Humana completes sale of long-term care insurance policy business KMG, at a loss of $790 million

https://www.healthcarefinancenews.com/news/humana-completes-sale-long-term-care-insurance-policy-business-kmg-loss-790-million?mkt_tok=eyJpIjoiWTJNeE5UZzRNalU1WWprMSIsInQiOiJRNjRWYXFQcSt3aHpGMlB4RVwvbXA3ckt4MVlxZ04zeHl5VWtKMzB4V2dpa21LTTY3U2pMdWlnSHh3MXRMWlwvWkdQNEdldGVjRWpWUG5Md0xmbTlQVE0zVTdFUStxY0lQcmNpUkRRRHpPelZSOUNBTW90WDNNbGd1ekZsZGZHVU04In0%3D

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Humana has completed the sale of its wholly-owned subsidiary KMG America Corporation, in a transaction first announced in November 2017.

Humana has owned KMG since 2007.

KMG subsidiary, Kanawha Insurance Company, offers commercial, long-term care insurance policies and currently serves an estimated 29,300 policyholders.

Humana sold its shares in KMG for a reported $2.4 billion to HC2 Holdings, which includes Continental General Insurance Company, based in Texas.

In its second quarter earnings statement, Humana reported a $790 million loss on the sale of KMG, which is expected to close during the third quarter.

Humana said it would no longer have plans in the commercial long-term care insurance business.

Humana instead is closing on two transactions to acquire an at-home provider in Kindred at Home and Curo Health Services, which specializes in hospice care, according to the Q2 report.

Curo provides hospice care in 22 states. Humana and a consortium of TPG Capital and Welsh, Carson, Anderson & Stowe, purchased Curo for $1.4 billion, Humana announced in April.

Humana will have a 40 percent interest.

Also, this past June, Humana partnered with Walgreens Boots Alliance in a pilot to operate senior-focused primary care clinics inside of two drug stores in the Kansas City, Missouri area.

Revenue remained strong for the insurer, which specializes in Medicare Advantage plans. Its MA business in Q2 realized both growth and lower utilization.

While revenue remained strong, Humana’s net income dropped to a reported $684 million this year compared to $1.8 billion last year.

The insurer benefitted from a lower tax rate year-over-year as a result of the tax reform law and negatively felt the return of health insurance tax in 2018.

“Our strong 2018 financial results are testimony to the underlying improvement in our operating metrics, like Net Promoter Score, digital self-service utilization and call transfer reduction, and to the growing effectiveness of our national and local clinical programs,” said Bruce D. Broussard, Humana’s CEO and president. “Also, we took another large step this quarter in helping our members, especially those living with chronic conditions, by beginning the integration of important clinical services through our investments in Kindred at Home and Curo, and through our partnership with Walgreens.”

 

Ascension’s latest ad campaign touts online scheduling

https://www.beckershospitalreview.com/healthcare-information-technology/ascension-s-latest-ad-campaign-touts-online-scheduling.html

Image result for ascension health online scheduling

St. Louis-based Ascension rolled out a national ad campaign June 4 across television, radio, billboards and direct mail to promote its online scheduling capabilities, which are available in all 22 Ascension markets.

The campaign is aimed at raising brand awareness and communicating patient scheduling options, even for last-minute or same-day appointments.

“Most of us use technology daily to simplify our lives, and the process of getting the care we need, when and where we need it, should be no different. Online scheduling allows consumers to view available appointments at their preferred location and select a time that fits their busy schedules,” Joseph Cacchione, MD, president of Ascension Medical Group, said in a press release. “As we work to improve access to compassionate, personalized care, we must also ensure we are letting consumers know about the new and innovative ways in which we are making the healthcare delivery process easier for them.”

Ascension currently offers online scheduling across 1,200 providers in primary care, urgent care and emergency department care. It has plans to add online scheduling capabilities for specialists and diagnostic and imaging services in the future.

 

 

Medicare Beneficiaries Feel The Pinch When They Can’t Use Drug Coupons

Medicare Beneficiaries Feel The Pinch When They Can’t Use Drug Coupons

This week, I answered a grab bag of questions about drug copay coupons and primary care coverage on the health insurance marketplace.

Q: My doctor wants me to take Repatha for my high cholesterol, but my Medicare drug plan copayment for it is $618 a month. Why can’t I use a $5 drug copay coupon from the manufacturer? If I had commercial insurance, I could. I’m on a fixed income. How is this fair?

The explanation may offer you little comfort. Under the federal anti-kickback law, it’s illegal for drug manufacturers to offer people any type of payment that might persuade them to purchase something that federal health care programs like Medicare and Medicaid might pay for. The coupons can lead to unnecessary Medicare spending by inducing beneficiaries to choose drugs that are expensive.

“The law was intended to prevent fraud, but in this case it also has the effect of prohibiting Part D enrollees from using manufacturer copay coupons … because using the coupon would be steering Medicare’s business toward a particular entity,” said Juliette Cubanski, associate director of the Program on Medicare Policy at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

The coupons typically offer patients with commercial insurance a break on their copayment for brand-name drugs, often reducing their out-of-pocket costs to what they would pay for inexpensive generic drugs. The coupons help make expensive specialty drugs more affordable for patients. They can also increase demand for the drugmaker’s products. If patients choose to use the coupons to buy a higher-cost drug over a generic, the insurer’s cost is likely to be more than what it would otherwise pay.

In addition, consumers should note that the copay cards often have annual maximums that leave patients on the hook for the entire copayment after a certain number of months, said Dr. Joseph Ross, associate professor of medicine and public health at Yale University who has studied copay coupons.

The coupons may discourage patients from considering appropriate lower-cost alternatives, including generics, said Leslie Fried, a senior director at the National Council on Aging.

According to a 2013 analysis co-authored by Ross and published in the New England Journal of Medicine, 62 percent of 374 drug coupons were for brand-name drugs for which there were lower-cost alternatives available.

Q: Last year, my marketplace plan covered five primary care visits at no charge before I paid down my $2,200 deductible. This year, it doesn’t cover any appointments before the deductible, and I had to pay $80 out-of-pocket when I went to the doctor. Is that typical now? It makes me think twice about going.

Under the Affordable Care Act, marketplace plans are required to cover many preventive services, including an annual checkup, without charging consumers anything out-of-pocket. Beyond that, many marketplace plans cover services such as some primary care visits or generic drugs before you reach your deductible.

The likelihood of having a plan that offers some cost sharing for primary care before you reach your deductible (rather than requiring you to pay 100 percent of the cost until you hit that amount) varies significantly depending on whether you’re in a bronze, silver or gold plan, according to a recent analysis by the Robert Wood Johnson Foundation.

In 2018, 77 percent of silver-level plans offered some cost sharing for primary care visits before enrollees had paid off their typical deductible of $3,800, the analysis found. In most cases, that means people owe a copayment or coinsurance charge for each visit until they reach their deductible. A small number of plans offered a limited number of no-cost or low-cost visits first, and then people using more services either had to pay the full charge for each visit or owed cost sharing until the deductible was met.

Bronze plans were much stingier in what they offered for primary care before people reached their deductible, which was $6,400 or higher in half of plans. Only 38 percent of bronze plans offered any primary care coverage before the deductible, and generally patients still had to pay a copayment or coinsurace. A smaller percentage of bronze plans offered limited visits at no cost or low cost before the deductible.

The share of people who chose bronze plans grew from 23 percent in 2017 to 29 percent this year, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation. While premiums are typically significantly lower in bronze plans than other “metal”-level plans, it can be worthwhile to check out how plans handle primary care services before the deductible, she said.

 

 

Would Americans Accept Putting Health Care on a Budget?

https://theincidentaleconomist.com/wordpress/upshot-maryland-global-payments/

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If you wanted to get control of your household spending, you’d set a budget and spend no more than it allowed. You might wonder why we don’t just do the same for spending on American health care.

Though government budgets are different from household budgets, the idea of putting a firm limit on health care spending is far from unknown. Many countries, including Canada, Switzerland and Britain, pay hospitals entirely or partly this way.

Under such a capped system, called global budgeting, a hospital has an incentive to deliver less care — including reducing hospital admissions — and to increase the efficiency of the care it does deliver.

Capping hospital spending raises concerns about harming quality and access. On these grounds, hospital executives and patient advocates might strongly resist spending constraints in the United States.

And yet some American hospitals and health systems already operate this way, including Kaiser Permanente and the Veterans Health Administration. To address concerns about access and quality, these programs are usually paired with quality monitoring and improvement initiatives.

That brings us to Maryland’s experience with a capped system. The evidence from the state is far from conclusive, but this is a weighty and much-watched experiment for health researchers, so it’s worth diving into the details of the latest studies.

Starting in 2010 with eight rural hospitals, and expanding its plan in 2014 to the state’s other hospitals, Maryland set global budgets for hospital inpatient and outpatient services, as well as emergency department care. Each hospital’s budget is based on its past revenue and encompasses all payers for care, including Medicare, Medicaid and commercial market insurance. Budgets for hospitals are updated every year to ensure that their spending grows more slowly than the state’s economy.

Because physician services are not part of the budgets, there is an incentive to provide more physician office visits, including primary care. According to some reports, Maryland hospitals are responding to this incentive by providing additional support outside their walls to patients who have chronic illnesses or who have recently been discharged from a hospital. Greater use of primary care by such patients, for example, could reduce the need for future hospital admissions.

In 2013, early results found, rural hospital admissions and readmissions were both down from their levels before the system was introduced.

In the first three years of the expanded program, revenue growth for Maryland’s hospitals stayed below the state-set cap of 3.58 percent, saving Medicare $586 million. Spending was lower on hospital outpatient services, including visits to the emergency department that do not lead to hospital admissions. In addition, preventable health conditions and mortality fell.

According to a new report from RTI, a nonprofit research organization, Maryland’s program did not reap savings for the privately insured population (even though inpatient admissions fell for that group). However, the study corroborated the impressive Medicare savings, driven by a drop in hospital admissions. In reaching these findings, the study compared Maryland’s hospitals with analogous ones in other states, which served as stand-ins for what would have happened to Maryland hospitals had global budgeting not been introduced.

But a recent study, published in JAMA Internal Medicine, was decidedly less encouraging.

Led by Eric Roberts, a health economist with the University of Pittsburgh, the study examined how Maryland achieved its Medicare savings, using data from 2009-2015. Like RTI’s report, it also compared Maryland hospitals’ experience with that of comparable hospitals elsewhere.

However, unlike the RTI report, Mr. Roberts’s study did not find consistent evidence that changes in hospital use in Maryland could be attributed to global budgeting. His study also examined primary care use. Here, too, it did not find consistent evidence that Maryland differed from elsewhere. Because of the challenges of matching Maryland hospitals to others outside of the state for comparison, the authors took several statistical approaches in reaching their findings. With some approaches, the changes observed in Maryland were comparable to those in other states, raising uncertainty about their cause.

A separate study by the same authors published in Health Affairs analyzed the earlier global budget program for Maryland’s rural hospitals. They were able to use other Maryland hospitals as controls. Still, after three years, they did not find an impact of the program on hospital use or spending.

Changes brought about by the Affordable Care Act, which also passed in 2010, coincide with Maryland’s hospital payment reforms. The A.C.A. included many provisions aimed at reducing spending, and those changes could have led to hospital use and spending in other states on par with those seen in Maryland.

A limitation of Maryland’s approach is that payments to physicians are not included in its global budgets. “Maryland didn’t put the state’s health system on a budget — it only put hospitals on a budget,” said Ateev Mehrotra, the study’s senior author and an associate professor of health care policy and medicine at Harvard Medical School. “Slowing health care spending and fostering better coordination requires including physicians who make the day-to-day decisions about how care is delivered.”

broader global budget program for Maryland is in the works. The U.S. Centers for Medicare and Medicaid Services is reviewing a state application that commits to global budgets for Medicare physician and hospital spending. An editorial that accompanied the JAMA Internal Medicine study noted that a few years may be insufficient time to detect changes. It suggests that five to 10 years may be more appropriate.

“Maryland hospitals are only beginning to capitalize on the model’s incentives to transform care in their communities,” said Joshua Sharfstein, a co-author of the editorial and a professor at the Johns Hopkins Bloomberg School of Public Health. “This means that as Maryland moves forward with new stages of innovation, there is a great deal more potential upside.” As former secretary of health and mental hygiene in Maryland, he helped institute the Maryland hospital payment approach.

Global budgets are unusual in the United States, but their intuitive appeal is growing. A California bill is calling for a commission that would set a global budget for the state. And soon Maryland won’t be the only state using such a system. Pennsylvania is planning a similar program for its rural hospitals.

Can this system work across America?

How much spending control is ceded to the government is the major battle line in health care politics. An approach like Maryland’s doesn’t just poke a toe over that line, it leaps miles beyond it.

But the United States has been trying to get a handle on health care costs for decades, spending far more than other advanced nations without necessarily getting better outcomes. A successful Maryland experiment could open an avenue to cut costs through the states, perhaps one state at a time, bypassing the steep political hurdle of selling a national plan.

 

Expert Advice For The Corporate Titans Taking On Health Care

Expert Advice For The Corporate Titans Taking On Health Care

An announcement Tuesday by three of the nation’s corporate titans — Amazon, Berkshire Hathaway and JPMorgan Chase & Co. — that they are joining forces to address the high costs of employee health care has stirred the health policy pot. It immediately sent shock waves through the health sector of the stock market and reinvigorated talk about health care technology, value and quality.

Though details regarding the undertaking are thin, the companies said in a release that their partnership’s intent is to improve employee satisfaction and hold down costs by bringing “their scale and complementary expertise to this long-term effort.”

They plan to create an independent company, “free from profit-making incentives and constraints,” to focus on “technology solutions.”

Berkshire Hathaway CEO Warren Buffett described health care costs as “a hungry tapeworm on the American economy,” and Amazon founder and CEO Jeff Bezos said the partnership was “open-eyed about the degree of difficulty” ahead. Jamie Dimon, chairman and CEO of JPMorgan, said the results could benefit the employees of these companies and possibly all Americans

But what does all of this mean and how can it be successful when so many other initiatives have fallen short? KHN asked a variety of health policy experts their thoughts on this venture, and what advice they would offer these CEOs as they go forward. Some of the advice has been edited for clarity and length.


Tom Miller, resident fellow, American Enterprise Institute (Courtesy of Tom Miller)

Tom Miller, resident fellow, American Enterprise Institute:

“It’s great that someone theoretically with resources would try to build a better mousetrap. But it’s been difficult to do, and part of it is regulatory and competitive barriers are well-constructed in the health care sphere, which tend to make it less receptive or subject to competitive pressures.

“I welcome any new capital trying to disrupt health care. … The incumbents are comfortable and could use disruption. If Amazon has an idea, and is willing to put some money behind it, that’s wonderful. What they are willing to do other than fly low-cost providers for home visits in drones — I don’t know. They’d probably have to miniaturize them, wouldn’t they?”


Stan Dorn, senior fellow, Families USA (Courtesy of Stan Dorn)

Stan Dorn, senior fellow, Families USA:

“Number one, look at prices. America doesn’t use more health care than European countries, but we pay a lot more and that’s because of prices more than anything else. Look at hospital prices and prescription drug prices. I would also say, look to eliminate middlemen operating in darkness. I’m thinking in particular of pharmacy benefit managers. Often, the supply chain is hidden and complex and every step along the way the middlemen are taking their share, and it winds up costing a huge amount of money.”


Bob Kocher, partner, Venrock (Courtesy of Bob Kocher)

Bob Kocher, partner, Venrock:

“It has been said that health care is complicated. One thing that is not complicated is that the way to save money is to focus on the sickest patients. And that’s the only thing that has proven to work in great primary care. I hope Amazon realizes this early and does not think that [its smart digital assistant] Alexa and apps are going to make us healthier and save any money.

“It would sure be nice if they invest in a ‘post-CPT-ICD-10-and-many-bills-per-visit’ world where we know prices, can easily know what is known about quality and experience, and have same-day service.”


Tracy Watts, senior partner, Mercer (Courtesy of Tracy Watts)

Tracy Watts, senior partner, Mercer:

“Everyone thinks millennials want to do everything on their phones. But that’s not necessarily the case.

“[There was a recent] survey about this — specifically, millennials are the most interested in new health care offerings, but it wasn’t as much high-tech as it is convenience they are interested in — same-day appointments with a family doctor, guaranteed appointments with specialists, home visits, a wider array of services available at retail clinics. That was kind of an ‘aha’ — this kind of convenience and high-touch experience is what they’re looking for. And when you think of ‘health care of the future,’ that’s not what comes to mind.”


John Rother, president and CEO, National Coalition on Health Care (Courtesy of John Rother)

John Rother, president and CEO, National Coalition on Health Care:

“Health care is complex and expensive, so the aim should always be simplicity and affordability. Three keys to success: manage chronic conditions recognizing the life context of the patient, emphasize primary care-based medical homes and aggressively negotiate prescription drug costs.”


Suzanne Delbanco, executive director, Catalyst for Payment Reform (Courtesy of Suzanne Delbanco)

Suzanne Delbanco, executive director, Catalyst for Payment Reform:

“The biggest driver of health care costs is prices. Those are being driven up by health care providers who have consolidated and will continue to consolidate and amass more market power.

“It sounds like they [the companies] are limiting the use of health plans, but if they’re going to get into that business, they’re going to come up with the same challenges health plans face. What would be really innovative would be to build some provider systems from the ground up where they can truly get a handle on the actual costs and eliminate the market power that drives the prices up, and they can have control over their prices.”


Brian Marcotte, president and CEO, National Business Group on Health (Courtesy of Brian Marcotte)

Brian Marcotte, president and CEO, National Business Group on Health:

“They recognize this is [a] long-term play to get involved in this. I’d have to say, this industry is ripe for disruption.

“I think we know technology will continue to play an increasing role in how consumers access and receive health care. We’ve also learned most consumers do not touch the health care delivery system with enough frequency to ever be a sophisticated consumer. What’s intriguing about this partnership is Amazon for many consumers has become part of their day-to-day world, part of their routine. It’s intriguing to consider the possibilities of integrating health care into consumer routine.

“And I think that therein lies the opportunity. Employers offer a lot of resources to their employees to help them maximize their experience, and their No. 1 challenge is engagement.”


Joseph Antos, health economist, American Enterprise Institute (Courtesy of Joseph Antos)

Joseph Antos, health economist, American Enterprise Institute:

“My first suggestion is to look at what other employers have done (some unsuccessfully) and consider how to adapt those ideas for the three companies and more broadly. Change incentives for providers. Change incentives for consumers. Work on ways to reduce the effects of market consolidation. The bottom line: Don’t keep doing what we are doing now. I don’t see that these three companies have enough presence in health markets to pull this off anytime soon, but perhaps this should be viewed as the private-sector version of the Affordable Care Act’s Innovation Center— except, this time, there may be some new ideas to test.”


Ceci Connolly, president and CEO, Alliance of Community Health Plans (Courtesy of Ceci Connolly)

Ceci Connolly, president and CEO, Alliance of Community Health Plans:

“We know that 5 percent of any population consumes 50 percent of the health care dollar. I would encourage this group to focus on how to better serve those individuals who need help managing multiple chronic conditions.”


David Lansky, CEO, Pacific Business Group on Health (Courtesy of David Lansky)

David Lansky, CEO, Pacific Business Group on Health:

“The incumbent providers of services to our members are not doing as much as we need done for affordability and quality. So, we are pleased to see them go down this path. We don’t know what piece of the puzzle they will tackle.

“We know well-intended efforts over the years haven’t added up to material impact on cost and quality. I would suspect they are looking at doing something broader, more disruptive than initiatives we have tried before.

“I think across the board they have the opportunity to set high standards for the health system in whatever platform they use. These companies have a history of raising the bar. Potentially, it could be a help to all of us.”

This new blood test can detect early signs of 8 kinds of cancer

http://www.latimes.com/science/sciencenow/la-sci-sn-blood-test-cancer-20180118-story.html

Image result for This new blood test can detect early signs of 8 kinds of cancer

Scientists have developed a noninvasive blood test that can detect signs of eight types of cancer long before any symptoms of the disease arise.

The test, which can also help doctors determine where in a person’s body the cancer is located, is called CancerSEEK. Its genesis is described in a paper published Thursday in the journal Science.

The authors said the new work represents the first noninvasive blood test that can screen for a range of cancers all at once: cancer of the ovary, liver, stomach, pancreas, esophagus, colon, lung and breast.

Together, these eight forms of cancer are responsible for more than 60% of cancer deaths in the United States, the authors said.

In addition, five of them — ovarian, liver, stomach, pancreatic and esophageal cancers — currently have no screening tests.

“The goal is to look for as many cancer types as possible in one test, and to identify cancer as early as possible,” said Nickolas Papadopoulos, a professor of oncology and pathology at Johns Hopkins who led the work. “We know from the data that when you find cancer early, it is easier to kill it by surgery or chemotherapy.”

CancerSEEK, which builds on 30 years of research, relies on two signals that a person might be harboring cancer.

First, it looks for 16 telltale genetic mutations in bits of free-floating DNA that have been deposited in the bloodstream by cancerous cells. Because these are present in such trace amounts, they can be very hard to find, Papadopoulos said. For example, one blood sample might have thousands of pieces of DNA that come from normal cells, and just two or five pieces from cancerous cells.

“We are dealing with a needle in a haystack,” he said.

To overcome this challenge, the team relied on recently developed digital technologies that allowed them to efficiently and cost-effectively sequence each individual piece of DNA one by one.

“If you take the hay in the haystack and go through it one by one, eventually you will find the needle,” Papadopoulos said.

In addition, CancerSEEK also screens for eight proteins that are frequently found in higher quantities in the blood samples of people who have cancer.

By measuring these two signals in tandem, CancerSEEK was able to detect cancer in 70% of blood samples pulled from 1,005 patients who had already been diagnosed with one of eight forms of the disease.

The test appeared to be more effective at finding some types of cancer than others, the authors noted. For example, it was able to spot ovarian cancer 98% of the time, but was successful at detecting breast cancer only 33% of the time.

The authors also report that CancerSEEK was better at detecting later stage cancer compared to cancer in earlier stages. It was able to spot the disease 78% of the time in people who had been diagnosed with stage III cancer, 73% of the time in people with stage II cancer and 43% of the time in people diagnosed with stage I cancer.

“I know a lot of people will say this sensitivity is not good enough, but for the five tumor types that currently have no test, going from zero chances of detection to what we did is a very good beginning,” Papadopoulos said.

It is also worth noting that when the researchers ran the test on 812 healthy control blood samples, they only saw seven false-positive results.

“Very high specificity was essential because false-positive results can subject patients to unnecessary invasive follow-up tests and procedures to confirm the presence of cancer,” said Kenneth Kinzler, a professor of oncology at Johns Hopkins who also worked on the study.

Finally, the researchers used machine learning to determine how different combination of proteins and mutations could provide clues to where in the body the cancer might be. The authors found they could narrow down the location of a tumor to just a few anatomic sites in 83% of patients.

CancerSEEK is not yet available to the public, and it probably won’t be for a year or longer, Papadopoulos said.

“We are still evaluating the test, and it hasn’t been commercialized yet,” he said. “I don’t want to guess when it will be available, but I hope it is soon.”

He said that eventually the test could cost less than $500 to run and could easily be administered by a primary care physician’s office.

In theory, a blood sample would be taken in a doctor’s office, and then sent to a lab that would look for the combination of mutations and proteins that would indicate that a patient has cancer. The data would then go into an algorithm that would determine whether or not the patient had the disease and where it might be.

“The idea is: You give blood, and you get results,” Papadopoulos said.

Nurses to the Rescue!

http://freakonomics.com/podcast/nurses-to-the-rescue/

A nurse checks a child's ear.

Our latest Freakonomics Radio episode is called “Nurses to the Rescue!” (You can subscribe to the podcast at Apple Podcasts or elsewhere, get the RSS feed, or listen via the media player above.)

They are the most-trusted profession in America (and with good reason). They are critical to patient outcomes (especially in primary care). Could the growing army of nurse practitioners be an answer to the doctor shortage? The data say yes but — big surprise — doctors’ associations say no.

How One U.S. Clinic Disrupted Primary Care, Made Patients Healthier And Still Failed

https://www.forbes.com/sites/robertpearl/2017/10/24/primary-care/#49ba8eee2c0f

Turntable Health launched in Las Vegas in 2013 and looked to turn the traditional primary care model on its head.

Zubin Damania has a face for television, a mind for medicine and the sort of fearless personality required to be one of the internet’s most famous MDs.

Damania’s celebrity began in earnest not long after someone posted a clip from his 1999 UCSF Medical School commencement address. In his opening, Damania jokes that he’s on a “time delay,” given his reputation as a “loose cannon.” The rest of the clip, which has been viewed over 130,000 times on YouTube, takes you briefly inside the mind of a versatile entertainer and healthcare visionary.

From UCSF, Damania completed his internal medicine residency at Stanford University. He spent the next 10 years as a practicing hospitalist by day and a healthcare satirist by night – writing, performing and filming musical parodies about the frustrations of being a doctor. He’s best known today by his online persona, ZDoggMD, and for his nightly Facebook show, covering the latest medical news with his trademark wit.

The rise and fall of Turntable Health

In 2013, Zappos.com CEO Tony Hsieh asked Damania to launch a next-generation medical clinic in Las Vegas as part of a $350 million downtown revitalization project. Founded as a primary care practice, Turntable Health looked to turn healthcare delivery on its head.

Inside a waiting room that resembled a sleek Silicon Valley startup, Turntable members passed the time by spinning records, playing Xbox and practicing yoga. As part of their membership, patients had access to an entire “wellness ecosystem,” complete with same-day visits, 24/7 doctor access (by email, phone or video), along with a dedicated health coach. Doctors at the clinic spent 45 minutes or more with their patients, quite unlike the 13 to 16-minute visits that have become standard in U.S. doctors’ offices.

Damania credits the vision for his clinic to a partnership he forged with Rushika Fernandopulle, CEO of another innovative primary-care organization called Iora Health. With Fernandopulle’s guidance, Damania focused on population health and disease prevention to improve patient wellness and, over time, lower costs. And rather than charging for each visit, test or procedure, Turntable patients who were not covered by traditional insurance paid a flat fee of $80 a month.

Unlike any other primary care clinic in Las Vegas, Turntable Health was a success, medically. By emphasizing prevention and doctor-patient relationships, Damania’s practice achieved superior quality outcomes, while providing rapid access to care and high patient satisfaction. But from an economic perspective, the clinic was a bust. Insurers shied away from member fees, insisting on more traditional reimbursements, which directly contradicted Damania’s long-term health strategy. Turntable Health was forced to close its doors in January 2017, just three years after opening.

In a public statement, Damania explained: “We flatly refused to compromise when pressured by payers to offer fee-for-service options, or to begin charging a co-pay. We firmly believe that healthcare is a relationship, not a transaction.”

Unfortunately for Damania, most health insurers are too impatient. Investing in primary care and chronic-disease management is proven to reduce and even avoid medical problems. But it can take five to 10 years for the improvements in the health of patients to offset the added upfront costs of providing the necessary care. Health plans worry patients will switch insurers before they can recoup such a long-term investment.

Primary care doctors can and do play a critical role in preventing disease, spurring lifestyle changes and warding off complications from chronic illness, when they have the time to do so. Today’s fee-for-service payment system doesn’t adequately reward these efforts.

Today’s insurers are systematically reducing primary care reimbursements, forcing doctors to see 20 to 30 patients a day while spending the bulk of their time in front of a computer, entering patient data for billing purposes. This backward approach to care delivery is wreaking havoc on the nation’s health and economy. As the incidence of chronic disease grows, the cost of American healthcare continues to rise more rapidly than the nation’s ability to pay.

The closure of Turntable Health was a major loss for Las Vegas, where residents joke that the best place to go for healthcare is the airport. Compared to people with access to integrated and coordinated medical care programs, Las Vegans are less likely to be insured, get the recommended cancer screenings and receive other necessary preventive care interventions.

Pushing primary care: Iora Health and One Medical

Damania’s partner in primary care, Iora Health, is experiencing relative success nationally, with 30+ clinics in 11 metropolitan areas. Using the same model of patient engagement and prevention that Turntable adopted, Iora has shown 35% to 40% drops in hospitalizations compared to their community peers, with 12% to 15% lower total healthcare costs. They’ve also established contracts with insurance companies who are willing to invest in primary care, thus solving one of ZDogg’s biggest challenges.

And they’re not alone. One of Iora’s leading competitors, One Medical, operates out of San Francisco under the leadership of Dr. Tom Lee. Labeled by some as a “concierge” medical practice, the company’s network includes 250+ doctors in 40 cities coast to coast. One Medical offers patients the ability to schedule same-day appointments, access their health records online, and fill prescriptions using the One Medical app – all for a relatively affordable yearly fee of about $149. With a promise that “your care is our highest priority,” the company makes the primary care experience more convenient and user friendly, a mission that’s been paying off since 2007. One Medical’s subscriber base continues to grow by tens of thousands of patients each year, particularly within the tech industry.

Although these extremely well-run primary care systems have improved outpatient quality and patient satisfaction, their impact on overall healthcare costs remains minimal. If Americans want to make healthcare affordable again, the scope and pace of change will need to accelerate at every point of care. This will require innovative approaches that rein in the rapidly escalating costs of specialty and hospital care, where most added national healthcare expenditures (NHE) exist.

 

 

Caring for veterans: A privilege and a duty

https://theconversation.com/caring-for-veterans-a-privilege-and-a-duty-67823?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20November%209%202017%20-%2087627308&utm_content=Latest%20from%20The%20Conversation%20for%20November%209%202017%20-%2087627308+CID_39875ee4af1bb4acf1d1c57209a48369&utm_source=campaign_monitor_us&utm_term=Caring%20for%20veterans%20A%20privilege%20and%20a%20duty

 

Veterans Day had its start as Armistice Day, marking the end of World War I hostilities. The holiday serves as an occasion to both honor those who have served in our armed forces and to ask whether we, as a nation, are doing right by them.

In recent years, that question has been directed most urgently at Veterans Affairs hospitals. Some critics are even calling for the dismantling of the whole huge system of hospitals and outpatient clinics.

President Obama signed a US$16 billion dollar bill to reduce wait times in 2014 to do things like hire more medical staff and open more facilities. And while progress has been made, much remains to be done. The system needs to improve access and timeliness of care, reduce often challenging bureaucratic hurdles and pay more attention to what front-line clinicians need to perform their duties well. There is no question that the VA health care system has to change, and it already has begun this process.

Over the past 25 years, I have been a medical student, chief resident, research fellow and practicing physician at four different VA hospitals. My research has led me to spend time in more than a dozen additional VA medical centers.

I know how VA hospitals work, and often have a hard time recognizing them as portrayed in today’s political and media environment. My experience is that the VA hospitals I know provide high-quality, compassionate care.

Treating nine million veterans a year

I don’t think most people have any sense of the size and scope of the VA system. Its 168 medical centers and more than one thousand outpatient clinics and other facilities serve almost nine million veterans a year, making it the largest integrated health care system in the country.

And many Americans may not know the role VA hospitals play in medical education. Two out of three medical doctors in practice in the U.S. today received some part of their training at a VA hospital.

The reason dates to the end of World War II. The VA faced a physician shortage, as almost 16 million Americans returned from war, many needing health care.

At the same time, many doctors returned from World War II and needed to complete their residency training. The VA and the nation’s medical schools thus became partners. In fact, the VA is the largest provider of health care training in the country, which increases the likelihood that trainees will consider working for the VA once they finish.

Specialized care for veterans

The VA network specializes in the treatment of such war-related problems as post-traumatic stress disorder and suicide prevention. It has, for example, pioneered the integration of primary care with mental health.

Many veterans live in rural parts of the U.S., are of advanced age and have chronic medical conditions that make travel challenging. So the VA is a national leader in telemedicine, with notable success in mental health care.

The VA’s research programs have made major breakthroughs in areas such as cardiac care, prosthetics and infection prevention.

I can vouch for the VA’s nationwide electronic medical records system, which for many years was at the cutting edge.

A case in point: Several years ago a veteran, in the middle of a cross-country trip, was driving through Michigan when he began feeling sick. Within minutes of his arrival at our VA hospital, we were able to access his records from a VA medical center over a thousand miles away, learn that he had a history of Addison disease, a rare condition, and provide prompt treatment.

I am therefore not surprised that the studies that have compared VA with non-VA care have found that the VA is, overall, as good as or better than the private sector. In fact, a recently published systematic review of 69 studies performed by RAND investigators concluded: “…the available data indicate overall comparable health care quality in VA facilities compared to non-VA facilities with regard to safety and effectiveness.”

The VA offers veterans more than health care

The most remarkable aspect of VA hospitals, though, is the patient population, the men and women who have sacrificed for their country. They have a common bond. A patient explained it this way:

“The VA is different because everyone has done something similar, whether you were in World War II or Korea or Nam, like me. You’re not thrown into a pot with other people, which would happen at another kind of hospital.”

The people who work at VA hospitals have a special attitude toward their patients. It takes the form of respect and gratitude, of empathy, of a level of caring that is nothing short of love. You can see it in the extra services provided for patients who are often alone in the world, or too far from home to be visited.

Take a familiar scene: a medical student taking a patient for a walk or wheelchair ride on the hospital grounds. It is common for nurses to say “our veteran” when discussing a patient’s care with me.

Volunteers and chaplains rotate through VA hospitals on a regular basis, to a degree unknown in most community hospitals. The social work department is also more active. The patients are not always so patient, but these visitors persevere. “They’re a good bunch of people,” one veteran said of the staff. “I know because I’m irritable most of the time and they all get along with me.”

Physicians everywhere are under heavy pressure these days, in part because of the increase in the number of complex patients they care for. Yet I have spent hours observing doctors in VA hospitals around the country as they sit with patients, inquiring about their families and their military service, treating the veterans with respect and without haste.

Earlier this year, I cared for a veteran in his 50’s, a house painter, whom we diagnosed with cancer that had metastasized widely. We offered him chemotherapy, which could have given him an extra few months, but he chose hospice. He told me he wanted to go home to be with his wife and play the guitar. One of the songs he wanted to sing was “Knocking on Heaven’s Door.”

I was deeply moved. I liked and admired the man, and I was disturbed that we had been unable to save him. My medical student had the same feelings. Before the patient left, the student told me, “He shook my hand, looked me in the eyes, and said, ‘Thanks for being a warrior for me.’”

That’s the special kind of patient who shows up at a VA hospital. Every single one of them should have the special kind of care they deserve. And we must ensure that the care is superb on this and every day.