Patients, Physicians, And Price Transparency: If You Build It, Will They Come?

While health care spending growth has slowed in recent years, it is still poised to consume a fifth of the US economy by 2025. As such, the pressure to constrain costs and improve value persists - with continued focus on patients and physicians as primary agents to reduce health expenditures.

And while both patients and physicians may have a role to play in price transparency efforts, their interests are not necessarily the same. Many experts contend that without accurate and reliable information on health care prices, patients do not have the incentives or tools needed to shop for the best value in their health care. For physicians, there is a lack of consensus around whether their role as health care providers includes financial stewardship.

In 2013 the Robert Wood Johnson Foundation (RWJF), in collaboration with AcademyHealth, funded six research studies to contribute to understand­ing the use and impact of price data in health care. The goal was to generate reliable and generalizable evidence to inform policymakers and other stakeholders and accelerate the pace of efforts to use price information effectively.

The grantees recently presented findings from their studies at an invitational meeting of policymakers, researchers, and other experts actively engaged in developing and using health care price information. The meeting discussion explored the “state of the art” in price transparency and sought to identify directions for future research.

Key findings presented at the meeting included the fact that patient demand for, and availability of, price information is growing, but many insured populations do not use price comparison tools when they are available. While the majority of Americans have sought price information before getting care, other RWJF-funded research found that fewer than 4 percent of eligible commercially insured individuals used an online price transparency tool developed by Aetna.

The disconnect between patient interest in, versus use of, transparent price information suggests that at least for some commercially insured patients, the available tools are not providing patients with the information they most value, in a timely manner, and/or in a form they can use or want to use. That disconnect might also relate to people's knowledge of how health care prices do or do not vary. For example, 57 percent of insured Americans do not think doctors in their insurance plans charge more than others for the same services.

Although previous research has suggested that clinicians reduce their ordering of lab tests when they are given information on prices, another RWJF study found no overall change in ordering tests when price infor­mation was displayed on physicians' ordering screens at the point of care.

Numerous factors may influence a physician's receptivity to discussing price information with patients, including their comfort level with, and/or patient interest in, these discussions, their payment arrangements, and the proportion of payments tied to value, as well as whether they view financial stewardship as an appropriate physician role. As the physician payment landscape changes, future research should address how provider behavior may be changing as prices become more transparent and as consumers are exposed to increasing amounts of cost sharing.

The six RWJF studies and the subsequent discussion they generated underscore that providing patients and physicians with transparent price information is not sufficient to substantially lower health care expenditures. Recent research has found that while most consumers may not believe that price corresponds with the quality of care, a substantial minority do make this association - demonstrating that reliable information on quality of care alongside information on prices is essential.

Also, 11 ongoing RWJF studies are examining what consumers value when they buy and use insurance and shop for care, but more evidence is needed on how and when transparent price and quality information can best support patient decision making.

Individual patients, and low-income or vulnerable consumers in particular, may lack the market power needed to effectively improve the value of the health care system. Low-income and vulnerable consumers may also lack the resources (for example, a computer, time, health literacy, websites in their language, or knowledge that such websites exist) to use many of the price tools that are currently available.

As such, physicians may be the next frontier for price transparency efforts - but we need to better understand the factors that contribute to greater receptivity among physicians to discuss treatment costs with patients. Little is known about how to best facilitate conversations between clinicians and patients about costs in ways that are productive, and that also do not jeopardize the patient–provider relationship.

To that end, RWJF recently released two calls for proposals aimed at uncovering ways to help integrate those discussions into the clinical workflow, as well as ways to develop principles that can optimize cost-of-care conversations between clinicians and vulnerable patients.

Price transparency tools have great potential, but if we want patients and physicians to truly engage with them, they must be designed to meet both parties where they are, and to provide users with information they value.

Competing for the Best New Ideas in Depression Care

By HEALTH 2.0

Starting around now, you're going to be seeing alot on THCB about our sister org Health 2.0. Its 10th Annual Fall Conference is coming up Sept 25-8, and everyone who is anyone in the world of new health tech, digital health or whatever you like to call it will be in Santa Clara. First up is a cool crowdsourcing contest from our friends at Medstartr, sponsred by Takeda–Matthew Holt

Next month at the Health 2.0 Conference Takeda will award $50,000 to the winners of the “MDDcare16 Open Innovation in Depression Care Crowd Challenge” to find the best new solutions to fight Major Depressive Disorder (MDD).

Major Depressive Disorder (MDD) is the leading cause of disability for people between the ages of 15 and 44 and affects  approximately 15 million US adults every year. Patients and care providers need new ways to treat and prevent MDD. The MDDcare16 Open Innovation in Depression Care Crowd Challenge invited all U.S. entrepreneurs, scientists, physicians, patients and passionate parties to submit their best ideas to help care for those who struggle with MDD. Nine teams were approved to compete in the MDDcare16 Crowd Challenge Showcase on MedStartr.com where the teams with the most support will go on to the finals. Hundreds have voted already and thousands more will in the next four weeks.

Crowd Challenges are online contests where the top teams are selected by a large community of patients, physicians, nurses, therapists, hospital staff and leaders, partners and investors. The five teams that drive the most engagement in terms of likes, follows, tries, adoptions, pilots, partnerships, support, and investor interest will be invited to take the stage to compete in front of a live audience at the 10th Annual Fall Health 2.0 Conference on September 27th, 2016. Two winners will be selected to share in $50,000 in grant funding.

You can vote for MDDcare16 here and you can buy tickets to the Health 2.0 Conference here.

Smallpox

Smallpox: A highly contagious and frequently fatal viral disease that is characterized by a biphasic fever and a distinctive skin rash that leaves pock marks in its wake. Because of its high case-fatality rates and transmissibility and because people haven't been vaccinated against it in years, smallpox now represents a serious bioterrorist threat. The disease is caused by the variola virus. The incubation period is about 12 days (range: 7'17 days) following exposure. Initial symptoms include high fever, fatigue, headaches, and backaches. A characteristic rash, most prominent on the face, arms, and legs, follows in 2 to 3 days. The rash starts with flat red lesions that evolve in 2 to 3 days. Lesions become pus-filled and begin to crust early in the second week. Scabs develop and then separate and fall off after about 3 to 4 weeks. The majority of patients with smallpox recover, but death occurs in up to 30 percent of cases. Smallpox is spread from one person to another via infected saliva droplets as occurs during face to face contact. Persons with smallpox are most infectious during the first week of illness because that is when the largest amount of virus is present in saliva. However, some risk of transmission lasts until all scabs have fallen off. Also known as variola.

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
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ACO Winners and Losers: A Quick Take

By ASHISH JHA, MD

Last week, CMS sent out press releases touting over $1 billion in savings from Accountable Care Organizations.  Here's the tweet from Andy Slavitt, the acting Administrator of CMS:

NEW ACO RESULTS: physicians are changing care, w better results for patients & are saving money. Over $1B. https://t.co/FEfe3QErb5

- Andy Slavitt (@ASlavitt) August 25, 2016

The link in the tweet is to a press release.  The link in the press release citing more details is to another press release.  There's little in the way of analysis or data about how ACOs did in 2015.  So I decided to do a quick examination of how ACOs are doing and share the results below.

Basic background on ACOs:

Simply put, an ACO is a group of providers that is responsible for the costs of caring for a population while hitting some basic quality metrics.  This model is meant to save money by better coordinating care. As I've written before, I'm a pretty big fan of the idea – I think it sets up the right incentives and if an organization does a good job, they should be able to save money for Medicare and get some of those savings back themselves.

ACOs come in two main flavors:  Pioneers and Medicare Shared Savings Program (MSSP).  Pioneers were a small group of relatively large organizations that embarked on the ACO pathway early (as the name implies).  The Pioneer program started with 32 organizations and only 12 remained in 2015.  It remains a relatively small part of the ACO effort and for the purposes of this discussion, I won't focus on it further.  The other flavor is MSSP.  As of 2016, the program has more than 400 organizations participating and as opposed to Pioneers, has been growing by leaps and bounds.  It's the dominant ACO program – and it too comes in many sub-flavors, some of which I will touch on briefly below.

A couple more quick facts:  MSSP essentially started in 2012 so for those ACOs that have been there from the beginning, we now have 4 years of results.  Each year, the program has added more organizations (while losing a small number).  In 2015, for instance, they added an additional 89 organizations.

So last week, when CMS announced having saved more than $1B from MSSPs, it appeared to be a big deal.  After struggling to find the underlying data, Aneesh Chopra (former Chief Technology Officer for the US government) tweeted the link to me:

@RahulRajkumar11 @ashishkjha open data is now the default in government

The Proposed 2018 Notice Of Benefit And Payment Parameters: Part 1

On August 29, 2016, the Centers for Medicare and Medicaid Services released its proposed 2018 Notice of Benefit and Payment Parameters.The proposed rule was accompanied by a fact sheet and CMS blog post. CMS also released on August 29 a draft actuarial value (AV) calculator and AV calculator methodology for 2018.

The “payment notice,” as it is called, is an annual CMS omnibus rule that pulls together in one place all the major changes the agency intends to implement for the next plan year for the marketplaces (in particular the federally facilitated exchange (FFE) and SHOP marketplaces), the premium stabilization programs, and the health insurance market reforms generally.

For the first three years of the marketplaces, the proposed payment notice was released in late November and a final rule in late February or early March. This year the rule has been speeded up for obvious reasons-the Obama administration wants to lay down the ground rules for the 2018 plan year before it leaves office in January, rather than leaving the market to the vagaries and confusion of a presidential transition. The early release may, however, mark a trend, as it does make some sense to release the rule earlier and to give qualified health plan (QHP) insurers more time to adapt to changes.

The proposed rule, preface, and analyses come in at under 300 pages, much shorter than proposed payment notices in prior years. It is very dense, however, containing literally dozens of proposals. Many of these are actually proposals for new rules or changes in current rules. But many others are requests for information or for ideas. Most of the proposals will not go into effect until 2018 or later years, but a few are intended to take effect already in 2017 and a number build on initiatives already underway.

The clear focus of the proposed rule is to strengthen and improve the marketplaces. The accompanying CMS blog post identifies four purposes of the proposed rule:

• Supporting insurers with high cost enrollees and updating risk adjustment;


• Strengthening the marketplace risk pool;


• Improving enrollment growth; and


• Removing obstacles to insurer entrance, growth, and innovation.

Given recent events, this emphasis on stabilizing the marketplaces makes a great deal of sense. The proposed rule, however, contains many provisions that are not so narrowly focused. It includes, for example, routine updates for various charges, thresholds, or limits; clarifications of earlier adopted rules that had been misinterpreted; attempts to align confusing directives dealing with the same or related issues or to achieve efficiencies; and attempts to align federal directives with state requirements.

The Affordable Care Act (ACA) overlaid a complex body of federal insurance law on top of an already extensive body of state health insurance law, and then added specific rules governing the health insurance marketplaces in the individual and small group markets, as well as the premium stabilization programs. The end result is a dense and bewildering jungle of regulatory requirements. Although to lay eyes the payment rule seems to be adding yet another layer of underbrush to this jungle, much of it is in fact intended to hack paths through the jungle to make it easier for insurers, consumers, and states to navigate.

The topics addressed by the proposed rule, and thus this post, include:

• modifications of the ACA's general market reforms (changes to the five-year ban on market reentry upon withdrawal of an insurer from a market, child age rating, and transitions to Medicare and coordination of benefits with Medicare, as well as changes in the medical loss ratio rules to assist new and rapidly growing plans);


• changes in the risk adjustment program for 2017 and 2018; the 2018 payment parameters (the FFE user fee, premium adjustment percentage, and annual limits on cost sharing);


• changes in plan benefits (bronze plan changes, gold and silver plan participation requirements, standardized options, and network requirements); and


• eligibility, enrollment and other changes (special enrollment periods, language access requirements, direct enrollment, and binder payments, SHOP participation requirements).

This first installment will address the general market reforms and risk adjustment program. The next installment will consider changes in plan benefits and eligibility and enrollment changes.

General Insurance Market Reform Changes

Although much of the focus of the debate over the ACA in recent months has focused on the exchanges or marketplaces, the ACA also included major changes in the regulation of health insurance generally, in particular in the regulation of the individual and small group markets. The 2018 proposed payment notice makes a number of tweaks in the rules governing insurance markets generally.

Market Withdrawal

First, rules dating back to the Health Insurance Portability and Accountability Act of 1996 provide that if an insurer leaves an insurance market in a state (individual, small group, or large group), that insurer cannot return for five years. The purpose of this requirement is to discourage insurers from lightly leaving markets with the intention of jumping back in when market conditions become favorable. This rule has been interpreted to mean that if an insurer discontinues all health insurance products it has been offering in a market, it must wait five years to reenter, even if it in fact is prepared to offer new products or if the same products the insurer was offering continue to be offered by a different insurer under common control.

The proposed rule would make it easier for insurers to remain in insurance markets. It would redefine the terms “plan” and “product” to allow a plan or product to be considered the same even though they are no longer issued by the same insurer but rather by a different insurer under common control (in the same “controlled group”). Products will also be considered to be the same products even though they have been modified, transferred, or replaced as long as they meet standards earlier established for uniform modification of coverage.

Under the proposed rule, if an insurer transferred all of its products to a related insurer under a corporate reorganization but maintained continuity of coverage within products in compliance with uniform modification of coverage standards, the transfer would not be considered a market withdrawal that would trigger the five-year reentry ban. The insurer would also not be required to send to its enrollees the discontinuation notice that is necessary when an insurer withdraws from a market, but would rather send a renewal notice. The products would continue to be considered to be the same product for federal rate review requirements.

CMS proposes to determine whether insurers within a controlled group are effectively the same entity using the definition of controlled group that the IRS applies in judging whether a group is a single entity for the ACA's insurance provider tax provisions, although CMS says it is open to alternative approaches. States that have different rules governing market withdrawal could continue to use their own rules.

CMS also proposes a modification in its current rules governing the situation where an insurer remains in market but discontinues all of its products, replacing them with a different set of products. Under current rules, an insurer that discontinues all of its products would be considered to have withdrawn from the market and could not reenter for five years. Under the proposed new interpretation, the insurer could remain in the market even though it is offering all new products.

CMS recognizes, however, that insurers could avoid federal rate review by changing their products every year. To remain in a market while replacing its portfolio of products, therefore, an insurer must identify at least one newly offered product that replaces a discontinued product and subject the new product to the federal rate review process. Federal rate review would apply if the premium increase for the new product was “unreasonable” as defined by the federal rules.

Child Age Rating

The proposed rule would also modify slightly the age rating requirements of current rules. The ACA permits premium rates to vary based on age only within a ratio of 3 to 1 for adults. Current age rating rules provide for a single age band for children aged 0 through 20. The default age factor for this group is .635. This single age factor not only does not accurately reflect claims costs for children (which are highest for children 0 to 4 and lowest for children age 5 to 14), but results in a significant jump in premiums (about 57 percent) when a child reaches age 21.

The proposed rule would increase the current age factor for children up to age 14 from .635 to .765 and would then gradually increase the age factor year by year from ages 15 to 20 to create a smooth transition to age 21. This would make coverage somewhat more expensive for children and less expensive for adults. CMS asks whether this change should be done all at once or phased in over three years. States would continue to be able to set their own age rating curves if they chose to do so.

Guaranteed Availability

The ACA's guaranteed availability requirement allows insurers that offer coverage through a network to limit offers of coverage to employers in the small and large group market that have employees who live, work, or reside in their service area. Federal law does not require that the employer have a principal business address within the service are (although insurers are not required to offer coverage to employers who do not have a place of business in a state).

Some insurers have network sharing agreements with affiliated insurers such that an affiliate is not allowed to offer coverage to an employer with a business headquarters outside of its service area but will offer coverage to employees of an employer covered by its affiliate that live in its service area. (For example, affiliated insurer A would not insure an employer located in the service area of affiliate B but would cover its employees in its service area if the employer was covered by affiliate B). CMS requests comments on whether these arrangements are consistent with the guaranteed availability requirement.

Transitions To Medicare And Coordinating Benefits With Medicare

CMS states in the preface to the proposed rule that it is considering further changes in the application of the ACA's guaranteed renewability provisions to individuals with marketplace coverage who are eligible for Medicare. Current law prohibits the sale of individual health insurance to individuals who are entitled to benefits under Medicare Part A or are enrolled in Medicare Part B when the insurer knows the coverage would duplicate Medicare coverage. Current rules, however, provide that Medicare eligibility or enrollment is not a basis for nonrenewal or termination. Under the proposed modified rules on guaranteed renewability described above, the renewal could be in a different product from the same insurer or in a product of a related insurer within the same controlled group.

Enrollees who are eligible for Medicare tend to be quite costly, and insurers have been questioning whether they should be required to continue to cover them in marketplace plans. On the other hand, marketplace plans may provide more comprehensive coverage than Medicare and thus might be preferred by individuals eligible for Medicare, even though individuals who are eligible for Medicare are likely not eligible for premium tax credits. Providers also prefer marketplace to Medicare coverage, as commercial plans usually pay more than Medicare does.

CMS seeks comments on how the guaranteed renewal requirement and duplication prohibition should be reconciled. Specifically, should renewal of coverage for a Medicare eligible individual be required or prohibited under a variety of circumstances concerning the modification or replacement of products or related insurers? CMS is particularly interested in how requiring or prohibiting renewal in these circumstances will affect consumers and the marketplace and Medicare risk pools.

Medicare payments are always primary to individual insurer payments. Some insurance contracts, however, also make individual insurance payments secondary to Medicare payments where an individual is eligible for but not enrolled in Medicare. CMS seeks comments on whether this should be allowed. It also seeks information on how coordination of benefits rules should apply to Medicare End Stage Renal Disease Medicare beneficiaries.

From 2010 to 2013, HHS operated a preexisting condition insurance program (PCIP). The ACA provided this for consumers with preexisting conditions as a bridge to 2014, when insurers had to offer coverage without regard to health status or preexisting conditions. The statute directed CMS to help these individuals transition into QHP marketplace coverage after 2013. CMS asks in the proposed rule preface for help in identifying former participants in the PCIP, identifying their claims costs and the impact they are having on the current risk pool, and determining steps that can be taken to ensure that they do not experience a lapse in coverage.

Medical Loss Ratio Rules

The ACA's medical loss ratio (MLR) requirements, like the guaranteed availability and renewability provisions, apply to all insurance markets in and out of the marketplaces. HHS laid down the general rules for the MLR in 2010 rules. The MLR statute authorizes HHS to consider the special circumstances of newer plans in applying MLR requirements.

In line with this provision, the original MLR rules allowed insurers to defer experience reporting for policies that were newly issued with fewer than 12 months of experience if these policies contributed to 50 percent or more of the insurers total earned premium in a reporting year. The idea behind this provision was that new policies often have low initial claims experience, but claims accumulate rapidly as the policy ages. New or rapidly growing insurers might therefore have to pay rebates based on excess premium over claims for new policies that are unwarranted given expected experience over time.

The proposed rule would recognize that as of 2014, new non-grandfathered policies must be issued for a 12-month plan year. To encourage entry of new plans and expansion of existing plans, CMS proposes allowing deferral of reporting of new business for insurers where up to 50 percent or more of their premium is attributable to policies with 12 months or less experience. The experience of those policies would need to be reported in the following calendar year.

Beginning in 2014, MLRs are calculated on a three-year rolling average. Insurers can thus offset high and low MLRs over the period, potentially allowing them to pay lower overall rebates. New entrants, however, do not have three-years of experience and are thus disadvantaged by this provision. Insurers that experience rapid growth may also not fully enjoy the benefits of three-year averaging. This may be an entry barrier for insurers that would otherwise like to enter or expand in a market.

The proposed rule would allow insurers the option of calculating their MLR liability for a single year if the insurer recalculates MLR liability for the two subsequent years based on total experience over the time period, with the insurer's rebate liability adjusted to take account of earlier payments. The proposal is more complicated than this, and is not only explained at length but also illustrated with an example in the preface, but the basic idea is to give new entrants and rapid expanders the same advantage that three-year averaging gives long-term market participants.

The Risk Adjustment Program

A primary purpose of the payment notice is to set the parameters for the ACA's premium stabilization programs. The ACA included three of these: the temporary reinsurance and risk corridor programs and the permanent risk adjustment program. The reinsurance and risk corridor programs ended in 2016, and thus are not covered by the 2018 payment notice. The proposed rule, however, discusses significant changes to the risk adjustment program for 2018 and a few changes for 2017. It also requests comments on a number of other potential risk adjustment changes.

The risk adjustment program is intended to transfer funds from non-grandfathered plans that cover lower-cost enrollees in the individual and small group markets to non-grandfathered plans that cover higher-cost enrollees; it is designed to remove incentives for insurers to risk select. The proposed rule builds on extensive discussions concerning the risk adjustment rule that have taken place over the past year. In March, CMS issued a White Paper discussing potential changes in the risk adjustment program and in May it held an all-day forum further exploring changes. The proposed rule moves this discussion forward and proposes adoption of some of the changes mooted earlier.

The proposed rule begins the risk adjustment section by dealing with some technical issues. In accordance with the 2017 federal budget, 6.9 percent of reinsurance funds and 7.1 percent of risk adjustment funds will be sequestered for 2017. That is to say, the total amount collected from insurers for risk adjustment will be reduced by 7.1 percent before payments are made to insurers. The sequestered funds may become available in 2018.

The proposed rule would also clarify that insurers should use counting methods determined by state law to decide whether an employer is a small or large employer for purposes of the risk adjustment and risk corridor programs as long as the state counting method takes non-full time employees into account. A small employer that becomes a large employer but continues to participate in the SHOP program should continue to be considered a small employer.

Beginning in the 2017 benefit year, CMS intends to treat states that combine individual and small group experience to establish a market-adjusted index rate as merged markets for purposes of applying the federal risk adjustment formula; this will be true even if a state has not merged the individual and small group market for other purposes, such as requiring calendar year coverage and not allowing quarterly rate adjustments for small-group coverage.

Focusing on changes to the risk adjustment model itself; CMS proposes modifying the risk adjustment formula beginning in 2017 to account for partial year enrollments. CMS has concluded that the current formula undercompensates plans that have disproportionately more partial year enrollments. This may be because short-term enrollments are associated with sudden high-cost acute episodes of care.

Beginning in 2017, adjustments for partial year enrollments of from one to eleven months will be considered as a factor in the risk adjustment adult model. Since HHS intends to finalize the payment notice before 2017 begins, and because it had already given notice of this potential change, this adjustment to the 2017 model is still possible.

Adding Prescription Drug Information To The Risk Adjustment Model

CMS is proposing more changes for 2018. First, as discussed in the White Paper, CMS is proposing to incorporate prescription drug utilization into its model. Drug prescribing information can be useful in risk adjustment both to identify high-risk conditions missed by the current model-which is based on recorded diagnoses-and to better establish the severity of conditions that are identified by the current model. Conditions may also be identified sooner and more easily and accurately from prescribing than from diagnosis information.

Adding prescribing data, however, increases the complexity of the model and creates incentives for over-prescribing. Drug use may also vary based on factors unrelated to risk, such as access to pharmacies or high cost-sharing. And many drugs may be used for both high- and low-cost conditions.

Working from United States Pharmacopeia (USP) drug classifications and applying the set of principles described in the White Paper and in the proposed rule preface, CMS has developed a set of prescription drug categories (RXCs), each of which is associated with a particular hierarchical condition category (HCC) or group of HCCs. CMS is proposing to incorporate a small number of drug-diagnosis pairs into a hybrid model that could impute diagnoses otherwise not coded or might indicate the severity of conditions otherwise indicated by medical coding. RXCs can be linked with more than one HCC and vice versa.

CMS is proposing initially a dozen RXC categories, ten of which can be used for imputation of a condition and for determining the severity of a condition and two for severity only. The drug categories are limited to those where the risk of unintended effects is low, but CMS intends to monitor prescribing for unintended effects and make changes as warranted.

CMS is also proposing to separate the current chronic hepatitis HCC into two new HCCs, one for Hepatitis C and the other for Hepatitis A and B, raising the total number of HCs to 128.

Using Risk Adjustment To Replace Reinsurance: Incorporating Very High Cost Cases Into The Risk Adjustment Formula

CMS further proposes modification of the risk adjustment formula for 2018 to take into account very high cost conditions. CMS is thus effectively planning to use the risk adjustment program to replace in part the reinsurance program which has been phased out. Although the current risk adjustment program accounts for higher than average cost cases, it does not adequately compensate insurers for very high cost cases, and thus does not adequately discourage risk selection against such cases.

The proposed change to the model would, using data from the EDGE servers, calculate the total amount of claims paid for high cost enrollees, defined as enrollees with costs in excess of $2 million. The costs of high cost enrollees would be pooled across all states and across the individual market (including catastrophic and non-catastrophic plans and merged markets) and small group markets. One pool would be established for the individual and merged markets and another for the small group market.

Insurers who incur claims in excess of $2 million would be reinsured through the risk adjustment program for 60 percent of the excess cost. They would continue to bear 40 percent of the cost, providing a clear incentive for managing cost. Risk adjustment transfers would be adjusted by a percent of premium to account for the cost of this program. CMS believes that this modification of the formula would only affect about 0.1 percent of premiums in either market but will help out insurers that incur extraordinarily high cost cases.

Rebalancing Rewards For High Risk And Low Risk Enrollees

CMS is also considering changes to the risk adjustment program to account for the belief that the current program overcompensates plans for high risk enrollees and undercompensates plans for low risk enrollees. One approach would be to use a two-step constrained regression model that would first estimate the adult risk adjustment model using only age and sex variables, and then re-estimate the full set of HCCs using the age-sex coefficients derived from the first estimation. This would put a greater emphasis on demographic variables as compared to medical condition variables than does the current model.

CMS briefly mentions other possible models that could better account for the cost of healthy populations. Alternatively, CMS is considering approaches that would directly adjust plan liability risk scores outside the model for certain sub-populations. Finally, CMS is considering alternative approaches for community rated states that use family tiering rating factors.

CMS is proposing changing its current rule so that it could provide final risk adjustment coefficients in guidance right before risk adjustment scores are calculated, rather than in the payment notice, so that it could incorporate more current data. Under this approach 2015, 2016, and 2017 MarketScan ® data could be used to produce blended coefficients in the spring of 2019 for 2018 risk adjustment calculations, while under the current rule the coefficients must be published for 2018 by spring of 2017 (or this year, in 2016), using 2013, 2014, and 2015 data.

CMS is also considering using data on actual enrollees drawn from the EDGE servers to calibrate the risk adjustment model. MarketScan® data is drawn from employer-sponsored plans, a different population than that found in the individual and small group markets. Beginning in 2019, CMS is considering using data drawn from the EDGE servers of individual and small group market plans-masked for enrollee ID, plan/issuer ID, rating area, and state-to recalibrate the risk adjustment model as well as the actuarial value calculator and methodology. The database could also be useful for other public programs and for researchers.

The Payment Transfer Model: A Decision To Continue Removing Plan Administrative Costs In Calculating Transfers

Once the risk adjustment model is applied to data provided by the health plans to calculate a risk score, the payment transfer model is applied to transfer funds among plans based on their relative risk scores. As already mentioned, CMS is proposing for 2018 to create a nation-wide high-cost outlier pool within which funds would be transferred to insurers with high cost cases to cover 60 percent of their costs above $2 million. The remainder of the risk adjustment funds will continue to be pooled at the state level and transferred among plans based on the relative member-month weighted plan average of individual enrollee risk scores of plans (adjusted for allowable rating and other factors) within a rating area.

The transfer formula has received substantial criticism. CMS believes, however, that it is working properly and does not intend to change it at this time. Specifically, it does not intend to remove administrative costs from statewide average premiums in calculating the transfers. CMS believe that, while this could reward efficient plans, it could also could penalize plans that have higher administrative costs because they have higher risk enrollees. CMS will continue to consider this and other proposals.

CMS is proposing to base the risk adjustment user fee on billable member months rather than enrollee member months, thus excluding from the charge children who do not count toward family rates or premiums. For 2018, CMS is proposing a user fee of $1.32 per billable enrollee per year (.12 per member per month). This is less than the 2017 fee of $1.56 per enrollee per year.

CMS requires health plans participating in the risk adjustment program to engage an entity to perform an initial validation audit which is in turn validated by CMS through a second audit. As of 2018, this validation will include pharmacy information. The cost of these audits is quite high. Beginning in 2017, CMS is proposing to implement a materiality threshold of $15 million in total premium. Insurers with premiums below this threshold would be subject to random and targeted audits, including likely an audit every three years, but not to annual audits. CMS estimates that only 1.5 percent of plan membership nationwide would be covered by plans with premium below the threshold. Insurers not subject to audit would still have their premiums adjusted by an error rate, perhaps a national or state average or the error rate of the insurer in past audits.

Finally, the proposed rule would provide an interim discrepancy reporting process for insurers to contest (within 15 days) the initial validation audit sample provided by HHS; it would also provide a final discrepancy reporting process through which an insurer can contest (within 30 days) the results of the second, CMS, validation process and the calculation by CMS of a risk score error rate. Insurers can request a reconsideration of or appeal only CMS processing errors, incorrect applications of the relevant methodology, or mathematical errors.

If a problem could have been identified through the discrepancy process, reconsideration and appeal will only be allowed if the problem was identified and remained unresolved. Risk adjustment charges will not be adjusted until 2016, and thus reconsiderations and appeals are not available until 2016 data is validated.

Hypothyroidism

Hypothyroid: Deficiency of thyroid hormone which is
normally made by the thyroid gland which is located in the front of
the neck:

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
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The Need For Additional Flexibility In Medicare Advantage

The Centers for Medicare and Medicaid Services (CMS) has recently exercised its Section 1115A waiver authority to allow Medicare Advantage plans in seven states to offer benefit flexibility in the form of Medicare Advantage Value Based Insurance Design (MA-VBID). The model will launch on January 1, 2017 and run for five years.

The intent of the MA-VBID model is to incentivize high value utilization of health care by restructuring enrollee cost sharing and other benefits to be more clinically nuanced. Under VBID, enrollees face low or no cost for high-value clinical services but may have higher out-of-pocket costs for low-value services. The ultimate goal of the MA-VBID model is to determine whether a flexible plan design based on value can help improve health outcomes and lower expenditures for targeted Medicare Advantage (MA) enrollees. MA plans that are part of the demonstration will be able to offer varied plan benefit design for enrollees who fall into one of seven groups defined by the following clinical conditions: diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure, past stroke, hypertension, coronary artery disease, and mood disorders.

Under Medicare Part C today, CMS establishes county level benchmarks for health plans to bid against. Health plans bid to provide Medicare Part A and Part B services to a “standard” Medicare patient. When bids are below the benchmark, plans receive a “rebate” that ranges between 50 and 70 percent of the difference (depending on their star rating) between the benchmark and the bid. The rebates are funded through lower cost sharing or an additional premium and are used to provide supplemental health benefits not covered under Part A or B such as dental, vision, hearing, and preventive services. Other services such as meals and transportation may be provided to beneficiaries but they are limited and need to be tied to health related issues and available to all members of the plan.

Per CMS regulations, health related supplemental benefits must “prevent, cure, or diminish an illness or injury” and not be used for “comfort, cosmetic, or daily maintenance.” CMS reviews all supplemental benefits and utilizes a test based on national typical usage and community patterns of care to determine if the item or service is “health related.” However, rebates cannot be used to provide valuable social services such as help at home, home energy needs, and other social determinants of health. Allowing plans clinical flexibility to use their rebates to add both health and social service benefits with the rebate would enhance patient care.

The move to test VBID under Part C of Medicare represents a move towards flexible, individualized plans that promote the consumption of high-value clinical services. Indeed one of the reasons why MA plans have generated lower costs than traditional Medicare is the flexibility they have to design prevention and care coordination strategies to treat patients that are not available in traditional Medicare. The demonstration is another step in the right direction of providing treatment flexibility.

However, it could go further and rather than target some chronically ill patients, it could allow plans to provide additional social services to all enrollees with their rebates that affect health care outcomes. A major avenue into high-quality care and cost savings is in the provision of social services that impact health. While social determinants of health are often addressed outside of the health care system, there is evidence that shows positive associations between social services spending and better health outcomes. In a recent Health Affairs article, Elizabeth Bradley et. al found that “states with higher ratios of social to health spending had better health outcomes one and two years later, compared to states with lower ratios.” This suggests that there is value in using some of the plan rebates to address social needs, such as nutrition and housing.

Social Determinants of Health

Access to affordable transportation is a major obstacle that low-income populations face. This barrier can impact an individual's ability to access much needed medical care, attend medical appointments, and keep up with preventative services. In 2003, the Government Accountability Office (GAO) reported that “the coordination of transportation services across government programs not only improves the quality but also increases the cost-effectiveness of service.” Access to nutritional meals is another barrier often faced by individuals who have been recently hospitalized. These individuals may be unable to shop for groceries or prepare meals and as a result their recovery may suffer. While the research on home-delivered meals has been more descriptive than outcome focused, nutritional services have been shown to decrease hospital readmissions and improve health of enrollees.

Some health care insurers have taken steps to cover benefits that aim to address social determinants of health. For example, Medicaid incorporates the provision of certain social services such as non-emergency medical transportation and home meal deliveries post-hospitalization, into their coverage.

CMS requires that states provide non-emergency medical transportation (NEMT) to eligible, qualified Medicaid beneficiaries. This service is an attempt to help low-income beneficiaries, who may be unable to afford transportation, access needed medical care. NEMT enables enrollees to have consistent access to medical services such as preventative care, which can help stop medical needs from escalating. Medicaid's NEMT requirement has been shown to have positive effects such as fewer missed appointments, fewer emergency room visits, and reduced length of hospital stay.

Providing NEMT has been shown to be cost-effective for a wide range of medical conditions and has actually been shown to be cost-saving for asthma, congestive heart failure, chronic obstructive pulmonary disease, and prenatal care. Medicaid also has home and community-based services waivers (HCBS Waivers), which enable states to provide additional targeted benefits, such as habilitation services, delivered meals at home, and personal care for beneficiaries who wish to receive services in their home. State level studies have shown that expanding the HCBS Waivers results in cost containment and slower spending growth rates. The studies reported lower per-individual average costs compared with institutional care, even in cases where absolute cost savings were not documented.

The Affordable Care Act's Medicaid Health Home Initiative is an additional avenue through which Medicaid funds the provision of social services to enrollees. Health Homes are structured so as to provide better and more comprehensive care for the patient. They incorporate and promote coordination among medical care, behavioral health care, and long-term community based services. States are required to evaluate their cost savings, but so far these have not been measured in a uniform manner. The program's overall effect on cost will be reported in 2017 as part of an independent longitudinal analysis.

Cost Savings

Many private providers have engaged in similar models of care to that of the Medicaid Health Home and have become certified as a patient-centered medical home (PCMH). These care models utilize various payment models such as capitated payments, shared savings arrangements, and hospital readmission penalties in an attempt to lessen health care costs and promote high-quality care. PCMHs incorporate social services as an attempt to address the health of the whole person and lessen overall health costs.

Cost savings have been reported from several different PCMH programs: Geisinger Health System has reported savings in acute inpatient care and the Pennsylvania Chronic Care Initiative has reported cost savings in their highest risk patients. A recent evaluation by RTI found that community health teams in Vermont delivered a 3-to-1 return on investment for Medicare. This is in part linked to the design of the teams care coordination functions, which include the Support and Services at Home (SASH) program that leverages services from social service agencies, community health workers, and non-profit housing services to improve health care outcomes.

Medicare and Medicaid have coordinated to create The Program of All-Inclusive Care for the Elderly (PACE), which does include social services. PACE is a Medicare program and a Medicaid state option that provides comprehensive home and community-based support to low-income, community dwelling seniors. Individuals are able to join PACE if they meet the following criteria: age 55 or older, live in the service area of a PACE organization, meet eligibility for nursing home care, and are able to live safely in the community. PACE services include adult day care, meals, transportation, social services, and more.

What the enrollee is required to pay for PACE depends on their financial abilities and the program through which they are accessing PACE long-term care services. If PACE is accessed through Medicaid then there is no required monthly premium, but if it is accessed through Medicare then there is a monthly premium and a premium for Medicare Part D drugs. In 1998, it was reported that costs for PACE enrollees were 16-38 percent lower than Medicare fee-for-service costs for a frail elderly population. The PACE program has also shown to cost 5-15 percent less than costs for comparable Medicaid beneficiaries.

Another route through which a Medicare recipient may receive limited social benefits is through a Medicare Advantage (MA) plan, as these plans may cover more, with extra services or an expanded amount of coverage. For example, CarePlus MA plans offer several different benefit choices, which may include transportation to plan approved locations and home meal delivery following hospitalization.

Other MA plans have similar comprehensive benefit packages. For example, Humana MA provides meals to their eligible members through their Humana Well Dine benefit at no additional cost. This service is for members recovering from an inpatient stay in a hospital or skilled nursing facility and for some Humana Medicare members who are enrolled in a qualified chronic-condition special needs plan.

Providing plans greater flexibility to provide both additional health care services and social services through the rebates received by MA plans may be a route to higher quality and more effective care.

What's Wrong With Medicine? You Decide.

By ROBERT McNUTT, MD

I have practiced medicine for over 40 years. I have yet to find a physician without a chronic disease in question who is smarter than the person with that chronic disease. I have been impressed that a patient's numeric insights and intuitions when they are ill surpass their skills when they were not ill. All a patient needs is information, in all its glory and messiness, to know if the information is worth anything to them when they face a medical decision.  Patients, in my view, are the best information managers and evidence experts I have ever seen, and I know a bunch of evidence experts to draw upon for the comparison. My interpretation may be biased, but I have been doing shared consults with patients for twenty plus years and I have learned that patients are smart. Consider the following:

1. The man had been advised to have surgery. The man and his wife stared in stunned silence at the data on prostate cancer treatment outcomes with surgery. The study was described in detail including a description of the people who were studied. The wife finally spoke, “You mean to tell us you want my husband to have surgery when so few have been studied! You mean to tell us that not a single person of our cultural heritage has been tested in the study?” I responded and reminded, “I am not asking you to have surgery. We are going over information of potential benefit and harm that you must balance for your choice.” They were kind in response, refused to consider surgery or further discussion, and, instead, chose to enter a clinical study.

2. The patient had been advised to have a CT to screen for cancer. He exclaimed, “Let me get this straight. You are saying that out of nearly 55,000 people studied, there were only about 30-80 fewer deaths from lung cancer over nearly 5 years if a low dose computerized scan (LDCT) was done rather than a chest-x-ray?” I replied, ''Yes, that is correct. There were, remember, about 100 fewer patients dying of any cause if they received the LDCT rather than the chest-x-ray.

As you also know, alternatively, about 10 extra people getting the LDCT died or got a complication within 60 days of the exam due to the work-up of abnormal findings on the exam. That is your trade-off for having a LDCT; a potential small benefit in the future balanced by a potential small chance of dying or having a severe complication early due to a work-up”.  He replied, “I am not a scientist, but these numbers represent miniscule differences. The study could be wrong. I am not willing to take the LDCT scan based on the data”.

Medical care has been described as a, “philosophy informed by science”.  There is a subtle problem with this view, however. This comment suggests that evidence informs the philosophy of how medical care should be delivered. It may be, however, as others have suggested, that evidence might be produced in biased ways by the prevailing philosophy. If this is true, then we have to sit up straight and reconsider our philosophy of medical care.

So, here is what's wrong with the present practice of medicine. The totalities of medical care delivery, the cost, the inequality, the profit margins for some and not others, the arguments, and political plotting are meted out by decisions made. Those who make decisions are those who define what the practice is.  The problem with medical care is that physicians decide. This is philosophically dysfunctional. Physicians should not, and should never have, made decisions for their patients. For sure, in an acute situation, acute care experts must make decisions. But, there is no such thing as a physician chronic care decision expert. Only patients are experts. They are the only ones who can know if one option is worth more than another based on the absolute differences engendered by the comparisons and their preferences for said differences.

The patients above compared the options proposed to them and chose in contrast to their physicians' decisions. These people embodied the appropriate philosophy that medical care is theirs to define. Their idea is the fix for medical care. If physicians followed these patients' philosophy, physicians could be worthy of being the patient's partner; if physicians do not, they are doomed to follow a problematic philosophic stance. Trying to fix medical care based on a philosophy that allows physicians to be the decision makers will be like trying to float a sinking battleship with bubble gum. It is impossible to overcome a poor philosophy of care with edicts, ruminations, and patchwork insurance fixes. It is time to rethink the goals of best medical care; patients will tell us what evidence is worthwhile and what their care is worth. It will never work the other way around.

Pseudomonas infection

Pseudomonas infection: Infection usually with Pseudomonas aeruginosa, the versatile "blue-green pus bacteria" that opportunistically infects people, especially those who are immunocompromised. Pseudomonas rarely causes infection in healthy individuals but it is a major cause of hospital acquired (nosocomial) infections. It tends to infect people with immunodeficiency or burns and those with indwelling catheters or on respirators. Infection with pseudomonas can lead to urinary tract infections, sepsis (blood stream infection), pneumonia, pharyngitis, and many other medical problems. Pseudomonas colonizes the lungs of patients with cystic fibrosis (CF) and contributes to the chronic progressive pulmonary disease and death rate in CF.

Pseudomonas normally resides in the soil, marshes, and coastal marine habitats. It can survive under conditions that few other organisms can tolerate, it produces a slime layer that resists phagocytosis (engulfment), and it is resistant to most antibiotics. Pseudomonas can multiply in an extraordinary assortment of environments including eyedrops, soaps, sinks, anesthesia and resuscitation equipment, fuels, humidifiers and even stored distilled water. It has also been reported in kidney dialysis machines. The characteristic color of the pus is due to a bluish pigment (pyocyanin) and a greenish pigment produced by pseudomonas.

The complete sequence of the genome of Pseudomonas aeruginosa has been determined. Published in Nature (Stover et al. 406:959-964, 2000), it was the largest bacterial genome sequenced to that time. The 6.3-Mbp genome contains 5570 predicted genes on one chromosome.

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ASPE: Medicaid Expansion Lowers Marketplace Premiums

On August 25, 2016, the Office of The Assistant Secretary for Planning and Evaluation (ASPE) released a report titled “The Effect of Medicaid Expansion on Marketplace Premiums.” ASPE concludes that Marketplace premiums are about 7 percent lower in Medicaid expansion states than in states that have not yet expanded Medicaid.

States that have expanded Medicaid under the Affordable Care Act (ACA) cover adults up to 138 percent of the federal poverty level (FPL) under their Medicaid programs. Financial assistance through advance premium tax credits and cost sharing reduction is not available in those states for individuals with incomes below that level except for lawful immigrants who have been in the United States for less than five years and are thus not eligible for Medicaid.

In states that have not expanded Medicaid, individuals with incomes between 100 to 138 percent of the FPL are not eligible for Medicaid but can access financial assistance through the marketplaces. In fact, in states that have not expanded Medicaid, individuals with incomes between 100 and 138 percent of FPL constitute 40 percent of marketplace enrollees, while in states that have expanded Medicaid, individuals in this income range make up only 6 percent of enrollees.

ASPE reports that the scientific literature shows a persistent connection between low-income and poor health. Most diseases are more common among the poor and near-poor of all ages. Poverty is connected with faster progression of diseases, more complications, and worse survival rates. About 20 percent of people with incomes between 100 and 138 percent of poverty report poor or fair health compared to 8 percent of individuals with incomes above 138 percent of poverty. It would thus be reasonable to expect that the share of enrollees with fair or poor health would be about 2 percentage points higher in non-Medicaid expansion states.

It is not surprising, therefore, that in 2015, as ASPE reports, marketplace premiums for the benchmark second-lowest cost silver plan were about 8 percent lower in states that had expanded Medicaid than in states that had not. There are many differences between expansion and non-expansion states, however, that could explain differences in premiums, so ASPE's analysis went further.

ASPE paired bordering counties in expansion and non-expansion states. These counties were relatively homogenous in terms of demographic characteristics. Only states using the Healthcare.gov platform were included in the analysis. ASPE found 94 county-pairs in 19 states meeting its requirements.

ASPE then examined the differences in premiums between the paired counties, using regression analysis to control for population characteristics, state policies that might affect premiums (such as rating area design or allowance of transitional policies), and market characteristics (hospital concentration, number of insurers in the marketplace). ASPE weighted the regressions for marketplace enrollment. It had sufficient data on 91 of the county pairs to perform this analysis.

ASPE concluded from this analysis that Medicaid expansion was associated with 7 percent lower age-adjusted marketplace premiums for the second-lowest cost silver plan in the matched border counties. Results were consistent for analyses performed on the lowest-cost silver plan, average silver plan, lowest-cost bronze plan, and average bronze plan.

The ASPE results suggest that Medicaid expansions not only benefit individuals eligible for the expansions, including individuals with incomes below 100 percent of the FPL who are not eligible for financial assistance through the marketplaces and individuals with incomes between 100 and 138 percent of FPL who receive more affordable coverage with Medicaid; they also benefit state residents with higher incomes who obtain coverage through the marketplaces, or indeed in the individual market outside the marketplaces since the entire individual market outside of Medicaid is a single risk pool.

The press release accompanying the ASPE study also notes that Medicaid expansion improves the health of newly eligible residents in states that expand. It also reduces the uncompensated care burden of providers in those states and saves the states behavioral health costs.

A Warning Label For Healthcare E-mail?

BY JIM PURCELL

Eric Jones, the CEO of a large hospital, is at the end of a long day.  It's 10 PM, he's very tired, and has had his maximum of three drinks.  He's checking his emails and sees one from Ralph Smith, CEO of a small community hospital, rejecting Jones' offer to joint venture hips and knees.  The small hospital has rated tops in those categories, and Jones had hoped to achieve a quality and marketing coup by joining forces, perhaps as a prelude to acquisition.  This rejection was the last straw, particularly since Smith and Jones never had gotten on very well.  Immediately, Jones whipped off an email excoriating and libeling Smith and his hospital, misrepresenting what happened in negotiations, and threatening to “go to war” and “destroy” him and his hospital if they don't “play ball.”

Think that far-fetched?  Nope.  Things worse than that have happened with astonishing regularity.  Assume that when Smith opens and reads that email the next morning, he then forwards it to his senior staff and the hospital's litigation lawyer.  The lawyer confirms that it's not only actionable for libel, but could constitute a violation of antitrust law, where damages can be trebled and attorneys' fees recovered.

Then one of the small hospital's senior staff decides to forward the email “without attribution” to one of his friends who is a local investigative reporter.  Two mornings later, the email, in its entirety with only obscenities deleted, appears above the fold on page one of the local newspaper, and a summary, with several choice quoted sentences, are run on local TV and radio news, just below a terribly unflattering photo of Eric Jones.

At that point, would you like to be Eric Jones?  Would you like to face his board of directors?  And the coming lawsuits, talk show commentary, blogs, etc.? Dust off the resume Eric.

We all use email.  Some 90% of Americans do today.  Some misuse it famously, as we see in the election cycle press every day, and with predictable results.  Because email IS different.  It's not the same as a face to face discussion, or even a phone call.

Clearly, the ubiquitous use of email has blinded many of us to its dangers.  Accordingly, the purpose of this piece is to discuss some of those dangers via do's and don'ts.  And for sure, healthcare is particularly apt for caution given that unauthorized disclosure of personally identifiable confidential healthcare information brings with it an avalanche of very nasty consequences.

Let's first consider everyday business use of emails.  We start with the “10PM Rule.”  The 10PM Rule says: “Never, ever, send a confrontational or angry email after 10PM.  Ever.”   If it's a really bad one, they'll assume you were drinking or worse.  At best, you exercised poor judgment because you were tired and cranky, not exactly inspiring confidence either.  It even has a name:  “email flaming.”

Truth is you should try to avoid sending any confrontational emails.  Yet so many people avoid confrontations by using confrontational email as a substitute.  Face to face is so much better for more reasons than we have space to write. And once the email is sent, the recipient feels she MUST respond, usually in kind, to “set the record straight.”  And there is now a “record” for the world to see if it really wants to.

The temptation to copy others must be avoided.  Don't make more of a spectacle out of yourself than you just did.  You've just turned what should have been a private discussion into a public washing of the dirty laundry.  Don't make it worse.  Moreover, emails too often get missent, or miscopied; and those who were erroneously copied just love forwarding something juicy to their 50 best friends, and it becomes, how do we say, viral.  All a bad email needs is a single recipient who wants to do you harm by forwarding it to your regulator, your enemy, your competitor, your boss, or your spouse.

Arguments by email are the height of inefficiency.  Write, respond, write, respond, claim, counterclaim, and never resolve.  Tit for tat.  And, email is decidedly NOT the medium for extended discussion of complex issues.

And extremely important:  email causes misunderstanding all too often.  One does not see the sender's face, expressions, and gestures, nor hear the tone of voice which is so important.  Tone, emphasis, and meaning count for much in communication.  A surprisingly high percentage of face to face communication comes from nonverbal, well over 50%.

And what about labelling it “confidential” or some such?  Meh.  That almost ensures it will catch someone's eye or end up in the absolutely wrong person's in box.  It also is one of the best ways to unintentionally waive the attorney client privilege if sent to the wrong person.

Emails never die and can always be retrieved, even if you've deleted them and your history, and crushed your computer with a sledgehammer.  Never die, get that?  Servers somehow retain them, despite best efforts to make them go away.  We also are reading all about that in the news during this election year.

So what do you do?  Try the following:

Avoid using email for:

• Confrontations


• Slurs or socially unacceptable commentary


• Judgmental commentary


• Jokes of any kind (I really mean this one)


• Confidential or sensitive business information, or privileged information, unless as advised by your attorney


• Write your emails with minimum use of adjectives and adverbs-stay factual


• Never, never use military or sports terms to juice up your point (in my organization, that was a CLM (Career Limiting Move)


• Write your email as if it WILL IN FACT somehow end up in the hands of your competitor, enemy, or the local newspaper, or Facebook


• Oh, speaking of Facebook, avoid business or sensitive personal communications there at all costs

If you have any doubts after drafting an email:

Keep it in draft and wait a day to reread it.  Your judgment might have improved.

Triple check that it is going to the right person and only that person.  Those chain emails have a nasty way of going to everyone despite your best effort to limit it to just one person.  I've been embarrassed in exactly that way.

Physician use of email can enhance communication with patients AND improve care.  After all, almost all Americans use and rely on email today as their primary communication tool.  But it's tricky.  Many payors do not yet reimburse physicians for emails, so it's not exactly a revenue driver, yet. But leave that aside.  If physicians decide they will use email because it enhances the relationship and the level of communication, they should consider the various legal and other risks and take the necessary steps to lessen those risks.

Patients who wish to communicate with their physician via email should be informed of the risks and sign a document whereby they assume risks inherent in email.  It would be well to seek legal advice for particular federal or state legal requirements or prohibitions.  State statutes on confidential healthcare information protection vary widely.  And there are HIPAA and HITECH, etc.

Note also that under HITECH, physicians are required to provide patients access to their information in the form and format requested by the patient.  That may well be electronically by email.  “Reasonable safeguards” must be in place to protect electronic transmission of such information.  So emails probably cannot be completely avoided.

As we've seen, it is impossible to absolutely guarantee the security and privacy of email.  Thus, all you can do is minimize the risks as much as you can.  Check for applicable guidelines (e.g., AMA).  Internal process should be adopted incorporating such guidelines.  If the practice has its own website, a secure website portal should be considered as the way to email.  Encryption also helps, but both parties must be able to use the encryption.

To summarize:  electronic communications can be wonderfully efficient, speedy, and practical in all sorts of contexts, including healthcare.  But please understand the risks inherent in its use, and take the common sense steps to protect yourself and others.

 

Phlebitis

Phlebitis: Inflammation of a vein. With phlebitis, there is infiltration of the walls of the vein and, usually, the formation of a clot (thrombus) in the vein (thrombophlebitis). Phlebitis in a leg, for example, causes the leg to swell with fluid (edema). Phlebitis can be superficial and not very serious, or it can be deep and carry the potential for dislodging blood clots to the lungs.

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Funerals For Friends: How Public Health In Colorado Handles Growing Prescription Drug Misuse

A health leader from Colorado's stunningly beautiful but economically challenged San Luis Valley sobered an afternoon crowd by declaring that his rural community was “flirting with an epidemic” of opioid overdoses and deaths.

Hours later, statewide experts called that assessment of substance use in the West too optimistic. “It's more like a shotgun wedding with an epidemic,” pronounced Robert Valuck, an epidemiologist, professor at the University of Colorado Denver Skaggs School of Pharmacy and Pharmaceutical Sciences, and coordinator of the Colorado Consortium for Prescription Drug Abuse Prevention.

The opioid painkiller epidemic, leading directly to use of cheaper and even more dangerous heroin, is all too real in every state of the union, Valuck warned his evening audience on the opening night of the Colorado Health Symposium 2016. Valuck elicited audible gasps from the crowd when he offered a math lesson in modern opioid prescribing-enough scripts are now written in the United States each year to give every adult a Vicodin every four hours for an entire month.

In Colorado's rural southern counties, where overdose death rates are climbing at an alarming rate, the destruction is all the more visible, said Freddie Jacquez, executive director of the San Luis Valley Area Health Education Center. “We know these people,” Jacquez said. “We're going to a lot of funerals.”

Intense and often emotional discussions of substance use were purposely programmed into the Colorado Health Foundation's 2016 forum in Keystone, Colorado. Substance use and other behavioral health issues were among the top community concerns at nearly every stop on a six-month listening tour of every county in the state undertaken by foundation president and CEO Karen McNeil-Miller. Unprompted, national health leaders invited to the conference also painted vivid portraits of substance use problems from their own work, including Baltimore Health Commissioner Leana Wen's battles to save a teenage patient in the emergency department (ED) who was addicted to pain pills.

Moderators at the symposium framed the talks this way: Colorado is in the midst of a unique experiment with its residents' capacity to handle a flood of mind-altering substances.

• Overdose deaths from opioid abuse have tripled or quadrupled in many counties, reflecting a national epidemic that has pushed prescription drug deaths above even car accidents and guns in causing injury-related deaths.


• Colorado is on pace to sell well more than $1 billion of legal marijuana in 2016, and while teenage use appears flat so far, the culture of drug acceptance worries many in the addiction treatment community.


• More and more babies are being born with marijuana or opioids in their systems in cities ranging from Denver to Aurora to Pueblo-thus, taxing hospital and community health services.


• Tourism and economic development officials celebrate Colorado's growing status as a pioneer in craft beer, yet binge drinking and alcoholism rates combine with other substance use to spotlight the state as a multidrug threat for abuse in federal statistics.

Valuck noted that state government officials and public health leaders are working to slow the flow of prescription opioids by improving the state prescription monitoring database and training doctors on the importance of checking it. But only seven states-not including Colorado-actually require doctors to check the database for abuse before issuing a new prescription, Valuck added.

Physicians can be hard pressed to use a complex database to track prescriptions and fully educate patients about the dangers of drug misuse and addiction when they practice in health systems often designed around twenty-minute appointment blocks, said Ingrid Binswanger, a practicing physician and senior investigator at Kaiser Permanente's Institute for Health Research. Patients arrive suffering real pain, and physicians must balance the risk of addiction with their professional obligation to offer help, she said.

Many people recovering from addictions would like the chance to sit down with prescribing providers and help them understand the reality of opioid use, said Austin Eubanks, a program director at The Foundry treatment center, in Steamboat Springs. Eubanks brought his personal story to the symposium, where he explained how his injuries from being a shooting victim in the 1999 Columbine High School massacre, and the psychological trauma of seeing a friend murdered in the school's library, led him to addiction.

Doctors and counselors need to help patients work through their mental health issues before prescribing mind-numbing opioids for pain that will delay holistic recovery and risk addiction, Eubanks said.

Back in Colorado's San Luis Valley, a growing network of community activists and agencies are trying to focus on what substance use issues they can control first. Jacquez worried that funding for the substance use fight in the San Luis Valley will end just as they are knitting together the right coalition. “We didn't get here overnight, and we're not going to get out of here overnight,” he told his audience.

Jacquez said the concept of slowing the supply of opioids can seem daunting, and what he and his colleagues need to do right now is keep people alive.

Health leaders are trying to spread the highly effective anti-overdose drug Naloxone-which anyone can administer through a nasal spray -to as many community sites as they can. They have already saved lives by getting this opiate-countering drug as close to at-risk addicts as possible, Jacquez said.

Save people first, and they can live to fight their addiction for another day, as Jacquez put it. Both Jacquez and Wen dismissed recent worries that Naloxone is merely an enabler, giving addicts a false sense that they can overdose without consequence.

If a girl with a peanut allergy walks into her Baltimore ED in reactive shock, no one says, “We're not going to give you the Epi-Pen because you might eat peanuts again,” Wen said. That would be absurd.

Jacquez said that spotlighting a community crisis is not popular in small towns, and yet the magnitude of the opioid epidemic has thickened his skin.

“Let's save some lives,” he said. “I'll take the heat.”

The Self-Care Rx

BY LEONARD KISH

“The system only changes if we empower the one person who cares about their health the most – the patient. Over the next decade, I believe people will become the CEOs of their own health.” Vinod Khosla

Self care is the future for the simple reason that nobody wants to be a patient. Of course we want care when we need it. We want to be well. We want a good life. We want independence. We want control, and we certainly don't want to need care nor to lose control.

And becoming a patient, for better or for worse, implies giving up control. Being a patient implies there are gatekeepers, there are limits, there are constraints, there are decisions we can't make for ourselves. We can't always get the access we want. Talk to patient advocates and you'll find people fed up with the lack of control, lack of ownership and the lack of help from the health care system.

While we won't ever get all the care we need from patient groups and new digital self care tools, we'll always need professionals to make decisions that are deeply complex and require a deep understanding, there's still a great deal we can get from our peers and our new tools and the list is growing every day. Many conditions simply don't need deep expertise, they only need to answer “what do I do next?” around a condition.

The desire for action and control drives our internal motivation, but, along with them, there are now also strong technological and societal forces driving an emerging self care movement.

Here are the major forces at work:

1. Internet of Things (IoT): Sensor costs are becoming very inexpensive. They will become commoditized. Telemedicine is growing, and, as payment aligns with outcomes, it will be routine. In 5 or 10 years, in a non-emergency situation, why will we need to go to a “bricks and mortar clinic”?

You may need to get a scan, or you may need a real physical exam, but less so every year. The world of medicine become more and more digital every day as measurements are enabled for the consumer. Philips recently made the move in the wearable marketplace from fitness to chronic disease, with a $600 system including a watch, scale, BP monitor and thermometer.  This is a big step, and foreshadows a self-tracking future for healthcare. More sensors are surely on their way to the home and mobile.

2. Shifting Risk: Patients and self-insured employers are looking for new ways to minimize their financial risks as plans move toward high deductibles and employers are looking for new ways to keep employees healthy and happy and looking for new measurements. It's historically been very expensive to get data on populations, and even more difficult for data around individuals. For individuals and employers, to bend the cost curve, they need the best information available on what costs will be and how behavior affects costs and disease risk.

Say someone is diagnosed with pre-Diabetes. How much will will he have to pay for those Diabetes meds if he gets full-blown diabetes? Will he have to get daily insulin injections? When risk is personal, we can start to change outcomes and drive engagement. While some health is measured and influenced at the population level, including social determinants, health is still driven by individual decisions on a daily basis. We are driving toward individual risks as we get better at measuring. This will have big implications for insurers in the not-to distant future, and for individual rights as well. As we gather more information, when we get to very accurate predictions of risk for an individual. What will population-based insurance look like with all this information? We all need the right information to make our own decision on our financial and health futures. Laws governing individual risk will likely change as well.

3. Interoperability around the individual. It's been a long time coming, but the recognition that patients must be the means by which health data is transferred is coming into the mainstream.

CIOs have indicated that relying on institutions, institutions that have neither the rights nor the incentives, to share health data might not be the right approach.

According to Dr. David Kibbe of DirectTrust,

“The real issue involves who owns the health information that is created by you and me, and about you and me, and who has the rights to view it, access it, use it, download it and move it around.”

Kibbe went on to say, ““We need a new and different national, maybe international, dialogue about how health data and information are centralized and de-centralized, about how to assure its privacy, about the use of encryption for security and about identity assurance,” Kibbe added. “Some of this is policy and some of this is social science.”

Kibbe gets it right on decentralization: decentralized technologies are allowing individuals the ability to track the information about themselves without a third party. Blockchain is being hailed as user-centric data store. Just as bitcoin is showing the promise of de-institutionalizing banks to protocols and distributed data stores, blockchain shows promise for other kinds of individual-centric data.

Don and Alex Tapscott have written “The Blockchain Revolution” which details how blockchain and related technologies will weave their way into many industries, driving decentralization of many currently centralized processes.This could be a core part of moving health data exchange to a truly individual-centric system. Bruce Boussard, the CEO of Humana recently confirmed this perspective, saying: “The promise of Blockchain is about putting the consumer at the center of health care, instead of the other way around.”

While Kibbe's comments above were on the care delivery side of health care, big changes will be impacted on the research side of things as well. Eric Topol and John Wilbanks highlight in a recent Nature article that, even if we have easily given up personal data rights around commerce, we need to draw the line on the privatization of personal data around health data. Just as we control our own bodies, so must we control data about our bodies and minds.

4. Precision medicine. Precision medicine is information science, population health, value-based care and patient experience driven to the level of the individual. Although we tend to think of individual and population health as opposite sides of the same spectrum, precision medicine is the path we'll follow to get to all the others. Take a look at the recent award for Scripps to understand Precision Medicine:

“This range of information at the scale of 1 million people from all walks of life will be an unprecedented resource for researchers working to understand all of the factors that influence health and disease,” NIH Director Dr. Francis Collins said in a statement. “Over time, data provided by participants will help us answer important health questions, such as why some people with elevated genetic and environmental risk factors for disease still manage to maintain good health, and how people suffering from a chronic illness can maintain the highest possible quality of life. The more we understand about individual differences, the better able we will be to effectively prevent and treat illness.”

Providing the right care to the right individual requires a complete picture of that individual. Precision medicine is the the nexus of the combining forces of medicine becoming and information science while being directed to the unique contexts of a person's lifestyle and genomics.

In June, Healthcare IT News and HIMSS released a study and the headline, “Hospitals rank population health, value-based care, patient experience as top strategic drivers of precision medicine.” The first part is perhaps not that surprising, but what's been missing is how tightly related population health, value-based care and patient experience are to each other, and they are all going to be accelerated with precision medicine. Precision medicine has the ability to become the medical science of how to do better care at lower cost and create a better experience for each individual. It has the potential to become the science of value-based care. The more we customize treatments, the better we can manage populations, it's not unlike the idea of mass customization in retail.

5. Volume to value is becoming ingrained in the health system. By this time, just about every pharma company either has or is thinking about putting together a patient engagement strategy. Part of this is driven by the success of Direct to Consumer Advertising and a desire to extend it, but the other part is that patients are a wealth of valuable information that can now be accessed for research and insight into disease and patients' experience with their disease.. There's a lot to learn at every step of the pharma value chain. Payers and providers are a bit slower to change, but, with value-based payments forcing movement, it's coming.

6. Self care is what people want. Finally, as discussed in the beginning. Nobody wants to be a patient. We want independence. The horrible experiences and the overall lack of access, all driven by the insane economics of health care, are driving people away from the current health system and towards personal choice and self care with new tools and new communities. People want to be well far more than they care how they get there. There will always be a role for the professionals, be we have to offload as much as possible. The core unit of value in healthcare is the right decision. It doesn't matter how the decision is made as long as it is correct.

7. It's the right thing to do. Patient engagement and personal empowerment with information means better outcomes. People actively engaged do better. It's simple, but powerful. When people have data they feel better, errors can be found, and outcomes improve. Self care is the natural end game.

Independence in care is  a huge improvement to care. It's not a cure, it's not a fix all, but ask any patient what they hate the most about the health system, and they'll often mention a loss of control. When we can feel like we are in control of our illness and recovery without a forced dependency for many simple conditions, it's a big part of the battle.

Quick plug on self care: Interested in exploring self care further? There will be a panel hosted by Dell Medical School and a workshop I'll be hosting with Self Care Catalysts (where I'm a Senior Advisor).  Please vote early and often!