29 March 2013

Another report says individual health plan premiums expected to rise

Story originally appeared on Market Watch.

Add this to the growing list of studies warning that individual health plan premiums are likely to rise…..

A report released Thursday morning from Covered California, the health exchange set up in the Golden State to act as a clearinghouse for coverage, says changes in the health-care overhaul bill known as Obamacare will bring up premiums 14% next year. The report, compiled by actuarial consultant Milliman, says that premiums are expected to rise another 9% due to ongoing market changes unrelated to Obamacare.

If additional coverage is purchases to augment what is covered by the exchanges, policyholders who don’t qualify for subsidies could see premiums rise as much as 30%. But lower-income groups who get government aid to pay for health insurance will see the amount they devote to coverage drop as much as 84% even with additional coverage, according to the report.

The Wall Street Journal cited the report in a story released earlier on Thursday.

The Covered California report comes on the heels of a Society of Actuaries study that says individual health plan premiums will rise nationwide under Obamacare. There also have been reports from insurers who say that individual plans, the kind that most often will be used to get coverage for the currently uninsured in state health exchanges, are likely to see an increase in premiums.

26 March 2013

Web health records firm expands to Boston

Story originally appeared on the Boston Globe.

Four years after its founding and three years after releasing an Internet-hosted software platform for sale to doctors, Miami start-up CareCloud Corp. already has become one of the fastest-growing and most disruptive players in the electronic health records EMR software business.

Now CareCloud is planting its flag in one of the nation’s health care capitals.

The company will formally open a Boston office Tuesday in a refurbished brick factory in the Innovation ­District, joining a Massachusetts health information technology cluster that includes established rivals such as athenahealth Inc. of Watertown and eClinicalWorks of Westborough.

Albert Santalo, founder and chief executive of CareCloud, said he was lured to Boston by the area’s health care and technology expertise and already has hired about 15 people here. They include senior engineering, sales, and marketing executives, some of whom were recruited from competitors like athenahealth and GE Healthcare. By the end of the year, CareCloud should have 35 to 40 people working out of South Boston, he said.

“I love the city,” said Santalo, who will attend a ribbon-cutting ceremony Tuesday with Mayor Thomas M. Menino of Boston. “I love the talent you can find here.”

Santalo, an engineer and ­serial entrepreneur, said he was drawn to the electronic health records space because he is ­convinced the US health care system has become overly ­complex and dysfunctional.

“It’s this big broken industry, and we feel a lot of the problems can be solved by better information technology,” he said, contending a company that comes up with solutions can ­become nearly as big as ­Amazon.com. “We see ­ourselves as having a $100 ­billion opportunity.”

Rival electronic medical records companies are watching CareCloud, which is backed by Intel Capital and Norwest Venture Partners and has signed up about 2,500 physicians — including 170 employed by Miami Children’s Hospital — in its first three years. Santolo said he expects to have 5,000 doctors enrolled by the end of 2013, and 10,000 a year later.

Jonathan Bush, chief executive of athenahealth, an Internet health records pioneer which last year agreed to buy the Arsenal on the Charles ­office campus that houses ­athenahealth’s headquarters, declined to talk about CareCloud, a spokeswoman said. But in a 2011 Twitter post, shortly after being introduced to Santolo, Bush tweeted, “I just met the man who will kill me. It won’t be for 10 years yet . . . but check-out carecloud.com. such a beautiful app!”

While many large hospital systems and multispecialty practices still opt for proprietary electronic medical systems that they can control in-house, Internet-based “cloud” systems are the fastest-growing segment of the market, analysts said. They are especially attractive to young physicians accustomed to doing work through websites and smartphones.

“I think they’re the future,” said Judy Hanover, research director for IDC Health ­Insights, a technology research firm in Framingham. “The cloud app is really resonating with health care providers. CareCloud is off to a good start. They’ve really gained a lot of traction, a lot of buzz.”

CareCloud is still too small to register on IDC’s ranking of the top sellers of electronic health records software (EHR), which includes eClinicalWorks, Epic Systems, GE Healthcare, athenahealth, and Greenway Medical. But at the rate it’s growing, that could change in coming years.

“They’re definitely an up-and-comer,” said Richard Close, research analyst at Nashville ­investment bank Avondale Partners, who said many ­doctors’ practices using federal stimulus funds to replace aging technology systems are ­choosing Internet platforms. “This is fresh technology ­compared to a lot of the older health IT software out there.”

Close said the number of doctors using the CareCloud platform has grown more than fourfold from a year ago. “That’s definitely fast growth, coming from nothing,” he said. “A lot of physicians didn’t adopt electronic health records EHR software in the past because the technology was old and cumbersome. But this is newer technology that can improve the work flow.”

Unlike older systems that are hosted locally, CareCloud can continuously update its software to accommodate changing health care delivery practices, payment models, and new technology. The company issues monthly updates, including lists of new features.

Santalo said CareCloud is working to differentiate itself from competitors in several ways. Doctors can use it through any browser or electronic platform. They can choose to buy only the software or a “concierge” service where they can outsource tasks such as billing to CareCloud. And they can share with patients an “elegant user interface” that is more akin to smartphones and consumer electronics than the clunky enterprise applications deployed in many workplaces.

“If doctors and their staffs are going to spend a third of their lives on our system, let’s make them feel smart, not stupid,” Santalo said. “Let’s let them have fun.”

iMRI Technology Leads to Better Neurosurgical Results for Patients

Story originally appeared on Spectrum Health.

With iMRI, our neurosurgeons can clearly see brain or spine tumors while performing surgery. Use of iMRI during tumor removal surgery greatly reduces the risk of damaging other areas located near a tumor and helps confirm successful removal of the entire tumor before the patient leaves the operating room. 

Clinical studies have shown that more complete tumor removal improves odds of survival and the effectiveness of other therapies, like radiation therapy and chemotherapy, which may follow tumor removal surgery.

Neurosurgeons can use iMRI to remove difficult brain tumors, like pituitary tumors or those located in the skull base, with greater accuracy and safety. They also may use iMRI during deep brain stimulation procedures and epilepsy surgery. 

The iMRI enables a surgeon to promptly confirm progress during brain and spine tumor surgery. Patients are smoothly moved from the operating side of a specially designed surgical suite into the imaging machine and then returned to surgery. With the imaging results immediately available, the surgeon can determine if as much of the tumor as possible has been removed, or if the surgery can or should safely continue.

19 March 2013

Healing the Hospital Hierarchy

Story originally appeared on the Opinionator

A hospital is, by its nature, the scene of constant life-or-death situations. It’s the work we nurses, doctors and other health professionals do; we chose it. The threat of harm can jazz you up or bring you down, but what it should demand, always, is the highest possible level of professionalism. Who’s at risk when that doesn’t occur?

Consider this encounter, from a few years ago. My patient, a middle-aged man scheduled for a stem-cell transplant, was having textbook symptoms of a heart attack. Serious cardiac side effects can result from the chemical used to preserve stem cells, making the transplant risky if a patient is unstable. An EKG was done, and we were waiting for a cardiologist when the oncology team came by on morning rounds.

The attending physician heard about the patient’s chest pain, then glanced at the EKG while checking his smartphone. “This does not concern me,” he said, tapping at his screen as he pushed the EKG paper aside.
This particular doctor was known for his explosive impatience. On a good day his temper simmered just below the surface. On a bad day, he openly seethed. If I asked him to delay the transplant it would be ugly for me; if I said nothing, it could be very dangerous for my patient. So I asked for a delay.
In the hallway, the doctor, in front of the rounding team, his large body twisted down to put his face close to mine, yelled, “Why?

This was intimidation, plain and simple. But it was also an example of a doctor’s abusing the legal, established hierarchy between doctors and nurses.

Similarly, there are also physicians who will blame the nurse when they find it inconvenient to do their jobs. The classic example of this is the doctor who reacts rudely to middle-of-the-night pages, even though, legally, the nurse must get an order even for something as ordinary as Tums.

Most people in health care understand and accept the need for clinical hierarchies. The problem is that we aren’t usually prepared for them; nor are we given protocols for resolving the inevitable tensions that arise over appropriate care. Doctors and nurses are trained differently, and our sense of priorities can conflict. When that happens, the lack of an established, neutral way of resolving such clashes works to everyone’s detriment.

This isn’t about hurt feelings or bruised egos. Modern health care is complex, highly technical and dangerous, and the lack of flexible, dynamic protocols to facilitate communication along the medical hierarchy can be deadly. Indeed, preventable medical errors kill 100,000 patients a year, or a million people a decade, wrote Rosemary Gordon and Janardan Prasad Singh in their book “Wall of Silence.”

Nurses cannot give orders, but they are considered the “final check” on all care decisions that doctors make, and we catch mistakes all the time. The most striking example from my experience: chemotherapy intended to be given intravenously was ordered with the formula for delivery to the brain. Depending on the drug, this could have been a thousandfold dosing error.

Unfortunately, there is no established way for a nurse to resolve such an error. Most docs will recognize the mistake and correct it. But if the physician won’t do that, the nurse’s only fail-safe option is to refuse to perform the order.

The harsh truth is that such intrepid nurses can easily be fired. As the physician Otis Webb Brawley wryly observes in his book “How We Do Harm”: “To throw this kind of challenge, you have to not mind being unemployed.”

The good news is that there are institutions trying to improve how nurses and doctors work together.
Some nurses reject the whole idea of doctor’s orders; they think the term makes nursing sound subservient. As a working clinical nurse, I don’t find that a practicable approach: someone has to be ultimately responsible for clinical decisions, and M.D.’s have that authority. The challenge is making the system we have work smoothly all the time.

The good news is that there are institutions trying to improve how nurses and doctors work together. One bright light in the area of interprofessional education is the University of Virginia. With the strong backing of Dorrie Fontaine, the dean of the School of Nursing, the university requires interprofessional education for its nursing and medical school curriculums. Courses, training modules and even faculty members are shared across both disciplines. Medical and nursing students are taught to respect each other’s areas of expertise and contributions to their shared mission.

One of the program’s core areas of focus is what collaboration means to doctors and nurses. Doctors believe they know what teamwork is, but for many it may mean what Tina Brashers, the lead physician for the interprofessional education program, calls the “poof factor”: “Doctors type into the computer and POOF, the order happens,” with no input from nursing needed and little knowledge of nurses’ importance to patient care. Nurses, in contrast, are more likely to define good teamwork as a relationship in which everyone’s input counts.

Let’s hope the interprofessional education model catches on; otherwise, patients will feel the lack. My patient waiting for his transplant was lucky. The cardiologist arrived on the heels of the oncologist’s temper tantrum. After an exam and a real look at the EKG, he said the patient wasn’t having a heart attack and we could safely do the transplant.

But such encounters can have latent consequences: the power differential in hospitals is such that if a doctor chews out a nurse it tends to make her less likely to speak up the next time.

Because successful health care needs to be interdependent, the silencing of nurses inevitably creates more opportunities for error. In a system that is already error-prone and enormously complicated, where health care workers are responsible not just for people’s well-being, but their lives, behavior that in any way increases dangers to patients is intolerable. When I became a nurse, that’s not the kind of harm I signed on for.

Theresa Brown, an oncology nurse, is the author of “Critical Care: A New Nurse Faces Death, Life and Everything in Between.”

14 March 2013

Radiation Raises Women’s Risk of Heart Disease Only Slightly, Study Finds

Story First Appeared on The Wall Street Journal

Radiation treatment for breast cancer can increase a woman’s risk of heart disease, doctors have long known. But the size of the added risk has not been clear.
Now, a new study offers a way to estimate the risk. It finds that for most women the risk is modest, and that it is outweighed by the benefit from the treatment, which can halve the recurrence rate and lower the death rate from breast cancer by about one-sixth.
According to the study, a 50-year-old woman with no cardiovascular risk factors has a 1.9 percent chance of dying of heart disease before she turns 80. Radiation treatment for breast cancer would increase that risk to between 2.4 percent and 3.4 percent, depending on how much radiation hits the heart.
“It would be a real tragedy if this put women off having radiotherapy for breast cancer,” said Sarah Darby, a professor of medical statistics at the University of Oxford in Britain, and the lead author of the study, published Wednesday in The New England Journal of Medicine.
Dr. Silvia Formenti, the chairwoman of radiation oncology at New York University Langone Medical Center, said she worried that women with cancer would misconstrue the findings to mean that radiation is dangerous and that they should have their breasts removed instead of having lumpectomies, in order to avoid radiation.
“There is a wave toward mastectomy in this country,” Dr. Formenti said.
But at the same time, she and other experts say that the cardiovascular risk is real and that when radiation is given, every effort should be made to minimize exposure of the heart.
In addition, women who have had radiation treatment need to be especially vigilant about controlling other factors that increase the odds of heart disease, like high blood pressureand cholesterol.
Dr. Lori Mosca, the director of preventive cardiology at NewYork-Presbyterian Hospital/Columbia University Medical Center, who was not involved in the study, said the findings meant that a history of breast irradiation should be added to the list of risk factors for heart disease and taken into consideration by all doctors who are treating such patients.
“We absolutely need to put on our radar screen that prior radiation to the breast may be a new and important risk factor for women,” Dr. Mosca said.
But she and other experts also warned that the results needed to be verified because the study was not a controlled experiment, but was based on an analysis of records and estimates of radiation exposure to the heart.
Dr. Javid Moslehi, co-director of the cardio-oncology program at the Dana-Farber Cancer Institute in Boston and the author of an editorial accompanying the study, said the research was the first to provide risk estimates correlated with doses in breast cancer treatment, over a long time period.
“This is a huge paper, both in terms of how many women it impacts, and how it opens the door for new studies that need to be done,” Dr. Moslehi said.
He said the study reflected the fact that many people with cancer are now living long enough to encounter long-term effects of both radiation and chemotherapy.
They have given rise to a new and fast-growing field in medicine, cardio-oncology.
About three million women in the United States have been treated for breast cancer, and the majority have had radiation.
Although doctors try to spare the heart, it still gets some of the dose, especially when the left breast is treated. Radiation can damage the linings of blood vessels and scar the heart muscle.
Dr. Darby’s study is based on the records of 2,168 women who had radiation for breast cancer from 1958 to 2001 in Sweden and Denmark; 963 of the women had “major cardiac events” sometime after their cancer treatment, meaning a heart attack or clogged coronary arteries that needed treatment or caused death.
From the treatment records, the researchers estimated the radiation dose to the women’s hearts. They found that the risk began to increase within a few years after exposure, and that it continued for at least 20 years. The higher the dose, the higher the risk, and there was some increase in risk at even the lowest level of exposure.
“It was certainly a surprise to us that the risk started within the first few years after exposure, as radiation-related heart disease has traditionally been thought of as usually occurring several decades after exposure,” Dr. Darby said.
Radiation is measured in units called Grays, and the researchers found that for each Gray to which the heart was exposed, the odds of heart attack or another coronary events rose by 7.4 percent. The average dose to the heart over an entire course of radiation treatment was 5 Gray, they said. For an individual woman, the net effect would depend on her baseline initial risk of heart disease and the total radiation dose to her heart.
Women who already had risk factors, especially those who had had heart attacks in the past, would have seen the largest absolute risk from radiation.
Some radiation oncologists say that nowadays, the dose to the heart is lower than 5 Gray.
Dr. Louis S. Constine, vice chairman of radiation oncology at the University of Rochester Medical Center, said that 2 Gray was more common and that doctors could now put shields in front of the heart and “curve radiation around the chest wall instead of shooting it through the heart and lungs.”
Dr. Formenti thinks that for most patients, the best way to protect the heart is to treat them while they are lying on their stomachs, instead of the usual way, lying on their backs. Women lie on a table or a mattress with openings that let the breasts drop away from the chest.
Anatomy differs, but in most women this prone position helps keep the radiation beams as far as possible from the heart and lungs. The heart still receives some radiation, but significantly less than when women lie on their backs, especially when the left breast is being treated.
“If you can keep it below 1 Gray, which is what we are doing, you are probably O.K. with the majority of patients,” Dr. Formenti said.
During the past 15 years, she said, she has treated several thousand patients this way.
Dr. Formenti and her colleagues also teach the technique to other doctors. But, she said, it is taking a long time to catch on.

01 March 2013

Hospitals and Health Insurers Battling Over New Insurance Plan Payments

Story First Appeared on The Wall Street Journal -

Hospitals and health insurers are locking horns over how much health-care providers will get paid under new insurance plans that will be sold as the federal health law is rolled out.

The results will play a major role in determining how much insurers will ultimately charge consumers for these policies, which will be offered to individuals through so-called exchanges in each state.

The upshot is that many plans sold on the exchanges will include smaller choices of health-care providers in an effort to bring down premiums.

To keep costs low, the insurers are pressing for hospitals to grant discounts from the rates hospitals usually get in commercial plans. In return, participating hospitals would be part of smaller networks of providers. Hospitals will be paid less by the insurer, but will likely get more patients because those people will have fewer choices. The bet is that many consumers will be willing to accept these narrower networks.

Tenet Healthcare Corp., one of the biggest U.S. hospital operators with 49 hospitals, Tuesday said it had signed three contracts for exchange plans that would involve either narrow or "tiered" networks, in which people pay more to go to health-care providers that aren't in the top tier.

Tenet said that in exchange for favorable status in these plans, it granted discounts of less than 10% to the three insurers, which it said were Blue Cross & Blue Shield plans covering 15 of its hospitals, or around 30%.

"It makes strategic sense for us," said Trevor Fetter, Tenet's CEO, in an interview. "There will be a market here, and it's important for us, we believe, to participate in that market." He said that insurers around the country have approached Tenet to discuss similar plan designs.

Analysts said Tenet's disclosures, which came during an earnings call with analysts, are the most explicit from any hospital chain so far about how the negotiations are shaping up. "It's the clearest statement they've gotten about exchange products, pricing and impact," said Sheryl Skolnick, an analyst with CRT Capital Group LLC.

Exchange plans will take effect in 2014. In that first year, health plans sold on the exchanges could have 11 million to 13 million enrollee's and generate $50 billion to $60 billion in premium revenue, according to an estimate from PwC's Health Research Institute, an arm of PricewaterhouseCoopers, LLP.

Stonegate Advisors LLC, a research firm that works for health insurers, has been testing clients' plans with consumers in a mock-up version of an exchange, which is an online insurance marketplace. Marc Pierce, the firm's president, says nearly all the products have included limited provider networks.

The tests have found that premiums are the most important factor in consumers' choices, he said, with more than half typically opting for a narrow-network product if it cost them at least 10% less than an equivalent with broader choice.

Florida Blue, the Blue Cross & Blue Shield plan in the state, will offer plans with a "tighter, more select group of providers" in its exchange, said Chief Executive Patrick J. Geraghty in an interview. "We believe the exchange is going to be driven by price, and therefore we're looking for a lower-price option."

The insurer has already struck deals for narrow-network plans and will use those same terms for the exchange versions, it said. Florida Blue said it has been winning discounts of 5% to 10% off typical commercial rates from hospital systems, but getting breaks as high as 20% in some cases.

Plans with smaller choices of health-care providers are a big focus for insurers, partly because many other aspects of exchange plans, including benefits and out-of-pocket charges that consumers pay, are largely prescribed by the law, giving them few levers to push to reduce premiums.

"The need for a smaller network with lower pricing was critical," said Juan Davila, an executive vice president at Blue Shield of California, which said it hopes to offer a preferred-provider-organization plan for individuals on the exchange. It would be built around a provider network around 40%-45% of its traditional PPO scope. Mr. Davila said Blue Shield had signed an exchange contract with Tenet but declined to comment on its terms.

So far, insurers and hospitals have sent differing signals on what kinds of discounts the hospitals might grant for the exchange plans, which would vary by market. Publicly traded hospital chains have said they are pressing to get paid approximately what they receive for traditional commercial health insurance.

Some insurers talk about steeper discounts from hospitals. WellPoint Inc. has said it is aiming to pay providers somewhere between Medicaid and Medicare rates, and sees talks trending toward rates close to Medicare. Medicare rates are often substantially lower than commercial prices. An Aetna Inc. official at an investor conference Monday suggested the rates might settle somewhere between Medicare and commercial.

For their part, hospitals have to weigh whether discounts they grant for exchange products pose a risk to the richer pricing they get for traditional commercial health plans, which include those now offered by employers.

Catholic Health Initiatives, a not-for-profit operator of 78 hospitals based in Englewood, Colo., said it is negotiating with insurers about exchange plans in around half of its markets, and insurers are often seeking to craft narrow-network designs.

CHI is taking a "conservative" approach and discussing "very modest discounts in exchange for a narrow-network opportunity," said Juan Serrano, a senior vice president, in an interview.