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15 posts categorized "Chronic care"

May 23, 2014

The Affordable Care Act: How Provider Organizations Can Succeed Under Health Reform

The Affordable Care Act has triggered many changes in the health care delivery system. Learn about the health reform-inspired approaches to redesigning care that work (or don't work) for management of chronic conditions, including diabetes -- from ACOs to bundled payments to patient centered medical homes.

I recently had the opportunity to present to the domestic affiliates of Joslin Diabetes Center on this topic.

Continue reading "The Affordable Care Act: How Provider Organizations Can Succeed Under Health Reform" »

October 30, 2013

Mobile Health Apps: Pass the Secret Sauce

6029363903_0e9abdceab_mThe IMS Institute for Healthcare Informatics released a report on the ecosystem bloody mess of 40,000+ mobile health apps that are available today. Hat tip to Jane Sarasohn-Kahn for writing about it today at Health Populi.

From the executive summary:

Over time, the app maturity model will see apps progress from being recommended on an ad hoc basis by individual physicians, to systematic use in healthcare, and ultimately to an end goal of being a fully integrated component of healthcare management. There are four key steps to move through on this process: recognition by payers and providers of the role that apps can play in healthcare; security and privacy guidelines and assurances being put in place between providers, patients and app developers; systematic curation and evaluation of apps that can provide both physicians and patients with useful summarized content about apps that can aid decision-making regarding their appropriate use; and integration of apps with other aspects of patient care. Underpinning all of this will be the generation of credible evidence of value derived from the use of apps that will demonstrate the nature and magnitude of behavioral changes or improved health outcomes.

(Emphasis supplied.)

We are nowhere near this endpoint -- integration of the use of health apps into health care management -- right now, due to a number of factors.

Continue reading "Mobile Health Apps: Pass the Secret Sauce" »

November 21, 2012

Engage With Grace

As patients, as family members, as friends, as health care providers, we have all faced end-of-life issues at one time or another, and we will face them again. And again. 

Having been through this process twice in the past year, I can only repeat that it is important to have The Talk, to help ensure that your family members' and friends' wishes about end-of-life care are clear, are documented and, as a result, are followed. If it helps to get the conversation going, use the Five Questions in the slide at the end of this post. 

Download your copies of the Massachusetts health care proxy form or other states' proxy or living will forms -- and add specific instructions about nutrition, hydration, and anything else that is important to you so that everything is crystal clear.  Having the conversation is a starting point; we all need to follow through and make sure that our loved ones' wishes are documented, placed in medical records, discussed with physicians and other caregivers, and honored.

And with that I turn it over to @engagewithgrace for #blogrally12 (the latest edition from a group of us kickstarted by Alexandra Drane, Matthew Holt and Paul Levy.) If you blog, consider copying the rest of this post, and putting it up now through the end of Thanksgiving weekend. 

- O -

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you'll most certainly be right.’

We love it for three reasons:

1) It reminds all of us that living with intention is one of the most important things we can do.
2) It reminds all of us that one day will be our last.
3) It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much.

And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….

Then one day it does – happen to someone else. But it’s someone that we love. And everything about our perspective on end of life changes.

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has. Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values. And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter. Here’s the crazy thing - in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony. So let’s take that off the table right now, this weekend. Know what you want at the end of your life; know the preferences of your loved ones. Print out this one slide with just these five questions on it.

Have the conversation with your family. Now. Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW. Have it this Thanksgiving when you are gathered together as a family, with your loved ones. Why? Because now is when it matters. This is the conversation to have when you don’t need to have it. And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating. We find sharing almost everything else about ourselves fascinating – why not this, too? And then, one day, when the real stuff happens? You’ll be ready.

Doing end of life better is important for all of us. And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama. Others had before. Why was this day different? Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too. Know the answers to just these five questions for yourself, and for your loved ones. Commit to advocating for each other. Then pass it on. Let’s start a revolution.

Engage with Grace.

Engage With Grace

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

January 06, 2011

Accountable Care Organizations: The Emperor Has No Clothes, Or, Jeff Goldsmith's Plan B

The current all-ACO issue of Health Affairs includes a piece by Jeff Goldsmith entitled: Accountable Care Organizations: The Case For Flexible Partnerships Between Health Plans And Providers.  It is a proposal for how private sector health plans ought to pay for services, in order to save us all from what Goldsmith sees happening in the near future thanks to the Gold Rush mentality among health care provider organizations working to become ACOs before they've been defined in regulation. 

He begins with a précis of how we've gotten into the health care market mess we're in, touching on the concentration of market power in horizontally and vertically integrated health care provider organizations, payors and providers mudwrestling over fee-for-service reimbursement rates, and the rise of the large specialty group and the growing bifurcation of in-hospital and out-of-hospital medical practice into two largely separate populations of doctors.  (He appears to be unmoved by the limited, but significant successes of some CMS demonstration projects in improving quality and reducing cost.)  He then turns to the panacea du jour, the ACO, and finds it wanting.  While one may quibble with some details, his indictment of the ACO model for Medicare is fairly convincing.  A product of the usual sausage-making approach to legislation, the ACO -- even if workable in its original conception by Fisher and others -- is a health care camel (a horse designed by committee), and Goldsmith finds it unlikely to yield any meaningful net cost savings to share in the near term.  I, for one, believe that physicians could exert greater influence within an ACO than Goldsmith would allow; while the bulk of health care costs are, as he notes, hospital-based, the most expensive piece of medical equipment is still the ordering physician's pen (or, these days, perhaps her iPad).  Still, offering providers an upside without exposing them to a downside doesn't really make them CMS's partners in the cost containment enterprise. 

I would agree that the time and dollar commitment needed to set up a really humming ACO are quite significant. It could take 5 years or so; folks will be able to meet the bare-bones requirements by 2012, once we know what they are, but most provider organizations will still have a lot of work to do to reap the maximum benefit from the new organizational structure, and it is not clear whether or when the shared savings will make that investment pay off on the Medicare side.

Goldsmith notes the likely cost-shifting that will occur in order to make up the Medicare losses, as bulked-up provider organizations negotiate with commercial payors (though I must note that some states -- including the People's Republic of Massachusetts -- and now the federales, are imposing stricter controls on premium hikes for health insurance), and lays out a new approach to payment on the commercial side.  He presents a set of payment and contracting strategies that he suggests should be adopted by all commercial payors, in order to reduce the administrative costs inherent in our current system, which has every provider dealing with the billing and payment idiosyncracies of every payor.  Nice idea but, as they say, that could take an act of Congress.  (Maybe this is the right Congress to roll back the antitrust laws just far enough for payors to do this, but of course it is unlikely that all payors would sign on in any event.)

In brief, Goldsmith recommends risk-adjusted capitation payments for primary care, fee-for-service payments for emergency care and diagnostic physician visits, and bundled severity-adjusted payments for episodes of specialty care.  Primary care would be provided through a patient-centered medical home model, which would likely have a collateral effect of reducing the total volume of emergency care and diagnostic physician visits.  Specialty care would be provided through "specialty care marts," ideally more than one per specialty per market to maintain a little healthy competition.

There is a great deal of merit to this proposal, and in fact, elements of the model are already in place in a number of markets around the country.  At the same time, I don't think that it may be easily and quickly implemented as laid out, for a variety of reasons.

I've worked with specialty "centers of excellence" that function much as the specialty care marts that Goldsmith describes, providing integrated services for bundled payments.  The ones that work well, work well, but the up-front investment in determining severity-adjusted payments, defining episodes of care, contracting the network of providers, and agreeing on clinical protocols is far from trivial.  Furthermore, given the consolidation that has taken place to date, getting a good price may be difficult for payors. 

Patient-centered medical homes exist in many locales, though just through demonstration projects for now, and the philosophy may not be consonant with a capitation-only payment model for primary care.  The core approach of the Patient Centered Primary Care Collaborative (PCPCC) calls for reimbursement for patient care management, for in-office services, for cost avoidance downstream, and for quality.  I believe that some monetary incentive for prevention and quality care must be included; the devil's in the details, but perhaps incentives based on patient panel health status over time rather than solely based on avoided downstream costs could be developed.

In sum, life is not perfect, we have to play the hand we've been dealt, and we've been dealt ACOs.  They will likely be a fact of life for many Medicare beneficiaries this time next year.  Commercial payors are in the habit of glomming onto Medicare payment system innovations, so moving them -- and providers -- in a different direction will be difficult, though it may ultimately be a win-win-win for payors, providers and patients. 

Depending on how flexible the regulatory waivers -- and Don Berwick promised the federales would be very flexible -- CMS may even be able to contract with ACOs in the manner described by Goldsmith.  That could be the real win-win-win scenario.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


December 28, 2009

Health Reform: What's a Provider to Do?

What should health care providers be doing in anticipation of the likely passage of an historic health reform bill?  There are at least three possibilities: (1) Lament the passing of the good old days and oppose it; (2) Insist that it isn't good enough because it is lacking some key provision (tort reform; SGR replacement; robust public option); or (3) Embrace it, because incrementalism works, and prepare for what's coming down the pike.

As you may guess, I would recommend taking the third approach, which requires focused preparation for the road that lies ahead.  So, what is a provider to do?

In the future, there will be pilots, demonstrations and mainstream programs trying to do more with less: providing health insurance and health care services to more people, with effectively fewer dollars per capita.  Payors -- be they public sector or private sector -- will therefore be squeezing providers.  The House and Senate versions of the health reform bill are equally clear on this point.  Providers therefore need to be proactive in preparing themselves to provide high-quality health care services at competitive rates.Instead of simply resigning themselves to negotiating percentage discounts off of current rates of payment, all providers need to be prepared to negotiate global payments, pay for performance deals, quality incentives and more -- as some forward-thinking provider organizations have been doing for some years now.

In order to be able to negotiate these terms effectively, providers must have a good handle on their own cost structure, and must begin to work at developing broader alliances of providers so as to be better positioned for negotiations with public and private payors.

In my years of experience in working with health care providers at that moment -- the point in time when folks with otherwise disparate interests realize the tremendous value of working together effectively in order to simultaneously promote better clinical outcomes for patients and better financial outcomes for providers -- I am always heartened by the epiphanies of the providers who realize that a new approach, or a new structure, can take them beyond their historical, positional, sometimes defensive attitudes, and into a future that they are able to shape and help define.

I look forward to working with more providers and provider organizations at this critical juncture so that they can be prepared for the future that will soon be upon us, and so that they can have a hand in crafting that future.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

September 18, 2009

Paul Grundy, MD, Patient-Centered Medical Home champion, speaks with David Harlow about the model and the challenges and opportunities ahead

Dr. Paul Grundy is on a mission -- a mission to promote the patient-centered medical home model that he has been instrumental in developing and rolling out, in his dual role as Director of Healthcare, Technology and Strategic initiatives for IBM Global Wellbeing Services and Health Benefits, and President of the Patient-Centered Primary Care Collaborative.  I had the opportunity to speak with him earlier this week, at the end of a day he spent in Washington, D.C., hard at work on this continuing mission.

The audio file of my interview with Paul Grundy (about 30 minutes long) is available for download/podcast.  A full transcript is at the end of this post (and in the linked Paul Grundy interview transcript).

I use the word mission because Paul frames the need for dissemination of the medical home model in terms of a transformational change in the nature of the covenant between doctor and patient -- not simply a reformation.  In his view, reformation without transformation creates as many problems as it solves: e.g., the primary care shortage exacerbated by increased insurance of the population at large in places like Massachusetts.

The Patient-Centered Medical Home model -- described more fully in materials from the Patient-Centered Primary Care Collaborative, and TransforMED, an affiliate of the American Academy of Family Physicians -- relies on a shift in physician compensation from a fee-for-service focus to a patient management focus; from an episodic focus to comprehensive, relationship-based care.  It's been implemented in over 100 pilots around the country.  Denmark learned about the model here in the U.S. decades ago and has implemented it fully across the country's health care system, shuttering most of the acute care hospitals in the country in the process.  Pilots in the U.S. include Geisinger's, which Grundy says has been remarkably successful, yielding an ROI of over 250%, including a 12% reduction in ER utilization, a 20% reduction in hospitalization, and a 48% reduction in rehospitalization.

Technology is an important part of these efforts and savings.  Even given the potential high cost of technological solutions and Health 2.0 tools, the costs pale in comparison to the $1 million-a-bed cost of hospital construction, let alone hospital staffing and other operating costs.

The key to catching up with places like Denmark and Spain, and systems like Geisinger, Intermountain and the VA, says Grundy, is the recognition and implementation of medical home-compatible payment systems by CMS, since it controls half of the country's health care spend, and providers march to CMS's tune.  Without that buy-in, it has been difficult to promote the model beyond integrated delivery systems, large group practices, and pilot-project-funded solo and small practices.

CMS announced Medicare funding for medical home program demonstrations in the states the day after Paul was in Washington earlier this week -- coincidence? I think not! -- and the concept is built into legislation percolating its way through Congress.

The model is a critical component of future improvements to our health care system; Paul Grundy and the patient-centered medical home both deserve our close attention.    

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Dr. Paul Grundy

Director of Healthcare, Technology and Strategic initiatives for IBM Global Wellbeing Services and Health Benefits

President of the Patient-Centered Primary Care Collaborative

September 15, 2009

David Harlow:  Hello, this is David Harlow on HealthBlawg, and with me today is Dr. Paul Grundy, who is the Director of Healthcare, Technology and Strategic initiatives for IBM Global Wellbeing Services and Health Benefits.  He is also President of the Patient-Centered Primary Care Collaborative, which is a group of large employers and primary care physician associations.  Dr. Grundy has years of experience in government and in the healthcare industry and I am happy to welcome him today to HealthBlawg.  Thank you, Dr. Grundy, for being with us.

Paul Grundy:  Thank you for inviting me; it's a pleasure to be with you.

David Harlow:  Well, I would ask if you could start off with a brief introduction on your experience with the patient-centered medical home initiative at IBM.  What is it exactly?  When you use that term what do you mean?  How long has this been a project of IBM’s and what kind of impact is it having both in terms of health status and cost savings?

Paul Grundy:  So the concept of a change of the covenant between the buyer of healthcare and the provider of healthcare is at least some years old in reference to the concept of better primary care - more integrated, more comprehensive primary care.  We as buyers of care really reached a conclusion that if we were going to really shift the curve or bend the curve as they call it now and we are going to begin to add the kind of value in the doctor-patient relationship that our employees were asking us to do, that it would take a transformation across the ecosystem, it would really take a change of covenant between the buyer and the provider of care, i.e., aligning payment at the macro level in exchange for micro-level transformation of practices to deliver better care.  

So our employees -- or just in general, the patients -- what they really want, they want convenience, they want access, they want comprehensive care, they want relationship-based care.  What they get now instead of that is they get episodes of care and what we buy is an episode of care, so: I can buy the kind of care that allows me to get pretty good amputation for my diabetic, but I can’t buy the kind of comprehensive integrated care that prevents my diabetics from needing an amputation -- is sort of the line I have been using for the last four years, and it's still true.  So we thought about that long and hard at IBM and certainly many other companies as well and some places have in essence created onsite facilities to do this, but since we have 60 percent of our employees that are scattered in every zip code and we really wanted to be equitable for all of our employees whether they happen to live next to a large IBM site or not.  We really decided to take a different tack and that was to begin to have a conversation with the folks who should provide comprehensive care, i.e., the primary care providers, which do that in most societies, and see if there was a way we could create a movement towards and ability for us to buy that kind of care across the spectrum.

So I guess about three years ago now we had 47 large employers that met with all of the primary care organizations and out of that meeting was born the joint principles of the patient-centered medical home, when the buyers said to the providers you need to agree on a set of principles around the concept of more robust, more comprehensive, more integrated care.  So that’s sort of the birth of the idea and the partnership between and buyers and the employers.  It's now grown much larger, with well over 600 organizations that are part of it including hospitals, all the national health care plans, many of the large consumer groups, the employer associations and I think there is a total of 19 medical specialty groups that have endorsed the concept, etc.  So it's grown to a rather large organization that’s really fundamentally trying to drive change towards more comprehensive primary care.

We also are a global employer, as many large companies are, and we noted that in many societies, those who have really integrated comprehensive robust primary care as the basis of their health care delivery system seem to be happier, and obviously the healthcare costs are twice as much in our society as they are in any other society -- you know that’s been quoted many times, but it's true.

David Harlow:  Right.  You mentioned the growth of the participation in the collaborative but from where I sit my perspective is that actual implementation of patient-centered medical homes has not been quite so wide spread and there is certainly a distance to go. I am wondering: From where you sit, how do you see this idea translating to the population at large? Or on what time frame?  Are the demonstrations that are included in some of the health care bills wending their way through Congress an appropriate right next step from your perspective, or do we need to take bigger leaps at this point?

Paul Grundy:  Well, the original concept when we first met after about a year of sort of sorting out our thoughts and directions in the partnership between the buyers and the providers, we asked the national health care plans into the room, because companies buy their health care through the 5 or 6 national health care plans, and some local ones as well, and we sort of thought probably the best way forward would be to really design some pilots around the concept, to kind of kick the tires to prove it out in various communities around the country, and so that led to a number of pilots beginning to evolve in the commercial marketplace.  Some legislation was passed for it to occur in CMS although they haven’t kicked off yet, but there are many pilots that are multi-stakeholder pilots with many health care plans that are rolling out.  I think at last count there were a little over 100 that I counted rolling out around the country, of which a dozen or 20 or so are really pretty far along and pretty robust in terms of the scope and the size of the pilots.
But the concept was to build into these pilots pretty rigorous analysis, to look at them academically, to kick the tires with them, to see how the results would look and then, from what we learned, to move forward.  Some of results are out on some of the early pilots at the first year and into the second year, and what we’re seeing consistently across the dozen or so that are out is that indeed better upstream care -- i.e., better care coordination, better primary care, better prevention, better access into the primary care provider’s office -- results in significant decline in the utilization of emergency rooms and hospital beds.

David Harlow:  Yes, I saw some press recently about Group Health of Puget Sound --

Paul Grundy:  That’s correct, that’s one of the early pilots, they now have data for two years; they have published for the first year.

David Harlow:  Yeah and so they and a number of other sites have been experimenting with this.

Paul Grundy:  That’s correct.

David Harlow:  Do you see differences across different pilot locations in the model being used, is there significant variation in the models being rolled out and tinkered with?

Paul Grundy:  Well there is variation in what’s looked at, there is variation in how it's rolled out.  I think what’s a pretty constant is just simply looking at applying better care coordination, on more robust primary care in an ambulatory setting, resulting in less need for hospital beds and emergency room utilization.  What’s been looked at has been different.  For example, in North Dakota they looked at the disease diabetes with a much more coordinated approach to the care management of diabetics, and they resulted in about a $500 a year savings for each of the patients which they shared with the practices.  That resulted in moving from a pilot to an actual roll-out across the state as we speak, which is what’s happening with many of these pilots.  The same in Geisinger.  Geisinger did better care co-ordination, better upstream care looking at a range of chronic diseases for elderly people, and what they discovered was a 48 percent reduction in re-hospitalization, a 20 percent reduction in hospitalization, a 12 percent reduction in ER utilization, an ROI of 251 percent, significant savings and again what they have - the lesson that they’ve learned from that is that, they are going to now move beyond the pilots stage and roll it out across their system.

The same with Intermountain.  Intermountain did it in a number of locations, saw the same kind of results. Those are integrated systems, and what we’ve seen in individual practices across the country -- and there’s probably been over a hundred that I’ve visited – Javier is an example: he is a pediatrician down in Florida, single physician, 41 percent Medicaid and again better care co-ordination, better empowerment, better education of the patients, better access to the primary care team resulted in going from an average of about one asthmatic admitted to the hospital a week to none in 14 months, and that, when you carry that beyond United States and look globally at places that are really doing this, who are 10 or 15 years ahead of us, is exactly the pattern we saw.

I mean in Denmark, for example, it is a rare event now to hospitalize patients for chronic diseases because that’s managed with better care co-ordination, better primary care, better care integration in a medical-home-type environment including, as migration occurs out, actually links to Wi-Fi equipment monitoring at the home, that sort of thing.

David Harlow:  I was just going to ask about how this model interacts with some other sorts of initiatives, new developments.  People talk about Health 2.0, for example, and you mentioned the Wi-Fi monitoring, and interactive connections.  Do those sorts of tools help to enable the demonstrations to work more efficiently and effectively or are they too expensive in some cases?

Paul Grundy:  No they are not.  In many cases most of those kinds of things are in fact much less expensive than you know, than hospital rooms, right? I mean, a hospital is about the most expensive place you can treat some of these diseases -- and by the way it's dangerous, it is not a place you want to go --

David Harlow:  There’s sick people in hospitals --

Paul Grundy:  Yeah, you have sick people in hospitals and people get sick in hospitals, it's an unsafe place, so what I think is happening, frankly, and I think it is a 2.0 kind of issue, we really had a juncture in time when the docs will have the kinds of tools -- and we’re already beginning to see them roll out -- that really empowers them from an outpatient sort of vantage point, with the control center really at their desk that has real information provided to them so, so some of this care, can and is done in it continuously and he has done virtually in which, in which you begin to have the kind of data flow that will empower the physicians minds the way X-rays empower their vision.I mean it's that kind of transformation and in some places it's further along than others, some places in United States it's further along than others and if you look globally there are places where again, like the Danish model -- they have gone from 155 hospitals down to 25 -- it's just, again, a rare event to have the kinds of diseases that can be monitored remotely, and can be monitored with a more integrated approach to care, to have to put them in a hospital where they are in danger.

I mean it's a phenomenal change and that’s exactly what the example of North Dakota was or what the example in Colorado was or in North Carolina.  In North Carolina, the State of North Carolina and Community Care North Carolina began to focus on better care coordination integration and resulted in, I think it was, a 44 percent reduction in the number of patients that were hospitalized for asthma, the same story that we talked about, and these aren’t integrated systems by any stretch of the imagination; these are folks that are eligible for Medicaid.  And the same in Colorado: very similar results within the Medicaid population with, again, better upstream care resulting in lower downstream cost.

David Harlow:  Are there any particular sets of incentives that you can generalize about that are proven to be most effective in yielding desired results?

Paul Grundy:  I think aligning payment around what it is you want to buy, right? I mean, we currently align payment around buying stuff; if a bill is submitted for doing stuff we pay for it.  What we find is that when you begin to align incentives around paying for care coordination, care integration -- for example in the United States most docs don’t have a clue who their patients are even and they don’t have a sense of responsibility for making sure that all of them have their colonoscopies done or their breast exams done or their immunizations done because here there is no sense of: I am responsible for that.

So you need to align that. So one of the alignments that other societies have done, and other integrated systems have done or the VA in United States has done is that they basically incent the patients and the docs and by aligning them in a location where both agree that that’s their home, that’s where there medical records are and somebody is responsible, they have got a target on their back to make sure they don’t die of breast cancer, because they are getting their breast screens, right?  I was visiting a clinic in Spain and I saw a - I went in to the doc’s work room and they were three names on the board and I said to one of the docs there, who are those names and she said well, those are three women in the community that after sending them an e-mail, after mailing them, after phoning them, they still haven’t got their breast exam, so we are sending a car out today to make sure that it wasn’t for our failure to make sure that they have got their screening exams, that they die of breast cancer.

That kind of community-based responsibility in aligning payment around that I think is key for a system to really work; I know we have the most mal-aligned system in the world --

David Harlow:  Yes, it clearly needs a lot of work --

Paul Grundy:  That’s why we are twice as expensive as anybody in the world. One part of the reason, it's kind of like the Olympics a few years ago, where we got the very best players in the world and we have a really good well trained physicians here.  We have really excellent hospitals, medical schools etc., and we put them on the court, the basketball players, and we got whipped – right? – by somebody, I can’t remember who it was, but mainly the fact was we didn’t play together as a team, we couldn’t throw the ball.  I mean, that’s what happens every day in our health care delivery system, we have nobody, nobody, coordinating care.  I mean somebody can have five specialists and you know one’s doing the exact opposite of what the other is doing and nobody is talking to each other, right?; it’s really dangerous.

David Harlow:  Right. So you’ve alluded to some of your experiences and what you have seen in other places around the world and I know you had a lot of other experiences around the world in earlier parts of your career and I am wondering which of these examples that you’ve seen or other experiences from your past do you particularly draw on and look at in developing this model further.

Paul Grundy:  Well, this is not even around the world, it's here as well.  I mean, one of the major systems here in United States that's really driven a lot of inefficiency out of the systems - the  Veterans’ Administration - they moved from a basically hospital-based system to an outpatient, primary care based system with clinics, 700 or so locations around the county, really with the focus on comprehensive integrated care and just drove tremendous efficiency and resulted in the highest patient satisfaction of any of our health care delivery systems in the United States.

A phenomenal change given my experience in training in their hospitals earlier in my career and if you look at, and if you look at other models of care here like Geisinger and Kaiser, some of the integrated systems, they really do well - the statistics show that if you are in a integrated system where somebody just pays enough attention to make sure that you take your aspirin, that your blood pressure is controlled and you take your Lipitor, or your lipid lowering agents that you know you have one third less likelihood of having a myocardial infarction than somebody age- adjusted in a system where nobody is coordinating your care.  It's a phenomenal difference.  I mean we have twice as many heart surgeons and heart surgeries in this country and I think you know part of the reason why we need to is that we fail to provide robust primary care and prevention.  

If you want to look globally at systems that are really taking this model I would have to say first that in my looking and studying and reading about this, it's really an American model that sort of went global.  It's kind of the like the Japanese model that came back to America and when they asked where it came from they said it’s the Wharton school of business, right?  The Danes came here under a Harkness fellowship and the Commonwealth Fund, studied what was going on at Kaiser, read the pediatric literature about medical home kind of went back to Denmark and designed a system and they really focused on that and you know they are one of the few countries in the world --

David Harlow:  They actually did it?

Paul Grundy:  They actually did it: one of the few countries in the world that actually has a curve of cost trends downward, I mean downward - not go-broke upward like our system is - downward and again it's not very hard, it's not very difficult, it was putting money into the front end of this system developing a robust system of prevention and primary care, putting the technology and the tools to really do more effective management at the level of the doctor-patient relationship in the primary care delivery system.  Spain is gone from being 19th in the world to fourth with the same transformation; in the meantime, according to the study in Health Affairs that I’ve read we’ve gone to 19th of 19 developed economies, dead last.

David Harlow:  Yeah so it’s troubling. So do you see an opportunity and a role for government-led health reform along these lines? What you have been describing to me is really private-payor-driven and integrated-delivery-system-driven developments in the direction of the patient-centered medical home. Is the job done? Is the job close to being done? Do we need the government to step in?  How can it help?

Paul Grundy:  Well to be frank and blunt, absolutely honestly, that’s the kinds of dialogue we’ve had at the level of the White House in the recent roundtable where we were discussing this and in fact I’m in Washington today visiting some of the folks on the Hill about this. Why?  Because how health care is delivered in our country is so dependent on how CMS buys health care, I mean that’s 50 percent of the spend --

David Harlow:  Sure, as the biggest buyer, yeah --

Paul Grundy:  Yeah, so when we try to buy health care and we don’t buy it in a model of health care that’s around how CMS buys it, it makes it very difficult for us, the non-government buyer.  We can buy it in integrated systems but that only accounts for about 6 percent of the places where we can buy, right?  Much of the country, even if I tried I couldn’t buy the kind of care that’s available at Geisinger, I just can’t buy it --

David Harlow:  Right, let’s have the systems in place --

Paul Grundy:  So we have to help virtualize what those guys do, look at what they do and virtualize it -- that’s Health 2.0, that’s, taking a primary care doc and helping him have the kinds of tools that would allow a simple registry -- the ability to track diseases -- the ability to be compensated for tracking diseases, the ability for payment reform to occur, where they actually get paid for having an e-mail, an asynchronous conversation with my patients to do follow up, they are only paid now for face-to-face encounters and the reason why they are paid that way is because that’s how Medicare buys, right?  That’s, that’s my dilemma, that’s all of our dilemma.

David Harlow:  Right, and there are certainly demonstrations looking at bits and pieces of this, and there is hope …. For example, in my home state, Massachusetts, we’re looking at a global payment transition over the next five years.

Paul Grundy:  Yeah, Massachusetts is doing some very exciting things and I think there is quite a bit of interest in the medical home there.  I was just recently meeting with some of the leadership on this in the state and there is a lot of excitement on the one hand, and the other hand they are closing primary care training programs at Harvard.  It’s very interesting, but what our system values, what they pay a lot of money for, is procedures and not for the kinds of relationship-based care, the kind of healing arts, that prevent procedures from being necessary.

David Harlow:  Right, and as you say, we really need to reform that at a more global level --

Paul Grundy:  Yeah, that’s going to take a national effort and that’s going to take a real emphasis on priorities but other countries have done it, and in having done that they are very successful.  I mean the VA has done it, right?

David Harlow:  Yes, yeah that’s really transformed the VA --.

Paul Grundy:  I mean they are continuing to look at improving it as we speak but I mean the amount of progress they’ve made is phenomenal.

David Harlow:  Yes, so you mentioned the White House roundtable.  I wanted to ask about that did you find that to be a productive encounter?  Did you feel that folks were listening? And in your current visit, do you feel that there is an opportunity to make an impact?

Paul Grundy:  Absolutely.  I think there is a great deal of interest -- the video’s out there on C-Span or you can YouTube White House roundtable and find it -- but what they really did was present seven or eight of these early pilots and some of the results and then had a conversation around it and I think that the White House came away with the realization that there was a whole lot more happening on the ground than they even were aware of -- and they were aware of a lot – and, by the way, on the political spectrum there is interest in this, this whole transformation which is different than reformation on both sides of the aisle, I mean Grassley has been very supportive of it in recent meetings that we have with him in Iowa, Hatch in Utah has been extremely supportive of it.

There are medical home pilots that are going on at the Medicaid level in just about every state and so regardless of whether they are red or blue states this whole drive for transformation is really got a lot of steam.

David Harlow:  So what’s your prognosis, Paul?  Do you think that in five years from now, do you think this will be more fully diffused through the country?  Do you think we need national legislation in order to implement this --

Paul Grundy:  Well I think we first of all we are getting national legislation, because there is language in both the Senate and House around this.  I think certainly the White House sees the importance of more robust primary care and prevention, which is really what we are talking about, with the technology underneath to drive it, and I think in five years we will have a much clearer picture of the value of this in non-integrated systems.  I think in five years we will have a very clear picture of it in integrated systems, where already we are getting to see the evidence of that, you know and I think we’ll be in a place perhaps of some desperation -- given the Massachusetts experience of reformation without transformation -- i.e., more folks that need primary care without access to it, because the infrastructure is not in place to deliver it effectively.

David Harlow:  Well, thank you very much, Paul. I wonder, before we wrap up, if there is anything else that you like to share with us today about the state of the art, or your vision for the future of the patient-centered medical home.

Paul Grundy:  I think you covered it very well.  I have a sense of real optimism.  I am a glass- half-full kind of guy and I have a sense of real optimism that we are really beginning to see some transformation at the ground level and that physicians and the patients in practices where this has happened are happier patients, happier physicians and more effective care turns out to be actually cheaper care or more valuable care.

David Harlow:  Right -- and hopefully nobody can argue with that.  Well you've heard it here, folks:  Dr. Paul Grundy, glass-half-full kind of guy, speaking with us today. He is the President of the Patient-Centered Primary Care Collaborative and Director of Healthcare for IBM Global Wellbeing and Health Benefits.  Paul, I appreciate you taking the time to speak with us today, thank you very much.

Paul Grundy:  Thank you very much, it's only a pleasure.

August 11, 2009

Chronic disease prevention and management: How the health reform bills measure up, and how medical home models can help

Ken Thorpe's Partnership to Fight Chronic Disease released a report today providing a side-by-side comparison of leading health reform bills' approaches to chronic disease prevention and management.  From the website linking to the report: 

The publication, "Hitting the 'Bulls-eye' in Health Reform: Controlling Chronic Disease to Reduce Cost and Improve Quality," offers five recommendations for how Congress could better improve quality and reduce spending over the long-term:
  • Roll out evidence-based models for nationwide coordination of care in Medicare within the next three years;
  • Immediately expand the types of treatments in Medicare that would be paid on a "value," not "volume," basis;
  • Aggressively promote chronic disease prevention in the traditional health care system and beyond;
  • Remove barriers patients face to avert the development and progression of chronic illness; and,
  • Move from a paper-based system to a high-tech system that helps to coordinate care.

OK, we get it.  Ken also participated in the latest White House health care roundtable (this, a medical home discussion around tables arranged in a square ...).

Since chronic disease accounts for 75% of our health care spend, it is reasonable to focus our collective energy on improving prevention and management of chronic conditions.  One of the best approaches to date is the medical home model, and a number of different approaches to implementing this model from around the country were presented at the recent White House roundtable.  The Joint Principles of the Patient Centered Medical Home (PCMH), a 2 1/2 year old consensus document produced by several medical societies, is a key starting point for any discussion of medical home implementation.

As Thorpe noted on a conference call accompanying the release of the report today, the various bills wending their way through Congress address the medical home concept, allocating as much as $1.5 billion over 5 years (in the most generous of the bills).  Thorpe suggests that a $25-30 billion commitment over ten years could yield $100 billion in savings by reducing expenses related to hospital readmissions (though I must point out that if bundled payments for episodes of illness are phased in, these readmissions would not be separately reimbursed, so this savings figure is perhaps not the best argument in favor of medical home funding).

The American Academy of Family Physicians announced the launch of its own social networking site today.
  TransforMED, an AAFP subsidiary, is promoting the service as a means for its members (MDs, PAs, NPS and physician office staff) to help primary care practices adopt the PCMH model.

Earlier today, I saw a demo of the site and heard a testimonial from an early adopter doc, and it seems that this could be a useful tool in disseminating information to far-flung smaller practices interested in adopting some or all of the approaches subsumed within the PCMH concept.

The key issue right now, of course, is who will pay for all this care coordination goodness?  Federal demos are a year or so away, and will be time-limited.  Some integrated and employed-physician systems (the Geisingers and Group Healths of the world) are funding this internally, and as their positive experiences are better understood, payors will be more willing to help foot the bill, understanding that there is a potential ROI on the order of 200-400%.  Key issue for the future: Who gets to pocket the change?

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

July 15, 2009

Red Flags Rule: The FTC piles on, because HIPAA, ARRA and overlapping state laws just weren't enough

Update 5/28/10:  Red Flags? Nah ... nothin' but blue skies.  The FTC delays implementation of the Red Flags Rule yet again, to December 31.

Update 11/3/09:  The FTC announced that implementation of the Red Flags Rule will be delayed once more, this time until June 1, 2010.  The announcement came on the heels of losing a court case to the American Bar Association -- the court ruled that the rule does not apply to lawyers -- and on the heels of a legislative attempt to bar its applicability to small health care, accounting and legal practices.  Stay tuned.  

Update 7/29/09:  The FTC announced today that implementation of the Red Flags Rule will be delayed once again, this time til November 1, 2009.  The agency promises to roll out additional information targeted at low-risk entities covered under the rule.  Thus far, nothing has changed with respect to the rule and its ultimate effect, so organizations subject to the rule should take the extra time to assess their compliance needs and implement their plans in advance of November 1.

After a couple of delays, the FTC Red Flags Rule will be effective August 1, 2009.  This rule requires "creditors" under certain "covered accounts" to maintain a heightened alertness to numerous categories of "red flags" that may indicate that the consumer who is the rightful account holder is the victim of identity theft.  If a red flag is triggered, the creditor must take steps to notify the consumer and correct any inappropriate information included the creditor's records.

As you probably already know, the FTC is extending its reach with this rule (among others) into the health care sector.  (Cf. the FTC's role in enforcing certain Son of HIPAA provisions.)  The AMA has all but dropped a draft complaint on the FTC's desk, citing assorted legal precedents in its correspondence with the FTC arguing that the Red Flags Rule should not apply to physician practices.  The FTC is unmoved -- except to the extent that it has been willing to delay the effective date twice (from November 2008 to May 2009 to August 2009).

At any rate, the August 1 effective date is around the corner, and affected health care entities need to develop and implement compliance plans now, if they haven't already.  (Even the AMA says so, and has published guidance and a sample policy for members.)

A few more general comments before stepping back and examining the language of the rule and its applicability to health care providers.

The federales are taking something of a common-sense approach here, recognizing that a compliance plan needs to be tailored to the specific entity, the nature of its "covered accounts" and its operations.  Bank of America, N.A. and Springfield Medical Associates, P.C. will have very different compliance plans, because their potential red flags and the potential risks are vastly different.

Affected health care providers need to understand that the Red Flag Rule requirements overlap with HIPAA and state privacy law requirements (and looming Son of HIPAA requirements in ARRA), but will not be satisfied by implementation of existing privacy policies and compliance plans.  Review of the intersection of existing policies and procedures with the new rule's requirements is the first order of business.

As with any other new regulatory scheme, preparing a compliance plan and putting it on the shelf won't cut it.  The rule calls for regular monitoring of the plan and issues that arise by a senior manager.  Furthermore, best practices would dictate the training of staff to deal with individual issues and, most importantly, with the affected consumers.

Even if not clearly subject to the Red Flags Rule, providers should undertake to comply, for a couple of interrelated reasons:

  • Good patient PR.  Data security is top of mind these days.  Much of the effort required under the rule should be expended anyway simply to respond to market pressures calling for improved data security.
  • Potential liability.  The creative trial attorney will seek to use the Red Flags Rule as establishing a standard of care for the stewardship of personal information.  The incensed jury will go along.  The health care provider caught in the middle between thieves and victims may be the only perceived deep pocket available.

OK, so what is a "creditor" and what is a "covered account?"

Any entity that accepts payment other than payment in full at the time of service is a creditor.  Health care providers that go the cash-on-the-barrelhead route aren't creditors; all others are creditors.

The FTC Guide defines covered accounts as follows: either

  • a consumer account you offer your customers that’s primarily for personal, family, or household purposes that involves or is designed to permit multiple payments or transactions; or
  • any other account that a financial institution or creditor offers or maintains for which there is a reasonably foreseeable risk to customers or to the safety and soundness of the financial institution or creditor from identity theft, including financial, operational, compliance, reputation, or litigation risks.” Examples include small business accounts, sole proprietorship accounts, or single transaction consumer accounts that may be vulnerable to identity theft. Unlike consumer accounts designed to permit multiple payments or transactions – they always are “covered accounts” under the Rule – other types of accounts are “covered accounts” only if the risk of identity theft is reasonably foreseeable.

Any creditor with covered accounts must have a red flags rule compliance plan in place with policies and procedures for dealing with "red flags" -- i.e., signs that personal information may have been compromised.  The World Privacy Forum suggests that the following red flags are the ones most applicable in the health care context:

• A complaint or question from a patient based on the patient’s receipt of:
   o a bill for another individual
   o a bill for a product or service that the patient denies receiving
   o a bill from a health care provider that the patient never patronized or
   o a notice of insurance benefits (or Explanation of Benefits) for health services never received.
• Records showing medical treatment that is inconsistent with a physical examination or with a medical history as reported by the patient.
• A complaint or question from a patient about the receipt of a collection notice from a bill collector.
• A patient or insurance company report that coverage for legitimate hospital stays is denied because insurance benefits have been depleted or a lifetime cap has been reached.
• A complaint or question from a patient about information added to a credit report by a health care provider or insurer.
• A dispute of a bill by a patient who claims to be the victim of any type of identity theft.
• A patient who has an insurance number but never produces an insurance card or other physical documentation of insurance.
• A notice or inquiry from an insurance fraud investigator for a private insurance company or a law enforcement agency.

If a situation is flagged, a creditor must take steps to mitigate the risk of identity theft or continued identity theft.  Again, the World Privacy Forum notes:

There need to be uniform but appropriately flexible answers to these questions:

  • What do we do when a patient claims fraud is in their files?
  • What do we do when a patient says the bills are for services she did not receive?
  • What do we do for patients and other impacted victims when we uncover a fraudulent operation?
  • When we have a real case of medical identity theft, how can we work with patients to fix the records and limit future damages?
  • What do we do when a provider has altered the patient records?
  • How do we handle police reports and requests for investigation from victims?

The answers to these questions need to viewed not just from the provider’s perspective, but also from the victim’s perspective, which can differ substantially.

There are a number of useful resources available for health care providers seeking to take stock of their situation, establish Red Flags Rule compliance policies and procedures, and undertake staff training on the subject.  For example, the FTC, the AMA and the World Privacy Forum have all released valuable guidance documents (all linked to above) that would assist any organization with coming into compliance. 

As with any effort of this sort, it is often valuable to have someone outside the organization come in to review existing policies, procedures and workflow in order to highlight potential risks and opportunities for improvement.  The HealthBlawger and members of the HealthBlawger's virtual consulting network are available to come in and assess, plan and help implement compliance strategies for organizations large and small touched by the Red Flags Rule.

Whatever the size or nature of your business, please take a moment to consider how the Red Flags Rule may apply to its operations, and how it may relate to other regulatory schemes such as HIPAA and state laws.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

May 28, 2009

Retail Health Clinic Summit: Can we get there from here?

At one of the pre-summit workshops yesterday, Tom Charland (ex-MinuteClinic exec and now consultant) channeled Clay Christensen (Mr. Disruptive Innovation) for a while and laid it on the line: unless retail clinics find a way to beef up off-season volume for at least 5-6 years, they may be dead in the water.  In that time, if Christiansen is right, HSA/HDHPs will become much more prevalent than they are today -- prevalent enough so that retail clinics could safely opt out of health insurance plan provider networks and have a sufficient patient base to draw from.

In the interim, Tom and I agree that retail health clinics need to break out of current operating modes, particularly into chronic care / disease management.  In fact, I was quoted on this point towards the end of a thoughtful piece on retail health clinics in BNA's Health Care Policy Report last month.  Retail clinic providers (including one from Spain), other consultants, payor representatives, drug and device reps, urgent care center operators, and even the US Armed Forces (planning a pilot project foray into retail health clinics) all showed up for the Summit, which provided a mix of perspectives on challenges and opportunities facing this nascent industry.

Slides from my talk at the summit on the Massachusetts experience, and lessons for the future  -- especially the need to move into chronic care and to partner more effectively with health care systems -- are provided here for your viewing pleasure.  My work with all components of health care systems -- including physicians -- makes clear that these combinations have the potential to be very powerful, and makes equally clear that the groundwork must be laid carefully with physician partners and champions in order to ensure the success of such an undertaking.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 19, 2009

Health Wonk Review: Spring has just about sprung

Michaels S C Welcome to Health Wonk Review, where everyone is above average.  We enjoy above-average health care costs per capita, above-average uninsured rates, and above-average obsession with health care reform.  That's what it's like today in America.  Our president has said, Change has come to America.  In the words of Robert Hayden's [American Journal]:

america     as much a problem in metaphysics as
it is a nation earthly entity an iota in our
galaxy     an organism that changes even as i
examine it     fact and fantasy never twice the
same     so many variables

Like Schrodinger's cat, America's health care system seems to change in the changing light as we examine it; one thing we can all agree on is that it needs some work. 

Franz Kline Steve Martin We begin with some broad brush strokes on form and amount of spending:

Len Nichols presents HEALTH REFORM: Moving Past the Impasse on the Public Plan | New America Blogs posted at New Health Dialogue

Maggie Mahar presents Health Beat: Thinking About Dr. Atul Gawande’s Congressional Testimony Part 1: Why Health Care Reform Will Require Additional Spending at Health Beat.

Lewis Hine Mechanic One cost, no matter what the payment system, is labor.  Lynn Nicholas, President of the Massachusetts Hospital Association writes about some pending changes to labor laws that might make it easier for labor to unionize, presenting the favored position of a non-union shop as one of worker, rather than employer, preference.  See Keeping Communication Lines Open in the Healthcare Labor Debate at CommonHealth, the Massachusetts health care reform blog of WBUR (a Boston NPR affiliate).

Who Will Pay for Prescription Drugs? asks Adam Fein at Drug Channels. CMS projections show that the government will have a very strong hand in managing retail drug spending and shaping the future of drug channels.  How will that affect pricing and R&D?  Richard Fogoros (DrRich) presents A Brilliant Plan For Preserving Pharmaceutical Progress at The Covert Rationing Blog, saying, The title says it all. Can we have our cake (drug price controls) and eat it too (continue drug innovation)? DrRich says, yes we can!  Check out his proposal.

Pills My dad used to say he wanted to listen to a radio station that broadcast only good news (not Good News, just good news).  Merrill Goozner, of GoozNews, suggests this week that there ought to be a journal dedicated solely to publishing negative results -- as soon as they're known -- as he is all hopped up due to delayed publication and/or suppression of data on adverse effects of drugs.  These issues in general, and a couple of current cases he discusses, have policy implications for the new leadership at the FDA.

At InsureBlog, Mike Feehan has a piece on Wellpoint's recent spinning off of its in-house PBM, About Wellpoint's PBM Auction, and future implications for prescription costs.


Ill and Uninsured in Illinois gives us a simple but eloquent presentation of the difficulty of accessing specialty care while uninsured: The Wait for Cook County Health Care.

At the other end of the spectrum, Health Access WeBlog's Beth Capell asks What are gold-plated benefits anyway? An interesting question, now that the president has indicated that he is open to signing a bill including taxation of health benefits.  (As an aside, Obama's approach -- White House Health Care Summit with stunning transparency, concluded with an invitation to Congress to send him a bill consistent with the policies he articulated throughout the campaign -- is both a refreshing change from the Clinton years and a strategy likely to insulate him from criticism on the exact contours of the plan when it reaches his desk.)

Mao_tse_tungJared Rhoads presents Less government, not more at The Lucidicus Project, discussing the recent report by Physicians for a National Health Plan (the single payor proponents).  I spoke with PNHP's David Himmelstein a little while back, and while he has a compelling argument for adopting a single-payor plan in this country (the savings would be impressive), I still believe that the more pragmatic approach is to make incremental changes in the system before us. 

Taking our cue from Dr. Himmelstein, we begin a bit of a grand tour by visiting our neighbor to the north. 

North of the border, Sam Solomon asks Can Canadian doctors fire their patients? at Canadian Medicine, and says in short, yes, but carefully.

At BNET Healthcare, Ken Terry writes that Massachusetts Needs to Deal With Primary Care Crisis, saying that while proponents of the healthcare reform program in Massachusetts tout it as a model for the entire country, and detractors point to the program's rapidly rising costs, neither side is really focusing on the need for better access to primary care in the state. He also observes that retail clinics are expanding in Massachusetts, and community health centers are pulling in federal cash for expansion.  One observation: retail clinics in Massachusetts are not currently expanding as they cannot find nurse pratitioners to hire.  Also, on a national level, Minute Clinic recently shuttered 90 sites for the season.  Even if they were growing, they are no substitute for primary care.

Looking at a new model of physician practice -- available 24/7, untethered to most of the traditional trappings of a physician practice (including that old-fashioned trope of accepting insurance payments), Ted Eytan, MD is Now Reading: Take Two Aspirin And Tweet Me In The Morning: How Twitter, Facebook, And Other Social Media Are Reshaping Health Care.

Great_Dictator_globe_scene_academy_print_bigGrrlScientist shares her overseas medicine story, Finnish Emergency Medicine: One American's Experience at Living the Scientific Life.  Seemed to work well for her without instantaneous contact back home.  (See my own tale of a close ecounter with an overseas health care system last year as well.)

Here at HealthBlawg, I recently interviewed the CEO of Satori World Medical, a medical tourism company that offers a twist: through an HRA, it funds patients' future years' insurance premiums with a portion of the savings their employers or insurers enjoy as a result of their overseas medical procedures.

Closer to home, many doctors are now leery of online ratings sites, and have started using a service, Medical Justice, to get patients to agree not to post negative reviews as a condition of being taken on as patients.  Dmitriy at Trusted.MD has been following this issue for a while and offers some insights.

Marx Brothers (A Day at the Races)_04_scrubbed_in Jaan Sidorov presents The Worrisome Outpatient Trend: What Does Disease Management Have to Offer? posted at Disease Management Care Blog.  Chronic care consumes 75% of the health care dollar in this country, and needs to be better managed.  Outpatient chronic care is a significant part of the equation.

Care management is also the theme of Julie Ferguson's post on The effect of obesity and other comorbidities on workers comp at Workers' Comp Insider.  In light of a new report which shows that workers comp medical claims can cost three times as much when the injured employee is obese, she makes the case for breaking down the silos between employer-based occupational health and general health programs.

David Williams' post on Wal-Mart and eClinicalWorks over at Health Business Blog concludes with a healthy bit of skepticism about this new EHR offering to small physician practices.

Using the cost per doc put out by Wal-Mart, John Moore does some calculations, and shows in his post The HITECH Challenge: Is $19B Enough to Drive HIT Adoption at Chilmark Research that docs getting wired and getting HITECH incentive dollars will be engaged in a money-losing proposition -- they'd actually be better off financially not implementing EHRs and getting hit with the penalty a few years down the road. 

Speaking of Wal-Mart, it bears mentioning that this day in history marks the anniversary of the Civil War Battle of Bentonville (No, not that Bentonville; the battle was in North Carolina.)

Tinker Ready, at Boston Health News, shares some insights from John Glaser, CIO of Partners Healthcare, on getting HIT right.

Shahid N. Shah presents Client/Server vs. ASP/Web-Based in Healthcare IT posted at The Healthcare IT Guy, since with the HITECH Act and stimulus bill making news, many users are asking if they should purchase software and use it on premises or if they should use a "cloud" package or an ASP/web-based solution.

Metropolis5 In addition to jump-starting HIT, current legislation is giving a boost to research funding.  One pot of funds is time-limited; Glenn Laffel looks at Beaker Ready projects ready for NIH funding at Pizaazz.

Jason Shafrin reviews some of the pros and cons of establishing a government body to conduct cost effectiveness research in Should the U.S. get NICE? at Healthcare Economist.

In The Color of Money: What Sort of School Doesn't Pay Its Faculty to Teach? Roy Poses at Health Care Renewal puts academic medicine on the spot, saying that some leaders have abandoned core missions in favor of collecting "taxes" from medical faculty, which makes faculty more dependent on commercial interests.  Strong words indeed, and an issue that needs to be rolled out front and center together with other payment issues if there is to be a wholesale revamping of health care financing in this country.

For those brave enough to enter the land of credit default swaps, Joe Paduda, at Managed Care Matters, examines the reasons for propping up AIG and why it may fail anyway.

And finally, to leave you with some doom and gloom from The Health Care Blog to ponder, Brian Klepper and David Kibbe ask Is the healthcare economy rightsizing?

Thanks for visiting HealthBlawg for this edition.  Please see me on twitter too, and join us again next time for Health Wonk Review.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting