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Cost of Medications

Needle and Pills

Over the past year we’ve heard about terrible price increases in the EpiPen® and how horrible this skyrocketing was because it’s a lifesaving medication. There’s no doubt that the EpiPen is lifesaving, but what qualifies a medication as lifesaving? Any medication that controls an acute or chronic medical problem is lifesaving.

As an endocrinologist, to me the most common lifesaving medication is insulin. Let’s look at what has happened due to the costs of insulin. Retail costs of newer insulins can cost up to $500 or even $600 per month. Older ones can cost about half that. And copays can range from $40 to $150. Patients sometimes tell to their physicians that they’ve stopped their insulin because they can’t afford it. In fact, some have reported that they stopped their insulins and ended up in the hospital, but their hospital copay was less than their prescriptions. Older patients have said that they stopped their insulins when they hit the “doughnut hole” in Medicare.

If you go on the Good Rx website, you’ll find that you can get regular or NPH insulin (an intermediate insulin) for around $27 each. I’ve sent patients in two different states to Wal-Mart pharmacies to buy these insulins, and they have all been told that Wal-Mart doesn’t have anything comparable to these prices. Many pharmaceutical companies offer discount cards that enable patients to purchase a month’s supply for $10 to $25 for up to 12 months. But, to get these cards, you must meet eligibility requirements. And if you’re on Medicare, Medicaid, Tricare, VA, Department of Defense or similarly federally or state-funded programs, you won’t qualify. One bright spot is that Federal Employees Health Benefits Program members do qualify.

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Celebrating Achievements in Health Care Quality

Doctors and Nurses

HealthInsight is acutely aware of the challenges health care providers face in improving the quality of care. We work hard with our community partners to advance quality initiatives that sometimes seem to take a step back for every two steps forward. In the midst of our labors, it behooves us to pause now and then to celebrate our successes.

Since 2004, HealthInsight’s Quality Award program has recognized Medicare-certified providers who demonstrate excellent performance on publicly reported quality-of-care measures. We created this program to encourage providers to invest in quality and systems improvement, and to promote transparency in measures of safety, quality and patient experience of care.

Public recognition of top-performing providers not only motivates other providers to improve their performance, but gives consumers information they can use to make choices about their own care. Our awards also tie into the nationwide movement toward paying providers for the quality of care they deliver.

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Pitfalls of Analytical Product Development and How to Escape Them

Data Analytics

Our health care analysts build data-driven products (dashboards, reports, etc.), and they think through all of the technical implementation steps required to make these products successful. The next step determines the success of the product: pinpointing and avoiding the potential pitfalls that can undermine its usefulness. These pitfalls include:

  • Failure to understand what we really mean by "business intelligence"
  • Poor understanding of the users of our product and their needs
  • Poor data management

Often data sources look like a dangerous cocktail of social determinants of health coupled with genetic, environmental and clinical data with other information thrown in. Finding a meaningful way to manage these data and capitalize on the value of the information can be challenging.

Let’s look at the end user of our analytical products – the provider. The volume, variety and velocity of available information can far exceed any professional’s abilities to process and interpret. For example, our Partnership to Advance Tribal Health (PATH) participating hospitals are bombarded and confused by multiple layers of mandatory reporting and dashboards provided by local area offices, their Medicare Quality Improvement Networks, their Hospital Improvement Innovation Network organization, tribal epidemiology centers, state departments of health and many more organizations.

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Why Talking Matters

speech bubbles

Late last year I decided to tackle a topic I had been putting off for quite some time – having the dreaded end-of-life conversation with my family. No, I am not ill (thankfully), nor are my loved ones currently going through a difficult situation. However, I think it’s important to have these discussions while my family and I are in good health, without the added pressure of chronic disease or terminal illness.

I decided to start the conversation with myself and then talk with my husband, adult children, sister, mother and so on. I wanted to make some decisions about what was important to me so that others wouldn’t one day find themselves trying to figure that out for me. I love my family, but do they know what matters most to me?

I live in a house where I am the only female, so history has taught me to be at least a little skeptical that my husband and sons would be in tune with my personal wishes. I’m thinking they could use a little help in that department and would be grateful to receive it – God forbid they would need to act on it anytime soon.

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We Can’t Let Inertia Set In!

Hands in a circle

Many of you may be wondering what will happen with federal legislation to either repeal or replace the Affordable Care Act. And we’re equally curious when it will happen. Many people have told me, “Surely, by the fall we will have some legislative fix around repeal or replace.” I don’t think that’s very likely. In fact, I don’t think it’s even very likely to happen in this calendar year. There are too many special interests and not enough working across party lines to reach consensus or alignment around the core issues impacting health care. The current discussion has essentially focused only on health care coverage – which is critical, but it hasn’t even touched the areas of changing how we provide health care, how we pay for care, the supply of health care professionals, and the innovative part of health care that we need as we move into this new health care environment. We have seen lots of talk but, as of yet, no real movement over the last couple of months. So, for now the Affordable Care Act is still the law of the land.

It’s anyone’s guess as to whether the gridlock in Washington will be resolved any time in the near future. For this reason, we must not allow inertia to set in. We have a broken health care system and we can’t expect that any one federal or state policy will fix it. There is so much uncertainty in all sectors of health care that you can almost sense the inertia beginning. We can’t let that happen: we need to continue to push and innovate transparency in the system around quality and cost; we need to continue to support and fund innovation; we need to continue to pilot and experiment with different payment models; and ultimately, we need to continue to push for the new health care system of the 21st century.

It’s hard work, but those of us in the trenches must roll up our sleeves and identify new partners to align with in order to drive toward a new agenda for health care. We must support our colleagues and providers on the ground in their day-to-day efforts to create a higher quality, more efficient system and walk hand-in-hand with them in a spirit of experimentation. We can’t go backward: we need to continue to look forward in our vision of how health care can and should look. We’re the torch bearers and we must continue to carry the torch forward.

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The Path of Totality—Did You See It?

Solar Eclipse

A young man, transported from 20th century Connecticut to King Arthur’s court, finds himself in a pickle, and tied to a stake for performing acts of sorcery. He happened to have an almanac with him and knew that a solar eclipse was about to occur. He warns the king that he will make the sun disappear, and on cue, the sky darkens and the sun sinks into a black hole. The king pleads with him and the young man agrees to make the sun reappear in return for his freedom.

Whenever I hear about a solar eclipse, I can’t help but think about Bing Crosby in the 1949 movie, “A Connecticut Yankee in King Arthur’s Court,” an updated version of Mark Twain’s 1889 novel. That particular scene portrays a historical representation of omens and superstition that have accompanied solar and lunar eclipses for centuries.

Today, we know that a total solar eclipse occurs when the new moon passes between the earth and the sun at a distance where the moon and the sun appear to be the same size. If in the path of totality, you would see the sun disappear for a short while, followed by images that are described as truly magnificent. The hype leading to the 2017 eclipse led millions of people to flock to the path of totality to observe what could be a once in a lifetime experience.

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Working Upstream

Granddad and granddaughter fishing

Summertime in the Pacific Northwest is a great time to catch a glimpse of salmon making the life and death journey swimming upstream back to the place of their birth.

We often talk about working “upstream” with patients with kidney failure and how critically important, yet difficult, this work can be. One out of seven Americans (30 million!) has chronic kidney disease (CKD), often referred to as the “silent killer,” due to symptoms that are undetectable until it is too late. Not only is CKD a growing public health threat, but the health care costs associated with CKD and end stage renal disease (ESRD) represent more than a quarter of all Centers for Medicare & Medicaid Services (CMS) claims.

Nephrologists who care for kidney patients have increasingly expressed their concern for the lack of care for patients in the early stages of ESRD (stage 1-4) before kidney failure (stage 5). Dr. Louis Cotterell, a nephrologist and member of the ESRD Network board of directors, relayed the importance of working “upstream”, he said:

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Medicare Payment Reform Ramps Up: How Are We Doing?

It’s been five years since the first Pioneer Medicare Accountable Care Organizations (ACOs) formed, marking the beginning of Medicare payment reform and now one year of the Quality Payment Program (QPP) is up. So, how are we doing? And what can we still learn as it rolls out? The QPP was created to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and if we’ve learned anything in the first year, it is that practices need support to make the changes needed to be successful. I want to highlight three recent articles that have given me pause and can give us direction for our efforts on the path from volume to value.

In the past quarter, a few interesting reports on MACRA and QPP have been published, framing the current status of provider participation, understanding, and potential impact of payment reform. Two reports take a pulse of American physicians. First, the American Academy of Family Physicians (AAFP) self-report Annual Member Survey of 2017 looked at member family physicians and found that 83 percent of reporters take Medicare patients, a record high in the last decade for family docs, yet only 50 percent consider themselves “somewhat-to-very-aware” of QPP/MACRA. And earlier this year, 45 percent reported being “undecided” on their plan to participate in MIPS or APMS.

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Medicare, Up Close and Personal

Senior Couple Gardening

Several months ago, I began receiving a flood of letters and phone messages from health plans, insurance brokers and others, reminding me—as if I needed reminding—that I was about to turn 65. “It’s almost time!” they said. “Congrats in advance!”

They were concerned about my future health coverage and wanted me to get the most out of life. They understood my confusion and were there to help. Some even offered me a free meal.

“You have a limited window of time to enroll,” they warned. “You have options, we have answers. Give yourself the coverage you need. You owe it to yourself…”

Not getting enough love from strangers? Join the Medicare marketing cohort!

Joking aside, Medicare is about to get up close and personal for me. Until lately, I thought of it as a nebulous bureaucratic system I would need to engage with “one of these days.” Even as a communicator for a Medicare contractor, I sometimes found it hard to relate to the quality-of-care issues our organization grapples with every day. Now the program and its future have my full attention.

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Health Cost Reform – Whose Ox Gets Gored?

Healthcare costs

There has been much ado in the news about health care reform, health coverage reform, health payment reform and clinical practice reform. All are tangential references to the real elephant in the room — health cost reform.

Why has the elephant grown so large? Is there a combination of diet and exercise that can help our elephant become slim and trim?

Your perspective on the reasons and solutions depends on the part of the elephant closest to you. If near the poor, unhealthy, uninsured patient part of the elephant, mandatory affordable health insurance for all is the ticket. If near the insurer part of the elephant, your focus is reducing the discretionary price-gouging, cost-shifting and wasteful choices of consumers and providers. If near the employer and plan sponsor part, you may wonder whether replacing employees with robots may be the better way to avoid health costs. Those near the care and treatment part fuss about the onerous rules, processes and habits that interfere with engaging patients in achieving and maintaining better health. Those near the social and mental health part of the elephant see a need for allocating more resources to prevention and education than to rescue.

Everybody sees that the big elephant is crowding out other important things desired for the room, such as wage increases, job protection, life choices, equitable access and security.

All parts of the elephant need to shrink to a more normal size. The March 2013 Time Magazine article by Steven Brill - Bitter Pill, Why Medical Bills Are Killing Us describes many wasteful practices that perhaps could be curtailed. But where do we start? Whose ox gets gored?

We Americans tend to prefer "nudges" to affect sustained change rather than voting for more government mandates typical in other lower-cost countries. Therefore, perhaps we should leverage all available resources to favorably influence the choices of health care users and providers to affordably improve our health.

We need to seek first to understand and prioritize what is most important.

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