Atul Gawande on Healthcare Reform.

Atul Gawande M.D. is a well known physician-author. Soon after he began his residency, his friend Jacob Weisberg, editor of Slate, asked him to contribute to the online magazine. His pieces on the life of a surgical resident caught the eye of The New Yorker which published several pieces by him before making him a staff writer in 1998.

A June 2009 New Yorker essay by Gawande^[12] compared the health care of two towns in Texas to show why health care was more expensive in one town compared to the other. Using the town of McAllen, Texas, as an example, it argued that a revenue-maximizing businessman-like culture (which can provide substantial amounts of unnecessary care) was an important factor in driving up costs, unlike a culture of low-cost high-quality care as provided by the Mayo Clinic and other efficient health systems.

Gawande published his first book, Complications: A Surgeon's Notes on an Imperfect Science, in 2002. It was a National Book Award finalist, and has been published in over one hundred countries.^[18]

His second book, Better: A Surgeon's Notes on Performance, was released in April 2007. It discusses three virtues that Gawande considers to be most important for success in medicine: diligence, doing right, and ingenuity. Gawande offers examples in the book of people who have embodied these virtues. The book strives to present multiple sides of contentious medical issues, such as malpractice law in the US, physicians' role in capital punishment, and treatment variation between hospitals.^[19]

Gawande released his third book, The Checklist Manifesto: How to Get Things Right, in 2009. It discusses the importance of organization and pre-planning (such as thorough checklists) in both medicine and the larger world. The Checklist Manifestoreached the New York Times Hardcover nonfiction bestseller list in 2010.^[20]

Please click on the blue hash bars for a surprise.

• Humane Endeavor: Grace Bello interviews Atul Gawande
• Article on Atul Gawande in Harvard Magazine Sep-Oct 2009
• Charlie Rose - interviews 2007-2010

Pocket-Cast (Audio)

The Tower of Babel and Consumer Confusion

Are you confused yet  ? I am.  No one is telling me that my health and health care are better than it was twenty-five years ago. We've spent billions of dollars on improving our health system however today it is much more complex. We are told that knowledge has grown and readily available for the asking on the internet,  and mobile devices.  Interestingly television is not even on the map.

Medical education has shifted. At one time having an M.D. was sufficient (in addition to a specialty training program) however now an M.D./MBA carries more weight.  It took me about 10 years of belonging to my own C-suite running a medical practice to earn my O.J.T.  credentials.  That in itself should be worth some type of certificate and/or CME credits.

Where do you go when sick ? Do  you call  your M.D, or seek an E.R. or urgent care clinic ? Perhaps you 'Google' your symptoms or disease for an answer.When and if secure email becomes readily available you can email your doctor for help.

Eventually your M.D. will see a pop-up notification from your EHR and/or PHR indicating you need an appointment. Then you will receive an automatic response with a time and date. There will be no or little human-human interaction. Once you arrive at the office you will sit down at a work station that weighs you, takes your pulse, BP, and temperature. A skin sensor senses  your blood glucose and electrolyte levels as well as kidney and liver function tests.

Today we are not at that level, and are wandering in a sea of confusion about it all. Patients and consumers are overwhelmed, as most of we physicians are.  No one quite know what technology to invest in that really matters or improves quality and/or outcomes. It seems to obsolete itself every five years or so, fueled by governmental regulations, and intense marketing by device manufacturers, or software vendors..

Meaningful use has devolved into meaningless spending.

John Lynn writes at EMR & HIPAA, which you can subscribe to here.
His topic gels with my own thoughts about Health Care Confusion.

Confusing the Consumer – Defining New Healthcare Roles

Musings on Connected Health by Joseph Kvedar, MD

 As we continue our journey to change provider reimbursement to a “Pay for Value” system, the lines between health insurers and health care providers are blurring. Physician/hospital systems, like Partners HealthCare, where I work, are taking on risk for populations of patients through contracts with the Federal government and local payers. According to Secretary of Health & Human Services, Sylvia Burwell, this trend is going to continue. She stated recently that HHS set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. Since the whole insurance industry is based on risk, we inevitably have to start thinking more like insurers if we’re going to be taking on risk.  Sadly, I didn’t learn much. Not because I didn’t listen and not because the speakers were less than talented. I walked away feeling like I hadn’t learned anything because I felt I had gone to a foreign land and was listening to talks in a foreign tongue. I simply couldn’t decipher the health plan lingo.

Tower of Babel  

Is this our inevitability, from Genesis?
As the King James version of the Bible puts it:
4 And they said, “Come, let us build ourselves a city, and a tower whose top is in the heavens; let us make a name for ourselves, lest we be scattered abroad over the face of the whole earth.”
5 But the Lord came down to see the city and the tower which the sons of men had built.
6 And the Lord said, “Indeed the people are one and they all have one language, and this is what they begin to do; now nothing that they propose to do will be withheld from them.
7 Come, let Us go down and there confuse their language, that they may not understand one another’s speech.”
8 So the Lord scattered them abroad from there over the face of all the earth, and they ceased building the city.
9 Therefore its name is called Babel, because there the Lord confused the language of all the earth; and from there the Lord scattered them abroad over the face of all the earth.

—Genesis 11:4–9^[1]

Are we pursuing the ultimate perfection in health care? Can perfection be the enemy of the good?

An aphorism which is commonly attributed to Voltaire, who quoted an Italian proverb in his Dictionnaire philosophique in 1770: "Il meglio è nemico del bene".^[2] It subsequently appeared in his moral poem, La Bégueule, which starts^[3]

Dans ses écrits, un sage Italien

Dit que le mieux est l'ennemi du bien.

(In his writings, a wise Italian says that the best is the enemy of the good) 

"Better a diamond with a flaw than a pebble without."

—Confucius,attrib.^[1]

At the highest level, it seems like we should be natural collaborators, as we bring very complimentary skills to the shared goal of building a health care system. As providers, we excel at understanding physiology, pathophysiology diagnosis and therapy. In most cases, we have strong relationships with the end users of the services offered, our patients, which often includes a high degree of trust. When someone’s doctor recommends a course of action, most people at least take it seriously and many often follow that path.

Payers, on the other hand, have always been challenged connecting with their members (you see, we are all a member, a consumer and a patient – all in different contexts – an example of the babbling). Payers excel at understanding risk and setting premium costs, something we as providers have no feel for. But if we’re going to take on risk, we’ll have to learn. Can these former negotiating foes come together to help improve your health? The current landscape does not lead to enthusiasm.

I’ll use some telehealth implementations as examples. Several national payers are adopting virtual visits as a tool for their members. For me, this is a dream come true! BUT, most payers are doing so in collaboration with one of the major vendors in the space and creating shadow physician networks to offer the service to their MEMBERS. When that member’s primary care doctor eventually sees them in the office, she will be puzzled that her PATIENT had an encounter via their health plan that she did not know about.

Walgreens just rolled out a virtual visit program as well. This could create even more confusion, as it brings in a new entrant — the pharmacy — into the battleground for that relationship. Will EMR interoperability solve this confusion? It certainly helps, but I’m also concerned about mixed messaging to the consumer/patient/member. It seems like we’re all fighting for your attention, which may lead to conflicting messages.

This reminds me of a time, about 25 years ago, when this new thing called disease management sprung up. Payers were frustrated by the cost of managing patients (members) with chronic illness. They got no help from providers, so they took matters into their own hands, hiring call centers staffed with nurses to contact patients/members with tips on how to manage their illness, and often sent generic brochures about high blood pressure and other conditions. Payers may have influenced the care of some patients/members, but no one was ever able to prove that this was an effective strategy.

There were numerous stories about patients receiving conflicting advice from these ‘disease managers’ compared to their own doctor’s advice, leaving patients confused. Doctors would get faxes from these same disease management companies and (perhaps arrogantly) throw them in the waste basket without reading them. As a result, the disease management industry collapsed in the middle to latter half of the last decade.

In the meantime, we now have workplace wellness programs, virtual visits offered by your health plan, retail clinics, virtual visits offered by pharmacies and — dare we forget — advice your doctor gives you, which should be more in tune with prevention now that providers are taking on risk.

See what I mean by a Tower of Babel? How do we fix it?

Adding to this conundrum we face increasing health information technology guiding consumers on another journey via a personal health record, a clinic portal, and numerous websites on disease, symptoms, and treatments.

In the near future "Watson" looms, a portender of artificial intelligence developed by IBM.

John Lynn concludes:

Joseph’s comparison to the Tower of Babel is a good one. The solution to all these new healthcare modalities is to make sure that everyone is speaking the same language. It doesn’t solve all of the problems, but it does help everyone get on the same page. I just hope that the business interests of many involved in healthcare don’t get in the way of this goal.

Digital Health | SOFTWARE DOESN'T HAVE AN MD

Digital Health | Andreessen Horowitz

Who is practicing medicine really ?  You are going to be surprised. The horse is out of the barn.

We only have about a million physicians in the United States — but they’re about to get reinforcements.
I don't mean nurse practitioneers, physician assistants, or other "mid-level" providers. It's not Minute Clinics, either.

If you think about the CAT scan that an MD is using, if you think about almost any modern device that a doctor is using — it’s useless without the code in it. That code was likely written by someone without an MD, someone who was evaluated as competent and hired by a commercial vendor of mission-critical medical instruments. The instruments that represent the foundation of modern medicine are thus today typically programmed by people who know how to code (but lack MDs) and used by people who have MDs (but usually do not know how to code).

So a large percentage of medicine is already being effectively practiced by non-MDs.

Moreover, the interior workings of the instruments are black boxes; MDs interface with them through vendor-provided UIs and interpret the readouts by looking up data stored in their head. As these UIs get better and smarter, less interpretive skill is required by the MD. The MD is happier — the instrument gets the right answer with less work. It’s used more frequently. Through successively more sophisticated engineering the instrument thus begins to move from the hands of the specialist to the generalist to the nurse practitioner to the nurse… and then, perhaps, to the general population in the form of a phone accessory or an app.

That last step is starting to happen as various personal genomic, quantified self, and mobile diagnostic technologies become more accessible. These technologies produce data from the body, and that data is going to be stored in our phones. The interpretation of that data is going to be performed by software.

And so that large percentage of medicine that is effectively being practiced by non-MDs is going to expand.

One center of action is likely going to be the mobile programmable medical record — the container for all diagnostics and test results — something like what Apple’s HealthKit may evolve into. Essentially just a bunch of data containers for your heart rate history, your blood pressure history, your exercise history, and the like.

All this diagnostic history isn’t necessarily “big data”; it’s just never been tracked and cross-correlated before in one place. Once technologies like HealthKit get a little more traction, millions of software engineers without MDs can build new applications on top of that data store.

How Senior Medicare Advantage Plans Game CMS and the System

GAO States CMS Overpaid Medicare Advantage Plans During the Years of 2010 to 1012–Flawed Risk Assessment Calculation Errors 

CMS discovers fraudulent use of algorithm and will sue several plans for $70B

CMS Discovers That Insurers Offering Medicare Advantage “Really Know How To Sharp Shoot A Model With Adjusting Risk For Profit”, A Common Everyday Occurrence in Financial Markets… - Medical Quack

 A report issued this week by the Government Accountability Office reports that the Centers for Medicare & Medicaid Services overpaid the Medicare Advantage program run by private health insurers by between $3.2 billion and $5.1 billion for the years 2010-2012.

The overpayments, according to GAO, were the result of CMS inadequately adjusting based on health status for members enrolled in Medicare Advantage. 

Insurers who run MA plans are paid a set amount per beneficiary, adjusted by a risk score that calculates the expected consumption of health services in the coming year for each beneficiary. 

In practice, the risk scores for beneficiaries with the same health conditions and with the same demographic profile should be the same. However, the GAO discovered in its analysis that coding differences between Medicare Advantage enrollees and those enrolled in the traditional fee-for-service Medicare plan led to “inappropriately high MA risk scores and payments to MA plans.” 

Fraud, What Fraud?

The Medicare Advantage (MA) program was established in 2003 in order to incentivize health plans to provide better care for the elderly and control expenses in doing so. Nearly 16 million seniors are presently enrolled in MA, costing an estimated $150 billion in taxpayer’s money every year. The MA program has grown in popularity with Medicare beneficiaries because it has lower out of pocket expenses than traditional Medicare, offers more benefits, and fills some gaps in coverage.

 Unlike the fee-for-service payment arrangement in traditional Medicare, where each service is billed directly to the government, Medicare Advantage plans receive a monthly, set capitated payment to provide care for their enrolled Medicare beneficiaries. However, health plans do receive a higher monthly capitated payment to care for sicker patients, based on the patient’s “risk score”. The risk score is determined by a variety of factors, but is primarily based on the patient’s Hierarchical Chronic Conditions, or HCC score, which are conditions tied to specific ICD-9 diagnoses.  Risk scores are required to be backed-up by medical record documentation, but the government still has difficulty verifying each diagnosis. (no simple process)

 While the problem of false or improper billing is essentially eliminated in the MA program, fraud remains an issue nonetheless.  Recent investigations by The Center for Public Integrity have highlighted some of the more egregious practices occurring in the Medicare Advantage program related to risk scores, which are not only damaging to the program’s reputation, but have also cost America’s taxpayers an astounding $70 billion since 2008.   However, the most shocking part of their investigation is highlighting how little control the government has in reigning in this problem.

 Research has shown that MA Plans exhibit greater “coding intensity” in documenting disease conditions, so that an MA enrollee’s risk score grows substantially faster than an FFS enrollee’s risk score.  Once Medicare enrollees switch from the traditional Medicare fee-for-service program to a Medicare Advantage plan, their HCC scores increase.  Medicare Advantage plans contend that the higher scores are due to sicker patients, but without intense auditing, it is difficult to support or disprove that logic.

 In addition to the diagnoses obtained from primary physician records, another method gaining ground among Medicare Advantage plans to bolster risk scores is via home health visits. While home health services may legitimately uncover previously unknown medical conditions, more unscrupulous health plans may leverage home health visits as a tool to inflate risk scores, and thus increase their profits from these patients by thousands of dollars each year. Health plans argue that these visits improve patient care, but opponents claim they unnecessarily inflate costs without actually providing more medical services.

Health Care Financing, CMS and HHS have devolved to a dysfunctional chaotic state.  The OIG reports these matters to Congress. So why do your legislators do nothing about it? 

Perhaps it is because they are not smart enough to plan health care while running the rest of the government.

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

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

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

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 

Healtlh Care Collaboration and Kenneth Cohn, M.D.

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

I couldn't read the rest of my emails until just now, 2:45 PM.  After a pause I decided to write this blog in memory of Ken, and to offer solace to his  family close fellow workers,  well as the rest of us who remain largely unknown to Ken other than the replies to his blog and other writings.

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

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

Thanks Ken for all the things you did for us.

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



In Memoriam

Gary M. Levin M.D.