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10/11/2017

Upcoming Podcasts: Bundled Payment Arrangements and Practicing Mindfulness in Health Care Delivery

Since this coming Monday, October 16th, comments are due to CMS concerning the agency's proposal to cancel the Obama administration's cardiac care bundled payment demonstrations, it is a good time to revisit bundled payment arrangements.  With me to discuss this type of pay for value contracting under Medicare will be Mr. Clay Richards, President and CEO of naviHealth, a convener of bundled payment arrangements under CMS' Bundled Payments for Care Improvement (BPCI) demonstration begun in 2013.   (Listeners may recall I discussed bundled payments with Jim Gera of Signature Health on April 1, 2016.)

In early November, I will discuss with the author, Dr. Ronald Epstein, Professor of Family Medicine, Psychiatry and Oncology at the University of Rochester, his recently published work, Attending: Practicing Mindfulness and Humanity.  

 

10/03/2017

MACRA's Virtual Groups (October 3rd)

If you're into the weeds relative to the regulatory implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the 2015 Medicare law that replaced the SGR (Sustainable Growth Rate), here's an essay I co-wrote with Manu Uppal, an information technology expert, regarding the Merit-Based Incentive Payment System (MIPS) Virtual Group provision CMS is proposing to implement in 2018.  The Virtual Groups provision is yet another example of Medicare policy that in theory or on paper sounds correct but relative to how in practice it's actually implemented, is black box.

"CMS Should Play the Role of Virtual Group Matchmaker, " is at: http://thehealthcareblog.com/blog/2017/10/03/cms-should-play-the-role-of-virtual-group-matchmaker/.

09/29/2017

Eric Weinberg Discusses His Recent Work, "Blood On Their Hands" (September 28th)

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Mr. Eric Weinberg is co-author with College of New Jersey Journalism Professor, Donna Shaw, of the recently published work,  Blood On Their Hands, How Greedy Companies, Inept Bureaucracy, and Bad Science Killed Thousands of Hemophiliacs (Rutgers University Press).  The book details how beginning in the late 1970s through the mid-1980s tens of thousands of hemophiliacs in the US (and tens of thousands more around the world) became infected with HIV via the use of life-saving plasma-based blood clotting medicines.  Manufactures knew plasma-based products transmitted disease, for example, it was well known clotting medicines had infected countless hemophiliacs with hepatitis.  Nevertheless, neither did they cleanse or purify their blood clotting products, technology that was also well known, nor warn patients of adverse side effects.  Federal regulators, similarly, did nothing.  As a result, by the late 1980s the mean life span of a hemophiliac declined by over fifteen years.  While (civil) financial settlements were reached with approximately 6,000 victims or their families and the Congress passed in 1998 legislation, the Ricky Ray Hemophilia Relief Act, that provided additional compensation, the Justice Department chose not to criminally prosecute anyone.      

During this 35 minute conversation Mr. Weinberg discusses among other issues how blood plasma was obtained in the 1970s and 1980s, the position manufactures held on the safety of their clotting medicines, a (failed) federal class action effort to compensate hemophiliacs and their family survivors, the influential Institute Of Medicines 1995 report on HIV transmission through blood products, eventual civil settlement with the major manufacturers of these products and how his work representing hundreds of hemophiliac patients and their families over more than a decade affected him.  

Mr. Eric Weinberg is the principal of the Weinberg Law Firm, based in New Brunswick, New Jersey, since Weinberg1984.  Since founding the firm, Mr. Weinberg has tried approximately thirty jury trials and over two hundred bench trials to verdict.  He has also served as a Visiting Lecturer at Cook College, Rutgers University and has taught Ph.D. candidates at the Rutgers School of Management and Labor Relations.  Previously, Mr. Weinberg worked for the law firm Franchino, Lenahan and Cross and prior still served as Chief of Juvenile Prosecutions and Assistant County Prosecutor in Somerset County, New Jersey.   Mr. Weinberg has been an invited speaker in many forums on topics relating to the prosecution and settlement of serious injury cases, including mass torts and catastrophic injury cases.  Mr. Weinberg is the recipient of numerous awards for his years of community service. He was graduated from Rutgers College in 1977 and from Boston University School of Law in 1980. He is admitted to the Bar of the States of New Jersey and New York as well as numerous federal courts.  

09/27/2017

Dr. Haider Warraich Discusses His Recent Work, "Modern Death" (September 27th)

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Earlier this year St. Martin's Press published Dr. Haider Warraich's Modern Death, How Medicine Changed the End of Life. As the dust jacket notes, "the mechanics and understanding" of dying, "the whys, wheres, whens and hows are almost nothing like what they were mere decades ago."  Today, eight in ten Americans die at an advanced age, or under Medicare, die in a medical setting after suffering for some while from a chronic, eventually fatal disease or diseases.  If lucky, how Americans die will have been determined, or at least informed, by an advanced directive or like document.        

During this 27 minute conversation Dr. Warraich discusses what characterizes "modern death,"  how the 1970s Karen Ann Quinlan case redefined death or dying, the role family caregivers play and the unintended consequences for them in providing a family member care, the limitations of advanced directives and living wills, euthanasia, physician assisted suicide and terminal or palliative sedation and whether "how medicine changed the end of life" has made "modern death" comparatively better. 

Dr. Haider Javed Warraich is currently fellow in cardiology at Duke University Medical Center.  He was graduate from Warraichmedical school in Pakistan in 2009 and did his residency in internal medicine at the Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School   He is a regular opinion page contributor to The New York Times, The Atlantic, The Guardian, The Wall Street Journal, the LA Times and has contributed to several academic publications such as The New England Journal of Medicine, the Journal of the American Medical AssociationLancet and Circulation.  

During the interview mention is made of a November 28, 2016 Fresh Air (NPR) interview titled, "The Debate Across the Nation Over Death With Dignity Laws," that featured Dr. Warraich along with Dr. Ira Byock.  The interview is at: https://dianerehm.org/shows/2016-11-28/aid-in-dying

 

08/24/2017

Review of Elisabeth Rosenthal's "An American Sickness" (August 24th)

Dr. Elisabeth Rosenthal's recent, "An American Sickness, How Healthcare Became Big Business and How You Can Take It Back," has received considerable attention.  Here is my review of her work titled, "Healthcare as a Moral Universe," i.e., at: http://thehealthcareblog.com/blog/2017/08/21/healthcare-as-a-moral-universal/.

If you're interested in how we find ourselves in a situation where, as Dr. Rosenthal notes, health care "attends more or less single-mindedly to its own profits," I'd recommend Stephen Metcalf's recent, "Neoliberalism, The Idea That Swallowed the World." It is at: https://www.theguardian.com/news/2017/aug/18/neoliberalism-the-idea-that-changed-the-world.

 

08/08/2017

The National Academy of Medicine's "Effective Care for High-Need Patients," A Conversation with Melinda Abrams (August 14th)

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Recently the National Academy of Medicine (NAM) (formerly the Institute of Medicine) released it's "Effective Care for High-Need Patients, Opportunities for Improving Outcomes, Value and Health."  The report attempts to address a long-standing problem in health care delivery, e.g., five percent of patients ("high-need" patients) account for, or consume, 50 percent of health care resources.  That is if these patients were identified in a more timely manner and better managed overall health care spending could be substantially reduced.   Beyond the complexities involved in managing care for these highly co-morbid patients, the US does a comparatively poor job of coordinating or blending clinical care with non-clinical social service supports these patients need to mitigate their functional status limitations.     

During this 28 minute conversation Ms. Abrams discusses among other things the NAM work group's efforts to calculate methods for identifying high-need or super utilizers, or more generally developing patient categorization schemes, the importance of accompanying clinical care with social service supports for those patients with functional status limitations, how/why the 14 profiled providers in the report are able to provide comprehensive quality care for these patients, and the need for improved reimbursement models to allow for or support such care. 

Ms. Melinda Abrams is currently Vice President at The Commonwealth Fund.  Since 1997 she has worked on, among other Abramsprojects, the Fund's Task Force on Academic Health Centers, the Child Development and Prevention Care Program and most recently has led the Patient-Centered Coordinated Care Program.  Ms. Abrams has served on numerous national boards and committees for federal agencies and private organizations and as a peer-reviewer for several health care journals.  She is the recipient of the Champion Award from the Primary Care Development Corporation and a Primary Care Community Research Leadership Award from the Patient Centered Primary Care Collaborative.  Ms. Abrams earned her undergraduate degree from Cornell and her M.S. in health policy and management from the Harvard School of Public Health. 

The NAM report is at: https://nam.edu/effective-care-for-high-need-patients/

For more on the Commonwealth Fund's work go to: http://www.commonwealthfund.org/ 

08/04/2017

The MACRA Proposed Rule: The Administration (Largely) Takes a Pass on Medicare Reform (August 4th)

In late June the administration released its 2018 proposed MACRA (Medicare Access and CHIP Reauthorization Act) rule.  The largest proposed change is to, again, exclude approximately two-thirds of Medicare (Part B) physicians and other eligible clinicians (ECs) from having to participate in MACRA's Merit-based Incentive Payment System (MIPS) that financially rewards or punishes ECs for performance based on quality measures, improvement activities and health information technology use. This performance year, 2017, over 800,000 ECs are excluded and the administration, namely CMS, is proposing to exclude over 900,000 ECs from MIPS in performance year 2018.  Why this is a problem for those excluded, for those included and for Medicare beneficiaries as well is discussed in my essay, "The Many Problems with Medicare's MIPS Exclusion Threshold," posted yesterday on the Health Affairs blog.   

See: http://healthaffairs.org/blog/2017/08/03/the-many-problems-with-medicares-mips-exclusion-thresholds/

 

08/03/2017

David Wallace-Wells Discusses His Recent Essay, "The Uninhabitable Earth" (August 3rd)

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Approximately three weeks ago New York Magazine published David Wallace-Well's 7,500 word essay "The Uninhabitable Earth, Famine, Economic Collapse, A Sun That Cooks Us: What Climate Change Could Wreak - Sooner Than You Think."  The article has to date been downloaded over 4.5 million times.  It is the most read essay the magazine has ever published.  The essay begins with, "If your anxiety about global warming is dominated by fears of sea-level rise, you are barely scratching the surface of what terrors are possible, even within the lifetime of a teenager today."  The work goes on to discuss worst case effects by the end of this century should carbon emissions or global warming not be successfully addressed.   

During this 36 minute conversation Mr. Wallace-Wells discusses what prompted him to write the essay.  He summarizes his findings, discusses Jim Hansen's concern climate scientists may be undermining their ability to effectively communicate the threat via what Hansen terms "scientific reticence," what, if any, edits he would make after learning the scientific community's response to the essay, and how hopeful he is whether carbon tax, carbon capture and other policies will avoid atmospheric warming by four, five or more degrees Celsius over the next several decades.

David Wallace Wells is deputy editor at New York Magazine.  His 2015 cover story about the epidemic of honey bee deaths, Wallace Wellsthe first magazine story to put the blame on neonicitinoid pesticides, is now accepted science.  He joined the magazine as literary editor in 2011 and became features director in 2016.  Before joining the magazine he was deputy editor at The Paris Review where he edited and published writers including Ann Beattie, Werner Herzog and Jonathan Franzen.  Previously Mr. Wallace-Wells served as The New York Sun's books editor.  Mr. Wallace-Wells graduated from Brown University with a degree in history.    

Mr. Wallace-Wells essay is at: http://nymag.com/daily/intelligencer/2017/07/climate-change-earth-too-hot-for-humans.html.   

The noted Popovich and Pearce article, "It's Not Your Imagination Summers Are Getting Hotter," in the July 28 issue of The New York Times is at:  https://www.nytimes.com/interactive/2017/07/28/climate/more-frequent-extreme-summer-heat.html.

Listeners may recall my March 31 interview with Professor Jonathan Patz regarding this past February's "Climate and Health Conference" at the Carter Center and links to two related essays by me posted this past June 13 concerning the medical community's non-response to the the Trump administration withdrawal from the Paris climate accord and one posted May 25, 2016 reviewing the Obama's administration's, "The Impacts of Climate Change on Human Health in the US."  

07/28/2017

Dr. Fischer-Wright Discusses Her Recent Work, "Back to Balance, The Art, Science and Business of Medicine" (July 27th)

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During this 20 minute discussion Dr. Halee Fischer-Wright discusses her recently published work, "Back to Balance, The Art, Science and Business of Medicine."  As the title suggests, Dr. Wright argues the practice of medicine has become dominated by the business and science aspects of care delivery both to the detriment of both the patient and the physician.  

Dr. Halee Fischer-Wright is currently President and CEO of MGMA (the Medical Group Management Association).  Prior to, Dr. Wright Firscher-Wrightwas a practicing pediatrician and management consultant in multiple industries. Immediately prior to accepting the MGMA position,  Dr. Wright  served as a Chief Medical Officer within Centura Health.  Prior to that she was President of the 680-physician Rose Medical Group in Denver for 12 years. She is the recipient of several national awards for leadership in innovation, healthcare, business and women's leadership.  She is also co-author of the work, "Tribal Leadership."  Dr. Wright earned her bachelor's and medical degree from the University of Colorado and holds a a master's in medical management from USC.  She completed her internship/residency as president of the Pediatric Residency at Phoenix Children’s Hospital/Maricopa Medical Center Program.

For information on "Back to Balance," go to, e.g., https://www.amazon.com/Dog-Complex-Bringing-Balance-Backwards/dp/1633310140.

06/25/2017

Will Senate Republicans Get 50 Votes to Repeal the ACA? (June 24th)

This coming week the Senate will take up their amended version of the House repeal bill, the American Health Care Act. Here is my assessment of the legislation's prospects posted yesterday on The Health Care Blog.  I conclude the essay by citing a 2014 study by Gilens and Page.  If the legislation passes it demonstrates, as Gilens and Page wrote, the "American public actually have little influence over the politics of our government adopts."  Phrased another way, "when a majority of citizens disagrees with economic elites or with organized interests," they said, "they generally lose."

My essay is at: http://thehealthcareblog.com/blog/2017/06/24/will-senate-republicans-get-50-votes-to-repeal-the-aca/

Gilens and Page's article is at: https://scholar.princeton.edu/sites/default/files/mgilens/files/gilens_and_page_2014_-testing_theories_of_american_politics.doc