Screen Shot 2015-06-25 at 10.44.49 AMIn a 6-3 ruling, the Supreme Court ruled that the federal health law may provide subsidies to help Americans buy insurance on the state exchanges, officially putting a stop to one of the slowest-moving and arguably most mind-numbingly boring — if important — news stories in recent history (with all due apologies to tax credit enthusiasts and the American Academy of Actuaries).

More importantly, the ruling means that 30 million Americans will continue to be eligible for health insurance through the exchanges. Practically speaking, the decision eliminates the last major challenge to the Affordable Care Act.

Health stocks rose on the news, as the uncertainty that has been shadowing hospital and health plan stocks for months was eliminated.

The dissenting opinion in King, authored by Justice Scalia, is already being called an “instant classic*,” is replete with memorable zingers such as:

“Words no longer have meaning if an Exchange that is not established by a State is “established by the State” and “..It is bad enough for a court to cross out “by the State” once. But seven times?

Dissenting opinions in important cases, of course, are almost always hailed as “instant classics” by supporters, just as they are thrashed as “incoherent judge-babble” by critics.

So to be taken with a grain of salt. Or not.

The line that is likely to be remembered, and quoted most widely by opponents of the Affordable Care Act, however, is this one:

“The Act that Congress passed makes tax credits available only on an ‘Exchange established by the State.’ This Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare.”


I remember the meeting as if it were yesterday.

It was a fine, crisp morning. My Health Catalyst team and I were at a new partner hospital with a national reputation, known for its excellent coordinated care and its outstanding performance on key quality measures.

I was looking forward to a low-key presentation. After the meeting, I planned to escape and take a relaxing run and catch the early flight back home.

Unfortunately for me and my running plans, when we began showing some of the data Health Catalyst had compiled, the confrontational questions began:

“And what does that show?”

“What’s the point of this exercise?”

“Not my patients …”

It was all I could do to not duck behind my notepad and shield myself from the onslaught.

After several years of successful quality improvement initiatives and a string of successes that had the won the hospital national recognition, tensions between the administration and the doctors had reached a breaking point.


Martin SamuelsIn 1970 I had the opportunity to spend time at the Royal Free Hospital in London.  One of my professors at The University of Cincinnati College of Medicine, the late Leon Schiff, a renowned liver expert, arranged for me to work under Professor Sheila Sherlock.  I was placed in a laboratory that was investigating the presumed immune basis of primary biliary cirrhosis.  Roy Fox and Frank Dudley, the faculty in the lab, warmly welcomed me and taught me the basics of immunology research.  My first scientific paper in Gut, was based on this work.  But, I was a budding clinician and I was drawn to the charismatic Professor Sherlock, so I took every opportunity to attend her rounds and teaching conferences.  In many ways a fearsome figure, The Prof dazzled me with her clinical acumen, rhetorical skills, sense of humor and drive.  Though only a lowly visiting medical student, she including me in the exercises and even turned to me as a local “expert” on American culture.  The entire experience is remarkably memorable.  The Prof was filled with pearls, anecdotes, stories and caveats.  Here are a few.

The “outpatient” consisted of the Prof seeing patients while the students watched.  The room was arranged with six cubicles, three on each side of her desk, each guarded by a watchful nurse (sister) with a neat uniform and starched hat.  In front of The Prof’s desk were several rows of chairs; perhaps a total of 16, for students who were to sit quietly unless specifically ask to speak or to feel the liver of one of the patients.


1. Be a real expert (have something real about which to mentor)

2. Don’t avoid being a mentor because you are not “like” the mentee (e.g. gender, age, field, ethnicity)

3. Give negative feedback when necessary but don’t hold a grudge

4. Use your power to substantively help the mentee

5. Be proud of your mentees and tell them so (take real pleasure in their accomplishments)


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Michael Lewis’ 2003 best seller Moneyball recounts how Oakland Athletics’ manager Billy Beane beat the big-payroll odds in major league baseball by using analytics to field a competitive team. The dynamic between Beane and his Yale-trained geek, Peter Brand is the central theme: together they fought off naysayers using Brand’s sabermetrics model later credited with the Red Sox World Series win the next season.

This week, thousands of financial officers from across multiple sectors in healthcare will descend on Orlando for the Healthcare Financial Management Association Annual Institute (ANI), a four day potpourri of knowledge-sharing sessions punctuated by keynotes from industry luminaries and an active exhibit floor.

The growing complexity of healthcare financial administrative issues is daunting. Case in Point: ANI organizes its 80 sessions in 8 tracks titled Business Intelligence and Analytics, Clinical Integration, Collaboration for Decision-Making, Cost Management-Margin Transformation, Finance-Capital Markets, Payment Trends and Delivery Models, Regulatory and Compliance Updates, and Revenue Cycle and the Patient Experience. There’s something there for everyone—from the rookie in internal audit to the CFO in the C-Suite.


flying cadeuciiRoughly 25 million Americans have been subjected to unwanted medical treatment at some point in their lives, and that means we have a healthcare system that is not listening to patients. We all say we believe in patient-centered health care, and now we have a bill in the U.S. Congress that would put our money where our mouths are. Literally.

Senators Mark Warner (D-VA) and Johnny Isakson (R-GA) introduced legislation this month that would make sure Medicare recipients and their doctors know how much or how little treatment those patients would want as they approach the end of life. The Care Planning Act of 2015 would specifically create a Medicare benefit for people facing grave illness to work with their doctor to define, articulate and document their personal goals for treatment. Doctors will be rewarded with reimbursement for helping patients make very important end-of-life decisions when there is time and space to do so thoughtfully, before a crisis and when the patient can advocate for herself.


Bob WachterNatural language processing might seem a bit arcane andtechnical – the type of thing that software engineers talk about deep into the night, but of limited usefulness for practicing docs and their patients.

Yet software that can “read” physicians’ and nurses’ notes may prove to be one of the seminal breakthroughs in digital medicine. Exhibit A, from the world of medical research: a recent studylinked the use of proton pump inhibitors to subsequent heart attacks. It did this by plowing through 16 million notes in electronic health records. While legitimate epidemiologic questions can be raised about the association (more on this later), the technique may well be a game-changer.

Let’s start with a little background.

One of the great tensions in health information technology centers on how to record data about patients. This used to be simple. At the time of Hippocrates, the doctor chronicled the
patient’s symptoms in prose. The chart was, in essence, the physician’s journal. Medical historian Stanley Reiser describes the case of a gentleman named Apollonius of Abdera, who lived in the 5th century BCE. The physician’s note read:

There were exacerbations of the fever; the bowels passed practically nothing of the food taken; the urine was thin and scanty. No sleep. . . . About the fourteenth day from his taking to bed, after a rigor, he grew hot; wildly delirious, shouting, distress, much rambling, followed by calm; the coma came on at this time.

The cases often ended with a grim coda. In the case of Apollonius, it read: “Thirty-fourth day. Death.”


As the health care community waits for the outcome of King v. Burwell, the latest Affordable Care Act (ACA) challenge, the focus has been on a key question:  What happens if the Supreme Court doesn’t allow the federal healthcare marketplace to continue to offer premium tax subsidies? But how such a decision would affect the rate of insurance is just the tip of the iceberg. Eliminating federal subsidies impacts a whole range of ACA policies that were carefully navigated during the legislative process. As we wait for legal decision, we have an opportunity to examine whether the choices made in 2010 remain on solid ground if a significant portion of subsidized coverage disappears.

The ACA is the result of a complex web of compromise and, of course, a healthy dose of politics. By its very nature, the legislative process seeks to balance interests and assign responsibilities. In the case of the ACA, this meant that a dramatic coverage expansion helped define which stakeholders – providers, insurers, employers, and others – would benefit down the line in the form of new customers (and revenue) or reduced costs.  In turn, it was reasoned, these stakeholders would bear burdens, in the form of reduced revenue or new tax or regulatory obligations, to help pay for the legislation.

If only the trade offs were that simple. In reality, complex and often charged discussions took place with numerous stakeholders and were linked to policies that extended beyond healthcare coverage (e.g. Medicaid drug rebates). Additionally, since the law passed numerous efforts to repeal, amend, or delay key ACA financing components – including insurer fees, medical device taxes, hospital subsidies, and the small business mandate – have surfaced and threatened to upend the ACA’s attempted balancing act.


On May 4, 2015 Department of Health and Human Services (HHS) Secretary Burwell announced that the Pioneer ACO program had saved the federal government $384 million and improved quality in its first two years and would therefore be expanded. HHS also released a 130 page independent program evaluation by L&M Policy Research that served as the basis for the Centers for Medicare and Medicaid Services (CMS) Actuary’s certification of the Pioneer program.

Burwell’s triumphant announceand ment was an intended shot in the arm for the troubled Pioneer ACO program, 40 percent of whose initial 32 members dropped out in the first two years. It also illustrated the yawning reality gap between DC policymakers and the provider-based managed care community. In reality, the Pioneer program badly damaged CMS’s credibility with the provider-based managed care community and sharply reduced the likelihood that the ACO will be broadly adopted.


CVS Health acquires Target’s healthcare biz

CVS Health will pay $1.9 billion to acquire Target’s healthcare businesses, including 1,600 pharmacies and 80 MinuteClinic health clinics.

CVS Health also just opened its Boston-based Digital Innovation Lab, which will focus on developing cutting-edge digital services and personalized capabilities that offer an accessible and integrated personal pharmacy and health experience.

CVS is making big strides to position itself as both a digital innovator and major provider of primary care services. Look for them to continue to build on existing partnerships with regional health systems. What’s next – maybe more integration of its health apps into EMRs, patient portals, and HIEs?

Former hospital CFO sentenced to prison for attestation fraud

Joe White, the former CFO of Shelby Regional Medical Center in Texas, is sentenced to 23 months in federal prison for falsely attesting that the hospital was a meaningful user of EHR. White was also ordered to pay almost $4.5 million in restitution to Medicare’s EHR Incentive program.