If Health Law Falls, Coverage For Young Adults Gets Tricky

Enlarge Courtesy of June Blender

Jackson Cahn, who graduated from Whitman College in Walla Walla, Wash., is one of the 3 million young adults the Obama administration says would have risked going without insurance if the health care law hadn't allowed them to stay on their parents' policies. Because of the law, his mother, June Blender, was able to add him to her insurance.

Courtesy of June Blender

Jackson Cahn, who graduated from Whitman College in Walla Walla, Wash., is one of the 3 million young adults the Obama administration says would have risked going without insurance if the health care law hadn't allowed them to stay on their parents' policies. Because of the law, his mother, June Blender, was able to add him to her insurance.

When it comes to health care, even the seemingly easy things become hard.

Take coverage for young adults under the Affordable Care Act.

It's one of the most successful � and popular � provisions of the law that have taken effect so far. Earlier this week the Obama administration announced that between September 2010 and the end of 2011, more than 3 million young adults under age 26 who would otherwise have gone without insurance gained coverage by remaining on their parents' health plans.

Last week, major health insurance companies, including United Healthcare, Aetna and Humana, announced they would continue to offer the benefit even if the Supreme Court strikes down the law when it issues its ruling, which is expected next week. Even some Republicans say they support the idea of letting young people remain on their parents' health plans.

But it turns out that might not be so easy.

 

"This could have adverse tax consequences, both to the employee whose child is on the plan and to the employer, for purposes of payroll taxes," said James Klein, president of the American Benefits Council, which represents large-employer health plans and companies that provide services to those plans.

How's that? Well, says Klein, the problem is that lots of those young adults are no longer dependents of their parents for tax purposes. So if the employer continues to provide coverage to that adult child, the value of that insurance could be considered taxable income to the parent. Under the health law, such coverage is not treated as taxable income.

As an example, he says, "if the value of adding a child onto your policy is $500 a month, that's $6,000 a year. So that's $6,000 of extra income on which you would be taxed, plus the payroll taxes that you the employee and the employer would be paying on behalf of that $6,000."

And while that could be a lot of money for some people, he says, the money is only part of the problem.

"It's the utter confusion that this would cause for employers. Because after all, there would be some 24-year-old kids who are legal dependents, for whom there would be no income tax owed," Klein said. "And then there would be others for whom they're not legal dependents and so there would be tax that would be owed. It would be extraordinarily confusing."

Then there's the question of whether workers and employers might owe back taxes for coverage that's been provided already. Klein says the Obama administration could theoretically take care of the problem by having the IRS issue some sort of clarification. But he worries that like everything else to do with the health law, even that could get caught up in partisan politics.

"I'm just afraid that rather than a quick resolution that provides clarity, both sides could arguably use this for their political benefit," he said.

Docs who used EHRs showed lower malpractice claims

BOSTON – A study by Harvard Medical School researchers, published Monday in the Archives of Internal Medicine, showed that Massachusetts physicians who used electronic health records saw a reduction in malpractice claims.

Correlation does not imply causation, of course. But the report's authors say their findings suggest that "implementation of EHRs may reduce malpractice claims and, at the least, appears not to increase claims as providers adapt to using EHRs."

The study, titled "The Relationship Between Electronic Health Records and Malpractice Claims," was written by Mariah A. Quinn, MD; Allyson M. Kats; Ken Kleinman; David W. Bates, MD; Steven R. Simon, MD.

"Given the potential of EHRs to reduce adverse events and health care costs, the question of whether EHRs reduce the risk of malpractice lawsuits is a logical one," they write.

"Risk factors for medical error and resultant malpractice claims, including poor communication between providers, difficulty in accessing patient information in a timely manner, unsafe prescribing practices, and lower adherence to clinical guidelines, may be ameliorable by health information technology," the report notes. "The high quality and availability of proper documentation in EHRs may increase the likelihood of successful defense against malpractice claims."

For this study, the researchers assessed groups of Massachusetts physicians who had previously been surveyed in 2005 and 2007 – tracking their malpractice claims over time.

"Because physicians in the sample were insured for different durations and used EHRs for variable amounts of time, the number of insured years was calculated for each physician before and after EHR adoption," they write. "We used Poisson regression to determine whether EHR use was associated with malpractice claims, modeling the rate of malpractice claims per year in periods with and without EHRs and adjusting for clustering by physician. We used the generalized linear mixed models version of Poisson regression to account for correlation between periods."

Of the 189 doctors surveyed in both 2005 and 2007, they note, 27 were named in at least one malpractice claim. Overall, 33 of the 275 physicians from multiple surgical and medical specialties who responded in 2005 and/or 2007 incurred a total of 51 unique claims. Forty-nine of those claims were related to events occurring before EHR adoption. Two were related to events occurring after EHR adoption.

"We found that the rate of malpractice claims when EHRs were used was about one-sixth the rate when EHRs were not used," the researchers write. "This study adds to the literature suggesting that EHRs have the potential to improve patient safety and supports the conclusions of our prior work,which showed a lower risk of paid claims among physicians using EHRs. By examining all closed claims, rather than only those for which a payment was made, our findings suggest that a reduction in errors is likely responsible for at least a component of this association, since the absolute rate of claims was lower post-EHR adoption."

[See also: Study sheds light on docs' perspectives on curbing diagnostic errors.]

The report does concede that other factors may be at work. "For example, physicians who were early adopters of EHRs may exhibit practice patterns that make them less likely to have malpractice claims, independent of EHR adoption; these early adopters contribute a disproportionate amount of time in our analyses, favoring an effect of EHRs on reducing malpractice claims."

Still, they argued, despite the small sample size, the reduction in malpractice claims shown in the EHR study "lends support to the push for widespread implementation of health information technology."

Access the report here.

FDA regulators face daunting task as health apps multiply

Want to monitor your blood pressure and sugar level? Eat healthier meals? Screen yourself for depression? Find out if you need glasses? Now you can do it all with apps on your smartphone.

In fact, there are 40,000 medical applications available for download on smartphones and tablets � and the market is still in its infancy. But that growth is in the cross hairs of new regulatory efforts from the Food and Drug Administration.

Medical apps offer the opportunity to monitor health and encourage patient wellness on a moment-to-moment basis, instead of only during the occasional visit to the doctor's office. Some even replace devices used in hospitals and doctor's offices, such as glucometers and the high-quality microscopes used by dermatologists to examine skin irregularities.

"There's a lot of enthusiasm now for the ability to use design and to use consumer technology to help improve people's health at the ground level," says Andrew Rosenthal of Massive Health, a mobile health app company in San Francisco.

But so far, the market has been unregulated; for both doctors and patients. It is difficult to know which apps actually live up to their health claims or provide accurate information.

Last year, the FDA began to lay down the law. The agency released a first draft of guidelines that require mobile apps developers making medical claims to apply for FDA approval for those applications, the same way that new medical devices must be proved safe and effective before they can be sold. But that process can be both time-consuming and expensive.

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Some app developers are bristling at the thought of a rigid regulatory structure, which they fear will stifle innovation in an industry known for rapid growth and flexibility.

"The FDA's current regulatory process was created when the floppy disk was around" � ancient history in the tech world, warns Joel White, executive director of the Health IT Now Coalition, which includes the computer chip maker Intel, pharmacy benefits manager Medco, Verizon, Aetna and the U.S. Chamber of Commerce.

According to the Government Accountability Office, the FDA takes about six months to approve a medical device that is similar to an existing product and 20 months to approve a brand new device. That's simply too slow, White says.

Top Paid Medical Apps for iPhones (from the iTunes store)

1. Pill Identifier ($0.99)

Developer: Drugs.com

Pill Identifier allows you to identify more than 10,000 different over-the-counter and prescription pills based on their appearance. Search by imprint, size, shape or color.

2. Pregnancy ++ ($2.99)

Developer: Health & Parenting Ltd.

Pregnancy ++ tracks the course of your pregnancy, including your weight, diet and exercise. It also includes HD fetal pictures, a kick counter and a contraction counter.

3. Baby Connect (Activity Logger) ($4.99)

Developer: Seacloud Software

Baby Connect tracks your baby�s everyday activities (including feeding, sleep, growth, health and vaccines) and creates graphical reports and trending charts. The information can be shared between parents, nannies and other child care providers.

4. Instant ECG: An Electrocardiogram Rhythms Interpretation Guide ($0.99)

Developer: iAnesthesia LLC

Instant ECG is an app for health care professionals, which teaches the basics of reading electrocardiograms (ECG). The app offers video demonstrations of 30 different arrhythmias to teach and then test a provider�s ability to diagnose irregularities.

5. MedCalc (medical calculator) ($0.99)

Developer: Mathias Tschopp and Pascal Pfiffner

MedCalc gives health care professionals access to more than 200 different diagnostic formulas, scores, scales and classifications that help measure a person�s health.

6. Pill Reminder by Drugs.com ($0.99)

Developer: Drugs.com

The Pill Reminder App keeps track of all of your medications, vitamins and supplements. Set up reminders to take your meds or refill a prescription, and check for drug interactions, dosage information and possible side effects.

7. Anatomy 3D: Organs ($1.99)

Developer: Real Bodywork

Anatomy 3D: Organs teaches users about structure and function of internal organs using 3D models, videos, audio lectures, diagrams, quizzes and a glossary.

8. Diagnosaurus DDx ($1.99)

Developer: Unbound Medicine, Inc.

Diagnosaurus DDX helps health care providers accurately diagnose patients quickly at the bedside. Providers can search over 1,000 differential diagnoses by organ system, symptom and disease, and use a special feature to consider alternative diagnoses when multiple conditions are possible.

9. Everyday First Aid ($0.99)

Developer: Portable Monster LLC

Everyday First Aid offers users information on how to handle an emergency. The medical information is based on guidelines from the American Red Cross and other health organization, and tells you how to handle situations including choking, wound cleaning, jellyfish stings, tick bites and heart attacks with illustrated training guides.

10. Drugs & Bugs ($5.99)

Developer: Haymarket Media

Drugs & Bugs is an app for medical students and health care professionals who care for patients with infectious diseases. It provides information on more than 100 antibiotics and nearly 200 bacterial pathogens, and allows providers to compare the effectiveness of various drugs.

"We're seeing mobile apps updated and created on a daily basis," he adds. "The life cycle is dramatically different."

It's also expensive: The cost of getting FDA approval for a standard medical device is about $24 million to $75 million, according to a Stanford University report.

The health app market currently is worth about $718 million and is expected to double by the end of the year, according to Research2Guidance, a global mobile research group.

Alain Labrique, who directs a global initiativeat Johns Hopkins University dedicated to mobile health technology, says that although the FDA guidelines could delay some tech development, they are an important consumer safeguard.

Labrique argues that many apps are "a lot of hype and very little evidence." While apps offer an exciting new opportunity in health care, "We also want to protect the public and be sure that medical claims are supported by data assessment and some comparison to a gold standard."

In particular, he warns that commercial interests and "the tendency to capitalize on the next big things" may lead app developers to overstate what their products can accomplish. "Making sure the public's best interests are met is not always the most expedient process."

The FDA expects to release final guidelines on mobile health apps this year, but some app developers aren't waiting. Many companies have started the formal application process, and the FDA has already approved a handful of apps.

White says that many app developers are not opposed to regulation, but they believe that the FDA process doesn't fit the industry. He suggested that the government set up a new regulatory framework for mobile health � something like the National Transportation Safety Board� to accommodate the speed, flexibility and innovation of this new marketplace.

Orrin Franko, 29, is part of a new breed of doctor-innovators in the mobile health industry. He's an orthopedic surgery resident at the University of California San Diego and runs a website called TopOrthoApps.com, where he reviews orthopedic apps for doctors and patients. He is also developing several of his own.

Recently, he invented a plastic attachment that works with an app that allows iPhones to measure the curve of the spine to test for scoliosis. It mimics a medical device called a Scioliometer, which is used in nearly every hospital across the country. The Scoliometer costs about $100 and was cleared by the FDA in 1983; the iPhone app costs 99 cents and Franko says his plastic attachment could be sold for about $10.

But he also knows that his device will have to be approved by the FDA, requiring a significant capital investment. He's planning to apply, he says, but with so many new apps coming on the market "there's no way the FDA is going to keep up."

Instead, he predicts, app developers with products that are not strictly medical, such as a healthy eating app, may avoid making medical claims in their marketing in order to skip the FDA process and will rely on good user reviews instead to generate publicity.

While the FDA sorts the process out with developers, Franko isn't wasting any time. In January, he helped launch the peer-reviewed Journal of Mobile Technology in Medicine to help doctors make sense of the bonanza of medical apps.

Franko's goal is to make sure doctors and patients know what they're getting as quickly as possible. "These apps already exist," he says, "and people are using them in hospitals to make medical decisions, but no one knows if they're actually doing what they claim to be doing."

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Experts to Senate: Healthcare reform won't be easy

WASHINGTON – Witnesses at separate hearings held Wednesday by the Senate Health, Education, Labor and Pensions Committee and the Senate Finance Committee said healthcare reform is  necessary and can't be achieved without spending money up front. The experts also recommended providing broader risk pools and establishing comparative effectiveness.

The new stimulus package provides incentives for doctors and hospitals to adopt healthcare IT and provides funding for comparative effectiveness research.

The Congressional Budget Office's new Director, Doug Elmendorf, said increasing health insurance pools – a concept contained in President Barack Obama's plan to expand healthcare coverage – will not work without mandating coverage.  Without mandating, only the sick will purchase insurance, jacking the price for those who aren't sick and driving away those who only marginally wanted to purchase it in the first place.

It will take time to make a change and investment up front, Elmendorf said.

"It's a big ship that's not moving that fast, but it's very big and very hard to turn," he said. "No doubt, if you started shifting incentives, the faster the ship will turn."

Many believe, along with President Obama, that healthcare IT will lay a foundation for change in the U.S. healthcare system and a venue for improving quality of care, cutting costs and saving lives. Healthcare IT will also allow the government to pay providers based on performance.

Cathy Schoen, senior vice president of The Commonwealth Fund, told the Senate HELP Committee that changes will require new leadership and collaboration across public and private sectors.

"Effective payment reforms will require time to develop and implement and flexibility to innovate as the nation learns," she said – a notion backed by the CBO. "Information systems require investment and time to yield maximum returns through adoption and use."

"Yet, wide public concern and stress on businesses and public sectors make it increasingly clear that we cannot afford to maintain the status quo. Each year we wait, the problems grow worse," Schoen said.

Sen. Sherrod Brown (D-Ohio), on the Senate HELP Committee, said, "It’s not enough to fight for affordable coverage, we must fight for real coverage. Health insurance shouldn’t be a vehicle for punishing the sick and rewarding the healthy. It shouldn’t be a hammer that beats healthcare costs down by arbitrarily denying care to those who need it."

Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee, said healthcare is the next big objective. "We need fundamental reform in cost, quality and coverage. We need to address all three objectives at the same time. They are interconnected," he said.

Republicans agree that reform is urgent and necessary, but differ on the means needed to get there. Sen. Charles Grassley (R-Iowa), disturbed by the lack of debate over the stimulus package, urged caution. "I have heard some folks say it is our moral responsibility to provide healthcare coverage for all. We have an equal if not greater moral responsibility to do so in a fiscally sustainable manner," he said.

Grassley said he is wary of spending money up front to reap savings in the future. "The President has an opportunity as he walks this razor’s edge between a broken healthcare system and fiscal catastrophe," he said.

Obama has called a gathering of stakeholders and a bipartisan mix of lawmakers to meet next week and begin the difficult work of smoothing out differences. The Obama administration had plans for healthcare reform prepared prior to the election, and the Senate Finance Committee has held hearings on the issue since last summer. Last fall, key Democratic congressional leaders said they were "ready to roll" on healthcare reform, and they will take the cue from Obama's guidelines.

 

 

 

ONC targets Rx drug abuse with new data initiative

WASHINGTON – The Office of the National Coordinator for Health IT has launched a pilot program to make existing prescription drug use data available to healthcare providers and pharmacists when they treat patients during office visits and in emergency departments.

The test projects in Indiana and Ohio will measure the effectiveness of expanding and improving access to prescription drug monitoring programs (PDMPs) as part of the administration’s efforts to reduce prescription drug abuse.

The monitoring programs are statewide electronic databases, which are designed as a tool for providers to identify and intervene in cases of potential prescription drug abuse. The databases collect, monitor and analyze electronically transmitted prescribing and dispensing data submitted by pharmacies and dispensing practitioners.

The idea is that by improving real-time access to the information it will encourage providers to use the program more than it is now. So far, 49 states have legislation authorizing prescription drug monitoring programs or have active programs.

“The PDMP pilot projects will help hospital staff identify a patient’s controlled substance history at the point of care to enable better targeting of appropriate treatments and reduce the potential of an overdose or even death,” said Farzad Mostashari, MD, national coordinator for health IT. “We are not creating new systems; we are adding value to those that exist,” he added.

In Indiana, emergency department staff will be able to receive a patient’s controlled substance prescription history directly through the Regenstrief Medical Record System (RMRS), a care management system used by Wishard Health Services, a community health system in Indianapolis, and other hospitals.

The project is a collaboration of ONC, Regenstrief, Wishard, the National Association of Boards of Pharmacy, Appriss Inc., and the State of Indiana. In some states, Emergency departments are responsible for almost 25 percent of all controlled substance prescriptions.

The Ohio pilot will test having a drug risk indicator in the electronic health record (EHR) and how that affects clinical decision making. The Ohio project is a collaboration with the Springfield Center for Family Medicine, Eagle Software Corporation’s NARxCHECK, the State of Ohio, and MITRE.

The hope is that the pilots will improve real-time data sharing among providers, increase interoperability of data among states, and expand the number of people using these tools, according to Gil Kerlikowske, director of National Drug Control Policy.

The Enhancing Access to PDMPs Project stems from joint efforts of public sector and private industry experts that participated in the White House Roundtable on Health IT and Prescription Drug Abuse last year and the subsequent action plan (PDF).

The Centers for Disease Control and Prevention has said that the United States is in the midst of an epidemic of prescription drug overdose deaths, which outnumber deaths from heroin and cocaine combined.

Parents can build in 'special time' with kids this summer

The unofficial start of summer may have arrived already, but for many families, what once were the lazy days of summer have become the crazy days.

Parents and kids often find themselves racing to work, camps, swim meets and ballgames, plus answering cellphones, text messages and e-mails 24/7. So how can parents get more out of their time with their family?

They should consider setting aside an hour a week for "special time" with each child, says psychologist David Palmiter, author of Working Parents, Thriving Families and a public education coordinator for the American Psychological Association.

For that hour, each parent should focus totally on the child while doing something enjoyable, such as shooting baskets, playing a video game or drawing, he says.

Parents should keep in mind that the child should choose his activity, and many things he would choose will work, except for watching TV, Palmiter says.

He often spends special time with his own children, ages 11, 15 and 16, when they are going out for breakfast, taking a walk or shooting baskets.

Make kids the priority

Parents should really listen to what the child has to say and enjoy the child's company by living in the now, he says.

During special time, parents should avoid correcting behavior or ideas or directing the conversation, he says. That should be done at another time.

"Just focus on being with your child and enjoying him all that you can," Palmiter says.

And don't jump up to answer your cellphone or check your text messages, he says, "because that suggests to the kids that your iPhone is a higher priority than they are."

Special time with children is different from quality time in which parents divide their attention across fun family activities such as going to sporting events, fishing or riding roller coasters. Those serve a different purpose for enriching family life and building memories, he says.

Psychologist Mary Alvord, who has a private practice in Rockville, Md., and is the author of Resilience Builder Program for Children and Adolescents, says parents and kids can do simple things such as playing board games, bowling, playing miniature golf or cooking.

This hour can even be time in the car. "With teens, it's a nice time to talk with them because they're captive. Just make sure they're not texting."

So often parents and children do parallel activities such as sitting together to watch TV or going to the movies, and they're not conversing with each other, Alvord says.

"When you look at the research, kids' resilience is often based on time they spend with their parents, knowing they are appreciated by the family," she says. "Parents have to really listen to them. If you are always multitasking, it's not the same kind of listening."

Palmiter says that special hour each week can be used for all ages, including adult children, and it's important to have special time each week with your spouse or significant other. Even a dinner or a picnic can provide the opportunity to focus on your spouse, he says.

The process is the point

For many families, the best way to have richer time together is to build on activities family members love, says psychologist Susan Linn, author of The Case for Make Believe. Parents can share the hobbies and activities they especially love with their children. That might be music, art, dance, woodworking, crafts, sewing, knitting, gardening or outdoor activities such as sports, fishing or hiking.

If parents are truly interested in what they're doing, they can pass that enthusiasm on to their children.

What's most important is that children enjoy the experience. So if you're making something with a child, perfectionism needs to go out the window. The process of doing it should be more important than the product, she says.

"One of my husband's most vivid childhood memories was hammering nails into a bench for fun at his father's picture-frame shop. He grew up to be an art restorer, and it all began with sitting hammering nails into the bench until the entire end of the bench was metal."

Parents also can share with their kids the games they played as a child. "I taught my grandchildren Mother May I, and they ask me to play it with them. We make up ridiculous steps.

"Parents have to keep in mind the importance of play for children � and for adults."

Voice recognition software helps with MU, doc says

SAN DIEGO – Voice recognition software has provided the means to lower transciption costs, speeding efficiency and populating data for achieving meaningful use, according to Richard Gwinn, MD, director of urgent care at Sharp Rees-Stealy Medical Group in San Diego.

Rees-Stealy Medical Group has 19 locations,400 physicians,1,700 staff members and is one of the largest, most comprehensive medical groups in San Diego County. The group offers primary and specialty care, laboratory, physical therapy, radiology, pharmacy and urgent care.

 [See also: Do doctors have to be typists to get MU incentives?.]

Prior to implementing Nuance Healthcare’s Dragon Medical voice recognition software, providers dictated or hand wrote all documentation, according to Gwinn. Transcribing notes took two to three days and was very costly. Handwriting was faster, but illegible. The group implemented an EHR, but soon found that populating it was too much work.

Two years ago, Rees-Stealy group adopted Nuance's Dragon Medical voice recognition software, and within ten months of implemention, the group went from recording 6,182 progress notes per month in Allscript's Enterprise EHR to 19,020 notes, Gwinn says. Paper chart usage declined from 102,000 per month to 4,000 per month. The group lowered transcription costs by $800,000 to $900,000 annually, representing an 80 to 90 percent reduction.

 "It took me less than one-half hour from the time I first opened Dragon Medical to the time I was using it," Gwinn says."It’s been a life changing application. I go home earlier. I don’t have stacks of charts on my desk and the swelling has gone down in my fingers (from typing).” 

With the advent of meaningful use, many physicians have recognized that while imperative, the task of manually entering data can be time consuming. The adoption of speech-recognition technology has enabled physicians at Dragon Medical to focus more on patient care instead of documentation, Gwinn reports.

Gwinn says the Nuance software has a 99 percent speech recognition rate. "It's wonderful for me, because now I can create charts accurately  and concisely for patients and I can put them in the correct fields and I don't have to touch the mouse, so I can do other things at the same time," Gwinn says.

Gwinn says Rees-Stealy is "among the most advanced groups in the country" when it comes to health IT and electronic health records. In addition, the group does "consistently very well on quality measures."

Physicians were strongly encouraged to use the voice recognition software to populate the EHRs, and most have, but there have been a few holdouts, Gwinn says. 

As for Gwinn, he is 70 years old and wasn't "in the least bit shy about adopting" the software. "I'm very entusiastic about this," he says.

AMA thinking seriously about ICD-11

CHICAGO – ICD-10 proponents are not going to like this one bit.

Certainly not any more than they enjoyed my suggestion that the proposed ICD-10 deadline extension puts the U.S. healthcare industry into a strange time warp in which providers and payers will be finally implementing ICD-10 in the same one or two-year timeframe that ICD-11 is entering this world – and that being the case perhaps holding out for the 21st Century classification system that will be ICD-11, then moving aggressively to that is, well, at least worth considering.

Here it comes: The American Medical Association late Tuesday took up the ICD-11 cause.

Until now, it was a soft chant by rather disparate voices. If recent history with the proposed ICD-10 delay is any indication, though, the AMA can bellow loud enough to be heard in the highest of strongholds.

Potential alternative
The AMA voted on Tuesday to evaluate ICD-11 as a possible alternative to ICD-10 for replacing ICD-9 – saying that it will report back to delegates in 2013 with its findings.

“It is critical to evaluate alternatives to ICD-9 that will make for a less cumbersome transition and allow physicians to focus on their primary priority – patient care,” AMA president-elect Ardis Dee Hoven, MD, said in a statement. “The policy also asks stakeholders, such as the Centers for Medicare and Medicaid Services, to examine other options.”

Practicing the ‘it can’t hurt to ask’ methodology ostensibly worked for the AMA in getting ICD-10 delayed earlier this year. Two unrelated anonymous sources, both well-positioned vis a vis ICD-10, told me separately that even HHS Secretary Kathleen Sebelius was surprised when word came down – from the White House? – that her department was to postpone code set compliance. Take that as an unconfirmed rumor, please. But know that somebody, somewhere made the delay happen.

[See also: ICD-10 deadline do-over?.]

To be fair, the AMA could be in a time dimension all its own. HHS is likely to decide whether October 1, 2014 will be the new deadline, or not, well before 2013. Let’s hope. Unless HHS pushes ICD-10 further into the future, the AMA may be too late to start calling for ICD-11.

But the WHO in mid-May posted what it calls the beta drafting platform of ICD-11 – meaning work is underway though the process is undeniably nascent.

Not alone
The AMA is not the only one chanting for ICD-11. In a blind reader poll, Government Health IT asked its readers ‘Should the U.S. leapfrog ICD-10 and opt for ICD-11?’

Nearly one-quarter indicated “yes” while one-third weighed in with a firm “no.” Given the circumstances, which include the fact that ICD-11 is not yet ready for primetime, the more telling perspective is the 43 percent of a total 115 respondents who voted that “it’s worth considering.”

Matt Murray, MD, a pediatric emergency physician and self-described health IT advocate, contends in a May 17 blog post that CMS “prematurely dismisses the alternative option to forgo ICD-10 and implement ICD-11,” adding that he is “very concerned that this dismissal is published without a comparative analysis of the total costs of each option. And there is good reason to seriously consider implementing ICD-11.”

That’s a point very similar to one the MGMA has made – that before mandating ICD-10, CMS should conduct a comprehensive cost-benefit analysis, pilot ICD-10, and fully evaluate alternative approaches. Sounds only reasonable to me.

“Implementing ICD-10 has been compared to buying a Betamax instead of a VHS recorder in terms of pending obsolescence,” Dr. Murray wrote. “Informatics experts are in agreement that ICD-11 is superior to ICD-10 and that we need to get to it as soon as is tolerable.”

Continued next page.

Voice recognition software helps with MU, doc says

SAN DIEGO – Voice recognition software has provided the means to lower transciption costs, speeding efficiency and populating data for achieving meaningful use, according to Richard Gwinn, MD, director of urgent care at Sharp Rees-Stealy Medical Group in San Diego.

Rees-Stealy Medical Group has 19 locations,400 physicians,1,700 staff members and is one of the largest, most comprehensive medical groups in San Diego County. The group offers primary and specialty care, laboratory, physical therapy, radiology, pharmacy and urgent care.

 [See also: Do doctors have to be typists to get MU incentives?.]

Prior to implementing Nuance Healthcare’s Dragon Medical voice recognition software, providers dictated or hand wrote all documentation, according to Gwinn. Transcribing notes took two to three days and was very costly. Handwriting was faster, but illegible. The group implemented an EHR, but soon found that populating it was too much work.

Two years ago, Rees-Stealy group adopted Nuance's Dragon Medical voice recognition software, and within ten months of implemention, the group went from recording 6,182 progress notes per month in Allscript's Enterprise EHR to 19,020 notes, Gwinn says. Paper chart usage declined from 102,000 per month to 4,000 per month. The group lowered transcription costs by $800,000 to $900,000 annually, representing an 80 to 90 percent reduction.

 "It took me less than one-half hour from the time I first opened Dragon Medical to the time I was using it," Gwinn says."It’s been a life changing application. I go home earlier. I don’t have stacks of charts on my desk and the swelling has gone down in my fingers (from typing).” 

With the advent of meaningful use, many physicians have recognized that while imperative, the task of manually entering data can be time consuming. The adoption of speech-recognition technology has enabled physicians at Dragon Medical to focus more on patient care instead of documentation, Gwinn reports.

Gwinn says the Nuance software has a 99 percent speech recognition rate. "It's wonderful for me, because now I can create charts accurately  and concisely for patients and I can put them in the correct fields and I don't have to touch the mouse, so I can do other things at the same time," Gwinn says.

Gwinn says Rees-Stealy is "among the most advanced groups in the country" when it comes to health IT and electronic health records. In addition, the group does "consistently very well on quality measures."

Physicians were strongly encouraged to use the voice recognition software to populate the EHRs, and most have, but there have been a few holdouts, Gwinn says. 

As for Gwinn, he is 70 years old and wasn't "in the least bit shy about adopting" the software. "I'm very entusiastic about this," he says.

Kiersten-Care: Using the Health Care Tax Credit to Take Care of Employees

Kiersten Firquain founded Bistro Kids in Kansas City, KS, seven years ago to provide locally sourced organic �kid-friendly� food to as many students as possible. While her chefs were cooking up healthy food for youngsters, she wanted to do something for her employees� health. The health care law tax credit for small businesses, she says, made it possible to offer them health insurance.

�We talked to our chefs and employees and asked, �What�s something you would like from Bistro Kids?� And one of the things that kept coming up was insurance,� Kiersten says.

Bistro Kids qualified for about $1,500 per year in tax credits under the health care law, the Affordable Care Act, which made a huge difference to a small business like hers. For one of her chefs, Kiersten says, health insurance means a $5 co-pay for a prescription instead of a $250 cost, which her chef would not have been able to afford.

YouTube embedded video: http://www.youtube-nocookie.com/embed/tBfZohqy3Q0 �

�The small business tax credit means that we can take care of our employees. It means they can walk into a pharmacy and know they can afford to pay for medication to take care of themselves,� Kiersten says. �For us, the small business tax credit means being able to take care of our chefs and our employees so they can take care of our clients.�

The health care law�s tax credit for small businesses also helps Kiersten to compete for the best employees�and that means a more successful business.

�Everybody wants to have the best employees that they can have. Our chefs are phenomenal, the best in the industry, and because of the health care tax credit, we�re able to offer them benefits that they might not be able to get somewhere else.�

New York RHIOs and HIEs team up to create 'model for the rest of the nation'

NEW YORK – The New York eHealth Collaborative (NYeC) and the New York State Department of Health announced Wednesday that three regional health information organizations (RHIOs) and three health information exchange (HIE) vendors will participate in the Statewide Health Information Network of New York (SHIN-NY), which officials say will function much like a public utility.

The RHIOs – Brooklyn Health Information Exchange, e-Health Network of Long Island and THINC – and HIE vendors (HealthUnity, IBM and InterSystems) have signed on with NYeC to facilitate information exchange across New York's downstate region, which comprises New York City's five boroughs, Long Island and the Hudson Valley, with a combined population of 13 million.

The collaboration represents a significant step, officials say, formalizing the creation of a single, unified statewide network for healthcare records. The SHIN-NY is coordinated by NYeC and will unify existing state HIE initiatives – such as within hospital systems and local RHIOs – making electronic health records secure and accessible to healthcare providers statewide.

"A health information network is relevant to all of us," said David Whitlinger, executive director of NYeC. "If we ever need to visit the ER, anytime we get an MRI or have lab work done and need to make sure our primary care doctor gets the results – our records must reach whoever is treating us as quickly as possible."

Brooklyn Health Information Exchange, e-Health Network of Long Island and THINC, each pioneers of HIE in their regions, have joined the SHIN-NY, connecting their databases and infrastructure to improve the care of the patients they serve and promote statewide health.??

"THINC has been running an HIE since 2001, and we know HIEs enhance coordination and continuity of care, improving quality and helping control costs," said said Susan Stuard, executive director of THINC. "NYeC should be commended, not only for coordinating this effort, but also for recognizing that we're not dealing with technology for its own sake. This is about supporting patient care."

HealthUnity, IBM, and InterSystems have also entered into strategic contracts with NYeC to bring their technologies to bear on the further development of the SHIN-NY and have agreed to standardization of software to permit safe and efficient interoperability, along with adherence to New York Statewide Policy Guidance.

Paul Grabscheid vice president of strategic planning at InterSystems, said his firm is "totally committed to taking connected care to the higher, more inclusive level that is essential to support optimal care delivery throughout the State of New York." To reach this goal, he added, "we need to move beyond low-level data exchange and implement strategic platforms with the intelligent aggregation and advanced analytics needed to improve individual and population health."

The secure communication enabled by the SHIN-NY will reduce time and resources currently wasted gathering disparate medical histories from multiple providers, officials say, benefitting patients with chronic conditions, who visit a variety of providers and treatment facilities, and are in need of more effectively coordinated care. It will also reduce the number of duplicate tests ordered.

The network will serve to prevent harmful drug interactions and highlight risks, allowing providers in emergency situations access to life-saving information, such as a patient's allergy and medication history. Doctors who spend less time trying to retrieve data will have more time to discuss treatment options and recovery plans with their patients.

As additional RHIOs connect to the SHIN-NY, the network will have greater reach, incorporating more secure clinical information from across the state.

The initial capability of the SHIN-NY will be that of Patient Record Look Up, a function similar to a highly secure search engine, which allows providers to search across databases within the SHIN-NY network to find health records relevant to their patient.

The next function the SHIN-NY will deploy is Direct Exchange, which works like email, where providers can query each other while collaborating on patient care.

"Many of the downstate region's 13 million people commute daily across regional boundaries," said Whitlinger. "They also seek healthcare across those boundaries, so it's a logical place for the SHIN-NY to focus first."

[See also: Albany pilot aims for direct results with Direct Project.]

"We always knew what we built would need to be flexible and able to scale, so BHIX created a robust infrastructure that the SHIN-NY can now use as the backbone for large-scale applications such as the state's Medicaid redesign efforts," said BHIX Executive Director Irene Koch. "It just makes sense for everyone to come together now to create efficiencies and expand connectivity."

"e-Health Network of Long Island is extremely excited about the collaborative approach to patients' care," said Denise Reilly, executive director of e-Health Network of Long Island. "We serve five hospitals and 13 nursing homes, and this moves our patient care to a new level."

"The work of NYeC is a model for the rest of the nation," said Paul Grundy, MD, director of healthcare transformation at IBM. "With a master view of the patient and provider allowing the linking of records, care can be more effectively coordinated."

"New York has long been a leader in health IT investment and implementation," said New York State Health Commissioner Nirav R. Shah, MD. "Today's announcement is the next step in the creation of a robust 21st century healthcare system that will better serve the people of New York. I applaud the hard work in regions around the state that has made these critical partnerships possible."

Rochester RHIO receives patient data from Excellus

ROCHESTER, NY – Doctors who electronically prescribe through the Rochester Regional Health Information Organization now can view all the medicines that their patients are taking, reducing the chance of drug errors and misuse, RHIO officials announced recently.

Excellus BlueCross BlueShield is supplying prescription data to authorized medical providers who use Rochester RHIO, joining Preferred Care and many national insurers. Excellus delivers healthcare services to 1.8 million people across upstate New York.

The Institute of Medicine reported that more than 1.5 million Americans are injured every year by medication errors. Rochester RHIO offers an e-prescribing feature that replaces handwritten "scripts" with an electronic ordering system that improves patient safety and makes prescriptions and refills available faster. Patients must give consent to make their information available to medical teams using Rochester RHIO.

Connected through Axolotl's Elysium Exchange and EMR Lite software, physicians use Rochester RHIO to receive electronic lab test results, radiology reports and medication history while ordering prescriptions or providing other medical care.

Having current and recent medication information reduces the chance of contraindication and incorrect dosages, RHIO officials said. Patients are also free from the burden of remembering previous prescriptions.

The RHIO links to the Rx-Hub Pharmacy Health Information Exchange, which connects providers, pharmacies and payers. Operated by Surescripts, RxHub is the nation's largest network of pharmacy information. Area physicians connected to the Rochester RHIO will see the most recent two years of medication history for patients in the Greater Rochester area from Excellus BCBS.

Meet Dr. Quentin Young

For those of you unfamiliar with Dr. Young, he has been a tireless advocate for single payer health care for over twenty years, but that is just one item on a CV that includes:
- Practicing medicine for over sixty years (he’s recently retired)
- President of the Medical Committee for Human Rights,(physicians who traveled to treat victims of racial violence)during the most tumultuous years of the civil rights movement, 1963-69
- Personal physician for Dr. King when he was in Chicago (Dr. Young was marching alongside Dr. King when attacked in Chicago. Can you think of a better guy to be next to you when you’re hit by a brick?)
- Chair of the Chicago Health Department under Mayor Harold Washington, and personal physician to Studs Terkel, and Mike Royko as well

Doc Young celebrated his 85th birthday this year, and his energy and enthusiasm puts us both to shame. Take it away, Doc!

Find the full article on the Daily Kos

Blacking Out Single-Payer–And Killing The Auto Industry

By Jonathan Tasini–

When the history of our current economic crisis is written, there will need to be a full chapter devoted to the willful ignorance or stupidity of the traditional media. Right before our eyes stands the solution to a huge chunk of our fiscal nightmare and a lifeline for the auto industry: single-payer health care. And, yet, there is a virtual traditional media blackout on single-payer, witness another example in yesterday’s New York Times.

In The Week In Review, reporter Kevin Sack stumbles through an entirely conventional wisdom article, with this brilliant observation:

Mr. Obama seems to recognize that the recession, with its devastating job losses, affords him the potential to accelerate public opinion. To broaden support for his plan — whatever it ends up being — he insisted last week that systematic improvements in health care would be essential to any lasting economic recovery.

Sacks goes on to chronicle some of the desperation faced by millions of uninsured and under-insured people. And, then, he arrives at the framing of the solutions:

There is a rough consensus, certainly among the Democrats who control both houses, around many key components of the Obama plan — to expand government subsidization of insurance for the poor, to stimulate competition through a new government plan, to require insurers to accept those with pre-existing medical problems and to invest in computerization, prevention and payment incentives for better care.

And…

Less certain, of course, is how to pay for it. During the campaign, Mr. Obama said he would get about half of the necessary total, estimated at more than $100 billion a year, by raising taxes on those making more than $250,000. The rest was to come from savings generated by various efficiencies (their value is a matter of considerable dispute).

Mr. Obama reaffirmed on Thursday that his proposal to roll back the Bush tax cuts might be deferred because of the recession. “We’re probably going to have to, then, find additional dollars to pay for some investments in the short term,” he said, adding that he wants his health plan to pay for itself over a decade.

Some of those dollars may be found by packaging health care initiatives as stimulus measures, a recessionary opportunity presented by the public’s acceptance of deficit spending to spur the economy. What, after all, is $100 billion for health coverage if the government can print $700 billion to bail out the banks?

What is startling–though, perhaps, it should not be by now–is that Sack cannot write the phrase “single-payer” in the entire article, even though it is the only health care plan that would SAVE money and relieve the auto industry–and the rest of the business world–of billions of dollars in health care costs.

Even The Financial Times is starting to get it, though indirectly. In an article today on the auto industry, it acknowledges that wages are pretty much the same between U.S. auto workers and non-union Japanese companies. The big difference is health care, particularly for retirees:

GM and Toyota workers earn similar wages of about $29 an hour.

The big difference is in fringe benefits, such as healthcare insurance and pensions.

The overall labour-cost figures also include retiree benefits. Thousands of GM, Ford and Chrysler workers were on pensions with generous healthcare benefits – foreign carmakers have a fraction of the number of retirees.

I wrote as far back as 2005 that single-payer was the solution to the cost issues of the auto industry. But, The New York Times, along with the rest of the traditional media, repeatedly refuses to include single-payer as a legitimate option.

This commentary is from the Huffington Post.

List of top children's hospitals is guide to quality care

U.S. News & World Report says its ranking of best children's hospitals, out Tuesday, puts an emphasis on institutions with top care in at least one of 10 specialties. A total of 80 hospitals excelled in at least one area, but its honor roll focuses on a dozen that ranked high in at least three specialties.

Although the highest ranked centers, Boston's Children's Hospital and Children's Hospital of Philadelphia, also topped last year's chart, the criteria were a bit different in the list's fifth year.

Health rankings editor Avery Comarow says reputation still factors into which centers rank best, but it's a shrinking role. He says "for reasons that may or may not be justified," the most esteemed hospitals tended to overshadow less recommended centers that still offered top care.

"It's important to remember that these rankings are not for routine pediatric care," he says. "They're for kids who just need the ultimate in care and I think that most parents are willing to travel at least some distance for that."

Gillian Ray, the Children's Hospital Association public relations director, says the list is informative. However, parents shouldn't assume they can only receive quality care at one of the 12 top-tier hospitals.

"Before you think you have to travel across the country for the top care, make sure you know what's in your own backyard," Ray says. "There are children's hospitals in most major areas and most kids are within two or three hours of a children's hospital."

Ray says parents could ensure their local hospital can care for young patients by asking about staff (for instance, whether there are surgeons trained in pediatric care), and such medical equipment as kid-sized intubation tubes and needles.

Comarow says the list should provide parents with a starting point. If a hospital tells a family they do "a lot of work" in a difficult heart surgery, they should still ask for a full picture.

"You have to say, 'Well, what does that mean? What is a lot of work, who's the best person there and what success rate does she have? What's the death rate and what are the complications?' " Comarow says. "It's important to find the person who can give your child what he or she needs and there's no getting around the fact that that takes work and there's no shortcuts."

The full rankings and methodology can be read at www.usnews.com/childrenshospitals.

Health Wonk Review

This week, Maggie Mahar edits the Health Wonk Review, a biweekly compendium of the best of the health policy blogs.

Voices from the Blogosphere, May 21-June 6

I've decided to let the "Voices" of healthcare bloggers become the theme of this edition of Health Wonk Review. Some are passionate; others are dispassionate; some are disarmingly candid; others are angry.

I'm not going to try to "rate" the posts, or tell you which ones I like. Instead, I want to let you hear those voices, as directly as possible, and decide for yourself.� To that end, I'm quoting liberally from the posts submitted to HWR.

A right to health care?

One of the most provocative entries that I received comes from the Center for Objective Health Policy (COHP), a group that reaches out to medical students while arguing that health care reform violates individual rights.

Nathan Fatal explains: "The problem with [the] assumption" that everyone has a "right to health care … is that a right to a good or service would require that somebody provide it, i.e., that somebody be forced to provide it."

He objects to the individual mandate: "Just as one cannot kick down a neighbor's door and hold a family hostage until all members pay a small fee toward his healthcare costs, a large number of citizens cannot properly hand the role of hostage-taker to the … government in order to exact indirect but forced payments from all fellow citizens … all such actions are the same since they violate freedom of action by initiating force against innocent people in order to provide ‘basic security' to those who ‘need' it."

Fatal also defends the rights of insurers and doctors:

"As Richard Salsman explains in Forbes, health insurance is�'a valuable service provided by intelligent, hard-working professionals . . . people who, like other Americans, … have a right to their own life, liberty, property and the pursuit of their own happiness. Doctors, nurses, hospitals, drug-makers, and health insurers are no more servants of the masses, or even of those in need of health care, than are businessmen, bankers, teachers, journalists, or truck drivers …'"

Supreme Court's ruling on health reform law

Here, on healthinsurance.org, Linda Bergthold also considers the mandate, and suggests that it's "worth reviewing again what's at stake" if the Supremes strike down the entire ACA. She writes:

"We could lose things that have already been implemented" including "free preventive services; children's access to coverage regardless of pre-existing conditions; tax credits for small businesses; and the provision that lets "children under 26 stay on their parents' plan." Meanwhile, "lifetime limits on your insurance plan would probably be reinstated."

If just the individual mandate is overturned, "Most economists and business analysts predict that health care costs would increase, because the uninsured would continue to use the system as a last resort, shifting the costs to those of us who are covered."�But, she notes, "There are a number of ways to get around the overturning of the individual mandate."

Over at the Health Affairs Blog, Alan Weil and Sonya Schwartz each review the impact the Court's decision could have on the states:

Weil writes that "the States' responses" to the ACA "have unfolded in three acts." When the Court issues its decision, "we will see the opening of Act IV. "He offers a "visual representation" of those four acts.

"It is unclear how long Act IV will run," Weil adds. "If significant aspects of the law are struck down, states may have to wait a very long time before it is clear how Congress and the President will respond. States in search of a stable, unambiguous federal statutory and legal environment will almost certainly be frustrated."

Meanwhile, Schwartz grades the possible Supreme Court rulings on a "Richter Scale" of disruption, as she looks at "what each possible ruling would mean for the states that have been most active in implementing the ACA."

"If the Supreme Court invalidates components of the Affordable Care Act, active states will try to adapt to the shifting ground by designing new policies to mitigate adverse selection and cover the uninsured," she concludes. "However, their success in doing so will depend in part on how much the ground shifts."

On Colorado Health Insurance Insider,� Louise explains why Governor Hickenlooper Says Reform Can Succeed Without an Individual Mandate. She agrees that "that if you can make health insurance attractive enough and affordable enough, people will buy it without a mandate." She believes that the generous subsidy program" included in the ACA "should be a significant help."

But if the mandate is struck down, and the provision holds that insurers cannot turn down applicants because of a pre-existing condition, "this could quickly lead to out-of-reach premiums" because healthy people would wait until they were sick before joining the pool. If that happens, she says "the states will have to be creative, and get to work hammering out some sort of carrot and stick program to incentivize people to purchase insurance."

The business of medicine

Over at the Prepared Patient Forum, Jessie Gruman turns from the politics of healthcare to the business of medicine.

Her post begins:

"On Monday morning at 8:30 a.m. the pianist was playing Chopin in the beautiful but deserted four-story lobby of the new hospital where my father was being cared for … the contrast between that lovely lobby and the minimal attention my dad received over the weekend, combined with a report about the architectural ‘whimsy' of a new hospital at Johns Hopkins ("a football-field-size front entrance" with ‘manicured gardens and a rectangular water feature') make me cranky."

Why do hospitals indulge in "conspicuous spending" on amenities that the truly sick cannot possibly appreciate, while accepting "staff shortages" (nurses checked her father just once each shift) and "dangerous medical errors"? Gruman:

"We should probably just grow up and recognize that our na�ve notions of the beneficence of health care generally and hospital care specifically are outdated … Health care is big business" and "these new fabulous facilities and all this advertising constitute the cost of … competing for private payers."

Cancer, too, has become a big business. On Health News Review, Gary Schwitzer critiques the media hype surrounding news of an experimental cancer drug.

"When the New York Times reports something, the TV networks are soon to follow," Schwitzer observes. "So when the Times reported ‘A new class of cancer drugs may be less toxic,' featuring a single patient's experience with T-DM1 ��NBC followed closely – featuring the exact same patient in the exact same setting."

"One woman out of 1,000 in the trial. Who chose her?" asks Schwitzer. "The drug company PR people? "

By contrast, Schwitzer calls USA Today's piece "refreshing."�He offers "Excerpts:

2nd sentence: ‘The experimental drug, T-DM1, doesn't cure anyone.'"Later: ‘… statistically, it's possible that those findings could be due to chance, Horning says.'"

Roy Poses, founder of Health Care Renewal� also questions how the quest for earnings affects healthcare, zeroing in on the for-profit hospice industry:

"Remarkable public comments by some for-profit hospice marketers show their focus on increasing patient volumes, even if that means recruiting patients who are not really at the end of life."

Poses explains that this means that some patients suffering from "acute illnesses and injuries may not receive … treatment" they need, while profit-driven hospice care "ends up shortening their lives."

"It's funny that the people who were so alarmed by ‘death panels' do not seem so alarmed by this pathway to denying care for profit," Poses observes.

Rising costs of Medicare and Medicaid

Meanwhile, on Managed Care Matters, Joe Paduda compares how fast the costs of Medicare, Medicaid and commercial insurance have been growing.

"Medicare and Medicaid trends are looking better these days" he writes. "And this trend looks like it will continue. Note this is per-capita growth, which is more accurate when comparing different payer types."�But he reports, "employers' health care costs are up 5.9% this year, and would have increased more if not for a significant increase in cost-shifting to employees (up over 19% from 2011 – 2012)"

Giving physicians a check-up

But money does not drive all of the problems in our health care system � at least not among doctors � writes Brad Flamsbaum in Why We Lie�on the The Hospitalist Leader.)

Doctors sometimes fib, Flamsbaum acknowledges, to insurers, in order "to obtain pre-certification for patient testing perceived as necessary"���and, yes, they lie to patients: "We are humble folk and he says, physicians have the same foibles as the flock we oversee."�Yet, "it's not about the money," he explains, "but a host of other factors ���surprisingly more potent than financial rewards."

Flamsbaum points to research on why humans lie that begins with our "ability to rationalize," followed by "conflicts of interest," "creativity," "previous immoral acts," and "being depleted," all illustrated here.

On�Health Business Blog, David Williams expresses his own�concerns about physicians. �He quotes a doctor advising that�doctors should be candid with families�and "raise the issue of a grim prognosis early on," giving them "an opportunity to deal with it." Otherwise families may fall victim to "optimism bias."

Williams is "wary." The Physician may be "wrong, or unduly certain." He realizes that doctors "must find ways to deal with death" or "they can't practice medicine. But … I don't want a physician to make peace with my relative's death … while he's still alive."

By contrast, Michael Gavin and Mark Pew, executives at Prium, a worker's comp utilization company, worry that�doctors are too quick to give injured workers a heavy dose of pain-killers. �Writing on Evidence-Based, they point to "A new ruling from Texas … that finds payers liable for a range of opioid-related side effects ranging from addiction to death. Prediction: This is just the beginning."

Finally, over at�The New Health Dialogue, Joe Colucci and Shannon Brownlee turn to�how television depicts physicians. "The Fox show House ended last week," they write. "It was entertaining, but as far as health policy is concerned, we're not sorry to see it go … Dr. House exemplified the "cowboy doctor" as "hero" who is in fact a "hazard" … practicing "reckless, unscientific, non-evidence based medicine."

Just "one point in House's favor: he works with a team" and they "actually talk to each other … Unfortunately, that's as unrealistic as the rest of the show."

Thoughts on obesity

In another post,�The New Health Dialogue's�Colucci examines New York Mayor Mike Bloomberg's most recent public health proposal,�banning sugary beverages�"gigantic enough for a small marine mammal to do laps in." Bloomberg would limit sodas served in restaurants to 16 ounces.

"The reaction has included furious opposition from �people claiming this is the nanny state run amok," Colucci reports, but in fact, "There is extensive evidence from psychology and behavioral economics that people respond to larger portions by eating more."

Over at 365 Days of Wellness, Kat Haselkorn focuses on a different profit-driven problem. In Unstoppable Obesity Epidemic, she acknowledges that "obesity is a bigger issue in low-income communities and is more likely to affect minorities." But "marketing and advertising play a significant role in childhood obesity, nudging children towards processed foods and sugar. Government subsidies allow Big Agriculture and top manufacturers to aggressively market products to children … 77% of obese children become obese adults."

Uninsured veterans

The government might better be spending that money on Veterans. On the Healthcare Economist, Jason Shafrin's Memorial Day post�reports that "About 10 percent of U.S. veterans under the age of 65 lack health insurance and are not being taken care of by the VA."�Eligibility for VA services "is based on veteran status, service-related disabilities, income level, and other factors," Shafrin explains. "Proximity to VA facilities and cost-sharing requirements" also affect access.

High anxiety

On Workers' Comp Insider, Julie Ferguson reports on another group at risk. The "boom in cell phones has spawned" a huge demand for radio towers, and "brutal" schedules are leading to more fatalities among tower workers. �(See this video from a prior post.)�"Tower work is carried out by" layer after layer of subcontractors, she explains allowing large companies to "deflect responsibility for on-the-jobwork practices." In an era of sub-contracting, "this layering makes OSHA enforcement almost impossible."

Electronic health records

Jann Sidorov focuses his concern on Electronic Health Records (EHRs)�and "The Need for Legal Framework." Writing on Disease Management Blog�about a piece in the Economist that examines the need for legal reform for military drones and driverless cars, �Sidorov argues that "since robot-like artificial intelligence is involved in electronic health records, the same legal protections may be necessary there."

Age rating

Although I'm a fan of health reform, I too, have my worries. Under the Affordable Care Act, insurers can charge older Baby-boomers (in their 50s and early 60s) premiums three times higher than they would charge a 20-year-old for exactly the same coverage.

I explore the issue here, on HealthInsurance.org, where I've recently begun posting. (Soon, I�ll be re-launching HealthBeat thanks to technical assistance from HealthInsurance.org. In the future, I�ll be writing on both web sites.)

Meet Dr. Quentin Young

For those of you unfamiliar with Dr. Young, he has been a tireless advocate for single payer health care for over twenty years, but that is just one item on a CV that includes:
- Practicing medicine for over sixty years (he’s recently retired)
- President of the Medical Committee for Human Rights,(physicians who traveled to treat victims of racial violence)during the most tumultuous years of the civil rights movement, 1963-69
- Personal physician for Dr. King when he was in Chicago (Dr. Young was marching alongside Dr. King when attacked in Chicago. Can you think of a better guy to be next to you when you’re hit by a brick?)
- Chair of the Chicago Health Department under Mayor Harold Washington, and personal physician to Studs Terkel, and Mike Royko as well

Doc Young celebrated his 85th birthday this year, and his energy and enthusiasm puts us both to shame. Take it away, Doc!

Find the full article on the Daily Kos

Health advocates go sour on sugar

The war on sugar is raging again.

This week, Walt Disney announced that it's going to stop advertising junk food to kids on its TV channels, radio station and website by 2015. It's eliminating ads for sugar-laden fruit drinks, candy and snack cakes.

Last week, New York Mayor Michael Bloomberg outlined a plan to ban large-size sugary beverages sold at the city's restaurants, movie theaters, sports venues and street carts. Some states and cities are working on "soda taxes" on sugary drinks. And in recent years, major health groups have discouraged the consumption of large amounts of added sugars.

The motivation is clear: The USA is in a full-fledged state of hand-wringing about overweight Americans who are among the most obese in the world and are heavier than they've ever been before.

It's a battle being waged on a number of front lines: Schools are beefing up their offering of fruits and vegetables, food and beverage marketers are being strong-armed to change how they market to kids and trans fats have been squeezed out of most processed foods.

Increasingly, the focus is being placed on sugar, the sweetener with a history that goes back 8,000 years.

Is something so sweet really that harmful to health? Or is it just being maligned as people look for a scapegoat for the obesity epidemic?

The American Heart Association says in a statement that research has tied a high intake of added sugars to many poor health conditions, including obesity, high blood pressure, type 2 diabetes and other risk factors for heart disease and stroke.

Diabetes educators often advise people with diabetes and pre-diabetes to watch their sugar intake, especially their consumption of sugary beverages. Nutritionists have said for years that sugar represents empty calories with no nutritional value.

The consumption of added sugars, especially from sugar-sweetened beverages, among some people in the country "is out of control," says Rachel Johnson, a spokeswoman for the American Heart Association and a nutrition professor at the University of Vermont.

Americans adults consume an average of 22 teaspoons a day, or about 355 calories, from added sugars, Johnson says. Every teaspoon has 15 to 16 calories.

You don't remember adding 22 teaspoons of sugar to your coffee or cereal?

Consider that sugar is used in everything from cakes, candy and cookies to muffins, jams, chocolates and ice cream.

People are downing table sugar, brown sugar, high-fructose corn syrup (in soda), maple syrup, honey, molasses and other caloric sweeteners. Added sugars make their way into many prepared and processed foods and beverages, from soda, sweet tea and lemonade to energy drinks and sports drinks.

One 16-ounce serving of regular soda, the proposed NYC cap, contains the equivalent of at least 12 teaspoons of sugar, says Cynthia Sass, a registered dietitian in New York City. "Many of my clients don't realize how much hidden sugar creeps into their diet, even in foods that don't seem sweet, like salad dressing, soups and crackers."

Sugar is "toxic" in the amount it's consumed by Americans, says pediatric endocrinologist Rob Lustig, a professor of pediatrics at the University of California-San Francisco and one of the country's most vocal critics of added sugars.

A little bit is OK, but it's the quantity that people are consuming that's harmful, Lustig says. "Everyone knows the dose determines the poison. I agree with that. There is a threshold, and right now we are way above that threshold."

The heart association recommends that most American women consume no more than 6 teaspoons a day, about 100 calories, from added sugars, Johnson says. For men, it's 9 teaspoons or about 150 calories. Kids should limit their intake to about the same amount, she says.

Others say not so fast. Added sugars have been "unfairly demonized" by some researchers, and "the reality is much more complicated," says James Rippe, a cardiologist who studies nutrition and fitness. He's worked with the food industry, including the Corn Refiners Association, which represents companies that make high-fructose corn syrup and other corn products. "Obesity is a bad problem, but to single out one component of the diet as a silver bullet to fix it is fantasy.

"And it distracts us from the serious multifaceted national commitment that we must have to solve this enormous public health problem of obesity," he says.

Sugar doesn't deserve to take the rap for the country's weight problem, says Andy Briscoe, president and CEO of the Sugar Association. "Sugar has been around for thousands of years. It's all natural. It's 15 calories (a teaspoon). It has been used safely by consumers by our grandmothers and our grandmothers' grandmothers."

What the research says

Research about the effects of excessive intake of sugary foods and drinks is coming out all the time, and there's not much that's reassuring, says Marion Nestle, a nutrition professor at New York University and co-author of Why Calories Count: From Science to Politics.

Johnson says recent studies show a link between high consumption of sugar-sweetened beverages and high blood pressure. So no surprise that when researchers conducted a study of people who reduced that consumption, their blood pressure dropped.

People with diabetes or pre-diabetes are often advised to watch their sugar intake. "The first thing we tell people to do for the prevention or management of diabetes is to not drink sugar-sweetened beverages," says Stephanie Dunbar, director of clinical affairs for the American Diabetes Association.

When someone with diabetes drinks a large quantity of sugary beverage, they get a huge dose of sugar at one time, she says. It hits their system quickly, raising blood glucose levels, she says.

That's not healthy for anyone, especially someone with diabetes or pre-diabetes, because high blood glucose causes damage to blood vessels, increasing risk of complications such as heart attacks, amputations and blindness, she says.

There are many kinds of studies that show sugared beverage consumption is linked to increased risk of obesity and type 2 diabetes, says Kelly Brownell, director of Yale University's Rudd Center for Food Policy and Obesity. There are a few studies showing no links, mainly funded by the beverage industry, but these stand against study after study showing that these beverages are having harmful health consequences, he says.

Is sugar to blame?

Much of the fuss about sugar comes because of questions about its role in a nation that has become way too heavy.

Thirty-six percent of adults in this country are obese, which is roughly 30 or more pounds over a healthy weight. About a third of children are overweight or obese. Obesity increases the risk of many chronic diseases including type 2 diabetes, heart disease and cancer.

Is sugar to blame for our bulging waistlines?

Overall, calorie intake has gone up since 1970, and about 16% to 17% of people's total daily calories come from added sugars, according to the U.S. Department of Agriculture's Economic Research Service.

Sugar is just one reason for obesity, but for many people, it's the big reason, Nestle says. "Some overweight kids drink 1,000 to 2,000 calories a day from sodas alone, and sweet desserts are a major source of calories in American diets."

The most important health concern about sugar intake is that it adds calories to the diet, which can be a ticket to weight gain and obesity, agrees Samuel Klein, director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis. "The calories we consume in beverages that contain sugar do not make us feel as full as when we eat the same amount of calories in solid food, so consuming large amounts of sugar-sweetened beverages or fruit juices can pack on the pounds."

Klein, an expert on fatty liver disease, says that when you gain weight, fat can accumulate in your liver and reduce the effectiveness of insulin, the hormone that regulates blood sugar. Extra body fat affects the liver, and your pancreas works harder to try to keep blood sugar normal.

Whether or not you're overweight, consuming high amounts of sugar can increase triglycerides (blood fats) and increase fat production in your liver, he says. Possible explanations: High amounts of fructose, found in both sugar and high fructose corn syrup, can cause chemical reactions in the liver that lead to health problems, he says.

For many people, reducing the consumption of high-sugar beverages is a good first step for maintaining a proper body weight and improving their health, Klein says.

When it comes to added sugars' impact on health, including the liver, Rippe says, "this is some of the most complex biochemistry you can ever imagine. The literature on this is very mixed."

As for sugar's impact on obesity, Rippe says, "Americans are eating about 425 calories a day more than they were in 1970, according to the government statistics, but only 9% of those increased calories come from added sugars."

Briscoe adds: Most foods and beverages add calories to the diet and can lead to weight gain and obesity if overconsumed, "so we do not feel sugar should be singled out. We need to look at total caloric intake in the fight against obesity."

The addiction question

Studies on food and addiction show that sugar works on the brain very much like classic substances of abuse, Yale's Brownell says. He has researched the topic for an upcoming book, Food and Addiction: A Comprehensive Handbook. "Sugar doesn't have as strong of an effect on the brain as heroin or cocaine, or even alcohol or nicotine, but the addiction still exists. Sugar activates the same reward pathways of the brain."

When you are really addicted to something, your willpower goes out the window, he says. "If a kid gets off of the bus everyday and has to have a soda, is his brain hijacked by sugar?

"The question is: Is sugar addictive enough to create a public health menace? And I think the answer is yes."

Rippe says this theory "is very controversial." Most of that food-addiction research is based on work on animal brains, and animal brains are much different than human brains, he says.

"When we eat any food, the reward pathways light up. That's why we eat, because it's pleasurable," he says. "The scientific literature on this is very mixed and very inconclusive."

Charles Baker, chief science officer for the Sugar Association, says, "The same brain reward pathways are set in motion by any food a person happens to like. Unraveling the intricacies of the crosstalk within the brain and between the brain and digestive tract during eating, is still an evolving body of science. Reward pathways are simply one part of a multi-part system."

A matter of degree

Even nutritionists have a bit of a sweet tooth and don't want to come down too hard on something so tasty. Consuming some sugar is OK for many people, they say. "Even the staunchest anti-sugar advocates say it's a matter of degree," Nestle says. "Nobody worries about 10% of calories or less from sugar. It's only when the amounts go over that problems kick in."

Johnson agrees: "Sugar is not the root of all dietary evil. A little bit of sugar adds to the taste of foods. But we've lost sight of moderation because of the gigantic portion sizes. You have to be so vigilant about portion sizes to avoid overconsuming.

"We have to be careful not to demonize one ingredient in the diet," she says. "We did that with fat, and it backfired because then low-fat products came on the market that were low in fat but high in sugar.

"It didn't lead people to an overall healthier diet which is one that is rich in fruits, vegetables, whole grains, non-fat dairy and lean protein."

Iatric Systems to offer endowment up to $100,000 in HIT privacy solution to worthy hospital

BOXFORD, MA – Iatric Systems, Inc., will endow a hospital in need with an enterprise-wide patient privacy and auditing security solution worth $50,000 to $100,000, company officers have announced.

The Boxford, Mass.-based vendor is accepting applications until March 2 and will announce the winner of the special endowment on April 6 at the HIMSS09 Conference in Chicago. The company will back the endowment with three years of service and support.

John Danahey, director of marketing at Iatric, said the idea for an endowment started small, then grew exponentially. "Iatric has been fortunate to have many consecutive years of success," he said. "The endowment program is a great way to give back in our industry."

The winning hospital will be selected based on financial need and a demonstrated need for more comprehensive personal health information protection. "Some hospitals don't have the resources to do comprehensive auditing, and some only do a random sample approach," Danahey said. "This is a time-consuming process and only scratches the surface."

Joel Berman, founder and president of Iatric Systems, said the endowment was created to help a hospital in need reduce its risk of internal security breaches and, ultimately, patient privacy. Iatric's Security Audit Manager is "a proven solution," he said, and is installed in more than 100 hospitals across the United States and Canada.

According to the Health Information Management Systems Society (HIMSS) 2008 leadership survey, internal security breaches are the top concern among CIOs regarding privacy of electronic patient records.

Berman said breaches are often caused by a breakdown in procedures and damage a hospital's brand name. A recent HIMSS Analytics report indicates hospitals lose about $6.3 million per incident.

Qualifying hospitals must by 400 beds or less, licensed, not-for-profit and single-facility acute care.

"We want the hospital to make its case," Danahey said.

Applications will be accepted at www.iatric.com/endowment.

Local man spearheads statewide healthcare movement

ROCKLAND (Dec 8): Jerry Call is a man with a mission. Call, who lives in Rockland and is one of the five founders of Midcoast Healthcare Reform, first learned about single-payer health care about a year ago when Dennis Kucinich was running in the Democratic presidential primaries and mentioned House Resolution 676 during the debates.

“Finally it sunk in as to what he was proposing,” Call said Dec. 5. “After he was shut out of the debates, a bunch of us were sitting around at dinner and decided to do something about it.”

In January 2007, Congressman John Conyers introduced the current version of H.R. 676, which Kucinich referred to as the “Medicare for All” bill. Currently the bill is in the hands of the congressional Subcommittee On Health.

H.R. 676 would establish the U.S. National Health Insurance program to provide all residents of the United States and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, prescription drugs, emergency care, and mental health services.

The law would allow nonprofit health maintenance organizations that deliver care in their own facilities to participate in the USNHI program and would give patients the freedom to choose from participating physicians and institutions.

Private health insurers would not be able to sell health insurance coverage that duplicates the benefits provided under H.R. 676, but would be allowed to sell benefits for care that is not medically necessary, such as coverage for cosmetic surgery or private hospital rooms.

Since January, Call has been traveling throughout Maine and beyond to promote Conyers’ bill. In March his organization coordinated showings of Michael Moore’s film “SiCKO” in seven locations throughout the state. MCHR maintains a mailing list of 250 interested parties in the local area and gathered more than 7,000 signatures at the polls statewide on Nov. 4.

The petitions Call is circulating ask the Maine Legislature to endorse the federal bill. While the resolution advanced by the petition is not binding on Maine’s elected officials, Call hopes a strong groundswell of support will encourage the federal delegation to sign onto H.R. 676.

So far, none of the state’s representatives in Washington, D.C. have joined the 93 congressional co-sponsors. In June the U.S. Conference of Mayors expressed its support of the bill and called upon federal legislators to work toward its enactment. And polls repeatedly show a majority of Americans supporting national health-care coverage.

In a letter to Call, Maine’s U.S. Sen. Susan Collins stated that she “continue[s] to have many reservations about a single payer system,” and that she instead supports S. 158, which would provide a tax credit of $1,000 to individuals earning up to $30,000 and $3,000 for those earning up to $60,000. According to the Web site smartmoney.com, private health insurance premiums cost upward of $4,000 a year for individuals and generally include co-pay requirements and high out-of-pocket deductibles.

Rep. Ed Mazurek of Rockland is sponsoring the single-payer resolution in the Maine Legislature, and Rep. Andrew O’Brien of Lincolnville has agreed to co-sponsor it, Call said.

On Dec. 5, Mazurek said he supports Call’s project. “The system we have now seems broken,” he said. “We have such high premiums for health insurance because it’s private.” He also said he hoped statewide efforts like Call’s would help average Americans by building support so that H.R. 676 would pass in Congress.

Congresswoman-elect Chellie Pingree of North Haven said throughout the election campaign that she would sign on to H.R. 676. If it comes to the Congress in this session, she said Dec. 8, she will support the bill. But she added that the election of Barack Obama has changed the discussion about health care.

“The new Democratic Congress will mean more movement,” she said. “It’s a different dynamic when you have a president with a vision.” Pingree said she didn’t think she’d have a lot of clout as a freshman in the House, but she will push for single-payer or the most comprehensive reform possible. “We don’t want Congress to end up passing another iteration of managed care,” she said.

According to an article in the Sept. 24, 2007, issue of the Palm Beach Post, businesses contributed $2,600 per employee, or $217 monthly, to employee health insurance in 2005. Under H.R. 676, employers’ average cost would be $1,425 annually, or $119 a month. According to a study by economist Dean Baker of the Center for Economic Research and Policy, a family of three making $40,000 annually would spend approximately $1,900 yearly for coverage. The Post article quotes the National Coalition on Health Care as saying that the average private insurance premium cost this same family $11,000.

The Web site for Republicans for Single-Payer states that close to a third of every health-care dollar is spent on administrative costs, and calls single-payer “the conservative approach to providing access to health care with informed choice of private providers.”

Call’s recent presentation pointed to a 2001 analysis by Health Affairs that showed 35 percent of drug companies’ costs going to advertising and marketing. He said 47 percent of the cost of workers’ compensation goes for medical payments that would be covered by the new program, thus saving employers even more.

The USNHI program would be funded through a payroll tax on employers and employees of 3.3 percent each, added to the 1.45 percent payroll tax each pays now, totaling 4.75 percent each. The top 5 percent of income earners, those earning $250,000 a year or more, would pay a 5 percent health tax and those at the top 1 percent would pay 10 percent. A small tax on stock and bond transactions amounting to one-third of 1 percent would also contribute to the USNHI program. Closing corporate tax loopholes and repealing the Bush tax cut for the highest income-earners would bring the estimated savings up to $56 billion.

With President-elect Obama’s emphasis on reforming the health-care system, Call said it’s important for citizens to express their preference for H.R. 676 as early and emphatically as possible.

“The thing that drives me is that a number of years ago I was diagnosed with cancer,” said Call. “I remember sitting in the doctor’s office and thinking, ‘If I can live with this I’m going to find a way to repay to society for my good fortune.’ This is the way.”

For information on H.R. 676, visit hr676.org. Call can be reached at midcoasthealthcarereform.org or by calling 596-7784.

This article appeared on VillageSoup.com.

Hospitals face $1.6 billion in penalties, survey says

NEW YORK – As they work to curb readmission rates and shift toward value-based reimbursement, hospitals are being slapped with big penalties that experts say are only increasing. A recent study from CipherHealth shows a mounting $1.6 billion in HCAHPS and readmission penalties facing hospitals today.

The survey calculated that at more than five hundred hospitals nationwide, three-year at-risk amounts were $3,500 per inpatient bed, a number experts say could provide clarity and prioritizing strategies for the healthcare industry. 

Value-based purchasing and readmission penalties for hospitals seek to align incentives around patient care, tying the successful recovery of a patient and that patient’s perception of the quality of the hospital to Medicare and Medicaid reimbursements. With 39 percent of hospitals running at a loss in 2011, even a small change to these reimbursement rates can lead to huge changes in staffing models at hospitals and ultimately the quality of patient care they are able to provide.

The CipherHealth study analyzed how this legislation would affect acute care hospitals, specifically. Using data from the American Hospital Association, Kaiser Family Foundation and CipherVoice patient surveys, the report found some surprising results.

In states such as West Virginia, the statewide risk is quite low, ranking 32nd when compared to the rest of the nation on three-year at-risk totals for readmissions and HCAHPS. However, at $3,600, the average amount at risk per bed in West Virginia is among the highest state averages in the country.

“The risk per bed view is a much more effective way to look at the data. Thinking of penalties on a per-bed basis helps hospitals to prioritize the dozens of different pieces of legislation and focus on what will create the most value for their organization,” says Zachary Silverzweig, one of the founders of CipherHealth. “It’s why we we’re able to establish such a strong presence in West Virginia. We quickly realized there was a serious pain point and we were well-positioned to deliver a solution to help hospitals avoid these penalties.”

In some states, however, the story is almost the exact opposite. California ranks second in terms of total at risk amount, yet ranks 30th when viewed on a risk-per-bed basis. Texas ranks fifth at the aggregate level, but on a per-bed basis, it ranks 32nd. However, when looking at the data for California and Texas at the health system level, there is wide variation.

Tenet Healthcare, which has a presence in 11 states, has an amount at risk per bed of $2,203 overall, but for its Texas facilities, amount at risk per bed is $1,481. Other health systems such as East Texas Medical Center have a much higher amount at risk per bed at $4,370.

The analysis also offers insights that defy geographic and demographic trends: North Dakota has a 70 percent higher per-bed risk than South Dakota and Mississippi has 51 percent higher average per-bed risk than neighboring Alabama.

With hospital executives facing everything from RAC audits to value-based purchasing to meaningful use to ICD-10, it is critical to be able to prioritize the various hospital initiatives and focus on key projects that can drive both short and long-term ROI, the study's authors note.