  I am beginning to see how much better it will be to be on my own.”

The key was when I realized that the system wasn’t going to change no matter how much I accommodated its unreasonable requests.  I felt that if I only did what it asked of me, however unreasonable, it would stop hurting me and, more importantly, my patients.  But I’ve come to see that all the promises to take care of me and my patients were written in sand, and that it couldn’t resist the temptation to cheat on me.  I tried to do what it asked of me, but as time went by I couldn’t take how dirty it made me feel.

But I can’t sit around and wait for the system to change any more.  My patients were getting less and less of my time, and I was getting to the breaking point.  I know there are a lot of other doctors who are willing to do whatever the system asks, but I can’t sit around and watch it self-destruct.  It’s not what’s best for the system, for us doctors, and for our patients.  Sometimes the best thing you can do for someone is to let them self-destruct and pray that they finally take responsibility and learn the hard lessons.  I just hope that happens soon.”

Dr Lambert comes from the perspective of a group medical practice which he founded years ago as a solo doctor. Time and events corrupted his basic model despite and efforts to halt the steady deterioration in the group culture.  He resigned from the very group that he formed decades ago.

“But I don’t want to brag.  I’m no saint, and the system I’ve built to this point is far from perfect.  I’ve still not taken a paycheck, (HOW DOES HE DO THAT?) and that can’t go on too much longer.  Things could still go wrong.  But my decision to no longer try to live in my dysfunctional and destructive relationship has been worth the pain and uncertainty.  I miss the patients I had to leave behind, and I am sad to hear about the care they are getting.  I hope I can build something good enough that lets me offer to them what my new patients have, something I’d given up on: hope for the future of health care.”

Rob made a radical change to no longer take Medicare, nor private health insurers and accept only cash. He refuses to deal with insurers and any agreements are between patients and their insurer.  Dry Rob gets paid by  patients, and they bill their insurance companies.  That is the way it always worked until CMS and HHS entered the room.

That’s all I’ve got for now.  Thanks for listening.  One day at a time.


Logo attributable to “Musings of a Distractible Mind” 

Thoughts of an odd, but not harmful primary care physician.


Saturday, June 22, 2013

Health 2014


We are at the half-way mark in 2013. In slightly more than five months, January 2014 many of the steps in the Affordable Care Act are mandated to launch.

Anyone able to read is keenly aware that not a minute or hour goes by unannounced without some breaking news about the future affordability of health reform, it’s consequences on your health and pocket book.

No doubt 2014 will be an adventure for patients, providers, hospitals, insurers and the Dept. of Health and Human Services.

Blame not these changes on the bureaucrats, nor President Obama. Many of these features were developed during the earliest parts of the Clinton Administration, when William Jefferson Clinton charged Hillary Clinton with forming a national health plan. That was almost 20 years ago, near the end of the last century.  Somewhat like a  wine fermenting in a bottle, the temperature should be constant and moderate, and not subject to light, or physical stresses. 

Health Reform fills some of those metrics, however it certainly has been subject to physical stresses.  Light has not been a problem, since most of the negotiating and meeting were done in the dark. So dark that congressmen did not read it prior to their irresponsible and negligent passage of the bill.  Not one Republican voted for it, even the most liberal ones.

Fearful of being left behind and/or penalized financially all states are rushing to implement the ACA, with minimal losses and/or expense.  While the new system is taking root, the federal government will prop financing with subsidies. Self sustaining financing will not kick in for several years as the uninsured find their way into the system of eligibility.  Rather than employing already existing resources in health insurance agencies and experts, HHS has deemed it fit to employ and train “Navigators”, twenty thousand and something.  It is not clear to me how long they will be employed, nor why the feds chose this route.  It was a move that completely bypassed existing organizations, and has not endeared the affordable care act to that segment of the present system.

Here are some of the examples

A Louisville Clinic Races to Adapt to the Health Care Overhaul

A feature common to all is the lack of specifics financially on eligibility and/or the premiums and benefits..There is a website, discussing the ACA, and Health Benefit Exchanges, however most patients and even providers have been unable to grasp just how it will all flow together.  One of the biggest issues will be if physicians will accept patients from a health insurance exchange, and expanded Medicaid, and the ‘strings” attached to the program.  It certainly does not appear to decrease paperwork and bureaucracy, rather it increase it.  One example is the HHS requirement that providers re-apply for Medi-caid  privileges.  There is no grandfather clause.

The County Board of Supervisors in my city met with the administrator of the Regional Medical Center. The administrator has a 25 year history of running the  busy medical center. About 20 years ago it was moved from a dilapidated structurally unsound building to a brand new structure certified to withstand a 9.0 earthquake,  It is located just adjacent to the San Andreas Fault less than five miles to the east.

The Supervisors had some excellent advice from consultants (from back east) and one of the supervisors owns an interest in a pharmaceutical company.  He seemed to have a substantial knowledge base in how the system has worked, or not worked as the case may be.

A significant problem in the United States is that there is a Polymorphic system, each with it’s own models  for reimbursement and a very different corporate culture.

City hospitals, county hospitals, federal hospitals, native American hospitals and community medical centers all have a unique cohort of patients, with vastly different sources of revenues. The patients who  use each system are segregated economically from each other.

View Larger Map  Aerial Map  (Google)

View Larger Map Street View  (Google)

The county’s President of the Board proposed integrating private sources into the patient model of the county hospital that predominantly patients who are assisted by the Department of Social Services. He proposes that the County Hospital enter the market place to compete with standard insurance companies, and operate as it’s own Accountable Care Organization (ACO).  The facility is modern and will be staffed by trainees from the new University of California’s Riverside School of Medicine


Riverside has a significant number of uninsured.  The funding for the school , with it’s new buildings has been dicey during the recent years as a result of the state’s ongoing budget crises.  However local stakeholders, local private hospitals, medical groups, chambers of commerce, and business leaders have donated millions of dollars to offset state shortages.

Medcaid is controlled by counties who rely on the state for control and funding of their budgets.  They have little real interest in the health of their ‘clients’. Their true function is to minimize reimbursements to providers, hospitals and medical equipment companies in an adversarial role,not a supportive role.  In the current California system there are pockets of Managed care which function much better than FFS.  However the only Medicaid patient who can receive managed care in the current system  are the ones who have a zero share of cost.  Since share of cost in month to month the reality is that if an eligible person is eligible in one month due to limited income, if the income exceeds a set limit the next month they lose their managed care, and most likely their primary care M.D.  Few MDs participate in both programs since Medi-caid requires providers to be either FFS or prepaid and capitated.


It is truly chaotic and dysfunctional.  What is the ACA going to do about this process? Medi-caid will be inadequate as it is now structured and the promise of eligibility for insurance for this population is questionable without significant reform.  It may just be a mandate that will not work.


Social Media’s Role in Outreach for Studies and Surveys

Social media is now playing a role in population health research.

Social media is no longer an option, it is an expectation on the part of many people.

One of the goals of the affordable care act is commendable, that of developing the Medical Home”. The concept of the "medical home" has evolved since introduction of the terminology by the American Academy of Pediatrics in 1967, which was envisioned at the time as a central source for all the medical information about a child, especially those with special needs.  Prior to the era of over specialization the family physician and general practitioner served in this role.  A gradual disintegration of  their role due to  a number of factors, including the increasing shortage of primary care physicians has led to a breakdown in the established referral patterns.

Patient advocacy groups also describe a “Patient Centered System”, one in which participatory medicine plays a great role.

Dr. Victor Montori, Lead Investigator from the Knowledge and Encounter Research Unit at Mayo Clinic, explores patient compliance issues at Transform 2009, a symposium sponsored by the Mayo Clinic Center for Innovation.


Person-Centered HealthCare- HealthCare Innovations Exchange: Short-Cut to Health Innovations News

Some physicians are aware of patient centered health care as part and parcel of ‘treating the whole patient, and not the disease. The person centered health care is nothing more than this concept.

Patients however are not that familiar with the new model for diagnosis and treatment.  They however are hungry for better patient More information needs to be offered to patients both in popular lay press, and especially social media. Social is a prime necessity for human existence, witness how isolation and social deprivation effect emotional health and interaction.

Social media offers a private, laid back approach to ideas, shared much like that at a coffee shop or around the ‘water cooler’ of life.

Person-Centered Health Care is a healthcare innovation. The Innovation Exchange provides support for not only patients and caregivers, it also provides support for physicians. With the Health Care Innovations Exchange,   AHRQ (Agency for Healthcare Research and Quality)  has vetted and collated new and better ways of delivering health care in the hopes of speeding up the implementation of these tools. It offers busy health professionals and researchers a variety of opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations.

Attributions:  Health Works Collective (exclusive post by) Amelia Burke-Garcia.


Wednesday, June 19, 2013

Medicare Costs Contained?


For the first time in 4 decades the cost of health care’s growth has slowed. This is not bad news however caution must prevail.

“This is understandable given the fact that health care spending represents nearly 18 percent of the overall economy and the Medicare and Medicaid programs combined account for nearly a quarter of the federal budget.”

What factors affect the medical cost trend?

Read more:  The Hill

However, despite this good news, or perhaps because of it, it is important that we make a point to emphasize the real and continued need for Medicare reform.
The Hill on Facebook

Much of the slow-down in spending growth can be attributed to the recession, which inevitably slows spending patterns across the board.  In addition, the imminent implementation of Affordable Care Act subsidies and Medicaid expansions will further boost spending.

Medicare is projected to add 30 million new beneficiaries in the next 20 years – which will place significant added cost pressure on the program.  This trend cannot be altered, nor avoided nor wished away.  Adding 30 million people to the program will raise the cost of program and must be dealt with.

As important as program solvency and financial health are, finances are not the only reason to fix the Medicare program.  Medicare was developed in the 1960s and, as such, no longer meets the needs of the Medicare patient today.  Today’s beneficiaries have different demands; they are living longer with more chronic conditions, and are receiving care in a variety of settings.  Medicare must be updated to adapt to these changing demands so that patients can receive the best, most effective care.”

Physicians no longer practice 1964 medicine and in the 21st Century there will be further advances. The business and payment models and governance also must change.  Currently we have 2013 autos running on 1940s roads.  It is no wonder health costs have escalated. The old system has been inadequate.

In addition to reforming the  SGR (sustainable growth rate for physician fees),

Policymakers should look past the narrow reforms and short-term cost trends to deliver to beneficiaries a program that better meets their needs.

The Future for Medicare:

What You Need to Know

There are four proposals currently before Congress to reform aspects of Medicare. The Medicare Board of Trustees' 2013 report projects the Hospital Insurance Fund would become insolvent after 2026. 

This process is inextricably interwoven with current reforms including the Affordable Care Act, the formation of Accountable Care Organizations and major reimbursement reform (including conversion from ICD-9 to ICD-10 as well as health information technology, including electronic medical records, health information exchanges and health benefit exchanges come on line in 2014.

The challenges for health care professionals is enormous.


Monday, June 17, 2013

Congress Has A Duty To Delay IRS Funding To Block ObamaCare's Implementation


In the midst of serious IRS ethical, moral and legal confusion, there is an inability to obtain accurate accountability for decision making.

Until these matters are successfully addressed expansion of IRS accounting and enforcement of Accountable Care Act monitoring and penalties for non-compliance with the mandate for obtaining health insurance coverage would be ill-advised.

The Galen Institute reports:

Americans already are fearful and confused about the sweeping changes that ObamaCare will inflict, and the widening IRS scandal deepens concerns about the agency’s major role in implementing and enforcing the health overhaul law.

Based upon Government Accountability Office data, we count 46 new responsibilities assigned to the IRS.

The Affordable Care Act assigns to the IRS  46 new responsibilities.

IRS officials have acknowledged the huge problems these major new responsibilities will create for the agency.

It is unprecedented in recent history, the amount of responsibility the IRS is being given in an area that most people don’t think of as an IRS function,” George said. Americans, he added, will have more questions about their taxes because of health care penalties or credits, flooding already busy call-in and walk-in tax help centers. “This is going to lead to problems, sir,” he testified.

Sunday, June 16, 2013

The Shortcomings of the Affordable Care Act

No law is perfect and often fails to attain it’s mission.  The ACA is like that, however it does many things counter to common sense and reduces the reality of purchasing insurance other than a mandated program that is unaffordable, and/or punitive.

For some workers, health reform brings no coverage, fewer hours

A common story is unfolding such as that of McCoy Faulkner who collects $81 a day as a substitute teacher in the Wake County (N.C.) Public School System. A mere sub, he has no benefits.

The 62-year-old former Raleigh, N.C., police officer shells out $580 a month for an individual insurance policy, more than half his monthly pay. The full-time teachers for whom Faulkner fills in, however, are eligible for free health insurance, with no monthly premiums, through their employer.

That’s why Faulkner was looking forward to the Patient Protection and Affordable Care Act, figuring he was the kind of person that the health care reform law was designed to help. Under the new law, anyone who works 30 hours or more a week for a large business will be eligible for employer-sponsored health care.

But instead of adding subs like Faulkner to its health care plan, the school system is looking for ways to avoid doing so. Wake is considering restricting its 3,300-plus substitutes to working less than 30 hours a week, effective July 1.

The reason: If just a third of the system’s subs were to qualify for employer-sponsored insurance, it would cost Wake schools about $5.2 million.

Some businesses will restructure themselves to employ mostly, or only, part-timers.

It’s expected that some will opt for the fines. Nancy Adams, owner of two Piggly Wiggly grocery stores in North Carolina, said that’s one option under consideration for her business. The $2,000-per-worker fine would apply to just five full-time employees at the two stores, amounting to $10,000 a year, she said, because the law exempts the first 30 workers from the fine.

Adams said the company would save considerably and likely give workers a $2-an-hour pay raise to help them buy individual policies on a health care exchange. Such exchanges, created by the Affordable Care Act, are designed for those who buy coverage on their own.

Adams’ grocery business has 86 employees and currently provides insurance to 31 of them at a cost of about $120,000 a year. Insuring all those who work at least 30 hours would raise the cost to about $165,000, she said.

“We don’t have the pockets to pay an extra $45,000 for health insurance,” Adams said. “It’s huge.”.  And should opt in these costs will be passed along to consumers.

It becomes obvious that the results of Obamacare will have both direct and indirect increases for health insurance.


Saturday, June 15, 2013

Mobile Health and the FCC

FCC Names New Director of Healthcare Initiatives

Brian Dolan, Editor, MobiHealthNews

At a time when mobile health initiatives and mobile apps are flooding the market, the Federal Communications Commission has shown enough interest to appoint Matthew Quinn as Director of Healthcare Initiatives.  “In this role, Quinn leads the agency’s efforts in facilitating and promoting communications technologies and services that improve the quality of health care for all citizens and help reduce health care costs; facilitating the availability of medical devices that use spectrum; and ensuring hospitals and other health care facilities have required connectivity. In addition, Quinn advises the FCC on health issues, working closely with the team overhauling the $400 million Rural Health Care program, and coordinating with federal partners including the NIH and the FDA, and with the private health care sector to develop effective FCC programs related to healthcare technology.”

Mr. Quinn will have expanding responsibilities at his new position. FCC is currently working on health initiatives to improve and enhance wireless communications and broadband connectivity nationwide. Projects include the Healthcare Connect Fund to expand telemedicine and revising its experimental licensing program to open more pathways for mobile healthcare app development.

This quiet appointment which occurred in April comes at a time when wireless technology is critical, because both  wifi and cellular systems will be essential for health information technology. It becomes one more step for FCC oversight of it’s authority over the radio-frequency spectrum.

“The incumbent will lead the agency’s efforts in facilitating and promoting communications technologies and services that improve the quality of health care for all citizens and help reduce health care costs; facilitating the availability of medical devices that use spectrum; and ensuring hospitals and other health care facilities have required connectivity,” the posting read.

The job description includes advising the FCC on health issues, providing guidance to the team overhauling the $400 million Rural Health Care program, working with other government bodies like the NIH and the FDA, and working with the private health care sector to develop effective FCC programs.

The job description includes advising the FCC on health issues, providing guidance to the team overhauling the $400 million Rural Health Care program, working with other government bodies like the NIH and the FDA, and working with the private health care sector to develop effective FCC programs.

The West Health Institute’s director of public policy Kerry McDermott was the last person to head up health care initiatives for the FCC.  McDermott previously led the FCC’s healthcare efforts and helped Mo Kaushal and Spencer Hutchins write the healthcare chapter in the FCC’s National Broadband Plan. Following the National Broadband Plan’s publication all three of them left the FCC to join the then-named West Wireless Health Institute. In 2011 the American Telemedicine Association published an open letter to the FCC criticizing the agency for going “silent” on healthcare since the publication of its National Broadband Plan in early 2010. In its letter the ATA also noted “the departure of every key professional staff from the Commission involved in healthcare policy.”

Last September the FCC held a public briefing this week with its mHealth Task Force, which formed in June 2012 to gather input from healthcare professionals and technologists to create a report full of “concrete” next steps that the FCC (and other agencies) can take to facilitate the adoption and acceleration of mHealth in the United States. One of the task force’s key suggestions was that the FCC hire a new healthcare director immediately.

My impression is that this is a low level appointment designed to give the appearance of FCC engagement in health.  It seems to be a redundant position one which is less necessary than FDA guidance for mobile health apps.


Friday, June 14, 2013

Obama+Superman+The Man of Steel



Obama as Superman

It looks like the man of steel has Obama’s back. Although The Affordable Care is due to come online a short less than 6 months and experts predict it will create chaos and not have the effect of significantly reducing the number of insured.

It is certain to increase overhead and operating expenses to develop accountable care organizations which are supposed to be the backbone of saving cost, improving outcomes and producing “big data”, which is now named “meta-data”.

Recent missteps by the Democratic administration and Mr. Obama have triggered Congressional Hearings on National Security, the IRS, and Benghazi to name a few. There is also the observation that this may be just the ‘tip’ of the iceberg.  Who knows what hidden secrets and agreements lurk in the making of the Affordable Care Act.


As a matter of political expediency the Democratic majority passed it unilaterally, not caring enough to even read the  ACA.

Popular demand does not seem to sway HHS or the President to review or consider modifications to the Act.  It appears they will push forward until the cracks widen, chaos ensuing and insolvency occur.

Let’s call for a Congressional Inquiry  into the Department of HHS, and it’s divisions such as Medicaid. 

Full Committee Hearing - Hearing for Secretary of Health and Human Services-Designate, Governor Kathleen Sebelius

The Cabinet members in the Department of Justice, the Internal Revenue Service (Treasury) and State Department all refused to ‘fall on their swords’ during their appearance before Congress.

Apparently raising your right hand and swearing to be truthful and not commit perjury do not hold sway with these Cabinet heads.


Not quite taking the fifth amendment option of not incriminating themselves, they developed ‘selective amnesia’ .  By admitting to ‘nothing’ or claiming mental inadequacy’ saves them from perjury.


I’d like to see Secretary K. Sebilius on the witness stand to answer many questions Congress will have for  her about the Affordable Care Act.


1. How did big Pharma play a role?

2 What role did insurance companies play?

3. What is her plan to follow the mandate of the ACA?


The passage and enactment of the  Patient Protection and Affordability Act seems to be an oxymoron, it will not be affordable for the country, and patients are not protected.

Only when these and more questions bring into the light of day how the ACA was formed.


Wednesday, June 12, 2013

Health Information Exchange and Accountable Care




Are HIEs Ready for Accountable Care?

This is a very interesting question.  HIEs were originally proposed long before the Affordable Care Act was law.  Their concept was to allow for  interoperability by harmonization and standardization of disparate EMR vendors.

The Accountable Care Organization is conceived to improve reimbursement paradigms, improve outcomes and to coordinate care among providers.

EMR and HIE came along long before the ACO was a concept.  The ACO in fact is not a reality in many places. Development costs, organization and implementation are a complex process.

I have not seen a concept of how HIEs would interact with ACOs. Technically all things are possible.

One of the centerpieces of the effort was support for the development of Health Information Exchanges. The government threw $564 million into the effort to create statewide HIEs, and some states followed suit with their own financial support.

But the big question facing the industry is what role, if any, HIEs can and will play in supporting the newest federal idea: accountable care organizations. As of February 2013, there were more than 250 Medicare ACOs, according to the Centers for Medicare and Medicaid Services; in a Health Affairs article published in February, David Muhlestein, an analyst at research/consulting firm Leavitt Partners, pegged the total number of ACOs at 428.

ACOs are credited as booming, and as of right now, there seems to be enough HIEs to support them. However, the future of HIEs is extremely murky due to the problem that has plagued the information exchanges since their conception-financial sustainability.

Most of the ACO effort has not been in terms of management, but the complexity of formation.   There are few operating Accountable Care Organizations working. Some that have been formed and operating are large health systems already operating as a single business entity.

The vast majority of medical practitioners and small hospitals function independently and have no contractual agreements with each other, a fundamental requirement for operating an ACO, to manage reimbursement, measure outcomes, and plan.

Stakeholder advocacy group eHealth Initiative assessed the state of HIEs in the United States in 2012 and identified 222 public and private HIEs, down from 255 in 2011.

A total of 161 HIEs responded to the organization's annual survey, the results of which highlight a big problem: Only 29 HIEs reported themselves as being financially self-sustaining. Ninety-three HIEs in 2012 said they were "highly likely" to be in business in three years, and 64 of those believe they will be financially sustainable within the next three years.

However, nearly half of those optimists currently depend on federal funds as their primary revenue source. And the $564 million in federal funding awarded to state HIEs under the HITECH Act stops in October 2013, with currently budgeted state funding sources expected to dry up by March 2014.

Very few HIEs are ready. The  eHealth Initiative survey also indicates that ACOs likely won't find the kind of data networks they could pay to piggyback on: Only 24 HIEs in 2012 reported being able to offer value-added services such as advanced data analytics, quality reporting, clinical decision support, and PACS reporting, all of which are services needed just as much by value-based programs as the actual exchange of data.

But too many HIEs are little more than a fax machine, sending a PDF-based Continuity of Care Document or medical image to a fax or into an EHR, and a surgeon can't operate the clinical decision support functionality of an EHR on information in a PDF.

Health Data Management also discusses further unknowns regarding the relationshiop between an ACO and a HIE.

Smoke and mirrors, cannot substitute for building ACOs on top of already inadequate Health Information Exchanges.


Reversal of HHS policy has Positive Outcome


Dying child was on life support when new lungs became available

Ten-year-old Sarah Murnaghan, who has cystic fibrosis, is receiving a lung transplant, at this moment.

The previous policy regarding the prohibition of children less than 12 years old with cystic fibrosis  receiving an adult lung transplant was reversed several weeks ago by the Dept of HHS in response to a public outcry  regarding the policy.  The policy was the result of obsolete statistics regarding survival statistics of children with the fatal genetic disease, cystic fibrosis which affect the lungs.  Previously adult lungs were also avoided due to size discrepancy between adult lungs and those of children.  The availability of adult lungs is much greater than children.

HHS Secretary Sibelius approves recommendations for lung transplant in child.


The criteria for lung transplantation in children with cystic fibrosis has been expanded .



Tuesday, June 11, 2013

Health Train Express on Pause


Health Train Express will not publish for the remainder of June 2013

We are focused on publishing important status reports on the topic of Accountable Care Organizations in an effort to educate those assigned to develop these new entities.

Numerous topics will be addressed, including:

What health IT is necessary to support accountable care?

The CCHIT ACO HIT Framework is a guide
to developing a technology roadmap   HIT framework is an essential enabler for ACO’s.

The market for these products will be considerable, and it is still in the development phase.  As yet the role of health information exchanges is not clear, however some are looking to HIE’s as a component for their ACO HIT infrastructure.

Follow the links to Digital Health Space for daily updates.


Thursday, June 6, 2013

The Achilles Heel(s) of The Affordable Care Act


Some Youths Unlikely to pay for Obama Care

President Obama had focused his long term objective as being the President that brought universal health care to America. Despite it’s passage unilaterally with only Democratic votes the law is unpopular and each day new challenges arise as to the fiscal integrity of the law, as much of it appears to be wishful thinking based on  the desire to see every citizen have health insurance without concern for affordability, it’s impact on businesses, and rough autocratic mandates the law gives to the Head of the Department of Health and Human Services, Kathleen Sebelius.


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By Grace-Marie Turner
Orange County Register, June 5, 2013

Virtually all Americans will be required to have health insurance under the Affordable Care Act (caution---this document is about 900 pages-- starting in 2014, and President Barack Obama especially wants young, healthy people to sign up.

About two-thirds of the uninsured are younger than 40. They use fewer health services, and their premiums are needed to help keep insurance costs down for everyone else.

Yet the incentive structures in the law work at cross-purposes with this goal and could well undermine its success. It will all come down to costs.

Four out of 5 people younger than 30 will face higher premiums than without the Affordable Care Act even with the subsidies many can receive.

The law requires young people to pay more for their health coverage so older people can pay less. A study published this year by the American Academy of Actuaries’ Contingencies magazine found that because of this provision, “premiums for younger, healthier individuals could increase by more than 40 percent.” Young men will pay even more than young women.

A former director of the Congressional Budget Office, Douglas Holtz-Eakin, conducted a survey that showed fewer than half of young people will sign up for insurance if premiums rise by 30 percent.

Young people also face a daunting approval process in applying for coverage. Applicants must divulge their income, family status and information about their employers, details on any insurance offered at work and their health habits — just to find out if they are eligible for subsidies.

Ezekiel Emanuel, a key architect of the president’s health plan, says he is worried that young people will be “bewildered,” and they may “forgo purchasing health insurance and opt to pay a penalty instead.”

That certainly will be an attractive option for many since the penalty starts at just $95 the first year.

And there is yet another disincentive for young people to enroll in coverage: They can wait to sign up for coverage until after they get sick or injured. The law requires health insurance companies to sell insurance to anyone who applies.


But if young people don’t sign up, the insurance pools are likely to be composed primarily of people who have high health costs. This could cause a “death spiral” where many more older — and sicker — people are enrolled, causing health insurance premiums to rise to cover their medical costs, thereby driving even more young people out of the market.

The White House believes that it will be able to persuade young people, who overwhelmingly supported the president, to enroll out of loyalty.

“The president connects with young people, too, so he needs to use that bond and get out there to convince them to sign up for health insurance to help this central part of his legacy,” said Emanuel, a health care expert at the University of Pennsylvania.

But young people may find that zeal may be severely tested when it comes down to paying thousands of dollars for health insurance that they may not want or need.

Consider, for example, a 27-year-old earning about $34,000 a year. He now could buy health insurance for about $200 a month. However, the new rules and more generous benefits required under the health law mean he would have to pay about $300 a month instead. He could get a subsidy of about $20 a month but, even with that, he still would be paying nearly $1,000 a year more for health insurance than without the law.

The White House is expected to mount a massive advertising campaign this summer to encourage people to enroll.

This will severely test his young supporters, who are having the hardest time finding jobs in our economy. Forcing them to also purchase health insurance — and pay more for it — may cool their enthusiasm to help the president fulfill his legacy.