The Summer Lull Edition of Health Wonk Review


Summer of 2017 is fading quickly into the memory books, but some of the happenings on the healthcare scene will be with us to bemoan, analyze and reform for years to come. Now that’s summer fun that lasts!

Let’s start with the philosophical underpinnings of the ongoing political healthcare debate – free market or socialism? Nobody is better equipped to take this on than David Williams of the Health Business Group who is a self-professed free market fan knee deep in the business of healthcare. With his background in economics and an MBA, as well as entrepreneurship, he acknowledges there are some limits to the free market. The healthcare system is one place where capitalism is tested. “Capitalism has a place in healthcare, but in developing policies we should also recognize the limits of free market approaches and be open to the benefits of socialist ideas,” David says. In this post, What Free Market Healthcare Really Looks Like, David walks us through a payment example and explains how a socialized medicine system fashioned on the Medicare model avoids some of the costs and shell games that happen in a free market model. Definitely take this one in.

Who really needs the social safety net public option solution anyway? Maybe the very people who oppose it, suggests Harold Pollack at In this entry, Who Really Needs the Public Option? Trump Country, Harold says Trump Country is most in need of a way to bypass the ACA marketplaces entirely. Democrats’ favorite policy option – the public option – would be most valuable in precisely the deep-red areas that went most fervently for Republicans and the President. Come for Harold’s great analysis. Stay for his groovy cartograms. Get it all here.

More guest blogging gems, this time from InsureBlog where Henry Stern pulled in guest blogger Patrick Paule who wrote about The Creation of ObamaCare’s Individual Market Mess. Patrick traces the history of the decline and fall of ObamaCare, letting no one – and we mean *no one* – off the hook in the process. Go here to get the full scoop.

And for those who wonder how the free market health insurance programs work, Louise Norris gives us a very cogent explanation of actuarial value in her guest blog for Verywell this week, What is Actuarial Value and What Does it Mean for My Health Insurance? She discusses what is actuarial value, how it is calculated and what it means for the individual member. Catch her explanation here.

Meanwhile, the health care reform debate in the US – which has really been about health insurance and specifically whether to repeal and/or replace the Affordable Care Act – is currently on hiatus. Roy Poses tells us, “This gave me a chance to list some of the major issues and causes of health care dysfunction which we have gone on about on Health Care Renewal but which rarely appear in polite conversation.” His list of issues includes: threats to the integrity of the clinical evidence base (which has had little public attention), deceptive marketing, distortion of health care regulation and policy making, and bad leadership and governance (which have had much less attention), concentration of power, abandonment of health care as a calling, perverse incentives putting money ahead of patients, education and research, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos. Roy says true health care reform requires ending the taboos on discussing all of the above, and then addressing the real causes of health care dysfunction. Roy makes a very good start in that direction in What the US Healthcare Reform Debate Did Not Address here at Health Care Renewal.

Sometimes medicine is lost in the policy debates in healthcare. Joe Paduda turned over the blogging reins to David Deitz MD, PhD, who wrote a guest post on a subject with which he is quite familiar – opioids. David unpacks the National Academy of Sciences, Engineering and Medicine’s report to give us his perspective, and he draws a conclusion. Simply put, opioid exceptionalism means that the FDA, as well as other public agencies, should go beyond the risk/benefit paradigm they currently use for new drug approvals that is based on individual patients and consider the implications of an individual opioid to patients’ families and society. Read his rationale in Opioid Exceptionalism: Why These Drugs are Different Than All Others at Managed Care Matters here.

Tom Lynch at Workers’ Comp Insider poses the question, Medical Care Experts: Where Would We Be Without Them? Tom notes that in recent years, workers’ compensation cost control has focused mainly on lowering medical costs, which is almost always an outsourced function. Consequently, many employers have relinquished control over their workers’ comp program, migrating away from best practices that are at the heart of true workers comp cost control. Read the full blog here.

Hospitals have reduced length of stay about as much as possible, and now it is time to take the longer view on the total cost of patients who are discharged to post-acute care. In this post, Bradley Flansbaum shares some data and discusses that a new measure, home-to-home care, will come to reframe the LOS debate as the total cost of home-to-home care becomes a measure of true cost. Read more in You Have Lowered Length of Stay. Congratulations. You’re Fired at The Hospital Leader.

Photo by Eddie Kopp on Unsplash


Posted in health economics, health insurance, health policy, health reform, pharmaceutical marketing | 12 Comments

CBO Estimates How Many Will Flee ObamaCare if Given the Chance


Those who control the language, control the debate. Let’s look at the language surrounding the Congressional Budget Office estimates that the Republican ACA alternative, AHCA, will result in about 22-23 million more uninsured over the next 10 years.

The meme is that the AHCA leaves more than 20 million more Americans without health insurance than under the current ACA (ObamaCare). And if the estimates are correct – which they rarely are! – it means that many people will cold-heartedly be thrown out into the streets without health insurance.

The truth is that many of those 20-some million only have health insurance, but they still don’t have affordable health care. The financial burden of buying ever-more-explosively-expensive health insurance makes actually using said insurance nearly impossible because the deductibles and copays aren’t manageable after paying premiums that rival the cost of most home mortgages. That’s not hyperbole. One friend over lunch a few months ago told me his premiums for just he and his wife are now $2,000 a month, more than his mortgage payment, which he attributes mostly to the fact his wife has a disease, psoriasis,  that requires monthly injections of a biologic that costs more than the monthly premium. They figure they are up a few hundred a month by paying the protection money…er, insurance premium.

We know that health insurance does not equal affordable health care because another statistic released this week highlights the unaffordability of using the insurance.

Update June 28: Health insurance does not always equal affordable healthcare, but pays the bills for most expensive procedures. One mom displayed her $231,000 hospital for her 3-year-old’s operation and her actual out-of-pocket of $500 in this MSN story.

According to an article in FierceHealthcare this week, MOST people who use hospital services do not pay their hospital bills. Here are the details of a report presented to the Healthcare Financial Management Association’s Annual National Institute.

Nearly 70% of patients with hospital bills of $500 or less didn’t pay off the full balance in 2016…

That’s a significant increase in the percentage of patients who didn’t pay their hospital bills in full in 2015 (53%) and 2014 (49%), the TransUnion Healthcare analysis found.

Other findings on payment patterns between 2014 and 2016 include:

  • 63% of hospital bills were $500 or less; of those hospital bills, 68% were not paid in full in 2016.
  • 4% of hospital bills were $3,000 or more; of those hospital bills, 99% were not paid in full in 2016.
  • 10% of hospital bills were $500 to $1,000, of those bills 85% were not paid in full in 2016.

“There are many reasons why more patients are struggling to make their healthcare payments in full, the most prominent of which are higher deductibles and the increase in patient responsibility from 10% to 30% over the last few years,” said Jonathan Wilk, author of the book “Healthcare Revolution: The Patient is the New Payer”…[italics mine]

Bolting the System

Another article by Doug Badger in National Review (a conservative publication) shares the details of how most of those 22 million people identified in the CBO estimates will become uninsured. About 15 million people who are forced into taking the insurance today will bolt the system.  He shares the CBO estimates that repealing the tax on the uninsured will “induce 7 million people to cancel their individual insurance policies, 4 million to drop their job-based overage and 4 million others to abandon Medicaid, even though the government provides it free of charge in most cases.”

Theoretically, compelling the purchase of health insurance should be good for the citizen, good for the medical community and good for society. It isn’t working out that way.

Under the current ACA, many (even covered!) patients still can’t afford care, the providers still wait for insurance payments or are parts of narrowing networks forced to take reduced rates, and the government is becoming the largest payer of healthcare. That’s not private insurance protecting citizens against an expensive illness. That’s a shell game moving money from the government to the insurance companies with the doctors and hospitals grabbing crumbs falling off the table during the exchange.

And, let’s face it, even the insurance companies aren’t making ends meet under the ACA. They are getting out of any marketplace where they see a crack in the door.

I can’t reasonably declare that the AHCA is a solution to the problems of the healthcare system exacerbated by the ACA, because I am not sure that it is. But I also don’t think that liberating people from purchasing insurance they don’t want, can’t afford to use and neither the government nor the patients can afford to maintain is such a bad idea either.

Health insurance is not health care. We have the data to prove it.

You can be insured and not be able to afford healthcare, so being “uninsured” is not the problem. We need to change the language and change the debate.

Medical care for all. It’s a different story.


Posted in health economics, health insurance, health policy, health reform | Leave a comment

Wow! Special DOUBLE Edition of Health Wonk Review – ACA and “Other”


Here it is…the FIRST EVER Double Edition of HWR. Part One is all ACA and Part Two is everything else you have come to expect from the Wonkers who wander through healthcare land. Enjoy. And comment below. We love hearin’ from ya.

Also, thank you to The Precision Medicine Daily this week that saw fit to include Health System Ed’s blog on CMS Meaningful Use Payments to Providers: Incentives or Sophie’s Choice.

Posted in electronic patient records, health economics, health insurance, health IT, health policy, health reform | Leave a comment

CMS Meaningful Use Payments to Providers: Incentives or Sophie’s Choice?

thSN5W8HTYSophie’s Choice: You have to choose when there are no good options.

Sophie’s Choice was an award-winning 1983 movie based on the William Styron novel about a Nazi concentration camp survivor who was forced to choose which of her two children to send to the death camps. In this most heart-wrenching scene ever filmed, the woman must choose and begs to choose “neither”.

For healthcare providers who are caught in a regulatory net by participating in government-funded programs, they were given a choice between installing an electronic health record system, attesting to meeting a list of nearly-impossible targets to get reimbursement for their multi-million dollar investments, or choosing not to participate which resulted in losing participation in said government-funded programs and incentives.

Most providers bit. They had no choice. And when it came time to collect the Meaningful Use incentive dollars, they attested to meeting at least the minimum requirements. The government bit back.

Department of Human Service auditors in the Office of Inspector General most recent review estimated that the Centers for Medicare and Medicaid Services has overpaid more than $729 million to providers whose paperwork didn’t pass muster. That’s more than a big whoops for many organizations. That can be an organizational nightmare to reconstruct and prove that your claims were accurate.  Click here to read the story.

Here’s an excerpt from the HealthcareITNews story reporting the overpayments:

All of these providers should begin – if they haven’t already – gathering the required documentation. While it varies by the program, [Erin} Whaley [partner at international law firm Troutman Sanders]  explained it will range from security risk assessments to screenshots. For other measures, providers will need a patient list of an audit log.

And documentation is required for every year attestations are made.

[Matthew] Fisher [partner at corporate law firm Mirick, O’Connell, DeMallie & Lougee] recommended that healthcare providers run an internal audit or review to ensure all documentation and information resides in one place and can be easily accessed.

Financial and Administrative Burdens

Yesterday, I met a young physician at a barbeque. Our conversation led to the typical “what do you do?” When I asked her what specialty she was most interested in, she said she was considering geriatrics or ob-gyn but that the business of medicine had become so dominant that instead she was thinking about getting her MBA and switching her focus completely. This woman spent her early career as a trauma nurse. She loves medicine and loves patient contact. She is currently doing toxicology research and interested in Alzheimer’s Disease research.  But her experience in the medical field is leading her to the conclusion that her brain and talents might better be used analyzing spreadsheets and business plans.

I used to think that healthcare was a positive driver of gross domestic product and a thriving sector of the economy. Now, I wonder if our focus on healthcare as a business isn’t costing us our focus on patients and causing us to lose some of our talented and dedicated medical professionals to regulation and bottom-dollar mentality. Loss for the patient. Loss for the doctor. Loss for society.

This is not a new thought.  But this is a problem that is becoming so acute that to save medicine, we need to reprioritize what we incent, how we incent it and whether the recordkeeping is worth the price of time, focus and energy toward the business rather than the medicine.

Health technology – like all technology – is making quantum leaps forward while we are looking backward to reconstruct Meaningful Use criteria that are quickly becoming meaningless.

In this article on the future of Precision Medicine here, architects of the future of healthcare at the Precision Medicine Summit in Boston last week said that the future of Precision Medicine is more accurately Precision Health. Precision Medicine was about the use of system data to help doctors make decisions about patients; Precision Health is about patient access to their own data to make good decisions about their own health.

This one move from focus on the system to focus on the individual calls into question the future value of the content of the electronic health record stored in your health system database as it relates to patient care. After all, we knew all along that the patient record was, at best, incomplete. It also further calls into question the value of the Meaningful Use criteria as they relate to the practice of medicine where it is today.

Perhaps CMS needs to call a timeout on the HHS auditors, call the MU money well-spent where it incented progress, sunk costs where it impeded progress, and walk away from this program that was as well-designed as it could have been nearly 10 years ago before we knew what we know now.




Posted in biotechnology, consumer health apps, electronic patient records, health economics, health IT, health policy, health reform | 1 Comment

XPostFactoid Inaugural Hosting of Health Wonk Review: Get It Here

th45W76ZWMWelcome Andrew Sprung to the Health Wonk Review crew for his debut hosting effort. Click here to read his roundup in the Alternative Facts, Alternative Realities Edition of HWR.


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Healthcare Visionaries Lead the Way

Technology is moving much faster than the snail’s pace of government and regulation. It is an exciting time to be – not just in healthcare – but to be alive.

I’ve been hanging around the virtual water cooler in healthcare for two decades, and now the promise of technology as it affects and improves our lives is beginning to come to fruition. With that, here is a roundup and just a few developments and their significance to the future of healthcare from a medical, business and financial perspective.

Med-Tech: At the head of the futurist pack is Dr. Peter Diamandis, known for oh-so-many things including a founder of the X-PRIZE, Singularity University and the Human Longevity Institute. In his May 19 Abundance Insider, he looks  at a bionic hand developed in the UK “capable of grasping objects without the wearer’s focused thoughts.  The researchers created a convolutional neural network training the hand and its algorithm on the images of over 500 objects in various orientation and lighting conditions with four programmed grasps that you might use to pick up things.”  Go to the link to see the video. Under that entry, you can read the next story about an 18-year-old Mexican student who designed a bra that detects breast cancer.

Health Biz-Tech: The business of healthcare is all about how we pay for medical services and the structure of the business model. Our current system is focused on an insurance-based payment model. Already, insurance companies are toying with issuing insurance policies in real time based on your current medical history that involves instantaneous analysis of your condition, the company’s risk and what it will cost you to be covered by them. This could blow all the regulations out of the water. It could also call into question the current model of trying to cover everyone with insurance and could instigate a movement to have us begin to look at a different business model completely, especially in light of the kind of Med-Tech advances in the pipeline that will completely alter our outcomes and lifespan.

Health Fin-Tech: How and why certain goods and services get paid keep many an insurance agent, claims administrator and government regulator up at night., not to mention the security people who need to lock down our data to maintain patient privacy. The blockchain has the promise of changing the financial world, and healthcare payments and security will be part of this revolution. I am attending a Meetup of blockchain people in my area this Saturday and I’ll report back at some point.

They say those in a movement need to either lead, follow or get out of the way.

At some point in the history of the evolution of healthcare, government was in a position to lead. In the past few years, it has been in the unfortunate position of having to follow as technical advances outpaced the ability of government to legislate and regulate at the pace of change. Now it is time for government to get out of the way. At some point, we’ll need to regulate for safety and security reasons. But this is not that time.

Posted in biotechnology, consumer health apps, elearning, electronic patient records, health economics, health insurance, health IT, health IT training, health policy, health reform | Leave a comment

“I Will Build a Great Health Wonk Review”…And He Has!

donald-trump-black-and-whiteBrag-a-docious much?

Nah, not Jason Shafrin. Our humble Healthcare Economist touts his very biggest, very best, nobody-does-it-better edition of Health Wonk Review right here.

Mightily nicely done, there, Mr. Shafrin!

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Health Wonk Review: Groundhog Zombie Goes Back to the Future

Halloween concept, zombie hand rising out from the groundWith a title like that, who is strong enough to resist clicking on this link to read more? I challenge the most susceptible among you to ignore this post!

Julie Ferguson at Workers’ Comp Insider is our creative mistress of ceremonies this week. Here’s what she has to say:

It’s quite the day to be going to press with a new Health Wonk Review. We were trying to think of  a movie themed metaphor for today’s edition but can’t decide between Back to the Future, Groundhog Day or a zombie flick, so we’re going for a mashup.  Click here to read more.

Posted in biotechnology, consumer health apps, electronic patient records, health economics, health insurance, health IT, health policy, health reform, healthcare marketing | Leave a comment

It’s That Time Again: Play Ball with Health Wonk Review



Enjoy the Whos’ On First Edition with Brad Wright with Wright on Health. Here’s the link to all the facts.

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InsureBlog Hosts the Pre-Passover Edition of Health Wonk Review






Yes, it is that time again! Oh, sure, the biweekly Health Wonk Review is on your newsstand today. But also, those religious rites of spring are right around the corner. So without further ado or comment from the cheap seats here at Health System Ed, here’s Henry Stern’s pre-Passover edition of HWR. Do yourself a favor and enjoy.


Photo by Phil Goodwin on Unsplash

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