healthama

[10:55 AM] Helicase21: Going to be setting up the guest's account this evening but figured I'd give a bit of background: our guest is an attorney with experience at a number of levels of the health industry: working compliance at a large university, working for both a small insurer and one of the biggest insurers in the nation, working at a high level at the Department of Health and Human Services under the Obama administration, and working in a health-tech startup. The guest is broadly knowledgeable but specializes in issues of health data access and privacy.

[1:53 PM] Helicase21: @everyone quick reminder that this starts in just over an hour

[2:23 PM] Russelsteapot42: I'll throw something up in advance, in case it takes some time for people to sign in:

[2:25 PM] Russelsteapot42: A lot of people have been bringing up how health insurance companies negotiating with providers tends to distort prices, and talk about preferring a more direct client-to-provider financial relationship. If it could be done, how would 'cutting out the middle man' actually effect the medical markets, as well as people's lives?

[2:53 PM] HealthExpert: Good first question. Maybe the younger generation will be less intimidated, but for most people, figuring out the right care, and what they should pay for it, is overwhelmingly complex. Imagine it is all you can do to drag yourrself to your radiation or chemotherapy sessions. How would you find the enerrgy to negotiate with your doctors for their payments.

[2:55 PM] HealthExpert: There are some good examples of consumerism and price shopping. Lasik surgery is a commonly cited one. But you'd think we'd see more shopping around for stuff like surgery you can schedule or MRIs. We don't, based on research about how consumers use available info. There are some great sites, though, incluing Guroo.com, amino.com , fairhealth.org, and maybe even your insurance company.

[2:55 PM] notjustamwac: Would you support universal care?

[2:57 PM] HealthExpert: There are a lot things good about it, but remember, even with universal care, what a doctor or hospital gets paid for which service becomes a political football, so don't think that part will go away. For more info, google "sustainable growth rate"

[2:57 PM] HealthExpert: In my world, hundreds of hours each year are spent on what Medicare should pay the doctors and hospitals, and Medicare is essentially single payer for seniors.

[2:59 PM] Russelsteapot42: Can you give us some examples of why medicare is such a beurocratic nightmare?

[3:01 PM] HealthExpert: Well, first off, it all coded, but the coding is subject to a lot of interpretation, upcoding, and error. Elizabeth Rosenthal just wrotea book about this. But an example is a premature baby has 5 levels of severity. you are not supposed to be able to discharge the at levels 3-5, but hospitals discharge premies with coding at level 4, then someone has to chase down what actually happened. That's one example. Another is Healthcare'ss complete inability to adopt e-signature technology,which I could talk about for hours, but won't. and that is just inerrtia and conservatism.

[3:02 PM] Russelsteapot42: Have you heard of the concept of 'cost disease'? It's a word used for the rapid increase in costs for industries like healthcare and education over the last few decades. You've already mentioned Medicare, but are you aware of any other likely causes of cost disease in healthcare?.

[3:02 PM] Helicase21: We often hear that the reason health costs are so much lower outside the US is that the US is effectively subsidizing these countries in terms of medical R&D--we're doing all or most of the R&D so that they don't have to. To what extent is that an accurate characterization?

[3:02 PM] HealthExpert: Also, on the insurance side, all the different companies compete on details to attract consumers and employers. These all cause variation that has to be managed. but you might get exactly what you want . . .

[3:02 PM] Leinadro: A lot of people are skeptical about insurance. From what you have seen do you think insurance companies are doing enough try to built a good trusting relationship with customers and the customers arent reciprocating or do you think perhaps insurance companies could do more to increase the faith from their customers?

[3:03 PM] wazzup987: What methods are you looking into for cost controls?

[3:03 PM] HealthExpert: I think that on the R&D side, there's a lot of truth to that. The Pharma and device companies can charge more here and recover their R&D costs more effectively. Although there are a lot of european pharma companies, they like doing business through their U.S. subsidiaries. However, we also have really huge government investment in research itself. That ay not last.

[3:03 PM] BOTMee6: GG @HealthExpert, you just advanced to level 1 !

[3:05 PM] HealthExpert: Cost cntrols: Well, the Republicans have been big fans of "skin in the game" with savings accounts and transparency.I think consumers are really good shoppers , but the transparency tools are in the early stages. and shopping only works when you are not in a health crisis.

[3:06 PM] HealthExpert: for me, another important cost control is in fact more widely available insurance. I know it sounds counter intuitiive, but more people in the insurance system (or single payer, maybe) creates a better counterweight to profit-taking by the big hospital systems. Also, with more insurance, hospitals, which are required by law to treat you in the emergency room even if you cannot pay, will collect from the risk pool, and not pass along to the insured the costs of treating the uninsured.

[3:10 PM] notjustamwac: I just can't comprehend the US system. It's so expensive to the end-user, so hard to navigate, and such a nightmare in so many ways. It makes me glad to be Australian.

[3:10 PM] skysinsane: So the concept of government subsidized insurance programs seems really inefficient to me. Is there some hidden benefit to this system that Im missing, or is it really as screwy as it seems?

[3:10 PM] choux-fleurs: I often hear about doctors and hospitals doing procedures and ordering tests that aren't strictly necessary, due to fear of malpractice suits. Unnecessary C-sections is a big example I guess. Are there any types of malpractice reform that you think would be effective at lowering health care costs (by reducing unnecessary procedures), while still protecting patients?

[3:10 PM] HealthExpert: Ok. Insurance companies. Well, tricky question. They do providen an econnomic counterweight to large provide conglomerrate. They do negotiate prices bettter than an individual can. They do cover financial risk you probably arren't preapared for. A premature baby can cost upwards of $750,000 and very few people have that in the bank. So, like any insurance ,its the total risk pool that matters, Alot. That said, they also take advantage of inertial and bureaucracy to deny payments. No doubt about it. And bot for and not-for profit insurance companies do this. But even single payer is "social insurance": we alll pay taxes into apool to share the risk that a few of us will suffer catastrophic health issues.

[3:13 PM] notjustamwac: Would you say it's accurate that universal is better for that as people are more likely to seek help earlier, rather than letting their condition become catastrophic?

[3:13 PM] HealthExpert: Governrmentt subsidy: you have to break that down. in the U.S. even insurance through your employer is subsidized becaues teh employer gets a tax deductoin and you get it tax free. Medicare is a pay-in system: you pay in through your life as a worker and when you can't workr any more because you are old, the system pays you back. Medicaid is, straight up, a fee transfer to the poor, so that people don't die. We kind of decided a while ago that we don't want people to die becuase they don't have insurance.. That is also why we require ERs to treat you whether you can pay. Some current conservative reject this idea on philosophical grouunds. That is part of what they are arguing about in DC these days. But even the Aussie system is a form of risk sharing through social insurance.

[3:16 PM] HealthExpert: @notjustamwac I don't know about people getting care earrlier. anecdotally, I know lazy, busy, overeducataed insured people who don't choose a regular doctor and go to the ER for school sports exams. And with our heterogeneous society, there are cultural barrriers. Do all of you have regular doctors for your preventive care? To me, there's a lot of psychology about health and inertia we don't understand very well, but knowing more would help with better policy making.

[3:16 PM] HealthExpert: Have I missed any questions?

[3:17 PM] skysinsane: And regarding the subsidies, I wasn't intending to call government intervention the screwy part, I meant to ask whether government intervention via insurance was really a good idea. It seems to me that subsidising the hospitals would make far more sense

[3:19 PM] notjustamwac: Most people I know have a regular doctor or at least a practice they visit. People clogging ER's with stuff like colds & flus is an issue, but we have things like walk-in centres that bulk-bill, meaning they don't pay anything for the visit. There's also an after-hours service that will come to you at home, though they have limited capacity, and HealthDirect, a phone line for advice from RN's who'll get a doctor to get back to you if they think it warrants further advice/questioning.

Personally, I have a practice I go to for big stuff, but use the walk-in clinic for basic bugs

[3:21 PM] HealthExpert: @skysinsane Govt already does subsidize hospitals, through a thing called "disproportionate share payements", or DSH payments, which are payments to hospitals which have more than their fair share of charity/uninsured care. More importantly, however, remember that historically, the largest and loudest objectors to Medicare or single payerr have been doctors . . . no doubt some specialties would see income fall in such a system. It is also a bit of a delicious irony because AMA and American Hospital Assn and the insurance companies are all against repeal of the ACA because it will, if possed, re-instate huge write offs by hospitals and doctors for charity care, and health insurers customer base will fall.

[3:23 PM] skysinsane: And moving the money currently going to subsidize insurance companies to instead help hospitals wouldn't fix that problem?

[3:23 PM] HealthExpert: @notjustamwac the after hours and drop in clinics are great, but interestingly in some locations where there is a really dominant hospital system there aren't any (East Bay is an example). Which forces ER visits for minor after hours stuff, but the hosptials make a alot of money on minor ER visits. An ER for stitches is probably upwards or $2,000, but skin glue in your doctor's office is around $150, maybe.

[3:23 PM] BOTMee6: GG @HealthExpert, you just advanced to level 2 !

[3:24 PM] Russelsteapot42: It's been suggested that a single payer system will lead to a stall in innovation in American healthcare. Do you believe that's the case? Are there any examples of innovation created by health insurance competition you can think of?

[3:25 PM] HealthExpert: I don't think so. First, the doctors are not employees of the hosptial for the most part. So if you give the $ to hospital, they have to convince teh doctors to let teh hospital pay them. Second, there is just a limited amount of money. I think you just move the fight.. Remmber, by law under the ACA, insurance companies have to spend 85% of theirr revenue on reimbursing healthcare services and related costs. No such limit exists. You can check out what Hospital executives are paid if the hospital is non profit using guidestar.org.

[3:26 PM] skysinsane: So at the very least there would have to be significant regulatory changes if they were to do something like that and have there be any chance of success

[3:27 PM] HealthExpert: @Russelsteapot42 not sure. Right now, about $6 billion a year is going into healthcare innovation, and teh slowest part of that is the speed with which government programs agree to pay for new stuff. of course with taxpayerr $ we want them to be extra cautious, but in general, insurance companies and sometimes employerrs adopt helpful innovations faster than the govt. So, single payer might cool innovation because it might take longer to get govt approval for new ideas.

[3:30 PM] HealthExpert: @skysinsane if you mean have hosptials get the $ and pay the doctors? There are a few models like that, most well known are Kaiser and Geisinger Health System in Danville, PA. But you've got to have everyone embrace it: the doctors have to want to get paid by hospitals, the hospitals have to pay fairly and treat poor and rich the same.And, BTW, hospitals have notoriously terrible data and billing systems. its not nefarious, just crappy. So, the hospitals have to be A LOT better at the business side. Lastly, we know that for the most part, the best care for teh most people is OUTSIDE a hospital. Do we want in that case to give the hospitals more $?

[3:31 PM] Russelsteapot42: We've all heard of companies misrepresenting costs and services for extra payouts, like in John Oliver's episode on dialysis, where they were using one pill out of a bottle and throwing the rest away. How common is this, in your experience? Is it easier to get away with from government sources? How much of an impact does this sort of thing have?

[3:31 PM] skysinsane: haha fair enough

[3:31 PM] HealthExpert: @skysinsane Kaiser and Geisinger are very successful, but one doesn's see others racing to copy their systems.

[3:32 PM] skysinsane: So what Im hearing is that it may be more efficient, but there are a lot of hurdles in order to get such a system working?

[3:32 PM] choux-fleurs: I've heard suggestions that we should be reimbursing doctors (or hospitals) based on outcomes, rather than per-procedure. Are there any examples of this in practice? Any thoughts on this idea?

[3:33 PM] skysinsane: Hurdles that might not be realistically surmountable?

[3:33 PM] HealthExpert: @Russelsteapot42 huge. Tons of waste. Waste in information. There is a lot of "overtreatment" due to bad information. But, you also don't want a hospital re-using its endoscopes (that' what they use for endoscopies, and they are covered in bacterial after each use.

[3:35 PM] Helicase21: How much of a driver of costs is people requesting treatments/tests that they don't actually need? How does that break down in terms of prescription drug abuse vs other stuff?

[3:36 PM] HealthExpert: @choux-fleurs Yes. it is called "value based purchasing" So, in our own family, two of us had ACL surgery. One was perfet--no infection, no re-do, perfectly functioning knee. On was not perfect: three surgical site infections and the knee is only abouut 90%. The idea is doctor #2 should be paid less, or Dr #1 should be paidi more becausee her outcome was better for less resources. There used to be some great HHS videos ont this idea, but I am not sure they are still up. outcomes work great for stuff you can bundle or measurre: a simple delivery of a baby. An orthopedic surgery; a year of diabetes or asthma control . About 30% of Medicare payments are paid this way right now.

[3:36 PM] HealthExpert: @skysinsane I don't get your further question. please elaborate.

[3:38 PM] skysinsane: You said that the Kaiser and Geisinger Health System was very successful, but that not many other people were keen on copying them. Am I understanding it correctly that this is just because of how difficult it would be to set up such a system?

[3:38 PM] choux-fleurs: Is value based purchasing available to individuals who aren't insured? ie, could somebody decide to purchase a year of care from a primary care provider for a flat rate?(edited)

[3:38 PM] HealthExpert: @Helicase21 .Mixed bag. Patient demand stuff they don't need, like antibiotics to fight a cold or flu. Hope none of you do that. Doctors do practice defensive medicine and sometimes over test. Doctors also re-test because the don't know or have the results from the same test done recently by someone else (see waste due to information gaps). RAND corpo has done some estimates of this, as have others. I am going to estimat 20-30% waste for thiese over testing and bad information scenarios, but don't quote me on that. Google it instead.

[3:40 PM] HealthExpert: @skysinsane HAH. actually, it is not more difficult legally than a traditional system. I thin the hard part is the relationships of trust among hospital, insurance company and doctor, and doctors wanting to get paid a salary instead of paid by the piece. Sizing this for you, I read a stotry about a Gastroenterologist who left a system where he was salaried and went into private practice, and his income went from about $200k to $600 k.

[3:43 PM] HealthExpert: @choux-fleurs no legal reason why not, but consumers often lack enough information and comprehension of that info to buy well. I just had breakfast wtih a healthcarae savvy guy (works in it) who negotiates for prices with his out of network doctor, but he's a very unusual case. If I tolkyou a fair price for a service ws 180% of what Medicare pays, would you go look up the Medicare fee schedule for all teh codes in that bundled service (and there could be 200 of them) and then negotiate? Sites like guroo, amino and fairhealth can help, but you have to be motivated. and I bet 9 of 10 doctors office managers have no idea what to charge you. Field test it by asking.

[3:45 PM] choux-fleurs: No, I certainly wouldn't expect people to look up all the Medicare codes -- but if different primary care providers offered different flat rate prices for yearly care, then consumers could certainly start comparing that. Agreed that doctors offices have no idea what to charge though.

[3:45 PM] HealthExpert: Can I ask you all a question? How many of you message your doctor through an app they gave you access to (they have to use apps that meet some security requirements)?

[3:45 PM] choux-fleurs: Nope.

[3:45 PM] skysinsane: nope

[3:45 PM] jolly_mcfats: nope

[3:46 PM] HealthExpert: @choux-fleurs so,, One Medical kind of does that, as do other "concierge" practices. you assign your insurance benefit to them and pay flat fee on top of that, and you get longer office visits, etc. people without the extra $5k a year (and that's about what it costs) cannot do that.

[3:46 PM] BOTMee6: GG @HealthExpert, you just advanced to level 3 !

[3:47 PM] HealthExpert: On that app thing, did you even know you can do that?

[3:47 PM] skysinsane: I have never heard of such a thing

[3:47 PM] jolly_mcfats: me either

[3:47 PM] choux-fleurs: same

[3:48 PM] Russelsteapot42: Yeah, don't really use it and have no awareness.

[3:48 PM] HealthExpert: there's soem great info about that on https://www.healthit.gov/patients-families/protecting-your-privacy-security, but trust me, just ask your doctor "Can I have an account on the portal so I can message you?"

[3:48 PM] skysinsane: yeah that sounds like it could be very useful

[3:49 PM] HealthExpert: And, some of those portals have scheduling features for non urgent things, or Rx refills, and your test results, of course, so you can seem them yourself.

[3:50 PM] HealthExpert: Even in Australia they have a similar feature

[3:51 PM] HealthExpert: And one more thing to think about: the current debate in DC has zero to do with why healthcare costs so much or you might get crappy care due to over-testing.

[3:51 PM] Helicase21: So I'm curious, how (if at all) has personally-generated health data changed the way doctors make decisions? ie is it helpful at all if your doctor looks at your fitbit or your sleep-tracking app or whatever?

[3:54 PM] HealthExpert: Great question. Theres a lot of controversy. Consumer advocates say all health data is patient generated. But seriously, trackers and apps have varying data quality, especially as compared to stuff approved by teh FDA, which is required to be very accurate. So, doctors don't really trust all new digital collection. Headway is being made, however, and some of that $6 billion in vc money is going to tools that will have higher quality data collection than yourr average step counter. Now, for example almost all urban practices use digital blood pressure cuffs.

[3:55 PM] HealthExpert: I think there is still a big philosophical disconnect between active, quantified self patients and the medical profession, who sees their authority being undermined in many domains.

[3:55 PM] choux-fleurs: What about services like 23andMe?

[3:55 PM] HealthExpert: If you are quantified self perrson, you should try to find a doctor who is open to that.

[3:57 PM] HealthExpert: So, 23&m3 is retail genetic testing. Remember, most doctors are not even trained to read a genetic analysis. so you cannot take your 23&me results to your family doc and expect her to know what to do with that. But, a lot of people find the testing fun, and the people's willingness to let their genome be studied anonymously is important to research. If I were tested by 23&me and they said I had a marker for depression, I would want to talk to a genetic counselor about that.

[3:58 PM] choux-fleurs: I used it to find out whether I was homozygous for a particular hereditary condition, so that was fun and useful

[3:59 PM] HealthExpert: That said, genomic medicine is a real thing. We can really identify who is likely to have certain types of breast cancer, etc. and the science is improving daily. for info you can google "all of us" and find the National Institutes of Health Precision Medicine Initiative.

[4:00 PM] HealthExpert: If you are interested in being genetically tested, I would just make sure the serrvers wherre the data is stored are in a country where they don't have a history of stealing identity information (criminal or goverment stealing).

[4:00 PM] HealthExpert: I think we are at time. I can take one last question. You've all asked some great ones.

[4:01 PM] Russelsteapot42: What is your prognosis on the future of healthcare as a whole? Are these problems solvable, or intractible?

[4:03 PM] HealthExpert: financing (insurance or single payerr) is a political problem. It may be intractable because of that. But I think progress can be made in modernizing care delivery through health information, and in changing how doctors and patients interact, especially as tech-savvy disrupters become parents and caregivers for their elderly patietnts. And on that politics thing: calling your Senator actually does work!

[4:04 PM] Helicase21: Awesome, thanks so much for taking the time @HealthExpert

[4:04 PM] choux-fleurs: thank you!

[4:28 PM] skysinsane: thanks a bunch!

[4:35 PM] Russelsteapot42: Yeah, that was very helpful

[11:39 PM] zahlman: I couldn't be here for it, but please leave the channel around so I can read it later, if there won't be a transcript elsewhere

July 23, 2017

[8:32 AM] Helicase21: definitely

[8:36 AM] wazzup987: @Helicase21 do you want me to maeka log of this ama or are you goign to

[8:37 AM] Helicase21: either is fine

Helicase21#2467

healthama

Health insurance AMA. 7/22/17 15:00 Pacific

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Welcome to the beginning of the #healthama channel.

[10:55 AM] Helicase21: Going to be setting up the guest's account this evening but figured I'd give a bit of background: our guest is an attorney with experience at a number of levels of the health industry: working compliance at a large university, working for both a small insurer and one of the biggest insurers in the nation, working at a high level at the Department of Health and Human Services under the Obama administration, and working in a health-tech startup. The guest is broadly knowledgeable but specializes in issues of health data access and privacy.

[10:57 AM] Helicase21: If you can't make the ama time please feel free to post questions here beforehand.

[11:01 AM] choux-fleurs: Oh interesting! Yes, if I can't make it I will post questions. Thanks for doing this.

July 20, 2017

[4:41 PM] Helicase21: @everyone I'd just like to ping people again to remind that A) this is happening and B) if you can't make the scheduled time but have a question or questions, please do leave them here and we'll get to them.

[4:43 PM] Russelsteapot42: What's the scheduled time again?

[4:49 PM] Helicase21: 3PM Pacific on 7/22

July 22, 2017

[1:53 PM] Helicase21: @everyone quick reminder that this starts in just over an hour

[2:23 PM] Russelsteapot42: I'll throw something up in advance, in case it takes some time for people to sign in:

[2:25 PM] Russelsteapot42: A lot of people have been bringing up how health insurance companies negotiating with providers tends to distort prices, and talk about preferring a more direct client-to-provider financial relationship. If it could be done, how would 'cutting out the middle man' actually effect the medical markets, as well as people's lives?

[2:53 PM] HealthExpert: Good first question. Maybe the younger generation will be less intimidated, but for most people, figuring out the right care, and what they should pay for it, is overwhelmingly complex. Imagine it is all you can do to drag yourrself to your radiation or chemotherapy sessions. How would you find the enerrgy to negotiate with your doctors for their payments.

[2:55 PM] HealthExpert: There are some good examples of consumerism and price shopping. Lasik surgery is a commonly cited one. But you'd think we'd see more shopping around for stuff like surgery you can schedule or MRIs. We don't, based on research about how consumers use available info. There are some great sites, though, incluing Guroo.com, amino.com , fairhealth.org, and maybe even your insurance company.

[2:55 PM] notjustamwac: Would you support universal care?

[2:57 PM] HealthExpert: There are a lot things good about it, but remember, even with universal care, what a doctor or hospital gets paid for which service becomes a political football, so don't think that part will go away. For more info, google "sustainable growth rate"

[2:57 PM] HealthExpert: In my world, hundreds of hours each year are spent on what Medicare should pay the doctors and hospitals, and Medicare is essentially single payer for seniors.

[2:59 PM] Russelsteapot42: Can you give us some examples of why medicare is such a beurocratic nightmare?

[3:01 PM] HealthExpert: Well, first off, it all coded, but the coding is subject to a lot of interpretation, upcoding, and error. Elizabeth Rosenthal just wrotea book about this. But an example is a premature baby has 5 levels of severity. you are not supposed to be able to discharge the at levels 3-5, but hospitals discharge premies with coding at level 4, then someone has to chase down what actually happened. That's one example. Another is Healthcare'ss complete inability to adopt e-signature technology,which I could talk about for hours, but won't. and that is just inerrtia and conservatism.

[3:02 PM] Russelsteapot42: Have you heard of the concept of 'cost disease'? It's a word used for the rapid increase in costs for industries like healthcare and education over the last few decades. You've already mentioned Medicare, but are you aware of any other likely causes of cost disease in healthcare?.

[3:02 PM] Helicase21: We often hear that the reason health costs are so much lower outside the US is that the US is effectively subsidizing these countries in terms of medical R&D--we're doing all or most of the R&D so that they don't have to. To what extent is that an accurate characterization?

[3:02 PM] HealthExpert: Also, on the insurance side, all the different companies compete on details to attract consumers and employers. These all cause variation that has to be managed. but you might get exactly what you want . . .

[3:02 PM] Leinadro: A lot of people are skeptical about insurance. From what you have seen do you think insurance companies are doing enough try to built a good trusting relationship with customers and the customers arent reciprocating or do you think perhaps insurance companies could do more to increase the faith from their customers?

[3:03 PM] wazzup987: What methods are you looking into for cost controls?

[3:03 PM] HealthExpert: I think that on the R&D side, there's a lot of truth to that. The Pharma and device companies can charge more here and recover their R&D costs more effectively. Although there are a lot of european pharma companies, they like doing business through their U.S. subsidiaries. However, we also have really huge government investment in research itself. That ay not last.

[3:03 PM] BOTMee6: GG @HealthExpert, you just advanced to level 1 !

[3:05 PM] HealthExpert: Cost cntrols: Well, the Republicans have been big fans of "skin in the game" with savings accounts and transparency.I think consumers are really good shoppers , but the transparency tools are in the early stages. and shopping only works when you are not in a health crisis.

[3:06 PM] HealthExpert: for me, another important cost control is in fact more widely available insurance. I know it sounds counter intuitiive, but more people in the insurance system (or single payer, maybe) creates a better counterweight to profit-taking by the big hospital systems. Also, with more insurance, hospitals, which are required by law to treat you in the emergency room even if you cannot pay, will collect from the risk pool, and not pass along to the insured the costs of treating the uninsured.

[3:10 PM] notjustamwac: I just can't comprehend the US system. It's so expensive to the end-user, so hard to navigate, and such a nightmare in so many ways. It makes me glad to be Australian.

[3:10 PM] skysinsane: So the concept of government subsidized insurance programs seems really inefficient to me. Is there some hidden benefit to this system that Im missing, or is it really as screwy as it seems?

[3:10 PM] choux-fleurs: I often hear about doctors and hospitals doing procedures and ordering tests that aren't strictly necessary, due to fear of malpractice suits. Unnecessary C-sections is a big example I guess. Are there any types of malpractice reform that you think would be effective at lowering health care costs (by reducing unnecessary procedures), while still protecting patients?

[3:10 PM] HealthExpert: Ok. Insurance companies. Well, tricky question. They do providen an econnomic counterweight to large provide conglomerrate. They do negotiate prices bettter than an individual can. They do cover financial risk you probably arren't preapared for. A premature baby can cost upwards of $750,000 and very few people have that in the bank. So, like any insurance ,its the total risk pool that matters, Alot. That said, they also take advantage of inertial and bureaucracy to deny payments. No doubt about it. And bot for and not-for profit insurance companies do this. But even single payer is "social insurance": we alll pay taxes into apool to share the risk that a few of us will suffer catastrophic health issues.

[3:13 PM] notjustamwac: Would you say it's accurate that universal is better for that as people are more likely to seek help earlier, rather than letting their condition become catastrophic?

[3:13 PM] HealthExpert: Governrmentt subsidy: you have to break that down. in the U.S. even insurance through your employer is subsidized becaues teh employer gets a tax deductoin and you get it tax free. Medicare is a pay-in system: you pay in through your life as a worker and when you can't workr any more because you are old, the system pays you back. Medicaid is, straight up, a fee transfer to the poor, so that people don't die. We kind of decided a while ago that we don't want people to die becuase they don't have insurance.. That is also why we require ERs to treat you whether you can pay. Some current conservative reject this idea on philosophical grouunds. That is part of what they are arguing about in DC these days. But even the Aussie system is a form of risk sharing through social insurance.

[3:16 PM] HealthExpert: @notjustamwac I don't know about people getting care earrlier. anecdotally, I know lazy, busy, overeducataed insured people who don't choose a regular doctor and go to the ER for school sports exams. And with our heterogeneous society, there are cultural barrriers. Do all of you have regular doctors for your preventive care? To me, there's a lot of psychology about health and inertia we don't understand very well, but knowing more would help with better policy making.

[3:16 PM] HealthExpert: Have I missed any questions?

[3:17 PM] skysinsane: And regarding the subsidies, I wasn't intending to call government intervention the screwy part, I meant to ask whether government intervention via insurance was really a good idea. It seems to me that subsidising the hospitals would make far more sense

[3:19 PM] notjustamwac: Most people I know have a regular doctor or at least a practice they visit. People clogging ER's with stuff like colds & flus is an issue, but we have things like walk-in centres that bulk-bill, meaning they don't pay anything for the visit. There's also an after-hours service that will come to you at home, though they have limited capacity, and HealthDirect, a phone line for advice from RN's who'll get a doctor to get back to you if they think it warrants further advice/questioning.

Personally, I have a practice I go to for big stuff, but use the walk-in clinic for basic bugs

[3:21 PM] HealthExpert: @skysinsane Govt already does subsidize hospitals, through a thing called "disproportionate share payements", or DSH payments, which are payments to hospitals which have more than their fair share of charity/uninsured care. More importantly, however, remember that historically, the largest and loudest objectors to Medicare or single payerr have been doctors . . . no doubt some specialties would see income fall in such a system. It is also a bit of a delicious irony because AMA and American Hospital Assn and the insurance companies are all against repeal of the ACA because it will, if possed, re-instate huge write offs by hospitals and doctors for charity care, and health insurers customer base will fall.

[3:23 PM] skysinsane: And moving the money currently going to subsidize insurance companies to instead help hospitals wouldn't fix that problem?

[3:23 PM] HealthExpert: @notjustamwac the after hours and drop in clinics are great, but interestingly in some locations where there is a really dominant hospital system there aren't any (East Bay is an example). Which forces ER visits for minor after hours stuff, but the hosptials make a alot of money on minor ER visits. An ER for stitches is probably upwards or $2,000, but skin glue in your doctor's office is around $150, maybe.

[3:23 PM] BOTMee6: GG @HealthExpert, you just advanced to level 2 !

[3:24 PM] Russelsteapot42: It's been suggested that a single payer system will lead to a stall in innovation in American healthcare. Do you believe that's the case? Are there any examples of innovation created by health insurance competition you can think of?

[3:25 PM] HealthExpert: I don't think so. First, the doctors are not employees of the hosptial for the most part. So if you give the $ to hospital, they have to convince teh doctors to let teh hospital pay them. Second, there is just a limited amount of money. I think you just move the fight.. Remmber, by law under the ACA, insurance companies have to spend 85% of theirr revenue on reimbursing healthcare services and related costs. No such limit exists. You can check out what Hospital executives are paid if the hospital is non profit using guidestar.org.

[3:26 PM] skysinsane: So at the very least there would have to be significant regulatory changes if they were to do something like that and have there be any chance of success

[3:27 PM] HealthExpert: @Russelsteapot42 not sure. Right now, about $6 billion a year is going into healthcare innovation, and teh slowest part of that is the speed with which government programs agree to pay for new stuff. of course with taxpayerr $ we want them to be extra cautious, but in general, insurance companies and sometimes employerrs adopt helpful innovations faster than the govt. So, single payer might cool innovation because it might take longer to get govt approval for new ideas.

[3:30 PM] HealthExpert: @skysinsane if you mean have hosptials get the $ and pay the doctors? There are a few models like that, most well known are Kaiser and Geisinger Health System in Danville, PA. But you've got to have everyone embrace it: the doctors have to want to get paid by hospitals, the hospitals have to pay fairly and treat poor and rich the same.And, BTW, hospitals have notoriously terrible data and billing systems. its not nefarious, just crappy. So, the hospitals have to be A LOT better at the business side. Lastly, we know that for the most part, the best care for teh most people is OUTSIDE a hospital. Do we want in that case to give the hospitals more $?

[3:31 PM] Russelsteapot42: We've all heard of companies misrepresenting costs and services for extra payouts, like in John Oliver's episode on dialysis, where they were using one pill out of a bottle and throwing the rest away. How common is this, in your experience? Is it easier to get away with from government sources? How much of an impact does this sort of thing have?

[3:31 PM] skysinsane: haha fair enough

[3:31 PM] HealthExpert: @skysinsane Kaiser and Geisinger are very successful, but one doesn's see others racing to copy their systems.

[3:32 PM] skysinsane: So what Im hearing is that it may be more efficient, but there are a lot of hurdles in order to get such a system working?

[3:32 PM] choux-fleurs: I've heard suggestions that we should be reimbursing doctors (or hospitals) based on outcomes, rather than per-procedure. Are there any examples of this in practice? Any thoughts on this idea?

[3:33 PM] skysinsane: Hurdles that might not be realistically surmountable?

[3:33 PM] HealthExpert: @Russelsteapot42 huge. Tons of waste. Waste in information. There is a lot of "overtreatment" due to bad information. But, you also don't want a hospital re-using its endoscopes (that' what they use for endoscopies, and they are covered in bacterial after each use.

[3:35 PM] Helicase21: How much of a driver of costs is people requesting treatments/tests that they don't actually need? How does that break down in terms of prescription drug abuse vs other stuff?

[3:36 PM] HealthExpert: @choux-fleurs Yes. it is called "value based purchasing" So, in our own family, two of us had ACL surgery. One was perfet--no infection, no re-do, perfectly functioning knee. On was not perfect: three surgical site infections and the knee is only abouut 90%. The idea is doctor #2 should be paid less, or Dr #1 should be paidi more becausee her outcome was better for less resources. There used to be some great HHS videos ont this idea, but I am not sure they are still up. outcomes work great for stuff you can bundle or measurre: a simple delivery of a baby. An orthopedic surgery; a year of diabetes or asthma control . About 30% of Medicare payments are paid this way right now.

[3:36 PM] HealthExpert: @skysinsane I don't get your further question. please elaborate.

[3:38 PM] skysinsane: You said that the Kaiser and Geisinger Health System was very successful, but that not many other people were keen on copying them. Am I understanding it correctly that this is just because of how difficult it would be to set up such a system?

[3:38 PM] choux-fleurs: Is value based purchasing available to individuals who aren't insured? ie, could somebody decide to purchase a year of care from a primary care provider for a flat rate?(edited)

[3:38 PM] HealthExpert: @Helicase21 .Mixed bag. Patient demand stuff they don't need, like antibiotics to fight a cold or flu. Hope none of you do that. Doctors do practice defensive medicine and sometimes over test. Doctors also re-test because the don't know or have the results from the same test done recently by someone else (see waste due to information gaps). RAND corpo has done some estimates of this, as have others. I am going to estimat 20-30% waste for thiese over testing and bad information scenarios, but don't quote me on that. Google it instead.

[3:40 PM] HealthExpert: @skysinsane HAH. actually, it is not more difficult legally than a traditional system. I thin the hard part is the relationships of trust among hospital, insurance company and doctor, and doctors wanting to get paid a salary instead of paid by the piece. Sizing this for you, I read a stotry about a Gastroenterologist who left a system where he was salaried and went into private practice, and his income went from about $200k to $600 k.

[3:43 PM] HealthExpert: @choux-fleurs no legal reason why not, but consumers often lack enough information and comprehension of that info to buy well. I just had breakfast wtih a healthcarae savvy guy (works in it) who negotiates for prices with his out of network doctor, but he's a very unusual case. If I tolkyou a fair price for a service ws 180% of what Medicare pays, would you go look up the Medicare fee schedule for all teh codes in that bundled service (and there could be 200 of them) and then negotiate? Sites like guroo, amino and fairhealth can help, but you have to be motivated. and I bet 9 of 10 doctors office managers have no idea what to charge you. Field test it by asking.

[3:45 PM] choux-fleurs: No, I certainly wouldn't expect people to look up all the Medicare codes -- but if different primary care providers offered different flat rate prices for yearly care, then consumers could certainly start comparing that. Agreed that doctors offices have no idea what to charge though.

[3:45 PM] HealthExpert: Can I ask you all a question? How many of you message your doctor through an app they gave you access to (they have to use apps that meet some security requirements)?

[3:45 PM] choux-fleurs: Nope.

[3:45 PM] skysinsane: nope

[3:45 PM] jolly_mcfats: nope

[3:46 PM] HealthExpert: @choux-fleurs so,, One Medical kind of does that, as do other "concierge" practices. you assign your insurance benefit to them and pay flat fee on top of that, and you get longer office visits, etc. people without the extra $5k a year (and that's about what it costs) cannot do that.

[3:46 PM] BOTMee6: GG @HealthExpert, you just advanced to level 3 !

[3:47 PM] HealthExpert: On that app thing, did you even know you can do that?

[3:47 PM] skysinsane: I have never heard of such a thing

[3:47 PM] jolly_mcfats: me either

[3:47 PM] choux-fleurs: same

[3:48 PM] Russelsteapot42: Yeah, don't really use it and have no awareness.

[3:48 PM] HealthExpert: there's soem great info about that on https://www.healthit.gov/patients-families/protecting-your-privacy-security, but trust me, just ask your doctor "Can I have an account on the portal so I can message you?"

[3:48 PM] skysinsane: yeah that sounds like it could be very useful

[3:49 PM] HealthExpert: And, some of those portals have scheduling features for non urgent things, or Rx refills, and your test results, of course, so you can seem them yourself.

[3:50 PM] HealthExpert: Even in Australia they have a similar feature

[3:51 PM] HealthExpert: And one more thing to think about: the current debate in DC has zero to do with why healthcare costs so much or you might get crappy care due to over-testing.

[3:51 PM] Helicase21: So I'm curious, how (if at all) has personally-generated health data changed the way doctors make decisions? ie is it helpful at all if your doctor looks at your fitbit or your sleep-tracking app or whatever?

[3:54 PM] HealthExpert: Great question. Theres a lot of controversy. Consumer advocates say all health data is patient generated. But seriously, trackers and apps have varying data quality, especially as compared to stuff approved by teh FDA, which is required to be very accurate. So, doctors don't really trust all new digital collection. Headway is being made, however, and some of that $6 billion in vc money is going to tools that will have higher quality data collection than yourr average step counter. Now, for example almost all urban practices use digital blood pressure cuffs.

[3:55 PM] HealthExpert: I think there is still a big philosophical disconnect between active, quantified self patients and the medical profession, who sees their authority being undermined in many domains.

[3:55 PM] choux-fleurs: What about services like 23andMe?

[3:55 PM] HealthExpert: If you are quantified self perrson, you should try to find a doctor who is open to that.

[3:57 PM] HealthExpert: So, 23&m3 is retail genetic testing. Remember, most doctors are not even trained to read a genetic analysis. so you cannot take your 23&me results to your family doc and expect her to know what to do with that. But, a lot of people find the testing fun, and the people's willingness to let their genome be studied anonymously is important to research. If I were tested by 23&me and they said I had a marker for depression, I would want to talk to a genetic counselor about that.

[3:58 PM] choux-fleurs: I used it to find out whether I was homozygous for a particular hereditary condition, so that was fun and useful

[3:59 PM] HealthExpert: That said, genomic medicine is a real thing. We can really identify who is likely to have certain types of breast cancer, etc. and the science is improving daily. for info you can google "all of us" and find the National Institutes of Health Precision Medicine Initiative.

[4:00 PM] HealthExpert: If you are interested in being genetically tested, I would just make sure the serrvers wherre the data is stored are in a country where they don't have a history of stealing identity information (criminal or goverment stealing).

[4:00 PM] HealthExpert: I think we are at time. I can take one last question. You've all asked some great ones.

[4:01 PM] Russelsteapot42: What is your prognosis on the future of healthcare as a whole? Are these problems solvable, or intractible?

[4:03 PM] HealthExpert: financing (insurance or single payerr) is a political problem. It may be intractable because of that. But I think progress can be made in modernizing care delivery through health information, and in changing how doctors and patients interact, especially as tech-savvy disrupters become parents and caregivers for their elderly patietnts. And on that politics thing: calling your Senator actually does work!

[4:04 PM] Helicase21: Awesome, thanks so much for taking the time @HealthExpert

[4:04 PM] choux-fleurs: thank you!

[4:28 PM] skysinsane: thanks a bunch!

[4:35 PM] Russelsteapot42: Yeah, that was very helpful

[11:39 PM] zahlman: I couldn't be here for it, but please leave the channel around so I can read it later, if there won't be a transcript elsewhere

July 23, 2017

[8:32 AM] Helicase21: definitely

[8:36 AM] wazzup987: @Helicase21 do you want me to maeka log of this ama or are you goign to