Obamacare Turns Wellness Exam into Dying Discussion

Last Monday I got up early, went to gym, did my cardio and took an hour long Pilates class. Then I had a shower and set off for my annual Wellness Exam. (One of those new mandated benefits of the Affordable Care Act [Obamacare] and/or Medicare).

It was a lovely bright blue summer morning, my first day free from a nine month project I had been managing for one of Silicon Valley’s elite technology companies. I was feeling really wonderful – until I got to Palo Medical Foundation.

The receptionist greeted me promptly and took my co-payment. Then she handed me a clipboard with a form attached.

Welcome to the Most Annoying Form on The Planet

It is legally required to be filled out annually by all of us who have reached a certain age.

I wonder if Hillary Clinton’s doctor or Nancy Pelosi’s doctor has the nerve to tell her the form is the law and she has to fill it out. I’m not as old as they are!

The first question asked if could bathe myself without assistance. It went downhill from there.

No, I am not depressed. At least I wasn’t until I walked into the clinic.

Yes, I live in a house with stairs. I run up and down them countless times every day.

Yes, I dispense my own medications – for allergies – because all native Californians are allergic to something. It’s in the air.

No, I have never accidently overdosed myself. In fact, I read the fine print that comes with the medication and take the pediatric dose because I don’t weight 100 pounds soaking wet. There’s nothing wrong with my reasoning!

Yes, I’ve filled out my Healthcare Directive. No, I don’t discuss it regularly with my son – he knows my wishes.

By The End of the Exam I Did Need Medication to Lower My Blood Pressure!

Not only did I have to fill out the questionnaire but the doctor then asked me all the same questions, again. The actual physical exam plus the laboratory blood draw took a total of 10 minutes. The argument about giving me the required referral to see my true primary doctor – allergy and immunology – took another 10 minutes.

The remaining 30 minutes of the exam had nothing to do with keeping me well, happy, productive and independent. Rather, the focus was on just the opposite – measuring the rate of my decline into Depression, Dementia and Death or as I like to call them – the 3 Ds.

One Size Fits All Government Mindset Taking Over Our Healthcare

It’s nothing personal – I had to remind myself – it’s the one size fits all mentality that pervades the bureaucracy at the Center of Medicare and Medicaid Services (CMS).

It’s a striking example of the outdated thinking that dominates Washington DC.

Today, more than 25 percent of 70 year olds are still in the work force – still paying Medicare taxes every pay period – active, vibrant, engaged and productive.

Any of the leading 2016 Presidential candidates would enter the White House already somewhere along the CMS 3Ds continuum– unless we elect Marco Rubio.

The logic behind the Wellness Exam is management of the four chronic disease conditions that cost the US health care system the most – diabetes, high blood pressure, obesity, and heart disease. The earlier these are identified the more effectively they can be managed – through lifestyle modification and, if necessary, medication – controlling the cost of care.

Put Patient at the Center of Healthcare

If health management is the focus of our modern healthcare system, doesn’t it make sense for the doctor to encourage my active and engaged life-style – maintaining my weight, blood pressure, blood sugar – rather than condescendingly telling me I am in denial?

It’s illogical, but the Federal government is incenting the doctor to focus everyone on preparing to die rather than to live.

They’re just following a basic tenet of modern politics – if you repeat a lie often enough it becomes the truth. Tell me I am in decline until I believe it and obligingly die.

I am a typical Baby Boomer – independent, grabbing the gusto. I’m not likely to return any time soon – unless I am sick or injured – adding rather than reducing the cost of my final care.

In the business world, when a policy or procedure is not customer friendly and may cost either customers or customer wallet share, we change it.

If the Centers for Medicare and Medicaid Services truly wanted to keep Baby Boomers well and productive they’d get the bureaucracy out of the exam room and let doctors and patients decide when and how often to focus on the inevitable questions that surround aging.

Photo Credit: Google Images

ACA Exchange = Shiny New Car Paint But There’s No Engine

The mainstream media is still reporting the Affordable Health Care (ACA) Exchange Website is not working well – when it works at all. Well, they’ve got it wrong. It’s not the website that isn’t working. It’s the very complicated software environment behind the website that’s dysfunctional. The website does not work because a significant portion of that software environment is not yet built or even designed – end to end.

ACA’s Bright Shiny Paint Job

A website is like the shiny bright paint job on a new car on the showroom floor. The paint attracts the buyer’s attention but it doesn’t drive the car.

What propels the shiny paint job down the road is a chassis, to which a body style can be attached, and a motor. The ACA chassis is the software architecture that is supposed to link the user, the government and insurance company systems together – the same way the chassis connects the axles and steering wheel to the driver.

When Ford or GM or BMW or Tesla, for example, build a new car they start with the chassis. Many body styles (and paint colors) can be built on a single chassis. The weight of the chassis and the associated body style determine the size engine that is needed to make the vehicle efficient and easy to drive.

In software the chassis is the systems or environmental architecture. The architecture is the super-superstructure to which each of the individual software modules are attached – for example, prove the identity of the applicant. The architecture also establishes the relationship between individual modules. For example, after establishing identity, the next module determines eligibility for subsidies and/or Medicaid. The software modules are grouped together to meet specific user needs – analogous to the auto body style. The modular relationships determine the type (and complexity) of software needed to make the whole thing work – the engine.

Oops, Engine Not Bolted To Chassis

The ACA Exchange website crashed on launch not because the shiny green user portal didn’t work but because the engine – the software – hadn’t been bolted securely to the chassis and fell off as soon as users “stepped on the gas”. In fact, we now know that the chassis has not yet been fully designed and consequently there really are no engine bolts.

For the past week, daily “cover their own backside” (“CYA”) leaks from both administration and Center for Medicare and Medicaid Services (CMS) officials have brought to light a troubling picture of political expediency, bureaucratic bungling and executive irresponsibility. The self-serving leaks have unveiled the truth.

At least 40 percent of the system has not yet been designed. OMG, beyond the shiny green paint – there isn’t even a complete design of the car – yet and White House officials knew it. The chassis is nothing more than a partial Plaster of Paris model –certainly not sturdy enough for any road test.

In the automobile design process there actually is a Plaster of Paris model of a proposed car. It is used by car manufacturers to secure bids from tool and die makers and other suppliers so that they can determine, at various points in the design process, the costs and challenges associated with the planned vehicle. It’s no different in the procurement of software (purchased systems) or software development.

If the Plaster of Paris model is incomplete, the tool and die maker can only tell the car manufacturer the hourly cost of labor and the cost of a ton of steel, not the wholesale cost of the car tooling. Similarly, in software development if the first task for the vendor will be to define the system, their bid must be limited to an hourly billing rate plus a specific percentage of that rate to cover miscellaneous development expenses.

Until the system has actually been defined, there can be no plan to develop it. No plan means no budget and no budget means no controls. That’s a software contract every vendor dreams of and is every client’s worst and unending nightmare.

ACA is a Shiny Green Edsel

An estimated $600 million dollars has been spent on the ACA Exchange to date. There’s still no end to end system designed or built. Absent strong executive guidance, detailed plan-to-complete and seasoned management, the ACA Exchange is a shiny green Edsel destined for the junk yard of failed government information technology projects. Except this time, it could take a significant part of the US economy along for the ride!!

As tax payers, we must insist that Congress freeze spending on the ACA Exchange, including so-called “fixes” at least until an end-to-end design is complete, new management and oversight team has been put in place, capable external contractors hired and zero-cost-overrun development and rollout milestones established. If you agree – call, write or forward this blog to your representative along with your own comments.

Photo Credit: Joe Raedle/Getty Images

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Government Plan For Patient-Centric Healthcare Reform Is Suspect

My primary care doctor spent half of our 20 minute appointment complaining that she has to waste too much of her time with each patient entering data into the computer. She became a doctor, she sighed, because she wanted to “help people live better, fuller, longer lives not to serve a machine”.

She needs-to-get-over-it! The computer in the exam room can facilitate scientific research that will help people live better, fuller, longer lives! That is, unless the science is co-opted by the government through the Institute for Patient-Centric Outcomes and the Independent Payment Advisory Board (IPAB) in 2015.

To illustrate the science – Kaiser has been trying to increase the number of patients who undergo routine colon cancer screening for 20 years. About 10 years ago, they migrated all of their patient health records onto a single, standardized computerized platform. I know, I wrote the business rationale.

For the first time, Kaiser could readily identify their entire 50 to 75 year old patient population and track test results over a decade. Researchers compared the effectiveness of screening colonoscopy to less invasive testing methods, both to determine diagnostic reliability and patient compliance. At the end of the decade, they had doubled the rate of patient participation and saved more lives through early detection.

This research technique is known as comparative effectiveness. Comparative effectiveness compares outcomes first on the basis of quality and compassionate care. Then, all things being equal, it considers comparative cost. In Kaiser’s case, it turned out the cost savings were significant.

It’s a technique well suited to Kaiser. Their patient population is large (8.9 million patients), diverse, stable, and in some cases includes a patient history over multiple decades – sometimes from pre-natal to birth through adulthood. This will allow future comparisons across generations to determine the impact of environment versus genetics, for example.

Now enter Obamacare. During the debate over the ACA some staffers apparently heard the term “comparative effectiveness research”, from an insurance industry lobbyist. Here, they thought, was a panacea for cost control and cost reduction.

Congress authorized $3.5 billion dollars to establish a Patient-Centered Outcomes Research Institute – under Centers for Medicare and Medicaid Services (CMS). The Institute is already identifying, funding and collecting comparative effectiveness studies from health care institutions around the country with the intent to establish national standardized diagnostic and treatment protocols.

Standardized and patient-centric – now there’s an oxymoron! Human beings are not shrink-wrappable! For example, standard basal temperature of a healthy adult is 98.6 degrees. But I am a healthy adult whose basal temperature is 97.6 – always has been. Under a standard reimbursement protocol, an emergency room might not be reimbursed for treating me for fever until I reached the standard of 103, instead of the more appropriate 102, even if that resulted in harm to me.

The same legislation established the Independent Payment Advisory Board (IPAB). The board, unelected and unaccountable, will begin to make Medicare coverage decisions in 2015 justified by comparative effectiveness studies collected by the Institute.  Medicare coverage decisions are usually quickly adopted by Medicaid and private insurers.

Congress stipulated that cost should not be considered in determining the relative effectiveness of test or treatment options. But I’m a bit too familiar with the difference between legislation and regulatory interpretation to take that stipulation seriously. ACA was an 1100 page bill that has spawned 100,000 pages of regulations and they are not done writing, yet!

If better treatment and higher patient satisfaction were REALLY Congress’ altruistic objective, the Institute would have been established as part of the National Institutes for Health (NIH). NIH is “the nation’s medical research agency – supporting scientific studies that turn discovery into health”. The NIH already regularly sponsors comparative research with private health care systems – i.e. Kaiser, Mayo etc. At best, the Patient-Centric Institute is a $3.5 billion duplication of effort. At worst, parallel efforts may lead to conflicting results adding confusion where clarity is the objective.

In the America I imagine, our national objective would be to reduce the cost of health care through unbiased scientific research — extending the limits of our knowledge instead of constraining the study to comparisons between known options. Sometimes research generates new drugs, new therapies, and new medical devices and sometimes it proves that less treatment is more helpful. The last is, in fact, the most patient-centric of medical choices.

Meanwhile, I am starting to worry about what penalty the IPAB will assess for being allergic to aspirin. It is, according to many comparative research studies, the best, low-cost preventative miracle drug against cancer, heart disease and arthritis – just not for me!

If you agree with this blog, please forward it to your representatives with your own comments.

Photo Credit: Health Allianze

  • It is up to YOU

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    In the coming weeks, Reimagineamerica.org will do what our Presidential Candidates and other politicians are not - throw out some positive and plausible ideas to "right the ship of state".

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