The pMD Blog

Here's The Latest in Health Care:

• The FDA is recommending that all blood donations in the U.S. be screened for the Zika Virus as additional precautionary measures against the spread of the virus. Not all states are required to test blood donations at once. Testing will begin within the next four weeks for 11 states that are within proximity to areas where Zika is actively spreading via mosquitoes. The expansion of blood testing to all states will occur within a 12-week time frame.  Read More

• Physicians are concerned that the new MACRA payment system, which rewards quality over quantity of care based on quality benchmarks, will put small practice or solo practice doctors at high risk of incurring payment penalties or even push thousands of these physicians into larger practices.  With the way this payment model is structured now, larger practices will do well and smaller practices are likely to do worse. Read More

• Less than one-third of ACOs (Accountable Care Organizations) qualified for bonuses from Medicare in 2015, according to CMS. However, ACOs participating in the past two years have improved on 84 percent of the quality performance measures used and have grown 13 percent in savings since 2014.  Read More

• A new ultrasound-enabled genetic therapy called sonoporation may one day be the new cancer and heart disease fighting tool. This strategy involves the use of "microbubbles" and ultrasound energy to poke holes in cells, administering genes on a molecular level. This approach allows researchers to deliver therapeutic agents to the precise location of the disease while sparing its healthy surroundings. Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news.
A recent conversation with a colleague got me thinking about the pursuit of perfection. He mentioned the old adage, “Perfection is the enemy of good,” and I found it struck a chord with me.

A paragon is defined as a person or thing regarded as a perfect example of a particular quality. It’s also defined as a perfect diamond, flawless and without inclusions. The largest flawless diamond ever found is known as The Paragon. Eventually it was acquired by a jeweler and cut into a seven sided jewel and set in a necklace. They say that having a higher quality cut removes rough material from a diamond and improves it. What, then, if the diamond is already perfect? Why change it?

Seeking perfection so often leads to endless rework, especially in software design and development. An overused phrase amongst developers is “this needs to be refactored.” What they really mean is, “I think this code is less than perfect and I'm going to improve it.”

Refactoring can be an important and useful tool, but it is also an exercise that can be detrimental to achieving the “good.” By definition, refactoring does not change the external behavior or functionality of the software. Its main purpose is to improve the internal properties of the software. Structure, readability, and ultimately maintainability are all potentially improved by refactoring. It's important to keep in mind the law of diminishing returns and strive for an effective creative process.

At pMD we encourage simplification and have a code review process that is part of every release. Every change we make is thoughtfully added and then reviewed by our peers. Ideally, we make incremental improvements to the areas of the software that we are working on and very rarely would we tear something down seeking perfection.

Our team at pMD is wholeheartedly committed to being creators of great software. My colleague’s statement that “Perfection is the enemy of good” served as a reminder that we can be trapped by the idea that things must be perfect. At some point, changes we make to our creations no longer make them better but rather different, and many times worse. Instead, it's best to leverage our desire for perfection to spur us toward better quality, no matter what form that takes. Perfection is a subjective concept and sometimes our first attempt is the best one, and for the time being, overworking something may be just as bad as failing to polish it.

Here's The Latest in Health Care:

• Dr. Karen DeSalvo officially stepped down as National Coordinator of the ONC (The Office of the National Coordinator for Health Information Technology) as of last Friday. Her predecessor, Dr. Vindell Washington, has been with the ONC since January 2016 and is a longtime proponent of health IT and information exchange. Read More

• The U.N. admits to playing a role in the Haiti cholera outbreak that began in the fall of 2010, just months after the devasting earthquake had struck Haiti. The strain found in Haiti was a perfect match for a strain found in Nepal. The source was believed to have come from Nepalese peacekeepers who were staying at the U.N. camp in Haiti. Coupled with poor sanitation, the infectious disease spread into local waterways from the camp's sewage. Cholera is spread through contaminated water and causes dehydration and can lead to death if left untreated. Read More

• Aetna is pulling back its Affordable Care Act exchange presence in 11 states, which leaves some counties with zero insurers offering plans in the 2017 open enrollment period starting November. This exit, combined with that of United and Humana's, will impact approximately 1 million to 1.5 million of the 13 million people who signed up during the 2016 open enrollment period. Read More

• Within the past three weeks, the number of confirmed Zika infections have increased to 35 in the greater Miami area. While public health officials do not expect the virus to spread as rapidly as it has in other countries, pregnant women are still worried. Expectant mothers are taking precautions by confining themselves indoors, spraying exposed limbs with insect repellent, wearing long clothing in 90-degree weather and even going so far as to stay with family and friends far outside of the Zika zone until they've given birth. Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news.
At pMD we describe our working style as fast, efficient, and fun - like a German engineered car. If we work that way, we should travel that way, too! We have an incredible resource available for getting our team members to all of the different nooks and crannies on the map: a private plane! Using private aviation cuts down on overall travel time, allows for our team members to have meetings on board the plane, and eliminates the pesky need to take your shoes off while going through airport security - or watch as the person in front of you in line thinks that the whole no water bottle, no belts, no shoes thing is for everyone else but him.

For many folks, private aviation is viewed as a luxury reserved for Real Housewives and rock stars. However, at pMD we’ve been introduced to private aviation as a great way to travel efficiently (we leave the champagne at home). It’s been fun for me to learn along with my teammates about how private aviation can help maximize our time on the road. My colleagues, Chris and Ryan, recently took a trip using a small, private plane to visit with customers and prospective customers. After reviewing their itinerary, it’s illuminating to compare what this trip would have looked like with commercial flights.

Here are all the stops:
• Cincinnati, OH
• Gallipolis, OH
• Charleston, WV
• Macon, GA
• St. Petersburg, FL
• Miami, FL
• Naples, FL
• Birmingham, AL

The trip started from our southern office in Birmingham, AL on Monday and wrapped up back there on Thursday. 8 cities in 4 days?! Thanks to private aviation, it’s totally possible. Reviewing the total travel time for the week, you get a comparison that looks a little something like this:

Travel time alone clocks in at over 33 hours on commercial travel compared to private aviation's breezy total time of just over 8 hours. Chris and Ryan benefited from several perks that come from flying privately that led to the overall huge time difference throughout the week. One big win is not having to navigate airport security; they saved hours of time with every flight. They also got to fly to destinations that aren’t served by commercial aviation. When it comes to the choice between flying directly to Macon, GA or flying to Atlanta, GA and then driving the rest of the way, the efficient choice is very clear.

Speed and efficiency is pretty clear from the graph above, but what about fun? With private aviation, Chris and Ryan could talk with each other about their work (yes, at pMD we’d call that fun). In contrast, on commercial aviation, work discussions and even work on laptops is limited by the proximity to other passengers. Fun also enters the equation when you think about the week as a whole: using private aviation, the guys spent very little time traveling compared to the same trip using commercial travel options. They had time left at the end of their days to grab a fun dinner in the different locations they visited - and hopefully got a little Graeter’s ice cream in Cincinnati!

With travel time numbers like these, it’s no wonder why we utilize private aviation to help with our sales and account management trips. Not using such a resource would be like using paper rather than an electronic charge capture program, or making lots of phone calls and emails rather than having a seamless and integrated care coordination product, or sending a carrier pigeon when you would send a pMD secure message. It just makes sense - and you get to roll like a rockstar.

Here's The Latest in Health Care:

• Some hospitals have established a separate medical unit for the treatment of elderly patients. Hospitalization can be very taxing on the elderly, especially when faced with drug side-effects, interrupted sleep, unappetizing food and long days in bed. San Francisco General opened the Acute Care for Elders (ACE) ward in 2007 and focuses on how to get patients back home and living as independently as possible. With only about 200 of these units around the country, they are rare yet promising. ACE units have been shown to reduce hospital-inflicted disabilities in older patients and decrease the length of stay. Source

• The greatest impact on reducing costs to health care organizations and maximizing ROI comes from remote patient monitoring. Coming in second and third are patient engagement platforms and EHRs (electronic health records systems). In order to help strengthen the quality of technology implementation in health care organizations, there should be priority in designing workflows that improve efficiency and technology adoption. Source

• A new, alternative approach to treating psychosis allows the voices in the patients' heads to be directly addressed by support group members. In this holistic, nonmedical approach, members help one another understand each voice, as a metaphor, rather than try to extinguish it. The Open Dialogue treatment approach begins with a team of mental health specialists who visit homes and discuss the crisis with the affected person rather than resorting to medication. The culture aims to provide a nonpsychiatric label, avoiding the words "patient" or "treatment". Source

• Studies have found that 20 percent of hospital patients are sent home before their vital signs are stable, increasing their likelihood of readmission or even death. Researchers suggest hospitals take further action to prevent such mishaps by closely monitoring patients' vital signs and conducting thorough outpatient follow-up education. Source

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news.
Over the weekend, John Carmack, a hero to many software engineers, tweeted the following:

In the Bay Area, job hopping is a de facto state for many engineers. If you’ve been at a software company for more than a couple years, you generally don’t bring it up in polite company. This has always seemed strange to me because I’ve tended to learn the more profound aspects of software development a couple years into my jobs. For a San Francisco citizen to read that John Carmack shares the same belief was both reassuring and refreshing.

One of those more profound lessons that seems to come only with “complete product cycles” is developing an intuition of what to build, when to do it, and whether you should be idealistic or pragmatic in how you go about doing it. At pMD, we constantly strive to answer these three questions. As a software team we split our time and resources between improving the present world for our users and their patients while also trying to shape the future for our industry. Writing and maintaining software that addresses both needs is a highly complex and risky process. If we build the wrong thing and execute poorly, we not only have wasted precious resources, but we quite possibly have endangered the quality of life for our existing users and the patients they care for. It’s necessary to have gone through several full life cycles of products and features to have a chance at doing the above successfully.

A full product life cycle begins with inception, planning, building, maintaining, and “ends” with continuous evolving of a product. For many products that tackle complex domains like health care, this cycle actually never really ends but provides a continuous stream of feedback that educates and inspires future decisions that may span many years. This “wisdom,” as Carmack calls it, colors the thousands of decisions that must be answered from what to build all the way down to the schema of a database table. It is unfathomable to me that a career that rarely extends beyond the building stage can lead one to the epiphanies needed to educate future work. I am growing optimistic, however, that more and more software developers are rediscovering the value of sticking around to see their work grow and mature. The more we hold ourselves accountable for the long term consequences of what we build, the more value we can add for our users and society.

Here's The Latest in Health Care:

• Medicare is dinging U.S. hospitals for excessive 30-day readmission rates. More than half of U.S. hospitals are being penalized this year, taking effect with the new fiscal year in October. These penalties mean that hospitals will lose upwards of $520 million in payments from Medicare. While these readmission penalties are controversial, fear of penalties are pushing hospitals to work harder torwards reducing their readmission rates. Source

• Will the latest health food trend arise from one of the least revered insects? Cockroach milk, secreted from the Pacific Beetle Cockroach, is actually a liquid that takes the form of protein crystals in the guts of baby cockroaches. It's high in protein, fat and sugar and researchers indicate this may someday be a food supplement worthy of human consumption. Source

• The largest settlement yet paid by a single entity for potential HIPAA violations came from Advocate Health Care to the tune of $5.6 million. In an investigation starting in 2013, it was revealed that Advocate Health Care was in violation of HIPAA-compliancy involving electronic protected health information. Source

• Researchers have found that microbes from farm animals, carried into the home via dust, could be the magic ingredient in preventing asthma in children. Children who are exposed to microbes that stimulate their immune system at an earlier age are more likely to be protected against asthma. Studies have shown that children who lived in far too clean environments were developing asthma at rate higher than those who grew up in other environments, such as a farm.  Source

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news.

In a previous post, I briefly touched on Bundled Payments for Care Improvement, or BPCI. As you may recall, a bundled payment model encourages providers to team up across the care continuum to treat a patient. These teams receive a single, fixed price for all the services necessary to treat a patient in a particular episode of care, such as a hip replacement. This moves away from the traditional fee-for-service model, where providers are paid separately for each service rendered to the patient. This new, innovative payment model hopes to reduce health care costs and to enhance efficiency and coordination of care.

Navigating through this topic can be a little daunting, so with the help of the tale of an infamously ill-fated egg, here are the four BCPI models explained:

Model 1: Acute Care

Humpty Dumpty sat on a wall and in his old age, lost his balance and had a great fall. Mr. Dumpty was rushed to the hospital with a broken hip and in need of a hip replacement. In Model 1, Mr. Dumpty’s episode of care begins in the hospital plus any related care within three days prior to hospitalization. All the providers involved in his treatment, such as the ambulatory service, surgeon and hospital, get paid separately for their services rendered. Then, once Humpty is discharged from the hospital, Medicare pays the hospital a lump sum to cover all the services carried out during Humpty’s episode of care. If the aggregate cost for treating Humpty comes in under the cost of the lump sum given by Medicare, a portion of the hospital’s savings is shared amongst the physicians. However, if the actual costs exceed the target threshold amount, bundled payment awardees are expected to pay Medicare for the excess expenditures.

Model 2: Acute and Post-Acute Care

Similar to Model 1, Humpty’s episode of care includes his hospital stay plus any related care within three days prior to hospitalization. However, it differs in that the episode continues for up to 90 days after his discharge from the hospital, which can include any visits to his rehabilitation or physical therapy facility. All participating providers continue to receive separate payments for their services. Once Humpty’s post-acute care is complete, Medicare compares the aggregate cost of all the providers involved in Humpty’s treatment against the target price of the bundled payment. If that total exceeds the target bundled price, the participants must pay Medicare for the difference. If the total falls below the target bundled price, providers get to keep the difference and benefit from the gainsharing bonus, resulting in little motivation for physicians to shorten lengths of stay or opt for higher-cost services.

Model 3: Post-Acute Care

Model 3 shares the same payment model as Model 2, however, it excludes the initial hospital visit from the bundle. Therefore, Humpty’s episode of care is initiated with the first post-acute care service provider, which in his case begins with his rehabilitation stay, and must be at least 30 days long.

Model 4: (Prospective) Acute Care

In Model 4, Medicare makes a fixed, upfront bundled payment to cover all hospital and related readmission services based on historical spending trends. Unlike the other three models, providers don’t actually receive separate payments during an episode of care. When Humpty is admitted to the hospital, physicians and practitioners submit “no-pay” claims to Medicare and are paid by the hospital out of the upfront bundled payment. This model bears the highest amount of financial risk because participants are fully responsible for costs in excess of the bundled price.

The graph below summarizes the care continuum portions included within each model.



More Points to Consider

*All models cover some portion of a patient’s episode of care ranging from pre-acute to related readmissions

*Medicare takes an expected minimum discount, ranging from 0% to 3%, from each of the bundled payments

*Quality reporting measures must be proposed and established by applicants in advance

*Providers continue to receive fee-for-service payments, in which the aggregate cost is then compared to the target bundle price, except in Model 4.

*Models 2-4 propose targeted clinical conditions based on Medicare Severity Diagnosis-Related Groups (MS-DRGs). Model  1 includes all MS-DRGs.

These models are designed with the intention of identifying and implementing cost-saving strategies across the care continuum. By achieving high-value care with just a single payment, providers can focus their efforts on providing the most coordinated care to put Mr. Humpty Dumpty together again.

For additional information, please visit the CMS website and refer to their BPCI Learning & Resources and BPCI Fact Sheet pages.

Here's The Latest in Health Care:

• Thirty percent of pediatric readmissions may be preventable by making improvements in post-discharge engagement. Family engagement and proper care assesment after a child is discharged from the hospital both play a huge role in preventable readmissions. It is essential for organizations to take an active role in preparing patients and their families for discharge. Source

• The Centers for Medicare and Medicaid Services (CMS) released its first overall hospital quality rating this Wednesday. The results were far more than dismal for many of the nation's best-known hospitals, while dozens of obscure hospitals were awareded top scores. Health care organizations are concerned about the potential consequences for patients that could result from painting such an overly simplistic picture of health care quality using a star rating system.  Source

• Four cases of Zika infection are traced back to a one-square-mile area north of downtown Miami. No mosquitos have tested positive yet for the Zika virus but people in that specific area are being tested to ensure there are no additional cases. Mosquitos have a very short range and tend to cluster, zip code by zip code, and at the moment avoiding widespread transmission. Source

• Rising costs of generic drugs may be blamed on insurers. Traditionally, health care professionals point the finger towards drug manufacturers but insurers can simply change the design of their health plan's drug benefit, moving drugs into a higher tier, for example, requiring consumers to pay a bigger chunk of the cost. Drug price increases can sometimes also be blamed on the rising cost of manufacturing or distributing the drug.  Source

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news.
I've been watching the HBO series Silicon Valley and it has reminded me of all the great, and terrible, and just-plain-weird things about the software industry.

The starry-eyed idealism is accurate. For example, the "What is Hooli?" promotional video by a software mega-corp features African children, a CEO holding a baby goat, and the saccharine line "We can't achieve greatness... without first achieving goodness." Like much of the show, this is over the top, but it's also eerily accurate - as though cobbled together from the cutting room floors during the production of every large software company's morale videos, combined with bullet points from a Forbes article listing 17 ways to attract millennials to your workforce. See also the startup founder who earnestly pitches, "We're making the world a better place... through paxos algorithms for consensus protocols." Big companies, startups, venture capitalists... everyone in Silicon Valley is making the world a better place. Everyone is changing the world.

But when you change the world, you don't necessarily make it better. Sometimes you just change it. There's no going back, but in return for ubiquitous, unlimited access to information, we've revealed the most intimate details of our lives to corporations whose only real purpose is to monetize that data. In return for instantaneous communication and increased productivity, we've created a culture where it's difficult to ever truly be away from our work. And in return for being connected digitally at all times with far-flung friends and family, we've spawned cyber-bullying and FOMO and social media addiction. Any software engineer who's paying attention must eventually come to terms with their own responsibility for the consequences - both positive and negative - of the change that they're creating.

There are ways to stay grounded, to understand the effects and side-effects of your software, and to adjust your approach to make sure you're really "achieving goodness." But it requires having users - which is a catch-22 for most newly-minted startups - and making the effort, especially as an engineer, to stay extremely close to those users. It requires a long-term commitment to what you're doing - in an industry where the leading companies have an average employee tenure between 1 year (Amazon) and 1.1 years (Google)*. And it requires working at a company with the discipline, control over its own destiny, and the financial independence to chart its own course rather than chasing trends, making shady deals, or finding ever-more-creative ways to monetize its users.

I just celebrated my ninth anniversary at pMD, and it's been an amazing journey. It's never easy to do the right thing in the right way, and we've chosen to turn down a lot of opportunities, investors, and partners along the way because they would have compromised our control over our destiny, or distracted us from our core mission to make doctors happy - which has never changed. Watching Silicon Valley has been a great reminder about the power of software to change the world - and how poorly situated most software companies are to do so in a responsible way.