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Medicare, Reversing Itself, Will Pay More for an Expensive New Cancer Drug

Medicare, Reversing Itself, Will Pay More for an Expensive New Cancer Drug | Healthcare and Technology news | Scoop.it

The Obama administration has decided that Medicare will pay for one of the newest, most expensive cancer medications, which costs about $178,000 for a standard course of treatment.

Patients, doctors, hospital executives and insurers have expressed concern about the high cost of prescription drugs, especially new cancer medicines and treatments tailored to the genetic characteristics of individual patients. Medicare officials recognized the cost and value of one such product, the anticancer drug Blincyto, by agreeing to make additional payments for it starting Oct. 1. The drug is made by Amgen for patients with a particularly aggressive form of leukemia.

The decision suggests a new willingness by Medicare to help pay for promising therapies that are still being evaluated. It is also significant because Medicare officials reversed themselves on every major scientific issue involved. After receiving pleas from Amgen and a dossier of scientific evidence, the officials agreed that the drug was a substantial improvement over existing treatments for some patients.

At issue are special “add-on payments” that Medicare makes to hospitals for new technology whose costs are not yet reflected in the standard lump-sum amounts that hospitals receive for treating patients with a particular disease or disorder.

In a preliminary decision in April, the Obama administration said it did not intend to pay extra for Blincyto because clinical studies were “not sufficient to demonstrate” that it substantially improved the treatment of Medicare patients with acute lymphoblastic leukemia, a cancer of the blood and bone marrow. Medicare officials said Amgen’s application was based on data from “a small sample group of patients whose age demographic is much younger than the age demographic of eligible Medicare beneficiaries.”

But in a final rule to be published in the Federal Register on Aug. 17, the administration says it received “additional information and input” from Amgen and other experts and now agrees with their arguments.

Blincyto “is not substantially similar” to other drugs available to leukemia patients, the administration said, and it “represents a substantial clinical improvement over existing treatment options.”

Jane E. Wirth, 59, of Reno, Nev., a former preschool teacher, said her cancer was in remission after 28 days of treatment with Blincyto, also known as blinatumomab.

“It was amazing to me that it could work so well so quickly,” Ms. Wirth said in an interview. “I had just spent a month going through standardchemotherapy, which did not make the cancer go away. It seemed so hopeless.”

The drug, engineered from two antibodies, harnesses the body’s immune system to help fight cancer. It brings certain white blood cells close to malignant cells so the blood cells can destroy the cancer cells.

Dr. Anthony S. Stein, a researcher at City of Hope National Medical Center in Duarte, Calif., who has treated more than 50 patients in clinical trials of Blincyto, said, “Its mechanism of action is totally different from that of any other approved drug.”

After the Food and Drug Administration approved Blincyto in December, Amgen said the price would be about $178,000 for the recommended two 28-day cycles of treatment, each followed by a two-week break. Medicare says it will now allow a “new technology add-on payment” to hospitals for a fraction of that amount, up to $27,000. Actual payments will vary based on the length of a patient’s hospital stays.

A cycle of treatment begins with intravenous infusions in a hospital. Patients typically continue treatments outside the hospital — at doctor’s offices, at infusion centers or at home, with the help of specially trained nurses — and Medicare will help pay for the drug at those sites, too.

The prices of new cancer drugs often exceed $100,000 a year.

Health policy experts said that President Obama had personally expressed concern in recent weeks about high drug prices and their impact on consumers and federal programs. In February, he asked Congress to authorize the secretary of health and human services to negotiate with manufacturers to determine prices for high-cost medicines taken by Medicare beneficiaries.

poll by the Kaiser Family Foundation released last month found that 94 percent of Democrats and 84 percent of Republicans support allowing the federal government to negotiate with drug makers to get lower prices on medications for those beneficiaries.

Dr. Steven M. Safyer, president of Montefiore Medical Center in the Bronx, said the Obama administration should use its influence with drug companies to restrain costs. “There are a number of very important breakthroughs with pharmaceuticals that can make a difference between life and death, and the price is too high,” he said.

More than 100 oncologists from cancer hospitals around the country recently issued a manifesto decrying the prices of new drugs.

“Effective new cancer therapies are being developed by pharmaceutical and biotechnology companies at a faster rate than ever before,” they said in a commentary in the journal Mayo Clinic Proceedings. But, they added, “the current pricing system is unsustainable and not affordable for many patients.”

Robert E. Zirkelbach, a spokesman for Pharmaceutical Research and Manufacturers of America, the lobby for drug makers, said that new spending projections issued by the government in July undercut such claims.

“Even with new treatments and cures for hepatitis C, high cholesterol and cancer,” Mr. Zirkelbach said, “spending on retail prescription medicines is projected to remain approximately 10 percent of U.S. health care spending through 2024, the same percentage as in 1960.” In the last two decades, he added, the cancer death rate has fallen 22 percent, thanks in part to new medicines.

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Does the Affordable Care Act Guarantee Healthcare as a Right?

Does the Affordable Care Act Guarantee Healthcare as a Right? | Healthcare and Technology news | Scoop.it

In his recent celebratory remarks after the Supreme Court (SCOTUS) upheld the legality of subsidies/tax credits under the Affordable Care Act (ACA), President Obama had this to say: "Five years ago, after nearly a century of talk, decades of trying, a year of bipartisan debate -- we finally declared that in America, healthcare is not a privilege for a few, but a right for all." (1)


It would be good if this were true, but it is not. Healthcare as a right has been debated over many years, but is still not in place for all Americans as this country remains an outlier among advanced industrial countries around the world. Instead, despite the ACA, we continue to have a patchwork of ever-changing programs assuring access to health care for some people some of the time.


Let's look at what we do have in this respect. In the 1960s, Congress established a broad right to health care under statutory law by enacting Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) for the elderly, disabled, people living in poverty, and children. In the 1980s it passed the Emergency Medical Treatment and Active Labor Act (EMTALA) requiring all Medicare-funded hospitals with emergency departments to provide appropriate emergency and labor care. More recently, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2013, which assures a right to equal access to care for patients with medical and mental health problems. SCOTUS has established a right to health care for prisoners and has protected some limited rights for women's reproductive care (2), but has never interpreted the Constitution as guaranteeing a right to health care for all Americans. In fact, the words "health," "health care," "medical care," and "medicine" do not appear in the Constitution. (3) 


It is disingenuous to claim that health care is a right in the U. S. when we consider these inconvenient facts:


  • 35 million uninsured, plus another similar number underinsured.
  • The first question asked of us in seeking care is "what is your insurance?"
  • 21 states have opted out of Medicaid expansion under the ACA.
  • Medicaid eligibility and coverage varies widely from one state to
  • another, in many cases falling far short of necessary care.
  • As the costs of insurance and health care continue to rise and shift
  • more to patients, a growing part of the population cannot afford either and forgo seeking care.
  • More than 40 million Americans now have an account in collection for medical debt. (4)


This situation stands in sharp contrast to elsewhere in advanced societies. Healthcare has been recognized as a right since 1948 when the General Assembly of the United Nations adopted a Universal Declaration of Human Rights including access to health care. (5) The right to health care was also later adopted by the World Health Organization (WHO) in its Declaration on the Rights of Patients. (6) As a result, most of Western Europe, Scandinavia, the United Kingdom, Canada, Taiwan, and many other countries have one or another form of national health insurance assuring access to care for their populations. Here we spend twice as much and still have no universal access to health care.


Can we ever see this country coming around to universal access to health care based on medical need, not ability to pay? The record shows that we never can, or will, as long as we permit corporate stakeholders in our medical-industrial complex to call the shots, and as long as they succeed in perpetuating our exploitive for-profit system. There is a fix -- single-payer national health insurance, as embodied in H. R. 676, Expanded and Improved Medicare for All.

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Top Obamacare official looks ahead after Supreme Court ruling

Top Obamacare official looks ahead after Supreme Court ruling | Healthcare and Technology news | Scoop.it

The U.S. official overseeing Obamacare said on Friday she has not seen any indication that states will back away from running their own health insurance marketplaces now that the Supreme Court has validated the federal insurance exchange.


Sylvia Burwell, secretary of Health and Human Services, also said she expected enrollment in both the state and federal health insurance exchanges established under the 2010 Affordable Care Act -- called Obamacare -- to decline from 10.2 million currently to 9.1 million by the end of 2015. That was the number her department had originally set as a goal for 2015.


Speaking with reporters in her office, an upbeat Burwell said now that the Court has upheld the law, she is ready to build on the five-year-old program's progress by continuing to expand Medicaid, which makes benefits available to low-income people.


Obamacare survived a major legal test on Thursday when the Supreme Court upheld the law's tax subsidies, which help millions of Americans pay for health insurance.


The plaintiffs contended the law's authors only intended the subsidies to be paid to consumers on state-based health exchanges. The court rejected that argument, confirming the subsidies were also legal in 34 states now relying on the federal website, HealthCare.gov.

U.S. President Barack Obama holds up a copy of a new National Action Plan for Combating Antibiotic-R …

"We're going to work with states that want to do state-based exchanges. We'll do federal exchanges where there aren't those," Burwell said.


Asked if some states might give up operating their own exchanges and let residents shop for insurance on the federal website, she said: "I don't think we have seen any indication of that, but we'll see."

Thirteen states and the District of Columbia have established their own exchanges where consumers can find insurance. Some state exchanges have had technical and logistical challenges as well as financial difficulties.


Burwell said she expected Obamacare enrollment to decline to 9.1 million by year's end for a combination of reasons. Some people will get insurance through new employment, others will marry and go on their spouses' coverage, and some may not be able to pay their premiums, she said.


She said she learned the administration had won the Court ruling on Thursday as she walked down the hallway of her department and heard a cheer. Then she asked her team: "Are we sure?"

"It was very emotional ... It was just such a moment of, you know, as I said, relief," Burwell said.

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The Supreme Court's Surprise Ruling Saves Obamacare

The Supreme Court's Surprise Ruling Saves Obamacare | Healthcare and Technology news | Scoop.it

The Affordable Care Act survived its second major challenge at the U.S. Supreme Court on Thursday. In a 6-to-3 decision, the justices ruled that the Internal Revenue Service can continue to provide health-insurance subsidies to middle-class people living in all states.


At issue in the case, King v. Burwell, was whether the subsidies should go to residents of the roughly three dozen states that use the federal health-insurance exchange, in addition to those who live in states that run their own exchanges.


It’s a highly technical difference, but had the decision gone the other way, Obamacare might have unraveled. Individuals who receive these subsidies make less than $48,000 per year, and many would struggle to afford health-insurance plans without the government’s financial help. Health-policy analysts feared that, without the subsidies in place, healthy people would withdraw from the health-insurance exchanges in large numbers. That, in turn, would cause premiums to skyrocket, making insurance unaffordable to almost anyone who does not receive insurance coverage through their jobs.

The Affordable Care Act gave states the option to either set up their own exchanges or to rely on the federal government’s marketplace through Healthcare.gov. The part of the law that describes the subsidies said they should only apply to people in the exchanges “established by the state.” The plaintiffs in the King case said that clause meant the IRS was offering subsidies to residents of federal-exchange states illegally.

In the opinion of the Court, Chief Justice John Roberts dismissed the idea that the fate of the entire Obamacare law should hinge on such a technicality.

“In petitioners’ view, Congress made the viability of the entire Affordable Care Act turn on the ultimate ancillary provision: a sub sub-sub section of the Tax Code,” he wrote. “We doubt that is what Congress meant to do.”


Many patient advocates cheered the decision. “It means that millions of people with serious health conditions such as cancer will continue to have access to essential treatment and care, and millions of others at risk for disease will be able to afford preventive screenings and tests that could save their lives,” said Chris Hansen, president of the American Cancer Society’s advocacy arm, in a statement.


Justices Antonin Scalia, Clarence Thomas, and Samuel Alito dissented, writing, “Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State.’”


Roberts concludes by saying that the Court is attempting to respect what Congress hoped to accomplish in passing the law: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”


There are still a few, more minor, legal challenges to Obamacare remaining. But at least for now, the law lives to see another day.

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Jannell Alino's curator insight, August 27, 2015 7:43 PM

Congress passed the Affordable Care Act and the Supreme Court ruled that the IRS will be able to continue to administer health insurance to middle class people to all in the United States. If this did not pull through Obamacare would have left thousands of people without insurance and helpless. Many who are on Obamacare make less than 48K a year and need assistance from the government. If this were to happen a large number of healthy people would withdraw from health insurances causing prices to go up and then no one would be able to afford health insurance! The Affordable Care Act gives states the option to set up their own exchanges or rely on the government. With the passing of this act people suffering from serious illness will be able to care and have access to treatment as well as others who are susceptible to illness. Some conclusions that can be drawn from this article are that by the passing of this act thousands of citizens are still able to have health insurance and do not have to pay with an arm and a leg. Yes this argument is logical because it would be irrational to take away a program that has aided so many Americans in getting the health care they need. This relates because if this act was to fail our health insurance prices would go up and going to get a simple checkup would cost a fortune! I think it is great that the congress passed this act because I would want everyone to be able to have the privilege to seek out help if they were ill. No there is no bias, it is objective to all citizens in the united states. 

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Obamacare’s Big Gamble on Hospital Productivity

Obamacare’s Big Gamble on Hospital Productivity | Healthcare and Technology news | Scoop.it

Can hospitals provide better care for less money? The assumption that they can is baked into the Affordable Care Act.

Historically, hospital productivity has grown much more slowly than the overall economy, if at all. That’s true of health care in general. Productivity — in this case the provision of care per dollar and the improvements in health to which it leads — has never grown as quickly as would be required for hospitals to keep pace with scheduled cuts to reimbursements from Medicare.

But to finance coverage expansion, the Affordable Care Act made a big bet that hospitals could provide better care for less money from Medicare. Hospitals that cannot become more productive quickly enough will be forced to cut back. If the past is any guide, they may do so in ways that harm patients.

The Obamacare gamble that hospitals can become much more productive conflicts with a famous theory of why health care costs rise. William Baumol, a New York University economist, called it the “cost disease.” (He wrote a book about it by that title; I blogged on it as I read it if you’d like to quickly get the gist.)

This theory asserts that productivity growth in health care is inherently low for the same reason it is in education: Productivity-enhancing technologies cannot easily replace human doctors or teachers. In contrast with, say, manufacturing — a sector in which machines have rapidly taken over functions that workers used to do, and have done them better and more cheaply — there are, at least for the time being, far fewer machines that can step in and outperform doctors, nurses or other health sector jobs.

But a new study casts doubt on that theory and suggests Obamacare’s bet may indeed pay off. The study, published in Health Affairs by John Romley, Dana Goldman and Neeraj Sood, found that hospitals’ productivity has grown more rapidly in recent years than in prior ones. Hospitals are providing better care at a faster rate than growth in the payments they receive from Medicare, according to the study.


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President Obama Signs SGR Repeal Legislation, Shifting Medicare Physician Payment Incentives

President Obama Signs SGR Repeal Legislation, Shifting Medicare Physician Payment Incentives | Healthcare and Technology news | Scoop.it

On Thursday afternoon, April 16, President Barack Obama signed the Medicare Access and CHIP Reauthorization Act of 2015, or “MACRA,” a bill passed by the House of Representatives on March 26 and by the Senate on April 14 that now permanently repeals the long-maligned Sustainable Growth Rate (SGR) formula for Medicare physician payment.


As the Washington Post reported, in signing the bill into law, the President praised the bipartisan nature of the legislation, cobbled together in the House by Speaker John Boehner (R-Oh.) and Democratic Leader Nancy Pelosi (D-Calif.) for negotiating the terms of the legislation. He further said that “It also improves it [physician reimbursement] because it starts encouraging payments based on quality, not the number of tests that are provided or the number of procedures that are applied but whether or not people actually start feeling better. It encourages us to continue to make the system better without denying service,” he added.


Congress’s passing of this legislation and the President’s signature on it, end a series of 17 so-called “doc fixes” since 1997 when the SGR formula was passed into law but never fully implemented because of physician uproar, the MACRA legislation averts what would have been a 21-percent cut to Medicare physician payment, replacing it with 0.5-percent “updates,” or physician payment increases, in 2015, 2016, 2017, and 2018.


More broadly, MACRA ends physician payment incentives  under the meaningful use program within the HITECH (Health Information Technology for Economic and Clinical Health) Act, and those under the Physician Quality Reporting System (PQRS), replacing the incentives in those programs with a new program called the Merit-based Incentive Payment Program, or MIPS. Physicians will also be able to opt for an alternative program involving slightly higher payments in return for participation in certain Alternative Payment Models, or APMs.

As Healthcare Informatics’ analysis of the legislation noted last month, it targets four key areas: quality, resource use, clinical practice improvement (including care coordination and improvement activities), and the meaningful use of electronic health record technology.


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Obama says he's ready to sign Medicare doctor payment fix

Obama says he's ready to sign Medicare doctor payment fix | Healthcare and Technology news | Scoop.it

President Barack Obama said Wednesday that he's ready to sign good bipartisan legislation to fix Medicare's doctor payment problem, without endorsing any specific legislation.


Without a fix, doctors face a 21 percent cut in Medicare fees, the consequence of a 1990s budget law that Congress has repeatedly waived.


The House is expected to vote Thursday on a bill with rare support from both top leaders in the House that would permanently fix the problem. Obama backed the idea of a fix at a White House event marking this week's five-year anniversary of his signing the Affordable Care Act, while stopping short of backing the House compromise.

"As we speak, Congress is working to fix the Medicare physician payment system. I have my pen ready to sign a good bipartisan bill," he said.


The House bills calls for a period of basically stable reimbursements, followed by gradually shifting a larger share of doctors' pay so that it's keyed to quality, rather than quantity, of service. The Medicare fix is packaged with an extension of children's health insurance, funding for community health centers and dozens of other provisions. The outlook in the Senate is unclear.


Drafted with the unusual support of both top leaders in the House — Speaker John Boehner for the GOP and Democratic leader Nancy Pelosi — the bill is aiming for the political center. That seemed to have collapsed on health care in the battles over President Barack Obama's overhaul.

The legislation is being criticized from the political right and the left. Conservatives don't like that most of the cost will be added to the federal deficit. Liberals object to higher premiums for upper-income beneficiaries, when drug companies are not being asked to share the burden through Medicare rebates.


Obama also announced a cost-cutting effort that the White House calls a Health Care Payment Learning and Action Network. The White House says more than 2,800 health care providers, patients and consumer groups have agreed to take part.


The goal is to tie more payments for health care services to the quality — not quantity — of services rendered. Earlier this year the administration set a goal to tie 30 percent of Medicare payments to quality and value, but Obama wants to go further.


"A central notion in the Affordable Care Act was we had an inefficient system with a lot of waste that didn't also deliver the kind of quality that was needed that often put health care providers in a box where they wanted to do better for their patients, but financial incentives were skewed the other way," Obama said.


"We don't need to reinvent the wheel — you're already figuring out what works to reduce infections in hospitals or help patients with complicated needs," Obama told health care providers gathered in the Eisenhower Executive Office Building next to the West Wing. "What we have to do is to share these best practices, these good ideas, including new ways to pay for care so that we're rewarding quality."


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Richard Harrington's curator insight, March 25, 2015 10:53 PM

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If Obamacare critics win high court case, effects will be wildly disparate

If Obamacare critics win high court case, effects will be wildly disparate | Healthcare and Technology news | Scoop.it

If the Supreme Court rules in favor of the plaintiffs in King v. Burwell, nowhere will the effect be more  stark than along the 400-mile border between two states my family has called home, Tennessee and Kentucky.

In the state where I grew up, Tennessee, thousands of people would in all likelihood be forced back into the ranks of the uninsured. That’s because the cost of coverage would quickly skyrocket for the 230,000 Tennesseans enrolled in a health plan this year through the insurance exchange that’s operating there.   

In Kentucky, where we lived when I worked for Humana Inc., it doesn’t matter what the Supreme Court does. No one there is facing the threat of suddenly finding their coverage unaffordable.

Kentucky is one of the 16 states (and the District of Columbia) that decided to establish and operate its own exchange. Tennessee, on the other hand, is one of the 34 states that defaulted to the federal government to operate its exchange.

The plaintiffs in King v. Burwell argued before the high court last Wednesday that because of the way the Affordable Care Act is worded, the Obama Administration is breaking the law by providing subsidies to people in those 34 states to help them buy health insurance.  Their argument is that the law allows subsidies only for enrollees in an exchange “established by the state.”  If the Court agrees, the subsidies for folks in exchanges operated by the federal government could come to an abrupt end as early as mid-summer.

Kentucky is also one of 29 states to have expanded its Medicaid program under the ACA. That means that folks earning up to 138 percent of the federal poverty level—about $16,000 for an individual and about $33,000 for a family of four—are now eligible for Medicaid in Kentucky. The federal government pays 100 percent of the cost of the expanded coverage through next year.  After that, the state will begin paying a portion of the cost, up to a maximum of 10 percent. 

But to the south, many poor people remain uninsured because lawmakers in Tennessee have repeatedly refused to expand the state’s Medicaid program, called TennCare. Their first refusal came right after the Supreme Court ruled in 2012 that the federal government couldn’t force the states to expand their Medicaid programs.  Legislators again voted against a Medicaid expansion just last month, even though Republican Gov. Jim Haslam favored it.


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What Do Women Know About Obamacare That Men Don’t?

What Do Women Know About Obamacare That Men Don’t? | Healthcare and Technology news | Scoop.it

For the second year running, more women than men have signed up for coverage in health insurance marketplaces during open enrollment under the Affordable Care Act. According to the Department of Health and Human Services, enrollment ran 56 percent female, 44 percent male, during last year’s open enrollment season; preliminary data from this year shows enrollment at 55 percent female, 45 percent male – a 10 percentage point difference.

What gives? An HHS spokeswoman says the department can’t explain most of the differential. Females make up about 51 percent of the U.S. population, but there is no real evidence that, prior to ACA implementation, they were disproportionately more likely to be uninsured than men – and in fact, some evidence indicates that they were less likely to be uninsured than males .

What is clear that many women were highly motivated to obtain coverage under the health reform law – most likely because they want it, and need it.

It’s widely accepted that women tend to be highly concerned about health and health care; they use more of it than men, in part due to reproductive services, and make 80 percent of health care decisions for their families . The early evidence also suggests that women who obtained coverage during open enrollment season last year actively used it.  According to Inovalon, a company that tracks and analyzes data for health plans and providers, people who used the coverage they bought through the marketplaces last year tended to be older, sicker, and more female than the general commercially insured population. As of June 2014, 41 percent of females who purchased coverage through exchanges had face-to-face visits with health care professionals, versus 32 percent of males.

Those numbers are consistent with the notion that many women who signed up for coverage under the ACA had preexisting conditions or other health issues that led them to seek treatment.  In some cases, their pre-ACA insurance may have excluded those conditions, or the preexisting conditions may have prevented them from obtaining coverage at all.

What’s more, as HHS points out in a recent report, there are plenty of benefits in the ACA’s qualified health plans that are especially attractive to women. These include coverage at no out of pocket cost for many preventive measures, such as mammograms or screening for gestational diabetes.  An estimated 48.5 million are benefitting from that provision of the law alone.

Other data support the notion that many U.S. women are in disproportionately higher medical need, relative to men – even adjusting for the fact that they typically live longer.  According to an analysis of Medical Expenditure Panel Survey data from the Agency for Healthcare Research and Quality, women constitute nearly 60 percent of people in the top tenth of medical expenditures in 2011 and 2012.  Most of those in the top tenth of spending are either ages 45 to 64, or 65 and older.

One obvious conclusion is that many, and perhaps most, of those who’ve benefited from coverage under the Affordable Care Act are female – and especially women in middle age and beyond. Another is that, if the Supreme Court rules in King v. Burwell that subsidized coverage can’t be obtained through the federal marketplace, women will be disproportionately harmed.

A case in point: Rosemary Forrest, 63, who lives in Augusta, Georgia.  Laid off from her job at a university science lab at age 55, she spent five years unemployed and without health insurance.   She now works as a contractor to a small nonprofit agency; battling painful osteoporosis, she sometimes earns less than $400 a month.  Last year, when the federal health insurance marketplace went live, she signed up for coverage.  This year, she re-enrolled, and after federal tax credits, pays $86 per month in premiums.


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U.S. deciding whether to extend Obamacare enrollment

U.S. deciding whether to extend Obamacare enrollment | Healthcare and Technology news | Scoop.it

Americans who have started enrolling for health insurance under the Affordable Care Act can still sign up, and the U.S. government is weighing whether to open a special enrollment period for those who missed Sunday's deadline, the health secretary said on Wednesday.

So far, 11.4 million Americans have enrolled in private health insurance through the health reform law known as Obamacare during the open enrollment period that ended on Sunday, according to the White House.

The Affordable Care Act requires most Americans to have health insurance or face a financial penalty. But some people may not realize they face a penalty for not having coverage until they file their tax returns in coming weeks.

 
 

HHS will decide within the next two weeks whether to allow another special enrollment period for consumers, Health and Human Services Secretary Sylvia Burwell told reporters in response to a question about those consumers amid the looming April 15 tax-filing deadline.

“We’re going to analyze it, we’re going to think about it, and we’ll be back. And we will be back quickly on it," she said at a news conference.

Separately, Burwell said fewer than 150,000 people were "in line" as of Sunday to get health insurance coverage through the marketplace set up by the Affordable Care Act. They will have until Feb. 22 to complete their application, she said.

Those applicants were in communication with the telephone call center for the federal exchange marketplace but could not complete their application before Sunday's deadline, according to HHS. They do not include people who had technical issues with the healthcare.gov website that prevented them from completing their enrollment, the department said.


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Last Chance to Enroll in Obamacare for 2015

Last Chance to Enroll in Obamacare for 2015 | Healthcare and Technology news | Scoop.it

Americans eligible for health insurance under the Affordable Care Act (ACA) are facing an important deadline. This year's sign-up period ends Sunday, Feb. 15.

For most people, it will be the last chance to select an ACA marketplace health plan or switch plans for 2015. That's why health advocates are urging uninsured Americans to take advantage of this final window of opportunity.

The 2015 open enrollment period kicked off on Nov. 15, 2014, with barely a hiccup compared with the online problems that dogged sign-ups for 2014, the inaugural year of the new insurance marketplaces, or exchanges.

The ACA, or Obamacare, requires most citizens and U.S. nationals to have health insurance coverage or pay a fine. Some people may qualify for exemptions due to religious beliefs, financial hardship or other extenuating circumstances.

If you are enrolled in a qualified health plan for 2015, you are considered covered under the law. The list of qualified plans includes Medicare, Medicaid, the Children's Health Insurance Program, job-based health insurance, military or veterans' health coverage and health insurance purchased on or off the Affordable Care Act marketplaces.

Penalties for not having health insurance in 2015 jump to 2 percent of household income or $325 per adult (and $162.50 per child) -- whichever is higher.

Close to 10 million people have already signed up for marketplace coverage for 2015, federal health officials reported earlier this month. That figure includes some 7.5 million who selected a health plan or re-enrolled in coverage through HealthCare.gov, the federal enrollment website serving people in 37 states. Others have secured coverage through state-operated health insurance exchanges.

Although the Congressional Budget Office had previously projected 13 million enrollees in 2015, federal health officials last November revised projected enrollment to between 9 million and 10 million for the year.

The ACA was designed to expand affordable coverage to people who cannot afford health insurance on their own. It does that, in part, by subsidizing insurance premiums for people of modest means.

If you make up to 400 percent of the federal poverty level (as much as $95,400 for a family of four), you may qualify for federal tax credits to defray your monthly health insurance premium. People with very low incomes will pay little or nothing for coverage.

The amount of the subsidy depends on your household income and the number of people in your household.

Many low-income people may qualify for reduced out-of-pocket costs as well.

Americans who choose a health plan before this year's cutoff date could have coverage as soon as March 1. After Feb. 15, the federal and state ACA marketplaces will only enroll people in health coverage for 2015 under special circumstances, such as a birth, death or move.

There's no deadline for enrolling in Medicaid or the Children's Health Insurance Programs.

The next ACA open enrollment period begins Oct. 1, 2015, for coverage that would kick in no earlier than Jan. 1, 2016.

For those hoping to squeak in under the wire for 2015, HealthCare.gov can tell you whether you live in a state with a state- or federally operated health marketplace. You can also find local experts to help you enroll.

Consumers can call the government's 24/7 hotline at 1-800-318-2596 for assistance.


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What if the president worked like doctors today?

What if the president worked like doctors today? | Healthcare and Technology news | Scoop.it

Perhaps doctors should be more like the president.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the president needs in order to manage his, and all our, business.


That is how things used to work in medicine, too, before computerization revolutionized our workflows. Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and x-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.

Computers changed all that.

Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the x-ray department faster via their Internet-connected computers. But in the typical medical office, we have now turned decision-making doctors into frontline mail sorters and de facto bottlenecks of routine information.

The average doctor sees a different patient every fifteen minutes and the medical assistant rooms patients, takes vital signs, inputs visit information into the EMR and listens to voicemails, which are turned into physician emails. At the same time, the doctor’s electronic inbox is continually filling up with lab reports, x-ray results, consultation reports, electronic prescription refill requests, emails from case managers, and messages from counsellors and other care team members to please read and respond to their issues.

So when does the doctor check his or her inbox?

Between patients is the way many people imagined this system to work. But, how much time do we have between all those back to back fifteen-minute patient encounters? And how do we prioritize in those precious moments between the various types of new information waiting for our review?

Most EMRs color code urgent or abnormal reports, but when it comes to standard laboratory panels, normal patients statistically have 5 percent of their results outside the normal range without being sick, so the majority of complete blood counts and comprehensive metabolic profiles show up red, whether they contain panic values or just statistical noise.

Where does a doctor even begin a two-minute dash through their overflowing virtual inbox?

By lunchtime, or after the last patient visit is over, we dive into the information that has been waiting all day, speedily delivered but bottle-necked for hours while we have been seeing patients.

Imagine if the White House IT department instituted a similar workflow for the president: After a day of speeches, audiences with foreign dignitaries, ribbon cuttings and baby kissing, he has a few minutes before the state dinner, and hastily types in his multiple passwords on the executive computer.

A hundred messages await. One of them contains information about hostile troop movements on our border, another a ransom demand from extremists threatening to blow up our embassy in a faraway land, but most of them are routine missives, reports and requests marked “urgent” in hopes of grabbing the president’s attention.

Is that any way to run a country? No, and any such proposal would surely be vetoed by the commander in chief. But that is exactly how information is managed in today’s medical office, on the front lines of primary care.

Tick-tock, doc! Three patients are waiting, no more time for refills, emails or test results, urgent or not.

And stop reminiscing about having a secretary. Who do you think you are? The president?


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Gilbert C FAURE's curator insight, January 14, 2015 8:52 AM

Most EMRs color code urgent or abnormal reports, but when it comes to standard laboratory panels, normal patients statistically have 5 percent of their results outside the normal range without being sick, so the majority of complete blood counts and comprehensive metabolic profiles show up red, whether they contain panic values or just statistical noise.

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Health Insurance Enrollment Strongest in Federal Marketplace

Health Insurance Enrollment Strongest in Federal Marketplace | Healthcare and Technology news | Scoop.it

The Obama administration on Tuesday reported a big increase in new customers signing up for health insurance in Florida, Texas and other states using the federal insurance marketplace.

But in states running their own insurance exchanges, the numbers were more modest.

All told, the administration said, in the first month of open enrollment for 2015 coverage, more than four million people signed up for the first time or re-enrolled through the federal and state insurance marketplaces. About 3.4 million of them were in the 37 states using HealthCare.gov, the website of the federal marketplace.

More than two million consumers signed up for the first time, the administration reported, and 1.8 million of them did so through the federal marketplace. States with large numbers of new customers in the federal exchange included Florida (330,000), Texas (205,000), North Carolina (110,000), Georgia (103,000) and Pennsylvania (95,000).

The report showed the importance of subsidies to people seeking coverage under the Affordable Care Act.

Officials said that 87 percent of those selecting health plans for next year in the federal exchange had qualified for subsidies that would reduce their premiums. That is larger than the proportion of people who qualified for financial assistance in the initial months of the first open enrollment period (80 percent from October to December 2013). But it is about the same as the proportion who eventually qualified for subsidies in the federal exchange: 86 percent through March 2014.

The subsidies are under attack in a Supreme Court case filed by critics of the health care law, who contend that it does not authorize such assistance in states using the federal exchange.

Larry Levitt, a senior vice president of the Kaiser Family Foundation, said, “It’s significant that the largest number of new enrollees this fall came from states like Florida and Texas, which were not the most enthusiastic supporters of the health care law.”

California, the most populous state, which led the nation with 1.4 million people insured through its state-run exchange in 2014, says it has added 144,000 new enrollees this fall, through Dec. 15.

New York, with the second-largest state-run exchange, signed up 370,500 people in the first open enrollment period and says it has enrolled nearly 83,100 new customers this fall, through Dec. 20. After snowstorms paralyzed much of western New York, the state extended the enrollment deadline to Dec. 20, for coverage starting on Jan. 1.

The demographic profile of people signing up for 2015 is similar to that of people who previously bought insurance on the exchanges. Twenty-four percent are age 18 to 34, a relatively healthy group sought by many insurers. Latinos account for 8 percent of people signing up for 2015 coverage in the federal exchange, compared with 7 percent this year.

“We see no signs that the administration has succeeded in getting significantly more young people and Hispanics,” said Caroline F. Pearson, who tracks the data as a vice president of Avalere Health, a research and consulting company.


The current enrollment period lasts three months, from Nov. 15 to Feb. 15. It is half as long as the initial open enrollment period, from October 2013 through March of this year.

The latest numbers include people who took action to renew their coverage for 2015 or changed plans, but generally do not include people who were automatically re-enrolled in their current health plans. The Obama administration repeatedly urged people to return to the marketplace, update information on their household income and shop for health plans that might offer better value. But several million people evidently failed to do so, and their coverage will be renewed in the same or similar health plans.

Mr. Levitt, from the Kaiser Family Foundation, said, “The administration appears to be well on the way to meeting its own enrollment target, but still short of projections by the Congressional Budget Office.”

Sylvia Mathews Burwell, the secretary of health and human services, has said she is aiming to have 9.1 million people insured in the federal and state exchanges next year, up from 6.7 million this year. The budget office had projected enrollment rising to 13 million in 2015 and 24 million in 2016.

Even though the federal government has awarded hundreds of millions of dollars to states to set up insurance exchanges, it has had difficulty enforcing standards for the reporting of enrollment data. The report on Tuesday was full of footnotes acknowledging gaps and inconsistencies in the data.

As a result, Ms. Pearson said, “it is very difficult to make apples-to-apples comparisons between states, between the federal and state exchanges, and between the open enrollment periods for 2014 and 2015.”


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What Obama's precision medicine plan needs to succeed

What Obama's precision medicine plan needs to succeed | Healthcare and Technology news | Scoop.it

President Obama's Precision Medicine Initiative to accelerate understanding of individual variability and its effect on disease and treatment is going to necessitate a regulatory system robust enough to facilitate big data analytics for genomics research – no small feat.


That's according to a white paper by the Center for Data Innovation and Health IT Now Coalition, in which the authors contend that to be maximally effective this initiative will require the public and private sectors to work in tandem to realize the next generation of medicine and overcome the institutional challenges that increasingly hinder progress.


Policymakers, in other words, must modernize the regulatory system. To that end, the authors recommend the following:


1. Improve interoperability and data sharing. Stronger federal requirements are needed to ensure that genomic and other health data can be retrieved and compared across health record systems


2. Engage patients. The public and private sectors share an interest in raising the tone of discourse on the role that genomics and other big-data applications might play in revolutionizing our expensive and underperforming health system


3. Re-think privacy law. The strict privacy requirements of the Health Information Portability and Accountability Act and complementary federal and state laws, including the Common Rule, present formidable obstacles to realizing the potential of genomic medicine


President Obama included $215 million in his latest budget to fund initiatives at the National Institutes of Health, the National Cancer Institute, the Food and Drug Administration, and the Office of the National Coordinator for Health Information Technology.

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Obamacare's next 5 hurdles to clear

Obamacare's next 5 hurdles to clear | Healthcare and Technology news | Scoop.it

In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges –including one resolved Thursday – and dozens of repeal efforts in Congress. But its long-term future still isn’t ensured. Here are five of the biggest hurdles left for the law:

  • Medicaid expansion. About 4 million more Americans would gain coverage if all states expand the state-federalMedicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.
  • Anemic enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.  Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.
  • Market stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.
  • Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.
  • Political resistance. Thursday’s ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.
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Three years on, U.S. Chief Justice Roberts rescues Obamacare again

Three years on, U.S. Chief Justice Roberts rescues Obamacare again | Healthcare and Technology news | Scoop.it

The healthcare law conceived by President Barack Obama and passed by Congress was by no means perfect, U.S. Chief Justice John Roberts said on Thursday. The law, for instance, had "three separate Section 1563s."


“The Affordable Care Act contains more than a few examples of inartful drafting,” the country's top jurist quipped as he announced the court's ruling from the bench preserving the law.


But the imperfections were not the point, he said.

Simply put, the 60-year-old chief justice said, the law was written to make healthcare insurance widely available, and the disputed tax subsidies at the heart of the case were crucial to keeping the cost of premiums down and enrollment up.


It was the second time in three years that Roberts had authored an opinion rejecting a conservative challenge to the 2010 law known as Obamacare.


If a law was ambiguous, it was the job of justices to provide a fair interpretation, he said, as he read from his majority opinion in the marble-columned chamber before some 300 spectators.


His corporate legal experience before joining the bench might have informed his understanding of insurance markets. But the man who cut his teeth in Washington as a lawyer in the government's executive branch also voiced understanding of the messy compromises that accompany bills taken up by the legislative branch.


'TOO COMPLICATED TO UNDERSTAND'


He referred to a cartoon described in 1947 by the late Justice Felix Frankfurter, “in which a senator tells his colleagues, ‘I admit this new bill is too complicated to understand. We'll just have to pass it to find out what it means.’"


Curtailing the subsidies, Roberts said, would lead to an economic "death spiral," with premiums rising and the number of people with insurance dropping.


Unlike three years ago, when Roberts was the only conservative joining the four liberal justices on the nine-member bench to uphold the law, fellow conservative Justice Anthony Kennedy, 78, a 1988 appointee of Republican President Ronald Reagan, signed on with Roberts.


The vote three years ago was 5-4; this time it was 6-3.

In 2012, Roberts drew the wrath of Kennedy, Republicans and other conservatives. Some right-wing advocates beyond the court deemed the 2005 appointee of Republican President George W. Bush a traitor.

Three years ago Roberts confronted a multi-faceted constitutional challenge and stitched together various rationales to uphold the law. His approach on Thursday was straightforward interpretation of statute.


SCOTUSCARE?


In the case decided on Thursday, the challengers, financed by the libertarian Washington-based Competitive Enterprise Institute, had argued that tax-credit subsidies should go only to people who bought insurance on marketplace exchanges "established by the state," as stated in one part of the law.


That reading would dramatically curtail the availability of subsidies because most of the low and moderate income people who qualify live in the nearly three dozen states with exchanges run by the federal government and not the states.


That interpretation also would conflict with the court's usual approach to ambiguous statutes, Roberts said. "Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," he said.


Spectators laughed along with Roberts when he quoted Frankfurter, but Antonin Scalia, a 79-year-old justice appointed by Reagan in 1986, was not amused.


Given a Roberts majority had now twice preserved Obamacare, the law might as well be called "SCOTUScare," said Scalia, one of the three dissenters, using the six-letter acronym for the Supreme Court of the United States.

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Obama Is Optimistic Justices Will Let Health Care Law Stand

Obama Is Optimistic Justices Will Let Health Care Law Stand | Healthcare and Technology news | Scoop.it

There has been a lot of discussion and focus on the "triple aim" of good patient care which translates to access, cost, and quality. Which factor is most important? It depends upon who is talking, but more importantly it depends upon who your customer is.

In a medical practice there are many customers, with patients coming first and foremost, followed by referring providers, staff members, and other business partners. In order to meet the needs of the customer, I believe that quality is the most important factor, or as some may remember from the Ford Motor Company, "Quality is job one!"


One way to achieve quality is to create a quality management system (QMS). A QMS focuses on the quality of the desired outcome, as applied to patient care. The premise here is that quality outcomes will ensure good patient access and also control costs — therefore the focus for any business must be on the quality of services provided.


Creating a quality system


Here are four basic requirements to create a system:

• A system is a coordinated approach to deliver services to meet the needs of the customer — patients, referring physicians, staff members.

• A system does not succeed without a focus, so your practice's purpose (mission statement) stated simply could be: provide quality patient care, efficiently and effectively, to meet customers' needs.

• A system requires resources, machines, processes, supplies/equipment, and people.

• A system requires the efficient use of these resources — the role of management is to coordinate activities, ensure there is not waste, and ensure the practice is achieving its goal of quality patient care.

The patients come to your practice with a set of expectations. The question that should be asked every day is, "Did we meet our patients' expectations?" The best way to answer "yes" to that question is using a coordinated approach to all aspects of your practice's operations. One that will lead to long-term survival and success.


Barriers to quality


Too often we find ourselves creating "silos," where staff members say, "My job is to do only this, and I don't care what others do." Physicians may say, "I want to do things my way, because that works for me, and that is what I think is best for the practice."


A systematic and coordinated approach to patient care, on the other hand, suggests that these silos be removed. For example: Look at the basic patient flow in your office. The five steps are: check in, triage, the physician/patient encounter, follow up, and check out. If the medical assistant does not consider the role of the receptionist and only focuses on what she does, there will be problems at some point in the patient visit. Focusing on a single role will lead to delays, barriers, and inefficiency in the delivery of patient care.


A systematic approach also takes advantage of the strengths of the physicians as a whole, standardizing operations as much as possible. This is the tough one, as physician training involves independent thinking and decision making. The idea of having to change "my" approach to care to meet some administrator's idea of making things better is foreign and difficult to achieve.


This is where the discussion must occur about the effective use of resources by physicians. Reviewing what works best to achieve the practice's overall mission is a good start. Comparing physician metrics through appropriate reporting and positive peer pressure will assist in changing behavior to a more systematic approach.


What's the key point of all of this? Your practice should focus on the quality of care it provides and the quality of relationships it has with customers, in a systematic fashion. If this is accomplished, your practice will flourish and meet the expectations of each of its customers.

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Obamacare Penalty May Not Be High Enough For Middle Incomes

Obamacare Penalty May Not Be High Enough For Middle Incomes | Healthcare and Technology news | Scoop.it

Even though penalties under the Affordable Care Act for not having health insurance jumped significantly this year, they still might be too low to attract Americans to signup for subsidized coverage, a new analysis shows.


Avalere Health, a Washington health policy and consulting firm, said some middle income healthy individuals would rather pay the fine when they weigh it against spending a few hundred dollars more on insurance.


The fee increased to $325 per adult or 2% of income for 2015, according to healthcare.gov. That compares to a fee of $95 per adult or 1% of income for those who went without coverage last year.

“Individuals earning more than double the poverty level may continue to forgo coverage since paying the fine is still much more affordable than purchasing insurance,” Caroline Pearson, senior vice president at Avalere, told journalists during a panel discussion Friday on exchanges at the Association of Health Care Journalists annual meeting in Santa Clara.


Avalere looked at such a person for its analysis, citing a 27-year-old who makes $23,000 a year. Here’s a link to the analysis and cost comparisons to income.


“If he did not buy insurance, he would pay $230 in penalties – $619 less than if he had purchased coverage,” Avalere said in its report. “However, with mandate penalties rising in 2015, if the same individual chose to stay uninsured in 2015, he would spend only $391 more on insurance than if he had paid the penalty.”


With such scenarios likely common, it’s no wonder just 68,000 Americans took advantage of the recent special open enrollment period for those who didn’t enroll in the regular open enrollment period that ended in February and faced a penalty for not signing up for 2014 coverage.

“That lackluster uptake of the special enrollment period is driven, in part, because for most people individual mandate penalties are much lower than actual costs of coverage,” Avalere said in a statement accompanying its report.

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Obama presents climate change as hazard to your health

Obama presents climate change as hazard to your health | Healthcare and Technology news | Scoop.it

President Barack Obama will ask Americans to think of climate change as a threat not just to the environment, but also to their health.


Warning of the perils to the planet has gotten the president only so far; polls consistently show the public is skeptical that the steps Obama has taken to curb pollution are worth the cost to the economy. So Obama is aiming to put a spotlight on ways that climate change will have real impacts on the body, like more asthma attacks, allergic reactions and injuries from extreme weather.


"It's not just the air we breathe — climate change is leading to more heat-related deaths," Obama senior adviser Brian Deese told reporters in a conference call previewing the announcement.


"The challenges we face are real and they are clear and present in people's daily lives."


Microsoft's research arm will develop a prototype for drones that can collect large quantities of mosquitoes, then digitally analyze their genes and pathogens. The goal is to create a system that could provide early warnings about infectious diseases that could break out if climate change worsens.


Google has promised to donate 10 million hours of advanced computing time on new tools, including risk maps and early warnings for things like wildfires and oil flares using the Google Earth Engine platform, the White House said. Google's camera cars that gather photos for its "Street View" function will start measuring methane emissions and natural gas leaks in some cities this year.


The Obama administration was also to announce a series of modest steps it will take to boost preparedness, such as expanding access to data to predict and minimize the health effects from climate change.

Obama's effort to link climate change to health comes as he works to build support for steps he's taken to curb U.S. emissions that are opposed by business and industry, including strict limits on vehicles and power plants. The president is relying on those emissions cuts to make up the U.S. contribution to a global climate treaty that he and other world leaders expect to finalize in December.


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Uninsured drop by 11M since passage of Obama's law

Uninsured drop by 11M since passage of Obama's law | Healthcare and Technology news | Scoop.it

The number of uninsured U.S. residents fell by more than 11 million since President Barack Obama signed the health care overhaul five years ago, according to a pair of reports Tuesday from the federal Centers for Disease Control and Prevention.

Although that still would leave about 37 million people uninsured, it's the lowest level measured in more than 15 years.

The most dramatic change took place in comparing 2013 with the first nine months of 2014. As the health care law's major coverage expansion was taking effect, the number of uninsured people fell by 7.6 million over that time.

That's "much bigger than can possibly be explained by the economy," said Larry Levitt of the nonpartisan Kaiser Family Foundation. "The vast majority has to be due to the Affordable Care Act."

Monday was the law's fifth anniversary, and supporters and detractors again clashed over its impact.

Obama says the law in many ways is "working even better than anticipated."

House Speaker John Boehner says it amounts to a "legacy of broken promises."

The health care law offers subsidized private coverage to people who don't have access to it on the job, as well as an expanded version of Medicaid geared to low-income adults, in states accepting it.

The White House says 16 million people have gained health insurance, a considerably higher estimate than Tuesday's findings from CDC's National Center for Health Statistics.

The figures cited by the White House cover a longer period of time, through the beginning of this month. That includes the law's second sign-up season. The estimate was produced by the principal policy adviser to Health and Human Services Sylvia M. Burwell.

The CDC reports compared the first nine months of 2014 with annual statistics going back as far as 1997, from the National Health Interview Survey. Among the highlights:

— The number of uninsured dropped from 48.6 million in 2010 to 37.2 million for the period from Jan.-Sept. last year. That amounted to 11.4 million fewer uninsured since the signing of the health care law.

— In 2014, about 27 million people said they had been without coverage for more than a year.

— Some 6.8 million people were covered through the health care law's new insurance markets during July-Sept. of 2014.

— The most significant coverage gains last year came among adults ages 18-64. Nearly 40 million were uninsured in 2013. But that dropped to 32.6 million in the first nine months of 2014.

— States that moved forward with the law's Medicaid expansion saw a bigger decline in the share of their residents uninsured.

The main question hanging over the law now is a Supreme Court case in which opponents argue that its subsidies are illegal in most states. They contend that the exact wording of the law only allows subsidized coverage in states that have set up their own insurance markets. Most have not done so, relying instead on the federal HealthCare.gov.

The administration counters that the context of the law makes it clear the purpose was to expand coverage in every state. A decision is expected to be announced by late June.


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Hospital Profits Soar As Obamacare Prescribes More Paying Patients

Hospital Profits Soar As Obamacare Prescribes More Paying Patients | Healthcare and Technology news | Scoop.it

Hospital operators continue to see profits and revenue not seen in a decade thanks to the Affordable Care Act and related efforts to sign up uninsured patients to coverage so facilities can reduce unpaid medical bills.

Large hospital operators HCA Holdings (HCA), Tenet Healthcare (THC) and Community Health Systems (CYH) in the last month issued robust 2014 earnings, revenues and large declines in uncompensated care costs, a key measure of expenses.

“We reported Tenet’s strongest quarterly EBITDA in more than 10 years,” Tenet chief executive officer Trevor Fetter boasted last week of a key earnings acronym in the hospital chain’s 2014 fourth quarter.

Hospitals have been working to enroll uninsured patients. Tenet said its “Path to Health program” launched in 2013 continued to enroll more patients in this year’s second open enrollment period through the use of financial counselors, direct mail marketing and community events.

“We held nearly 800 outreach and enrollment events, reaching tens of thousands of people in our priority markets,” Fetter said. “Our daily enrollments have increased by more than 60% during this enrollment period and we estimate that we will exceed the number of exchange enrollments that we achieved last year.”

Hospital operators are reporting more paying patients and fewer uninsured, which means far fewer unpaid medical bills. “For the last four quarters, the decline in self-pay admits and adjusted admits and the increase in Medicaid in expansion states have grown quarter over quarter,” Community Health CFO Larry Cash said.

HCA reported a decline of nearly 9 percent in “same facility self-pay and charity admissions,’ executives said on its fourth quarter earnings call.  “These represent 7.2% of our total admissions compared to 8.3% last year and has continued to turn favorable for the company,” HCA chief financial officer William Rutherford told analysts.

But it wasn’t just the health law that helped hospitals with the improving economy and more Americans with jobs and commercial insurance boosting health facility finances.

“ACA enrollments bore a lot of fruit for hospitals last year as previously uninsured patients sought healthcare, but year 2 is a different ball game,” Fitch Ratings’ Senior Director of Healthcare Megan Neuburger said.“We can’t discount other factors like greater disposable income as the economy improves or seasonal issues like the flu."

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Obama Cites Health Plan Tally of 11.4 Million

Obama Cites Health Plan Tally of 11.4 Million | Healthcare and Technology news | Scoop.it

President Obama said Tuesday that 11.4 million people had selected private health insuranceplans or renewed their coverage under the Affordable Care Act in the enrollment period that ended Sunday.

“It gives you some sense of how hungry people were out there for affordable, accessible health insurance,” Mr. Obama said in a video released by the White House.

Administration officials said the numbers would grow in the next week as insurance marketplaces, or exchanges, signed up people who had tried to enroll but encountered technical problems on HealthCare.gov or state insurance websites.

The White House celebrated the latest numbers as evidence of the success of the health law, which was adopted in 2010 without any Republican votes.

“The Affordable Care Act is working,” Mr. Obama said. “It’s working a little bit better than we anticipated — certainly, I think, working a lot better than many of the critics talked about early on.”



More than a million people selected health plans in the last nine days of the latest open enrollment period.

“On the final day,” said Sylvia Mathews Burwell, the secretary of health and human services, “we had more consumers sign up than we’ve every had, last year or this year.”

Many people cited the threat of tax penalties as a reason for obtaining insurance.

Federal health officials emphasized that the latest numbers were preliminary. People are not formally enrolled until they pay the first month’s premium. Some people who gain insurance and pay the initial premium lose the coverage because they do not pay their share of premiums in later months.

Ms. Burwell had set a relatively modest goal for 2015, saying she wanted to have 9.1 million people signed up and paying premiums at the end of the year. The Congressional Budget Office had projected enrollment of 12 million for 2015.

The administration has had difficulty establishing a firm count of people gaining insurance under the health law.

In April 2014, Mr. Obama announced that eight million people had signed up in the initial enrollment period that had ended March 31. By October, that number had declined to 7.1 million because some people failed to pay premiums or were found ineligible because of unresolved questions about their citizenship or immigration status.

The number shrank again in November, to 6.7 million, as congressional investigators discovered that the administration had overstated enrollment by including about 400,000 people with dental insurance.


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Personalized Medicine Informatics: The Sky’s the Limit

Personalized Medicine Informatics: The Sky’s the Limit | Healthcare and Technology news | Scoop.it

President Obama’s 2016 budget includes a $215 million investment in research on personalized medicine to provide clinicians with new tools, knowledge, and therapies to select which treatments will work best for which patients. That figure includes $5 million for the Office of the National Coordinator to support the development of interoperability standards and requirements that address privacy and enable secure exchange of data across systems.

Last week I had the opportunity to interview A John Iafrate, M.D., Ph.D., founder and director of the Center for Integrated Diagnostics (CID) at Massachusetts General Hospital, about some of the informatics challenges his organization faces as personalized medicine takes off.

The CID was one of the first centers to look at large panels of genes in cancer to support clinical decision-making, Iafrate said. It looks for mutations and other genetic alterations in patient tumors with the idea of getting those patients on new targeted agents. Its SNaPshot assay screens for well over 100 cancer-associated mutations that have important clinical implications. Iafrate’s organization has begun using the HealthShare health informatics platform from InterSystems to target issues involving large data set management and cross-organizational collaboration in support of genomic research and clinical innovations.

At Mass General, once a tumor is genotyped, the patient’s oncologist receives that information in a plain-text report in the EHR. The oncologist can act on that information if they have a clinical trial open or a drug available, Iafrate said.

 I asked him how the oncologists keep track of all the available trials.

“In fact, one of our first projects with InterSystems is a clinical trials locator,” he said. “That is app No. 1.” An oncologist who sees 100 patients, all with different genetics, cannot keep track of it. “If I am in an academic practice group, maybe there are 50 trials. Someone could make an Excel spreadsheet of genome types and trials available,” Iafrate explained. “But how would I know next Wednesday, when I see Mrs. Smith, whether or not she has other clinical parameters that make her ineligible? But a piece of software can have all the entry criteria, know the lab values for all the patients, and in real time know the genotype and entry criteria for trials and whether there is a spot available in those trials.”

Iafrate says that there seems to be some consensus that this “apps” model is the approach of the future. “To get novel analytics, you need a stable database structure and then let people build reliable apps you can put on top,” he said. “That is what we are excited about. I think most people would view that as the most efficient way forward.”

He said InterSystems has helped solve a lot of the problems around data security and data formats. “One of the reasons we liked InterSystems is their focus on building HIEs,” he said. “This is not a research project. We are dealing with identified data that needs the highest level of security. The capabilty to share between sites is critical.”

There are still many informatics issues to address, he said. “How do we get data out of the current data repository and how do we share data between institutions in a safe way that limits the risk?”

There are big macro-issues with genetics, he added. “In this day and age, when we can sequence a genome, is any data de-identifiable? You can de-identify some clinical data, but if you have DNA sequence linked, that is no longer de-identified,” he said. “There is no consensus on how to deal with this issue,” he said, and no national consensus within the healthcare informatics world on how risky someone’s DNA sequence is.

Iafrate said another challenge is all the unstructured data in healthcare settings. “That is the major issue we are dealing with,” he said.  “As good as any natural language processing software is, there will always be data quality problems.”

He said the CID hopes to create a physician portal — not just a viewer, but a way for clinicians to generate their notes in a way that is as fully structured as possible. “To do cutting edge research and cutting edge clinical analytics, you really need the highest quality data possible,” he explained, because every data point will have noise associated with it. You can have a physician’s note that says ‘Mrs. Johnson has been receiving chemotherapy and is doing fantastic. She feels great.’ If you want to do research on quality of life, natural language processing will hone in on it, but there is noise associated with it. “What you really want is a scale of 1-10,” he said. “We want to build into a physician portal a way they could enter data that is as high quality quantitative data as possible.”

I asked Iafrate if it was likely that EHR vendors would soon start to build in tools that support genetic data sharing. “Definitely, everyone is moving in that direction,” he said. “Epic has a working group around that. Everyone understands that personalized medicine is important.”

Iafrate is working with the Global Alliance for Genomics and Health, which was formed in 2013 to create a common framework of harmonized approaches to enable the responsible, voluntary, and secure sharing of genomic and clinical data. He said most of the work in genomics has been done by a few large research facilities. “They have an interest in sharing data among large genome centers but not in sharing it widely with community hospitals and primary care physician practices,” he said. “They can agree on one or two large databases they share with each other, but that does not solve the problem of how we democratize it,” he said. “Without standards, you are limited in transporting data and comparing studies. We won’t get companies like Epic to invest a whole lot unless there is a standard format.”

Iafrate said that once data is structured sufficiently and a single database can store large amounts of genetic data and can bring it together with clinical data, then “the sky is the limit.” 

“We could create real-time clinical analytics apps that you could put into Epic or another EHR, he said. One future app could be called “Patients Like Mine.”

Here is how Iafrate explained it to me: Twenty years ago oncologists would rely on their medical knowledge and experience to make decisions because they didn’t have so much data. Now when the genetics results come back, they are complicated. “Can we help those clinicians by showing them real-time survival rates?” he asked. “How can you generate a Kaplan-Meier curve, a survival curve, for the patient sitting right in front of you? This is not a research tool, but a clinical real-time tool.” What if you had structured data on every time the patient came in, what drugs and dosage they had, and a CT scan measurement of the size of the tumor at each point in time. You could do a quantitative measure of drug response in that patient — and that is the equivalent of a clinical trial, he said. “Today that is not done in routine clinical care, where you quantitate the response rate or tumor shrinkage, because there is not a need for doing that in the clinic.” But now there would be a reason. If you measure the tumor size of every patient that comes through, the oncologist sitting with that patient could pull up a Kaplan-Meier curve of all the patients in their practice and say ‘query the data by defining 50-year-old females with this mutation and this tumor type. Tell me how my patients have done.’

And providers could toggle between looking at only their own patients or patients in the HealthShare HIE network. “Once you structure that data, if you can de-identify it to some degree,” Iafrate said, “then it could be shared and turned into something really special.”


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Obama Gives Data Security Some Needed Momentum

Obama Gives Data Security Some Needed Momentum | Healthcare and Technology news | Scoop.it

Every year, I see Mac McMillan at HIMSS and wonder if he’ll ever be positive.

Of course I’m joking, but in a way you can’t blame McMillan—a renowned data security expert, chair of the Healthcare Information and Management Systems Society (HIMSS) Privacy and Security Policy Task Force, and CEO of the consulting firm, CynergisTek—for being a “Debbie Downer.” Data security in healthcare has been and is abysmal.

Every year, the Traverse City, Mich.-based Ponemon Institute releases its annual patient privacy and security study and the results are somewhat startling. This past year, 90 percent of respondents say they’ve had at least one data breach over the past two years, while 38 percent have had more than five data breaches in the same time period. The economic impact of a breach has remained steadily high.

And this is just one study of many, one voice of many, and one indication that healthcare has a big problem with data security. It’s not exactly far-reaching to say we have a long ways to go if these abysmal statistics are to reverse.

Moreover, it could get worse before it gets better. Hackers are now starting to target healthcare data holders. This week, Jason Roos, CTO at Stanford Hospital & Clinics and Stanford University Medical Center in Palo Alto, Calif., explained to me why the exposure of the threat is significant in healthcare, compared to other sectors.

 One of the big problems is that it seems like a lot of high-level executives in hospitals don’t care about data security until it’s too late. They don’t want to be put in protections, do a risk analysis, and pay for extensive training until they have the Department of Health and Human Services’ (HHS) Office of Civil Right (OCR) knocking at their door.

It’s not just healthcare that lags in this way. The retail, entertainment, finance, education, and government sectors seem to have this problem too. In our podcast conversation, McMillan called 2014 the year of the incident. You could say that again. Sony, JP Morgan, Community Health, Home Depot all had high profile breaches. Incidents were everywhere in 2014.

I guess that’s why I was excited to read about President Barack Obama’s dedication to data security, which made the news this week. Specific information on his proposal is sparse, with most details expected to be announced during the State of the Union on Tuesday, but let’s just acknowledge that something is better than nothing. As a privacy expert said in this CNET article, "This is a huge shot in the arm to a much-needed advancement for our legislative protections.”

A nationally recognized data security policy tells every higher up, whether they are in healthcare or not, “Respect the threat. Be prepared.”  

In New York, Attorney General Eric Schneiderman quietly took it a step farther. He proposed a bill that would expand the definition of private information to include email addresses in combination with a password or security question and answer; require entities that store private data have reasonable technical and physical safeguards, assess risks regularly, and obtain third-party certifications showing compliance with these requirements; incentivize companies to provide higher levels of data security and share forensic reports with law enforcement officials. I admire the fact that he wants the strongest data security law in the country.

While these measures are not directed at the healthcare industry specifically, they very well could have a trickledown effect that gives it the kick start that is so desperately needed. In other words, maybe in a few years, I’ll go to HIMSS and Mac McMillan will be a little less annoyed at the way things are with data security in healthcare.


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Think Filing Taxes Was Tough Before Obamacare? Just Wait

Think Filing Taxes Was Tough Before Obamacare? Just Wait | Healthcare and Technology news | Scoop.it

The Affordable Care Act, aka Obamacare, is part health law, part tax law. Some feel benefited by the law, some burdened by it. And one’s perceptions about that can change over time. Either way, you may be annoyed by the extra forms and extra tax compliance, even if your tax bill doesn’t go up. The IRS has a far more important role in the law than you might think.

This year for the first time, the Affordable Care Act has created a trickier tax season. It is more expensive too, as virtually all Americans filing tax returns will have to consider the law’s impact on them and their taxes. There is likely to be considerable confusion this first year, and probably many mistakes. Yet many expect the IRS to be lax for a time. The agency is already stretched thin, and tax season looms large, especially this year.

A major feature of the law is a mandate requiring that most Americans must carry health insurance. In its simplest, that means you must state on your tax forms whether you have coverage. You also must say whether you got tax credits to help pay for it. If you did not have coverage in 2014 as required—and you are honest and say you didn’t—there’s a fine. Yet if you fail to pay it, many in the tax filing business think you may slide by without incident.


On the other hand, if you are entitled to subsidies, your tax refund is likely to go down. In fact, your refund may go down so much that you may even owe the IRS money. The subsidy process is confused and many people who received subsidies are likely to owe the IRS. Why? Because there is estimating involved, the tax credits they received to offset their insurance premiums may have been too large.

In fact, H&R Block estimates that up to one half of the approximately 6.8 million taxpayers who got subsidies in 2014 may have to send money back to the government. Tax preparation firms are trying to gear up to provide the kind of hybrid health insurance tax law advice that consumers are needing this year. But like any new system, there are likely to be some hiccups. It will also be one more reason taxpayers may need tax professionals, even if their situations seem simple.

In that sense, this could be a pivotal tax filing season. Obamacare was enacted in 2010, eventually rolled out, and repeatedly delayed. As enacted, employers were supposed to send in to the IRS lists of employees with health coverage through their employment. After delays, though, it’s now clear that there will be more self-reporting than originally envisioned.

Given that the IRS is administering the massive health care/tax law, you might assume that there would be something like a Form W-2 or Form 1099 that would reveal key data. For now, though, the IRS says it has to trust tax filers to answer truthfully whether they had health insurance or need to pay a penalty. In some sense, it might be similar to answering the question whether you have a foreign bank account. That too is a yes or no question.

Some taxpayers are likely to just skip the question about health insurance, just as some skip the foreign bank account question. If you don’t say yes or no, the reasoning goes, how can they penalize you? Tax return preparation software may or may not default to yes or no for health insurance. Remember, though, that you must sign your tax return under penalties of perjury.

If you must pay a fine, you pay it as part of your tax bill. That will make some people unhappy. Still, the flak from people who got subsidies and then are getting smaller refunds than they thought–or even owing money–may be greater.

Finally, a major impact on many higher income taxpayers is likely to be the 3.8% net investment income tax. It was enacted in 2010 expressly to fund the health law. It first took effect in 2013, and 2014 is likely to be a big year. If you need guidance, the IRS has released these questions and answers on the net investment income tax.


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