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Friday, April 27, 2018

Healthcare is not broken — it is working precisely as designed-Casey Quinlan

What’s All the Palooza – Nick van Terheyden, MD – Medium

After many years of living in the DC Metro area, I finally managed to attend the HealthData Palooza event at the Washington Hilton (famous for amongst other things the Assassination attempt of Ronald Regan) that first took place in 2010 — created in part as a response to the then newly established Website and database
The group sponsored by the AcademyHealth brings together a wide range of companies, people and patients — problem thinkers and solvers big and small to share their voices, insights and above all else passion for solving some of the most intractable health care problems
Pro tip: patients/consumers/PEOPLE can’t navigate current US healthcare system ’cause “system” is sick-care focused wealth transfer play. It ain’t broken, it was built this way. #rightcare #HDPalooza
— Casey Quinlan (@MightyCasey) April 26, 2018

Which begs the question how do we fix it — there is no simple fix to the problems of the complex lumbering system that is an integral part of everyone’s lives. If by some miracle you are in the small minority of people who have not intersected with healthcare…just wait
Focusing on real problems vs creating solutions that are seeking out problems is the better place to start — HIE’s being cited as a good example where the business case does not support the model or the investment. That’s not to say that sharing data is not desirable but rather than the economic model and incentives do not drive the necessary investment in solutions. The health systems do not perceive the value in sharing the patient data to allow patients the ability to select a provider that is not in their network. This is the reality of the Health system working as designed which will fight actively or passively to protect their interests.

The Palooza attempts to summarize the advances in analytics and its effects on health care advances.
For those of you who have made it this far,   please read on...

.What’s All the Palooza – Nick van Terheyden, MD – Medium

What’s All the Palooza – Nick van Terheyden, MD – Medium

Wednesday, April 25, 2018

A small but growing movement of doctors that don't accept insurance and charge a monthly fee could be a model for big employers like Amazon and JPMorgan

  • Direct primary care is a small but fast-growing movement of doctors who don't accept insurance and instead charge a monthly membership fee.
  • At a time when many are feeling pressure from high healthcare costs, direct primary-care models can be a cheaper alternative that offers perks like quick access to doctors and sometimes wholesale prices on medications or lab tests.
  • And it could be a model employer — including JPMorgan, Amazon, and Berkshire Hathaway through their nonprofit healthcare venture — could tap into as a way of lowering costs.
A new kind of doctor's office that charges a monthly fee and doesn't take insurance has been spreading around the US. 
The practices are part of a movement known as direct primary care. Instead of accepting insurance for routine visits and drugs, these practices charge a monthly membership fee — often between $50 and $150 a month — that covers most of what the average patient needs, including visits and drugs at much lower prices. The movement's been gaining momentum at a time when high-deductible health plans are on the rise.
In most cases, the practices recruit patients on an individual or on a family-by-family basis. But often, employers who cover their employee's healthcare have turned to practices as well. 
For many large companies, they're the ones ultimately paying out their employees' claims. Insurance companies are there in the middle to handle the logistics of getting the claim from one place to another, which means you might not realize your employer's footing the entire bill on the other end. 
"I tell people, JPMorgan Chase already buys a $1.5 billion of medical, and we self-insure," JPMorgan CEO Jamie Dimon told Business Insider. It's why his company, along with Amazon and Berkshire Hathaway, two other massive self-insured employers, are looking for new options through a nonprofit healthcare venture. "Think of this, we're already the insurance company, we're already making these decisions, and we simply want do a better job," Dimon said.
Finding ways to "do a better job" could mean a number of things, from leveraging the number of people they cover to negotiate lower rates, to digging in and upending the way healthcare's done entirely.
And it's possible direct primary care could be a consideration.

The potential for employers to tap into direct primary care

Here's how that might look: An employer could cover the monthly direct primary care fee — either directly to the practice or as a reimbursement to the employer — or cover a certain amount. The direct primary care practice could be heavily involved in that process or relatively hands-off. 
For the majority of the practices Business Insider spoke with, employers make up a small portion of their business. Often, a relationship with an employer was sparked by someone who first came to the practice for their family's healthcare and decided they want their part-time or full-time employees to have the service as well. 
The direct primary care practices could be located within the community or housed on-site at the company's offices.  For example, Dr. Kim Corba, who runs Green Hills Direct Family Care in Allentown, Pennsylvania said she's been asked to set up a clinic situated between two employers to cover their needs.
Carolyn Long Engelhard, a public-health expert and professor at the University of Virginia School of Medicine — who has her concerns about direct primary care and its lack of connectivity to the larger healthcare system — said that this is one area where she could see direct primary care thrive because it'd be attached to employer-funded plans. A small but growing movement of doctors that don't accept insurance and charge a monthly fee could be a model for big employers like Amazon and JPMorgan
The bottom line for Direct Primary Care is simplicity.  The patient pays for the visit at the POS. Introducing an employer may create the kind of bureaucracy that DPC attempts to remove.
The minute a third party payor enters the equation, costs and bureaucracy escalate.

Sunday, April 22, 2018

Think Your Doctor is better because he is Recertified? Guess again. The National Board of Physicians and Surgeons

Think Your Doctor is better because he is Recertified?  Guess again. The National Board of Physicians and Surgeons

Is   MOC contributing to  'burnout"?  Watch this video from Dana Farber Cancer Institute

Maintenance of Certification (MOC) tests for doctors like us might sound like a good idea at first glance. MOC requires us to take frequent modules and tests to remain certified and keep our jobs.
But the truth is that these tests provide no value to doctors or patients; in fact, they contribute to rising health care costs because they take doctors’ precious time away from treating patients.
Recognizing the MOC burden, nearly 20 states have introduced legislation to curb it, with Washington state passing a bill to forbid it as a condition of licensure in late March. The rest should follow suit.
MOC is a cash cow for the American Board of Medical Specialties (ABMS) and its 24 specialty boards, which administer the exams. According to its most recent tax filings, ABMS president Lois Margaret Nora made nearly $700,000 in compensation from the organization in 2016. Thirteen other executives made over $150,000 from the nonprofit in the same year. In total, ABMS spent over $10 million on compensation, more than half its annual revenues, which largely come from inflated testing fees. That’s good work if you can get it.
as reported in Forbes Magazine. By NIRAN AL-AGBA and MEG EDISON   April 9, 2018

MOC Journal Club - The National Board of Physicians and Surgeons

Thursday, April 19, 2018

Physicians Disagree with Merit Based Incentive Plan . MIPS

ACP calls for revision of physician performance measurements

In an effort to restrain  costs Medicare has implemented a new system designed to do away with procedural based billing, also known as fee for service (FFS).  Physicians have previously submitted a bill to patients that are encoded by a  CPT code. (current procedural terminology)

It has been posited that this methodology encourages upcoding, or increasing the number of procedures as an incentive to increase income by physicians or others.

During the last five years Medicare has proposed several changes to accomplish improved quality of health care. Their early proposals were fraught with inaccuracy and were embedded with other suggestions including health information technology,  

The present and resulting algorithm, called MIPS is the outgrowth of heated and repeated negotiations between CMS and physician organizations, including the AMA, ACP, FACP and most ot her specialty groups. During the past 20 years, a calculated decrease in physician fees was calculated but was never applied at the end of each fiscal years. The increases were deferred each year, until the decrease became an impractical reality and would have bankrupted all physicians.  In further hardball and last minute negotiations an alternative system named MACRA emerged. 

Both MACRA and MIPS are complex algorithms which are difficult to decipher. They are also based on unproven metrics, which the American College of Physicians and the American Academy of Orthopedic Surgeons is now challenging.

As reported in Healio

In Medicare’s Merit-based Incentive Payment System or MIPS, most ambulatory internal medicine quality measures are not compliant with ACP criteria, according to ACP in a paper published in the New England Journal of Medicine.
“ACP has long supported and advocated improving performance measures so they help physicians provide the best possible care to their patients without creating unintended adverse consequences,” Jack Ende, MD, president of ACP, said in a press release.
To address physicians’ concerns that current performance measures do not meaningfully improve patient outcomes, ACP conducted an analysis of 86 measures in Medicare’s MIPS and Quality Payment Program. The analysis revealed that 37% of the performance measures were valid, 35% were not valid and 28% were of uncertain validity. A majority of measures that were not valid had insufficient supportive evidence.
Some performance measures included poor specifications that could potentially lead to the misclassification of high-quality care as low-quality care, according to the ACP. Measures containing flaws frustrate physicians and may be harmful to patients, ACP noted.
Performance reports cost physician practices $15.4 billion per year, yet almost two-thirds of physicians report that the quality of care that they provide is not adequately captured by current performance measures, according to ACP.
Leading organizations in the United States showed “troubling inconsistencies” in how they rate the validity of physician quality measures, according to ACP.
The ACP recommended that a set of standards for the evaluation of the trustworthiness of performance measures be developed. Performance measurement should not be an isolated drill and not be limited by administrative data, according to ACP.
“A possible solution is to have physicians with expertise in clinical medicine and research develop measures using a clinically relevant methodology,” Ende said. “Performance measures should be fully integrated into care delivery so they can help to address the most pressing performance gaps and direct quality improvement.”
Noting that more than 2,500 measures are used inconsistently, ACP urged for a “time out” to review and improve how physician performance is being assessed. – by Alaina Tedesco
Another ill-defined term which has been used frequently by payers (Medicare et al) is EVIDENCE-BASED MEDICINE.  A problem arises since there are many treatments for conditions where there are no valid metrics for defining what treatments are successful. 
Health Catalyst created an enterprise data solution which merged meta-data with clinician input.  

The basis for many of CMS algorithms are based upon this one company's statements. The difficulty with this is that it was not peer reviewed, nor subject to scientific scrutiny.

The entire validity of alternative payment methodology (APM) rests on their numbers.

Now early studies and statements by credible physicians groups such as the ACP cast doubt on what we call Evidence Based Medicine.

Monday, April 16, 2018

The art of medicine is slowly being pushed out. Is that a good thing?

Medical students often see the folly of what experienced physicians do or accept as normal.

One late evening on pediatrics call, a frantic young couple brought in their few weeks old baby. She had spiked a fever which refused to go down and was fussier than normal. The cause of her symptoms could have been anything — at best, a mild respiratory infection, in which case we would simply watch her and manage her symptoms, but at worst, it could be meningitis, an infection attacking the membrane covering her spinal cord and brain. It’s a grave condition that would be fatal if left undiagnosed, but diagnosing it meant doing a lumbar puncture, an extremely invasive procedure for anyone, let alone a baby, involving inserting a needle into the spinal column.
The situation was a classic dilemma: to tap or not to tap. After an hour of deliberation with the residents, I found myself holding down a writhing and crying infant by her legs and torso and while resident stuck a needle into her lumbar spine. After a few attempts, we finally drew enough spinal fluid for analysis.
The next morning, the lab results came back — she didn’t have meningitis after all. Did we make the wrong decision by putting the baby and her parents through needless suffering and risk? When science fails to give us right answers, we’re forced to resort to our instincts, to dig deep into our clinical memory banks for guidance and have faith that our training was sufficient. And that ambiguity and nuance, as our attending at the time told us, capture the art of medicine and is what drew me into this field.
And yet, the art of medicine is slowly being pushed out. Much of clinical decision making, at least the simple kind, already use personal health data. Go into any family doctor practice these days, and you can find a provider plugging your information into an online calculator to determine what tests to do and what drugs to prescribe. Are you an older male with a history of high blood pressure, high cholesterol, and smoking? According to the algorithm, other patients with similar health profiles have benefited from taking a daily baby aspirin. Evidence-based medicine has eclipsed medical dogma — now we do what is scientifically sound instead of what we feel is right. The American College of Cardiology provides online calculators which is a  simple algorithms which calculate risk.
But what about more complicated decisions? At a conference I attended last month, a computational researcher and his colleagues presented the results of their latest machine-learning project. Over the past year, they designed a remarkable and elegant algorithm that could distinguish thousands of normal tissue from cancerous tissue of any type with up to 96 percent accuracy. The group plans on applying the same strategy to blood samples, opening up the possibility that a simple blood draw could lead to earlier and less invasive cancer diagnoses. Even the most talented pathologist in world would be hard pressed to recapitulate such efficiency.
Medicine is not immune to disruption. And with the rise of computers, we as physicians may see our autonomy and creativity, some of the very reasons why we decided to become doctors, marginalized. You’d think that the dim prospect of computers taking over medicine would frighten me — that after 26 years of schooling and endless loans, I’d find myself unemployed and my skills obsolete. But computers will never be infallible and there will always been a need for human oversight — after all, we humans built these machines.
What we should be more concerned with is the depersonalization of medicine. Stripped of human interpretation and judgment, medicine becomes cold and distant: Face time supplanted by screen time, probes and wires instead of a human hand and ear. Some resident physicians already spend 40 percent of their time in front of a computer screen and only 12 percent of their time with direct patient care. Will those numbers eventually turn to 100 and 0?
My generation of physicians may one day be practicing more as overseers rather than decision makers. But along with this change comes the standardization of care and improvement in outcomes by closing the gaps of inefficiency and erasing human bias. For our patients, that’s a good thing. And ultimately, isn’t that what matters most?

The art of medicine is slowly being pushed out. Is that a good thing?

Association of a Smartphone Application With Medication Adherence and Blood Pressure Control: The MedISAFE-BP Randomized Clinical Trial | Hypertension | JAMA Internal Medicine | JAMA Network

Association of a Smartphone Application With Medication Adherence and Blood Pressure Control

Remote monitoring of vital statistics has been attempted., however analytics has shown for blood pressure control, it made no difference. Better medication compliance was revealed, despite no change in blood pressure control.

Remote monitoring may be useful for increasing compliance for taking antihypertensive medication. This may be due to increased awareness by users regarding their blood pressure. Not evaluated was the benefits of certain antihypertensives to prevent heart disease via other mechanisms. such as ACE inhibitors.

Intervention arm participants were instructed to download and use the Medisafe app, which includes reminder alerts, adherence reports, and optional peer support.

MediSafe is available on the:

Bottom Line
Among individuals with poorly controlled hypertension, patients randomized to use a smartphone app had a small improvement in self-reported medication adherence but no change in systolic blood pressure compared with controls.
Trial Registration Identifier: NCT02727543
Association of a Smartphone Application With Medication Adherence and Blood Pressure Control: The MedISAFE-BP Randomized Clinical Trial | Hypertension | JAMA Internal Medicine | JAMA Network

Thursday, April 12, 2018

Physician Nurse Patient Communications

Often times there are miscommunications or even worse no communication between staff and  physician regarding patient communications.  The video and following explain a method to avoid lack of communications.

Phillip Hanck, MD a plastic surgeon in Seattle, WA discusses methods to reduce risk of medico-legal issues and to improve the quality of care.

Dr Planck's message is to be certain all contacts via phone or written communication, social media such as messenger must be recorded in the medical record.  Staff must be educated as to the imporance of recording these contacts.

Staff must also be aware that these tools are NOT  HIPAA compliant..  The electronic health record and/ or a patient portal may be a better method of communication with patients.

It should be emphasized to the staff the signifcant penalties for ignoring HIPAA regulations. Questions regarding this issue should be referred to the compliance officer of the medical practice.

 Innovations in Patient Safety - YouTube

Wednesday, April 4, 2018

Apple announces solution bringing health records to iPhone - Apple

Apple brings to market their new app. The new feature is present on the iPhone with iOS 11.3 beta, Health Records Brings Together Hospitals, Clinics and the Existing Health App to Give a Fuller Snapshot of Health

The updated Health Records section within the Health app brings together hospitals, clinics and the existing Health app to make it easy for consumers to see their available medical data from multiple providers whenever they choose. Johns Hopkins Medicine, Cedars-Sinai, Penn Medicine and other participating hospitals and clinics are among the first to make this beta feature available to their patients.
Now, consumers will have medical information from various institutions organized into one view covering allergies, conditions, immunizations, lab results, medications, procedures and vitals, and will receive notifications when their data is updated. Health Records data is encrypted and protected with the user’s iPhone passcode.

Apple already entered the health market with their Health Care Research Kit

Apple debuts medical records on iPhone | Healthcare Dive

Apple announces solution bringing health records to iPhone - Apple

Monday, April 2, 2018

Doctors just Used a Brand New Gene Therapy to Try to Save a Child’s Vision

Doctors just Used a Brand New Gene Therapy to Try to Save a Child’s Vision

The Potential Is Enormous
Jack Hogan has never been able to play baseball because of his poor eyesight. Now 13, Jack was born with a rare genetic disorder that has eaten away at his vision. At night, he’s fully blind, so before dark, he has to leave his friends behind and return to his family’s home in Fair Haven, New Jersey.
Jack’s parents had been told that he could be legally blind by his 20s unless a treatment became available. That day, astonishingly, has arrived.
On Tuesday, Jack became the first patient in the US to get a new gene therapy for adults and children with inherited forms of vision loss. It’s called Luxturna and was approved by the Food and Drug Administration last year as the first treatment available to treat these genetic disorders.
The treatment delivered into Jack’s left eye a synthetic version of a gene that’s important for vision — and one that Jack was missing. In a week, he’ll get the same surgery on his right eye. After he recovers from the surgeries, his peripheral vision might improve and he should be able to see more clearly at night.
“I won’t have to go in at like 8 or 7 [at night], and I can sit and watch my friends play a game or something,” he told Vox, a day after his operation at Massachusetts Eye and Ear in Boston. He may also finally be able to play baseball too — something he’s looking forward to.
Jack is now one in a small club of patients to receive the first-ever gene therapies approved by the FDA — including Luxturna, which was developed at the University of Pennsylvania and now owned by Spark Therapeutics.
“Twenty years from now, when gene therapy or gene editing drugs are widespread, we’ll look back on today and think of this as truly momentous,” said Fyodor Urnov, associate director at the Altius Institute for Biomedical Sciences.
But there’s a catch. With a price tag of $850,000 — or $425,000 per eye — Luxturna is the costliest drug ever approved for sale in the US. That means it’s completely out of reach for the vast majority of Americans who, like Jack, have genetic disorders that impair their vision.
“This is a fantastic story of tremendous innovation,” said Dr. Steve Pearson, the president of ICER, an independent research organization that evaluates the cost of drugs.
But he’s also very worried. “As a system, it feels sometimes like we’re headed 100 miles per hour at a brick wall in terms of how we are going to pay for these drugs, and how the prices can reflect what we know about their benefits for patients.”
Luxturna works by delivering patients a synthetic copy of a missing gene
About 1 in 4,000 people in the United States are born with inherited retinal diseases called retinitis pigmentosa or leber congenital amaurosis, which can be caused by dozens of genetic mutations. In a very small subset of patients, about 1,000, mutations in the RPE65 gene specifically bring on their vision problems.
RPE65 is essential for the health of the retina, the layer at the back of the eye that’s sensitive to light. “Vitamin A is the chemical that changes shape when light hits the retina,” said Jason Comander, Jack’s doctor at Massachusetts Eye and Ear. RPE65 carries the instructions needed to make the vitamin A chemical processing machinery work. People with RPE65 mutations can begin to experience losses of vision in their infancy, including the loss of peripheral vision and night vision. Most are legally blind by their 20s.
Defect of RPE genetic mutation 

 Appearance of Retina in Patient (adult) with Leber's Disease

Luxturna was designed to address the RPE65 genetic mutation — in the best cases, permanently — for patients who have RPE65-associated retinitis pigmentosa or leber congenital amaurosis. To perform the therapy, doctors take a synthetic copy of RPE65 and put it in a virus whose sole function is to deliver the new gene to the cells that support the retina. The virus is injected — in three drops of liquid — into the space underneath the retina.
“Once you put [RPE65] back in, the eye is ready to see,” Comander told Vox. “It’s potentially a one-time treatment.”
There isn’t a ton of data on the treatment. But the results from the biggest and most robust clinical trial to date are why Jack’s doctors are optimistic it will work for him.
The phase 3 clinical trial of Luxturna was conducted in 2012 and 2013 and found that 27 of the 29 patients who received the treatment gained vision over a follow-up period of at least one year, according to a test that measured their ability to see dim light. In a test of their ability to navigate independently in varying degrees of darkness, 21 of the 29 could function at the lowest light level evaluated. (The trial was small, but not unusually small in the world of rare diseases, which have few patients eligible to participate.)
There was, however, some variation in individuals’ responses. Some people had complete turnarounds. “One kid got kicked out of School for Blind because [their] vision got better,” Comander said. But another person in the trial lost visual acuity as a result of the therapy.
Researchers only have four years of follow-up data, so the very long-term outcomes of Luxturna are unknown. For now, doctors do know that the surgery also promotes cataracts, which would require additional surgery later.
“There are risks with any surgery,” Comander said. “Jack will probably have to have cataract surgery earlier than he would otherwise. But overall the ratio of potential benefits to potential risks is amazing for this. It works — it’s not even a close call as to whether people should do it or not.”
“We were very happy and grateful our son was able to receive this surgery — the first one in the US,” Jack’s mom, Jeanette Hogan, told Vox. “Everyone deserves to be able to see”
Reckoning with the cost
But not everyone who is eligible will be able to afford Luxturna. The treatment costs $850,000 — a price tag that reflects the fact that the market of patients who need the drug is small, and that the investment could have a huge potential payoff: permanently fixed vision. But it also reflects the fact that, in the US, pharmaceutical companies can essentially charge whatever they want for drugs.
In a great story, published in Stat, journalist Eric Boodman details a moment that nearly derailed Jack’s surgery — and it had nothing to do with the medicine of science. Instead, it involved Jack’s insurance company.
A few days before surgery, Comander got a call from Jack’s family insurer, asking for proof that the cause of Jack’s vision problems is indeed the RPE65 genetic mutation. They’d only cover the surgery with that evidence. Comander had to scramble to muster it — one of the many administrative challenges that came with performing the operation, he told Vox. (In the end, it’s not clear exactly how much of the cost Jack’s family’s insurance covered and his mother declined to discuss the details.)
This is just one example of the hurdles patients may face in trying to access Luxturna, even when they have health insurance.
“There’s always an annual cap on out of pocket spending, so there could be a substantial payment that eats up a family’s deductible or hits their out-of-pocket maximum,” said Pearson of ICER. And patients who have no insurance, or whose insurance companies don’t cover — or adequately — Luxturna, may be out of luck.
To address these access issues, Spark, the company that makes the drug, is exploring rebate programs for patients who don’t fully respond to the therapy. It’s also working with insurers to allow patients to pay for the drug in installments.
But these are patchwork fixes for a drug pricing system that is fundamentally broken. “If we don’t get our act together, we may hit an affordability crunch that’ll be bad for patients, it’ll be bad for manufacturers, it’ll be bad for everybody,” Pearson said. “We have a new science, and we need a new policy — in terms of looking at the pricing and payment [system] — that will be consistent [with these] innovations.”
 This application of gene therapy is just the beginning of a potential paradigm shift for the treatment of genetic diseases. How will our health financing system accomodate these treatments.  Time will tell. Will these treatments still be effective after 5, 10, ot 20 years post-treatment