Category Archives: healthcare

complex adaptive systems, data saving lives, EF, health market quality, healthcare, healthy habits, nutrition, policy, politics, quantified self, rapid learning health systems

Creating a Market for Disease Prevention

 

http://thevitalityinstitute.org/news/focus-on-pharma-creating-a-market-for-disease-prevention/

Focus on Pharma: Creating a Market for Disease Prevention

SustainAbility Newsletter “Radar” | Oct 30, 2014

Should pharmaceutical companies be in the business of producing pills, or of making people well? The answer is both. Elvira Thissen argues that with diminishing returns in medicines it is time for pharma companies to move away from philosophical discussions on prevention and adapt to new realities instead.

[…]

The Business Case for Prevention

A recent report by The Vitality Institute – founded by South Africa’s largest health insurance company – estimates potential annual savings in the US of $217–303 billion on healthcare costs by 2023 if evidence-based approaches to NCD prevention are rolled out.

At an estimated global cost of illness of nearly US$1.4 trillion in 2010 for cardiovascular disease and diabetes alone, there is a market for prevention. In the UK, the NHS spends 10% of its budget on treating diabetes, 80% of which goes to managing (partly preventable) complications. Reducing disease incidence represents a considerable value to governments, insurance companies and employers.

Some sectors are already eyeing the value of this market.

[…]

For access to the full article and SustainAbility newsletter, click here.

health market quality, healthcare, healthy habits

On PSA Testing

http://www.australiandoctor.com.au/opinions/guest-view/why-do-doctors-keep-silent-about-their-own-prostat

Simon Chapman’s ebook: Let-sleeping-dogs-lie

http://www.australiandoctor.com.au/news/latest-news/nhrmc-finally-releases-its-psa-advice

For every 1000 low-risk, 60-year-old men tested annually over a decade:

  • Two will avoid dying of prostate cancer before age 85
  • Two will avoid metastatic prostate cancer before age 85
  • 87 will have a false-positive test leading to an unnecessary biopsy, and 28 will suffer significant side effects as a result
  • 28 will be “overdiagnosed” with a prostate cancer that would likely otherwise have remained asymptomatic
  • 25 will be “overtreated”, 7-10 of whom will be left impotent or incontinent as a result
  • PSA testing has “no discernible effect” on overall mortality

The figures are largely unchanged from a draft version released last

Not sure what to say about PSA testing?

David Brill 6 comments

The NHMRC has finalised its PSA testing advice for doctors, in what is claimed to be the best summary of the evidence to date.

Released Tuesday, the document provides a backgrounder for GPs to discuss both the benefits and harms of PSA testing with asymptomatic men.

Following an extensive literature review, with input spanning general practice, urology and oncology, the guide provides a list of statistics to use in conversation with patients (see below box).

Professor Ian Olver (pictured), a member of the NHMRC’s expert advisory group, said the group was “as confident as we can be” in the figures.

“We’re trying to say that the reason this can’t be promoted as a population test for everyone is that there are benefits and risks that have to be balanced. Every man has to decide where that balance lies for him,” said Professor Olver, CEO of the Cancer Council Australia.

“We’re providing an evidence-based tool for practitioners to be able to have that discussion.”

For every 1000 low-risk, 60-year-old men tested annually over a decade:

  • Two will avoid dying of prostate cancer before age 85
  • Two will avoid metastatic prostate cancer before age 85
  • 87 will have a false-positive test leading to an unnecessary biopsy, and 28 will suffer significant side effects as a result
  • 28 will be “overdiagnosed” with a prostate cancer that would likely otherwise have remained asymptomatic
  • 25 will be “overtreated”, 7-10 of whom will be left impotent or incontinent as a result
  • PSA testing has “no discernible effect” on overall mortality

The figures are largely unchanged from a draft version released last year, although the NHMRC has now stressed that the document “is not a substitute for relevant clinical practice guidelines and therefore does not contain recommendations”.

Meanwhile, GPs will have to wait until December for full consensus clinical practice guidelines, which are currently being developed by the Cancer Council Australia and Prostate Cancer Foundation of Australia.

These guidelines also have broad, multidisciplinary representation, and it is hoped they will provide some resolution to a debate that has divided Australia’s medical colleges in recent years.

complex adaptive systems, data saving lives, EF, health market quality, healthcare, healthy habits, meaning, nutrition, policy, politics, rapid learning health systems, storytelling

Dr Atul Gawande – 2014 Reith Lectures

Lecture 1: Why Do Doctors Fail?

Lecture 2: The Century of the System

Lecture 3: The Problem of Hubris

Lecture 4: The Idea of Wellbeing

http://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atul-gawande-2014-reith-lectures

Dr Atul Gawande – 2014 Reith Lectures

Atul Gawande, MD, MPH is a practicing surgeon at Brigham and Women’s Hospital and Professor at both the Harvard School of Public Health and Harvard Medical School.

In his lecture series, The Future of Medicine, Dr Atul Gawande will examine the nature of progress and failure in medicine, a field defined by what he calls ‘the messy intersection of science and human fallibility’.

Known for both his clear analysis and vivid storytelling, he will explore the growing importance of systems in medicine and argue that the future role of the medical profession in our lives should be bigger than simply assuring health and survival.

The 2014 Reith Lectures

The first lecture, Why do Doctors Fail?, will explore the nature of imperfection in medicine. In particular, Gawande will examine how much of failure in medicine remains due to ignorance (lack of knowledge) and how much is due to ineptitude (failure to use existing knowledge) and what that means for where medical progress will come from in the future.

In the second lecture, The Century of the System, Gawande will focus on the impact that the development of systems has had – and should have in the future – on medicine and overcoming failures of ineptitude. He will dissect systems of all kinds, from simple checklists to complex mechanisms of many parts. And he will argue for how they can be better designed to transform care from the richest parts of the world to the poorest.

The third lecture, The Problem of Hubris, will examine the great unfixable problems in life and healthcare – aging and death. Gawande will argue that the reluctance of society and medical institutions to recognise the limits of what professionals can do is producing widespread suffering. But research is revealing how this can change.

The fourth and final lecture, The Idea of Wellbeing, will argue that medicine must shift from a focus on health and survival to a focus on wellbeing – on protecting, insofar as possible, people’s abilities to pursue their highest priorities in life. And, as he will suggest from the story of his father’s life and death from cancer, those priorities are nearly always more complex than simply to live longer.

Five things to know about Dr Atul Gawande

Find out about Atul Gawande ahead of his 2014 Reith Lectures…

1.

In 2010, Time Magazine named him as one of the world’s most influential thinkers.

2.

His 2009 New Yorker article – The Cost Conundrum – made waves when it compared the health care of two towns in Texas and suggested that more expensive care is often worse care. Barack Obama cited the article during his attempt to get Obamacare passed by the US Congress.

3.

Atul Gawande’s 2012 TED talk – How do we heal medicine? – has been watched over 1m times.

4.

Atul Gawande has written three bestselling books: Complications, Better and The Checklist Manifesto.

The Checklist Manifesto is about the importance of having a process for whatever you are doing. Better focuses on the drive for better medicine and health care systems. Complications was based on his training as a surgeon.

5.

In 2013, Atul launched Ariadne Labs – a new health care innovation lab aiming ‘to provide scalable solutions that produce better care at the most critical moments in people’s lives everywhere’.

EF, health market quality, healthcare, policy, rapid learning health systems

 

Professor Guy Maddern’s tips on protecting yourself in surgery

1. If you are away from a major hospital, get yourself to one. A particular problem, Professor Maddern says, exists when rural patients resist transfers to major hospitals because they don’t want to leave their families.

2. Lose weight and don’t smoke.The proportion of deaths where obesity was a factor increased slightly this year. “An operation done on a thin person relative to a fat person can have a completely different outcome,” Professor Maddern says. This is particularly important for older people, who have the most operations.

3. Go to a hospital that performs a lot of the type of surgery you are going to have, particularly if it is complex. Remember, practice makes perfect.

http://www.canberratimes.com.au/national/health/one-in-10-surgery-deaths-due-to-flawed-care-or-injury-caused-by-treatment-20141203-11z5y1.html

One in 10 surgery deaths due to flawed care or injury caused by treatment

Date December 3, 2014

Health Editor, Sydney Morning Herald

View more articles from Amy Corderoy

Dangerous: Surgery risks can outweigh benefits.

Dangerous: Surgery risks can outweigh benefits. Photo: Nic Walker

More than one in 10 deaths during or after surgery involved flawed care or serious injury caused by the treatment, a national audit has found.

The Australian and New Zealand Audits of Surgical Mortality shows delays in treatment or decisions by surgeons to perform futile surgeries are still the most common problems linked to surgical deaths.

But surgery also appears to be getting a little safer, with the audit, which covers almost every surgery death in Australia, finding fewer faults with the medical care provided to patients than it has in the past.

Audit chair Guy Maddern said of the deaths where there were concerns, about 5 per cent involved serious adverse events that were likely to have contributed to the person’s death.

In about 8 per cent of cases, the audit found some area of care could have been delivered better.

“These are the sorts of deaths where it was a difficult surgery, and instead of going straight to an operation, maybe additional X-rays and imaging should have been pursued, or maybe the skill set of the team that was operating could have been more appropriate,” he said.

“Sometimes, of course, the result would have been exactly the same.”

Professor Maddern said some surgeons, particularly in general surgery, orthopaedics, and, to a lesser extent, neurosurgery, still needed to work on deciding not to proceed with surgeries where the risks outweighed the benefits.

“People are thinking a little bit longer and harder about whether an operation is really going to alter the outcome,” he said. “These are the types of cases where you know before you begin that it is not going to end well.”

However, in some areas with many patients with complex conditions, things were just more likely to go wrong.

The report, which includes data from nearly 18,600 deaths over five years, found in 2013 the decision to operate was the most common reason a death was reviewed.

Overall, delays in treatment, linked to issues such as patients needing to be transferred or surgeons delaying the decision to operate, were still the most common problem, and in about 26 per cent of the deaths no surgery was performed.

Between 2009 and 2013, the report shows a decrease in the proportion of patients who died with serious infection causing sepsis from 12 per cent to 9 per cent, while significant post-operative bleeding decreased from 12 per cent to 11 per cent. Serious adverse events halved from 6 per cent of deaths in 2009 to 3 per cent in 2013.

Every public hospital now participates in the audit, along with all private hospitals in every state except NSW. However, Professor Maddern said he was pleased NSW private hospitals had agreed to participate in future.

Doctors are now provided with regular case studies from the audit, in which de-identified information about the death is provided, so they can learn from any mistakes.

“What we are seeing is an overall decrease in deaths associated with surgical care, which may be due to many things, and we think the audit is helping,” he said. “It’s making people think twice.”

Professor Guy Maddern’s tips on protecting yourself in surgery

1. If you are away from a major hospital, get yourself to one. A particular problem, Professor Maddern says, exists when rural patients resist transfers to major hospitals because they don’t want to leave their families.

2. Lose weight and don’t smoke.The proportion of deaths where obesity was a factor increased slightly this year. “An operation done on a thin person relative to a fat person can have a completely different outcome,” Professor Maddern says. This is particularly important for older people, who have the most operations.

3. Go to a hospital that performs a lot of the type of surgery you are going to have, particularly if it is complex. Remember, practice makes perfect.

complex adaptive systems, health market quality, healthcare, policy, politics

Blumenthal on Health Reform: Foolish, Courageous, or Both

http://www.commonwealthfund.org/publications/blog/2014/dec/health-reform-foolish-courageous

Health Reform: Foolish, Courageous, or Both

Thursday, December 4, 2014

By David Blumenthal, M.D.

Some supporters of the Affordable Care Act (ACA) are worried they’re paying a political price for health care reform. The political fallout should come as no surprise.

The history of comprehensive health reform shows unequivocally that it’s a short-term political disaster. That’s why so many political leaders have either avoided the issue, or regretted engaging it. Franklin D. Roosevelt, arguably one of our most politically adept presidents, turned his back on national health insurance in 1934 when advisors argued for including it in the Social Security program. He continued to dodge it for most of his long presidency. Both Jimmy Carter and Bill Clinton paid heavy political prices for their proposed national health care programs.

Health reform’s political toxicity is all about math and voting.  Even prior to the ACA, more than 80 percent of Americans under 65 had health insurance, and most were satisfied with their coverage and regular care. These are people—better educated, employed, with middle to higher incomes—who vote, especially in mid-terms. The elderly, of course, have Medicare and they too are generally satisfied with their insurance and care. The 20 percent who didn’t have insurance before the law was passed were—and are—much less likely to show up at the polls. They tend to be younger, less-educated, and less well-off.

Then there’s the nature of health care as an issue: highly personal, highly consequential, and incredibly complex and confusing. Health care is about people’s deepest hopes and fears, for themselves and for their loved ones. And the health care system has become a multi-layered maze of huge insurance chains, enormous and acquisitive provider organizations, government regulation, and constantly changing therapeutics.

This makes it easy for opponents of health reform to stir opposition by arguing—fairly or not—that any new program will make things worse for people who are satisfied with their insurance and their care. This is precisely why President Obama felt the need to promise, inaccurately as it turned out, that every American who liked their insurance plan would be able to keep it under the ACA.

And supporters of reform have difficulty explaining any new program and motivating its beneficiaries to take advantage of it. Witness the large numbers of uninsured Americans who remain unaware of the availability of subsidized insurance through the ACA marketplaces.

So, to put it crudely, why would any sane politician push a program likely to scare and confuse large numbers of people who vote, in order to help small numbers who don’t?

There are two possible responses. One is that it’s the right thing to do, since a lack of insurance is essentially a death sentence for millions of Americans. Doing the right thing, however, can be politically costly: when Lyndon Johnson pushed through the Civil Rights Act in 1965, he gave away the southern United States to the other party for a generation.

A second argument for braving health reform is practical: it simply has to be done to make our health system viable. The private health insurance industry in the United States, and our health system as a whole, have been in a downward spiral that threatens the interests of all Americans, including the now contentedly insured. Prior to the ACA’s enactment, more and more people were losing insurance, or being forced—because of huge premium increases—to purchase coverage that offers less and less protection.

For some years now, insured Americans have been the proverbial frog in the cooking pot, barely noticing as the water slowly approaches the boiling point. A health care system in which, year after year, the cost of insurancerises faster than workers’ wages is not sustainable for anyone.

Relatively little attention has been paid to ACA reforms that attempt to make the system sustainable by tackling fundamental problems with the health care delivery system and with the structure of the private insurance markets. The reason may be that insurance markets and delivery systems—their problems and solutions—are complex and much less interesting than the political battles surrounding covering uninsured Americans, and whether currently insured Americans may face cancellation of their plans. While the major long-term political gains to supporters of health reform may lie in these delivery system and insurance reforms, President Obama and many current congressmen and senators will likely be long gone when and if those gains materialize.

So ACA supporters have every right to be concerned about the politics of health reform. Each will have to decide for themselves whether health reform was foolish, courageous, or both.

In the meantime, millions of Americans now have health insurance who didn’t before, and the cost of health care is increasing at the lowest rate in 50 years.

data saving lives, EF, entrepreneurship, health market quality, healthcare, rapid learning health systems

Health Analytics Intrapreneurial JV

Teams building analytics technology for healthcare organizations find themselves jointly holding intellectual property and equity in new arrangements not seen before in healthcare.

Extrapreneurial energy turns intrapreneurial analytics initiatives into companies in which healthcare enterprises retain some equity, remain customers, and benefit other healthcare enterprises who wish to purchase analytics technology and services.

Involves a definitive ten-year agreement valued at more than $100 million, to combine technologies, some of which Allina developed since becoming the first customer of Health Catalyst technology in 2008.

“We have a lot of confidence in our partner in Health Catalyst. Eighty percent of that [$100 million] is standard, but 20% of it is at risk, based on how we perform on key indicators, like how well the tools perform, for example, on reducing readmissions or unnecessary admissions for people who can spend nights in their own bed.

Wheeler says use of Health Catalyst technology has permitted Allina clinicians to significantly reduce readmissions, elective inductions of labor, time required to diagnose breast concerns, and sepsis rates.

http://www.healthleadersmedia.com/print/TEC-312328/Allina-Health-and-Health-Catalysts-Unusual-Deal

Allina Health and Health Catalyst’s Unusual Deal

Scott Mace, for HealthLeaders Media , January 20, 2015

Teams building analytics technology for healthcare organizations find themselves jointly holding intellectual property and equity in new arrangements not seen before in healthcare.

Follow the money, they say. It’s not always easy. “Terms of the transaction were not disclosed” is the common coin of many a deal. But despite this, some deals are harbingers of bigger things.

To make my point, I will appropriate a word: extrapreneur. It’s a word that you won’t find in most dictionaries. In 1992, the American Heritage Dictionary defined intrapreneur as “a person within a large corporation who takes direct responsibility for turning an idea into a profitable finished product through assertive risk-taking and innovation.”

So what’s an extrapreneur? One suggestion from England: Someone who shares information among organizations that they wouldn’t share among themselves.

That’s a good place to start when trying to understand what is occurring at Cleveland Clinic, Geisinger Health System, and, most recently, Allina Health, where teams building analytics technology for healthcare organizations find themselves jointly holding intellectual property and equity in new arrangements not seen before in healthcare.

Extrapreneurial energy turns intrapreneurial analytics initiatives into companies in which healthcare enterprises retain some equity, remain customers, and benefit other healthcare enterprises who wish to purchase analytics technology and services.

The term extrapreneurial also reminds me of extranets, the early e-commerce concept that extended intranets (internal TCP/IP-based corporate networks) to business partners as supply chains started being built when the World Wide Web was young.

In 2009, Cleveland Clinic’s extrapreneurial initiative spawned Explorys, an analytics platform which now counts numerous large healthcare systems among its clients. Yet, for quite some time, Explorys remained located on the Cleveland Clinic campus. And Cleveland Clinic remains an investor.

Geisinger created xG Health “to bring Geisinger’s expertise in healthcare delivery transformation to organizations nationwide,” according to xG’s Web site. xG describes itself as the primary provider of Geisinger’s health performance improvement intellectual property.

Launched in 2013 with $40 million of financing from venture capital partner Oak Investment Partners, and located in Columbia, Maryland, xG is not far from Geisinger’s Pennsylvania base of operations.

Allina and Health Catalyst
Then, on January 6, Allina Health joined the extrapreneurial ranks. A few terms of the agreement are intriguing the entire analytics industry. Allina took an undisclosed stake in analytics firm Health Catalyst.

Health Catalyst had just come off an impressive year, having raised $41 million in funding in January 2014, and convening a conference of its own rapidly-growing healthcare system analysts last fall in Salt Lake City, where the company is located.

But back to those interesting terms between Allina and Health Catalyst. It’s a definitive ten-year agreement valued at more than $100 million, to combine technologies, some of which Allina developed since becoming the first customer of Health Catalyst technology in 2008.

Once a year, a governing committee of the Allina / Health Catalyst partnership will identify a prioritized list of improvement projects, each designed to provide measurable care improvement and financial value to Allina. As the partnership achieves each goal, both partners will share in the benefits of that success.

The deal also means that Allina is outsourcing its data warehousing, analytics, performance improvement technology, content, and personnel to Health Catalyst to accelerate advances. Beginning this month, in phases, Allina employees working in these areas—some 60 in all—will become onsite Health Catalyst team members.

When you have a partnership of this magnitude, extrapreneurial forces also allow each partner to remain agile rather than locked into an arrangement that has the possibility of souring due to the changing vicissitudes of technology and healthcare.

The $100 million represents the cost of what the staff and tools were costing Allina, says Penny Wheeler, MD, president and CEO of Allina Health, a $3.7 billion not-for-profit organization whose more than 90 clinics, 12 hospitals, and related healthcare services provide care for nearly 1 million people across Minnesota and western Wisconsin.

Use the Best Tool
“We weren’t falling back on hope as a strategy,” Wheeler says. “We have a lot of confidence in our partner in Health Catalyst. Eighty percent of that [$100 million] is standard, but 20% of it is at risk, based on how we perform on key indicators, like how well the tools perform, for example, on reducing readmissions or unnecessary admissions for people who can spend nights in their own bed.

Wheeler says use of Health Catalyst technology has permitted Allina clinicians to significantly reduce readmissions, elective inductions of labor, time required to diagnose breast concerns, and sepsis rates.

“Our agreement with Health Catalyst says that if we find a better tool out there, we can use it,” she says. “So, for example, if [Epic analytics software] Cogito excels at the capabilities that we work with, then we use that,” she says.

“So it’s more about what can you use the best to improve care than any exclusivity. That just speaks to the confidence level we both have in our ability to partner and make things better, despite what else is out in the market.

“I’m pretty confident that we’re going to have a ten-year agreement and beyond,” Wheeler says.

“The margins in healthcare right now are so razor-thin, and that’s pretty apparent at Allina, given some of their recent financials. But they want to be able to create a little bit of a for-profit business around this core competency they’ve built in terms of managing their clinical performance with IT, which is what’s going on here,” notes Judy Hanover, research director of provider IT transformation at IDC Health Insights.

In the era of extrapreneurs, it’s all part of doing business.

Scott Mace is senior technology editor at HealthLeaders Media.

complex adaptive systems, data saving lives, EF, health market quality, healthcare, healthy habits, rapid learning health systems

Population Health: A riddle wrapped in an enigma

PN: The health sector is very happy to take full responsibility for the health of the population for as long as substantial monies are tied to that claim. The moment the health sector is asked to account for it, they get nervous.

Tying funding to value is a terrifying prospect for the health sector as having to account for the benefit they deliver would inevitably lead to a diminution in income and status.

“Because so many factors lie outside clinicians’ control, we need to understand what factors the healthcare system can reasonably be expected to act on, given professionals’ training, infrastructure and scope of practice,” they said. “We also need to determine the appropriate levels of health system accountability for population health outcomes.”

http://www.modernhealthcare.com/article/20150108/BLOG/301089997/population-health-improvement-still-a-riddle-wrapped-in-an-enigma

Population health improvement still a riddle wrapped in an enigma

By Melanie Evans  | January 8, 2015
Population Health
New England Journal of Medicine
The push to invest more of the healthcare industry’s time and money into promoting good health is, so far, uneven and uncertain in terms of effectiveness. Perhaps nowhere is that more apparent than in federal initiatives to broadly improve health by extending care beyond clinics and pharmacies into neighborhoods and homes.Federal funding for population-health efforts—the management of health and medical care for an entire group of patients or a community—has expanded under the Affordable Care Act. It’s included financing for states and providers to experiment with ways to better coordinate healthcare and other needs that affect health, such as housing and transportation. But the initiatives are not without risk or challenges, a point three federal officials underscored in the latest issue of the New England Journal of Medicine.

Efforts are still underway to identify what works and how to make widespread use of the most effective strategies, write Dr. William Kassler, Naomi Tomoyasu and Dr. Patrick Conway of the agency that oversees Medicare and Medicaid. The CMS Innovation Center, in a report to Congress last month, also said results were largely not yet available for nearly two dozen initiatives to bolster population health, improve quality and increase efficiency in healthcare, financed with $2.6 billion through last year.

Calculating a dividend from those investments presents another challenge, the trio wrote. Kassler is one of the CMS’ chief medical officers; Tomoyasu is deputy director of the prevention and population health care models group within the CMS Innovation Center; and Conway is the CMS’ deputy administrator for innovation and quality.

The return on any investment in prevention will necessarily take time, raising the risk that “current actuarial methods used to evaluate return on investment may underestimate potential savings,” they warned.

Investment at the federal level is not small. Medicare and Medicaid—which combined account for $1 of every $3 the nation spends on healthcare—have increasingly poured money into strategies for disease prevention and health promotion.

Those strategies extend the reach of healthcare beyond hospitals, clinics and pharmacies into neighborhoods, homes and schools. Such extended investment can include help with housing, transportation, literacy, day care and groceries, the officials wrote.

But with that expanded reach comes a debate “regarding the specific population-based activities that fall within healthcare providers’ scope of practice,” wrote the CMS officials. “Because so many factors lie outside clinicians’ control, we need to understand what factors the healthcare system can reasonably be expected to act on, given professionals’ training, infrastructure and scope of practice,” they said. “We also need to determine the appropriate levels of health system accountability for population health outcomes.”

Follow Melanie Evans on Twitter: @MHmevans

data saving lives, EF, entrepreneurship, healthcare, healthy habits, quantified self, rapid learning health systems

WSJ: Can a Smartphone Tell if You’re Depressed?

 

http://www.wsj.com/articles/can-a-smartphone-tell-if-youre-depressed-1420499238

TECHNOLOGY

Can a Smartphone Tell if You’re Depressed?

Apps, Other Tools Help Doctors, Insurers Measure Psychological Well-Being

By

JOSEPH WALKER

HUNTERSVILLE, N.C.—Toward the end of Janisse Flowers’s pregnancy, a nurse at her gynecologist’s office asked her to download an iPhone app that would track how often she text messaged with friends, how long she talked on the phone and how far she traveled each day.

The app was part of an effort by Ms. Flowers’s health-care provider to test whether smartphone data could help detect symptoms of postpartum depression, an underdiagnosed condition affecting women after they give birth. The app’s developer, San Francisco-based…

health market quality, healthcare, policy, politics

Margaret Faux: Unitended consequences of streamlining Medicare billing

 

http://blogs.crikey.com.au/croakey/2014/12/16/tony-abbott%E2%80%99s-medicare-%E2%80%9Cdeforms%E2%80%9D-or-how-to-trick-senators-101/

Tony Abbott’s Medicare “deforms” or How to Trick Senators 1.01

MARIE MCINERNEY | DEC 16, 2014 3:51PM | | PRINT

The Federal Government’s co-payments Plan B will add another layer of co-payment complexity to the Medicare system that neither doctors nor patients fully understand now. That raises a whole range of issues around unintended consequences, particularly for patients but also for our system, which has prompted this appeal to the Senate to learn from what’s happened in the past and look to different solutions in the future.

***

Margaret Faux writes:

Senators, section 20A needs your help, urgently!

Section 20A of the Health Insurance Act 1973 (the Act) is Medicare’s heartbeat. One of the key machinery provisions of the Act, it describes Medicare’sbulk billing arrangements, and it is fibrillating on the verge of collapse.

Section 20A has been amended, repealed, re-introduced and tinkered with on 16 occasions since it was first introduced. Some of the changes have been incidental but one was not, and it has had long term consequences which have contributed to the continuing upward spiralling of inpatient medical fees. The intention was that it would have the reverse effect.

Tony Abbott’s latest stunt will see the same upward spiralling of GP fees, because when you look beyond the smoke and mirrors of the most recent co-payment iteration, it is nothing more than a cunning manoeuvre to divert attention from the main game. The new proposal cannot be introduced by regulation alone, and it’s the sneaky little legislative change that is required, that will break Medicare’s back. It happened in 2000 and it is happening again.

Bulk billing 1.01

Unlike much of Medicare’s legislative scheme which is mind bogglingly complex, section 20A describes a simple two step bulk billing process (the legal term being an assignment of benefit). My changes in brackets and bolded:

S20A Assignment of Medicare benefit

(1)  Where a medicare benefit is payable to (a patient) …. (the doctor and the patient) may enter into an agreement, in accordance with the approved form, under which:

(a)  (the patient) assigns his or her right to the payment of the medicare benefit to (the doctor); and

(b)  (the doctor) accepts the assignment in full payment of the medical expenses incurred in respect of the professional service by the (patient).

Bulk billing has always been optional by virtue of the inclusion of the word ‘may’ in section 20A, however in choosing to bulk bill, the doctor forgoes his or her right to collect any additional fees from the patient, because he or she must accept the bulk bill amount ‘in full payment’ for the service provided.

Doctors have been found guilty of criminal fraud for breaches of this section in circumstances where they have charged their patients additional fees or ‘co-payments’ when bulk billing, including when the co-payments have been called something else such as booking fees or counselling fees. The current legal position therefore is that irrespective of the name allocated to any ‘co-payment’, it is illegal to charge it when bulk billing for a single professional service. The only exception involves the administration of certain vaccinations, which provision is neatly tucked away in the regulations.

The High Court has upheld this interpretation on numerous occasions and, with the exception of two brief periods in the history of s20A,bulk billing has always operated in this way. Seems pretty straight forward.

Last week in his joint press release with Health Minister Peter Dutton, Prime Minister Tony Abbott announced that under the new proposal an optional co-payment of $5 will be permitted when bulk billing. To enable this, an amendment to s20A of the Act will be required. So what’s the big deal about that?

Well we’ve been down a very similar path before when s20A was amended by the introduction of subsection (2A), which was necessary to facilitate the introduction of no-gap schemes, and unfortunately, it didn’t quite go as planned.

No-gap billing 1.01

No-gap schemes are a sort of hybrid bulk billing system for inpatient services. The fee paid to the doctor has two components; the first is a 75% Medicare rebate, the second is a top up by the private health fund, after which one total amount is paid to the doctor.

When introduced, the stated purpose of these schemes was to limit the out of pocket expenses faced by patients when they go to hospital. The idea was that there would be…well…no-gap, except when there was a gap, called a known-gap, which would be permitted under a sort of sub-branch of the new no-gap schemes.

When these schemes were debated in the House of Representatives on 10 April 2000, MPs variously espoused the complete protection and safeguarding of consumers, expressed concern that there appeared to be insufficient detail as to how patients would be informed about fees, celebrated the fact that medical fees had finally been conquered and patients would thereafter be empoweredto shop around for doctors, and one particularly excited and optimistic MP even suggested that these schemes would somehow help us all to better understand how health insurance operates.

It was only the Member for Lowe John Murphy who was alive to the fact that changing s20A might have unforeseen consequences. He said:

I believe that the amendments made to the Health Insurance Act 1973 to allow automatic assignment of a contributor’s Medicare benefit to a registered organisation to facilitate simplified billing and payment arrangements to be built into the gap cover scheme will mean yet one more way in which bulk-billing will be undermined—something that the Liberal Party has always wished to accomplish. Bulk-billing is something that those who sit on this side of the House will defend to the death.

Bulk billing was indeed undermined but the seemingly innocuous change to s20A was largely over-shadowed by the greater objectives of streamlining and simplifying inpatient billing processes. The necessary change to s20A appeared to be nothing more than a simple mechanical tweaking of the Act to facilitate the operation of the new schemes. And it was true that the schemes could not operate without this tweak. When the go live date came around, the schemes were sold to consumers and health professionals as ‘simplified billing’ arrangements. It’s perhaps the greatest misnomer in the entire Medicare mire.

There are just under 6000 Medicare services, most of which are claimable to each of the 36 registered health funds in Australia, all of whom have no-gap schemes but not known gap schemes, all with unique rules and requirements, some capping their known gap amounts, others not, all with different fee schedules and payment arrangements and some even pay different rates in different states. Only those at the claiming coal face (where the tax payer dollars are spent) really understand just how complex medical claiming is, how easy it is to make unintentional errors and how difficult it is to correct them. No-one knows that in practice, the known gap is usually known to no-one except the patient. And this is not because of any deliberate misuse of the system by anyone, it occurs because the system itself is flawed. And that innocuous little tweak to s20A took the patient right out of the transaction, which in effect created an open book of cheques pre-signed by the patient (though the patient is oblivious to this) just waiting to be cashed.

While doctors do their level best to stay off Medicare’s radar, out of court and comply with the rules, if the rules are labyrinthine and the machinery of billing is left to secretaries, administrators and third parties, then there are bound to be unintentional slip-ups.

In attempts to apply quality control measures to the huge volumes of claims hitting their systems, some health funds are now using data matching processes to try to capture inconsistencies between the hospital claim (this is for the accommodation and theatre fees) and the medical claim. The two claims are supposed to match. But this is also fraught because there is no way of knowing which of the two claims is incorrect when a mismatch is identified. Hospital account departments make errors too. In fact this week a client asked me what she should do because she had become aware that the hospital had claimed incorrectly in her name. She said:

The hospital has sent a hospital accommodation bill to the patient stating that the mirena was inserted for contraceptive reasons but it was actually for another reason for which the relevant MBS item number is different than the one they submitted which was incorrect. When I submit my claim which item number should I use?

Confused and worried doctors are as common as confused patients in the world of medical billing. Patients have often been told one thing by their health fund, another by Medicare, another by the hospital, yet another by the doctor and often we tell them something different again.But spare a thought for doctors, they struggle too. Yesterday, on a fairly typical day in the office, a phone call came through from a brand new surgeon just starting in private practice enquiring about medical billing. I asked him if he had given consideration to the claiming method/s he wanted to use – bulk billing, no-gap, known-gap, full gaps? He replied:

‘Sorry, I don’t know what any of those are; I’m just new to all of this.’

It’s a standard response, no surprises there.

Patients are mostly in the dark when it comes to medical fees and would not know if Medibank Private’s known-gap scheme has a cap or not (it does) and will have no hope of understanding when the proposed $5 co-payments can or can’t be charged, and it will be impossible to protect them from incorrect charges being raised (even if they are raised unintentionally). Consider these real examples of a trip to the GP which were put to me by GPs during a webinar presentation just a few weeks back.

‘What if a patient has a consultation, a mirena inserted, and a wound dressed? Do I have to bulk bill them all or can I split them and charge fees for some and not others? What are the rules?’

‘What about a complex skin cancer removal, a consultation and a vasectomy?’

‘What if the patient comes in and has a consult, is sent off for an x-ray and then comes back later that day with the x-ray results and we find a fracture, but it was caused by a metastasis (cancer invading the bone)?’ – This means that what started off as a suspected simple broken bone has now become a cancer diagnosis and the doctor will likely spend a very long time planning the treatment and management of the patient –‘Is it two item 23s or one item 23 and one item 36 or just bundle it all up into one item 44 or how do we bill for that?’

The rules that apply to each of these scenarios are neither simple nor consistent nor even readily accessible by perusing the Medicare Benefits Schedule. Given doctors are already unsure about how to correctly bill for these services, what hope will patients have? Rumour has it that the Government will try to explain the new scheme by way of an advertising campaign. But so unique is each patient encounter that no national advertising campaign is ever going to make this clear – not for patients, or doctors. It would be a bit like trying to explain the tax system in a 30 second grab on prime time television.

There are two end user groups of the Medicare system, doctors and patients, neither of whom fully understands how it works, and adding another layer of co-payment complexity, facilitated by a seemingly minor change to the legislation, will only serve to compound the difficulties they already grapple with. And just as there were insufficient safeguards to protect consumers when s20A (2A) was inserted to facilitate no-gap schemes, there are not only insufficient safeguards under the Government’s co-payment proposal, there are none.

Instead of shifting responsibility for the health of Medicare to the end users, a responsible government will first look within Medicare for answers. There is known waste, inefficiency and incorrect claiming amounting to over $1 billionper year, that neither increasing the Medicare levy nor introducing co-payments will fix. And if addressing internal inefficiencies to save costs is good enough for the ABC why is it not also good enough for Medicare?

So Senators, your predecessors made what they thought was an innocuous change to s20A for the purposes of simplified billing. Don’t fall for today’s ruse of establishing a ‘price signal’. Do what every responsible householder would do – see if you can make what you have work better for you first, before deciding you will have to pay more for the same service.

Margaret Faux is a lawyer, the founder and managing director of one of the largest medical billing companies in Australia and a registered nurse. She has been involved in Medicare claiming for 30 years and is a research scholar at the University of Technology Sydney examining the interface between Medicare and medical practitioners. 

The illustration is by Bradfield Dumpleton, a freelance illustrator and independent arts educator with a passion for creative communication and who specialises in cartoon art for community health and educational organisations.  For more info: bradfielddumpleton.com

complex adaptive systems, data saving lives, EF, facts & data points, health market quality, healthcare, policy, politics, quantified self, rapid learning health systems

Yach: Changing the Landscape for Prevention and Health Promotion

 

http://www.huffingtonpost.com/dr-derek-yach/changing-the-landscape-fo_1_b_6439328.html

Become a fanExecutive Director of the Vitality Institute

Changing the Landscape for Prevention and Health Promotion

Posted: Updated:

By Bridget B. Kelly and Derek Yach*

Chronic diseases like heart disease, diabetes, and cancer are major contributors to poor health and rising health care costs in the U.S. The cost of treating these conditions is estimated to account for 80 percent of annual health care expenditures. More and more, experts agree on the great potential for preventing or delaying many cases of costly chronic diseases by focusing on environmental, social, and behavioral root influences on health. Yet the U.S. has been slow to complement its considerable spending on biomedical treatments with investments in population-based and non-clinical prevention interventions.

What is getting in the way of strengthening our investments in prevention and health promotion? A few consistent themes emerged across multiple expert consensus studies conducted by the Institute of Medicine (IOM), which were summarized in the report Improving Support for Heath Promotion and Chronic Disease Prevention — developed in support of the recent Vitality Institute Commission on Health Promotion and Prevention of Chronic Disease in Working-Age Americans.

First, prevention is challenging — chronic health problems are complex, and so are the solutions. Second, decision-makers who allocate resources have tough choices to make among many competing pressures and priorities; prevention and promotion can be at a disadvantage because their benefits are delayed. Third, there is a need for better, more usable evidence related to the effectiveness, the implementation at scale, and the economics of prevention interventions. Decision-makers need information that makes it easier to understand, identify, and successfully implement prevention strategies and policies. As noted in a recent opinion piece in the Journal of the American Medical Association (JAMA), limited investment in prevention research has resulted in an inaccurate perception that investing in preventive measures is of limited value. This has profound implications for federal funding allocations.

The mismatch in funding allocations is seen right at the source of our nation’s major investment in new health-related knowledge: the National Institutes of Health (NIH). A new paper in the American Journal of Preventive Medicine found that less than 10 percent of the NIH annual budget for chronic diseases is allocated to improving our knowledge base for effective behavioral interventions to prevent chronic diseases. This means that despite the immense potential for prevention science to reduce the burden of chronic diseases in the U.S., it is woefully underfunded compared to what we invest in researching biomedical treatment interventions for these conditions. NIH investments affect what evidence is ultimately available to those who decide how to allocate resources to improve the health of our nation, and they also affect the kinds of health experts we train as a country. By not investing in prevention science and in a future generation of scientists capable of doing high quality research in prevention, we are perpetually caught in the same vicious cycle where prevention continues to lag behind in our knowledge and therefore our actions.

There is hope that the landscape is slowly changing. Initiatives such as the NIH Office of Disease Prevention‘s Strategic Plan for 2014-2018 and the Affordable Care Act’s mandated Patient-Centered Outcomes Research Institute (PCORI) have the potential to strengthen prevention science and build the evidence-base for effective prevention interventions. Innovations in personalized health technologies and advances in behavioral economics also show great promise in improving health behaviors for chronic disease prevention.

The Vitality Institute Commission’s report emphasized the need for faster and more powerful research and development cycles for prevention interventions through increased federal funding for prevention science as well as the fostering of stronger public-private partnerships. It is essential to generate and communicate evidence in a way that enables decision-makers to understand the value of investing in prevention while taking into account their priorities, interests and constituencies. This will lead us to more balanced investments, make prevention a national priority, and boost the health of the nation.

*The authors are responsible for the content of this article, which does not necessarily represent the views of the Institute of Medicine.