Monday | Sept 12, 2011 Why you need to understand the "responsible corporate officer doctrine" Health innovators hardly need another reason to wince over the FDA, but The Wall Street Journal reports that U.S. authorities are now stepping up enforcement of a 1938 law known as the "responsible corporate officer doctrine," which seeks to hold executives personally and criminally responsible for corporate violations of U.S. food and drug laws. Feds have applied the doctrine, in particular, to healthcare exectives. Citing Medicare law, HHS has sometimes sought to exclude executives convicted of violations, or those who submit to plea agreements, from future participation in Medicare and Medicaid. Most of the cases referenced in the Journal involve pharma executives and officers of device manufacturers, but with the industry in such flux, it is wise to keep yourself abreast of the regulatory arsenal currently in favor at DoJ. Read up on the law here.  As an aside, and since reform-through-cost-savings is on everyone's agenda, it would seem the feds will eventually seek to more evenly apply the doctrine to include officers of healthcare providers who defraud Medicare, such as at Maxim (a $150 million fraud), or the "company owners" rounded up in this Sept. 7 sting (a $295 million fraud).

 

Friday | Sept 9, 2011 How the ACA might affect U.S. employment  It is tempting to examine Massachusetts' health reform for indicators of how the ACA will impact the U.S. economy, and in particular, the national jobs picture. Researchers from Dartmouth, Vanderbilt and RAND examined the impact of Massachusetts' reform on the workforce in that state, and today published their results in the New England Journal of Medicine. Reform was good for jobs growth in Massachusetts (see chart), but the growth was overwhelmingly in administrative healthcare jobs, rather than provider professions, such as doctors and nurses. This makes sense, as doctors burdened with new compliance papework would likely hire back office help. But is it bad, or good? The authors worry that if a successful ACA requires growth in the adminstrative workforce, reform will inflate costs and "exacerbate expected shortages of physicians and registered nurses." Perhaps. Yet the authors also write, reform spiked job growth "particularly in occupations to which people can shift rapidly with brief training time." This should be very welcome news to the 14 million Americans still looking for work. Also, the less time nurses and doctors spend pushing paper, the more time they have to share with patients. Will jobs growth spike costs? Sure, but limiting jobs growth to shave costs hardly seems a wise choice if one takes a long view. Some of these new jobs will balance losses from entitlement cuts, and there are so many obvious, comparatively easy, places from which to trim fat that won't mean job losses. Consider hospital supply purchasing. One study suggests savings of $55 billion annually merely by reforming the payment incentives enjoyed by group purchasing organizatins (GPOs). Read more on GPOs in Senator Grassley's 2010 report. 

Tuesday | Sept 6, 2011 Is the foreclosure crisis making us sick?  A new study by economists Janet Currie of Princeton and Erdal Tekin of Georgia State University investigates the relationship between foreclosure activity and our health. Their longitudinal study combines foreclosure data from 2005 to 2009 with data on emergency room visits and hospital discharges for residents in four states hard hit by the mortgage crisis: Arizona, California, Florida and New Jersey. Some of the results aren't surprising, like: an increase in foreclosures is associated with increases in medical visits for stress-related illnesses and mental health (e.g. anxiety or suicide attempts); or that foreclosures have a negative impact on elective procedures. More alarming is the data that suggests "the foreclosure crisis is having its most harmful effects on individuals 20 to 49 years old." These are Americans in their prime. Their study also shows greater negative health effects on African Americans and Hispanics faced with foreclosure -- also not surprising, but it begs an uncomfortable question: Will the healthcare industry ever be able to candidly discuss the association of health risks and race? Their study is published by the National Bureau of Economic Research, and you can find it here.

 

Monday | Sept 5, 2011 Halamka waxes romantic on the future of medicine In a new MIT Technology Review piece, author Jon Halamka describes five technology advancements that he says portend  The Rise of Electronic Medicine over the next five years. Halamka is CIO of Beth Israel Deaconness Medical Center in Boston, and it is challenging to find a healthcare professional more astute on technology than he. But you should also read the follow-up criticism of his article by Fierce Healthcare editor Ken Terry. Terry points out that after the development of so much technology, and the establishment of so many important protocols, interoperability between technologies, standards and--most crucially--between operators (be they doctors or databases) must also take root for the future to arrive. Terry writes:

The "new standards for secure email of data between providers" already are being integrated into some EHRs. But the Direct Project protocol for these secure email exchanges only allows physicians to "push" messages and attachments to other trusted providers who have Direct addresses--assuming that both parties have a health Internet service provider (HISP) available. It doesn't let doctors locate and retrieve data that they need at the point of care. Consequently, the Direct protocol will not lead to the creation of a national health information network that is a "federation of subnetworks," as Halamka predicts.

 

Interoperability is always underrated, and with peril. Look at financial services, an industry that lives on the cutting edge of technology adoption, and one which is not hobbled by the same operational limitations as healthcare. For example: if two bank units have different technology capabilities, or use different platforms, or simply aren't "interoperating" well, a bank will just choose one and shut the other down. Hospitals cannot (or will not) do this. But even with so much flexibility and copious resources, the biggest banks still suffer over the interoperability of their technology systems -- ask anyone who banks with Bank of America. Halamka paints an inspiring and not-inaccurate picture of the future, but perhaps this is because the path to get there isn't as pretty a portrait. Cloud computing will transform healthcare, but public infrastructures are insufficient and private infrastructures elevate the interoperability challenge. Will it be hybrid clouds? For more read this Tripple Tree paper. (Image courtesy of MIT Technology Review.)

 

Sun Sept 4 | 2011 What innovators can learn from a baseball pitching coach Today public radio stations nation wide re-broadcast a fascinating conversation between author Michael Lewis (Money Ball, Liar's Poker, The Big Short) and New York Times columnist, David Brooks (The Social Animal). The pair touched on many issues, including behavior change and, more specifically, how making even very small amendments to our physical behavior rewires our synapses and ultimately changes the way we think. They focused on the writing of an Oakland A's pitching coach named Harvey Dorfman, whose professional challenge was to draw slumping pitchers out of their ruts. Pitchers are notoriously superstitious and Dorfman discovered that merely by changing the way a pitcher walked to the mound could set in motion a series of mental shifts that ultimately changed his state of mind -- breaking a rut.  Most of us are more familiar with the adage "mind over matter," when in fact we ought to be thinking "matter over mind." Dorfman's book, The Mental ABC's of Pitching will be a tactically useful read for change agents of all stripes, but especially for health innovators and employers trying to alter the way workers think about their health.  If you have time, also consider reading Brooks' The Social Animal, essentially a treatise on how our conscious and unconsious minds are formed.

Saturday | Sept 3, 2011 Fodder for an inspiring Obama speech: A new Stratfor report explains why geography will keep the U.S. prosperous no matter what Jobs report have you down? Read Stratfor's two-part analysis explaining why the boon of our geography will keep the U.S. exceedingly wealthy: more navigable internal waterways than the rest of the world combined; the largest and most productive contiguous piece of farmland globally; more warm water ports than the rest of the Western Hemisphere combined. These are things that do not change with a credit rating downgrade or a surge in the VIX.  Concludes Stratfor: "The United States has the agricultural, transport, trade and political unification capacity to be a world power — even without having to interact with the rest of the global system." Other global powers have no such luxury: Russia has not not one real warm water port;  China has 20% less arable land and four times the population. No one is recommending isolationism, this is just to point out the raw material we are working with. (Critics say President Obama must deliver a motivating speech with a vision of our future Thursday night. These stats may be one place to start.) Once wealthy, the U.S. became one of the most educated countries (we still are, with 99% literacy). So what's our biggest risk? This audience knows it is the declining health of our population, namely, our children.  Healthcare is still producing more jobs than any other sector -- but to what end? A bigger question would be, how does this industry leverage its resources differently so the country is healthy enough to husband its massive natural bounty efficiently into the future?

Thursday | Sept 1, 2011 UnitedHealth, Mayo & Cleveland Clinic add momentum to physician practice "roll-ups" Couching their deals in various terms, hospital systems, payers and private equity shops continue to bolster their ties to provider groups nationwide. Displeased with federal guidelines for ACOs,  Mayo Clinic and Cleveland Clinic are extending themselves instead through new "physician affiliations." United bought a large California practice group through its non-payer unit, Optum (a regulatory necessity). Fierce Healthcare chronicles the PE deal list, see espeically Oak Hill's wise decision to team up with Ascension Heath to grow its hospital portfolio. In the era of ACOs--where care is coordinated across groups of providers who are then held responsible to payers for quality and cost-savings--entities with more doctors will get more referrals and achieve economies of scale. It is an eventual feedback loop, which is why provider purchases are a dominant trend in healthcare, and why payers, especially, are so active (WellPoint, Humana and Highmark). Congress has noticed, but how much consolidation will the government permit before the market forces that would enable cost-efficiency and real reform, i.e. a diversity of vendors, all but go away? Update: Industry responses to Ways & Means Committee hearing.

 

Wed | Aug 31, 2011 A picture of the deficit-reduction supercommittee We've found several good statistics-based graphics that map the ideological dispersion of the 12-member supercommittee and none of them is very encouraging, but Keith Poole at VoteView does the best job of explaining the nuances. His X-axis uses Common Space scores to plot the location of each committee member. His Y-axis shows the committee's ideological density, by party and chamber. We abbreviate Poole's assessment immediately below the chart.

"First, the three most liberal members of the committee are all House Democrats appointed by Nancy Pelosi (D-CA). . .  Conversely, John Boehner’s (R-OH) appointments are much more ideologically dispersed . . .Second, if Keith Krehbiel’s “pivotal politics” theory holds in this case, the committee’s recommendations should converge on the preferences of the two most moderate members–Senator Max Baucus (D-MT) and/or Representative Fred Upton (R-MI). If voting patterns in the super committee follow a “two ends against the middle” patter[n], then a 7-vote majority could include Kyl, Portman, Camp, Upton, Baucus, Kerry, and Murray/Van Hollen."

Encouragingly, both sides are enthusiastic about their new staff director, Republican tax expert Mark Prater. So how might the committee members lean on healthcare-related cuts/taxes?

• Sen. Murray (D-WA) healthcare votes ; co-chair, has incentive to negotiate: Seattle-based Boeing could lose big if the supercommitte deadlocks, triggering cuts in defense spending.
• Sen. Kyle (R-AZ) health care votes ; no incentive to negotiate: walked out of Biden talks over taxes increases, not seeking re-election.
• Sen. Kerry (D-MA) healthcare votes ; supported then-Gov. Romney's health reform plan. During reform debate, criticized special Medicaid deals for Nebraska and Louisiana, but won $500 million in such funds for Massachusetts.
• Sen. Toomey (R-PA) healthcare votes ; wants to replace the ACA, instead allow insurance purchases across state lines.
• Sen. Baucus (D-MT) healthcare votes ; voted against Simpson-Bowles recommendations and to means-testing Medicare Part D recipients.
• Sen. Portman (R-OH) healthcare votes ; White House budget director in Bush administration, wants to repeal ACA as a "job killer" that fails to contain costs.
• Rep. Hensarling (R-TX) healthcare votes ; co-chair, voted against requiring negotiated prices for Medicare Part D, signed Norquist's anti-tax pledge.
• Rep. Van Hollen (D-MD) healthcare votes ; ranking Dem on Budget Committee. Voted against Ryan budget,  limiting medical malpractice damages and Medicare benefits. Supports importation of prescription drugs.
• Rep. Becerra (D-CA) healthcare votes ; served on the Simpson-Bowles debt commission, voted against it over cuts to spending and lack of revenues.
• Rep. Camp (R-MI) healthcare votes ; served on the president's debt commission, voted against it over tax hikes, failure to address healthcare costs.
• Rep. Upton (R-MI) healthcare votes ; supports treating mental health as important as physical health; supported decreasing tax cuts in the Bush administration.
• Rep. Clyburn (D-SC) healthcare votes ; third ranking Dem is close to Pelosi, supports establishing a federal fund to invest in prevention and public health programs.

Their first meeting is Thursday. Nov. 23 and Jan 15 are the big deadlines. A full list of key dates is here.

 

Monday | Aug 29, 2011 Towers Watson contradicts McKinsey, or does it? Media  reported that Towers Watson's employer survey results contradict those produced by McKinsey in June. Maybe, maybe not. We included McKinsey's controversial results in an earlier Newsspottr: that 30% of employers (and 60% of well-informed employers) would likely drop their health plans after 2014. Towers Watson polled 368 companies and found "over two-thirds (71%)" of respondents said they will continue employee healthcare coverage through 2014. So this essentially the other side of the same statistic, although that remaining third of Towers' respondents are "unsure" if they will continue offering health benefits or not. Employers do seem confused: three-quarters of Towers' respondents believe health benefits will remain a key part of the "overall employee value proposition" after 2014, yet 70%  doubt the value of exchanges (where lower-cost competitive options are meant to be found) and 47% say they will "substantially reduce the health care benefit value of active employees." Fully 56% expect to pay the excise tax on Cadillac plans (worth $10,200 or more) by 2018. Either they don't really intend to change much, or the so-called income gap in healthcare benefits is about to balloon. Then again, this indicates a specific opportunity for the innovator who can help employers manage benefits to a target of $10,199 a worker. Meanwhile, we wonder two things: When will the tide of employers swtich to defined contribution? When will employer-provided insurance come to an end, full stop?

 

Wednesday | Aug 24, 2011 Bundled payments may be easier path to accountable care than the ACO CMS released four models for its so-called "bundled payments" program, and Deloitte's Paul Keckley lays them out clearly here. A bundled payment, also known as an "episode-based payment," is a reimbursement for several services delivered during a defined episode of care (e.g. a childbirth). They are an alternative to the ACO, and doctors seem to like the approach better as it exposes them to less risk. ACOs also are challenged to embrace the lionshare of doctors who work independently or in very small practices. (The rise of ACOs also explains the rollup of physician practice groups by hospitals and payers nationwide.) Too often in healthcare the chasm between present and future is one operators fear to cross, but bundled payments could be a bridge. In a New England Journal of Medicine essay, Robert Mechanic weighs the good and bad of bundled payment: they ease providers into payment reform (good); they don't discourage unnecessary episodes (bad). Then this got our attention:

"Payers will be able to configure [software] to make prospective payments to provider groups or to calculate episode budgets but continue paying individual providers on a fee-for-service basis, an approach that is more feasible for loosely organized physicians and hospitals. Under that approach, insurers could pay periodic bonuses to clinicians whose episode costs are below budgeted amounts and assess penalties on those whose costs exceed their budgets."

Some would call this incremental innovation. Yet if it is even a littel less intimidating than the much-hyped ACO, it could move doctors in the right direction. A wise man once told us: "Never to confuse motion with progress."

 

Friday | Aug 25, 2011 7 ways to use Google more effectively  Chances are you spend a lot of time doing research on the Web. Today a friend pointed me to a study indicating that most of us use search very poorly. An example: Google search anthropologist Dan Russell recently told  The Atlantic that 90% of computer users do not use CTRL + F (PC) or Command + F (Mac) to search for keywords in Web pages. I use it with text documents and e-mails too, and it's a big time-saver. But this nudged me to find this list of tricks for using Google well. (I reject the first rule; if you know what you're looking for, more words and specificity help.) These tips work on Bing too. Here they are, condensed:

1. Search a specific site for your topic of interest:  "health games site:healthspottr.com"
2. Search across a whole class of sites: "health games site:.org"
3. Place a minus symbol (-) with a single space in front of words you want to avoid: " - Zynga"
4. Use (-) to avoid specific sites too: " - site.theatlantic.com"
5. Use the pipe symbol (|) between words to allow any of several words in your results: "games | gamification | casual games  site:.org"
6. Don't know what you're looking for? An asterik (*) to treat the star as a placeholder for unknown term(s). It will find the best matches. Try:  "gaming IPO *"
7. use "CTRL + F" on a PC or "Command + F" on a Mac to search for a keyword in your results 

For more search shortcuts see Google Guide. Here are shortcuts for Microsoft Word, shortcuts for Power Point, and tips for Excel.

 

Thursday | Aug 24, 2011 Jobs' 2005 Stanford commencement address

In case you haven't seen it, take 15 minutes to watch this: