^{Prospectively,  ObamaCare Sounded Good, in Retrospect Not So Good}

^{In retrospect,}

^{Seven years ago,}

^{ObamaCare’s big idea  sounded simple.}

Cover everybody.

^{Regulate the doctors.}

^{Cut their fees.}

^{Put them on salary.}

^{Organize them.}

^{Herd them into organizations,}

^{Where they didn't  want to go.}

^{Make them provide better more accessible care
at lower costs.}

^{Guide, direct, and control}

^{all aspects of care,}

^{health plans, hospitals, and medical practices.}

^{Minimize  doctor  independence.}

^{Maximize  doctor dependence.}

^{Think big.}

^{Think oxymoronically.}

^{Increase coverage.}

^{Decrease costs.}

^{Cut Medicare by $575 billion}

^{Promise to save money}

^{Promise to reduce premiums}

^{By $2500 per family.}

^{Promise you can keep your doctor}

^{and your health plan.}

^{Think systematically.}

^{Think in terms of big systems.}

^{Think about what you know patients need.}

^{Develop systems for them.}

^{Launch big new programs in name of innovation,}

^{with impressive sounding acronyms,}

^{CMMI(Centers of Medicare and Medicaid Innovation),}

^{ACOs (Accountable Care Organizations),}

^{BPCI (Bundled Payments for Care Improvement -BPCI ),}

^{APMs  (Alternative Payment Models).}

^{MWV (Medicare Wellness Visits),}

^{MACRA (Medicare Access and CHIP Reauthorization Act).}

^{Promise more care at  lower costs.}

^{Think as a team.}

^{Stress  improvement.}

^{Involve everybody, cover everybody.}

^{Convince the public the old ways were bad,}

^{and unfair.}

^{Remind them where you’re going.}

^{Set goals.}

^{Give reasons when you miss your targets.}

^{Think about the big picture.}

^{Think about how the big problems.}

^{Organize to solve them in  big ways.}

^{Think about what kills people too soon.}

^{Prevent what kills them prematurely,}

^{through Medicare Wellness visits.}

^{Think how to minimize complications.}

^{Promise to save Medicare money.}

^{Give doctors the electronic tools,}

^{You think they will need at site of care,}

^{even if the tools  costs $29 billion.}

^{Give patients information they need -}

^{at home, at work, and at sites of care.}

^{Invest heavily in electronic health records.}

^{Say we’re all  in this together}

^{Broadcast your accomplishments.}

^{Rationalize  your shortfalls,}

^{Never admit your failures.}

^{Minimize the information gap}

^{between caregivers and patients,}

^{and sooner or latter,}

^{everybody  will recognize,}

^{where you’ve been}

^{and where you’re going,}

^{and what it all means.}

^{Your chief information officer, Philip Fasano}

^{will be quoted in}

^{“The Face of Future Health Care”}

^{(New York Times, March 20, 2013),}

^{as saying.}

^{“We have all the pieces,}

^{Anything a patient needs,}

^{You can  get in the four walls of our offices”}

^{The article will also quote,}

^{George Halvorson,  CEO of  Kaiser Permanente,}

^{He will sum it up simply,}

^{“All of this adds up to better care and cheaper care."}

^{The future prospects of health care}

^{sounded simple prospectively.}

^{But in retrospect,}

^{realities kept getting  in the way,}

^{costs rocketed  higher,}

^{doctors choose to see fewer Medicare and Medicaid patients,}

^{access became difficult,}

^{choices narrowed,}

^{insurers revolted,}

^{they exited exchange markets.}

^{raised  premiums,}

^{deductibles made care unaffordable.}

^{Unpopularity of your health  law grew.}

^{Millenials complained and did not join exchanges,
Older folk who joined were sicker.
and left exchanges after being treated.}

^{The middle class groused about  low wages and high health costs.}

^{Patients chose direct care without 3rd party coverage.}

^{ObamaCare  paved the way for concierge medicine.}

^{and became its best salesman.}

^{In retrospect,}

^{As poet Robert Burns said,}

^{“The best laid schemes o’ mice and men}

^{Gang aft a-gley.”}

^{Translated, this means:}

^{In retrospect, foresight is never 20/20:}

^{hindsight always is.}

 

 

 

 

 

Eleven  Factors  Impacting Physicians in Transition to Information Age

We now live in the Information  Age.  Computers, algorithms, and apps  are transforming society and dramatically  altering  politics ,  government,  the economy,  and its institutions.

 Many online  forces  are  at work.

Just this week, a political outsider, Donald Trump,  broke  the Republican Party’s lock  on its conservative base,  using frequent tweets to make his case;  a socialist candidate, Bernard Sanders,  won another primary against Hillary Clinton,  partly by raising more money than she on the Web;  and the New York Times,  announced it lost money  last quarter due to ads lost to online competitors. 

On the health care front,  ObamaCare again failed to live up to expectations,  partly because of  healthcare.gov  stumbles and  partly due to  failures of electronic medical records to make health care more interoperative and easier to use and access.

IT Reshaping Health Care

The cybereconomy is  reshaping health care.  IT helps us better understand complex systems and their interrelationships.  IT disperses care to multiple locations. IT allows radiologic images to be interpreted anywhere in the world. IT fosters entrepreneurship and permits more people to work independently.  And,  to some extent, IT replaces pattern recognition by human with pattern recognition by machines.

Here are eleven  ways the information revolution  impacts physicians and requires their participation.

1.        It crunches data to offer  better diagnosis and treatment by keeping track of patient histories,  helping doctors keep up with the literature, and analyze  treatment options.

2.      It helps  doctors communicate with their patients – individually  and to their total patient base.

3.      It links doctors with other doctors,  primarily  through electronic  health records.

4.      It connects doctors with patients at a distance – with wearable devices,  medical consultations,  SKPE evaluations,  and  monitoring  patients on foot, at work, and in bed.

5.      It helps  patients stay healthy  with vital sign recording,  calorie counting, and heart rhythm monitoring.

6.      It helps  doctors educate patients and  market the availability of their services  and their expertise 

7.      It  empowers concierge medicine practitioners by allowing doctors to remain independent  yet have access to the latest information on the Net.

8.     It offers decision support systems.

9.      It  fosters collaboration and cooperation between medical specialists  within and outside of institutional settings.

10.   It makes possible such apps as the instant medical history .  tested and widely used software allows patients to record their history, complaints,  symptoms  before seeing the doctor, thereby saving the doctor 6-10 minutes per patient by helping the doctor zero in on problems.

11.   Major projects -   the government’s $29 billion EHR initiative,  M.D. Anderson’s Moon Shots,  IBM’s Watson investments,  Silicon Valley’s  Health 2.0 programs – rely on information technologies and physician input.

 

 

Physician Payment in the Information and ObamaCare

Read not to contradict or confute, nor yet to believe and take for granted, nor to find talk and discourse, but to weigh and consider.

Francis Bacon (1561-1626 ), Of Studies

Today I am reading The Oxford History of the American People,  The Sovereign Individual: Mastering the Transition to the Information Age, and Kaiser Health News (“Medicare Lays Out Plans for Changing Doctor Pay.”)

From this reading, I conclude:

1)      The United States is unique among nations  in that it was founded on the basis of individual freedoms and choices with checks and balances between 3 branches of government – executive, legislative, and judicial. 

2)      Nothing new exists  under the political sun.  Deep, partisan, and raucous divisions have always existed  between political parties,   and Americans voters desiring fundament change  often elect populist presidents (Andrew Jackson, 1828) and wealthy presidents (Franklin Delano Roosevelt, 1932).

3)     The information age changes everything economically,  and the new  information society, heralds, among other things,  the last days of insider politics,   decline of centralized government, and the nanny state,   rise of IT-skilled individuals and the fall of middle class without those skills,  fewer major wars but more random crimes,   and  middle class anger over stagnant or falling incomes secondaru to  globalization, immigration, and a slow growth economy.

4)       CMS (Centers for Medicare and Medicaid) has introduced MACRA (Medicare Access and CHIP Reauthorization Act) designed to pay doctors for quality and outcomes using computer data rather than on the basic of fee-for-service and clinical judgment. Many  America  physicians are disappointed with the decision because of its infringement on their clinical freedoms and decision making and its emphasis on large groups.   MACRA raises a fundamental question:  How can government judge what is “quality” and “value” for patients  and what clinicians can and cannot do when federal officials  are  far removed from patient-physician interactions?  I suppose the Piper calls the tune. CMS is, after all, the biggest single doctor payer.   But CMS officials may forget:  1) the American creed rests on the beliefs of individual choice and freedom, even among physicians; 2) American physicians still have the choice and the freedom whether or not to accept or slow down acceptance of Medicare and Medicaid patients; 3) physician withdrawal from these programs will exaggerate physician shortages and access to care.  

That said,  here from Kaiser Health News is a question and answer explanation of the CMS act.

“ Medicare Lays Out Plans For Changing Doctors’ Pay”

By Mary Agnes Carey April 29, 2016   Kaiser Health News

Federal officials have unveiled their roadmap to a revamped Medicare physician payment system designed to reward doctors and other clinicians for the quality of care delivered, rather than the quantity.

Purpose

The proposed regulation would replace a patchwork of programs that now govern physician payments in Medicare. It would allow doctors to choose from a new menu of measures and activities that officials said would be tailored to the type of care clinicians provide in Medicare’s traditional fee-for-service program.

“By proposing a flexible, rather than a one-size-fits-all program, we are attempting to reflect how doctors and other clinicians deliver care and give them the opportunity to participate in a way that is best for them, their practice and their patients,” said Patrick Conway, acting principal deputy administrator and chief medical officer at the Centers for Medicare & Medicaid Services (CMS), the federal agency that is implementing the new physician payment program.

How Doctors Are Now Paid

Currently doctors are paid for things like tests, treatments and other procedures, but not necessarily for spending time with patients to learn more about their health or develop a treatment plan. Officials say the new payment program will change that.

With wide bipartisan support, Congress last year voted to scrap the existing Medicare physician payment formula and transition to a new system focused on quality, value and accountability. Here are some questions and answers about the newest phase of this effort

Q: What is the government offering

A: The proposed regulation would create two new payment systems. One, called the “merit-based incentive payment system,” or MIPS for short, would evaluate the value and quality of care on four performance categories: cost, quality, how doctors use electronic health record technology in their daily practice and share that information with other providers, and activities that improve care, such as care coordination or how much beneficiaries are engaged in their care. That composite score is used to determine a positive, negative or no adjustment to a provider’s Medicare Part B payment for a medical service.

The second system for doctors sets payments through “advanced alternative payment models” or advanced APMs. Under these models, clinicians accept more risk — and could also make more money — for providing coordinated, high-quality care, according to CMS. Examples include efforts to create a centralized “medical home” in which a team of health professionals provide coordinated care to improve patients’ health, and newer models of accountable care organizations in which doctors, hospitals and other health care providers form networks that work together to help improve the quality and reduce the spending for patient care.

CMS officials expect that most Medicare clinicians will initially participate in the MIPS program but over time will move more toward the alternative payment models.

Q: Who will get paid this way?

A: Most doctors that treat patients in the traditional Medicare program, as well as other clinicians, such as physicians assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, that also provide care to Medicare beneficiaries, will be paid under either the MIPS or advanced APMs system. Clinicians can be exempted from MIPS if they are new to Medicare, have less than $10,000 in Medicare charges or see 100 or fewer Medicare patients or are “significantly participating” in an advanced APM.

Q: Why is this happening now?

A: As part of legislation Congress passed last year to overhaul the Medicare physician payment system, CMS had to publish a plan by May 1 that detailed how it would measure physician quality under the new system. Doctors and other interest groups can now comment on the proposal until June 26, and CMS is expected to issue a final rule this fall.

Q: What happens next?

A: Under the law setting up the changes in payment, physicians will receive a fee increase of 0.5 percent per year between 2016 and 2019 as the new system is developed and put into place. In 2017, Medicare will begin measuring performance for doctors and other clinicians for the MIPS program, with payments based on those measures beginning in 2019. Under that system, payments generally won’t increase or drop by more than 4 percent, rising gradually to 9 percent from 2022 and beyond. Doctors can earn additional bonuses for exceptional performance.

Practitioners who pursue APMs would qualify for a 5 percent Medicare Part B incentive payment for the years 2019 through 2024.

Q: Does this mean that Medicare beneficiaries will pay more to see their doctors?

A: The law does not change payments by beneficiaries. Medicare Part B premiums, which cover visits to a physician and other outpatient services, are set by law and adjusted yearly. Once the Part B deductible is met, beneficiaries usually cover 20 percent of the amount Medicare pays, or purchase a supplemental policy that can pick up much of that cost. If Medicare’s Part B costs increase because of the new payment formula, beneficiaries’ premiums and co-payments could potentially rise as well.

Q. How did the doctor payment formula become an issue?

A: The prior physician payment system, which was called the sustainable growth rate or SGR, was created in a 1997 deficit reduction law, a broader legislative effort to control federal spending. For the first few years, Medicare expenditures did not exceed the target in that law and doctors received modest pay increases. But in 2002, doctors were furious when their payments were reduced by 4.8 percent. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size of the fix needed the next time. Last year, lawmakers finally agreed to cut a deal for repeal and move on.

Q: What’s been the reaction to the new physician payment proposal?

A: Doctor and physician groups appear to be on board so far and a few lawmakers in both parties also have expressed support. All pledge to continue to monitor the process.

In a statement, the president of the American Medical Association, Dr. Steven J. Stack, said the group’s “initial review suggests that CMS has been listening to physicians’ concerns” in particular by modifying federal rules concerning physicians and electronic health records and reducing burdens on quality reporting. The new system, Stack said, “needs to be relevant to the real-world practice of medicine and establish meaningful links between payments and the quality of patient care, while reducing red tape.”

Robert Berenson, a fellow at the Urban Institute, said a key question for the law is “have they set it up so small practices can actually stay in business and report so they don’t have to throw in the towel and get hired by somebody because the reporting burden is too great?” Berenson, who has been critical of the new Medicare physician payment law, is a member of a technical advisory committee created in the law to evaluate its implementation.

Paul B. Ginsburg, who serves as director of the Center for Health Policy at the Brookings Institution and is also director of public policy at the Schaeffer Center at the University of Southern California, said the proposed rule gives physicians a lot of flexibility in choosing how they are rated under the MIPS program but is more restrictive on what qualifies as an APM.

Payment increases under either system may not be generous enough to keep up with other costs, such as increases in practice expenses. “This is better than a 20 percent cut (under the old system) but in a sense it means that the very severe constraint on physician payment is going to continue for some time,” (italics mine).

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ObamaCare and the November 1 Insurer Waiting Game

Many consumers will see large rate increases for the first time Nov.1 – a week before they go to the polls. Proposed rate hikes are just starting to dribble out, setting up a battle over health insur”ance costs in a tumultuous presidential election year that will decide the fate of ObamaCare.

Paul Demko, “ObamaCare’s November Surprise,” Politico, May 2, 2016

As the September Song lyrics go,

“Oh, it's a long, long while from May to December
But the days grow short when you reach September
When the autumn weather turns the leaves to flame
One hasn't got time for the waiting game.”

The Obama administration and the Hillary Clinton campaign are anxiously awaiting health insurers announcement  for premiums hikes on November 1, 2016. 

The last thing Democrats want just a week before the Presidential election  are double-digit insurance hikes as millions of Americans begin signing up for ObamaCare.   Premium hikes are expected to average over 10% - 15%as compared to an average of 8% in 2016.  Dramatic spikes of 20% to 50% have already been requested in New Mexico, Maryland,  Tennessee, and North Carolina.

Insurers' Problems

The insurers’ problems are two fold:

One, they have been unable to choose who to insure.

Two, they do not know how much to charge because they cannot, based on medical histories.

So insurers have been shooting in the dark.  They have experienced heavy losses on ObamaCare  exchanges.   UnitedHealth, the nation’s largest insurer, pulled out of exchanges in 34 states,  after suffering losses of $475 million in 2015 and a projected $650 million in 2016.    Aetna  says it expects to break even in 2016, but legislative fixes are needed if it is to stay in the game.  Blue Cross Blue Shield will remain in 14 states has also experienced heavy losses but says  will continue to insure exchange customers, as will Anthem and Centene,  the nation’s largest Medicaid insurer.

The future of ObamaCare is at stake if voters reject Democrats at the election.  Republicans  have announced they will repeal ObamaCare.   The GOP has already denounced ObamaCare as unworkable because of the UnitedHealth decision,  but have yet to announce an alternative to ObamaCare.    

Many critics have said ObamaCare insurance markets are unstable, unsustainable, and unworkable.      Blue Cross and Blue Shield pans have seen profits plunge by 75% , mostly in the exchange segment of their businesses.   Over half of 23 nonprofit insurer startup have collapsed.   One  big reason behind these losses  is the lower-than-expected enrollment of younger healthier people, who reject the exchanges as a bad business deal and who resent paying for the sick.   Just 28%  of Healthcare.gov customers  were between 18 and 34, far below the 35% needed for a balanced marketplace.

Another reason is that only 12.7 million Americans  signed up during the recent enrollment period  compared to the22 million projected by the Congressional Business Office.

The Obama administration and some insurers say the market will stabilize, but the voters may not be so sure, and they may vote their pocketbooks.  From May to November may not be enough time for markets to stabilize.  Sooner or later,  I expect ObamaCare to disintegrate, to collapse under the weight its economic misunderstandings and its failure to deliver on its premises (ultimately universal coverage) and its promises (choices of doctors and health plans,  lower premiums and deductibles, and greater quality and access).

Health Care Present and Future Already Online

Before this time, before now, so soon, so early – used to describe situation that exists now and will continue to exist.

Definition, “already,” Merriam Webster

Last night, May 1, on CBS 60 Minutes,  I was watching Leslie Stahl interview two Irish brothers,   John and Patrick Collison, ages 25 and 27, who 4 years ago dropped out of Harvard and MIT, to form Stripe, a start-up online financial form that has offices in San Francisco with offices around the world. Stripe is part of an explosively growing financial sector known as Fintech, which has already raised $20 billion from venture capitalists, mostly situated in Silicon Valley.

As I listened to the Stahl interview with the Collison brothers, I thought of how  young entrepreneurs with a back ground in programming and app development are already revolutionizing the business world.   I thought of how online apps have impacted newspapers, bookstores, travel agents, taxis, car buyers and hotels, I thought of Mark Zuckerberg, founder of Face book, who last week made $4 billion in a single day when Face book stock rose on the basis of increased quarterly profits.  I thought of the millennial, aged 18 to 34, now the largest demographic segment of the U.S. population, whose successful IT practitioners, who are rapidly becoming the world’s withiest individuals, who are helping widen the rich-poor income gap, and who are contributing to the declining influences and shaking up financial firms, banks, and national governments, and who are transforming how society operates.

And I thought of health care’s present and future.  How will this young IT wizards impact health care now and forever more?  Already visitors to the web rate health care information sites as their number one destination. Already most physicians have EHRs and get much of their information off the Net.   Already data from online clouds are used to judge the “value” of care and are said to be replacing clinical intuition and judgment as the best way to improve the quality of care.   Already large integrated health care health organizations, including CMS, are using online data to supplant and supplement clinical care.   Already online access allows entrepreneurial physicians, who choose to be independent, using the web, are breaking off relationships to 3^rd parties and to government, to bypass government programs and to offer specialized, expert, and personalized services in widely dispersed locations and as direct cash transactions.  Already health care customers can find care that suits their needs at worldwide sites.  

What do these revolutionary changes portend for ObamaCare?  For independent physicians? For savvy health care consumers?   I know not.   But I know the future belongs to those with  online savvy.

A Modest Proposal to Boost Clinical Efficiency and Patient Health

The Megapolitics of the Information Age: The Triumph of Efficiency over Power.

Title of chapter in The Sovereign Individual: Mastering the Transition to the Information Age, Simon and Schuster, 1999

Everybody knows the American health system and the health law to reform it have been inefficient at lowering costs and promoting health of the general population.  

Everybody knows we live in the information age – the internet, computer networks, databases, modems, apps, iphones, social media, and electronic health records.  

Everybody knows a nation’s health depends not so much on a nation’s health system but more on its culture and its citizens’ life styles, poverty, family coherence,  and economic prosperity.    

Everybody knows that the United States exceeds other industrialized nations in its high rates of obesity, diabetes, prescription drug use, premature drug deaths.

Everybody knows we  trail most other countries in  longevity. 

Everybody knows the path to good health is proper diet, physical activity, and  everything in moderation. 

Lastly,  everybody knows that physicians and their effective interaction with patients are key in transmitting health information and in making any sound health system work more efficiently and effectively.

But how to integrate this information in an effective way, that is the question.

Patient Preparation Before Physician Visits (PPV)

I have a modest proposal, which I  call  “ Patient Preparation before  Physician  Visits (PPPV).  

After all,  all of us, soon or late, visit a physician,  for minor or major ailments, or  to see how sick or how well we are.   Most of us are now online and have access to online health information.    Most physicians have electronic health records, capable of receiving, transmitting, and storing  health information.  

There is now an obsession with one’s personal health  and how to preserve and maintain it.   

And there is a widespread  movement towards Patient Engagement, which includes  sharing health information with patients,  transferring monetary risks to them,  and initiating and   giving them more control over health decisions by allowing them to order and interpret health care tests on their health,  monitor their vital signs,   and control their own health destinies.    

That is the basis for  Medicare’s  periodic  wellness exams,   corporate  health and wellness programs, the renewed emphasis on long-term prevention rather than  treatment after the disease  horse has left the barn,  the obsession to monitor fitness using  wearable devices,  and the Theranos company’s attempt to allow patients to order 200 tests on a finger-tip drop of blood on their own without a physician’s orders.  The Theranos venture generated $9 billion value for the company, a vivid testament to the venture capital industry's interest in innovative patient engagements.

My Proposal

My proposal  is  straightforward and based on patient autonomy, and   patient preparation for a physician office visit using  existing information technologies.

One,  have  patients  prepare for a physicians visit by having them  record  on their own computers their vital signs (blood pressure, weight, height,  waist circumference, and so forth) using reliable and available devices.

Two.  have physicians re-order a panel of relevant clinical tests - such as glucose, total cholesterol and its components, creatinine, and renal and liver function tests.

Three,  have patients enter their  health information ( gender, age, state of health ,  family history,   chief complaint,  signs and symptoms using  computer interview  technologies  such as existing  the  tried and tested Instant Medical History. 

Four,  integrate vital sign and body measurement information, with Instant Medical History.

Five,  give health consumers the ability to generate  a report for themselves with  this type of HQ information on their health status –  0-50,  health problems exist, consult a physician immediately ,   60-75,  below normal health,  consult a physician,  75-125, within range of  normal health,  but could be improved,  125 or greater,  excellent health.

 This pre-visit preparation should  include   the patient’s  health status  compared to persons of their age and gender (a health IQ with a normal range of  75 to 125 is a useful marker) which can improved with better health habits;   and a brief  differential diagnosis of possible  health problems based on the demographic information and medical history with suggestions  before visiting a doctor.

This proposal promotes clinical  efficiency.  It saves physicians’ time in evaluating patient’s health, gives patients objective evidence of their health and disease status,  employs and integrates  the latest technologies,  and helps put patient in control of their health with physician input when appropriate and necessary.

On the other hand, the proposal raises certain questions -   Can patients  be trusted to enter their own demographic , vital signs, and body measurement data?  Can patients handle the objective results?   Can patients and doctors protect this highly personal data against hackers and now and future employers?  What would such an approach cost patients and the health system?  How would physicians and patients react to such a proposal?