Health Business Blog

The Wall Street Journal’s Health Blog asks (Is Your Spouse Really Your Spouse? A Dependent Audit Wants to Know). Companies that offer benefits to their employees and dependents don’t want to pay health care costs for husbands and wives who aren’t the real thing. So they hire companies to check up on people to make sure they’re legit.

I haven’t experienced this particular kind of checking myself (perhaps because I own my own business) but it seems like just about every time a dependent or I have a claim we get a letter from some kind of auditor working for Blue Cross Blue Shield of MA wanting to make sure the charge is appropriate. Usually the instruction is to call a “recovery service” –typically done via interactive voice response– and answer some questions.

It’s kind of annoying and time consuming so I usually blow it off. Typically that results in another letter or two and then they give up. Maybe if I cost them more or triggered more doubts they wouldn’t give up so easily.

On average these interventions probably reduce costs to the insurance company or employer, otherwise they wouldn’t be sustained. Still, the spouse example shows pretty clearly a cost of having a patchwork of insurance plans rather than universal coverage with a single payer. In a single payer system it really doesn’t matter who’s married to whom or whether kids have aged out of their parents’ coverage, since everyone is in the system.

These kinds of checks are particularly onerous for people who are sick –just the ones who don’t have the strength to wade through all the requests or demands.

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Care360 started as a Quest Diagnostics platform to allow small physician offices to receive lab test results electronically. Over time it has developed into a full-fledged EHR that can be used to help physicians meet Meaningful Use requirements and qualify for incentive payments from the Federal government. In this podcast interview, Rohit Nayak, Vice President of Sales for Quest’s MedPlus subsidiary, discusses how physicians are using Care360 to transition incrementally from paper to digital records.

Rohit and I discuss the newly-finalized meaningful use regulations, the importance of interoperability, and linkages with health information exchange and various ONC programs.

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David Williams interviews Rohit Nayak Play Now | Play in Popup | Download

American Medical News reports that hospitals are stepping into patient-specific marketing by using data from electronic medical records to target messages to patients’ specific situations.

CPM Marketing Group, a Madison, Wis.-based marketing company specializing in CRM technology, has created an automated mechanism that generates website ads and content geared specifically for a visitor. If a patient is at risk for heart disease, for example, he or she might find a banner ad at the top of the page for a heart risk assessment.

Edward Hospital & Health Services in Naperville, Ill., was the first hospital to launch CPM’s automated system, which the company calls iCRM. Brian Davis, vice president of marketing for Edward, said the system essentially works like a patient portal. Patients are sent mailers encouraging them to sign up for a personalized URL for the Edward website.

Once a patient signs on, every time that patient returns to the website, they automatically arrive at their personalized URL, which means after the main web address, there would be a “/JaneDoe.” Similar to the way Amazon makes purchasing suggestions, the system generates content and ads based on the data the hospital has regarding that person’s medical history.

Davis said the system “is a way for us to give patients information in a more relevant and meaningful way.”

I do think this is the start of a significant trend, and that it won’t be just hospitals that are using this information for customer relationship management. A similar approach is already seen on Google. Start doing searches related to a disease –even if only indirectly related– and the search algorithms will start targeting you.

Three years ago (What if Google finds out you have cancer before you do?) I wrote about a friend who started seeing ads for Neulastin –designed to counteract the side effects of chemotherapy– in his Google searches. Had Google and the drug maker picked up the telltale signs of cancer before my friend’s doctor? The situation will be even more likely with the EHR data, and if doctors don’t get out in front of this patients may end up being diagnosed (or misdiagnosed) by the marketing department.

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I did a lot of driving around Wisconsin this week and used the time to listen to a lot more radio stations than I would otherwise. Among other stations I listened to NPR, Christian radio, an African American-themed talk show, and right wing and left-wing talk. I find each of those genres mildly annoying to almost unbearable so I flipped around a lot. Music stations played a heck of a lot of songs from the 70s and 80s so it was like going back to junior and senior high school.

One of the things I noticed was the use of fairly extreme words to denigrate political opponents. One conservative station referred to President Obama –and many others– as “socialists,” without ever defining the term. (I guess they mean a really liberal liberal.) “Racist” was another term used by the NAACP and its opponents in the Tea Party. At first I was kind of excited to hear a “progressive” talk show –after all Wisconsin has a long history of progressives– but was pretty disappointed when the host came on and started raving about how we should make outsourcing (I think he meant offshoring) illegal. Crazy stuff.

I’ve been reminded of another bad word recently: “rationing.” That’s a popular one among opponents of health reform. And it’s been thrown around a lot in relation to Dr. Don Berwick, the new CMS administrator. Of course the Wall Street Journal is one of those places. But a letter (In Defense of Dr. Donald Berwick) puts rationing in a different light:

You criticize Dr. Berwick for wanting to “see a system in which those [rationing] decisions are transparent—and that the people who make them are held accountable” and that we must “weigh public welfare against the choices of private consumers.” Your point seems to be that Dr. Berwick does not understand the difference between rationing “through individual choices and price signals and rationing through politics and bureaucratic omniscience.” On the contrary, Dr. Berwick and many others perfectly understand this difference. Their point is that there currently is rationing of health services by both public and private payers based on access to care, coverage and price.

What we need to do is to acknowledge this rationing, make the rationing transparent and understandable to the public, and base this rationing, to the degree possible, on objective scientific evidence, not on politics or bureaucratic omniscience.

In the past words like Queer have been reclaimed by those against whom they have been thrown. Perhaps it is time for Dr. Berwick to grab the rationing bull by the horns and claim it. Actually, I think the proper time is a few years off. The general public isn’t ready to listen yet.

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I’ve posted quite a bit about the problem of excessive exposure to radiation from medical imaging, especially CT scans. A lot can be done to reduce exposure including reducing the number of unneeded tests (which should be done regardless of radiation concerns) and using better imaging protocols. These approaches can yield solid, even dramatic reductions in radiation.

But I’m especially intrigued by the findings of UCSD researchers, which demonstrate the ability to reduce radiation from cone beam CT (used in image-guided radiation therapy) by an order of magnitude or more. From Fierce HealthCare (Video Game Processors Help Lower CT Scan Radiation):

Based on recent advances in the field of compressed sensing, Jia and his colleagues developed an innovative CT reconstruction algorithm for graphic processing unit (GPU) platforms. The GPU processes data in parallel — increasing computational efficiency and making it possible to reconstruct a cone beam CT scan in about two minutes. (Modern GPU cards were originally designed to power 3D computer graphics, especially for video games.)

With only 20 to 40 total number of X-ray projections and 0.1 mAs per projection, the team achieved images clear enough for image-guided radiation therapy. The reconstruction time ranged from 77 to 130 seconds on an NVIDIA Tesla C1060 GPU card, depending on the number of projections — an estimated 100 times faster than similar iterative reconstruction approaches, says Jia.

This is impressive and makes me wonder whether similar results could be obtained with other scans if developers put their mind to reducing the use of radiation.

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I’m quoted in the Boston Globe today (A new practice: The doctor will see you today) on open access scheduling. (I’m all the way down at the bottom of the article.)

Open access is one of my favorite innovations because it improves customer service and quality levels. As we add patients to the system open access provides a way to preserve or improve access to the physician. It’s better –in my view– than other solutions such as using more mid-level practitioners and trying to boost the total number of doctors.

Open access means seeing today’s patients today rather than forcing them into a slot far in the future or trying to squeeze them in to a crammed schedule. The example given in the Globe article is a more extreme version than what I’m used to. I’m not sure such a radical shift to open access is optimal. It might be best to preserve a lower percentage of slots for same-day access rather than forcing folks in today who’d prefer to wait a bit!

What’s required to make open access work?

• Working overtime to chip away at the existing backlog (otherwise there’s no free time to offer up)
• Varying number of hours worked per day to accommodate fluctuating demand
• Having the right sized patient panel –something that’s somewhat hard to assess in advance, since the true demand is unknown (offices usually just know how far out they are scheduling)

Why does it work?

• There’s a high no-show rate from appointments made weeks or months in advance

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Remember when the Republican-controlled Congress passed the Medicare Prescription Drug and Modernization Act in 2003, providing “Part D” drug benefits to Medicare recipients while enacting offsetting cost cuts and tax increases to make the measure deficit neutral?

If you do you’re memory’s faulty because the net cost of the program in its first ten years is expected to be $500 billion or more –or roughly $50 billion per year. There was never a serious attempt to make the program deficit neutral. And Medicare is not a means tested program. That means plenty of well-off seniors are having their Medicare expense –including but not limited to Part D– subsidized by working class people paying FICA (aka, suckers) who themselves are uninsured. I’ve been opposed to Part D on inter-generational equity grounds from the beginning, and I’m still against it.

Now the Senate is stalling on providing an extra $24 billion in Medicaid funds to cash-strapped states. Deficit hawks (mainly Republicans) insist that the funding be made deficit-neutral, which is not wise or practical in the current depressed economic times. As a result states are getting ready to tighten up Medicaid eligibility and cut services, even though Medicaid expansion is meant to be a foundation for health reform. That tie-in of Medicaid to health reform helps explain the opposition to the current funding.

But there is a straightforward and equitable way to make the $24 billion available: cut the Part D subsidy –preferably by means-testing the program– and move the funds over to Medicaid.

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USA Today (National strategy on AIDS focuses on new infections, testing) does a nice, clear job of reporting on the newly released National HIV/AIDS Strategy, which seeks to lower new HIV infections by 25%, reduce transmission by HIV positive people by 30%, and increase the percentage of HIV positive people who are aware of their infection from 75 to 90 percent.

I particularly liked that the article explained the interaction between prevention and treatment, paraphrasing HIV expert  Judy Auerbach:

Auerbach says the line between prevention and treatment “has become blurred” because research shows that people who know they’re HIV-positive and get treated are less likely to spread HIV. That’s partly because people who know they’re infected are more cautious with sexual partners. Evidence also suggests that people who get treated are less infectious even if they do engage in unsafe sex, she says.

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As a light-skinned, blue-eyed redhead I’ve been careful about sun exposure since childhood. When I started going bald in my early 20s I got even more serious about it. People laugh at my broad brimmed hat, sunglasses and long-sleeve Sun Precautions swimshirt, but most understand by looking at me that these are reasonable measures. Even with these measures I sometimes get more sun than I want.

I wasn’t surprised to see Skin cancer is universal in today’s USA Today. The message: it’s not just people with my complexion who can get sub damage and raise their risk of skin cancer through overexposure. Many Hispanics and African Americans think they don’t have to worry about sun exposure or skin cancer (whether caused by the sun or not). While it’s true that the risk is a lot lower for someone with dark skin, the risks are still there and tend to be overlooked.

When it comes to melanoma, a dangerous form of skin cancer, a lack of concern can be deadly. Studies show that though blacks and Hispanics are much less likely than whites to get melanoma, they are much more likely to be diagnosed at a late stage and die from it.

One recent study of 41,072 melanoma patients in Florida found advanced cases in 12% of whites, 18% of Hispanics and 26% of blacks

“This is a tragedy because it’s preventable,” says Claudia Hernandez, a dermatologist in Chicago. “Unlike a lot of cancers that are internal and cannot be seen, these are cancers that can be caught at an early stage.”

According to the article, the American Academy of Dermatology is sending spokespeople out to do interviews with radio stations that are popular with African Americans and Hispanics. That’s probably a good idea.

On the other hand the African American oriented radio show I listened to this morning while driving through Milwaukee (The Tom Joyner Morning Show) did a disservice to its listeners by airing an ad for Super Beta Prostate, using an empathetic African American pitchman to sell an herbal supplement with unsupported therapeutic claims.

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According to the Financial Times (US claims of higher drug costs under fire) a study to be published soon in Health Economics, Policy and Law will demonstrate that US prices for branded drugs are similar to prices paid in Europe, once discounts and rebates are taken into account. That is quite different than the conventional wisdom, which is that US buyers subsidize R&D in other rich countries by paying more for drugs. It’s actually not that surprising, because US based pharmacy benefit managers (PBMs) specialize in negotiating with drug companies.

There is a modest price premium in the US compared to Europe, but the premium is declining over time.

The FT doesn’t say much about generic drug prices, but the market for generics is cutthroat in the US and perhaps less so elsewhere. Considering that generics are such a big part of the market here I wonder whether are overall unit drug costs are actually lower here than in Europe.

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Incidentally when I registered to view the article on the Financial Times site it asked me what industry I’m in. Health care wasn’t even one of the approximately one dozen choices in the pull-down menu! Now there’s a big difference between the UK and US.

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