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We’re Just Getting Started with an Internet of Healthy Things (Part 1 of 3)

Posted on November 24, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The release of Joseph Kvedar’s book The Internet of Healthy Thingscoincided with the 15th annual symposium on Connected Health, which he runs every year and which I reported on earlier. Now, more than ever, a health field in crisis needs his pointed insights into the vision widely shared by all observers: collaborative, data-rich, technology-enabled, transparent, and patient-centered.

The promise and the imminent threat

A big part of Dr. Kvedar’s observations concern cost savings and “scaling” clinicians’ efforts to allow a smaller team to treat a larger community of patients with more intensive attention. As I review this book, shock waves about costs are threatening the very foundations of the Affordable Care Act. Massive losses by insurers and providers alike have led to the abandonment of Accountable Care Organizations by many who tried them. The recent bail-out by UnitedHealth was an ominous warning, eagerly jumped on by Fox News. Although other insurers issued assurances that they stay with the basic ACA program, most are reacting to the increased burden of caring for newly signed up patients by imposing insufferably high deductibles as well as extremely narrow networks of available providers. This turns the very people who should benefit from the ACA against the system.

There is nothing surprising about this development, which I have labeled a typical scam against consumers. If you sign up very sick people for insurance and don’t actually make them better, your costs will go up. T.R. Reid averred in his book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care that this is the sequence all countries have to follow: first commit to universal healthcare, then institute the efficiencies that keep costs under control. So why hasn’t that happened here?

Essentially, the health care system has failed us. Hospitals have failed to adopt the basic efficiency mechanisms used in other industries and still have trouble exchanging records or offering patients access to their data. A recent study finds that only 40% of physicians shared data within their own networks, and a measly 5% share data with providers outside their networks.

This is partly because electronic health records still make data exchange difficult, particularly with the all-important behavioral health clinics that can creat lifestyle changes in patients. Robust standards were never set up, leading to poor implementations. On top of that, usability is poor.

The federal government is well aware of the problem and has been pushing the industry toward more interoperability and patient engagement for years. But as health IT leader John Halamka explains, organizations are not ready for the necessary organizational and technological changes.

Although video interviews and home monitoring are finding footholds, the health industry is still characterized by hours of reading People magazine in doctors’ waiting rooms. The good news is that patients are open to mobile health innovations–the bad news is that most doctors are not.

The next section of this article will continue with lessons learned–and applied–both by Dr. Kvedar’s organization, Partners Connected Health, and by other fresh actors in the health care space.

Economists Display What They Don’t Know About the Health Care Industry

Posted on October 7, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Recently, I resorted to a rare economic argument in a health IT article, pointing out that it’s unfair to put the burden of high health care costs on the patients. Now 101 economists have come out publicly recommending that very injustice. Their analysis shows the deep reluctance of those who are supposed to guide our health care policy to admit how distorted the current system is, and how entrenched are the powerful forces that keep it from reforming.

My argument cited numerous studies and anecdotal reports to show the deplorable record of the US health care industry regarding costs: providers who don’t reveal prices, providers who don’t know what the patient’s out-of-pocket costs will be, wrenching differences in insurance payments for the same procedure, missing quality information that consumers would need to make fair comparisons, and more. Just as icing on the cake, the most recent Consumer Reports (November 2015) offered a five-page article on all the screw-ups that lead to medical “sticker shock.”

Probably I’m foolish to launch an economic argument with the distinguished signers of the brief letter to key members of Congress. The signers’ credentials are impeccable, placing them in an impressive list of universities and think tanks–all of which, I’m sure give generous coverage for any health care these economists need. If any of the signers should be burdened with the Cadillac tax, they could cover it with an extra consulting gig at the World Bank. (What’s the economics behind “nice work if you can get it”?)

But the economists just aren’t facing realities in the health care industry. Let’s expand their telescoped argument, full of assumptions and leaps of faith, to see what they’re saying.

First, they expect that the Cadillac tax will not be quietly absorbed by firms wooing professionals in high demand (such as health IT developers), but will drive those firms to reduce coverage. The burden will explicitly fall on the individual patient. I suspect that many firms facing staff shortages would just compensate key high-performers for the high-cost health coverage, but let’s accept the economists’ assumption and move on.

Next, the economists assume that the patient will make rational choices leading to what they call “cost-effective care.” What could such choices be?

Can the patient tell her doctor that a certain test is unnecessary, or that a certain treatment is unlikely to improve her condition? Does the patient know that the test has too many false positives, or is unlikely to add to the doctor’s knowledge? These questions lie precisely within the expertise of the provider, not the patient.

Can the patient determine whether a high-cost drug will pay for itself in reduced future health care and improved quality of life? This calls for extended longitudinal research.

Can the patient tell her provider or insurer to adopt a rigorous pay-for-value regime? If she goes looking for an ACO, will it actually gather enough data to treat her efficiently, and does it truly get rewarded for doing so? These are nation-wide policy issues outside the patient’s control.

As I pointed out in my earlier article, the patients lack the information needed to compare the costs and quality of procedures from different providers. Patients try to do so, but data is inadequate. Nor will yelling and screaming about it make any difference–we’ve all known about the problem for years and it hasn’t made much difference so far.

I don’t like dumping on economists. After all, they rarely cause the problems of the world, and are all too often tasked with solving them. The perennial occupational hazard of the economist is to be forced to make recommendations on the basis of insufficient knowledge.

But in this case, the average patient has knowledge that these economists lack. The problems are also well known to anyone in the health care industry who has the courage and clarity of vision to acknowledge what’s going on. If we want the system to change, let’s put public pressure on the people who are actually responsible for the problems–not the hapless patient.

Healthcare Costs and the New Cost Conscious Patient

Posted on June 30, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

My favorite health economist, Jane Sarasohn-Kahn, has put out a really interesting post on her Health Populi blog talking about what the SCOTUS ACA ruling means for health consumers (Side Note: Here’s the lesson I took from the ruling.). Jane offers an important perspective that we should think about as we look to the future of healthcare. Here’s an excerpt from her article:

There are still tweaks and adjustments to be made to the law, and market supports that must deal with the ever-rising price of health care. While optimists report health care cost increases moderated to 6.5% in 2015, this growth rate is nonetheless many times greater than peoples’ wage increases (relatively stagnant for a decade) and the Consumer Price Index which in the previous year was actually negative (due to lower costs of petrol and other decreasing costs in the household budget). The one cost households can count on going up, up, up is….healthcare.

And so with the growth of high-deductible health plans and health savings accounts, health consumers must become health care shoppers — that is, if people want to gain some control over their financial wellness.

What does this new cost conscious patient mean for healthcare? What systems are we going to need to be able to handle the patient? Will we be able to continue providing care to patients without any real idea on how much that care will cost? Or will we need systems that help us know what the cost of care will be so the patient can choose to buy that care or not? Will cost conscious patients want to be kept well instead of just having their current complaint treated?

There are these and a lot of other questions that are raised by this shift in patient consumption of healthcare services. Understanding these changes is going to be extremely important for healthcare organizations to survive.

Do Doctors Care About the Triple Aim?

Posted on May 13, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The stated goal of Patient Protection and Affordable Care Act (PPACA) (i.e. Obamacare) and healthcare reform is what people like to call the Triple Aim. For those not familiar with it, it goes as follows:

  • Improve patient satisfaction and quality of care
  • Improve the health of the community/population
  • Reduce the cost of healthcare.

I’ve regularly heard people reference the triple aim as a reason why we should act a certain way. They refer to the triple aim as the main goal of what we are doing with healthcare IT. It’s the unifying vision for which all of healthcare wants to achieve.

I’m here to tell you that it’s just not the case. There are plenty in healthcare that couldn’t care less about the triple aim of healthcare. Many in that group are doctors. Ok, maybe the word “care” isn’t the right one. They do care about patient satisfaction and quality of care. They do want the health of their community to be better. They do want the costs of healthcare reduced. They do care about those things, but do they care to the point where it will actually spur action?

Another way to look at this is do they care about the triple aim enough for them to change what they’re doing. Plus, do they care about other things more than the triple aim.

Let’s look at them backwards. Do doctors want to reduce the cost of healthcare? As citizens, of course they want the cost of healthcare reduced, but with one small caveat: As long as it doesn’t mean I get paid less. This isn’t a knock on doctors either. This is the perfectly rationale response to the idea of lowering costs in healthcare. It’s not something we should criticize. It’s something we should understand and apply to whatever we’re trying to achieve.

The same thing applies to improving the health of a community or population. Hopefully the shift to value based reimbursement, population health, and ACOs will help to realign the incentives to make it so doctors care more about this than they do now. Otherwise, many of these programs look like we’re asking our providers to provide more free work for the benefit of the community. Hard to blame them when you phrase it like that, no?

The majority of doctors embrace this first aspect of the triple aim. They really want to provide the very best care they can to the patients (with a few sad exceptions which give a bad name to the hundreds of thousands of doctors who are doing their best). The question I’d ask ourselves is are we putting doctors in a position where they can have satisfied patients who receive quality care or are we burdening our highest paid resource with tasks that don’t work towards this end goal? Every doctor I know would welcome the opportunity to have better satisfied patients and improved outcomes.

I love the components of the Triple Aim as an ideal, but as it is today I think there’s a misalignment between the ideal and the day to day reality for doctors. I’m not against being idealistic and ambitious in our goals. Although, don’t expect our healthcare system to reach the triple aim if we don’t realign the incentives. Plus, let’s not forget that not all incentives are financial.

HealthCare.gov

Posted on December 26, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

If you haven’t been to HealthCare.gov for a while, go and check it out. If you didn’t know better, you’d think that HealthCare.gov was built by a company and not the government. This is true all the way down to the HealthCare.gov Blog featured on the home page. I applaud Todd Park and the others at HHS who took a different approach to how a government website should look and feel. They even have a scrolling set of stories about patients and benefits. You’d think they have something to sell us.

Well, I guess they do have something to sell. They are definitely trying to sell us on ACA (aka Obamacare) and the benefits that come from Obamacare. Although, the tools that I found most interesting were the Insurance Options Wizard which walks you through all the options you have to getting insurance. Not to mention a whole set of tools to try and help people understand using insurance. Although, I’m pretty sure most of that’s not going to be read. So, hopefully it’s got a good dose of search engine optimization applied so that it will show up in search engines where it might get a chance at being read.

We’ve written about the “Comparing Care Providers” part of HealhCare.gov before. It’s pretty gutsy for a government organization to go there at all. Certainly they are taking a pretty high level approach to their “comparison” but we’ll see how much they dig into it going forward. Will those doctors that are part of an ACO that’s striving to be reimbursed on the quality of care be listed different than other doctors? It will be interesting if tools like these start to differentiate which patients go to which providers.

I do wish that the website did more to get patients involved in their healthcare. Here’s what I said in my “All I Want for Christmas…” post on EMR & HIPAA:

More Empowered and Trusted Patients – Imagine where the patient was a full participant in their healthcare. That includes being trusted and listened to by their doctor and a patient who thoughtfully considers and listens to their doctor. This is not a one sided issue. This is something that both patients and doctors can improve. There are as many belligerent patients as their are arrogant doctors. We need a good dose of humility, care and trust re infused into healthcare. I think they only way we’ll get there is for the lines of communication to open up on an unprecedented level.

Seems like HealthCare.gov is one place that could help reach this goal. I guess in some ways the physician comparison engine could work towards this. How cool would it be if they listed which of the physicians used EHR and which EHR that physician used? Reminds me of “Got EMR?” ad campaigns I first wrote about about 6 years ago.

EMR or Not, we’re quickly heading to a world where doctors are differentiated on the technical services they provide their patient. Doctors are starting to be judged by their medical website and the services they provide on that website. Do they accept online appointment requests? Do they accept online payments? Can the patient communicate electronically with the clinic? Can the patients receive their patient records electronically?

It will start with a handful of doctors and then start to spread. Plus, it will be accelerated if HealthCare.gov or some other website starts to highlight those doctors who offer these type of services and those that don’t.

ACA Implications, Hurricane Sandy, and Interoperability — #HITsm Chat Highlights

Posted on November 10, 2012 I Written By

Katie Clark is originally from Colorado and currently lives in Utah with her husband and son. She writes primarily for Smart Phone Health Care, but contributes to several Health Care Scene blogs, including EMR Thoughts, EMR and EHR, and EMR and HIPAA. She enjoys learning about Health IT and mHealth, and finding ways to improve her own health along the way.

Topic One: Obama’s re-election secures the future of the #ACA, but what changes/concessions are we likely to see during its rollout?

Topic Two: What #healthIT strengths and weaknesses did Hurricane Sandy expose?

Topic Three: What business continuity/disaster recovery strides do health providers still need to make?

 

Topic Four: A national #HIE would have come in handy during #Sandy, so why does the industry still fail to embrace interoperability?

 

 

Affordable Care Act and Employee Health

Posted on May 14, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Over at healthaffairs.org, there was a super interesting brief on Affordable Care Act and its forthcoming changes regarding employee health. Starting in 2014, employers will be able to offer incentives to employees regarding their enrollment in employee wellness programs. Employers can offer incentives such as monetary rewards for positive employee behavior like enrolling in a smoking cessation program, or joining a gym at discounted rates. Or these can work like the proverbial stick, by imposing penalties on non-compliant employees, e.g. increasing the cost of participating in an employer health plan by $1000 for employees who say they have smoked in the last year.

Now all those good components of the ACA will still be applicable i.e insurance companies will not be able to refuse patients based on prior medical history. But I can’t help but notice the irony of the ACA being used to discriminate between a healthy employee and a sick one.

One of the examples cited in the brief is that it will be legal for an employer to offer a health plan to employees who fulfil certain wellness criteria such as enrolling in a gym in addition to the other health plan options available to its other employees. The cost of the other health plan options to a truly unwell employee could well be so exorbitant as to make it impossible for him/her to enroll in it. Options for such employees could be to enroll through a spouse’s plan or purchase private insurance through the health information exchanges. The brief says that there are plugs for these sorts of employer excesses, such as companies with over 50 employees will be penalized even if one employee enrolls in a subsidized state insurance program in lieu of the company sponsored one.

I’m also wondering if there will be any kind of guidelines for companies to design their incentive/penalty programs. Health and wellness are incredibly nuanced issues. For every person who can exercise a half hour a day and lose a pound a week, there are those who seemingly subsist on air and water and barely make a dent in their BMI. Genes determine plenty of factors in a person’s helath profile, including weight, propensity to develop certain conditions and so on. It makes me wonder if we’re oversimplifying things by gauging employee wellness based on criteria such as gym enrollment.

Plus what if you have lots of people like me who might enroll in a gym and never see the inside of it beyond the first few days? Simple enrollment might not be enough. But, to my mind at least, tying enrollment to outcomes has the unfortunate whiff of a mini nanny state in the making. Who wants to be the person at the company weigh-in whose BMI has come down by .1 while the muscled, rippled company health club employee looks at you quizzically? Not me.

I also worry about the unwell employee who feels pressured into signing up for risky activities (from his/her health perspective), simply in order to get the rewards offered or to avoid the penalties. S/he might have something truly tangible to lose both ways.

I would love to see how ACA transforms in the next couple of years but right now I think I have way too many unanswered questions.

Obamacare Before SCOTUS

Posted on April 2, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

So the Affordable Care Act got hauled up before the SCOTUS last week. From the way the questions were framed it looks like the individual mandate portion might be struck down, though it is too soon to tell.

I have mixed feelings about the Affordable Care Act. On the one hand I can see why affordable health for all must be a priority. I know people who use the ER room as their sole point if contact with the healthcare system, and sadly some of them have paid the price with their lives. There’s also a selfish reason behind my reasoning. Each time someone uninsured turns up at the ER, and gets top notch care, it is MY tax dollars that fund the treatment. Surely there are better ways to use tax dollars.

And yet a mandate makes me queasy. If the government mandates health insurance today, will it start mandating annual exams and flu shots a few years down the road. I think the most succint response on this topic was summarized thus by a Twitterer: “The problem with the mandate is the insurance is private. Make the insurance public and call it a tax. Problem solved.”

I can hear Americans collectively go This isn’t Canada at this point. But think about it: directly or indirectly, we are paying for the uninsured with our tax dollars. Public health insurance might take away some of the worries we have around bouts of non-insurance resulting from unemployment or old age.