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Reimbursements red herring, trust, and key infrastructure needs for Telemedicine success  

Reimbursements red herring, trust, and key infrastructure needs for Telemedicine success   | Healthcare and Technology news |

Telemedicine is a growing part of modern healthcare and could play a pivotal role in the U.S.’s efforts to streamline and expand preventative services. Virtual, video-based doctor’s appointments can help alleviate the general practitioner shortage and encourage preventative care. They also offer a cheaper, more convenient alternative to in-person appointments for many patients. Unfortunately, there’s a lot of hype and misinformation being reported so I was pleased to see that TechnologyAdvice (TA) surveyed 504 U.S. adults about telemedicine and their willingness to use such services. I think the results shed important light on where healthcare providers and telemedicine vendors still need to gain acceptance with patients so I reached out to Cameron Graham, Managing Editor at TA to see if he can give us the facts on the ground. Cameron heads market research for healthcare IT, business intelligence, and other emerging technologies and is uniquely qualified to help shed some light on the subject. Here’s what Cameron said:


1. It’s not just about reimbursements

Despite the promise of telemedicine, the vast majority of Americans still aren’t using such services. One oft-cited reason for this is the lack of insurance reimbursement for many telemedicine procedures. While some private insurers will cover telemedicine, many only cover select types of visits or specific applications. Medicare, for instance, covers face-to-face interactions, but only when the originating site (point of care, not the patient’s home) is in a Health Professional Shortage Area (HPSA). Although coverage is slowly improving in many states, the American Telemedicine Association gives just five states (plus DC) an A grade in coverage and reimbursement.


However, the current hodgepodge of reimbursement rules is not the only thing holding back telemedicine from widespread use. An equally important factor is likely Americans general comfort with video-based platforms and their trust in remote appointments. According to our study, less than half of adults (44.9%) said they would be comfortable conducting a doctor’s appointment over video. Only 35.3% of respondents said they would choose a video appointment over an in-person one. Until patients are more comfortable with the notion of remote care, it is unlikely that telemedicine will gain significant traction.


In order to facilitate acceptance of telemedicine among Americans, providers and vendors need to work on educating patients about the benefits of such systems. Telemedicine vendors, in particular, should help patients navigate the complex reimbursement rules currently in place, and promote the cost-savings of remote appointments. By doing so they will not only gain brand awareness among patients but will be able to recruit patients as advocates for more comprehensive insurance reimbursement policies.


2. Trust is a key component of effective telemedicine

Americans are not only hesitant about scheduling telemedicine appointment, they are also sceptical about diagnoses made through video platforms. Forty-five per cent of respondents said they would trust a virtual diagnosis less than one made in person. An additional 29.3% said they simply would not trust a virtual diagnosis. This suggests there is a distinct lack of trust among Americans in the quality of medical services that telemedicine platforms can provide.


Much of this scepticism is likely due to a lack of familiarity with the services. It also reinforces the fact that telemedicine providers must earn patients trust before they can effectively increase adoption rates. Once that trust is established, it appears people are far more likely to consider using remote appointments. While initially, only 35.3% of respondents said they would choose a virtual appointment over an in-person visit, 65% of respondents said they would be more likely to conduct a virtual appointment if they have first seen the doctor in-person.


It’s unlikely that providers or vendors will be able to dramatically change such preferences given the personal nature of many medical visits. However, increased awareness about the qualifications of physicians could make potential patients more comfortable about conducting preventative care via video. Incorporating a rating system, or minimum quality threshold for participating physicians is one potential solution.


3. Personal and professional infrastructure is key

The personal infrastructure for telemedicine is already in place across much of the United States, in the form of video-enabled smartphones. According to the latest PEW research, 64% of Americans own a smartphone. In theory, this provides them with the basic means to access remote, video-based health care. Smartphones will likely serve as first means of exposure to such services for many people.


More advanced, capable systems (such as dedicated telemedicine kiosks) however are far from established. Aside from a few test programs in select areas, there is no nationwide, professional infrastructure or technology for telemedicine. This hinders adoption and limits the use of telemedicine to basic, preventative care that can be conducted entirely remotely. Dedicated kiosks can greatly expand the use-case for telemedicine, by incorporating sensors, multiple cameras, and other advanced technology. Further investment from telemedicine vendors and insurance companies could help to boost the nationwide profile of telemedical services and expand access for many Americans.

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Putting Precision Medicine For Cancer At Work In America's Largest Hospital

Putting Precision Medicine For Cancer At Work In America's Largest Hospital | Healthcare and Technology news |

In one of the largest initiatives of its kind, the for-profit hospital chain Hospital Corporation of America (HCA) has embarked on a plan to molecularly profile the tumor of cancer patients, marry the genomic information to clinical data from a patient’s electronic health record, and recommend targeted therapies.

In a one-size-fits-all approach, patients who now receive a cancer diagnosis get the standard of treatment, which may or may not work. Those who fail first-line treatments are then subjected to other therapies through trial and error. “We’re seeing the light,” says Howard Burris, chief medical officer of Sarah Cannon, an arm of HCA which runs 75 cancer centers across the country and the U.K., and is heavily involved in cancer drug development. Its facilities treat more than 100,000 newly diagnosed cancer patients annually. 

Two years ago, Sarah Cannon profiled the tumor of 1,000 late-stage cancer patients to match them with the appropriate early phase clinical trial, and hopefully boost their outcomes. The results which Sarah Cannon presented at the American Society of Clinical Oncology last year, showed that up to 25% of patients enrolled in a trial based on their gene mutation. 

While promising, the project proved overwhelming in terms of tracking various clinical and genomic data. To profile cancer patients on a grand scale, patient information had to be aggregated and displayed in a way doctors can understand, to enable them to recommend the right therapy or clinical trial.

To do so, HCA reached out to Syapse, a venture-backed start-up that counts Intermountain Healthcare, University of California San Francisco, and Stanford University School of Medicine among its customers. It is deploying its software to some 60 oncologists in Nashville, Tenn., HCA’s headquarters, before expanding to other Sarah Cannon outposts in Florida and other states later this year. Through its platform, doctors will be able to measure the impact of a tailored treatment in conjunction with a patient’s history, other treatments, biopsies, side effects, and other relevant clinical information that reside in an electronic health record. “We’re collaborating with them to implement this at scale,” says Jonathan Hirsch, Syapse’s founder. 

“The real missing piece is the physician looking at the cancer patient, and determining that the patient needs to be profiled. They might think they don’t need it yet, or some don’t have the education,” says Burris.

Patients who’ve experienced a recurrence, have advanced or a hard to treat cancer will have their tumor profiled. Insurance companies typically don’t reimburse genomic profiling for newly diagnosed patients.

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Many Choose Not to Save in the Health Marketplace

Many Choose Not to Save in the Health Marketplace | Healthcare and Technology news |

Steven Norton, recovering from a severe stroke, says he is renewing the health plan he got this year through the Affordable Care Act insuranceexchange. He will pay more in 2015 — $501 a month including his federal subsidy, up from $485. But for him, continuity matters more than price, so he has not logged on to to search for alternatives.

“If it’s working, why try to fix it?” said Mr. Norton, 51.

Nancy Allman, a retiree outside Tucson, sees things differently. Ms. Allman, 64, said she was surprised to learn her exchange plan would cost $235 a month next year after her subsidy, up from $158. Overwhelmed by her choices on, she called the customer service line and received help finding a plan from a different insurer that will cost only $77 a month. The plan has a smaller network of providers, but it includes her primary care doctor, and she is in good health.

“It was like a no-brainer to switch,” she said.

Across the nation, millions of people who bought insurance through the exchange in this inaugural year of coverage under the health care law must decide by Monday whether to switch plans for 2015 if they want a new plan starting Jan. 1. If they do nothing, most of the 6.7 million people who remained enrolled as of last month will automatically be re-enrolled in their current plans or similar ones. More often than not, the premiums for those in the most popular plans will increase, according to a New York Times analysis of data from the McKinsey Center for U.S. Health System Reform.

The Obama administration is urging them to shop around, and with good reason: Many can find a better deal or at least keep their costs steady. That is especially true in states like Arizona, where the competition is robust, new insurers have entered the marketplace, and the price for the cheapest plans in many areas has dropped.

At the same time, the availability of less expensive “benchmark” plans means that the federal subsidies that help many lower-income Arizonans pay their premiums will go down, because subsidies are pegged to those plans. That means customers who stay in more expensive plans will have to pay a larger share of the price.

Another potential problem is that subsidy recipients will receive the same amount in 2015 as they did in 2014 unless they ask for a recalculation. That means some people could be required to pay back part of their subsidy at tax time.

Despite those issues, the data so far suggests that many customers are keeping what they have and not even window-shopping. As of Dec. 5, only about 720,000 customers had returned to the federal exchange serving 37 states to re-enroll or switch plans, according to the Department of Health and Human Services.

Here in Arizona, insurance agents and enrollment counselors last week reported a steady stream of customers seeking advice. But the demand has not yet been huge, they said, indicating that many enrollees may be succumbing to inertia, are willing to pay more to their keep their networks and level of coverage, or are unaware that they have a choice. About 120,000 residents of Arizona signed up for exchange plans this year, according to federal data.

“I’m concerned about the confused,” said Kathleen Oestreich, the chief executive of Meritus, a new insurer, which, after dropping its rates by 23 percent on average, is offering many of the lower-priced plans here for 2015. “That natural inclination to simply not change because it’s too much effort: How will it affect the population of low-income people in particular?”

Shanna Goldenberg of Phoenix, who works two jobs and pays $160 a month for her exchange plan, said she had no idea if her premium was going up. But Ms. Goldenberg, 27, said she would probably let her plan be automatically renewed, because the enrollment process last year was so confusing.

“I’m the kind of girl who just sticks with what’s easy,” she said in an email.

But in a later note, Ms. Goldenberg said she had discovered her plan would not be offered next year, adding: “I guess now I have to shop around again. ... If only I can figure it out this time.”

Mr. Norton, of Scottsdale, Ariz., did call on Thursday for a recalculation of his subsidy. It will drop by $30, he learned, and his portion of the premium will grow to $385 from $338.

Ms. Oestreich said those who were researching their options seemed fairly savvy about insurance. That is a big change from last year, she said, when many customers seemed baffled by the enrollment process and the policies they were buying.

“They are calling with specific questions and looking for specific products,” she said. “In many cases, they’re buying up a little bit — going to a little bit bigger network because they’ve understood the value of that.”

In other states, too, enrollment groups said that people shopping around were asking smart questions.

Brenda Cardenas, an enrollment counselor in Phoenix who helped dozens of families sign up for coverage last year, said that only about 15 had sought her help with the renewal process as of last week. Most people are picking new plans, often ones with smaller networks of doctors and hospitals, to avoid paying more, she said. For many, the switch will require finding new doctors, but Ms. Cardenas said nobody had complained so far.

“For a lot of our consumers, this is the first year they’ve had health coverage,” she said. “For them, switching to a new provider isn’t a big deal yet.”

In one case, Ms. Cardenas said, a couple learned the amount of their subsidy would drop by $66 because of the availability of new lower-cost plans that influence the calculation. They decided to switch from a Health Net plan with a large network of providers and no deductible to a Meritus plan with a smaller network and a $1,000 deductible. By doing so, she said, they will spend almost $200 less a month.

Health Net signed up 65 percent of exchange enrollees here this year, but its rates are rising by an average of 12 percent, a company spokeswoman said. Altogether, 11 insurers are selling on the exchange here for 2015, up from eight.

Leslie McGee, an acupuncturist in Tucson, also found a better deal when she went to and updated her personal information. Her income has dropped, so she will qualify for a subsidy in 2015 after receiving none this year. The premium on her current plan is increasing by 17 percent, so she is switching to a different insurer and will save $100 a month.

Ms. McGee, 60, will have higher out-of-pocket costs if she goes to the doctor, but she is gambling that she will need only preventive care, which is free.

Michelle Steinberg, 54, of Phoenix, is avoiding a 23 percent increase by switching to a less expensive plan that will not cover as much of her medical costs. Her premiums will still increase 13 percent, to $450 a month, but she said she was satisfied with her new choice, which has a lower deductible.

“I’m not averse to switching companies,” said Ms. Steinberg, who is moving from Health Net to United Healthcare.

The big question is whether people who have not yet shopped around will flock to the online exchanges by Monday in a last-minute crush — and whether those who do not will later regret it. They can switch until Feb. 15, when open enrollment ends, but their new coverage will not begin until February or March if they wait past Monday.

In Maitland, Fla., Rebecca Pando, 60, said that she was happy to do the painstaking research to find a new plan.

Her insurer, Florida Blue, is replacing her plan with one that has a substantially higher deductible: $5,000 compared with $1,300. Ms. Pando found a new plan from United Healthcare that will cost $400 a month in premiums, about $50 less than what she paid this year including her subsidy. It has a $4,000 deductible, she said, but a better choice of doctors.

“It’s pretty time-consuming and you get a little crazy,” Ms. Pando said of the shop-and-compare process. “But it certainly is better than not being able to buy insurance.”

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Empowering Patients through Decentralized Information Governance 

Empowering Patients through Decentralized Information Governance  | Healthcare and Technology news |

Health care will be transformed if we empower patients and physicians through access to information. Don Rucker is right to focus attention on APIs to enable the transformation. A year and a half into the new administration and the massively bipartisan 21st Century Cures Act, the Department of Health and Human Services (HHS) is having to navigate between the shoals of highly unpopular Meaningful Use regulations and the apparent need for regulation to undo the damage of market consolidation that they caused. From my perspective, it looks like HHS is doing a good job.

Prediction is a dangerous game but it’s necessary for investments that depend on health information technology. Nowadays, pretty much everything in healthcare depends on information technology, particularly if we need effective quality measures to enable transition to value-based healthcare.

Based on Verma’s most recent remarks, it’s safe to predict that HHS will use the power of the $900 Billion purse as a way of avoiding regulation as it tries to break down the oligopoly of the consolidated “integrated delivery networks” and their even more consolidated EHR vendors. What’s more interesting is to anticipate how Rucker’s recent remarks about Persistent Access will be translated into decision support information for patients and physicians that will actually drive the practice innovation Verma is talking about.


Today, the information available to physicians and patients at the point of care is centrally governed by hospitals and by EHR vendors. A service seeking to present a piece of information such as therapeutic alternatives, quality ratings, out-of-pocket expenses, and research or clinical trials opportunities, must run a gauntlet of censorship by both the hospital and the EHR vendor. A thoughtful paper on how preemptive genomic testing has significant impact on subsequent treatment decisions shows the evolving connection between medical science and information governance.

The barriers to providing independent decision support when it matters most, during the physician-patient encounter, are immense. Let’s list some of them.

An independent information service

  • Must be “certified” by the hospital even if a particular physician wants to get it
  • Must be “certified” by the EHR vendor before it’s even accessible to the hospital certifiers
  • Involves up-front certification costs that are incompatible with open source or other non-profit information sources
  • Can’t access the complete patient’s record in the EHR
  • Requires the physician to sign-in to a separate system with a separate password
  • Is not covered by insurance, or, if covered, is subject to pre-certification delays that the physician won’t put up with
  • Is unaffordable because each EHR and each hospital presents a different integration challengecan’t get investors because the EHR vendors will demand unspecified rent on access to the physician-patie t relationship or, in many cases, actually demand access to the intellectual property itself.

The task ahead for HHS is formidable. Regulation that drives patient empowerment at the point of care (when the physician is about to sign that order that drives $3.5 Trillion of healthcare costs) is inconceivable under the US healthcare system and out of reach for even the nationalized health systems in other rich countries. The proprietary EHR vendor business model means EHRs must control the “app store” as the driver of future growth. Separately, the Accountable Care Organization business model for hospitals drives them to control their physicians and restrict access to “out-of-network” providers regardless of what’s best for a particular patient.

But there is hope, particularly if CMS, ONC, and maybe even the VA orchestrate their actions. The hope lies in the upcoming definition of “information blocking” as mandated by 21stC Cures.

HHS can and should define information blocking in terms of independent decision support at the point of care.

Access to independent decision support at the point of care is an outcome rather than a process. It’s easy to tell if it’s blocked without resort to heavy-handed regulation of the API technology. No new legislation is required because HIPAA, HITECH, and 21stC Cures already enable patient-directed information sharing via API at no significant cost. Patient-directed APIs are also directly accessible to the physician, subject to patient consent.

Technically, what’s required is that *every* API of an EHR be supported as a patient-directed API. That’s not much to ask since the EHR vendors are already building the APIs to use in the app stores they need to stay competitive. What’s also required is what Rucker calls Persistent Access which is what FHIR calls Refresh Tokens and is already widely implemented in the Apple Health APIs. Finally, what’s needed is the ability for a patient to direct information anywhere we choose, without censorship or delay, via the API. (Note that patient-directed exchange is different from patient access rights that require information to flow through personal health records. PHRs have largely failed in the marketplace.) Under HIPAA, patients have this right to patient-directed use for in-person requests to send patient records using paper forms, but this right to uncensored patient-directed exchange needs to be made accessible via the patient portal and linked to the FHIR API. The technical term for this is Dynamic Client Registration and it’s a unimplemented security capability of the FHIR API.

Patient-directed APIs can impact the physician-patient encounter in real time when one or both parties have a smartphone, although ideally the independent decision support will also be available in the EHR as long as the physician and the patient approve.

I’m calling this prescription for empowering patients Decentralized Information Governance. It’s completely consistent with both Verma’s and Rucker’s vision. Because it’s also consistent with current law, it can be implemented by Medicare, Medicaid, VA, and All of US immediately by joining the Health Relationship Trust (HEART) workgroup and implementing our profiles in the VA BlueButton 2.0 and CMS MyHealthEData projects.

The key is for all of us to reject calls for centralized governance of information services by government, academic hospitals, or global corporations (Facebook, Google, etc…) that have all proved resistant to regulation in the digital age. We must also reject the idea that new information governance bureaucracies like DirectTrust, or CARIN Alliance, or some government-controlled Recognized Coordinating Entity can be invented to ensure that our incredibly valuable health information drives open medical science. Decentralized information governance explicitly gives each patient the power to choose which patient interest groups, community organizations, or congregations one trusts to control access to his or her health records for both clinical and research uses.

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So Far, 6.4 Million Obtain Health Care Coverage for 2015 in Federal Marketplace

So Far, 6.4 Million Obtain Health Care Coverage for 2015 in Federal Marketplace | Healthcare and Technology news |

The Obama administration said Tuesday that 6.4 million people had selected health insurance plans or had been automatically re-enrolled in coverage through the federal insurance marketplace.

New customers accounted for 30 percent of the total, or 1.9 million.

For 2014 enrollees who took no action by Dec. 15, coverage was automatically renewed for 2015 by the federal government.

Sylvia Mathews Burwell, the secretary of health and human services, who is in charge of the federal marketplace, said she did not know how many people had been automatically re-enrolled by her department. But she and her aides suggested that the number was in the range from 2.7 million to three million.

Dec. 15 was the deadline to sign up for coverage that would start on Jan. 1. The automatic or passive re-enrollments, combined with a surge of interest among consumers just before the deadline, produced a big increase in activity in the federal marketplace. People could sign up a first time, switch to new plans, choose to extend coverage in their current plans for a year, or do nothing and be re-enrolled in the same or similar plans.

Is the Affordable Care Act Working?

In the first four weeks of the three-month open enrollment period, through Dec. 12, nearly 2.5 million people selected health plans, the administration said. In the week after that, more than 3.9 million people signed up or had their coverage automatically renewed, lifting the total to 6.4 million. The enrollment period ends on Feb. 15.

Officials said that about 35 to 40 percent of people already enrolled had returned to the online marketplace, allowing them to shop for new health plans as the administration had recommended.

“This is an encouraging start,” Ms. Burwell said, but she added, “We still have a lot of work to do.”

The administration has been more successful in signing up new customers than in changing public opinion of the health care law. Polls show that people’s views remain deeply divided, with those holding unfavorable opinions of the law slightly outnumbering those with favorable opinions.

The new enrollment numbers do not include people signing up for insurance through state-run exchanges like those in California, New York and 11 other states. Taking account of federal and state exchanges, officials said they were on track to meet their goal of having a total of 9.1 million people enrolled and paying premiums next year.

Those who go without coverage in 2015 may be subject to tax penalties that could approach 2 percent of household income for some taxpayers., the website for the federal marketplace, is working much better than last year, but the back end of the system, used to update enrollment information and to pay insurers, is still a work in progress, so federal officials often lack vital data.

As of mid-October, before the latest enrollment period began, 6.7 million people had insurance through the federal and state exchanges. But Ms. Burwell said Tuesday that she did not know how many of them were in the federal exchange, which now serves 37 states.

About 85 percent of people with marketplace coverage receive federal subsidies to help defray the cost. Critics of the law have challenged the authority of the federal government to pay those subsides for insurance bought in the federal marketplace. They contend that the Affordable Care Act allows subsidies only for people who use an exchange established by a state.

The Supreme Court is considering those arguments in the case of King v. Burwell, which the court is scheduled to hear on March 4. Supporters of the health care law, who see the litigation as a threat to subsidies for millions of people, have urged the administration to develop contingency plans.

Ms. Burwell refused to say if she was working on such plans, but said she was confident that the administration would prevail in court.

“Nothing has changed in terms of the subsidies and assistance people can get,” Ms. Burwell said. “We believe that our position is the position that is correct and accurate.”

She said she had seen no evidence to suggest that “Congress intended for the people of New York to receive these benefits for affordable care, but not necessarily the people of Florida.”

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