Health Benefit Exchange

Has health care improved since the ACO went into effect??  We have been told that already the ACA has saved millions and perhaps billions of dollars. How is that so?  Where are the details?

I have an open mind and I am willing to consider the facts....so just show me the numbers. How is it that the government has infused billions of dollars into health IT and providers must now support it operationally ? Given the lifetime of IT hardware and software obsolescence in five years at the most it will all have to be upgraded and/or replaced with a second generation of sofware that has real meaningful usability, not the garbage that HHS is insisting we use to accomodate the "quants" at HHS who massage the information spewing out of their machines.

Health care now supports an industry of high tech that has nothing to do with patient care. Vendors of hardware, software, consultants, IT consultants, a stream of auditors, review firms, outcome studies. What idiots think we are saving money?  The money in health care no longer is going to patient care......it is going to many parasitic organizations.  The only good thing about it is that unemployment would be much worse than it is already.

How long will  health benefit exchanges  be useful after the initial period of signing up the uninsured. Surely it will cost a great deal to fix it, and maintain it.

If the affordable care act continues to roll out the next five years will be a financial and health disaster.

For all the details on Health Benefit Exchanges and which insurance companies have signed up here is the list. It does not mean your doctor will accept these plans since the reimbursement rates in the Affordable Care Act will be very low compared to the current rates.

Stay tuned.

NIH Leader Calls for Evidence on mHealth

Only about 20 randomized clinical trials involving mHealth tools or services have been conducted in the United States since 2008 under the auspices of the National Institutes for Health. And more than half of them have failed to document clear evidence of improved outcomes.

 Francis Collins, MD, the NIH's director, delivered the message to attendess at the 2012 mHealth Summit in his closing keynote on Dec. 5. Collins pointed out that the lack of trial-based evidence is hindering acceptance of the technology by a healthcare industry that could really use these tools.

Dr. Collins also noted that controlled trials often are diffiicult to design in the real world by saying,

"The mHealth field is evolving so rapidly that oftentimes the technology used in trials is outdated by the time the trials are completed. For that reason, he said, the scientific and healthcare communities have to work together to fine-tune the process, producing viable results in a timely manner.

The alternative? Forge ahead with mHealth without evidence that mHealth is improving healthcare."

This viewpoint may be highly biased as to the cohort and demographics of such a study.  Presently there are thousands of mobile apps in development, most stimulated by public perception and enthusiasm from the HIT community. The feeding frenzy for profit is dynamic with the federal stimulus packages.

Many vendors in mHealth would argue differently. Hopefully some of them will comment here.

[See also: New bill would create FDA mHealth office.]

Health Reform: A Play in Multiple Acts

It is a very exciting and troubling time  for health care in the United States.  The stage is set for multiple acts occurring simultaneously.

For those who have boots on the ground with financial commitments and assets the changing landscape means unknown profits (if any) or losses.  Health institutions and providers charged with improved outcomes and 'less cost' are facing the conundrum of supplying more care with less money.

Leonard Zwelling M.D., a Houston physician who was a congressional staffer during the writing of the affordable care act puts it this way, as he discusses a statement made by

Norman Ornstein, a scholar at the American Enterprise Institute, one of the leading experts on the workings of Congress, summed it up in one sentence during a briefing for the press and politicos in November 2008. He said:

"Every one's idea of health care reform is the same: I pay less."

Where I was trying to get my head around a solution to the three tenets of my idea of health care reform, everyone around me was trying to preserve or increase his piece of the health care payoff pie. I was looking for a legislative solution to assist the country in arriving at the place where the rest of the civilized world was - the provision of some form of universal health care as a right of citizenship. Everyone else was looking to cut a deal that preserved his place at the trough of health care profiteering. Guess who won?

With the full cooperation of the Congress and the White House, health care was not even remotely reformed. The Affordable Care Act is not about health care reform. It is about money, particularly preserving the insurance industry's hold over how health care dollars are spent.

Hospitals and providers had little to do with the Affordable Care Act.

"The Affordable Care Act continued to allow hospitals to jack up prices with no relation to actual costs. Only the doctors gave up something because, unlike the insurance industry and the pharmaceutical industry, medicine did not speak with one voice when lobbying on Capitol Hill and thus could largely be ignored. This is health care reform? I don't think so.

The reason the Affordable Care Act did what it did is because that's what it aimed to do - increase access to insurance for the uninsured, get everyone else to pay for it, and make sure no one currently in the health care business loses a dollar from the amounts they are already extracting from patients and doctors alike.

Complicating Ornstein's comments are the multiple scenes ongoing in the 'reform' efforts

Technological advancements such as

Health information technology which includes electronic health records, health information exchanges, the proposed upgrading of the ICD - 9 to ICD -10, the advances in mobile health, telemedicine and more.......

The increased regulatory arm with meaningful use in 3 steps.  MU is linked with financial  incentives from CMS to offset the expense of providers and hospital acquisition of electronic medical records.

The challenging role of an unproven health benefit exchange system, with an incomplete back end disconnecting the actual payment to insurers.





The details of connecting the dots are only now coming into focus for bureaucrats and congress who badly underestimated the complexity of health care delivery.  The turmoil is clearly more evident among providers, hospitals and the patients who are the "guinea pigs"

During the next 12 to 24 months the 'symphony" will unfold.  Will it be harmonious or an unfinished symphony?

Freedom of Information Act Request filed by Health Train Express

Doctors Complain They Will Be Paid Less by Exchange Plans.  Many will opt out of private plans. News reports indicate that 70% of California MDs will not participate in the Health Exchange and the Private plans Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.

Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors.

If you’re a physician and you’ve negotiated a rate from insurance, shouldn’t it be the same on or off the exchange?” said Matthew Katz, executive vice president of the Connecticut State Medical Society. “You’re providing the same service.”

The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.

Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.

Health Train Express has filed a FOIA request from CMS (Freedom of Information Act which will require full disclosure to the providers and public  (ie, transparency that Obama claims to encourage)  Watch for the published link in about one month

Affordable Care Act "It ain't over until it's Over"

If you are reading this blog and waiting for me to tell you what is going to happen in health reform, you have come to the right place.  I know as much about this as Kathleen Sebelius or Barak Obama.

I am certain that makes you all feel better.

I know that is reassuring to my readers, because Obama and Sebelius had access to and heard many learned opinions on developing the affordable care act. However they were not listening and the elephant in the room was political intrigue, and 'what's in it for me ?"

Today my spouse received the magic letter from Covered  California stating that she has qualified, and now all she has to do is go to the website  log-in and pick her (Silver plan) That is no small task.

Among many other things, the subsidies make no logical sense to me (or others)  I need all of my funds to support myself and my disabled wife who has been unable to work for over ten years.  $250 USD would help pay for the pain medication she takes as a result of a bad wrist injury in 2002. After that she was uninsurable, so I am grateful that the ACA now affords her the ability to become insured until she reaches age 65 and  will be eligible for Medicare.

 It seems that my user id and/or password is incorrect, and I do not remember any of the questions, or answers for the security questions. Small wonder....their selection of Q&As is quite a mystery to me. I am so old I don't remember who my best friend in high school was, no the color of my first car, nor my favorite food (I like them all). Whatever happened to my mother's maiden name?

I called the telephone numbers listed on Covered California for lost user ids/passwords, and was either greeted with a busy signal or a 'we are busy right now, go to our web site, coveredca.com. Now would anyone call them if they had not already tried to use the web site.  The live on line chat room brings up a blank white screen.

The ACA has created stress for all of us, not knowing the eventual outcome...success or failure or some point in between  For those whose former policies  have been cancelled I say let's let them get to the front of the line.

It makes a lot of sense......they are already paying customers and the system needs their premium dollars now.

Everyone else should wait several weeks. Another month won't make much difference to those who have not been insured for the past decade or so.

Although I have never liked insurance companies, I do feel empathy for the mess the affordable care act has produced on top of the measly 15% margin they must operate upon now, and all those pre-existing condition patients waiting in the wings.

As Yogi Berra (byname of Lawrence Peter Berra) once told me, "It ain't over, until it's all over"  (Yes, he did tell me that personally when I was a sprite living in Connecticut.)  My Dad took me to at least a hundred Yankee games in the Bronx. I also have a signed Mickey Mantle original photo of the "Bronx Bomber"

So what does that have to do with the ACA? Let's listen and take seriously what Yogi had to say. I trust him, after all he was a Yankee on a team that broke all records winning  7 world series' back to back.

Would you rather trust President Obama, our Congress, or Secretary Sebelius?  After all Yogi batted left handed and threw right handed. (source Wikipedia)/

To Be or Not to Be (Or What is This Post About?) hint: Medical School

The title of this post is not going to sit well with search engines....Shakespeare will probably appear often. In fact I did a quick search of the  "quote", and the listing began with, Wikipedia's listing on Shakespeare, The Complete Works of Shakespeare,Shakespeare Online, a listing of all Shakespeare productions in process, and not last nor least, "How Shakespeare would end "Breaking Bad"

I admit I have plagiarized much of this writing from Ali Binazir, who I assume is an MD.  Kudos to him for not punctuating his name with M.D. As  Yankel in      states, "A blessing on your house"...Mazel tov, mazel tov !  (or perhaps he did not graduate)  However, no aspersions are cast upon this author.  He articulates the 10 reasons why you should not become a doctor, and points out the one reason you should become a doctor.

Ali Binzar is an M.D. he graduated from Harvard (B.A.) and then the University of California San Diego.

My google search failed to show him listed on Healthgrades.com. (a real accomplishment, one which most of my readers would like to know how he did that). Most of the searches yielded writing, books, mostly centering around love, and dating. He is on the UCSD faculty of Medicine.  This I found on Doximity a peer social media platform for physicians.

Why You Should Not Go To Medical School     

1) You will lose all the friends you had before medicine.
2) You will have difficulty sustaining a relationship and will probably break up with or divorce your current significant other during training.
3) You will spend the best years of your life as a sleep-deprived, underpaid slave.
4) You will get yourself a job of dubious remuneration.
5) You will have a job of exceptionally high liability exposure.
6) You will endanger your health and long-term well-being.
7) You will not have time to care for patients as well as you want to.
8) You will start to dislike patients — and by extension, people in general.
9) People who do not even know you will start to dislike you.
10) You’re not helping people nearly as much as you think.

AND THE ONE AND ONLY REASON WHY YOU SHOULD GO INTO MEDICINE:

You have only ever envisioned yourself as a doctor and can only derive professional fulfillment in life by taking care of sick people.*

Following the article there are many comments from wannabee doctors, and young medical students, with a fresh view on this subject

WHY YOUR DOCTOR WON'T (CAN'T) SEE YOU NOW , AND HOW TO GET AROUND IT

October, November and December 2013 have been rough months for all Americans. The effects of the Affordable Care Act are having some predictable effects on our health system.  In addition to what has happened, unknown secondary effects are still boiling below the surface of health reform.

Many Americans are concerned about the viability and even the enrollment process for the Affordable Care Act.

Some of these patients will seek out alternative methods to obtain acute or even routine necessary health care.  Cash will become a new source for paying your doctor.

In the midst of the Obamacare fiasco, direct payment and concierge practices are an alternative, and perhaps a necessity to obtain health covereage, even for the short term.

For every great challenge there are also great opportunities, such as direct payment practice. However caution is a necessity.

CALIFORNIA: 70 percent of California doctors plan to boycott Obamacare exchanges

Many reputable neutral sources have reported, " About 70 percent of California’s 104,000 doctors are reportedly planning to stay out of the state’s health insurance exchange, a move that could have significant impact on implementation of the Affordable Care Act.  

This is not a 'willful" arbitrary decision on the part of these physicians.  It is a logical and sound business decision to remain fiscally viable and avoid insolvency. As states across the country work to enroll Americans in the ACA, one question that remains is exactly what kind of doctor access patients will have when their coverage kicks in. According to the president of the California Medical Association, Dr. Richard Thorp, residents there could find limited options at the start of the new year.

Thorp told the Washington Examiner the primary reason that seven-out-of-10 California doctors are boycotting the Obamacare exchange is due to the state’s low Medicare/Medicaid reimbursement rates, which typically land 30 percent below those in other parts of the country.

For example, Medicare typically pays doctors $76 for return-office visits, but in California doctors only receive $24. A tonsillectomy, meanwhile, pays out between $500 and $700, whereas doctors in California receive $160 for the procedure.

“We need some recognition that we’re doing a service to the community,” Thorp said. “But we can’t do it for free. And we can’t do it at a loss. No other business would do that.”

“This is so poorly designed that a lot of doctors are afraid to participate,” said Dr. Sam Unterricht, president of the 29,000-member medical society, to the New York Post.“There’s a lot of resistance. Doctors don’t know what they’re going to get paid.”  California’s Medi-Cal reimbursement rates have long been a sticking point for doctors, but when insurance companies revealed their rates would be tied to the state’s Medicaid program, many physicians balked.

This sign indicates the extreme distress the Medi-cal system will endure from ObamaCare in California.

To make matters more confusing, multiple medical association leaders told the Examiner that many of the doctors listed as participants in Covered California, the state’s insurance marketplace, have not stated they’d accept patients from the exchange.

“They may be listed as actually participating, but not of their own volition,” said Donald Waters, executive director of the Alameda-Contra Costa Medical Association.

“Enrollment doesn’t mean access, because there aren’t enough doctors to take the low rates of Medicaid,” Alex Briscoe, health director for Alameda County Health Care Services Agency in California, said to the Examiner. “There aren’t enough primary care physicians, period.”

Rob Lamberts M.D. a DPC physician offers his experience and advice to other physicians

RT, a popular online Russian news source reports the same information

If you want to know more about direct payment programs, and models consider reading Concierge Medicine Today

The content of this post offer opinions on both sides of the issues, patients and providers.

Steve Case cautions digital health entrepreneurs not to build “printer drivers” | mobihealthnews

mHealth during 2012-2013 did expand exponentially as predicted by many HIT experts...Steve Case and Esther Dyson give up their recommendations regarding mobile apps and the unique characteristics which require a comparison with the growth and acceptance of other services, such as AOL.

Citing his experience at AOL, Co-Founder Steve Case told attendees at the mHealth Summit this week that entrepreneurs in new markets typically will experience three phases as a newer field like digital health matures: hype, hope, and happiness.

Hype, of course, is one of the first phases when most everyone is excited about the potential, but “revolutions happen in an evolutionary” way, Case said, they don’t happen overnight. The hope phase is when expectations crash for one reason or another and only the most passionate and committed entrepreneurs decide to stick it out. Case said at that time the passionate ones even “double down”. The happiness phase is later when things are going well and the market is relatively established.
For AOL and the rise of the internet, Case said it took 20 years for it to become established and mainstream. Even by the end of first decade, Case said it appeared that the skeptics were right — only about 3 percent of the general population was online and for only about one hour each day on average. It took that much time to get the infrastructure in place, however, and during the second decade adoption ramped up as services flourished.  Case said that by his count digital health is already about one decade in.

Widely lauded angel investor Esther Dyson joined Case on-stage at the event to help put the digital health market’s progress in perspective. She said that the entrepreneurs in this market are not “healthcare transformers” but “creators” rooting at the edges of healthcare with something new. Mobile phones didn’t compete with landlines at first, Dyson reminded the audience. What they are creating will be called “health”, she said, not healthcare.
Dyson also noted that digital health entrepreneurs are fairly different from the early PC and dotcom entrepreneurs from previous decades.
“[In digital health] it’s not just enough to change behavior, but also did it change outcomes?” Dyson asked. One of the companies in her portfolio, Voxiva, has a smoking cessation tool that “doubles the rate of quitting,” she said. That’s good, “but that’s something like 10 percent instead of 5 percent. That’s pathetic. [Digital health] still has a long way to go.”

Steve Case cautions digital health entrepreneurs not to build “printer drivers” | mobihealthnews

Poll: Americans better understand, still don’t love, health-care reform

Lake forming behind an Ice Dam

The recent melt-down of the Affordable Care Act's opening of the Health.gov website served to cast a spotlight on the entire law.  More than 60% of the public pretend to know what it is about. That is about the same as Congress knew when they voted to enact the bill into law.

Despite and perhaps because of it's sudden visibility and the topic of all news media most know of it's shortcomings and how it was passed with major deceptions on the part of the Democrats, HHS, and President Obama's administration.

According to the Seattle Times, "A poll released today by Harris Interactive dug more deeply into the opinions of the uninsured, who face penalties if they don’t get insurance by March of next year. The survey found that more than one-third of uninsured Americans say they are prepared to make health-insurance choices — but 31 percent said they didn’t know about the health insurance exchanges set up to sell the coverage.

On top of that, 61 percent of the uninsured say they have done “nothing” in the past year to get ready for the Affordable Care Act. More than half say they don’t know what they’re going to do about the requirement that they get insurance."

As you may recall, it’s been rough going since the Oct. 1 launch of online insurance markets created to enroll people in individual insurance plans. The federal site, which serves 36 states, essentially wasn’t working for weeks and only really kicked into gear over the last week or so. Washington state’s site had some hiccups, then got itself sorted out, but in the past few days has been down again for software fixes.

Added to those technical glitches like a bee sting on a raging sunburn was the outcry by folks who learned their individual and family insurance plans were being canceled at the end of the year. People felt betrayed by President Obama’s promise that if you liked your health care plan, you could keep it.

A survey conducted and released last week by Gallup found that only 37 percent of Americans approve of the Affordable Care Act or would like to see it expanded while 52 percent want it revised or repealed (the rest are undecided).

The crazy thing — given all of the recent attention to the problems with the roll out of the health-insurance exchanges — is that public opinion hasn’t changed a whole bunch from the same Gallup survey nearly three years ago. In January 2011, 37 percent of those surveyed approved of the ACA while 57 percent did not.

So it begs the question: How and Why was the ACA passed into law?

Many think this was a major move toward consolidating control of healthcare costs, and giving government a major role in 1/6th of the American Economy. It effectively destroys a major freedom of choice of what Americans buy in a market place.

How could public opinion remain so constant despite the tumult in recent news? It could come down to politics.

The Seattle Times teamed up with the Elway Poll in September to take the ACA pulse of Washington residents. It turned out that public opinion on health-care reform largely hewed with political leanings.

In that survey, 80 percent of Democrats approved of the Affordable Care Act, while 80 percent of Republicans did not.

This may reflect more upon the discordance between Democrats and Republicans overall, including budget difficulties which are also severe given the expanding national debt.  Republicans are vehement about corraling the national debit, which will again take canter stage in March 2014.

CMS AND ONC ACT TO SLOW DOWN THE HEALTH TRAIN EXPRESS

The Center for Medicare Services and the Office of the National Coordinator are responding to the intense "push back' from providers, insurance companies, health consultants and others. Realizing the debacle of  Healthcare.gov may be a tremor of impending catastrophic health reform failure they have chosen to 'back off' and delay several major milestones for HIT.

Numerous mandates for the Affordable Care Act have been delayed due to what seems to be a systemic overload of HHS and other regulatory agencies that go beyond the Affordable Care Act.

1. Individual Mandate
2. Last date of enrollment on Healthcare.gov pushed back to December 23rd for a January 1 2014 enrollment. (Is this another pipe dream?  7 days from enrollment to eligibility with authentication of finances?..Another example of fantasy planning by Obama and his administration..

These delays are only the tip of an iceberg upon which the Titanic Obamacare ship founders.

Early on in 2010 shortly after the Affordable Care Act became law, the DOJ warned about employer sponsored health plans.  Rather than the Health Benefit Exchange impacting on only five percent of the population, the actual numbers willl be much greater perhaps as great as 80% excluding public programs.

The Cream rises to the Top

Each day as I search for fresh material for Health Train Express I have no shortage of articles and/or topics that strike me as important.

Like my readers we are all struck by the quantity and quality of well written articles that could fill an entire edition of a daily newspaper such as the WSJ, the LA Times, or the Washington Post to  just name a few of the dying breed of print publications, slowly being replaced by a digitized news world.

One of my favorite sources is always KevinMD. His blog now is mostly filled by other bloggers. This may not be a bad thing, since his blog is so well known. If your article is selected by KevinMD it has a very good chance of being read by other aggregators as well.  Kevin was an early and successful example of someone who recognized the sea-change in medical communications.  One of his recent articles by Neil Baum MD

Doctors: 10 lessons from the humble bumblebee

     This article by Dr Baum is 'spot on"  and describes the multi-tasking physicians must do to suceed in their goals. The exciting part is that Social Media and other network connectivity empowers doctors to do this quite successfully with little additonal help and/or overhead.

We’re already throwing grandma under the bus

     This post by Gene Uzawa Dorio MD addresses the real and growing interference in quality health care by insurers and government. The stories are heart-rending. How do we stop this? 

It’s a fearful time for medical students

     Finally in this post by medical student Nathaniel Nolan, questions, "will I have a job?" That is a bit like the question at this time of year, "Is there a Santa Claus?  Is the answer "Imaginary"?

Remember today is the 70th anniversary of the attack on Pearl Harbor

Accountable Care Organizations

.PPACA does not define who or what can form an accountable care organization.

I may have missed something, but my view was that the organization(s) would be amongst hospitals and their provider group(s) including IPAs. The prevailing concern was who would lead the effort, providers or hospitals ?

Well, fool me as the insurance companies and/or payers  do an end run to possibly score the touchdown and perhaps even the after point.

Originally CMS promoted the idea of accountable care organizationr which would interface with CMS and private insurers would do the same.  It remains to be seen if any of these designs will work to reduce cost, or just reduce care, increase frustration and bureaucracy for the delivery of health care.

During the past several weeks a number of insurance companies (Blue Shield is among the group) have announced formation  of ACOs and are "inviting" their physicians and hospitals to join with their ACO to improve quality of care and reduced costs

No where in PPACA does it state that insurers cannot initiate or direct and ACO. It squarely places the insurer in control of the ACO, who can mandate standards of care.  Was this an intent by omission in the 1300 pages of PPACA?

I would like to think so, however reading PPACA which covers a great deal of minutiae in health reform it is difficult to believe so.

Each day I receive at least ten emails inviting me to a meeting or webinar...usually in the D.C. area. Not many are held in mid country or on the  west coast. National Consultant Organizations and Insurance Industry players charge hefty conference fees and someone is making a fair profit on these meetings. Even the relatively low cost of presenting webinars yield a tidy sum for an archived copy of the meeting on the internet.

ACO's will surely contribute to the increase in health costs to offset whatever ACOs were predicted to save.  True governmental efficiency !

5 Doctors You Should Be Following on Twitter

5 Doctors You Should Be Following 

on TwitterRead , and Health Train Express @glevin1 or @digitalhealthspace

The article describes five pioneers in blogging and online information.