Friday, September 8, 2017

Insurance Comissioners

<h1>Vital Health Officials You’ve Never Heard Of: Insurance Commissioners In The Hot Seat</h1> <span class="byline">
By <a href="http://californiahealthline.org/news/author/julie-appleby/"><strong>Julie Appleby</strong></a> </span>
<p>With insurance premiums rising and national efforts at health reform in turmoil, a group of 50 state bureaucrats whom many voters probably can’t name have considerable power over consumers’ health plans: state insurance commissioners.</p>
<p>As insurers threaten to exit state markets and voters at town halls complain about unaffordable prices, the state commissioners are central characters in the unfolding drama that is America’s health coverage.</p>

<p>“What’s the worst job to have right now? Insurance commissioner,” said Christopher Koller, a former commissioner from Rhode Island who is president of the Milbank Memorial Fund, a foundation that works to improve health. “They’re trying to keep the market stable.”</p>
<p>Most are wrestling with how to take on this task amid ongoing political rancor over the fate of the Affordable Care Act. Several commissioners are slated to testify <a href="https://www.help.senate.gov/hearings/stabilizing-premiums-and-helping-individuals-in-the-individual-insurance-market-for-2018-state-insurance-commissioners">Wednesday</a> before the Senate health committee to talk about market stability and how to ensure patients have affordable health care.</p>
<p>The political debate highlights the role of this crew of wonk-ish administrators who sometimes preside over underfunded, understaffed offices and whose range of duties usually spans well beyond health care and its myriad complexities.</p>
<p>In all but one state, the commissioner regulates all types of insurance, and in several he or she might hold other jobs — such as lieutenant governor (Ohio), state auditor (Montana) and fire marshal (Mississippi, North Carolina, Tennessee and Georgia).</p>

<p>Most commissioners have the authority to reject premiums or modify rates they deem excessive. They also have the power of their bully pulpit. California Commissioner Dave Jones, for example, lacks the statutory muscle to override insurers’ rate increases, but he often uses his position to publicly call out insurers’ premium hikes.</p>
<p>In an unusual arrangement, he shares regulatory authority over health insurers with Shelley Rouillard at the Department of Managed Health Care. She regulates a much larger share of the health care market but doesn’t grab the spotlight as much. She too has <a href="http://www.latimes.com/business/la-fi-aetna-rate-hike-20150716-story.html">publicly scolded</a> major insurers, such as Aetna, for unreasonable rate hikes. Her agency is reviewing next year’s premium increases for the Covered California exchange.</p>
<p>Unlike Jones, a Democrat who is <a href="http://www.sacbee.com/news/politics-government/capitol-alert/article113581408.html">preparing to run for state attorney general</a>, insurance commissioners lean nonpartisan. “Historically, insurance commissioners have seen themselves as civil servants more than politicians … and have kind of stayed out of political battles,” said Tim Jost, emeritus professor at the Washington and Lee University School of Law, who also serves as a consumer advocate with the National Association of Insurance Commissioners (NAIC).</p>
<p>But, he added, “at least for the moment, it’s more politicized than it has been in the past.”</p>
<p>Eleven commissioners are elected and the remainder are appointed and — as such — face new political pressures in a highly partisan health care debate.</p>
<p>The individual insurance market, where about <a href="http://www.markfarrah.com/healthcare-business-strategy/A-Brief-Look-at-the-Turbulent-Individual-Health-Insurance-Market.aspx">17 million people</a> purchase their own plans because they don’t get it through their jobs, is the focus for much of this drama.</p>
<p>GOP repeal-and-replace talking points have hammered a message that the individual market — including the government exchanges — are imploding. But Democrats counter that though they face difficulties, this is not the case. The insurance commissioners are caught in the middle and have the power to make either narrative come true.</p>
<p>Many had to scramble this summer — negotiating, offering incentives or just downright pleading — to get insurers to stay in their markets.</p>
<p>At one point, there were more than 40 counties nationwide with zero insurers for next year. As of Aug. 24, when insurer CareSource agreed to provide coverage in Ohio’s Paulding County, no more of these so-called “bare counties” remained.</p>
<p>When Julie Mix McPeak, commissioner of Tennessee’s Department of Commerce and Insurance, persuaded Blue Shield to return to areas of the state that it had pulled out of last year, she recalled: “Some critics said I was going out of my way to prop up Obamacare. Others said I wasn’t doing enough because I’m from a red state and that must mean we want Obamacare to fail. But I just want access to coverage.”</p>
<p>Critics worry that in some states the position is a <a href="https://www.washingtonpost.com/investigations/drinks-junkets-and-jobs-how-the-insurance-industry-courts-state-commissioners/2016/10/02/1069e7a0-6add-11e6-99bf-f0cf3a6449a6_story.html?utm_term=.21073464b328">revolving door</a> with industry, moving them to do less than they could.</p>
<p>“It a double-edged sword,” said Sabrina Corlette, research professor at Georgetown University’s Health Policy Institute. “Knowledge of industry … is very important in the job. [But] … if someone is coming from and going back to industry, it does raise some red flags about where their interests really lie.”</p>
<p>Sometimes a past résumé draws increased public scrutiny of a regulator’s actions on issues under the department’s purview.</p>
<p>Connecticut Insurance Commissioner Katharine Wade, who was a Cigna executive before being named commissioner, was fined $500 in June after the state’s Freedom of Information Commission ruled that she improperly withheld documents related to a proposed merger between Aetna and Humana. She is appealing the ruling, her office said, seeking clarity on what they see as a conflict between insurance laws, which require confidentiality for some information, and the freedom of information statutes. The proposed merger was called off in February after a federal court blocked the deal, but not before a state review of Connecticut-based Aetna’s plan drew criticism because of Wade’s past employment.</p>
<p>McPeak and other commissioners also say that cost issues need to be tackled, but there’s no bandwidth to take on these thorny issues because they have to deal with the more immediate problems.</p>
<p>“We can’t get to affordability if I don’t have a policy for people to buy,” said McPeak. For next year, “I’m telling consumers there will be problems and they will see rate increases. But at least they have an option.”</p>
<p>These efforts are made more complicated by President Donald Trump’s repeated threats to eliminate subsidies used to lower deductibles for some ACA policyholders, which would raise premiums. Payments are currently being made on a month-to-month basis. It will likely be a topic during the upcoming Senate hearing.</p>
<p>“We would all like to know what the rules are. When there is uncertainty, it’s difficult to make short- or long-term decisions, said Al Redmer, who was appointed Maryland’s insurance commissioner in 2015 by Republican Gov. Larry Hogan.</p>
<p>And the subsidies aren’t the only point of contention, with the partisan divide also reflected among some commissioners.</p>
<p>Trump and Congress are causing uncertainty that is “sabotaging the progress we’ve made,” Washington state Insurance Commissioner Mike Kreidler <a href="www.insurance.wa.gov/news/eleven-health-insurers-file-2018-individual-market-37-counties-leaving-two-no-coverage">wrote</a> in June. His state strongly embraced the ACA.</p>
<p>Kreidler, a Democrat who formerly was a member of Congress, was first elected commissioner in 2000.</p>
<p>In contrast, Oklahoma Insurance Commissioner John Doak, whose state opposed the ACA from the start, has made it no secret that he supports repeal of the law, calling it “this disastrous experiment.” Doak, a Republican who was elected to the position in 2010 after working for various insurance companies, <a href="https://www.ok.gov/triton/modules/newsroom/newsroom_article.php?id=157&article_id=33277">blamed ACA regulations</a> for “so many insurers dropping out of exchanges or resorting to double digit premium increases.”</p>
<p>Commissioners’ regulatory powers vary by state, depending on the rules state legislators have put in place for them to enforce.</p>
<p>“Some states have comprehensive protections for consumers … while others have limited protection,” said Claire McAndrew, director of campaign strategy at Families USA.</p>
<p>But if they are so motivated, consumers can always find means to take an activist role.</p>
<p>Past commissioners, for instance, talk of using the regulatory process itself — pushing the boundaries in drafting the rules or using a “slow walk” toward their implementation — to work around these boundaries.</p>
<p>Even so, they face other limits. For instance, staffing levels for their departments are down nearly 6 percent since 2008, according to the most recent NAIC <a href="http://www.naic.org/prod_serv/STA-BB-16-01.pdf">statistics</a>.</p>
<p>That’s a big disadvantage when contrasted with the “strength of insurance industry lobby,” said J. Robert Hunter, a former Texas commissioner and now director of insurance at the Consumer Federation of America.</p>
<p>And some fail to counter industry influence in legislatures and even inside their own offices, he added.</p>
<p>He recalls that when he took up his post in Texas, he met with lawmakers in the Statehouse, some of whom were “unabashed” in their support of the insurance industry, warning “we’ll hurt your budget” if he went too hard on industry.</p>
<p>He didn’t play ball.</p>
<p>“If insurers are always happy, something is wrong,” said Hunter. “Insurance commissioners’ jobs are to hold them to account.”</p>
<p>Correction: This story was updated on Sept. 6 to correct the spelling of Connecticut Insurance Commissioner Katharine Wade. It also adds a description from her office of the dispute she is appealing. The interactive map was updated Sept. 6 to reflect the appointment of a new insurance commissioner in Pennsylvania.</p>
<p>This story was produced by <a href="http://khn.org/">Kaiser Health News</a>, an editorially independent program of the <a href="http://kff.org/">Kaiser Family Foundation</a>.</p>

Monday, August 7, 2017

3 Doctors Over 60 Tell Us How Healthcare Has Changed

"It's not like it used to be"




How has medicine changed in the last 30 or 40 years?  

circa 1950

circa 2000



circa 2015

 Just in the last decade medicine has changed a lot. For instance, by the end of the year approximately 90% of office-based physicians nationwide will be using electronic health records (EHRs).

The doctors: Over 100 years of collective experience

  • Barbara Bergin, MD, is an orthopedic surgeon at Texas Orthopedics and has been a doctor for 31 years. I highly recommend you check out Bergin’s blog, where she offers tips on keeping your joints healthy using conversational language, humor, and personal anecdotes.
  • Damien Howell, PT, DPT, OCS, is a physical therapist at Damien Howell Physical Therapy, and has been practicing for more than 40 years. Howell also blogs. “I started that webpage in 2003 before blogs existed,” he says with a laugh.
  • John Errol Asher, MD, is a board-certified infectious disease physician and internist, who began practicing more than 40 years ago before retiring this year.

As a senior retired ophthalmologist I have witnessed most of these changes. In 1962 when I was a junior medical school student Medicare came into existence.

The reference article focuses on the electronic health care record, which is too narrow a focus on changes over the last 49 years.

Perhaps the most annoying aspects of change have been the growth and interference with doctor and patient choices for treatments requiring authorizations for payment of claims. This interference is perhaps the one greatest change in health care.  This is the result of increasing costs, yet health care costs continue to increase.

Recently increasing regulations and CMS rules have been found to increase costs offsetting any possible reductions in health care cost.

In an effort to decrease overhead, many physicians have created group medical practice business structure,   in an effort to build an organization with greater negotiating power,  and to reduce overhead.  The former may be valid, the latter is in doubt.

3 Doctors Over 60 Tell Us How Healthcare Has Changed

A new Partnership between Humans and Machines in Healthcare



GregorTobeitz, Editor The Healthcare Nerd & The Digital Strategist


Artificial intelligence is on the lips of computer scientists. Many computer scientists promise great things for it's use in health care and medicine. It will add to the growing number of digital systems to aid in care of patients.


Nearly on a monthly basis, research that documents how algorithms are over-performing on humans, have been published.
With the current pace of advancements in AI one can easily assume that in 10 years from now algorithms will over-perform humans on 80% of today’s classified diagnosis.
10 years is a long time, when you consider that during this period we will have access to new neurosynaptic processing power such as IBM’s TrueNorth or cloud based quantum computing. Ten years ago the iPhone got introduced which led to the development of 180.000 registered health apps, which equals 50 apps a day. Yes, a large part of them aren’t useful, but we can’t ignore the impact apps had on patients and clinicians. During the last 5 years we have seen error rates on speech and image recognition drop by over 20 percent to nearly human accuracy. So it is not a long shot to predict that, soon algorithms will over-perform humans on specific tasks such as diagnosing disease or selecting the best personalized treatment plan. We can’t ignore technology that, depending where you live, can deliver 10 to 100 times better results. We should discuss on how we will design our future healthcare systems and future work, and not question if this is going to happen, as at one point it might be too late to influence our future.



Harvard Medical School, showed that AI isn’t about Humans versus Machines. They trained a Deep Learning Algorithm for identifying Metastatic Breast Cancer, interpreting pathology images. Their algorithm reached an Algorithm Accuracy 92.5%, where Pathologists reached an Accuracy of 97%. But used in combination, the detection rate approached 100 percent (approximately 99.5 percent).
It is exactly this kind of collaboration between humans and machines that is going to play a vital role in the age of AI and we already have a blueprint of how a productive partnership could look like.
Chess was one of the first areas that was taken over and subsequently dominated by machines almost 20 years ago. After Garry Kasparov, the reigning world champion at the time, lost to the IBM Computer ‘Deep Blue’ in 1997, the head to head contest between humans and machines lost much of it’s appeal. Today no human, not even the grandest of all grand masters, can beat even a mid-tier chess program running on an iPhone. After this huge symbolic victory for the machines there was doubt that humans could contribute something meaningful to the world of chess ever again.

What helped the team win didn’t have anything to do with being the best chess players or having the most powerful chess computer but having the best process of collaborating with machines. It was all about the partnership and the complementary interplay between humans and machines. Humans still have a lot to offer to the game of chess if they are not racing against the machines but with the machines. To achieve the best results humans and machines have to collaborate — they have to become partners. But this requires a new set of skills and a new way of thinking on the part of humans.
Bart de Witte is keynote speaker, innovator, intrapreneur and healthcare nerd. Bart is involved in leading edge technologies leading the Digital Health Business for IBM DACH, he has been intimate involved as a mentor in the formation and growth of a dozen startups within the healthcare sector. He is passionate about technology and data-driven transformation of healthcare systems.



We also know that in our current healthcare systems we are lacking the human element. Recent studies have shown that our social determinants count for more as 50% to our health status. From a 7 minute consultation a a physician spent less then 20% for true human interaction, and is focussed on collecting clinical data, reasoning, documenting, administrating and coordinating. But one of the most important parts of care delivery, empathy and compassion have become neglected. This already starts at medical school.
A recent study done at Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School, showed that AI isn’t about Humans versus Machines. They trained a Deep Learning Algorithm for identifying Metastatic Breast Cancer, interpreting pathology images. Their algorithm reached an Algorithm Accuracy 92.5%, where Pathologists reached an Accuracy of 97%. But used in combination, the detection rate approached 100 percent (approximately 99.5 percent).
It is exactly this kind of collaboration between humans and machines that is going to play a vital role in the age of AI and we already have a blueprint of how a productive partnership could look like.
Chess was one of the first areas that was taken over and subsequently dominated by machines almost 20 years ago. After Garry Kasparov, the reigning world champion at the time, lost to the IBM Computer ‘Deep Blue’ in 1997, the head to head contest between humans and machines lost much of it’s appeal. Today no human, not even the grandest of all grand masters, can beat even a mid-tier chess program running on an iPhone. After this huge symbolic victory for the machines there was doubt that humans could contribute something meaningful to the world of chess ever again.
We now know that is not the case.







A new Partnership between Humans and Machines in Healthcare