Turnaround for Riverside County's Financially Beleaguered Medical Center

The ACA and it's effects on the county public health hospitals....are they more than a safety-net?

by Lauren McSherry, California Healthline Regional Correspondent, California Healthline, Monday, January 11, 2016

Riverside County took drastic action in recent years to turn around its financially mired public hospital.

The county loaned the Riverside County Regional Medical Center $200 million, spent nearly $26 million on a contract with Huron Healthcare to turn the hospital toward profitability and this year, embarked on a rebranding effort. The hospital now is called Riverside University Health System Medical Center.
Hospital CEO Zareh Sarrafian, who took the reins a little over a year ago, has advocated for equipment and technology upgrades and a hospital expansion that he said are geared toward improving efficiency, quality of care and the hospital's financial health.
Sarrafian said the hospital has the financial means to support new investments, which include a new $53 million electronic health record system that will enable improved records sharing and data mining. Also in the works are a new catheterization lab and the purchase of new medical equipment.
"We wouldn't be making these investments if we didn't think they were vital to our existence and the future and quality of care," he said.
Another project on the horizon is a new medical office complex on undeveloped land neighboring the hospital. Through a public-private partnership, the hospital plans to build physician offices, an out-patient surgical center and a new mental health center.
Sarrafian, who previously worked for Kaiser Permanente and Loma Linda University Medical Center, said the investments are necessary to prevent the hospital from falling behind in its capital expenditures.
The hospital's overall strategy is to play a role in unifying the Inland Empire's somewhat fragmented marketplace, with the goal of "integrating vital parts of the continuum of care," including mental health, he said. The hospital also has been working to establish a system of providers, he said.
Jennifer Bayer, vice president of external affairs at the Hospital Association of Southern California, said the hospital's turnaround is a welcome change, but it's still early in the process to make a final call.
"They have put a tremendous amount of investment into the facility," she said. "They are certainly on the right track from what we are hearing."

Quality of Care

Hospital administrators said part of their strategy has been renewed focus on quality of care.
They point to a sharp decline in sepsis mortality, catheter infections, surgical site infections and ventilator-associated pneumonia in the Neonatal Intensive Care Unit.
Gary Thompson, the hospital's medical director for quality, said the attention to improved quality of care has resulted in cost savings due to decreased length of hospital stays. For example, the decline in sepsis mortality resulted in savings of more than $3 million and addressing diabetic hypoglycemic rates among patients resulted in more than $1 million saved per year, he said.
This month, the hospital received a "gold-plus" rating from the American Stroke Association and last September was selected as a national top performer on key quality measures by The Joint Commission, a not-for-profit hospital accrediting agency. The hospital also is pursuing becoming a Level 1 trauma center.
The focus on improved outcomes has been influenced by increased competition among medical providers following the rollout of the Affordable Care Act.
"How can you attract patients if you don't have quality care?" Thompson said.
Sarrafian said the hospital's role as a safety-net hospital means it needs to survive, even though it is no longer the only game in town. His aim has been to stabilize the hospital financially, while creating a delivery model that included coordination of care for the entire county.
Bayer said public hospitals across the state are giving attention toward how to attract patients and private insurers because they can no longer rely on a "shoo-in" Medi-Cal population. Medi-Cal is California's Medicaid program. Patients in the vast region encompassed by Riverside County can now opt to go to a medical center closer to home, particularly if they live far from the hospital's Moreno Valley campus.
"With Medi-Cal expansion and the ACA, many people have much more choice," she said. "It has caused many county facilities to rethink the way they deliver care so they can compete."
Due to health care reform, public hospitals are re-evaluating themselves from a competitive standpoint rather than a mandatory standpoint, Bayer said. And like RUHS Medical Center, they are considering new investments in technology, structural improvements and expansions, realigning general efficiencies and patient satisfaction, she said.
Some of the medical center's improvements, such as those related to patient infection rates, are related to new Medicare standards that can reduce hospitals' payments if they do not meet certain performance thresholds.
"You could lose 8% to 9% of your revenue based upon performance," said Craig Garner, a health care lawyer and former hospital CEO. "It's quite a challenge. They are trying to look at additional revenue streams to keep them afloat, and the question becomes, is that going to be enough?"

Building a New Image

With its rebranding, the hospital seems to be trying to tap into the prestige of other academically affiliated medical centers, such as Loma Linda, UCLA and UC-Irvine, Garner said.
The hospital's rebranding and expansion plans also appear to be part of a strategy to attract private insurers and a wider patient base.
"People want to go to the best facilities," Garner said. "It's hard to compete with other academic institutions or conglomerates."

Staying Afloat

Garner said the road ahead for public hospitals like RUHS Medical Center is not an easy one.
"They have to become very efficient. They have very little room for error," he said. "If people are being encouraged to utilize less, and providers are being paid less and they already had slim profit margins, something has to give. That's the burden of health care reform, to find a way to bridge that gap."
The hospital appears to be on better financial footing. It reported a $54 million profit in fiscal year 2015, compared with a $62 million loss in 2014. And the $200 loan from the county in the form of a line of credit is no longer on the books as the hospital has a positive cash flow, according to a statement from the hospital's spokesperson. Meanwhile, the hospital has 10 years to pay back its debt obligation to Huron Healthcare.
Sarrafian conceded that the ACA has required public hospitals to adapt in order to survive new competitive forces. He foresees more consolidation and said size is going to matter and some hospitals will need to become part of a larger network to survive.
"It's been very difficult for many organizations to anticipate the ramifications," he said. "Public hospitals have probably been the most adversely impacted."

Source: California Healthline, Monday, January 11, 2016

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.

ObamaCare Co-ops: Cause Célèbre or Costly Conundrum? 

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 

Obamacare, Is the American Public Stupid or were they Deceived....Again

According to government sources, Obamacare is a resounding success. Yet industry experts and pundits examining the implementation say otherwise.

More information is forthcoming about ObamaCare. Jonathon Gruber, Professor of Economics at M.I.T a primary author for the Affordable Care Act was interviewed by

the Daily Motion (video)

He was a key architect of both the 2006 Massachusetts health care reform, sometimes referred to as "Romneycare", and the 2010 Patient Protection and Affordable Care Act, sometimes referred to as "Obamacare".^[1]

Sen. Rand Paul (R-Ky.) made a guest appearance on “Hannity” Monday and said that embattled Obamacare architect Jonathan Gruber should be made to give back the money he received for his work on the health care bill.

ObamaCare Architect Thinks You’re Stupid; Pelosi Does Too

Gruber admitted multiple times that Obamacare was written in a non-transparent way intentionally, to exploit the “stupidity” of the American voter.

WHY AMERICA IS LOSING THE HEALTH RACE

Article attributed to:  New Yorker Magazine

Many Americans are aware that the United States spends much more on health care than any other country in the world. But fewer people know that the health of Americans—by many different measures—is actually worse than the health of citizens in other wealthy countries.

Two major reports, both released last year, provide further elaboration of this apparent paradox. The first, “The State of US Health, 1990-2010,” documented trends in mortality and morbidity across the thirty-four member countries of the Organization for Economic Cooperation and Development (O.E.C.D.). The study, published in The Journal of the American Medical Association (to which I am a contributing writer), showed that both life expectancy and healthy-life expectancy improved in the United States over two decades. But the pace of those improvements was considerably slower in the United States: in 1990, the U.S. ranked twentieth among O.E.C.D. countries for life expectancy, and fourteenth for healthy-life expectancy; by 2010, it had fallen to twenty-seventh and twenty-sixth, respectively. The other charts and tables in the report—about heart, lung, and kidney disease; diabetes; injuries and homicides; depression; and drug abuse—all show Americans suffering poorer health.

The second report, commissioned by the National Institutes of Health, and conducted by the National Research Council (NRC) and the Institute of Medicine (IOM), convened a panel of experts to examine health indicators in seventeen high-income countries. It found the United States in a similarly poor position: American men had the lowest life expectancy, and American women the second-lowest. In some ways, these reports were not news. As early as the nineteen-seventies, a group of leading health analysts had noted the discrepancy between American health spending and outcomes in a book called “Doing Better and Feeling Worse: Health in the United States.” From this perspective, the U.S. has been doing something wrong for a long time. But, as the first of these two reports shows, the gap is widening; despite spending more than any other country, America ranks very poorly in international comparisons of health. The second report may provide an answer—supporting the intuition long held by researchers that social circumstances, especially income, have a significant effect on health outcomes.

Americans’ health disadvantage actually begins at birth: the U.S. has the highest rates of infant mortality among high-income countries, and ranks poorly on other indicators such as low birth weight. In fact, children born in the United States have a lower chance of surviving to the age of five than children born in any other wealthy nation—a fact that will almost certainly come as a shock to most Americans. But what causes such poor health outcomes among American children, and how can those outcomes be improved? Public-health experts focus on the “social determinants of health”—factors that shape people’s health beyond their lifestyle choices and medical treatments. These include education, income, job security, working conditions, early-childhood development, food insecurity, housing, and the social safety net.

Steven Schroeder, the former president of the Robert Wood Johnson Foundation—the largest philanthropic organization in the United States devoted to health issues—had a definitive answer to my question about why Americans might be less healthy than their developed-country counterparts. “Poverty,” he said. “The United States has proportionately more poor people, and the gap between rich and poor is widening.” Seventeen per cent of Americans live in poverty; the median figure for other O.E.C.D. countries is only nine percent. For three decades, America has had the highest rate of child poverty of any wealthy nation.

Steven Woolf, of Virginia Commonwealth University, who chaired the panel that produced the NRC-IOM report, also pointed to poverty when I asked him to explain the causes of America’s health disadvantage. “Could there possibly be a common thread that leads Americans to have higher rates of infant mortality, more deaths from car crashes and gun violence, more heart disease, more AIDS, and more premature deaths from drugs and alcohol? Is there some common denominator?” he asked. “One possibility is the way Americans, as a society, manage their affairs. Many Americans embrace rugged individualism and reject restrictions on behaviors that pose risks to health. There is less of a sense of solidarity, especially with vulnerable populations.” As a percentage of G.D.P., Woolf observed, the U.S. invests less than other wealthy countries in social programs like parental leave and early-childhood education, and there is strong resistance to paying taxes to finance such programs. The U.S. ranks first among O.E.C.D. countries in health-care expenditures, but as Elizabeth Bradley, a researcher at Yale, has documented, it ranks twenty-fifth in spending on social services.

The NRC-IOM report emphasized the effect of social forces on children and how those forces carry over to affect the health of adults, noting that American children are “more likely than children in peer countries to grow up in poverty” and that “poor social conditions during childhood precipitate a chain of adverse life events.” For example, of the seventeen wealthy democracies included in the report, the U.S. has the highest rates of adolescent pregnancy and sexually transmitted diseases, and the second-highest prevalence of H.I.V. This platform of adverse health influences in childhood sets up the health disadvantage that remains pervasive for all age groups under seventy-five in the United States.

It seems likely that many Americans would respond to these figures—and to the role poverty plays in poor health outcomes—by assuming that the data for all Americans is being skewed downward by the health of the poorest. That is, they understand that poor Americans have worse health, and presume that, because the United States has more poor people than other wealthy countries, the average health looks worse. But one of the most interesting findings in the NRC-IOM report is that even white, college-educated, high-income Americans with healthy behaviors have worse health than their counterparts in other wealthy countries.

Woolf explained this disparity by citing the work of the British social epidemiologist Richard Wilkinson, who has proposed that income inequality generates adverse health effects even among the affluent. Wide gaps in income, Wilkinson argues, diminish our trust in others and our sense of community, producing, among other things, a tendency to underinvest in social infrastructure. Furthermore, Woolf told me, even wealthy Americans are not isolated from a lifestyle filled with oversized food portions, physical inactivity, and stress. Consider the example of paid parental leave, for which the United States ranks dead last among O.E.C.D. countries. It’s not hard to see how such policies might have implications for infant and child health.

Other countries have used their governments as instruments to improve health—including, but not limited to, the development of universal health insurance. Health-policy analysts have therefore considered the effect that different political systems have on public health. Most O.E.C.D. countries, for example, have parliamentary systems, where the party that wins the majority of seats in the legislature forms the government. Because of this overlap of the legislative and executive branches, parliamentary systems have fewer checks and balances—fewer of what Victor Fuchs, a health economist at Stanford, calls “choke points for special interests to block or reshape legislation,” such as filibusters or Presidential vetoes. In a parliamentary system, change can be enacted without extensive political negotiation—whereas the American system was designed, at least in part, to avoid the concentration of power that can produce such swift changes.

Whatever the political obstacles, a major explanation for America’s persistent health disadvantage is simply a lack of public awareness. “Little is likely to happen until the American public is informed about this issue,” the authors of the NRC-IOM report noted. “Why don’t Americans know that children born here are less likely to reach the age of five than children born in other high income countries?” Woolf asked. I suggested that perhaps people believe that the problem is restricted to other people’s children. He said, “We are talking about their children and their health too.”

The superior health outcomes achieved by other wealthy countries demonstrate that Americans are—to use the language of negotiators—“leaving years of life on the table.” The causes of this problem are many: poverty, widening income disparity, underinvestment in social infrastructure, lack of health insurance coverage and access to health care. Expanding insurance coverage under the Affordable Care Act will help, but pouring more money into health care is not the only answer. Most experts estimate that modern medical care delivered to individual patients—such as physician and hospital treatments covered by health insurance—has only been responsible for between ten and twenty-five percent of the improvements in life expectancy over the last century. The rest has come from changes in the social determinants of health, particularly in early childhood.

Self-interest may be a natural human trait, but when it comes to public health other countries are showing the U.S. that what appears at first to be an altruistic concern for the health and care of the most vulnerable—especially children—may well result in improved health for all members of a society, including the affluent. Until Americans find their way to understanding this dynamic, and figure out how to mobilize public opinion in its favor, they will all continue to lose out on better health and longer lives.

Allan S. Detsky (M.D., Ph.D.) is a general internist and a professor of Health Policy Management and Evaluation and of Medicine at the University of Toronto, where he was formerly physician-in-chief at Mount Sinai Hospital. He is a contributing writer for The Journal of the American Medical Association.

Photograph by Ashley Gilbertson /VII.

Taxpayers subsidizing 76% of premium under health care law Associated Press

Healthcare.gov  If you missed signing up, here are some other alternatives

People who signed up for coverage under President Obama's health care law are paying about $80 a month in premiums on average, the administration reported Wednesday.


The new numbers from the Health and Human Services Department cover only the 36 states where the federal government took the lead in setting up new insurance markets, accounting for about 5.4 million of the 8 million people who signed up nationally.

Among the major findings:

-- Taxpayers are subsidizing 76 percent of the average monthly premium in the 36 federally administered markets.

-- The average premium is $346 a month, but the typical enrollee pays just $82. Tax credits averaging $264 a month cover the difference. The government pays the subsidy directly to insurers.

-- After tax credits, Mississippians paid the least for coverage - averaging just $23 a month on average premiums of $438. Among people in the 36 states, New Jersey residents paid the most - an average of $148 on premiums averaging $465 a month.

-- For this year, the average consumer could pick from five insurance companies and 47 different plans, although choice was more limited in a small number of states. From a range of platinum, gold, silver and bronze plans, most people picked silver.

-- There was a link between greater competition and lower premiums. For each additional insurer in a local market, premiums for the benchmark silver plan declined by 4 percent.

-- Premiums varied widely between states, ranging from an average of $536 in Wyoming to $243 in Utah.

Federal officials say they don't yet have complete data on the 14 states running their own markets.

Physician Abdication of Power

Background:

During the last two decades physicians have abdicated their role to CMS and payers fo policing each other. Resident physicians are closely supervised and gradually given more responsibility for decision making as they proceed from PGY 1-PGY4.  As a chief resident they are responsible for much of the activity of junior residents. Surgical and/or medical residents in certain specialties have their proposed surgical cases reviewed by either a chief resident, or director of the training program prior to scheduling.

During the first year of practice or if the MD change hospitals medical staff regulatons require providers to have a  proctor during a certain number of cases to insure proper judgment and  competence.

Following this period they are allowed to operate alone.  Further proctoring is usually not necessary unless there is a complication or a death. Usually this takes place in a departmental meeting for review. This often serves as a learning experience and is not a punitive affair. If the difficulties persist the physician will be required to obtain further training or more supervision until he demonstrates competence.  The entire process is physician led. It is private and confidential and not discoverable by non-physicians.

During the last two decades physicians have been lax in many regards, and have not required chart reviews prior to surgery nor review of treatment protocols unless there is an untoward event resulting in a morbidity or mortality and after the fact.

Current:

The review and authorization procedure now is conducted by insurers for prior authorization by a non-physician or a medical director for a payer.  This occurs away from the clinical setting when the physician submits the case  history, and proposed procedure.  The intensity of the review by CMS and payers is usually determined by the level of cost and number of procedures that are done.  The ultimate goal is not patient safety, nor quality of care. It is to reduce cost.  Their benchmark for what is reviewed is a simple algorithm.   #of cases X cost/case = total cost. Cases that are done in high volume, or high expense will require prior authorization. Such cases or diagnostics include Cataract removal, Hysterectomy, Spine surgery, Interventional cardiology. Many of these are surgical or advanced medical interventions. Many of the reviews are for expensive imaging, such as MRI or CT imaging.

There has been a gradual erosion of self determination and  pre-surgical review by physicians and surgeons, allowing CMS and payers to intrude into physician-patient relationshiphs.

Future:

Physicians will reclaim the role of ascertaining quality control and prevention of abuse and fraud by peer-review of  expensive and high volume procedures prior to procedures, both diagnostic and Invasive.  It will be required that all pre-surgical cases be reviewed by another member of the department prior to scheduling (except for emergent or urgent need.) The insurance company should not have any role in  prior authorization.  That will be the purview of medical staff, much like PQRI was performed in the late 1980s for cataract removal.  

This system will allow peer and case review for the medical staff and immediate feedback for non-compliant providers.

The insurance system will be simplified.   Delays and/or denials could be eliminated for review, authorization and payments.  Administrative expense could be reduced. This will require some additonal time and effort by physicians.  That is the price for professional freedoms.  Freedom takes effort to maintain.

Is this an idealized vision for the future, or will it come to pass?  Only you and I can decide.

The time has come to draw a red line in the sands of health care.

ACA and the Three I s

The Three “I’s” of the Affordable Care Act

The triple ‘AIM’ is a term often quoted by health policy pundits.

CALIFORNIA’S MEDICAID CONUNDRUM

While California’s Medicaid enrollment exceeded projections by 1.4 million, many of those new enrollees had already been eligible for the program. The federal government provides states a 100% Medicaid match through 2016, but that’s only for those individuals newly eligible under the 2010 health-care law; if individuals who had already been eligible for but not enrolled in Medicaid come out of the woodwork, states will pay a portion of those costs. In 2012, the Department of Health and Human Services estimated that states would pay an average of 43% of those enrollees’ Medicaid costs in this fiscal year.

Some states opted to expand Medicaid under the health-care law, raising costs and budgetary pressures at a time of volatile tax revenue. In some cases, the result has been cognitive dissonance. California Gov. Jerry Brown was quoted in Thursday’s Journal saying: “We can’t spend at the peak of the revenue cycle--we need to save that money, as much of it as we can.” But two days earlier, Mr. Brown had expressed pride in the “huge social commitment” that health-care expansion represented in his state--even as it caused a billion-dollar overspend.

Ultimately, states that expand Medicaid could face pressure to cut other important services, whether health-related or in areas such as corrections or education. Recent trends have moved toward reductions because when an irresistible force such as a shrinking tax base meets an immovable object--the rising costs from expanding Medicaid--something has to give.

SOURCE: Wall Street Journal

The three Is of the Affordable Care Act,  Inadequate  Ill-conceived,   and incompetent

Affordable Care Act------Silk Scarf or Pig's Ear ?

Silk Scarf or Pig’s Ear ?

President Obama and the Democrats insist that the Affordable Care Act is working and has increased the number of insured, yet most Americans do not like the law.

The question now is what kind of bang did we get?  

Figures from the Heritage Foundation in their Consumer Power  Report “Obamacare Squandered $1.2 Billion on Failed Exchanges

It all began when HBX was enrolling carriers for each state. At best it was a difficult sell with much arm-twisting   In Maryland, Mississippi, New Mexico, and South Dakota, officials had to beg and plead just to get one carrier into the state’s private market.

Continuing problems are ongoing in many state exchanges. There’s only one insurance carrier – Blue Cross Blue Shield – in West Virginia’s exchange.

Hawaii is another consensus pick, and some experts say the state might never be able to support its Obamacare exchange. Hawaii was near the bottom for total enrollment, signing up just 15 percent of its eligible population, and had the second-worst mix of young adults. The state’s exchange also suffers from the fact that Hawaii had a low uninsurance rate to begin with – meaning there’s a smaller pool of potential customers there, which makes the state less attractive to insurers. Hawaii’s “Health Connector” has signed up the smallest number of people of any state in the country and has no plans to finance their operations moving forward. Their current plan appears to be to all-but-close-up-shop and outsource all of the exchange functions to the state Department of Human Services. The state’s leading insurance company says it is time to pull the plug. Expect this one to be official any day now.

Health care analysts are also keeping an eye on premiums in Maryland, Mississippi, New Mexico, and South Dakota, where officials had to beg and plead just to get one carrier into the state’s private market.

The expected rise in premiums will vary greatly from state to state, smaller states with fewer enrollees and a bias toward older and sicker people will see sharp rises in premiums.  It’s impossible, though, to say with any certainty whether a particular state will see an above-average price increase next year.   Maryland, Mississippi, New Mexico, and South Dakota,  are among those HBXs to watch.   Minnesota’s exchange has been a disaster, and they recently brought in [Deloitte] on a nine-month $4.95 million contract to fix it. It is unclear whether they will be successful.

Vermont, the tiny state with giant ambitions to use Obamacare as a stepping stone to single-payer, government-run health care is still facing enormous problems dealing with its tiny population. They are using CGI, the same vendor that failed on the federal healthcare.gov, and have given them a deadline of July 2 to get the site working. It is unclear what Vermont will do if they fail to deliver by that date.

The total is $ 1.2 billion…..and it is not over, yet

HTE DIGEST Vol 1 No 2

HTE Health Train Express is Celebrating 10 years of publishing on the internet. Throughout this month we will publish articles from the past ten years.

JAMA (Journal of the American Medical Association) study claims low value care cost Medicare $8.5 B

A substantial number of Medicare Beneficiaries receive low value medical care. Several criteria were used to measure low value care. Medicare spent $8.5 billion, or $310 per beneficiary, on services detected by the study's more sensitive measures of low-value care, while spending on low-value services with more specific definitions totaled $1.9 billion, or $71 per beneficiary.

That accounted for 0.6 percent to 2.7 percent of overall spending, depending on the measures' level of sensitivity. While representing "modest proportions" of total Medicare spending, the researchers note the findings suggest widespread overuse of unnecessary treatments. JAMA Study  KHN Study

SPOTLIGHT ON... First 2015 rate filings show premium hikes

Virginia is first state to release rate proposals for 2015. Premium rates will rise 3.3% (KFHP), 8.5% (Wellpoint Anthem). to accomodate poorer health of many new members likely to boost their health care utilization.

Aetna: Bumpy road ahead for ACOs

Webinar events  Mark Your Calendars:  A collection of free webinars of timely subjects

> Next-Generation Subrogation Solutions - Wednesday, June 4, 2014, 12pmET / 11amCT / 9amPT

> Healthcare's new entrants: Who will be healthcare's Amazon.com? - Wednesday, June 3rd, 11am ET / 8am PT

> New Rx Savings Strategies for Payers - SPONSORED BY: Elsevier

> The Growing Challenge of Medical Identity Theft - Thursday, June 5, 2014 | 1pm ET, 11am PT

> The Internet of Things: How connected devices put data in your hands - Thursday, June 12th, 1pm ET / 10am PT

> Developing for the Internet of Things: Challenges and Opportunities - Wednesday, June 18th, 2pm ET

> Boosting physician adoption of CPOE to maximize its benefits - Wednesday, June 25th, 2pm ET/ 11am PT

Better MLR compliance reduces consumer rebates

Insurers issued about $513 million in rebates for 2012 under the medical-loss ratio requirement, according to a Commonwealth Fund report released Tuesday. That's half of the amount paid in 2011, showing greater compliance by insurers with the Affordable Care Act's MLR rule.  Commonwealth Fund announcement and study (.pdf)

CMS decided to increase the Medicare Advantage payment rate by 0.4 percent after it proposed in February to lower rates for plans,  Despite the reversal, some insurers like Aetna and Humana have still predicted Medicare Advantage payments will drop by as much as 4 percent.

Health IT News:

> Within two decades, Google might dominate the medical technology industry as the company currently spends $8 billion a year on research. Article

Shortage of Health IT Professionals Imperils Health Care Reform…

During the past ten years  adoption of EHR, HDX, and Hospital EHRs created a tsunami of demand for experienced IT professionals.  Despite funding for training of HIT personel via the HITECH ACT ongoing demand has created a shortage, impacting EHR installations, and Health Care Reform.  Much of Health Care Reform requires integration of data silos and data analytics

Is Meaningful Use is On the Ropes?

Controversy and disagreement continues in regard to Federal mandates for inclusion of Meaningful use standards for electronic health records. Meaningful use was designed to guide transition to EHRs that would exchange data, increase patient involvement, and allow data collection for analysis.  Providers are mandated to either modify their present EHR or completely replace their software.  This comes at a time when there are many competing increases in bureaucracy, planned adoption of the ICD-10 diagnosis tables.  Providers have said that the definition of Meaningful Use by HHS is not the same as meaningful use by providers.  EHRs continue to be inconsistent, not user friendly, nor intuitive.

Health IT Potpouri

There is an overwhelming amount of information about HIT on the web, blogs, email newsletters and a Google search will turn up literally hundreds of resources.

For this week, May 8 2014 I have compiled this list of hot topics and links:

Innovation event brings new ideas, ROI ROI -- whether the "I" stands for innovation or for investment -- will be among the many topics up for discussion at the National Healthcare Innovation Summit, which kicks off May 13 in Boston. The organizers promise "the kinds of innovations that people can take home and use tomorrow." When EHR design is a 'what not to do' Among the healthcare developers workshopping better approaches to technology design at HxRefactored in Brooklyn next week will be Stephen Buck, who'll offer some "lessons learned" from looking closely at leading EHRs -- specifically, how not to design a user interface. EHR incentive payouts climb to $23B More than 370,000 Medicare and Medicaid eligible providers have earned an EHR incentive payment so far, with 64,000 new participants attesting to meaningful use for the 2013 reporting year. Health agency inks $71M EHR contract The Defense Health Agency has put a foot forward with revamping its clinical information systems after it inked a bridged contract with a Reston, Va.-based technology and defense company.

The current landscape of data exchange networks is disjointed, with health care systems scrambling to uncover sustainable business models. The need for interoperability is greater than ever. What will the model look like in the future and what are organizations doing to move toward more valuable data exchange? Ashish Shah, Medicity’s CTO, and I recently discussed these industry drivers with Anthony Brino, editor of Government Health IT. Read the article HIE at a Crossroads.

Carolinas HealthCare System CareConnect got an early start on creating a robust network for data exchange. Take a look at this recent case study highlighting Medicity’s role in connecting the health care ecosystem to enable a 360-degree view of patients across the care continuum.

Still no consensus on digital/mobile/connected health Posted: 06 May 2014 10:06 PM PDT A while back — three months, to be exact — I asked readers if they had a preferred term to describe “the application of new, personalized technologies to healthcare.” I gave you the choice of digital health, connected health, wireless … Continue reading →

Interoperability beyond doom or gloom

HIE among U.S. non-federal acute care hospitals has been trending upward since 2008, in fact, and it took some major leaps forward in 2013.

An EHR 'buying spree'? Maybe not quite

M*Modal Drives Anywhere, Anytime Medical Dictation with Enhancements to iOS Mobility Solution

Posted: 05 May 2014 09:01 AM PDT

Understanding that physicians require more comprehensive, flexible clinical documentation solutions that reflect the fast-paced highly mobile health care environment, M*Modal today announced enhancements to its Fluency Flex™ Mobile dictation application for iOS 6.0+ devices. Moving beyond the capture of clinical notes during … Continue reading →

Patients want online access to records

More than half of people with chronic conditions say the ability to get their electronic medical records online outweighs the potential privacy risks, according to a new survey by Accenture.

Big chill for telemedicine?

New guidelines issued by the Federation of State Medical Boards could have a chilling effect on the growth of telemedicine -- especially in rural areas and among low-income patients, say some patient advocates, healthcare providers and healthcare companies.

An EHR 'buying spree'? Maybe not quite

Some analysts are predicting the next "great wave" in EHR purchasing among U.S. hospitals to be just around the corner. But do the numbers really bear that out?

EHR certification criteria under fire

The hits keep on coming for the new EHR certification criteria, as the American Medical Association and Telecommunications Industry Association send their complaints to ONC on the heels of similar criticism submitted earlier by the EHR Association.

The “unconfirmed rumor of a huge acquisition” that HIStalk (a.k.a. the National Inquirer of health IT) tweeted about on Wednesday apparently is that IBM was going to acquire Epic Systems. Mr. HIStalk on Thursday expressed some reservations.   @DaLAWon Much … Continue reading →

• » Why EHRs are Key to Better Clinical Data

EHR certification criteria under fire

The hits keep on coming for the new EHR certification criteria, as the American Medical Association and Telecommunications Industry Association send their complaints to ONC on the heels of similar criticism submitted earlier by the EHR Association.

$11 Billion DoD EHR Contract

Posted: 01 May 2014 10:51 AM PDT

Nextgov has a great article up which outlines many of the details of the soon to be bid out Healthcare Management Systems Modernization contract. I’d prefer to call it the DoD EHR Contract or AHLTA replacement contract. Certainly there’s more … Continue reading →

10 technologies on the rise

Explore Medical Practice Insider's guide to emerging apps and devices for the medical practic

If you want to learn more about ACO formation and Operational Issues: Attend

this event either in person, or as a webinar.

Press Release: Brookings/Dartmouth Fifth ACO Summit Announces New Keynote Speakers Sean Cavanaugh & Alice Rivlin

A Hybrid Conference and Internet Event The Leading Forum on Accountable Care Organizations (ACOs) and Related Delivery System and Payment Reform Sponsored by Engelberg Center for Health Reform at the Brookings Institution and Dartmouth Institute for Health Policy and Clinical Practice June 18 - 20, 2014 Hyatt Regency on Capitol Hill, Washington, DC Online In Your Own Office or Home live via the Internet with 24/7 Access for Six Months www.ACOSummit.com

For Summit registration information, visit www.ACOSummit.com/registration.php, email registration@hcconferences.com, or call 800-503-3597.

Brief EHR Notes, 40% EHR Replacement, and $23 Billion EHR Market http://ow.ly/2GkTlr

Brief EHR Notes, 40% EHR Replacement, and $23 Billion EHR Market | EMR and HIPAA

RT @kevinmd: Brevity is the soul of a good EMR note http://t.co/AuHO9FWPp2— athenahealth (@athenahealth) May 4, 2014 It's amazing how this has shifted.

Outsourcing IT for Small & Mid-size Hospitals