Evacuation insurance?

Caught my eye: a Slate article juxtaposing Republican governor of New Jersey Chris Christie's comments regarding evacuation before the hurricane with his comments around health care reform, with a reference to the "free-rider problem" (*cough* Stone's chapter on Interests *cough*) for good measure. 

"Hurricanes and health care are different in many ways, of course...  But in both cases, the question is whether you should be allowed to make your own choices when the cost of bailing you out will fall on others. If the state has no business forcing you to buy health insurance, even when the premiums are subsidized, why should it be empowered to order you out of your home in a storm, just to save your skin?"

http://www.slate.com/articles/news_and_politics/frame_game/2012/10/hurricane_sandy_why_does_chris_christie_think_it_s_selfish_to_ignore_evacuation.html

After our discussion on Monday about EHR I wanted to post an article I read regarding the implementation of EHR and the effects on medical education. This particular article discusses more of the subjective comments of physicians, but also highlights the lack of programming to focus on how to integrate EHR with medical education. Article

Temporary Medicaid Pay Hike

Interesting article regarding how the temporary pay hike in Medicaid reimbursement rates for primary care doctors may affect access to care. The ACA has a provision which will raise rates for primary care doctors beginning on January 1, paid for by the feds - however, this is a short-term fix and will only be implemented for the next two years. While it is intended to encourage more physicians to accept Medicaid, for which rates are so low that many refuse to take it - there are several questions raised about how many doctors will actually be incentivized to participate. One question is regarding the temporal aspect of the pay hike - two years is a limited time frame with no guarantee that states will continue the pay hike. Not to mention the uncertainty with the impending election - if Romney is elected, what will happen to this provision?

With California gearing up for the Medicaid expansion, I think it is crucial that we consider long-term solutions and innovations to motivate doctors, particularly primary care, to accept Medi-Cal. With California having some of the worst Medicaid reimbursement rates in the country, any temporary pay hike that returns to previous levels could have serious consequences on access issues. One suggestion would be updating California's Relative Value Scale, which is highly outdated and should account for geographic disparities.

US Rankings

Came across this interesting site that ranks global attitudes.  One of the rankings is which country's have the most favorable view of the United States.  In 2011, the US had only the 3rd most favorable view of the US in the world (behind Japan and Kenya).  But this year, the US loves the US the most....

USA! USA!

Electronic Medical Records in the NYT

As someone interested in health care management, administration, and practical application of new practices and policy decisions, electronic medical records are of particular interest to me. I was excited to see an article in the NYT about EMRs, but it felt a little sensationalist to me, and raised more questions than it answered.

There are clearly problems with electronic medical records, both within and between individual platforms as well as with the security and legal issues involved with moving to digital record-keeping. This article's evidence of the flaws of EMRs are a little bit of a stretch, however. An example close to home: The system that the author sites in Contra Costa County in California that "slowed to a crawl" was based on Epic, a system that's been widely, and successfully, used in large health systems nationwide, including Kaiser. It has only been in place in Contra Costa County for 3.5 months, and the problems cited in the article likely have more to do with poor planning and support for implementation than problems with the system itself. There were reasons for Epic's rocky roll-out in CCC, including that the county was committed to "going live" before a July 1st federal grant deadline, and the rushed customization/building and training process that preceded that deadline. No surprise that there were difficulties when patients first walked through the door on July 1st.

Here is an article the same author wrote in January about that system, Epic, and its beginnings 30 years ago.

Questions this article leaves me with:
The "Impact of IT" article for Monday clearly shows the benefit of these systems. But how can we make them work better for us?
What are the most pressing practical, ethical, and legal problems as we as a nation transition to EMR?
Where will these questions be answered, who will set guidelines?
What will it take for platforms to talk to each other? Will Health Information Exchanges (HIE) be embraced by programs like Epic?

The Policy Behind Measuring Health Outcomes

We are discussing in our Foundations class right now the concepts of value, both in defining what value means in health care, and also, how to measure it. I came across this Health Affairs article through the California Health Care Foundation website. It discusses a research institute which was funded by the ACA and will attempt to look at outcomes which are particularly relevant to patients. The institute only has funding until 2019. This gets at yet another issue in measuring our system's progress: many of the evaluators are funded through the government and only for a very short time. How can an institute that is essentially brand new put together a research agenda and execute it in such a short time period? Even if this program were to advocate and receive more funding in 2019, the way that evaluation of outcomes is treated as an afterthought in our healthcare system will only ensure that we never get the data adequate to learn from our mistakes.

Just when I think I'm getting too jaded...

...An article like this comes along.  What a great example of how advocacy really can make a difference!

http://www.kevinmd.com/blog/2012/10/lance-armstrong-hero.html

Factcheck.org takes on the VP debate

Hi all,

Unfortunately, I missed last night's VP debate because I was in class/in transit, but I feel like I know it all (once again) based on real-time social media commentary!  I couldn't help but notice that with Biden taking a much more offensive role (as opposed to defensive, that is), none of my favorite liberal followers were citing counts on lies and mis-statements for this debate.  I hunted down the factcheck.org article, and although they don't explicitly count the lies it appears to be 10 for Ryan and 4 for Biden.  Here's the link to their analysis:

http://factcheck.org/2012/10/veep-debate-violations/

If anyone else has seen other counts, I'd be very interested!  I've started to believe we learn more useful facts from following coverage of lies than from any other source.

Health Care Comparison

I wanted to share this easy-to-read chart from UCLA which breaks down each component of the Affordable Care Act and compares what the Romney/Ryan plan would do to it. It offers a clear picture of just how much Romney and Obama differ and what it might mean for folks if Romney is elected.

http://www.healthpolicy.ucla.edu/pubs/files/ProposalsPNoct2012.pdf

1. newsmap.jp  = This is a visual representation of trending news stories. The newest stories are lighter colored, the older, darker. The more read the subject is, the bigger the square. And you can set it to look only at a certain topic of news (like Health), as well as broadening or restricting the countries and languages of news sources. It's mostly AP-sourced, and unfortunately NYT, CNN, and other big-players are not sourced for this website. But it is an interesting way to visualize news, and gives an idea of what the general public is reading and interested in, health-wise.

2. The Atlantic's article "The Cost of Assuming Doctors Know Best "(http://www.theatlantic.com/health/archive/2012/09/the-cost-of-assuming-doctors-know-best/262993/) touches on several issues, including: new technology, shared decision making, payment methods (FFS vs. other), and lean management. It succinctly recommends various cost-cutting and care-improving ideas, and discusses a few barriers to implementation, but doesn't delve into how to get beyond the barriers.

3. While we're on the Atlantic... social media in the OR. The article below documents how photo-sharing social media apps can be used to document surgeries, especially as a way to relieve other potential patients' anxieties about the procedure. This idea, along with the recent study about releasing medical records to patients as a way to improve compliance and patient involvement, seem incredibly useful for many reasons. I also wonder if increased access to these photographs (and records) might increase lawsuits, as patients, patient advocates, and others who are given access may be able to comb for errors in a way they haven't before. Thoughts?
http://www.theatlantic.com/health/archive/2012/10/instagram-in-the-or-hearing-restoration-surgery-live-tweeted/263145/

Coverage Disruptions

I came across this story on NPR this morning that discusses the difficulty of navigating the insurance market for individuals that experience coverage disruptions. The article points out a few scenarios that may occur when a spouse retires, becomes eligible for Medicare, and loses private insurance. For example,

1) A spouse that retires and becomes eligible for Medicare risks their dependent spouse having to shop for health insurance in the individual market,
2) A dependent child (under age 26) may have to purchase expensive COBRA insurance when their parent retires and loses private insurance coverage (even though the ACA mandates their coverage on the private plan), or
3) An employee of a small employer (20 employees or less) decides to keep working and stay enrolled in the companies private plan even though they are eligible for Medicare, risking the private company recouping the costs provided to a technical Medicare beneficiary.

I think the article points out very complex scenarios that are not that rare. My main concern is the ability of the average person to shop for health insurance in a complex environment. How will Medicare and insurance companies provide transparency for enrollees facing these situations? Will this result in higher  premiums as companies increase administrative costs to meet patient demand (Thanks, Justin!)? Moreover, assuming vouchers become the Medicare reality, how will new Medicare enrollees and the elderly without a health care advocate make informed plan decisions? I think these are issues the current administration and potentially a new administration will have to answer prior to 2014.

Romney's Post-Debate Hangover - Pre-existing Conditions

Of all the glaring inaccuracies in Romney's debating last Wednesday against President Obama, the most egregious was likely his claim that under his health plan, people with pre-existing conditions will be guaranteed coverage. What he should have said, according to his own staff, was that he will leave it up to the states to decide whether to protect individuals with pre-existing conditions. It isn't surprising that Romney would make this misleading statement, considering how popular that provision of the ACA is.

It's about kindness, not a cost-benefit analysis

http://www.nytimes.com/2012/10/08/opinion/keller-how-to-die.html?_r=1

The perspective of these British palliative care physicians is refreshing.  Potentially having the same backlash as their US counterparts, they place sole emphasis on kindness and gentleness as the motivating factor in their care, and not a cost-benefit analysis.

How does ACA help the homeless

Of about 650,000 homeless in America 63 % are individuals, the rest are families. Prior to the ACA childless individuals and individuals without disability could not be enrolled under Medicaid. A large number of the homeless face mental health conditions, substance abuse, and alcohol abuse issues and could benefit from regular medical care instead of relying on ER's. ACA’s expansion of Medicaid coverage to include low-income childless-adults is a huge step in providing a large number of America’s homeless with access to healthcare. Kaiser Family Foundation recently issued a report on this, the 5 page executive summary of the report can be found at the link below

http://www.kff.org/medicaid/8355.cfm

The Future of HIV

We've been talking a lot about the health system at a macro level and I just thought it might be interesting to look at how policy and technology interact in the context of a specific disease. Recently, two new products received FDA approval that have far-reaching implications for HIV/AIDS. The first is called PrEP (which stands for Pre-Exposure Prophylaxis) which essentially is an antiretroviral that uninfected people take daily to help guard their chances of infection. My colleague at CREGS recently wrote about the implications for PrEP as a "cure" for HIV, especially for young men of color.

The second product is home testing for HIV. While this test was invented for the purpose of testing yourself privately in your own home (the idea being that many at-risk folks won't get tested in public), the NY Times just looked at an obvious "off label" use of the test: to screen potential sex partners. A test costs about $40 -- you can order it online so as not to shame yourself at the drug store.

The emergence of such products is still relatively novel, but I'm curious as to how the use of these products will play out in marginalized communities and within communities of privilege. Think of all the over-the-counter products we might have in the future... Perhaps we don't need medical intervention for such things. Maybe preventing HIV/AIDS, which still infects approximatley 50,000 new cases annually in the U.S., is just important enough to require them. And yet, I can't help but think that we are somehow jumping the gun. I won't be surprised if there is some law or regulation that limits the use of one or more of these interventions down the road.

For any of you interested in the Patient Centered Medical Home (PCMH) model and particularly the scopes of practice for primary care providers, the American Academy of Family Physicians (AAFP) just put out an interesting report.  perhaps not surprisingly, they feel that physicians not Nurse Practitioners should lead the medical home.  You can find the full report at:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf

A friend recently sent me this great site, that I did not know about.
https://www.coursera.org/courses


This website has tons of great high quality content on various topics, some of these are particularly relevant to policy, management, and public health. I have gone through the list of courses on the website and here are just a few of the really high quality courses (in my opinion). All the courses are free.

1. Community Change in Public Health -- William Brieger, Johns Hopkins
2. Model Thinking -- Scott E. Page, University of Michigan
3. An introduction to Operations Management -- Christian Terwiesch, University Of Pennsylvania
4. Organizational Analysis -- Daniel Mcfarland, Stanford University
5. Principles of Obesity Economics -- Kevin Frick, Johns Hopkins
6. Introduction to U.S. Food Systems: Perspectives from Public Health -- Robert S. Lawrence, Johns Hopkins

And just because I love history and if there are any other who do too --
7. A History of the World since 1300 -- Jeremy Adelman, Princeton University

Report: Mitt Romney Plan to Leave 72M Uninsured

A new report was issued by the Commonwealth Fund, indicating Mitt Romney's plan would make the uninsured problem in the United States worse than it was before Obamacare was enacted. Two primary reasons cited for this is the conversion of Medicaid into a block grant program and the expansion of Medicaid that would occur under the ACA.

The article does mention that the Commonwealth Fund tends to issue reports that portray the ACA in a favorable light, so perhaps the numbers can be taken with a grain of salt. However, leading up to the election, it will be interesting to see if this report might have an effect in shaping public opinion.

http://www.politico.com/news/stories/1012/81900.html

http://well.blogs.nytimes.com/2012/10/01/when-doctors-stop-taking-insurance/?src=dayp

Is this what a primary doctor shortage going to look like?

How do the candidates' policies impact you?

There's a cool website, Politify.com, that let's you look at the financial impacts of policies on you.  Just enter in some demographic information and have fun (or not)!