Saturday, December 19, 2009
Assuming the Senate passes a bill, the next procedure would be for the House and Senate to attempt to reconcile the bills. This is far from over.
Tuesday, December 15, 2009
Monday, November 23, 2009
CER is the darling of the government-dominated health reform movement (not a government take-over, to be clear). The use of evidence-based medicine when combined with cost-benefit analysis has the potential to save a great deal of money while better serving the patients. Many see downsides though; too rigid protocols and interference with physician judgment, or the dirty "R" word, rationing.
The U.S. Preventive Services Task Force recently released a study on various breast cancer screening modalities, recommending more limited screening protocols, particularly delaying routine mammography until age 50 (except in women with unusual risk factors).
Kah – boom!
USPSTF points out film mammography does cut mortality, with the greatest reductions in women over 50, with the best results in the age 60 – 69 cohort. Film mammography does carry a risk of false positives and the pain and inconvenience of unnecessary biopsies.
USPSTF also recommends ceasing mammography on women over 74, citing a lack of reliable evidence of reduced mortality.
There was a huge backlash from women, physicians, cancer activists and some health care associations.
USPSTF also recommends against teaching women to perform ”breast self-exam” (BSE) which has been a standard tool for decades. More backlash.
USPSTF does point out that digital and MRI mammography do not show, at this time, significant improvement over film mammography, but do have greater costs.
None of the conclusion appear to have been made on strong and startling statistics, but on think pros and cons, as one might expect from quants and scientists.
Women apparently want a little less quant and a lot more consideration.
Thursday, November 19, 2009
Thursday, October 29, 2009
The Blade (Toledo) reports on October 28th an imaging technician was arrested in Ohio for driving infractions and possession of marijuana.
During the arrest the police scanned his cell phone.
In his phone were photos of dozens of partially clad patients preparing for imaging tests, including minors.
The penalties and lawsuits are likely to be massive.
Thursday, October 1, 2009
Tuesday, September 29, 2009
Senator Baucus has been in the lead in the Senate, but his opposition to the public plan (he thinks the plan, whatever the merits, would kill the bill) has irritated some senior members of his own party.
Thursday, September 10, 2009
First impressions - the numbers do not add up.
And every President since Nixon has promised to reduce "waste, fraud and abuse" from Medicare and Medicaid.
Wednesday, August 26, 2009
Some business organizations are using these social networks, some not, but either way it is a good bet your employees are using these sites to connect with and expand their social networks.
That can be a huge problem!
Employees used to flashing every aspect of their lives on-line are very likely to discuss work on-line as well.
Social networks sites create a huge risk for HIPAA violations, and also for employee problems (some of the comments posted can be incredibly vicious),
HIPAA is 24/7!
No, you cannot control your employees lives, EXCEPT as it relates to work.
Every health care organization should develop policies and procedures on the use of social networking sites for the broadcast of work related information. Soon.
Wednesday, August 12, 2009
Many see the progressive left pushing a gradual move to the Doomsday Scenario, something like this:
1) private health insurance is hyper-regulated, underwriting standards are eliminated, and premium costs rise astronomically
2) employers, especially smaller employers, drop coverage and push employees to the “public plan”
3) the resulting dislocation of coverage and expansion of the public plan becomes a rationale for single payer – “see, we told you so.”
Having read thousands of pages of reform material over the past 18 months, and having studied the various reform movements since the early 90s, I think the Doomsday Scenario is quite feasible, and certainly I wouldn’t put it past the progressive left.
In public President Obama emphatically denies any such scenario. However, if the Scenario were to evolve, would he revert to his earlier ideas on single payer?
My request is for an honest debate. If Obama really wants to move to single payer, he should say so, and let the real debate begin.
For now, expect fireworks (not excusing rude behavior by the way).
Thursday, July 23, 2009
Question: Can these two models be replicated throughout the country?
Answer: Not likely. Certainly not in the near term.
The Mayo Clinic is unique but has replicated itself a few times, and the Cleveland Clinic is unique and to the best of our knowledge has not been replicated.
Even if these models could be replicated, it is unlikely they could be replicated in any but some urban areas. And if they could, the transition cost in most markets would be immense, and who would pay for that? (the new Mayo Clinics are in high growth and very prosperous areas, Florida and Arizona)
Can we learn anything from these clinics. Possibly yes. Can we duplicate these models in other areas? Not likely, and certainly not in the near term.
Wednesday, July 22, 2009
Saturday, July 4, 2009
1) this is a real dispute
2) this is a clever ruse to allow a compromise that gives political cover to all types of Democrats
3) this is just some foreplay designed to allow Kennedy to be a hero one more time, with serious cred to Baucus, a rising power in the Senate
4) some combination of #1 - #3
Kennedy and Dodd’s latest: http://dodd.senate.gov/?q=node/5062/print
Monday, June 15, 2009
Typical scenario: an elderly patient is admitted to the hospital for pneumonia and related distress. After a four day stay the patient is discharged to a long-term care facility.
A week later the patient is re-admitted with acute distress, after the nurse requests orders from the patient’s physician. After several days the patient is again discharged to the nursing home.
This cycle is very costly to Medicare, and the feds would like to see it slow down.
(Based on conversations with long-term care nurses and reviews of Minimum Data Set (MDS) summaries, the patients are usually very old, very frail, but not at death’s door quite yet.)
One solution is to ‘train” physicians and families not to be so quick to send the patient back to the hospital. This is tough on families, who often pressure the physician to readmit. Sometimes the patient demands readmission, it is easy for the physician to say yes. This can also be tough on the nursing home, where higher acuities are colliding with the nursing shortage.
A proposed solution is bundling. President Obama mentioned it in his 6/15 speech to the AMA. How does it work? The hospital gets a flat fee per incidence and then has to pay the physician, nursing home, ambulance/transport company, physical therapist, etc.
This requires a lot of administrative work and some intense negotiations, and puts the hospital at significant risk.
Could this work? Maybe. Is it good for Medicare? Probably yes. Good for patients? Unknown. Good for physicians? It depends. Good for the nursing home? Doubtful.
Monday, June 8, 2009
In recent days:
- President Obama, in his Saturday radio address, promised to get hands on the issue.
- Senator Kennedy let draft reform legislation float around, creating the appearance that he is stepping in front of Senator Baucus.
- Senator Kennedy and Senator Baucus issue a statement about how well they are going to work together.
- The possible tax on health care benefits bubbles to the surface once again, as do possible taxes on sodas, beer, wine, and other sinful pleasures; other possibilities include taxes on securities dealers, life insurers and elimination of certain estate planning practices.
- President Obama lets it be known he wants to tax the rich, not working people, possibly via deduction caps (Axelrod and Goolsbee floated this trial baloon on the Sunday talking head shows).
- The House is circulating a proposal with an almost mandatory coverage rule, and penalties for anyone with the means who refuses to buy health insurance (?). All non-group policies would be channeled through a federal policy exchange. A spokesmen for Rep. Waxman made clear the circulating drafts are not the official work product of any committee.
More on this as the trial baloons become more official.
Tuesday, June 2, 2009
Economic advisor Christina Romer distributed an op-ed piece today explaining how health care reform would 1) improve family incomes, 2) enhanced GDP, 3) lower budget deficits, 4) lower unemployment, 5) provide greater health care coverage (of course) and a 6) better labor market.
Wow. This is quite a claim.
Full report: http://www.whitehouse.gov/assets/documents/CEA_Health_Care_report.pdf
Thursday, May 28, 2009
President Obama’s ambitious health care reform plans may have run into an immovable object – money.
In order to move forward on his plan the President has to find and/or reallocate something on the order of a trillion dollars or so.
One means of expanding health care coverage while containing health care costs is “efficiency” a fuzzy and hard to predict concept at best, especially while expanding insurance coverage.
Other potential means are been discussed by various constituencies, in no particular order:
Taxing the rich (also discussed to solve the deficit and other problems)
Tax some or all employer-paid health care benefits
Tax all sorts of “sin” products
Broaden the Medicare tax base
Cut payer reimbursements, possibly offset by insuring most Americans
Create new reimbursement systems for providers, perhaps “outcomes based”
Reduce or eliminate the tax sheltering benefits of Flex Savings Arrangements (FSAs)
Alter Health Savings Accounts (HSAs)
A national value added tax (VAT) or sales tax
Accomplishing this in the midst of a nasty and deep national recession may prove to be difficult if not impossible, but it appears Congress is going to move ahead and give it a try in the next few months.
President Obama, on a conference call from Air Force 1 with a coalition of supporters, warned that if health care reform is not accomplished this year it may never be.
(Ed: Never is a long time .......)
Obama is trying to enlist his political organization, Organzing for America, active and engaged in the political process.
Obama is leaving the details of health care reform to Congress, apparently having learned something from the 1993 mistakes of the Clinton administration, which did an end run on Congress.
Wednesday, May 13, 2009
Medicare does cover regular invasive colonoscopies.
The x-ray procedure is a substitute for invasive colonoscopies. It is cheaper and non-invasive, but does involve x-ray radiation.
The invasive colonoscopy allows the surgeons to excise any pre-cancerous polyps found, saving a second procedure.
If the CT colonoscopy finds pre-cancerous growths, then a regular colo must be done to excise the polyps, thus causing two procedures instead of one.
Medicare does point out that the Medicare population, almost all of whom are 65 and over, may not be a good indicator for the under-65 population. Medicare is willing to look at future data.
These are the sorts of dilemmas health insurers must wrestle with. No decision will make everyone happy.
Rationing or evidenced-based medicine? Depends on your point of view.
Tuesday, May 12, 2009
Senators weigh tax hikes to pay for health care
WASHINGTON – Senators are considering limiting — but not eliminating — the tax-free status of employer-provided health benefits to help pay for President Barack Obama's plan to provide coverage to 50 million uninsured Americans.
Finance Committee Chairman Max Baucus, D-Mont., said Tuesday that there are no easy options. Senators began grappling with how to finance guaranteed coverage, a cornerstone of Obama's plan to overhaul the health care system. Independent experts put the costs at about $1.5 trillion over 10 years......
Saturday, May 9, 2009
Over the years this “loophole” has popped up in various discussions of tax fairness and expanding health care coverage.
The Obama administration has floated various trial balloons, and Senator Baucus (D. Montana), an influential player in the health care reform debate, thinks the time for change may have come.
Rep. Charles Rangel (D. New York) a veteran representative and powerful chairman of the House Ways and Means Committee says simply, “no way.” All tax legislation originates in Ways and Means.
Candidate Obama criticized John McCain for proposing the taxation of health insurance benefits, but advisors to President Obama will not close the door, including new DHHS secretary Sebelius.
President Obama needs a major funding source to help close the deficit and to provide a $600M plus health care reserve fund.
Some labor unions fiercely defend the tax break, as middle class union members would be hit hard by a tax on health insurance benefits.
(Using real tax family returns and creating pro formas by adding policy amounts, the tax increase could range from about $1500 - $5000, depending on the structure of the tax, the possible applicability of FICA and Medicare taxes, and the taxation policies of state and local governments.)
In theory, employers would save some money because enhanced government programs would slow or eliminate “cost shifting” from the uninsured to the insured. However, employers might end up paying higher matching FICA taxes. Employees would be unlikely to see any of the savings (if any).
This could be a nasty debate, with some strange bedfellows.
Thursday, May 7, 2009
The hackers are demanding a $10 million ransom for the data, or the data goes on the internet.
Virginia health officials and the FBI believe the threat may be credible.
The future of EMR?
Sunday, April 26, 2009
"WASHINGTON, April 25 - A new and unusual strain of swine flu is likely widespread and impossible to contain at this point, experts agree.
The H1N1 strain has killed at least 20 people and possibly 48 more in Mexico and has been confirmed in at least eight people in the United States, all of whom had mild illness.
Probable cases also were found at a school in the New York City borough of Queens and experts at the U.S. Centers for Disease Control and Prevention say they fully expect to find more cases."
This strain of influenza spreads easily from person to person, has been diagnosed in several places and some victims have had no known contact with carriers. Not pretty.
Thursday, April 9, 2009
Given the targeted patient demographic this might be an interesting test of electronic medical records capability.
Tuesday, April 7, 2009
No program can stop a crazy killer or an armed robber, but training employees to react properly can hasten the arrival of police and the protection of residents.
This should also be a reminder that facilities open 24/7 have special issues with security and safety.
OSHA fact sheet:
Wednesday, March 25, 2009
This follows a similar colonoscopy problem in another region, and another recent problem with ear-nose-throat equipment.
The care standards for these procedures are quite well known, and the number of exposures indicates a serious management problem (as opposed to a batch or two of sterilization problems, which can happen).
Odds of infection should be low, but low is too high for those infected.
The administration proposed that a veteran's care could be billed to a vet's private insurer in some cases, raising $500M a year.
The feedback from veterans' groups and Congress was swift and ugly.
Veterans' feared losing private insurance coverage, and members of Congress proclaimed veterans' care a convenant not to be broken.
The administration moved on to other topics - quickly.
Wednesday, March 11, 2009
Sam's Club and Dell.
Sam's Club will partner with Dell and eClinicWorks for software, hardware, training and maintenance. No joke.
The system will integrate patient appointments and billing (the billing modules are ultra-complex and carry significant risk of major problems).
Wal-Mart has some experience with health care IT, primarily in pharmacy and optometry. WM also has used the software in a limited number of redi-clinic settings (which are much different than a regular physician office).
Does Wal-Mart understand the complexities of physician office operation and the vagaries of dealing with physicians?
The $20B stimulus money had to attract a lot of vendors, this may be the surprise leader of the pack.
Tires, lettuce, underwear, health IT. Such a concept.
Hat tip: International Herald Tribune 3/11/2009
The management issues we want to discuss simply cannot be woven in here.
A new blog, http://practicemanagementnews.blogspot.com/ will focus on management issues and regulatory matters. There will be some cross posting.
Spread the word!
Sunday, March 8, 2009
Proposal: the federal government should channel funds to colleges and universities that provide programs we need, rather than graduating more Ph.D.s in overcrowded disciplines.
Nursing - high stress, bad hours, physical exertion, exacting standards, little respect.
Thursday, March 5, 2009
A patient was given an IV push dose of Phenergan, apparently the administration was done in a negligent manner and the medicine entered an artery, and the patient lost her arm.
As best I can tell there was no allegation that Phenergan, a widely used drug, was hazardous, but that the drug maker Wyeth should have provided better warnings about what could happen if an IV push administration was done improperly.
(I checked with my favorite nurse, who tells me that she doesn't need to be warned not to put an IV into an artery, as she said "what do you think the "V" stands for." Nurses rarely read warning materials on commonly used drugs anyway. Just one opinion. She does administer Phenergan regularly, although not via IV.)
The legal argument?
Wyeth claimed that since the FDA had found Phenergan to be safe and effective, and because the FDA has approved very precise language on the label, there was no duty to provide further warnings and no ability to unilaterally rewrite the warning materials.
SCOTUS says the state could find a duty and that Wyeth could have unilaterally changed the labeling.
So what does label approval by the FDA mean today? How far does the unilateral rewrite authority go? What if the FDA disagrees with the unilateral rewrite.
From a liability standpoint, how much liability should a drug or device maker have for provider malpractice?
Sunday, March 1, 2009
Dirty little secret -- some states use "bed taxes" or "provider taxes" or "provider fees" to generate match money for federal Medicaid funds, a maneuver which is legal but on shaky ethical grounds. This is "dog chases tail" gimmick financing. Who is to blame? Fed reform of Medicaid would help.
A nursing home will pay the "tax" on all licensed days of service, but will be reimbursed for the "tax" only for those days used by Medicaid recipients. This amounts to a tax on all residents not funded by Medicaid, what the federal government calls cost shifting.
When criticized for using stunts and gimmicks to balance the budget (and avoid restructuring the government), Strickland uses the everybody else has done it defense.
To be fair, the states have many difficult budget decisions. This is not a healthy balance budgeting tool, especially after the feds pouring stimulus money into the states.
For more details, excellent reporting in the Columbus Dispatch.
Saturday, February 28, 2009
Friday, February 27, 2009
Sunday, February 22, 2009
(The political theory is private payers will take the lead and refuse to pay for anything not paid for by Medicare and Medicaid.)
Question: if the drugs and procedures are not paid for, and clinicians do not use them, how do we compile the evidence of effectiveness?
For drugs we do have clinical trials, but many physicians are more convinced when they see the effectiveness in clinical practice.
For surgical techniques and hardware, most progress has been made with years of trial and refinement (such as the immense progress in orthopedic joint replacement).
Will we slow innovation? How will we balance cost versus progress?
Who is spearheading the "effectiveness review" concept inside the Obama administration?
Peter R. Orszag.
Orszag is Director of the Office of Management Budget for the Obama administration.
By all accounts he is a brilliant economist, and an expert on retirement issues.
Best I can determine, he has little or no background in health care.
We love economists here, but wonder about health care reform being driven by economists.
Time will tell.
Update: Apparently Orszag did some HMO consulting during a stint with McKinsey and Co.,
More than 200 of those pages are health care reform, including a massive health care IT plan.
How much time was spent debating the largest health care reform plan of the past two decades?
Also included are updates on HIPAA security and privacy, and perhaps the provisions that will shape the future of U.S. health care, the "effectiveness review" plan. I just reread Tom Daschle's book, and his brief stint as almost-Secretary allowed him to have immense influence.
In front of me is a full 3" ring binder, perhaps containing the future of our health care system, perhaps not.
First, a few days with the grandchildren. Then, the work continues in earnest.
Update: I was curious. Printed in pieces from the Thomas site, I have 261 pages.
Saturday, February 14, 2009
Printing the health care sections nearly burned up my printer.
Look for analysis coming almost every day.
Surprise - Congress revisited HIPAA, just to add work and confusion to the situation.
Tuesday, February 10, 2009
This is still developing.
In brief, Daschle wanted massive government data bases of patient information combined with a board to determine which treatments and medications physicians could order for government patients.
More as this develops.
Saturday, February 7, 2009
Sebelius had reportedly been considered for this and other cabinet posts before Tom Daschle was slotted for DHHS. Daschle melted down in a tax controversy.
Sebelius was Insurance Commissioner before becoming Governor, a back ground that would be helpful in the job.
Sebelius has deep roots in the Democratic Party, her father was a liberal Governor of Ohio.
This appointment is not assured. Stay tuned.
Tuesday, February 3, 2009
Sunday, February 1, 2009
Daschle was working as a $1M a year "consultant" to a media private equity fund run by his friend, and receiving free car service, a very substantial benefit in Manhattan's gridlock.
Reports say on one return Daschle forgot an $89k consulting payment, as it was excluded from his Form 1099 (how does an accountant not multiply 89 x 12?).
The Daschle's paid the back taxes this year with interest, but are also reported beneficiaries of a special influential insider penalty waiver by the IRS (how sweet).
Time will tell.
UPDATE: The Daschles may have to re-amend their tax returns. Developing....
In other (better) news.....
Professor David Cutler of Harvard, an influential voice in health care reform discussions, has been selected to serve as a health care advisor to President Obama.
Monday, January 26, 2009
The Federal Health Board, modeled after the Federal Reserve Board, would initially be directed at the federal government programs, but Daschle makes it clear that with enough influence the FHB would assert signficiant control over the entire U.S. health care system.
"I believe a Federal Health Board should be charged with establishing the system's framework and filling in most of the details. This independent board would be insulated from political pressure [emphasis mine] and, at the same time, accountable to elected officials and the American people. This would make it capable of making the complex decisions inherent in promoting health system performance. It also would give it the flexibility to make tough changes that have eluded Congress in the past." (page 169)
"The Federal Health Board would have regional boards that would have a say in national decisions, but would focus primarily on promoting best practices and quality of care locally...... Over time, the regional boards might assume other roles, such as ensuring an adequate supply of certain services or linking payments to performance....." (page 170)
Next post, the five functions of the proposed FHB.
Saturday, January 24, 2009
Given Daschle's major influence in the new administration, I am studying the book to look for insights into possible reform plans.
(Daschle has been working at a DC law firm which also does lobbying, but Daschle was apparently kept insulated from the lobbying operation.)
We open with something v-e-r-y interesting. From the dustcover....
"Daschle's solution lies in the Federal Reserve Board, which has overseen the equally complicated financial system with great success. A Fed-like board would offer a public framework within which a private health care system can operate more effectively and more efficiently - ...."
To be fair to Daschle, I believe this book was written before the current financial meltdown, but this concept is a little scary. More in the next post.
Critical: What We Can do About the Health-Care Crisis - Daschle, Greenberger, Lambrew, Thomas Dunne Books, St. Martin's Press, 2008
Saturday, January 17, 2009
The current set of outpatient diagnoses codes, the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) will be replaced by the tenth edition (ICD-10-CM). Physician practices and others must begin submitting ICD-10-CM diagnoses codes by Oct. 1, 2013.
Administrative transactions standards
CMS released the final rule mandating the latest set of administrative transactions standards as part of the Health Insurance Portability and Accountability Act (HIPAA). The ASC X12N 5010 standards replace the current ASC X12N 4010A1 version of the electronic transactions standards. CMS has set Jan.1, 2012, as the compliance date for the 5010 standards.
These will require an immense amount of work by provider and tech geeks to make this work.
The government's attempts to make health care billing totally incomprehensible continue apace.
(Sources include Modern Healthcare and the Medical Group Management Association.)
Thursday, January 8, 2009
I have picked up Daschle's book and will have a post on that soon.
The usual preening by Senators, followed by Daschle's assurances that he can fix any problem.