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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

06/22/2017

Improving the Use of Evidence-Based Medicine: A Conversation with Dr. Todd Feinman (June 21st)

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 A 2012 National Academy of Sciences (Institute of Medicine) study titled, "Best Care and Lower Cost," found about one quarter of all medical spending is wasted, much of this excessive spending going to pay for treatments that are of unknown effectiveness.   With medical spending now accounting  for one-sixth of the nation's GDP, or over $3 trillion annually, how do we limit spending to treatments that are proven effective or are of high value.  How do we increase the use of evidence-based medicine.  While this issue or problem has been, or is being, addressed by several federal health care agencies including the Agency for Healthcare Research and Quality (AHRQ) and the the ACA-created Patient Centered Outcomes and Research Institute (PCORI), progress has been frustratingly slow.   (For example, a day prior to this interview a Health Affairs blog post discussed the persistent use, despite clinical evidence to the contrary, of pre-cataract surgery blood analysis and EKG testing.)      

During this 23-minute conversation Dr. Feinman discusses how his background as a hospitalist led to his co-founding Doctor Evidence, what explains the variation in the use of evidence based medicine, how Doctor Evidence is working to improve the timely collection, dissemination and use of evidence-based medicine, how his work is related to the Cochrane Collaborative, and how work by Doctor Evidence can influence quality measurement and drive or improve health care value, or patient outcomes achieved relative to spending. 

Dr. Todd Feinman is the Chief Medical Officer and co-founder of Doctor Evidence where he works to create evidence Feinmantechnologies that will lead to improved care, better health care outcomes, greater patient satisfaction and reduced spending growth.  Among other partnerships, Doctor Evidence works with the USC Center of Body Computing and with several medical associations and pharmaceutical companies.  Dr. Feinman began his career as a hospitalist, developing the first such programs in Southern California.   He is a board certified internist.   Dr. Feinman earned his medical degree at UCLA's David Geffen School of Medicine and did his residency work at Cedars-Sinai Medical Center in Los Angeles and at Huntington Memorial Hospital in Pasadena. 

For information on the firm Doctor Evidence go to: http://drevidence.com.

 

 

06/15/2017

Medicare As a Neutral Payer (June 15th)

If your're interested in Medicare payment reform generally, you may be interested in my essay, "Medicare Programs Should Compete," posted today on the Health Affairs blog.  It is at:  http://healthaffairs.org/blog/2017/06/15/medicares-programs-should-compete/.

06/14/2017

The Medical Communities (Non) Response to Trump's Withdrawal From the Paris Climate Accord (June 13th)

If you're interested in learning what was the response by the trade and professional medical association communities to President Trump's June 1 announcement regarding the Paris accord please feel free to read my essay, "Medical Association's Non-Pulsed by Trump's Withdrawal From Paris Accord," posted yesterday on The Health Care Blog: http://thehealthcareblog.com/blog/2017/06/13/medical-associations-non-pulsed-by-trumps-withdrawal-from-the-paris-accord/.

06/03/2017

Extraordinary Altruism in Voluntarily Donating a Kidney to a Stranger: A Conversation with Professor Abigail Marsh (June 2nd)

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Approximately 8,700 Americans die annually awaiting a kidney donation or become too ill to receive one.  This is half the number of those who annually receive a kidney, or 17,000.   Over 100,000 at any time are awaiting a kidney.  The median wait time is over three and a half years.  One-third of kidney donations are live donations typically from a child, parent, sibling, spouse or other relative.  However, an increasing number of live donations are made by strangers voluntarily choosing to donate. The number of these donations while small, at less than 400 annually, has doubled in recent years.  The benefits of receiving a donated kidney are pronounced, the expected benefits to the recipient are estimated at 100xs the expected costs to the donor. 

During this 26 minute conversation Professor Marsh explains why she became interested in altruism particularly extraordinary altruism, what her and her colleagues' research has found that explains donor reasoning in providing a kidney, how "social discounting" and other factors play into their decision making, how brain development, or the size of a donor's amygdala (the part of the brain responsible for decision making and emotional reactions including compassion), plays a factor and to what extent normalizing voluntary kidney donations may over time reduce or eliminate the shortage of kidney donations.

Professor Abigail Marsh is an Associate Professor in the Department of Psychology and the Interdisciplinary Program in MarshNeuroscience at Georgetown.  Prior to Georgetown, Dr. Marsh conducted post-doctoral work at the National Institute of Mental Health at the National Institutes of Health from 2004 to 2008.   Her areas of expertise include social and affective neuroscience, particularly understanding emotional processes like empathy and how they related to altruism, aggression and psychopathy.   Her work has appeared in the Proceedings of the National Academy of Sciences, Psychological Science, the American Journal of Psychiatry, JAMA Psychiatry and Nature Human Behavior.  Dr. Marsh was graduated with a BA in Psychology from Dartmouth and a Ph.D. in Social Psychology from Harvard.   

Professor Marsh's June 2016 TED talk, "Why Some People Are More Altruistic Than Others," is at: https://www.ted.com/talks/abigail_marsh_why_some_people_are_more_altruistic_than_others.

A 10-page, footnoted discussion weighing the pros and cons of voluntary donating a kidney can be found on the Effective Altruism Forum website, at: http://effective-altruism.com/ea/ay/kidney_donation_is_a_reasonable_choice_for/

06/02/2017

AHCA In Context of Social Justice: A Conversation with Jason Silverstein (June 1st)

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This past May 4, US House or Representative Republicans passed the American Health Care Act (AHCA).  The bill, defined by Republicans as a repeal of the Affordable Care Act (ACA), is now under debate among Senate Republicans. (Neither any House Democrat voted for the AHCA nor are there any Senate Democrats expected to vote for related Senate bill should it make the Senate floor.)  Per the Congressional Budget Office's (CBO) estimate of the AHCA's spending and revenue effects, published May 24, the AHCA would cause 14 million Americans to lose their health insurance in 2018 and 23 million by 2026, 14  million of this latter total would be Medicaid recipients.  This is because the AHCA would cut $834 billion from the Medicaid program over the ten year budget window, or by 2026.  The cuts in Medicaid spending, along with substantial reductions in tax credits, would allow for ACA taxes, approximately $600 billion, to be rescinded.  For example, the ACA's 3.8% tax applied to capital gains for family incomes over $250,000 and a 0.9% Medicare surtax on wage income in excess of $250,000 per year, i.e., tax cuts that would benefit the comparatively wealthy.           

During this 25 minute conversation Dr. Silverstein provides, among other things, his assessment of the AHCA, i.e., legislation moreover as tax relief for the wealthy, the likely effect it would have one women's health and on disparities in care and alternatively how the ACA could be improved. 

Dr. Jason Silverstein is a Lecturer and Writer-in-Residence at Harvard Medical School in the Department of Global Health Silversteinand Social Medicine. He is also currently an Instructor at the Harvard T. H. Chan School of Public Health.  He is also a faculty affiliate of the Science, Religion and Culture Program at the Harvard Divinity School.  He is a regular contributor to VICE's health channel, Tonic.   He has written for The New York Times, the Atlantic, The Guardian, Slate, The Nation and others and has provided commentary for, among others, MSNBC, NPR, HuffPost Live and BET.   His previous experience includes conducting research at Children's Hospital Boston, the Dana-Farber Cancer Institute, Harvard Law School's Program on Disability, and Stony Brook's HIV Treatment Development Center. Dr. Silverstein holds a Ph.D. and Master's in Anthropology from Harvard, a Master's in Religion, Ethics and Politics from Harvard Divinity and an undergraduate degree in philosophy from Penn. State. 

Dr. Silverstein's Tonic writings are at: https://tonic.vice.com/en_us/contributor/jason-silverstein

05/04/2017

"Would Repealing the ACA Violate International Law?" (May 3rd )

 

The Health Care Blog (http://thehealthcareblog.com/) posted an essay under this title on April 28th by myself and Jason Chung. The blog post summarizes Washington Post opinion writer, Dana Milbank's, April 25th essay noting the UN forwarded to the Trump administration on February 2nd a letter arguing repeal of the ACA would likely violate several US-agreed to international treaties and other international agreements concerning the rights of everyone to enjoy the highest attainable standards of physical and mental health. As Milbank noted, and as repeated in the blog post, the Trump administration, despite the UN's request to make known the letter to Congressional leaders, buried the correspondence.  The letter was leaked by a DHHS employee who had obtained a copy from the State Department.   

Milbank's article and the UN letter are at: https://www.washingtonpost.com/opinions/apparently-repealing-obamacare-could-violate-international-law/2017/04/25/2794a77c-29f4-11e7-b605-33413c691853_story.html?utm_term=.3d3cbd497026 and  https://www.washingtonpost.com/r/2010-2019/WashingtonPost/2017/04/25/Editorial-Opinion/Graphics/103_17_ACA_Repeal_Request_for_Information.pdf?tid=a_inl