House v. Price and the CSR Payments Paradox

House v. Price and the CSR Payments Paradox

Many countries in the world have dysfunctional governments. Some have corrupt and devious ones, or even deadly ones. We’ve lived with serious dysfunction in Washington for two decades. Now we join the ranks of countries with a corrupt and devious government, one without a moral compass.

And I’m not just talking about Trump.

The news and blogosphere is replete with this sentiment surrounding the White House, of course, a la the “Russia thing” and Comey’s firing and all the rest.

But the cynicism and political bankruptcy that suffuses our elected leaders’ failure to assure that the cost-sharing subsidies for people buying health insurance through the exchanges will be secured for 2017 and 2018 is a new low in the wretched ongoing saga of Obamacare vs. Trumpcare.

This is playing out right now and could affect 12 million people come this fall and in 2018.

To be sure, there’s a legal issue that deserves attention. Here’s the quick background if you haven’t been following this closely:

The Republican-led House of Representatives in November 2014, in an unprecedented move, legally challenged the Obama administration’s payment of subsidies to insurers to compensate them for helping people between 100 and 250 percent of the poverty level pay their deductibles and out-of-pocket payments.

The House claimed that Congress never appropriated money to fund these payments; thus the administration was making them unconstitutionally. In May 2016, a judge ruled in the House’s favor, holding that Congress had indeed not specifically appropriated money to cover the “cost sharing reduction” (CSR) payments.

The judge ordered that future payments stopped until Congress specifically appropriated the funds, but then stayed that ruling pending certain appeal. The Obama administration did indeed appeal, in October 2016. The House then requested additional time to file its responsive.

Then came the election and Trump’s win.   The House asked the court in February that the appeal be stayed until the new administration took a position. The judge agreed and issued a deadline of May 22, 2017. (See below for what happened on Monday.)

From Jan. 21 through May 22, Trump and administration health officials sent mixed signal after mixed signal on the fate of the lawsuit and the CSR payments, which totaled $7 billion in 2016 and helped 7 million people.

One minute the White House seemed to agree the payments had to continue—while ACA repeal and replace was being debated and legislated—only to undermine that sentiment within days.

In particular, on numerous occasions, Trump said flatly that letting the CSR payments lapse would “kill Obamacare.” He threatened to do just that, by ordering the payments be stopped—something he can do. He also suggested several times that he might use continuation of the CSR subsidies in 2017 as leverage to get the Democrats to support the House Republican health care bill.

And Trump said: Congress can authorize the payments if they want to, though he never indicated (to my knowledge) that he supported that course of action or that he would sign such a law.

Notably, the House’s American Health Care Act (AHCA) would continue the CSR payments through 2019—something Trump seemed not to know. But, as Tim Jost points out in this Health Affairs blog, “the bill provides no additional funding for the program, necessitating continued defense of the appeal to stop the lower court’s order from going into effect prior to that time.”

Virtually every major healthcare lobby group—insurers, physician, hospital and consumer groups—argue that failure to continue the CSR payments will have a dramatic negative impact on the ACA marketplaces in 2018.

Insurers have all but said that premiums will spike even further in 2018 without the payments. The Kaiser Family Foundation put a nationwide average on that increase of 19 percent.

The deadline for states to let the federal government know whether they will participate in the exchanges in 2018 is June 21.   That means they are figuring it all out NOW.   Several states have already given insurers permission to submit two sets of proposals—one assuming the CSR payments continue and one assuming they don’t.

Fast forward to recent days.   Recognizing the dire nature of the situation and the political failure at the federal level, on May 18 attorneys general from 15 states and the District of Columbia filed a motion to “intervene” in the litigation.

Again, courtesy of Tim Jost, that means the states are claiming they have an immediate interest on behalf of their residents to seek a resolution to the litigation. Namely, the states argue that subjecting future CSR payments to an unpredictable appropriations process will lead to higher insurance costs and to more insurers abandoning the individual health insurance market.

The states further assert, according to Jost, a healthcare attorney, that:

“President Trump’s statements demonstrate that the administration cannot adequately represent the states’ interest in the litigation,” and that they, the states, “have a sovereign interest in administering their insurance markets and protecting their residents.”

The National Association of Insurance Commissioners, along with a number of large insurers and major employers, also weighed in to warn Congress and the administration of the danger ahead if the CSR subsidies cease.

On Monday May 22—the deadline for the administration’s decision—this dirty can, filed with political mold and moral decay, got kicked down the road.

The House of Representatives and the Department of Justice jointly sought an appeal court’s permission to preserve the status quo for another 90 days, until August 20.

The court is expected to issue a decision soon. But make no mistake, this leaves states, insurers and millions of exchange customers in a state of deep uncertainty and angst—even if the administration, as reported, agrees to pay the subsidies through August.

The stupidity of all this is exacerbated by the fact that ending the CSR program would actually cost the government more money, as long as the ACA exchange system is in place. That’s because higher premiums translates to higher premium subsidies from the government. Of course, many people would drop out if, as predicted, insurers hiked premiums an average 19 percent in addition to increases planned for other reasons.

The Congressional Budget Office score of the House-passed repeal and replace bill may shed further light on the impact of the CSR payments—or not.   The CBO is expected to issue its report this week.

As Jost notes, passing an ACA repeal and replace bill (if the Senate gets its act together) will not resolve all of House vs. Price, as the case is known. Apart from the CSR subsidies, it’s legally murky whether a single chamber of Congress has standing to sue an administration to stop the expenditure of funds that it believes were not properly appropriated.

If our elected officials had any sense at all and were acting in the public interest, the CSR issue would get resolved as soon as possible. The solution is simple: Congress has but to authorize the subsides and appropriate the money. They can and should do that for the remainder of 2017 for starters.

ACO Turnover is High. Doctors Have Few Patients, and Those Patients are Unusually Healthy

ACO Turnover is High. Doctors Have Few Patients, and Those Patients are Unusually Healthy

ACOs suffer astonishingly high turnover rates among their doctors and patients; their patients are unusually healthy; and those unusually healthy ACO patients constitute about 5 percent of each ACO doctor’s panel of patients. These facts appear in three recent reports: CMS’s final evaluation of the Pioneer ACO program, and two papers published in Health Affairs by John Hsu et al.

Each of these facts – high turnover, healthier patients, and few ACO patients in each physician’s panel – poses problems that cannot be solved without a substantial redefinition of the ACO. How are doctors supposed to influence the health and cost of patients they see only sporadically or not at all? How are ACO doctors supposed to lower costs if their sickest and most costly patients are not in the ACO? How are ACOs supposed to alter physician behavior when their physicians see fewer than 100 ACO patients out of a typical panel of 1,500 to 2,000 patients?

This post is the first of a three-part series in which I discuss the documents I mentioned above – the final evaluation of the Pioneer program and the two papers by Hsu et al. In this essay I will review the findings of those documents regarding turnover, biased selection, and numbers of ACO patients per doctor. In the second installment I’ll discuss the implications of these findings for ACOs and for MACRA’s “alternative payment model” program. In the third installment I’ll ask whether the final evaluation of the Pioneer ACO program sheds any light on why the program failed to work as advertised.

The ACO revolving door

The final evaluation of the Pioneer program, published quietly last December, indicates the 23 Pioneer ACOs that participated in that program over the three-year period 2012-2014 lost two-thirds of their doctors and patients during that time. [1] Here is how L&M Policy Research, the firm that wrote the evaluation, described physician churn: “Looking across 23 ACOs in all three performance years …, 34 percent of Pioneer ACO providers (11,777 of 34,882) were affiliated in all three years.” (p. 25) And here is how L&M described patient churn: “Looking across all three performance years at the 23 Pioneer ACOs… , only 30 percent of aligned beneficiaries were aligned in all three years (352,421 of 1,173,843)….” (p. 29).

In two papers published over the last year in Health Affairs, one published last April and the other in March 2016, John Hsu et al. reported high turnover among doctors and patients in the ACO run by Partners HealthCare, a Boston hospital-clinic chain. That ACO was the second largest of the 32 Pioneer ACOs. [2] In the April 2017 paper , Hsu et al. reported that only 52 percent of the 748 primary care physicians listed as participants in Partners HealthCare’s ACO during the 2012-2014 period were affiliated during all three years. Oddly enough, 13 percent of those 748 doctors did not have any Medicare recipients assigned to them at all and, therefore, had no ACO patients to lose through the ACO revolving door.

In their March 2016 paper , Hsu et al. reported, “In 2014 …, only 45 percent of the beneficiaries [in the Partners ACO] had been aligned with the ACO since 2012….” (p. 425)

These churn rates should be no surprise to anyone who was paying attention to the Physician Group Practice (PGP) demonstration, a test of the ACO concept conducted by CMS over the period 2005-2010. CMS assigned Medicare recipients to the PGPs using the same plurality-of-primary-care-visit method they employed to assign recipients to the Pioneer ACOs. According to the final evaluation of the PGP demo, the PGPs lost 37 percent of their assigned patients over the first three years (see Table 11-2a p. 222). “PGPs generally retained approximately 70 percent of their assigned beneficiaries from one year to the next,” the report stated, “and … PGPs generally retained approximately 40 percent of their assigned beneficiaries after five years.” (p. 221).

CMS shunts sicker patients away from ACOs

In its first evaluation of the Pioneer program released in May 2015 (with a March 2015 date on it) in which L&M Policy evaluated the program’s first two years, L&M suggested that CMS’s method of assigning Medicare recipients to ACOs could result in favorable selection, that is, the assignment of healthier patients to ACOs. In this final evaluation, L&M did not mince words: They clearly stated that CMS’s assignment algorithm causes highly favorable selection.

To measure the degree of favorable selection, L&M calculated what they called a “spillover group” of patients for each ACO. This group consisted of Medicare recipients within the ACO’s market area who had at least one primary care visit with an ACO doctor during the year in question but did not have enough contact with the ACO’s primary care doctors to be assigned to the ACO by CMS’s plurality-of-primary-care-visit algorithm. These “spillover groups” turned out to be much sicker and more expensive than the groups CMS assigned to the ACOs. Here is how L&M put it (note that L&M uses CMS’s trendy word “aligned” as a substitute for “assigned”): “Aligned beneficiaries tended to have … substantially lower spending compared to those not aligned but receiving at least one qualified service from an ACO provider during a performance year (spillover group).” (pp. ix-x)

Data reported by L&M indicates the “spillover” patients were about 1.6 times sicker and more expensive than the assigned patients. Here are more quotes from the final evaluation: “The average PY1 [performance year 1] expenditures of these two populations differed significantly: $11,605 per aligned beneficiary compared to $18,992 per spillover beneficiary.”(p. 32) “In PY2, for example, [spillover patients] were more expensive than the beneficiaries aligned with ACOs in PY2 – $19,313 per beneficiary compared to $11,768.” (p. 34) “The spillover populations had higher proportions of beneficiaries with dual eligible status, six or more chronic conditions, or more inpatient stays than the aligned populations….” (p. 34)

Finally, it’s important to note that the spillover and assigned groups tended to stay separate over the three years of the Pioneer demonstration. As L&M put it, “[T]here was consistency over time for the two groups: aligned beneficiaries tended to be re- aligned in the following year, and spillover beneficiaries tended to remain not aligned with the ACO.” (pp. 34-35) [3]

ACO doctors see few ACO patients

Hsu et al.’s April 2017 paper reported that a total of 748 primary care doctors participated in Partners’ ACO during at least one of the three years (2012, 2013, or 2014). Those 748 doctors had an average of 91 ACO patients assigned to them during those three years out of an average panel size of 1,700. “This means that ACO beneficiaries accounted for less than 5 percent of the median physician’s patient panel,” the authors concluded (p. 644). (I calculate the percent to be 5.4 percent.)

To make matters worse, the sick patients that did get assigned to Partners’ ACO were not evenly distributed among the ACO doctors. A few doctors got far more than their share of sick patients. Hsu et al. illustrated how badly skewed the distribution of sicker patients was with this ominous remark: “ACOs’ ability to deliberately select participating physicians year to year … creates a relatively simple mechanism to ‘game’ the risk pool. For example, in our sample, dropping the twenty-two primary care physicians (top 5 percent) with the most high spending beneficiaries (spending more than $81,000) would reduce the mean Medicare ACO spending per beneficiary by 17 percent ….” (p. 646).

Finally, I remind you that the figures I’m reporting here are for the second-largest ACO among the 32 Pioneer ACOs. It’s possible that in smaller ACOs beneficiaries assigned to the ACO account for even smaller percentages of physician panels.

A restatement of the exceedingly obvious

Is it any wonder that ACOs are failing to cut Medicare’s costs, or that when ACO intervention costs are added, ACOs are probably raising total spending? Is it any wonder that ACOs are having, at best, only minor and mixed effects on quality?

I hereby announce the obvious: ACOs cannot possibly work as long as they must labor under the three handicaps I am discussing here – high doctor and patient turnover, limited ability to focus on the sickest patients because CMS is shunting sicker patients away, and few ACO patients per ACO doctor. For the ACO proponents who should have thought about these handicaps before they climbed on the ACO band wagon a decade ago, let me spell it out clearly.

The revolving door problem: It is neither logical nor fair to “hold doctors accountable” for populations of patients that include large numbers of phantom patients (patients doctors never see but are nevertheless “accountable” for) and patients who see numerous other doctors outside the ACO.

The biased selection problem: ACOs probably cannot lower total spending even if they were to receive a random selection of the Medicare population, but we can be certain they cannot do that if CMS continues to assign ACOs a disproportionately healthy population. Most readers of this blog have probably heard of the 20-80 problem – the sickest 20 percent of the population accounts for 80 percent of total medical costs. If it’s possible for ACOs to reduce net costs for at least a portion of their assigned patients, it will be for their sicker patients. But by sending ACOs disproportionately healthy Medicare beneficiaries, CMS is ensuring that a very difficult assignment under the best of circumstances is even more difficult.

The small-patient-pool problem. No one knows what tactics ACOs use that will allegedly make their doctors better doctors, but whatever it is, those tactics are unlikely to be effective when they’re applied to just 5 percent of the patients seen by the average ACO doctor. Even if ACOs could apply their magic to all 1,700 of each doctor’s panel, in other words, even if ACOs were just staff model HMOs with a new name, we would still have no evidence or reason to think they would lower costs or improve quality on balance. After all, if HMOs of any stripe had worked, we would not now be discussing ACOs and “medical homes” and other managed care fads invented decades after the HMO was unleashed on the populace. But when that ACO magic is applied to such a tiny percent of each doctor’s patients, it becomes even more difficult to imagine how ACOs are supposed to lower costs or improve quality.

Next post

In my next post I will ask whether these three problems – high turnover, biased selection, and small ACO patient pools – are fixable without a substantial redefinition of the ACO. My answer will be no. I’ll argue that ACO advocates can either redefine the ACO to look like staff-model HMOs, or they can radically redefine the ACO so that it focuses on a few clearly defined chronic diseases or subsets of patients. I’ll recommend the latter. I’ll also argue that even if ACO proponents wanted to choose the first option and risk another patient and doctor backlash against HMOs dressed up as ACOs, there’s no reason to believe that the HMOs in ACO drag would work any better today than they did in the closing decades of the last century.

[1] Thirty-two groups signed up for the Pioneer program and participated in the first year, 2012, but only 23 participated during all three years.

[2] Partners HealthCare was the second largest of the 32 ACOs if we use number of attributed Medicare beneficiaries as our measure of size. Partners ranked lower if we use number of participating doctors as our measure. The CMS final evaluation presents data on the number of physicians and patients in each of the 32 ACOs that participated for at least one year in the Pioneer program (see Table 30 p.99 and Table 32 p. 102). This data is presented for each of the three years (2012, 2013, and 2014) and for “any year.” The “any year” data show how many doctors and patients passed through the ACO revolving door over the three-year period. Partners was the second largest of the 32 ACOs as measured by total assigned patients in 2014 (77,135) and in any year (98,196). Heritage California ACO was the largest (96,617 in 2014 and 162,264 in any year).

[3] Deep within the final evaluation of the Physician Group Practice demo published in 2012, one can also find evidence that the plurality-of-visit method CMS uses guarantees that ACOs will get healthier patients. According to that evaluation, the average risk score for the Medicare recipients assigned to the ten PGPs in year one was 0.921 (1.0 equaled average risk). Interestingly, the report demonstrated that these risk scores would have risen to approximately average (that is, 1.0) if the method of assignment had been merely “one or more visits,” and would have fallen to 0.898 if “a majority of visits” had been used (see tables at page 222 of the final report ). In other words, the more patient loyalty CMS’s assignment algorithm requires before a patient can be assigned to an AC), the greater the favorable selection enjoyed by the ACO. The biased selection problem caused by the plurality-of-visit assignment method is worse for ACOs enrolling non-Medicare populations under 65, because the proportion of that population that fails to seek any medical attention in the course of a year is much higher than the proportion of those over 65.


Suppose It’s an Obligation and Not a Right?

Suppose It’s an Obligation and Not a Right?

Suppose we frame the current health insurance* debate in a different way?

*It is about insurance. “Health insurance”=/=”health care,” although the former should lead to the latter.

Rather than arguing whether American individuals have a right to health care (beyond what you can already find in EMTALA, and please God let’s not consider repealing that), because people get very huffy about this concept, can we ask a different question?

Should we Americans collectively assume an obligation to “promote the general Welfare” by providing everyone access to basic health services, in the way that we have obliged ourselves to provide all children with access to a free public education (largely from each state’s constitution, with the exception of protections for disabled children)?

Consider this:

We have already agreed, by enacting EMTALA in 1986, that as a society we don’t want to see people die because an ER turns them away if they can’t pay. We have already assumed that obligation. But waiting until people are very nearly dead before we assume any obligation for their care is extremely expensive, and in the case of many ailments, just cruel. Think heart disease. Think diabetes. Think cancer.

We have already agreed, by enacting mandatory vaccination laws (although we have wobbled a little on this one with exemptions), that we have an obligation to protect the herd by requiring this simple public health measure. We also have quarantine laws to fulfill our obligation.

We have already agreed that we have an obligation to provide safe water to all (coughs Flint coughs), also pretty basic for health.

We have also agreed, via our Supreme Court, that it is a violation of the Eighth Amendment prohibition against cruel and unusual punishment to deprive prisoners of necessary medical care in Estelle v. Gamble, 429 U.S. 97 (1976). Let me repeat that. People in prison have a right to medical care (although even they can be charged co-pays).

It does not seem like that far a reach to propose that we have an obligation (collectively) to provide people who are not incarcerated access to health care before they show up at the ER, if for no other reason than to reduce the expensive ER visits that we are already obligated to fund.

Given the way our system is currently set up, rather than nationalizing the health care system, which sounds like quite the disaster, or providing everyone with a government doctor (which also sounds like a disaster, given how the VA has been struggling), making sure everyone has health insurance coverage seems the least disruptive path. Although nationalizing the insurance companies has a brutal appeal to me, and eliminating the middlemen in the long run through gentler measures will probably be helpful.

So for those of you who don’t want to grant other people individual rights in this area, ask whether you might be shirking the societal responsibility that you have already undertaken. And see also this interesting analysis of the free rider problem in this area.

Not your brother’s keeper, you say? Can we have a talk about the corporal works of mercy?

The Dark Goddess of Replevin is a lawyer in recovery. She majored in Russian and has a varsity letter in extemporaneous speaking.

Maintainance of Conflict of Interest?

Maintainance of Conflict of Interest?

In the May 2nd issue of the Journal of the American Medical Association (JAMA), the American Medical Association (AMA) discusses the subject of physician conflicts of interest in medicine. This puts them at an interesting juncture when the editor-in-Chief and executive editor of JAMA failed to disclose their relationship with the AMA and the AMA’s relationship with US physicians. The AMA still presents itself to the public and legislators as representing Americas’ doctors, even though representing US physicians’ interests has not been their financial priority for many years. In fact, it is telling that their mission statement no longer includes the words doctor or physician. If they do represent US physicians as they often claim, then the AMA (and its publication JAMA) are rife with numerous conflicts of interest and public clarification of this fact is desperately needed.

Which is it?

In June 2016 at the invitation of the Pennsylvania Medical Society, concerns regarding the conflicts of interest inherent to the American Board of Medical Specialties’ (ABMS) Maintenance of Certification (MOC) program were brought before the interim national AMA House of Delegates meeting. The AMA and ABMS are co-member organizations of the Accreditation Council for Graduate Medical Education (ACGME) and each organization took interest. The room was full of concerned physician delegates who had taken time away from their practices to represent their colleagues, alongside the President and chief council of the AMA, senior executive officer of the American College of Physicians, and the President and CEO of the ABMS. These courageous practicing physician delegates issued a “vote of no confidence” in the American Board of Internal Medicine (ABIM) – the largest ABMS member board representing approximately 200,000 US physicians – during a national panel discussion. They later passed a resolution to end the ABMS MOC program, which is a laborious recertification process plaguing overburdened physicians across this nation. Unfortunately, the AMA leadership has yet to honor this resolution.

Which is it?

In June 2016 at the invitation of the Pennsylvania Medical Society, concerns regarding the conflicts of interest inherent to the American Board of Medical Specialties’ (ABMS) Maintenance of Certification (MOC) program were brought before the interim national AMA House of Delegates meeting. The AMA and ABMS are co-member organizations of the Accreditation Council for Graduate Medical Education (ACGME) and each organization took interest. The room was full of concerned physician delegates who had taken time away from their practices to represent their colleagues, alongside the President and chief council of the AMA, senior executive officer of the American College of Physicians, and the President and CEO of the ABMS. These courageous practicing physician delegates issued a “vote of no confidence” in the American Board of Internal Medicine (ABIM) – the largest ABMS member board representing approximately 200,000 US physicians – during a national panel discussion. They later passed a resolution to end the ABMS MOC program, which is a laborious recertification process plaguing overburdened physicians across this nation. Unfortunately, the AMA leadership has yet to honor this resolution.

If the House of Delegates is little more than a figurehead that makes a mockery of representing practicing US physicians before the AMA, then the public, legislators, and participating physicians should be formally notified and the perceived conflict clarified. Likewise, when a physician notifies JAMA’s Editor in Chief of ABMS authors that have consistently failed to disclose their affiliation with their own for-profit wholly-owned subsidiary ABMS Solutions, LLC in JAMA and elsewhere, a response and action addressing this specific conflict should occur.

However, if the AMA has chosen to serve as an independent business entity paying their journal’s editor-in-chief (who also serves as their Senior Vice President) $687,290 while also earning $111.1 million from CPT code “royalties and credentialing services” and $20 million from advertisers, then there is no conflict and the editors can feel reassured their disclosures in JAMA were proper. The AMA is one of the largest nonprofit 501(c)(6) business leagues in the country and has accumulated assets of over $686 million for its purposes.

Publishing an entire journal issue dedicated to the topic of physician conflict of interest while failing to acknowledge their own conflicts with physicians threatens to render JAMA’s coverage of this topic to little more than ethical “fake news.” The onus is on the AMA to clarify their role and potential conflicts with working US physicians or as Maya Angelou once said, “When a person shows you who they are, believe them.”

GEHA’s Seven-Year “Glitch”

GEHA’s Seven-Year “Glitch”

In a little piece of legislation known as the Affordable Care Act, preventive services are mandated to be covered with no out-of-pocket expense to consumers. According to the website, approved insurance plans must cover a “list of preventive services for children without charging a copayment or coinsurance.” Number 18 on that preventive care list is: childhood immunizations for children from birth to age 18, acknowledging regional variation in the standard recommendation schedule. After all, vaccinations are the cornerstone public health achievement of the last century and have saved countless pediatric lives.

Alas, all fairy tales must come to an end. For government employees choosing GEHA insurance coverage, that type of prevention comes at a definitive out-of-pocket cost. According to Wikipedia, GEHA is a self-insured, not-for-profit association providing health and dental plans to federal employees and retirees and their families through the Federal Employees Health Benefits Program (FEHBP) and the Federal Employees Dental and Vision Insurance Program (FEDVIP). According to the US Census Bureau 2014 statistics, Washington State has approximately 341,000 state and local government employees. My hometown has three very large installations, the Puget Sound Naval Shipyard, Naval Undersea Warfare Center Keyport, and the Bangor Naval Submarine Base employing a large number of full-time employees and contractors.   Many of these individuals have health insurance coverage provided by the Government Employees Health Association (GEHA) insurance plan.

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Is Health Privacy a Human Right?

Is Health Privacy a Human Right?

Health privacy sits at an uncomfortable junction between three interests: individual human rights, public / population health, and private business interests. There’s no obvious reason for these three interests to be misaligned but a lot of pain and money are involved so either politics or competition are typically in the picture.

Health privacy is a subset of the human right to privacy, what Supreme Court Justice Brandeis called “the right to be left alone”. But privacy has never been defined, and is seldom enforced, in health care because of the competing interests of society to manage populations, and a $100 Billion industry in data brokerage that’s hidden from public view. Big Healthcare business seeks our trust on the one hand while doing their best to manipulate prices on the other.

Privacy is very different from security, but the two are used interchangeably by interests that want maximum leverage to sell or benefit from use of our personal data. Security problems arise as a result of hacking, bugs, and other unforeseen failures of a system. Privacy problems are in the system by design. Sale or abuse of personal data is done by people acting within their legal authority using technology that’s working as designed. The misdirection of privacy concerns to security discussions is intentional because it makes money.

HIPAA is a good example of the misdirection at work. The part of HIPAA we all hear about and the part that’s enforced is security. The part of HIPAA that looks like “information blocking” or your inability to easily get a health record from your hospital is hardly ever in the news and never the subject of enforcement action. HIPAA actually took away your right to control to how a hospital shares your data and, with the exception of a few states, you have no private right of action if your privacy is breached.

Outside of the US, in the European Union, where human rights benefit from some very bad experiences in the first half of the 20th Century, the regulatory climate is different than the US. EU privacy is now front and center for business as a result of the General Data Protection Regulations (GDPR) due to come into force less than a year from now. This marked divergence from US health privacy practice will certainly shake up the global market for personal data (ab)use.

The rapid rise of blockchain technology for trusted transactions is also coming into healthcare focus. Much of the HIPAA “information blocking” problem and the lack of transparency in how our personal health data is actually used is due to the consolidation of data around giant regional institutions that benefited most from nearly $40 Billion of Federal incentives and a relaxation of the Stark anti-kickback statutes as applied to electronic health records. Blockchain trust replaces institutional trust with trust in mathematics and health record systems can now be built that are truly patient-centric.

Is Health Privacy a Human Right? This and related topics are on the agenda at the 7th International Summit on the Future of Health Privacy on June 1 and 2 at Georgetown Law Center in Washington, DC. Admission is free and open to the public and the sessions are live streamed, also free.

10 Reasons Why You MUST Attend HxR 2017!

10 Reasons Why You MUST Attend HxR 2017!

We know there are plenty of healthcare conferences to choose from if you’re looking to get inspired. However, we strongly believe our conference really sets us apart when it comes to applying design and technology to improve health. Here’s why…

10. Networking
There are plenty of opportunities to rub elbows with hundreds of high-level individuals who are changing the game in health. Take advantage of coffee breaks, lunches, and the reception at the end of day one!

9. Workshops
Register for the workshops at HXR to get hands-on information and be able to apply what you learned, right away.

8. Connect with companies
The exhibit hall will be filled with companies who are showcasing their latest and greatest work in health. Strike up a conversation and take a look at case studies from various companies.
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Why Health Reform is a Risky Business for Politicians: Even Winning Can Cost You at the Polls!

Why Health Reform is a  Risky Business for Politicians: Even Winning Can Cost You at the Polls!

In August 1989, Chicago Congressman Daniel Rostenkowski, then Chairman of the “powerful” House Ways and Means Committee, narrowly escaped an angry mob of seniors in his own district who attacked his car with umbrellas. His crime: eliminating the gaping patient financial exposure built into the Medicare program in 1965 by raising taxes on the “high income” elderly.   In November, 1989 Congress rescinded the so-called Catastrophic Coverage Act, a bipartisan reform signed into law by Ronald Reagan just sixteen months earlier.

In the spring of 1994, Bill and Hillary Clinton abandoned their famously arcane health reform plan and months later, forfeited control over Congress in the 1994 mid-term elections. Health reform was a major factor giving Newt Gingrich’s House Republicans control for the first time in forty years. Twenty five years later, Barack Obama succeeded, with huge Democratic majorities, in passing the Affordable Care Act and . . . lost control of the House less than eight months later in the largest Republican landslide since 1938, due in major part to voter backlash against “ObamaCare”.

What was the common denominator of all these political events? The answer: powerful voter retribution for tinkering with the healthcare system, successfully or not.  Why is health reform such risky business for politicians?

First, US. healthcare is a vast enterprise, the size and complexity of a large industrial nation.  In 2017, we will spend more than $3.5 trillion on healthcare, roughly equal to the GDP of Germany.   It employs sixteen million people.   Its physicians, scientists and engineers, hospitals, pharmaceutical and technology firms, information technology vendors, not to mention patients themselves, are, collectively, the most powerful private interest group in the country. Invading a third world country like Iraq or Afghanistan is child’s play compared to reforming the US health system.

Second, and more important, the health system touches every American at vulnerable times. Virtually every mother in America became a mother in one of its hospitals.   One third of us will die in those same hospitals, and perhaps half of us will spend some time in the hospital in the last month of our lives. There are nearly 5000 US hospitals, more than 800 thousand practicing physicians and millions of nurses and other health professionals devoted to sheperding us through critical life passages. They see us, and try to help us, when we are not at our best.

But third and most important, American voters view health reform schemes emanating from Washington through a prism of fear borne of intimate personal experience. For example, nearly 1.6 million people will be diagnosed with cancer this year, and six hundred thousand people will die of the disease.  There are over 14 million cancer survivors in the US, most of whom have families to dealt with the fear and risk together with their family and friends. That adds up to many tens of millions of people directly affected by just one illness. Every one of those 14 million cancer survivors, including the author of this post, is the proud owner of a “pre-existing condition”.

The primal fear of becoming ill is now accompanied by the fear of being bankrupted by the medical bills that result. More than 43 million Americans have unpaid medical bills. Nearly 40% of adults have been contacted by bill collectors for those bills.

And there isn’t much of a margin in most household budgets for that surprise medical bill. Almost half of American households cannot cope with a surprise $400 bill without borrowing the money or selling something they own.   Medical expenses are the major contributor of personal bankruptcy .   It is worth noting here that personal bankruptcies have fallen by HALF since the Affordable Care Act was passed.

And finally, as the 2016 election of consummate outsider Donald Trump, with nary five minutes of prior experience in government, conclusively demonstrated, tens of millions of voters do not trust the competence of the federal government or believe that it is working for them.

So- health care- nearly 20% of the economy, hellishly complex, intimate attached to voters’ darkest fears and their pocketbooks, encased in a huge mesh of powerful interest groups and vast public skepticism over whether government can do anything right.  What is there for a politician not to love here? Political leaders intent on “reforming” healthcare are messing with something with a lot of nerve endings attached to primal voter fears, both for their own health and their finances. And there isn’t a great deal of trust to go around.

Republican health reformers, as you take your turn, take note: health policy isn’t brain surgery. It’s actually a lot harder.  Voters remember what you promised. Recall Obama’s most costly promise: “If You Like Your Health Plan, You Can Keep It”.   It also pays to be humble about what you can accomplish. Trump promised a “terrific” health plan that “covered everybody”.   And the Hippocratic Oath doesn’t just apply to medicine. It applies in force to health policy, particularly the “At First, Do No Harm” part.

Failure to Translate: Why Have Evidence-Based EHR Interventions Not Generalized?

Failure to Translate: Why Have Evidence-Based EHR Interventions Not Generalized?

The adoption of electronic health records (EHRs) has increased substantially in hospitals and clinician offices in large part due to the “meaningful use” program of the Health Information Technology for Clinical and Economic Health (HITECH) Act. The motivation for increasing EHR use in the HITECH Act was supported by evidence-based interventions for known significant problems in healthcare.

In spite of widespread adoption, EHRs have become a significant burden to physicians in terms of time and dissatisfaction with practice. This raises a question as to why EHR interventions have been difficult to generalize across the health care system, despite evidence that they contribute to addressing major challenges in health care.

Problems Motivating Use

EHR interventions address known problems in health care of patient safety, quality of care, cost, and accessibility of information. These problems were identified a decade or two ago but still persist. Patient safety problems due to medical errors were brought to light with the publication of the Institute of Medicine report, To Err is Human, with recent analyses indicating medical errors are still a problem and may be underestimated. Deficiencies in the quality of medical care delivered was identified about a decade and a half ago and continues to be a problem. The excess cost of care in the US has been a persistent challenge and continues to the present. A final problem motivating the use of EHRs has been access to patient information that is known to exist but is inaccessible, with access stymied more recently by “information blocking”.

Evidence Base

These problems motivated initial research on the value of EHRs. One early study found that display of charges during order entry resulted in a 12.7% decrease in total charges and 0.9 days shorter length of stay. Another study found that computerized provider order entry (CPOE) led to nonintercepted serious medication errors decreasing by 55%, from 10.7 events per 1000 patient-days to 4.86 events, with preventable ADEs reduced by 17%. Additional studies of CPOE showed a reduction in redundant laboratory tests and improved prescribing behavior of equally efficacious but less costly medications. Another analysis found that CPOE increased the use of important “corollary orders” by 25%. Additional studies followed from many institutions that were collated in systematic reviews published first in 2006 and then updated in 2009, 2011, and 2014 that built the evidence-based case for EHRs. There were some caveats about the evidence base, such as publication bias and the benefits mostly emanating from “health IT leader” institutions that made investments both in EHRs and the personnel and leadership to use them successfully.

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Bob Wachter’s 2017 Penn Med Commencement Address “Go to Radiology”

Bob Wachter’s 2017 Penn Med Commencement Address “Go to Radiology”


Dean Jameson, Trustees, Faculty, Family and Friends, and most of all, Graduates of the Class of 2017:

Standing before you on this wonderful day, seeing all the proud parents and significant others, I can’t help but think about my father. My dad didn’t go to college; he joined the Air Force right after high school, then entered the family business, which manufactured women’s clothing. He did reasonably well, and my folks ended up moving to a New York City suburb, where I grew up.

There were a lot of professionals in the neighborhood, but my dad admired the doctors the most. He was even a little envious of them. This became obvious on weekend evenings when he’d get dressed to go out to a neighborhood party. He’d look perfectly fine – slacks, collared shirt, maybe a sweater. But there was one thing out of place: he’d be wearing our garage door opener on his belt. “Dad, what exactly are you doing?” I would ask, somewhat mortified.

“There’ll be lots of doctors at the party tonight,” he’d reply. “They all have beepers, I have nothing.” The strangest part was when the party was next door, the garage door would sometimes go up and down, as dad showed off his “beeper.”

You can just imagine how proud my dad was when I was accepted to Penn Med and chose to come to this special place.

When I was a second year med student, evidence was emerging in the literature that an aspirin a day might prevent heart attacks. I told my dad he should start taking one. A few months after starting the aspirin, my mother called to tell me my father was in the E.R., having passed out on his way to work. He was bleeding into his stomach.

I was overcome with guilt, certain that my baby aspirin had caused the GI bleed. I rushed home to be there for his endoscopy. The gastroenterologist attached a teaching scope, so I got to watch my dad’s procedure. “I’m sure we’ll see an ulcer or gastritis,” he told me reassuringly. He was wrong.

My 51-year-old father had gastric cancer. It had already spread to a lymph node, which dropped his chances of cure to 5-10 percent. In fact, it probably was my aspirin that caused the cancer to bleed. After a massive operation, my father quit his job, got his affairs in order, and hoped.

One of his hopes was that he’d live to attend my Penn Med graduation three years later. He did, and I recall his pride, a pride that all of you are feeling today as you reflect on your loved one’s accomplishment.
By the way, my dad turned 87 last month.

The experience taught me many things. How terrifying illness is for patients and family members. How doctors aren’t necessarily too great at prognosticating. And how important human-to-human contact is in medicine – not just between doctors and patients, but also among members of the care team. That’s what I want to talk to you about today.

When I started my ward rotations at HUP, it became clear that the central hub of the hospital was not the mahogany-paneled C-suite, or the glittering O.R. of the most famous transplant surgeon. Rather, it was in the dimly lit chest reading room in the radiology department on the ground floor of the Dulles Building.

You see, there lived Dr. Wallace T. Miller, chief of chest radiology and the kind of teacher that you remember vividly 35 years later. Every day, each clinical team – medical, surgical, ICU – cycled through Wally Miller’s chest room like cars going through a car wash. Sure, they were coming to look at their films – perhaps later, some of the elders can explain to the young folks what films were. But mostly, they were coming to See the Oracle.

I was a third-year student, and my team had admitted an elderly man with a fever and cough. Wally pulled up the film, and I began my little speech. “This is a 78-year-old man with a week of fever and productive cough,” I said. “What do you think?” asked Dr. Miller, pointing to an upper lobe infiltrate. “Pneumonia,” I answered feebly. “Mwaaaaa,” he said, an unforgettable sound that was both endearing and terrifying. “Look at this,” he said, pointing to a subtle area of cavitation. “It’s tuberculosis.”

Two decades ago, the field of radiology went digital. This was no less of a magic trick than podcasts, Amazon, or GPS. You could now see images anywhere – on the wards, in the clinic, even at home. The films, the contraptions called alternators on which they were hung, the cluttered film library… they all left the building, literally overnight.

Sadly, just as abruptly, radiology rounds ended. Nobody said that they should, nobody predicted that they would. They just did. Now that you didn’t need to schlepp down to radiology to see your films, people simply stopped going.

And with that, an important medical ritual died. Not only did we lose the collegial exchange and the learning – learning that enriched both the front-line clinicians and the radiologists – but we all lost the opportunity to slow down for a few minutes and to think deeply about each case. Instead, we briefly glanced at the image on a computer screen (or sometimes didn’t even do that), read the radiologist’s report, and continued on our sprint to get through rounds and polish off our checklists.

Your careers are launching at the start of a period of massive transformation in healthcare. When you entered college, medicine was an industry whose information backbones were the piece of paper, the three-ring binder, the post-it note, and the fax machine. Now it is the electronic medical record.

History has shown that, while information technology ultimately reshapes every industry it touches, it doesn’t immediately deliver on its promised improvements in quality and productivity. This lag is known as the Productivity Paradox of I.T. You see, humans aren’t quite imaginative enough to appreciate the opportunities or to understand the changes inherent in going digital… until they’ve actually gone digital. So they get it wrong. As it happens, this is an age-old problem in technology: Henry Ford was reputed to have said, “If I’d asked people what they wanted, they would have said, ‘faster horses.’” They had no ability to imagine their world with cars until there were cars.

During the past few years, we’ve witnessed our own maddening version of the Productivity Paradox. Doctors and patients no longer looking at each other, both feeling alienated and more than a little pissed. Residents hunched, dead-eyed, over their computers. The numbers tell the story: from the E.R. doctor’s 4,000 clicks a day; to the 2.5 million alarms – virtually all of them false – that go off in my hospital’s ICUs each month; to skyrocketing rates of physician burnout. There are a number of culprits, but high on the list are digital tools that are poorly designed, often unhelpful, and sometimes even dangerous.

You’ll be glad to know that the history of the Productivity Paradox offers room for hope. We’ve learned from other industries that it takes about a decade after widespread digitization for the massive potential of IT to be realized. In healthcare, of course, it’ll take longer – we’re complicated, there are boatloads of regulations, and the Silicon Valley mantra of “failing fast” isn’t terribly appealing when failing can mean a dead patient.

But IT will eventually deliver on its promise in healthcare.

There are two messages I want to leave you with regarding this transformation.

The first is that you will be the ones to figure out how to make this work. Believe me, we’re counting on it! It turns out that the key to overcoming the Productivity Paradox is that people need to reimagine the work. It’s smart young people like you who are best positioned to do that.

They ask – you’ve probably already asked this yourself – Why is the doctor’s note a flat digital document, accessed by clicking on a tab? Because that’s what the note looked like when it sat in a three-ring binder. And so, when we ditched the paper, we just digitized the same old note. And young people say, “That’s absurd. Haven’t you ever seen a Facebook wall? Or a Twitter feed? How about a collaboratively created note, a la Wikipedia? Why isn’t there audio or video?”

Reimagining the work doesn’t mean that you need to learn Java Script, move to Menlo Park, and begin hitting up VCs to fund your start-up. It does mean that you are constantly on the lookout for ways to improve the systems you work in. This involves some skills, yes, but much more importantly a mindset – one that says that the great doctor is no longer just a smart diagnostician or a talented proceduralist. He or she is also a great leader, an improver of systems, a relentless re-imaginer. Having graduated from this extraordinary school, everyone will be looking to you for leadership and inspiration. I know you’ll deliver.

My second message to you is just as important. As the work becomes digitized and the software gets better, we will spend more of our time interacting with our digital tools, and less interacting with each other, and with our patients. This is natural, and – assuming the tools are any good – it might even be OK. After all, computers will hold much of the information, and they will be where we develop and implement many of our diagnostic and treatment plans.

But, there is a huge danger from hunkering down in our digital caves.

You can never fully understand a consultant’s thinking by reading her note. You can never place a complex radiology finding in context without speaking to the radiologist. You can never allay the anxiety of a sick patient’s spouse by sending a text message. And you can never comfort a dying patient without sitting at the bedside and holding his hand.

In his magnificent commencement address at Kenyon College in 2005, the late author David Foster Wallace began with the classic parable about the two young fish swimming along. An older fish briefly joins them and asks, “How’s the water?” A bit later, one of the younger fish turns to the other and asks, “What the hell is water?”

Wallace ends his speech – the only commencement address he ever delivered – by talking about the real value of an education: “[It] has nothing to do with grades or degrees,” he said, “and everything to do with simple awareness – awareness of what is so real and essential, so hidden in plain sight all around us, that we have to keep reminding ourselves over and over: ‘This is water…. This is water.’”

Our digital tools offer us breathtaking capabilities, and we have to use them to our fullest. But it is the people who are real – our patients, our colleagues, our teachers, our students. They are what matters. They are our water.

So take full advantage of the magic of technology, and figure out how to make it work. And then go to radiology. Talk to your colleagues. Be with your patients. You’ll be a far better doctor. And you’ll be happier.

Several years ago, our UCSF department chair at the time was leading a faculty meeting. He was ticking off the massive changes in the world of medicine: new payment models, new technologies, new regulations, new pressures to improve value. I could see many of the faculty, particularly the older ones, squirming in their chairs. A few were mentally tallying the value of their Roth IRAs to see when they’d be ready for retirement.

One of our senior cardiologists, an amazing clinician-teacher but most decidedly of the old school phenotype, got up to speak. He was usually quiet in these meetings, so all of us perked up.

“You know,” he began, “this could be worse.”

This was surprising, coming from him. But then he continued.

“I could be younger,” he said.

You, my young colleagues, should listen to such lamentations with sympathy – after all, change is hard – and humor. And then you should emphatically reject them.

We have the opportunity today to do more for our patients than ever before. And you have the knowledge, skills, values, and habits of mind to thrive in this changing world. You are the ones who will reinvent the work to deliver for our patients. And you will figure out how to balance our new digital capabilities with the enduring truth that medicine is, and must remain, the most human of professions.

Thank you for the honor of speaking to you today. Congratulations to each and every one of you.