duffpkg

I'm author of Hacking Healthcare for O'Reilly, 20 year health system executive, blah, blah.

It's very easy for people to forget the scale of the US "health system", we are talking 1/5, maybe more, of the entire US economy. If US healthcare spending were a country, it would have the third largest GDP in the world. Accidents of history and the massive federal beauracracy created the crazy monster of ICD/CPT codes that results in the very clumsy way of pricing healthcare services that results in this massive matrix of data.

As pointed out elsewhere there is a tremendous amount of cost distribution that goes into the code matrix and this plays a large role in negotiations with health insurers as well. Ground is given in one set of procedures and lost in others.

This is a big step in shining light into areas that need it to improve the system overall.

It's really convenient to cherry pick parts of "healthcare" or the "healthcare system". The thing is, it's 20-25% of our entire economy, so it's really hard to make meaningful comparisons to other countries and their distinct economic systems, in my opinion. To compare you end up having to get into labor, education, taxation, political systems, etc. The most obvious thing is that the USA is a federation of states and with regard to healthcare the federal government has relatively little direct power (but a lot of money). I think the transparency regulations are an excellent small step, I think that there is a little bit of disconnect in regards to timeframe. It will take several more years to see how that plays out.

Regulation is one piece but ultimately dysfunction stems from huge differences between what different constituents want from a healthcare system and what they want it to be (and not be). People hold extremely different views about it. Depending on your circle and where you live you may not realize just how far apart your thinking is from people in other circles and places. Creating palatable compromises between those groups has proved almost impossible and so a lot of what we have in lieu of a compromise occurs by default and accident.

The primary cause today of doctors prescribing name brand medications without the ability for substitution of generics is a form of institutional stupidity. EMR prescribing systems are driven by a common "formulary" that has an entry for each drug and defaults. Often the people that define formularies are a weird mix of technological people that don't know anything about the drugs/medicine and medicine people that don't know anything about the technology. The checkbox for the formulary entry that defaults to "allow substititions" is not properly set or is defaulted to disallow them.

Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion.

https://www.justice.gov/usao-vt/pr/electronic-health-records...

Wrote Hacking Healthcare for O'Reilly, created ClearHealth/HealthCloud open source EMR, managed health systems for 15+ years, blah, blah, blah.

It is very good there is are the transparency regulations. It is worth briefly explaining some of the reasons why many facitilities are having a hard time complying. There are some bad actors, absolutely true. However "Hanlons Razor" -- never attribute to malice that which is adequately explained by stupidity -- definitely applies.

Many health systems are a lot more like "medical malls" than they are single monolithic enterprises. Lots of health systems use really, really old technology and also a lot of it from a company called "Epic". Epic does what it wants, when it wants and there is basically nothing anyone can do about it. There is rarely one central consistent mechanism and source of truth for pricing data because it gets generated from a complex web of different entities, systems, and processes. Herding all those cats is why it can take a health system a long time to comply. And also why a fine of even a million dollars can be small potatos vs the cost of actually complying in a timely manner.

Just one facet, MUMPS is a widely used technology which you probably haven't heard of and which very few technologists understand. Lots of people are struggling to create new code to meet the new regulations using 1970s era technology including MUMPS.

Another, a lot of health systems have been around a really long time. The insurers they work with also, (since the 1960s at least). They have Electronic Data Interchange EDI relationships built on the standard called 837. Business logic that surrounds pricing and billing is often buried in 50 years of tech debt. Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent. People still have hard physical lines connected to Medicare mainframes.

This is a similar situation to other regulated industries like banking, airlines, etc. Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.

Disclaimer: I have been involved with the development of some of the fee schedules and health systems mentioned/criticized.

It's appropriate to pick on UHC here but a lot of this insanity derives from rulemaking by Health & Human Services and Center for Medicare/Medicaid Services with a healthy dose of legacy everything thrown in. Even if you really wanted to fix this in an overall way you cannot without acts of congress, rulemaking by federal departments and individual legislation in each of the states and local medical jurisdictions. UHC has no inventive to make it easy to submit a claim but likewise they realize the futility of expending a lot of resources to make it the tiny bit better that current regulation would permit.

I am author of Hacking Healthcare for O'Reilly, 20+ years experience building and managing health systems

Author of "Hacking Healthcare" here. Myself and Fred were able to contribute to the discussions on our cover selection. I suspect some animals are probably much more in demand than others. Our editor was Andy Oram and he was outstanding. He is no longer with O'Reilly unfortunately.

Having worked with different publishers in different contexts, 90% of your experience will be as a result of your relationship with your editor.

I get asked sometimes by new authors, should I write for X or Y or Z. My answer is to always try and see who your editor will be and how well you think you can work with them.

If you consult the details you will find the allegations are of direct payments, trips, and other hard assets up to and including duffle bags full of cash.

After losing some deals that just seemed like there was no credible way we could lose, better "product", better price, better team, etc. You start asking hard questions about all the people involved and eventually someome will confidentially explain what happened. Especially people who actually need to work with the worse vendor that just got selected.

If you read through the settlement I linked ("The settlement also resolves allegations that ECW paid kickbacks to certain customers in exchange for promoting its product.") and other documentation regarding that case you can find details of several situations. I am singling out ECW there because that settlement exists. You would have to be pretty naive to think they were the only vendor engaged in that type of behavior and that the recipients of kick backs were only receiving kick backs from them alone.

I created a company around an Open Source Electronic Medical Records system I also created, ClearHealth. It took me a couple of years to realize we were losing deals for health systems not because our system was bad (it was great), not because our sales teams were bad (they were great) but because we weren't engaging in kick-backs and outright bribery. This has become such a normalized part of business at institutions that it is extremely hard to be competitive if you don't do it.

https://www.justice.gov/opa/pr/electronic-health-records-ven...

Location: Phoenix/Los Angeles

Remote: yes

Willing to relocate: no

Technologies: Fractional COO/CTO, Architect, Strategic Consulting. Extensive experience in Healthcare in both technology and clinical operations. Created the open source HealthCloud/ClearHealth electronic medical record system.

Notes: I'm author of "Hacking Healthcare" for O'Reilly. Helmed ClearHealth for 15+ years to a successful 2017 acquisition. Completed a two year project for SUBWAY leading the team modernizing their payments infrastructure.

LinkedIn: https://www.linkedin.com/in/duff-david-uhlman-281741/

Email: du@50km.com

Walgreens tried to pull this against one of ClearHealth's (Open source EMR system) trademarks. We prevailed but expect to spend $20k in legal fees and in TTAB court you could not recover fees (at that point in in time anyway).

https://ttabvue.uspto.gov/ttabvue/v?pno=92058521&pty=CAN

A LOT of money is tied up in reporting that is all but impossible to do without comprehesive electronic versions of medical record information.

Is there any electronic paper that works well and is reasonably priced?

I wrote Hacking Healthcare for O'Reilly Media, created ClearHealth/HealthCloud, WebVista, yada yada...

There are several factors that collide to make everything in software associated with health exponentially more difficult than in other areas. First, people's lives are actually on the line, the stakes are very high. Second, government regulation plays a significant role in how things can and cannot be done, this is a double edged sword in preventing some abuses but also making iteration and innovation more difficult.

The other most signifcant point is that there are often very large gaps in vision between different layers of a very large and complex human system. The needs of keeping the lights on and billing are often in direct tension to the needs of optimal care, this often manifests in software as a chimera that pleases no one.

One other tidbit I will add is well covered in my book's chapter "The incredible bandwidth of paper". When you actually sit in a room and see how fast and how complex the information recorded by a group of medical professionals with nothing but pen and paper form is, it is daunting to actually deliver that level of performance and reliability with any technology that exists today.

I wrote "Hacking Healthcare" for O'Reilly, which is still in print after 10 years, amongst others. My intention in writing it was never pecuniary but to hopefully encourage smart technology people to enter healthcare. It has sold more copies than many popular authors I read who seem much more "bestselling", which always surprises me.

It is my opinion that piracy has helped that book much more than it has hurt it. It is very widely pirated in torrents in non-us countries from what I can tell from google searches and a longstanding history of emails to the effect "hey your book is being pirated [here]". I sincerely doubt that the overwhelming majority of people who pirate that work did so instead of purchasing it.

This is a very salient comment. I wrote "Hacking Healthcare" and created ClearHealth/HealthCloud. If you are in any way looking for opportunities I'd love to chat with you.

du@50km.com

What is really unfortunate and not communicated in this article is just how much Google's various star crossed forays into healthcare took oxygen from other fruitful and deserving efforts. It's an indictment of healthcare institutions as well for falling for it every time one of the tech megaliths promises the moon.

At ClearHealth we lost many, many potential projects, partners and dollars over the years to "we are going to see what google is doing", "we are in talks with google", etc.

The damage is very large but difficult to calculate.

The open source release of mattermost has a lot of underutilized potential in the healthcare industry.

I wrote Hacking Healthcare for Orielly, created ClearHealth, yada yada...

Devil is always in the details of these rules but on the surface it looks like a good attempt. It is a sort of a bandaid though.

To understand why this occurs know that most jurisdictions have certain staffing requirements for service lines. You must have X many neurologists covering X shifts. There is almost universally a shortage of these folks for other reasons, so you end up with a lot of non-staff doctors to fill the coverage requirements. Those non-staff often have different insurance relationships than staff doctors and so are "out of network".

The two serious changes that would have a more durable impact on this are to free the lock the AMA has on residencies that exacerbates doctor shortages and to dramatically streamline the way insurance program enrollment is done for doctors. Further opening up interstate health insurance would also probably help.

I wrote Hacking Healthcare, created clearhealth open source EMR, a decade plus managing hospitals and multi-practice groups. There are a couple of bad actors out there but for many of these organizations, though it may seem impossible to believe, they really haven't yet been able to coordinate all the entities involved to put together the list. People think of hospitals as monolithic entities but many are much more like medical malls than anything.

Further for many institutions there is a plain cost/benefit. The maximum penalty for non-compliance is $109,500 a year though as far as I know 0 fines have been assessed yet. If you are a large institution it can easily cost many times that to put together and maintain this list in a compliant manner.

Byzantine barely begins to describe the way medical procedures are billed, inpatient especially. It is not at all like a retail interaction. For a given patient on a given insurance program on a given period within a contractual cycle, the rate of charge and reimbursement may differ. Many contracts include a most-favored-nation type clause that mean when one program's reimbursements change then many other ones may need to be updated as well.

I'm not trying to defend any of this but just point out that there is a lot of behind the scenes complexity to the current system that is easy to gloss over when it is thought of in retail terms.

Not likely. There is a lot of nuance to the way fee schedules are actually (from a legal perspective) created and applied. Having created many such fee schedules and been resposible for operations at many facilities large and small they are done in compliance with applicable laws even though it may seem byzantine. There are always a handful of fraudulent operators though.

I think you may have jumped the gun on this statement. Dolthub is a bit like github for data. You can clone the entire database without so much as a login right now, see the clone drop down situated in a similar location as it appears on github. (It is 165GB)

(install dolt which is apache licensed)

dolt clone dolthub/hospital-price-transparency-v2

The data changes over time so it is possible they will stop publishing it. Also note that this data is open to begin with and they are just aggregating it, though from a quick glace doing a nice job of it. Under HHS/CMS rules hospitals have had to publish a price index since january of this year.

This is content marketing for a "concierge" doctors service called "the Lanby" launching in NYC in september 2021.

One important piece of context here is that these rates are negotiated as part of a contract bundle where an insurer is bringing a pool of patients to the facility. Prices can vary widely procedure to procedure because they are associated with over or under representation of certain factors within that pool. For example, grossly simplified, I might have a particular service line, hip replacements (an ortho program). The insurer whose patient population is going to 'keep the lights on' in that service line is going to see a very different rate per service than a different insurer who rarely has patients that need it. Nothing about these prices shown are really reflective of the costs of doing the procedure such as pricing in a retail store.

I do think this transparency initiative will result in more consistent costs but not necessarily net lower costs.

Comparisons to other countries that are smaller than the united states are somewhat apples to oranges. There are a lot of factors that are glossed over when someone says "costs are 5x higher in the US than my country" including real estate, energy subsidy, and so on. Its a deep well.

I like it but it does not seem to compute when a board has become impossible until all moves are exhausted. The point of impossibility can happen long before that.

If you think it is only like this in Brazil I'm sorry to deliver the bad news that this is also the case in the USA.

I worked in healthcare for ~20 years. The worst casual breach I ever witnessed was a state health director emailing an unencrypted spreadsheet of all of that states HIV+ persons to a widespread mailing list including name, DOB, SSN, etc. Sadly it was not accidental (would that be better?). Even worse no one batted an eye and it was not even a notable event.

For all the HIPAA lip service paid at the front end in many sites, all the data walks wholesale out the backend to an absolute parade of "hipaa business associates". It is a firehouse of data that is vacuumed by almost everyone.

Health and human services has statutory authority to fine $50k per patient violation. They never ever ever do and so no one really cares.

... I wrote Hacking Healthcare, created ClearHealth & HealthCloud, many other credentials...

I have negotiated with the AMA in several arenas. If they had anymore lawyers in a single place it would create a black hole.

Everything in healthcare anything (procedure, test, sponge, scalpel, etc) that gets billed or reported to the federal government, that is roughly ~2.7 Trillion worth of transactions a year, roughly 160 billion line items, requires a CPT code (current procedure terminology). The federal government legally requires this. CPT is owned and licensed by the AMA, they spend incredible lobbying dollars to maintain that the CPT codes are used and required by the federal government. It is legally impossible to create an alternative. It is complete regulatory capture. That CPT revenue was 160 million a year as of 2018. A pure tax on healthcare, sadly one among many. Also a reason truly fully open source systems are impossible in healthcare.

This seems to be a rehash of the same GPT3 gobbledygook packaged in a very low effort SaaS. Several attempts yielded nothing but basic templated pages you see everywhere containing mostly the verbiage I provided and some non-sensical filler that seems to have been grabbed from reddit comments.

Malpractice is a totally separate thing from Medicare Fraud. With respect to malpractice, having automated or semi-automated encounter notes with huge systematic similarity looks absolutely terrible if something goes wrong. Don't take my word for it, consult your attorneys.

With respect to Medicare fraud see the False Claims act and its interpretation in the enforcement actions against many parties beginning in 2016. Keywords would be like "not medically necessary" and "upcoding". I believe the monster enforcement action just this week against GHC also involves that.