Tag: Patient Trends
A computer programmer and a kid in a Batman suit walk into a pancake house …
It sounds like a joke, but it really happened, and now the programmer — Dave Vockell — has a new product to bring to market. It’s an app to help seniors talk to their doctors about medical care.
“Like all great health care breakthroughs, it happened at the International House of Pancakes,” he says, half-jokingly.
Venture capitalists are pouring more money than ever into digital health startups — more than $2 billion so far this year alone, according to the venture capital firm Rock Health. These investors are betting that entrepreneurs can help doctors, hospitals and insurers become leaner — which the Affordable Care Act strongly encourages.
Vockell’s endeavor started back in April, when Medicare released a huge database detailing how much it pays individual doctors. The government health plan for the disabled and for adults ages 65 and older had kept that payment information secret for decades.
So when Medicare suddenly dumped an entire year’s worth of data, finally making public millions of transactions, coders like Vockell tried to figure out how to make it useful for seniors.
Enter the IHOP.
“My kids go there after school one day for [the] funny face pancake lunch,” he says. “There were lots of seniors there. And my kids run around, and the seniors love when they come up and sit with them.” That’s when it hit him, Vockell says: “I could totally use my kids to source a whole bunch of interviews pretty fast.”
His 3-year-old in a Batman suit proved a great icebreaker; over a lot of pancakes, 43 seniors told Vockell that knowing which doctors charge more and which charge less wouldn’t necessarily send them shopping for the lowest price. Seniors generally like their doctors and don’t want to shop for new ones.
But many in the pancake house that day did tell Vockell that they had some medical procedures on the horizon and weren’t sure what the procedures would cost, entail or require of them. “I’d love to get some insight into that,” they told him.
They also asked, “Could you make the print really big?” Vockell says. And several added, he says with a laugh, “The blueberry syrup is magnificent.”
So Vockell developed a website that helps seniors understand the procedures their doctors are recommending, and the costs — so they can start conversations with their doctors. The site also helps users print out the information in really big type.
It’s too early to say whether his product will be the hot new topic on the shuffleboard circuit, but it was a winner at the big Health Datapalooza conference this month in Washington, D.C
Big data on health care is the raw material for a whole new segment of the information technology sector. Entrepreneurs like Sean Power are also exploiting databases such as the price list that Medicare released this spring.
“That’s hot,” he says. “Anytime anybody releases a new set of data, we get excited.”
Power’s company, karmadata, is founded on the idea that software engineers can find ways to use big data to save the government or large companies money — and that such organizations will share some of their savings with him. There’s a lot of opportunity in streamlining health care, Power says.
“It’s a great time to be starting a company in the health care data space,” he says. “I think the gold rush is on.”
Just like in a real gold rush, hitting pay dirt requires a lot of prospecting. Entrepreneurs can’t always find the information they really need to make a truly useful product.
Dr. Omar Alvi is with a startup called Accordion Health. This firm’s big idea is to help families estimate future health care spending. So you could type in that Grandpa has hypertension, Mom has diabetes, and one of the kids has asthma, and then get some idea of how much that’s all going to cost — and maybe even shop for the best price. A great idea, Alvi says, but he adds: “Each patient is very different. And so in order to be able to make a meaningful prediction, you have to have a lot of data, so you can say [that] patients just like this went through these problems as they moved through the medical system. That’s really where it requires hundreds of millions of data points.”
And not even close to the millions of data points that Alvi’s company needs are available yet. A lot of information about procedures, cost and effectiveness remains locked up inside insurance company computers, or in hospitals’ and doctors’ medical records — information that insurers, hospitals and doctors don’t want to share.
Patients in San Francisco and Oakland appear to be happiest with their doctors, while the least satisfied American healthcare consumers live in other California cities as well as in New York State locales, according to an in-depth evaluation of the ever-contentious online physician reviews that many denounce.
In a nationwide study, Denver-based Vanguard Communications – a healthcare marketing, public relations and communications technology firm – deployed special software to scour Internet reviews of 46,300 healthcare providers on Google+ and Yelp.com websites.
Vanguard’s software collected ratings of individual doctors, group medical practices, clinics and hospitals in the 100 largest U.S. cities. Vanguard then ranked each city according to its average patient rating on the five-star scale used by both Google+ and Yelp.com.
Vanguard tabulated the results in what the firm is calling the Happy Patient Index (HPI), providing a comparative snapshot of the state of satisfaction with American healthcare.
Cities in New York and California account for eight of the 10 unhappiest municipalities in the HPI, while cities with the happiest patients are spread coast to coast (and beyond) in nine different states in virtually every region, including Hawaii.
Vanguard also discovered that the majority of online reviewers gush over their healthcare providers: 56.8 percent give their physicians four stars or better; only one in eight doctors (12.1 percent) gets an average of less than two stars.
“From these findings, I’d say that doctors get much better reviews than hotels, restaurants and retail businesses,” said Vanguard CEO Ron Harman King. “Another discovery is that you can find happy patients everywhere, not just in sunny, warm places but also in relatively cloudy and damp locations such as Cleveland and Seattle.”
The happiest ten cities in the HPI: (1) San Francisco / Oakland, Calif.; (2) Honolulu, Hawaii; (3) Indianapolis, Ind.; (4) Seattle, Wash.; (5) St. Louis, Mo.; (6) Cleveland, Ohio; (7) San Jose, Calif.; (8) Austin, Texas; (9) New Orleans, La.; (10) Birmingham, Ala.
The unhappiest ten cities in the HPI (starting with the unhappiest): (1) Bakersfield, Calif.; (2) Modesto, Calif.; (3) North Hempstead, N.Y.; (4) Sacramento, Calif.; (5) Buffalo, N.Y.; (6) Riverside, Calif.; (7) Orlando, Fla.; (8) San Bernardino, Calif.; (9) Washington, D.C.; (10) Huntington, N.Y.
Vanguard’s evaluators looked for correlations between rankings and each city’s population size and average income, age and educational attainment, as well as political leanings (blue cities versus red) – and even percentage of residents with health insurance – but found no such connections.
In concert with the saying that money doesn’t buy happiness, wealth does not appear to affect patient satisfaction. Three of America’s wealthiest cities rank in the 20 unhappiest with their doctors: Arlington, Va. (median household income of $102,459, according to the U.S. Census), Huntington, N.Y. ($105,426), and North Hempstead, N.Y. ($104,378).
At the same time, three of the top-10 happiest cities have mean household incomes below the national mean of $51,017: Indianapolis ($42,144), St. Louis ($34,384) and Cleveland ($26,556).
Online doctor reviews have fueled growing controversy over their accuracy and fairness, particularly among the medical profession, with some doctors suing their patients over comments on the Internet. Nonetheless, a recent study published in the Journal of the American Medical Association reports that among patients who used physician-review websites, 35 percent have selected healers based on good reviews, while 37 percent avoided doctors based on bad reviews.
For more information including rankings of all 100 cities and details on the study methodology, visit VanguardCommunications.net/hpi-100-rankings/.
The calls may come in the middle of the night and from hospitals more than an hour away. Someone is having a stroke and is en route an emergency room in the Florida Keys, but there aren’t any neurologists on call.
Within 15 minutes, a University of Miami neurologist pops onto a computer screen and can order an IV drug that should be given within three hours. It’s that sort of potentially life-saving technology that some lawmakers say will drive down health care costs, while also addressing serious doctor shortages around the state.
A Senate bill would increase the use of telemedicine in Florida and establish requirements for health providers who treat patients remotely. A companion bill is also making its way through the House, but that bill doesn’t require doctors to have a Florida license — only that they be licensed in their home state and registered in Florida.
“If we didn’t have an access problem we wouldn’t be here today … everyone would rather see the doctor face to face, but when your mother is having a stroke in rural Florida and the choice is having a doctor via telehealth versus having no doctor,” said Rep. Cary Pigman, an emergency room physician who supports the bill.
The Senate bill requires doctors providing telemedicine services to patients within the state to be licensed in Florida or meet an alternative requirement. For example, an insurer using a doctor that’s in-network in another state would also be allowed to treat a Florida patient. The bill recently passed a Senate committee, but has two more stops before it’s heard on the floor. Dozens of other states have passed legislation supporting telemedicine.
The Senate bill also would require Medicaid to reimburse for telemedicine services and allow doctors to negotiate payment rates with insurers. The House bill doesn’t address payments.
“If you’re a patient in Florida and you have a specific heart defect and the guru is a doctor in Philadelphia, you should be able to consult with her,” said Republican Sen. Aaron Bean, who is championing the bill.
But critics worry that requirements for doctors in other states could compromise patient care. Some say that doctors practicing telemedicine in Florida should be licensed here.
“It may be the wave of the future, but I still think we need to concentrate on the patients and the bottom line is these (out of state) doctors are not licensed in Florida so they don’t have the same accountability,” said Sen.Dorothy Hukill, who voted against the bill.
Bean said they will be held accountable through the insurance company or the doctor’s network they practice within.
Rep. Gayle Harrell, voted for the bill, but noted it still has problems.
“I also need to know what my recourse action should be should some malpractice incident take place,” she said.
She also wants to see a website created where people can find information about the out-of-state doctors who may be treating them. After all, she noted, patients can’t walk into the office of an out-of-state doctor and see medical degrees on the wall.
The Florida Chamber and several other groups, including ones representing nurse practitioners, physician assistants, nurses and pharmacists all support the bill.
But the powerful Florida Medical Association is strongly opposed, worrying it doesn’t require treatment by a licensed Florida physician or mandate a review of the patient’s medical history. The organization said such technology holds great promise, but does not support the bill in its current form.
“This will revert Florida back to the days of the Wild West where anyone with a bottle of whiskey, a pocket knife and Skype can practice medicine. That’s what happens to the bill in its current form, said David Custin, a lobbyist for the group.
Several hospitals around the state have had success with telemedicine in recent years, helping patients in rural areas connect to specialists or getting multiple consultations conducted simultaneously for acute emergency cases. University of Miami neurologist Dr. Gustavo Ortiz has done more than 600 consultations since their program’s inception in 2009.
Telemedicine saves money by reducing hospital and ER admissions and doesn’t require medical transportation, supporters say.
Dr. Kim Landry, an emergency room physician and EMS medical director for four counties in the Panhandle, began a pilot program where 911 responders connect patients remotely to an ER doctor for a quick evaluation.
“Eight out of 10 times, they don’t require transport to the hospital, so in a lot of cases, it’s made life easier for a lot of sick patients,” said Landry, who found those results after testing the program in nursing homes.
During a recent consultation, University of Miami dermatologist Dr. Anne Burdick asked an assistant at a Fort Pierce county health clinic to zoom the camera in on some scaly, white patches on a 10-year-old boy’s legs. The boy is often kept indoors and complains of constant itching at night. Burdick, who diagnosed him with eczema, modified his prescriptions and added a weekly bleach bath to reduce bacteria. The boy was one of five pediatric patients seen remotely from her Miami office that day.
Burdick, who estimates 40 percent of her practice includes telemedicine patients, also does medical consultations for two cruise lines, the Indian Health Service and a weekly program for school children.
“For some areas in the state, it’s going to be impossible to get specialists to that area and so telemedicine is really the best option, ” said Burdick. “The bill will be a really good step forward for Florida.”
Medicare’s release Wednesday of millions of records of payments made to the nation’s doctors comes as the government is looking to find more cost-efficient ways to pay physicians, particularly specialists.
The federal government published data tracing the $77 billion that Medicare paid to physicians, drug testing companies and other medical practitioners throughout 2012, and what services they were being reimbursed for. The data cover 888,000 different practitioners. More than 6,000 procedures are included, and the full database is so large that it requires statistical software to analyze it. While the database provides tantalizing details, showing for instance the huge amount ophthalmologists are paid to treat a common eye disorder, experts cautioned that the data can be easily misunderstood and could lead to some doctors’ incomes being unfairly pilloried.
The release comes 35 years after a court-issued gag order that prevented anyone from revealing Medicare Part B payments to individual doctors, and advocates for more transparency in health care payments heralded the release as a leap forward. “Taxpayers have the right to understand what is being paid for and how it is being paid for,” said Jonathan Blum, principal deputy administrator for the Centers for Medicare & Medicare Services.
He asked for the public to comb through the information to help find waste and fraud and also encouraged researchers to use it to try to determine why spending on health care for the elderly varies so much in different parts of the country. This could replicate on the physician level what the Dartmouth Atlas of Health Care has been doing for decades in showing variances in Medicare’s hospital spending.
“The uses of this data can and will go significantly beyond the identification of fraud, waste and abuse,” said Niall Brennan, the Medicare official who oversaw the development of the database.
The release also comes at a propitious time for the government’s effort to refashion the way America’s health care system is financed. Earlier this year Medicare invited advice on how it should devise new ways of paying specialists to replace the current system, in which doctors are paid a set fee for each visit or procedure. The goal of these approaches is to remove the financial incentive for practitioners to do more services.
Under the authority of the federal health care law, the Obama administration has already launched experimental programs aimed mostly at hospitals and large medical groups. There are hundreds of trial efforts under way to pay medical practitioners a set fee to treat a defined ailment, such as replacing a knee, with the fee covering all aspects of the care from before the operation through the recovery and any setbacks.
Medicare is in the midst of creating a similar program for cancer specialists. In February, the government’s Center for Medicare & Medicaid Innovation invited suggestions on how it should fashion new payment programs that “would be designed to improve the effectiveness and efficiency of specialty care, in part by clarifying the specialist practitioner’s clinical role.” The deadline for ideas and suggestions is Thursday.
Dr. Kavita Patel, a former White House health care expert and a researcher at the Brookings Institution, a Washington-based think tank, said the administration’s timing was not coincidental. “They are building the case for doing targeted specialty payment models,” she said. “The administration is trying to get at the delivery system from all angles.”
Unsurprisingly, medical specialties that rely on expensive drugs, such as oncologists and ophthalmologists, appeared at the top of the list of biggest reimbursements. That’s because in 2012 Medicare pays doctors for the market cost of drugs they use plus 6 percent, Blum said. (That amount has been lowered by the spending cuts imposed by Congress, known as the sequester.)
Despite their size, the Medicare records omit as much important information as they include. The records do not include any treatments doctors do on non-Medicare patients, such as people on private insurance, Medicaid and those who pay cash. The records also lack any information about roughly a quarter of Medicare beneficiaries who have coverage through Medicare Advantage private insurance plans, and for various experimental payment reforms the government has initiated. The payments for some doctors may be larger than it appears in the data because they also could have billed Medicare through a combined medical practice or other medical organization.
Fred Trotter, a heath care data expert pre-emptively warned reporters and analysts that: “We should be very careful to not draw any conclusions at the low end of the spectrum. That doctor who ‘only’ performed procedure X eleven times? That probably means nothing. What the doctor is actually doing with his/her patients is just not showing up at all.”
Procedures billed to one doctor may actually have been performed by a number of workers in one practice such as medical residents, nurses and physician assistants. A Los Angeles rheumatologist who Medicare paid $5.4 million in 2012 told The Washington Post that about $5 million of that paid for very expensive drugs and the billings also helped cover his staff of 40 people. CMS’ Brennan said that one goal of the release was to encourage each individual medical practitioner to bill Medicare directly, so that the government could get a better handle on spending.
In a note published on the website of the Association of Health Care Journalists, Charles Ornstein, a senior reporter at the investigative nonprofit Pro Publica, cautioned reporters to be careful in interpretation, writing: “Don’t just assume that because a number is large, a doctor has done something wrong.”
In addition, there’s no information about the quality of the care provided, and no information about how sick the patients were or why a particular procedure was performed. In fact, to ensure that the identity of any patient could not be known, Medicare has only included procedures that each doctor performed at least 11 times.
Large numbers of procedures performed by a doctor may be a good sign. Someone billing a lot might well be a very talented practitioner, since research has found that medical skill tends to improve the more times a physician performs the same operation. In fact, health care experts often encourage patients to choose a doctor based on the volume of cases the physician has done. Alternatively, in some cases—probably a small number—a doctor with lots of billing could be ripping off the system. Several doctors with the biggest Medicare payments are already under investigation for potential fraud, such a Dr. Salomon Melgen, a Florida ophthamologist who The New York Times said was paid $21 million in 2012. His lawyer said Melgen has followed all Medicare rules.
The back story of the gag order on this data stretches back to 1979, when a Florida court issued a permanent injunction barring the government from releasing information about Medicare payments to individual physicians in any manner that would allow the doctor to be identified. In 2011, the parent company of The Wall Street Journal successfully sued to overturn the injunction as the paper prepared a detailed look at Medicare spending.
The American Medical Association complained that physicians were not allowed to review the data for inaccuracies. However, Medicare’s previous release of similar information about hospital payments did not result in reports of any major errors. Brennan pointed out that the data is based on claims medical providers billed to Medicare and were reimbursed for. “We are quite confident this data is accurate,” Brennan said.
Where Can I Find The Data?
If you just want to look up a specific doctors or a few dozen in an area, both the Wall Street Journal and The New York Times have handy interactive look-up tools.
Doctors worry they won’t get paid by some patients because of an unusual 90-day grace period for government-subsidized health plans.
So several professional groups for doctors are urging their members to check patients’ insurance status before every visit. Consumer advocates say these checks could lead to treatment delays or denials for some patients.
If a person with subsidized insurance falls behind in paying the premiums, the Affordable Care Act requires insurers to cover his medical bills for 30 days.
But for the next 60 days, insurers can hold off paying those claims — and ultimately, deny them if the patient doesn’t pay the premiums in full. An insurer’s denial means doctors don’t get paid for their services. If the insurer ends up canceling the policy after 90 days, doctors can bill patients directly but may face difficulty collecting.
“This puts the physician and their patients in a very difficult situation,” said Dr. Ardis Dee Hoven, president of the American Medical Association, which advised physicians Wednesday about how to minimize their risk.
“If a patient is being treated for a serious illness that requires ongoing care, the physician is having to assume the financial risk for this,” she said. “That’s the bottom line.”
The way things work now, insurers generally cancel a policy if a subscriber falls behind more than 30 days. The insurer is usually on the hook for bills incurred before that cancellation.
The AMA and dozens of other physician groups have urged the administration to spell out how and when insurers must notify physicians when their patients fall behind on premiums.
Doctors’ groups got a prompt-notification law passed earlier this month by the Washington state Legislature.
But some consumer advocates fear that doctors who know they may not get paid have a strong incentive to withhold treatment. “The reason they want that notification is so they can start denying services,” said Brian Haile, senior vice president for health care policy at Jackson Hewitt Tax Service.
If the insurer notifies the physician that a patient is behind on premiums and the insurer is holding up claims payments, “Nine times out of 10 the doctor is not going to provide the services — no matter what their network contract says.”
“The doctors aren’t bad guys — they’re business people,” Haile added. “Any economically rational actor would do it.”
For some medical specialties, treating patients who have fallen behind on their payments could end up being quite costly.
Oncology practices that administer chemotherapy drugs costing thousands of dollars have to purchase them in advance. If a patient’s claims aren’t paid, the cost to the practice is high.
Obstetricians who provide prenatal care throughout pregnancy could also take a hit if women fall behind on payments when they’re about to deliver their babies.
Hoven, the AMA president, said physicians are contractually and ethically bound to continue caring for their patients. “Most physicians are not going to turn away these patients, particularly if someone comes in with a life-threatening condition,” she said.
The AMA’s guide to the grace period specifically warns physicians that postponing or rescheduling patients could be a breach of contract because of anti-discrimination clauses in many managed care contracts.
“This is the kind of thing we’re going to watch really closely, and it’s one of the reasons we want to make sure people are careful on the front end selecting plans that are affordable,” said Kirsten Sloan, senior policy director for the American Cancer Society Cancer Action Network.
Dr. Dan McCoy, vice president and chief medical officer for Blue Cross Blue Shield of Texas, said his plan will cover claims throughout the entire 90-day period as a result of a state prompt-payment law but can recoup payments from physicians if patients’ policies are terminated.
He stressed that participating physicians are expected to care for patients throughout that period even if payments have lapsed. “We strongly feel that people who carry a Blue Cross Blue Shield card in their pocket should be treated as members,” he said.
The AMA, meanwhile, is encouraging doctors to broach financial concerns with their patients and explain why it’s important to maintain insurance coverage.
The group released materials Wednesday including a sample letter to patients explaining that while the doctor will continue to see them during the grace period, “you may be obligated to pay the full cost of services that we provide to you” if insurance is terminated. The letter also encourages patients to discuss changes in their financial circumstances with doctors.
Healthcare providers and policy analysts are increasingly anxious that Congress will fail to eliminate Medicare’s flawed physician payment formula and once again default to a temporary fix.
All eyes turned to the Senate after the House of Representatives passed a bill on Friday that repeals the sustainable growth-rate formula and also includes a five-year delay of the financial penalties for people who don’t purchase health insurance—which the Senate is sure to reject.
Congress will return from a weeklong recess on March 24, which gives lawmakers one week until the temporary SGR patch expires on March 31.
Under an amendment added by House Ways and Means Committee Chairman Dave Camp (R-Mich.), the House bill would keep the Patient Protection and Affordable Care Act’s individual mandate in place but would not penalize anyone for violating it until 2019. The nonpartisan Congressional Budget Office estimated this week that this move would increase the number of uninsured Americans by about 13 million in 2018.
The SGR Repeal and Medicare Provider Payment Modernization Act passed 238-181 and picked up support from 12 Democrats. Though cheered by House Republicans, the legislation is viewed by Democrats, policy analysts and healthcare providers as purely a political move that is not likely to go anywhere beyond the House floor.
“We’re dismayed that Congress sabotaged their own work by linking legislation to unrelated, ideological issues—particularly in light of the nearly universal opposition to such action from patients, insurers and the medical community,” Dr. Reid Blackwelder, president of the American Academy of Family Physicians, said in a statement reacting to the vote.
Even the conservative Heritage Foundation did not support Friday’s House vote. “If you are going to have a permanent repeal, which incurs permanent costs, you need permanent savings to offset those costs,” Robert Moffit, a senior fellow at Heritage, said in a statement.
Senate Finance Committee Chairman Ron Wyden, who introduced a version of the SGR repeal this week, said he is committed to sound, sensible policy over politics.
The Oregon Democrat also cautioned that hospitals, home health providers, drug companies and skilled-nursing facilities will once again be at risk if Congress doesn’t find approve a permanent SGR repeal. “Make no mistake about it: Those providers are going to be the ones who pay for yet another patch,” Wyden said on the Senate floor.
The bill that Wyden introduced this week—the Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014—includes the compromise agreement from the Senate Finance, House Ways and Means and House Energy and Commerce committees to repeal and replace the SGR, as well as the extension of certain Medicare programs that are expiring.
It does not, however, include a way to pay for these provisions. Meanwhile, the House bill that passed on Friday includes the compromise agreement on SGR, no language on the Medicare extenders and the dead-on-arrival delay in the ACA’s individual mandate to pay for it.
“For me, the positive side is the House has done something,” said Julius Hobson, a senior policy adviser at law firm Polsinelli and a former lobbyist for the American Medical Association. “And when they get back from recess, the Senate will attempt to do something. It may heighten talks between the House and Senate, and that’s my hope.”
But others expressed more frustration than hope, given that lawmakers still are not talking seriously about how to pay for repealing the SGR, which the CBO estimates will cost $138.4 billion over 10 years. This week, the bipartisan Committee for a Responsible Federal Budget released a statement that criticized House Republicans for trying to pay for a permanent repeal of the SGR with a temporary delay of the individual mandate’s penalties, which the nonpartisan fiscal watchdog group said will only add to long-term deficits.
The organization also criticized House Democrats for proposing “phantom war savings” as a way to pay for the overhaul and the Senate for proposing none. The “phantom war savings” refers to funding for the Global War on Terrorism/Overseas Contingency Operations, most commonly referred to in Washington as “OCO funds.” Congress provided about $92 billion in OCO funding for 2014 and none for subsequent years, according to the CBO.
“There are ways to look at a package of things, from expanded means-testing to rationalizing co-payments to reforming Medigap plans,” said Maya MacGuineas, president of the Committee for a Responsible Federal Budget.