Mar 19, 2019

Axios Vitals

Good morning ... This story is insane: A fertility doctor inseminated patients with his own sperm for years. His many children are now discovering each other via at-home DNA test kits.

1 big thing: Where electronic health records went wrong


Electronic health records were supposed to revolutionize the U.S. health care system, saving money and improving quality in one fell swoop. The actual results are much less satisfying. And so Kaiser Health News took a very deep dive into what went wrong.

The big picture: Doctors hate most of these systems. That's what a lot of this comes down to. The theoretical benefits of EHRs are/were real, but KHN offers many examples of how difficult they are to use in practice.

  • One system deleted everything doctors typed in between brackets, which they didn’t know would happen.
  • Others complained about the number of options in the drop-down menu they use to prescribe Tylenol; apparently, 1 in 1,000 accidentally prescribe a suppository instead of a pill.
  • Prescribing ibuprofen to a female patient always brings up a warning about the dangers of prescribing it to pregnant women, even if the patient is a child or a senior.
  • As KHN puts it: "The average ER doc will make 4,000 mouse clicks over the course of a shift, and that the odds of doing anything 4,000 times without an error is small."

Between the lines: Even some strong EHR proponents say the 2009 stimulus flooded the sector with too much money and too many demands too quickly.

  • "This is something the government mandated," one ER doctor told KHN. "There really wasn't the time to let the cream rise to the top; everyone had to jump in and pick something that worked and spend tens of millions of dollars on a system that is slowly killing us."
2. How Americans ration their care

Roughly 11% of adults don't take medicine as prescribed as a way to try to keep their health care costs under control, according to new data from the Centers for Disease Control and Prevention.

  • That includes people who skipped medications, took a smaller dose or didn't fill a prescription, specifically to save money.

By the numbers: Unsurprisingly, the uninsured were more likely to employ one of those strategies.

  • More than one-third of uninsured adults said they had saved money by not taking medicine as prescribed, compared with 13% of Medicaid recipients and 8% of people with private insurance.
  • Higher percentages, including nearly 40% of the uninsured, said they had asked their doctor for a cheaper medicine.

Flashback: Broadening beyond just prescription drugs, roughly one-third of Americans say they've delayed care due to its cost, according to Gallup.

3. Price-setting as an answer to surprise bills

A coalition of employers and health insurers wants Congress to step in and set doctors' payment rates, in some cases, as a way to combat surprise medical bills, Axios' Caitlin Owens writes.

What they're saying: In a letter to congressional leaders, the group — which includes America's Health Insurance Plans and the American Benefits Council — said Congress should set reimbursement rates for certain services either based on market rates or as a percentage of what Medicare pays.

  • They also suggested banning providers from sending surprise bills to patients in "cases of emergency, involuntary care, or instances where the patient had no choice in their provider."
  • The threat of high out-of-network rates can also raise in-network rates, causing higher premiums for everyone.

Between the lines: It's not every day that insurers endorse government price-setting, even in narrow circumstances.

  • "Large employers and insurance companies are not generally fans of price regulation, so opening the door to that is a big deal, even considering that it’s someone else’s prices they’re talking about controlling," said the Kaiser Family Foundation's Larry Levitt.

The other side: "Not only is it a dangerous precedent for the government to start setting rates in the private sector, but it could also create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks," the American Hospital Association and the Federation of American Hospitals said in response.

Go deeper: Why ending surprise medical bills is harder than it looks

4. Medicare Advantage fines get a tweak

The federal government has proposed slightly altering the penalties for Medicare Advantage plans that run afoul of the program’s rules, my colleague Bob Herman reports.

Yes, but: These technical changes may not make much of a difference, because MA plans' penalties are capped.

  • The government fines MA plans for things like inappropriately denying care or not covering drugs.
  • But these penalties are capped based on the plan's enrollment — making them slaps on the wrists for the biggest players.
  • For example, UnitedHealth and Humana collect billions of dollars in MA revenue each year. But insurers with more than 3 million MA enrollees (in other words, UnitedHealth Group and Humana) can be fined a maximum of $2 million, regardless of how many violations Medicare finds.
5. How HIV keeps spreading
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Data: Centers for Disease Control and Prevention; Chart: Andrew Witherspoon/Axios

The vast majority of new HIV infections in the U.S. in 2016 were transmitted by patients who either did not know they had the virus or were not receiving care, according to the CDC.

Why it matters: Treatment can suppress HIV patients' viral load to low enough levels that they aren't able to transmit the virus — hence the adage that "treatment is prevention."

  • That's why treatment is the cornerstone of President Trump's State of the Union pledge to dramatically curtail the rates of new HIV infections.

The big question: The highest-risk populations are generally among the hardest to reach. Public-health officials will need a lot of money and willpower to make the kind of dent they're hoping for in new infections.

Over half of new HIV infections occur in the South, and LGBTQ black men are at the highest risk. The New York Times has a sobering look at the layers upon layers of obstacles to treatment in Jackson, Mississippi.

  • Mississippi requires abstinence-first sex education, and even many adults don't know how to use condoms, the NYT reports.
  • The state hasn't expanded Medicaid, leaving more people uninsured, and has slashed its health budget.
  • Knowingly infecting someone with HIV is a crime in Mississippi — a disincentive to get tested. And the diagnosis is a shock that sometimes sends people running.

"People want us to jump to being San Francisco right away, and we're just not there," Thomas Dobbs, who leads Mississippi's health department, told the Times.