humani nil a me alienum puto

random rants about news, the law, healthcare law, economics and anything I find amusing

Reform Moves Stir Talk of Bundled Payments | BNET Healthcare Blog | BNET

A BNet article, Reform Moves Stir Talk of Bundled Payments, discusses healthcare reformers’ conceptualizing bundling payments to align physician and health system/hospital outcome interests.  The article has a number of cites to other reports, discussions and administration statements.  It also points out what I find facinating about the trend — what did not occur in the 1990s may be coming through healthcare payment reform today.   But are today’s integrated delivery systems (and the regulatory environment) prepared for risk in any format other than PPS payments?

All of this reminds some observers of the rapid formation of integrated delivery systems during the ‘90s, when many hospitals and physicians were circling the wagons to fend off the expected onslaught of capitated managed care plans. That never materialized in most places, but many systems retained all or some of their employed primary-care physicians. Now, partly in expectation of healthcare reform, they’re also stepping up their hiring of specialists.

“The handwriting is on the wall,” Bill Jessee, MD, president and CEO of the Medical Group Management Association, tells BNET. “The push is going to be towards more integration of physicians, hospitals, home health, and other services. And Medicare or a private insurer may put the provider at risk, instead of the insurer being at risk. It’s not explicit, but it’s implicit in a lot of the reform discussions that that’s the direction they’d like to move. The bundled payment demonstrations are a manifestation of that.”

via Reform Moves Stir Talk of Bundled Payments | BNET Healthcare Blog | BNET.

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Filed under: Comparative Effectiveness Rearch, Health Law, Payment, Reform, , , ,

TED Talk: Reimagining Global (Health) Data

I just love these TED talks. I previously have postedabout TED. I first discovered it when Pogue (NYT columnist) was talking about the conference and the wonderful web site. This talk is by Hans Rosling who was confronted by a dilemma. There’s tons of great data out there that tells wonderful stories about the world that can inform policy, destroy myths, demonstrate compelling trends, affect both our views of the world and what we have done and can to to improve. But tables and non-interactive graphs are just incredibly boring — and the underlying stories can be completely missed. Take a look at his presentation and then take a visit to his site. Kudos to Health Economist blog to turning me onto this. Really neat stuff. I’m trying to think how I could use something like this in a presentation (even being a lawyer — has to be something creative I can glom onto here).  About Hans Rosling from TED:

Even the most worldly and well-traveled among us will have their perspectives shifted by Hans Rosling. A professor of global health at Sweden’s Karolinska Institute, his current work focuses on dispelling common myths about the so-called developing world, which (he points out) is no longer worlds away from the west. In fact, most of the third world is on the same trajectory toward health and prosperity, and many countries are moving twice as fast as the west did.

What sets Rosling apart isn’t just his apt observations of broad social and economic trends, but the stunning way he presents them. Guaranteed: You’ve never seen data presented like this. By any logic, a presentation that tracks global health and poverty trends should be, in a word: boring. But in Rosling’s hands, data sings. Trends come to life. And the big picture — usually hazy at best — snaps into sharp focus.

Rosling’s presentations are grounded in solid statistics (often drawn from United Nations data), illustrated by the visualization software he developed. The animations transform development statistics into moving bubbles and flowing curves that make global trends clear, intuitive and even playful. During his legendary presentations, Rosling takes this one step farther, narrating the animations with a sportscaster’s flair.

Rosling developed the breakthrough software behind his visualizations through his nonprofit Gapminder, founded with his son and daughter-in-law. The free software — which can be loaded with any data — was purchased by Google in March 2007. (Rosling met the Google founders at TED.)

Rosling began his wide-ranging career as a physician, spending many years in rural Africa tracking a rare paralytic disease (which he named konzo) and discovering its cause: hunger and badly processed cassava. He co-founded Médecins sans Frontièrs (Doctors without Borders) Sweden, wrote a textbook on global health, and as a professor at the Karolinska Institut in Stockholm initiated key international research collaborations. He’s also personally argued with many heads of state, including Fidel Castro.

Filed under: Health Law, Personal Posts, Public Health, , ,

Haunting Images

I found this article interesting as it is local in flavor and surrounding what some might think is a morbid topic.  I disagree, and can see why dissection of a cadaver would be a central experience in the education of medical student. When I was in high school, I interned at the Cuyahoga County Morgue and observed an autopsy.  There I learned that Quincy (yeah, I’m that old and way before CSI) was not really how it worked.  I became an attorney, of course.

diss-colorCWRU’s Allen Memorial is putting on an exhibition of photos from a century or more ago showing medical students with their cadavers.  Many of the exhibits and photos are from the recently published book, Dissection, Photographs of a Rite of Passage in American Medicine 1880-1930 by James Edmonson from Case Western Reserve University and John Harley Warner from Yale University.  As is discussed in the link to the photo below, during this era there was limited access to cadavers for anatomical teaching.  So, learning, for many students, required a bit of self help.  We’ll leave it at that.  The link on the photo at left has some of these photos.

I find the photos fascinating.  Here we are, seeing photos of these student in the prime of their life exhibiting their anatomical subjects, that they treat well, humorously or in poor taste, but that all recently lost of the spark of life.  And these students, too, are now long, long since passed.  From the Plain Dealer article:

dissectionLong before “Tales from the Crypt ” “The Twilight Zone” and horror author Stephen King there were medical students.  Students who at the turn of the 19th-to-the-20th century posed for photos with bodies they had dissected in their studies; who gathered in groups around flesh-peeled cadavers and skulls like hunters displaying trophies…Dissection portraiture had its heyday from 1880 to 1930…The photos were a visual representation of a rite of passage dissection to a new identity a “boundary-crossing experience that left the participant forever changed ” as Warner wrote in the book…Back then there was no legal means of obtaining bodies for dissection. Some were unclaimed bodies but many were provided by grave-robbers known as “professional resurrectionists.” … Warner described most of the photos as almost “reverential” in the treatment of the subject some bearing such phrases written on the dissection tables as “Know Thyself ” “Man s usefulness endeth not with death” and “Her loss is our gain.” But he noted that others the gag photos and macabre images almost seem to revel in the transgression — posing human remains in outlandish poses or providing such accompanying table-epigraphs as “Such the vultures love ” “Rest in pieces” and “The Lord giveth We taketh away.”

via Case Western Reserve University’s Allen Memorial Medical Library displays ‘Haunting Images’ from a century ago – Metro – cleveland.com.

Filed under: Bioethics, Health Law, Personal Posts, , , , ,

Continuing 1Q Drops In GDP and Increasing Effects in Healthcare Sector

I recently posted on a WSJ article and Reuter’s research paper on the effect of the current recession on hospitals and the healthcare system job growth.   The AHA recently surveyed over 1,000 community hospitals (of the nearly 5,000 to which they sent surveys) seeking information on the recession’s effect on the hospital sector.   Similar to the Reuter’s paper from last month, the AHA’s survey shows significant effects on hospital total margins, operating margins, efforts to reduce costs, capital plans.

Healthcare tends to be recession resistant industry, but “The Great Recession” seems to be taking its toll.  And 1Q 2009 reports of economic contraction is worse then expected.   The Department of Commerce in a report issued this morning said that real GDP decreased at a remarkable annual rate of 6.1% Q1 2009.  In Q4 2008, real GDP decreased 6.3% and .5% in 3Q 2008.   Many economists had expected a 4.7% decline in GDP for the Q1 2009.  This is the worst two quarters in more than 60 years.  Since 1947, the economy “had never contracted by more than 4% for two consecutive quarters,” according to MarketWatch.com.  Three consecutive quarter losses has not occured since 1975.

Of note from the AHA survey summary of hospitals:

  • 90 % have taken steps to reduce costs
  • 80 % have reduced administrative expenses
  • 48 % have reduced staff
  • 20 % have reduced services in subsidized service areas
  • 58 % have had at least a moderate increase in uninsured ER visits
  • 70 % have had at lease a moderate increase in uninsured/Medicaid
  • 59 % report at least a moderate decrease in electives
  • 55 % report at least a moderate decrease in admissions
  • 65 % report at least a moderate decrease in total margin
  • 39 % report a significant decrease in total margin
  • 57 % report at least a moderate decrease in operating margin
  • 43 % expect a negative total margin 1Q 2009 (vs. 26% 1Q 2008)
  • 59 % report a at least a moderate decrease days cash on hand
  • 77 % are reducing capital spending
  • 46 % are scaling back established programs for capital spending
  • 54 % have discontinued planned (not started) capital projects
  • 65 % have seen increase in physicians seeking “financial support”
  • Of these 79% for call or other services; 71% seeking employment

via AHA : Press Release : Economic Downturn Taking Toll on Patients and Communities Hospitals Serve: New Survey Finds.

Filed under: Health Law, , , ,

The Future is Here; Just Not Evenly Distributed

Interesting presentation by Futurist Jim Carol.  He asks, what will we learn if we look back to today’s health care system from the vantage point of 2020?  Many of these concepts are not completely novel, so it reminds me of the science fiction writer William Gibson who observed that “the future is here; it’s just not evenly distributed yet.”

From Jim Carol’s presentation “It’s January 15, 2020: What Have We Learned About Healthcare in the Last Decade?”, he discusses a number of trends that he thinks will reshape health care.  A few:

  • Focus on preventive medicine reshapes healthcare delivery and finance, and by 2020 patients are treated for the conditions we know they are likely to develop, rather than principally for those that they already have.
  • Focus on “customer service” as job #2 (#1 always the efficient and effective delivery of care) reshapes healthcare delivery and rebuilds the entire philosophical underpinning of the system, so that “customer focused, friendly, fast, subject to expectation metrics makes it more consistent with other economic industries.”
  • “When Silicon Valley got involved in a big way, everything changed” launching “new products, new business models, scientic discovery tools, bio-informatics platforms that provided the foundation for diagnostic medicine, and many other incredible items.”
  • “Bio-connected devices — home health care medical monitoring, diagnosis and treatment devices — [will] provid[] … a renaissance” in the modality of care.  “A good proportion of both critical and non-critical care patients [will] receive …at home… [causing a] transition[] to a virtual community oriented caregiving strategy which has resulted in cost reductions and a refocus of critical health care spending” away from inpatient services.
  • “[T]he role of medical packaging [will] transition[] from being a passive protector of the product, to becoming an active component of the overall effectiveness of the particular medication” — prescription bottles will have internet enabled RFID tags with bio-sensors, providing specific information to patient’s provider and general information to pharmecutical clinical trials about patient’s current condition and the efficacy and interactions of the drug.
  • By 2020, “the average doctor and nurse [will need to] refresh[] their entire knowledge base every 18 months [due to the velocity of innovation, knowledge growth and change].  The result [will be] that the relationship between medical colleges and students [will] change[], from a period of short term, concentrated knowledge delivery, to one of lifelong, ongoing replenishment and rejuvenation of knowledge.”

via It’s January 15, 2020: Do you know where your healthcare system is? | WorldHealthCareBlog.org.

Filed under: Health Law, Reform, ,

The Human Analog to a Pet or a Public Resource?

Uwe Reinhardt has a piece on the Economix blog arguing for universal coverage and public financing of children’s health insurance through age 22.  Dr. Reinhardt is a professor of economics at Princeton University and a leading health policy expert.

What’s most notable about his post is his provocative start.  He asks the question:  do we in the United States view children as the “human analogs of pets … or…, as most European and Asians, as precious national treasures.”  Kind of  a disturbing question, when you think about it.  What’s he getting at?

He believes that answering this question “informs the nation’s health policy.”

If …the human analog of their parents’ pets, then … children’s health care is primarily the parents’ financial responsibility [and]…it is just and proper that, of two households with identical incomes, the one with children will have substantially less discretionary income …than does the childless household.  [I]f …national treasures — and the nation’s economic future — then …health care of children [is] the financial responsibility of society as a whole, just as is the financing of public elementary and secondary education.

Aside from remarking about S-chip and the 9 million children that are estimated to be uninsured, he also observes that Americans “seem to impute different social values to the health care of children, depending on their socioeconomic status, even if they have insurance.”  In other words, there can be a hundred dollar or more swing in basic primary care reimbursement depending whether a child is insured through private payors or public public programs.  And this price signal has real effects – many physicians, including many in Reinhardt’s New Jersey, will simply refuse to see Medicaid patients.

He then goes on to argue that a system similar to our public school system — but with vouchers for parents who would opt out of the public system — should be established for all American children under 22:

The purchasing function under this public program, that is organizing and managing care, could be delegated to private for-profit or nonprofit insurers, as in Medicaid Managed Care. Private insurers would then compete over the quality of their disease-management programs, not through judicious risk selection…[T]he fees paid providers under the public program would be set equal to the average of fees paid by the largest two or three private insurers in the state, lest the professional work of physicians caring for poor children continue to be relatively undervalued.

I think this is interesting reading in light of the McKinsey Study that I posted on recently.  If suboptimal health care is a contributing factor to sub-standard educational attainment of differing racial groups or social/economic classes in the United States, how much does our current health care financing system contribute?  How much, if any, lost GDP opportunity are we leaving on the table due to suboptimal financing of health care for children K-12?   If, as Dr. Reinhardt argues, health care for this cohort should be a public good, what’s the real GDP return on investment to Dr. Reinhardt’s program?  To me, asking and answering these questions are critically important to advance the policy debate.

via Seriously, What Is a Child? – Economix Blog – NYTimes.com.

Filed under: Bioethics, Health Law, Reform, , , ,

The Public and the Health Care Delivery System

The Kaiser Family Foundation, NPR and the Harvard School of Public Health recently conducted a poll of public attitudes concerning EHR, coordination of care, patient and doctor interaction around effectiveness and cost, the cost of care, the role of government and insurers in cost and comparative effectiveness, the uninsured and cost.  I found a few of the findings from the survey of note.

  • A larger portion of respondents (34%) thought that EHR’s would actually increase costs of healthcare in America than decrease (22%) it.  Even more (39%) thought it would increase their own family’s healthcare costs!
  • There is significant concern about unauthorized access (76%) to online medical records.
  • A significant minority (40%) of Americans report at least minor problems with coordinating care between their different doctors, while half say this is not a problem at all. A smaller minority (17%) say they experience “major problems” coordinating their health care services.   Interesting, those Americans who reported having personally experienced at least three ‘coordination of care’ issues are much more likely (63%) to see overtreatment in the system as a whole compared to other Americans (48%).
  • About half (49%) think that overutilization is a major problem.  Of course, only a minority (16%) say that they have received unnecessary care and a bit more than half (56%) think that insurance companies should have to cover expensive treatments even if they have not been proven more effective than other, less expensive options.
  • A significant majority of Americans  (72%) believe that there is not always clear scientific evidence about which treatment is likely to work best for any one patient.  But only a small minority (9%) say that they have received an expensive medical test or treatment in which a less expensive alternative would have been just as good.
  • A significant majority of Americans (65%) say their doctor’s charges are reasonable and (63%) believe that their doctor is working to keep the cost of their health care down.
  • There is a significant disconnect between the actual cost of insurance and what uninsured Americans are willing to spend for insurance.  Majorities report being willing to pay $25, $50 or even $100 per month for coverage, but only a minority (29%) would pay $200 per month, and only a very small minority (6%) say they would pay $400.  (Nationwide, annual premiums averaged $2,613 for single coverage and $5,799 for family plans in the 2006-2007 period).

The WSJ Health Blog commented on this survey: while patient seem to recognize that there is waste in the system, it wasn’t their physician.  She’s perfect.

Filed under: Comparative Effectiveness Rearch, Health Law, Reform, , ,

Republicans And Universal Health Care (Only Nixon Could Go to China)

Regina Herzlinger (the McPherson Chair at Harvard Business School and author of Who Killed Health Care? (McGraw Hill, 2007); a health care adviser to John McCain’s presidential campaign) writes an interesting op-ed in the Atlantic.  She argues that the Republicans need to seize the moment, realize that the “time for universal health insurance coverage has come” and that they should go to China, figuratively speaking.  “Republicans should…seize the lesson of Nixon’s trip to China”, where in one swoop Nixon brought the middle Kingdom out of isolation and removed the issue from his political adversaries.  [As Spock says in Star Trek VI, there’s an old Vulcan proverb that ‘only Nixon could go to China’ — perhaps only the Republicans can get sustainable health care reform passed?].

Ms. Herzlinger argues that there is a “a massive constituency behind [a potential Republican] policy” and her fellow republicans can do a “better version of universal coverage.”  She highlights challenges with what appears to be the current Democratic plan to rely “on universal coverage through a government-controlled system like Medicare”: (i) distrust government’s ability to apply fiscal controls needed so that any plan would not bankrupt us as Medicare is appearing to do; (ii) concern that the government will control costs by rationing health care to the sick (citing the UK experience with cancer rate survival due to UK’s pathetic approval of new cancer drugs and therapies); (iii) government as a monopolistic buyer of health care could negatively affect the supply of doctors; and (vi) government-controlled system would likely impair the medically and economically important private investment — particularly in the emerging genomic sector.

The Republicans, she argues, should instead offer a “consumer-controlled universal coverage system, like that in Switzerland in which the people, not the government, control how much they spend on health.”  The Swiss choose from 85 private health insurers.  [I believe that the Swiss government causes a degree of plan standardization so that consumers can compare “apples to apples.”]  In Switzerland, the poor shop for health insurance like everyone else, using funds transferred to them by the government.  Rather than the “degraded” Medicaid program, the Swiss poor get the same insurance options that everyone else get.  The Swiss taxing authority, according to Ms. Herzlinger, enforce the mandatory system and achieve 99% enrollment.

This consumer-driven, universal coverage system provides excellent health care for the sick, tops the world in consumer satisfaction, and costs 40 percent less, as a percentage of GDP, than the system in the US. The Swiss could spend even less by choosing cheaper, high deductible health insurance policies, but they have opted against doing so. Swiss consumers reward insurers that offer the best value for the money. These competitive pressures cause Swiss insurers to spend only about 5 percent on general and administrative expenses, as compared to 12-15 percent in the US. And unlike Medicare, the private Swiss firms must function without incurring massive unfunded liabilities. Competition has also pushed Swiss providers to be more efficient than those in the US. Yet they remain well-compensated.

She cautions that the Swiss system is not perfect, we can learn from it.  It maintains some of the same problems we have with fragmented care and poor integration of payments between vertical provider groups for episodes of care.

She concludes by observing that movement to this model will have real economic impacts:

Republicans could enact Swiss-style universal coverage by enabling employees to cash out of their employer-sponsored health insurance. (Although many view employer-sponsored health insurance as a” free” benefit, it is money that would otherwise be paid as income.) The substantial sums involved would command attention and gratitude: a 2006 cash out would have yielded $12,000 — the average cost of employer-sponsored health insurance — thus raising the income of joint filers who earn less than $73,000 (90 percent of all filers) by at least 16 percent. Employees could remain in with an employer’s plan or use this new income to buy their own health insurance.

via Why Republicans Should Back Universal Health Care – The Atlantic Business Channel.

Filed under: Health Law, Reform, , ,

HHS issues guidance on safeguarding PHI

On Friday, April 18, 2009, the Department of Health and Human Services released its guidance on protecting personally identifiable healthcare information by encrypting or destroying it so that it is rendered “unusable, unreadable or indecipherable to unauthorized individuals.”  (See http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechrfi.pdf).

Because the breach notification requirements of the HITECH Act apply only to breaches of unsecured PHI, the Department’s guidance provides the means by which covered entities and their business associates are to determine whether a breach has occurred to which the notification obligations under the Act and its implementing regulations apply.   Recall that under the HITECH Act, if there is a “breach” of  “unsecured PHR identifiable information” as personal health record (PHR) identifiable health information that is not protected through the use of a technology or methodology specified in the Secretary’s guidance (this document), and the “breach” is not qualified as provided in the HITECH Act, then certain disclosures by the covered entity are required.  These would include direct certified mail disclosure to individuals, “in cases in which there is insufficient or out-of-date contact information, substitute notice, including, in the case of 10 or more individuals for which there is insufficient contact information, conspicuous posting (for a period determined by the Secretary) on the home page of the Web site of the covered entity” and in cases of 500 or more records notice to prominent media outlets within the State or jurisdiction and immediately to the Department.   Notice by covered entities to HHS of all breaches is also required on an annual basis.  The Secretary will also post to its web-site notice concerning all disclosed breaches of 500 patient records or more.

[W]e have identified two methods for rendering PHI unusable, unreadable, or indecipherable to unauthorized individuals: encryption and destruction *** Protected health information (PHI) is rendered unusable, unreadable, or indecipherable to unauthorized individuals only if one or more of the following applies:

a) Electronic PHI has been encrypted as specified in the HIPAA Security Rule by “the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without use of a confidential process or key”15 and such confidential process or key that might enable decryption has not been breached. Encryption processes identified below have been tested by the National Institute of Standards and Technology (NIST) and judged to meet this standard.

i) Valid encryption processes for data at rest are consistent with NIST Special Publication 800-111, Guide to Storage Encryption Technologies for End User Devices.17

ii) Valid encryption processes for data in motion are those that comply with the requirements of Federal Information Processing Standards (FIPS) 140-2. These include, as appropriate, standards described in NIST Special Publications 800-52, Guidelines for the Selection and Use of Transport Layer Security (TLS) Implementations; 800-77, Guide to IPsec VPNs; or 800-113, Guide to SSL VPNs, and may include others which are FIPS 140-2 validated.

b) The media on which the PHI is stored or recorded has been destroyed in one of the following ways:

i) Paper, film, or other hard copy media have been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed.

ii) Electronic media have been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, Guidelines for Media Sanitization,19 such that the PHI cannot be retrieved.

The Department indicates that its list is an exhaustive list, but it opens discussion of other methods to make PHI unusuable, unreadable, or indecipherable.  In the development of this guidance, the Department reported that it had considered whether PHI in limited data set form should be treated as unusable, unreadable, or indecipherable to unauthorized individuals for purposes of breach notification.  It does not, but suggests that in the future, based upon additional comments and analysis, further restrictions on Limited Data Sets (e.g., removal of some of the digits of ZIP code) might effectively make re-identification such a remote possibility that the more limited data set would be unusable, unreadable, or indecipherable.  The Department also ask for comment on use of fingerprint protected Universal Serial Bus (USB) drives, for example, or whether it should, in providing future guidance on this topic, identify specific “off-the-shelf” products that may “meet the encryption standards identified in this guidance.”

In advance of its guidance to be issued on its interim final regulations on breach notifications, it also asks for comments.  The request for comments seems to indicate that the Department is concerned about need for covered entities to send multiple notices due to inconsistency between federal and state legal requirements.  They also are seeking examples of situations that covered entities think that the exceptions under the HITECH act will actually apply (perhaps to agree, disagree or to use in their own illustrative examples).

1.  Based on experience in complying with state breach notification laws, are there any potential areas of conflict or other issues the Department should consider in promulgating the federal breach notification requirements?
2.  Given current obligations under state breach notification laws, do covered entities or business associates anticipate having to send multiple notices to an individual upon discovery of a single breach? Are there circumstances in which the required federal notice would not also satisfy any notice obligations under the state law?
3.  Considering the methodologies discussed in the guidance, are there any circumstances in which a covered entity or business associate would still be required to notify individuals under state laws of a breach of information that has been rendered secured based on federal requirements?
4. The Act’s definition of “breach” provides for a variety of exceptions. To what particular types of circumstances do entities anticipate these exceptions applying?

Filed under: Health Law, HIPAA, , , ,

Recession Now Hits Jobs in Health Care

In the April 12, 2009 WSJ, they report on healthcare sector softening as the recession lingers.   The article mentions cuts at Mayo, Akron General and others.  Also quotes Paul Levy from Beth Israel Deaconness in Boston (author of Running a Hospital blog earlier posted about concerning their transparent efforts at saving costs):

More than 16 million people — one in eight workers on U.S. payrolls — work in health care today, up from just 1% of the work force 50 years ago…Employment in health care and social assistance — which includes hospitals, doctors offices, nursing homes and social services such as day care — has grown by half a million jobs since the recession began in December 2007, while the rest of the economy has shed 5.1 million jobs…But the pace of job growth in health services has slowed sharply this year. The sector added an average of 17,000 jobs per month in the first three months of the year, less than half last year’s pace…Since1958, there have been nine recessions, but employment in health services has declined only a handful of times…The only significant losses to date occurred in mid-1984, as the industry shed 41,000 jobs…Since then, no month has seen a drop of more than 4,000 jobs in health care, and there have been no back-to-back declines…The decline, while unusual, is still likely to be a temporary break in the industry pattern. Growth in health-care spending, and thus employment in the sector, is likely to rebound when the recession ends, a function of the enormous advances in medical technology and Americans’ strong appetite for health care… “It’s a long-term shift reflecting changes in technology and what consumers want,” says Robert Fogel, a Nobel laureate and professor at the University of Chicago’s Booth School of Business. “Health care is the growth industry of the 21st century.”

via Recession Now Hits Jobs in Health Care – WSJ.com.

Compare to an earlier analysis of the state of US Hospitals and the Current Recession.  Hospitals may be recession resistant; but are by no means recession proof:

“Observed impacts that appear related to the recession:

• Hospital non-operating and total margins have decreased dramatically, especially in the third quarter of 2008. Total margins are at historically unprecedented lows.

• Approximately 50% of hospitals are operating in the red.

• Hospital days-cash-on-hand has deceased significantly, following a pre-recession trend.

• Restricted investment assets have shrunk substantially for major teaching hospitals. These are non-realized losses that are not reflected in total margins declines.

• Hospital reimbursement rate increases appear to be shrinking — with possible negative impacts on net patient revenue in 2009.

• Total inpatient admission volumes may be falling below expectation.

Filed under: Health Law, Reform, , , ,

PartnersHealthCare Announces Industry Relationship Policy

The WSJ Health Blog in its April 10, 2009 posting reported that Parterns Healthcare, which includes Harvard-affiliated Mass General, had issued a report recommending tighter restrictions on industry relationships with its physicians.

The news release by Partners listed key recommendations from its report:

Prohibition of all gifts, including meals and funding for meals, provided directly to staff by industry for their personal use, on a Partners site or off site. This ban also applies to Partners institutions accepting industry gifts for this purpose.

Development of mechanisms to have free drug samples distributed only through the hospital pharmacy or some other centralized system, and not provided directly to or distributed by physicians.

Requiring that industry representatives have written invitations defining the purpose and terms of visits before having access to Partners sites and staff.

Establishment of a process to identify and manage significant financial interests held by physicians in companies that make products they prescribe or use in their practices.

Acceptance of industry funding for educational programs and fellowships only if provided through a centrally pooled institutional President’s Fund at each hospital or approved by a newly-created, Partners-wide Educational Review Board.

Establishment of a robust, tiered approach to evaluate research-related conflicts of interest, including continued prohibition of certain high-risk circumstances.

Adoption of a stricter policy holding certain officials to a higher standard because of their influential positions within the organization.

Strengthened oversight of permitted outside activities, including a ban on faculty participation in industry speakers bureaus, an express prohibition on faculty being listed as authors on papers ghostwritten by others, and a more rigorous internal review process for certain outside activities.

Development of an enhanced infrastructure, including creation of a new Conflict of Interest Review Committee, responsible for education, oversight, and enforcement of Partners policies and practices in regard to industry interactions.

The system plans to adopt revised policies and procedures by October 1, 2009 and acknowledges that a significant training and education program will be necessary during the roll-out of these changes.  The 30 page report details the commissions charge, its process, its internal review, external factors and recommendations. The press release link is below.

CommissionPressRelease_PartnersHealthCare2009.pdf (application/pdf Object).

Filed under: Conflicts of Interest, Drug Policy, Fraud and Abuse, Health Law, Reform, , , ,

Researcher Faked Data in Sleep Apnea Study – Health Blog – WSJ

The WSJ Health Blog reports another individual fabricating research study data.  Not much about industry ties, except that he later went on to work in industry.

“Robert Fogel, a former assistant professor at Harvard Medical School, fabricated and falsified data in a study of sleep apnea in severely obese patients, the Office of Research Integrity at HHS said…Fogel, who worked at Brigham and Women’s Hospital at the time but later moved on to work at Merck, told a former supervisor in 2006 that he had falsified the data, the Scientist reports.”

via Researcher Faked Data in Sleep Apnea Study – Health Blog – WSJ.

Filed under: Conflicts of Interest, Health Law, , , ,

Finding a Doctor Who Accepts Medicare Isn’t Easy – NYTimes.com

A New York Times article on April 1, 2009 discusses some trends: (i) a national shortage of internists, (ii) more internists and other primary care physicians refusing to accept Medicare entirely or at least new Medicare patients, and (iii) boutique/concierge  medicine.

On the first two points:

[T]he American College of Physicians, the organization for internists, estimates that by 2025 there will be 35,000 to 45,000 fewer than the population needs — and internists are increasingly unwilling to accept new Medicare patients. In a June 2008 report, the Medicare Payment Advisory Commission, an independent federal panel that advises Congress on Medicare, said that 29 percent of the Medicare beneficiaries it surveyed who were looking for a primary care doctor had a problem finding one to treat them, up from 24 percent the year before. And a 2008 survey by the Texas Medical Association found that while 58 percent of the state’s doctors took new Medicare patients, only 38 percent of primary care doctors did.

On the last point:

Another, more expensive option is concierge or “boutique” care, which comes in two forms. In the most popular kind, doctors accept Medicare and other insurance, but charge patients an annual retainer of $1,600 to $1,800 to get in the door and receive services not covered by Medicare, like annual physicals. Before signing up and paying the retainer, patients should get a written agreement spelling out which services the doctor will bill Medicare for and which the retainer covers. And always check carefully for double-billing…The other form of concierge medicine — doctors who have opted out of Medicare — is more expensive still. Fees range as high as $15,000 a year and cover office visits, access to the doctor when care is needed, referrals to specialists and thorough annual physicals…Dr. Knope, the author of “Concierge Medicine: A New System to Get the Best Healthcare,” has this kind of practice in Tucson. His patients sign a contract agreeing to pay $6,000 a year for individuals and $10,000 a year for couples. The fee covers office visits, physical exams and phone consultations, and Dr. Knope will meet patients in the emergency room, see them in the hospital and occasionally make house calls…A list of about 500 concierge doctors throughout the country is available on Dr. Knope’s Web site, http://www.conciergemedicinemd.com.

via Finding a Doctor Who Accepts Medicare Isn’t Easy – NYTimes.com.

Filed under: CMP, Concierge Medicine, Health Law, Medicare, Payment, Primary Care, Reform, , , ,

Stanford Medical School to Disclose More About Industry Comp – Health Blog – WSJ

According to the April 1, 2009 WSJ Health Care Blog, Standford is to publicly disclose on its web-site those of its medical school faculty receiving industry money greater than $5,000 — although specific amounts will not be disclosed.

Stanford University’s medical school said today it expects to post an online list by the end of the summer showing its staff members who received payments, royalties, stock grants and other compensation topping $5,000 in 2008. Companies providing the compensation to each staff member on the list will be identified but the dollar amounts staffers received above $5,000 won’t be included. Among the targets of the Grassley’s investigations was Alan Schatzberg, who chairs Stanford’s psychiatry department.

via Stanford Medical School to Disclose More About Industry Comp – Health Blog – WSJ.

Filed under: Conflicts of Interest, Health Law, Reform, Risk Management, , ,

The Health Care Blog: “Mr. Obama, Tear Down These (Hospital) Walls”

On the Healthcare Blog, Rober Wachter analyzes the recent NEJM report on hospital readmissions, the related

[T]he DRG system created a big black hole, and it is time to fill it. It’s called the post-discharge period. And one large part of the detritus emerging from that hole is readmissions. You probably saw this week’s NEJM study by Stephen Jencks (a former Medicare official and now a Baltimore-based consultant), and my pals Mark Williams and Eric Coleman, of Northwestern and Colorado, respectively. The study found that 20% of Medicare patients are readmitted within a month of discharge, and one-third return within 90 days. Even more remarkably, by a year out more than half of patients (56%) discharged from an acute care hospital are re-hospitalized. The authors estimate that the cost of preventable readmissions was $17 billion in 2004 (the study year), which would make it more like $25 billion today.

via The Health Care Blog: “Mr. Obama, Tear Down These (Hospital) Walls”.

Wachter also summarizes some interesting points of the study:

Like so many things in healthcare, there was striking geographic variation in readmission rates – from a low of 13% in Idaho to 23% in Washington, D.C.

There were also variations by DRG, with the highest readmission rates in patients with heart failure, psychosis, vascular and cardiac surgery, and COPD – pointing the way toward targeted interventions.

More than half the patients readmitted within 30 days appeared not to have had an outpatient visit between hospital discharge and readmission, perhaps another target for intervention.

Most (70%) surgical patients who are readmitted come back for a medical diagnosis such as pneumonia or UTI.

Approximately 30% of readmitted patients come back to a different hospital, so hospitals will underestimate the extent of their readmission problem by looking solely at their own bounce-backs.

via The Health Care Blog: “Mr. Obama, Tear Down These (Hospital) Walls”.

Wachter continues and and discusses why this is becoming critical (healthcare reform/savings dollars) and the health system’s current state as it relates to discharge planning/readmissions:

The Obama budget plan depends on figuring this out. The budget, which aims to save $300 billion (which used to seem like a lot of money) in Medicare/Medicaid costs over the next decade, includes a projected $26 billion in savings from “driving down hospital readmission rates for Medicare patients” …The manifestations of this myopic focus on hospitalization as the unit of analysis can be seen in the paucity of attention that hospitals give post-discharge care. Studies have chronicled a litany of post-discharge disasters…In other words, when it comes to post-discharge care, we suck…Despite powerful literature that shows that simple interventions – like post-discharge phone calls or the use of a transitions coach – can lead to impressive improvements in post-discharge care and decreased readmission and return-to-ED rates, few hospitals have put these interventions in place.

Wacther then makes an observation concerning financial efforts to address the system’s performance in this area:

Harvard’s Arnie Epstein reviews the policy initiatives addressing readmissions – including those that are here today (publishing readmission rates on the Web) and those being actively discussed (financial penalties to hospitals with high readmission rates). But the Cool Kid on the Payment Block is “bundling” – aggregating  payments for doctors and hospitals for a period of time after an illness (an “episode of care”) in an effort to create accountable integrated entities that will improve care across the continuum (the entities somehow have to split up the spoils between hospitals, hospitalists, SNFs, primary care docs, specialists, care coordinators… Have fun with that). Epstein’s verdict: worthy of pilot studies, but “the likelihood that [bundling] will prove to be a successful model is still uncertain.”

He recognizes the challenges, and the laments, of hospitals, that have difficulties in controlling other healthcare provider’s post-discharge data.  Why, hospitals ask, can you hold us responsible if we are not in control of this.

I would also put on the table that if the government goes this route, query if it makes any sense to maintain Medicare CoP restrictions on promotion of hospital/health system owned and controlled providers — such as those exist for home health.

He observes that there are tools ready out there to assist hospitals in this area, including those developed through the Society of Hospital Medicine and its “splendid” Project Boost.

Finally, he observes that “I, like you, don’t know where the money will come from for all of this.”   I tend to disagree.  I pretty much know where (most of) the money will come from — where the largest portion of the Medicare premium dollar comes from — inpatient admissions.   Get ready!

Filed under: Comparative Effectiveness Rearch, Health Law, Medicare, Payment, Quality Reporting, Reform, Risk Management, , , ,

Authors of Psychiatric Guidelines Get Funding from Drug Makers – Health Blog – WSJ

The WSJ Health Blog reports a significant portion of those writing the APA’s treatment guidelines have financial ties to industry.

[A]mong 20 authors of the guidelines for treatment of depression, dipolar disorder and schizophrenia, 18 had at least one financial tie to a drug maker, and 12 had ties in at least three categories, such as consulting, research grants, speaking fees or stock ownership.The guidelines are a powerful influence on the way doctors treat patients. This week, big-name docs argued in a JAMA paper that medical specialty groups, which put out the guidelines, should tightly limit their funding from industry. (Drug trade group PhRMA responded that industry funding helps doctors obtain important medical information.) Earlier this year, amid news that many heart-disease guidelines aren’t backed up by rigorous scientific testing, an editorial in JAMA argued that guidelines “often have become marketing tools for device and pharmaceutical manufacturers.”

via Authors of Psychiatric Guidelines Get Funding from Drug Makers – Health Blog – WSJ.

In the referenced Boston Globe article one of the authors Dr. Roy Perlis, after noting that the guidelines in his area promote generics and non-pharmeceutical interventions states:

“My job is to find better treatments for my patients. These are awful illnesses. People really suffer,” he said. “And the people who are most responsible for developing new treatments right now are the pharmaceutical companies. What is being lost in all this is that if I didn’t work with them, I couldn’t do my job as a scientist – the part of my job that says we have people who are suffering that need new treatments.”

Filed under: Conflicts of Interest, Health Law, Pharmacy, Reform, Risk Management, , , ,

Hospital Doors Revolve for Many Medicare Patients – Health Blog – WSJ

The WSJ Health Blog reports on April 2, 2009 that MEDPAC is recommending restructuring hospital payments in a “bundle” to incentive hospitals to minimize readmissions of Medicare patients.  We’ll see how this plays out, but I can certain envision greater integration of bundled prospective payments for, at least, certain types of admissions.

Some 20% of Medicare patients discharged from the hospital are readmitted within a month, and 34% return within three months, according to a study published in the current New England Journal of Medicine. Unplanned rehospitalizations cost Medicare $17.4 billion in 2004, the study says…MedPac, a commission that advises Congress on Medicare policy, has recommended that Medicare start a pilot program in which “bundled” payments extend beyond the first hospital stay to include, say, the first 30 days after discharge. The idea, which is also part of President Obama’s budget proposal, is that if hospitals get paid fixed rates for caring for certain conditions — and they don’t get paid more for those same conditions if patients return — hospitals will have a financial incentive to reduce the risk of readmission.

via Hospital Doors Revolve for Many Medicare Patients – Health Blog – WSJ.

Filed under: Comparative Effectiveness Rearch, Health Law, Medicaid, Medicare, Payment, Quality Reporting, Reform, , , ,

JAMA Sets New Policy in Wake of Disclosure Flap – Health Blog – WSJ

There seems to be a conflicts of interest fight brewing between JAMA, a professor of neuro-anatomy and BMJ.  According to WSJ Health Blog, “Leo, a professor of neuro-anatomy at Lincoln Memorial University in Harrogate, Tenn., faced criticism from editors at the Journal of the American Medical Association when he published a letter in another medical journal, BMJ, that highlighted an unreported conflict of interest in a study published by JAMA…The editorial… scolds Leo for publishing his letter in the BMJ before JAMA weighed in on the matter. In addition, the editorial says JAMA contacted the dean at Leo’s medical school in an attempt to apply pressure from above…As a result of the flap, JAMA says it is adopting a new policy under which anyone asserting that study authors have failed to disclose conflicts of interest should keep the matter confidential until JAMA investigates… That move is already generating controversy.”  What I find interesting is (1) apparently, the discovery of the potential conflict arose when Dr. Leo questioned material omissions in the study; (2) JAMA apparently contends that it is inappropriate for a third party to write about an apparent undisclosed conflict until JAMA has done its own thorough investigation and reported back; (3) apparently all this disagreement devolved into some name calling.   Interesting reading.

Read the JAMA editorial at http://jama.ama-assn.org/misc/jed90012pap_E1_E3.pdf

Read the Dr. Leo’s WSJ statement at http://online.wsj.com/public/resources/documents/leo_statement_for_WSJ.htm

Read the BMJ letter at http://www.bmj.com/cgi/eletters/338/feb05_1/b463#208503

via JAMA Sets New Policy in Wake of Disclosure Flap – Health Blog – WSJ.

UPDATE.  In the March 30, 2009 WSJ, WSJ reports that the American Medical Association (which controls JAMA) has appointed an oversight committee to investigate charges that the top editors threatened a researcher who publicly faulted a study in the publication. via Medical Group Seeks Probe of Its Journal – WSJ.com.

Filed under: Conflicts of Interest, Health Law, , ,

The Washington Independent » Rick Scott on His Health Care Record

The NY Times did an article on Mr. Rick Scott recently. Also of note, The Washington Independent interviewed Rick Scott on March 31, 2009.  You’ll recall him as the ousted CEO of Columbia/HCA after their trillion dollar fraud settlement with the federal government.  He’s back in the headlines as a ‘conservative’ voice against a potential Obama healthcare reform initiative.  I note only due to his comments on Columbia/HCA at the time.

RICK SCOTT: There’s no grudge. First off, if you go back and look at what we accomplished at Columbia/HCA, it was the lowest prices and best outcomes. I left and nothing happened to me. I can’t do anything about what people want to complain about. But if you look at what we’re doing, we’re doing the right things.

TWI: What, specifically?

RICK SCOTT: If you go look at Solantic [which Scott co-founded in 2001], we have transparency on prices, we’re dramatically less expensive than everyone else and we have a great service. Or go back and look at Columbia, look at all the objective measures. Go look at joint commission, accommodation, at accreditation. If you look at the top 100 hospitals, we started with less than seven percent of them. My last year, we had 27 percent of those hospitals. If you look at my management team, all of my management team went on and ran hospital companies.

TWI: People can still say, “Look, this was the guy who resigned in the biggest fraud settlement in American history.”

RICK SCOTT: But, you know, we were the biggest company. If you go back and look at the hospital industry, and the whole health care industry since the mid-1990s, it was basically constantly going through investigations. Great institutions, like ours, paid fines. It was too bad.

via The Washington Independent » Rick Scott on His Health Care Record.

Filed under: AKS, CMP, Drug Policy, Executive Compensation, Health Law, Reform, Risk Management, , ,

Healthcare Economist · Comparison of Pharmacists and Primary Care Providers as Immunizers

In his Healthcare Economist blog, Jason Shafrin writes about a recent paper he wrote with John Fontanesi, Jan Hirsch, Sarah Lorentz, and Debra Bowers and had published in American Journal of Pharmaceutical Benefits.  The paper (which I have not reviewed) analyzes the efficacy and quality of immunizations as provided in primary care offices and pharmacies in California.  The abstact is below and observes that from a consistency, cost and productivity stand point, pharmacies might be a better alternative. 

This study examines the potential role of “alternative community immunizers,” specifically pharmacists, in providing immunization services. A convenience sampling of almost 700 adults eligible for vaccinations was taken from 15 ambulatory care settings and 11 pharmacies in San Diego, California between 2006 and 2008. The results of the study found that patient characteristics and beliefs were similar between primary care and pharmacies, but pharmacies proved more consistent in following safety protocols; had lower unit costs; and were more efficient, with greater productivity. We conclude that pharmacies combine the best immunization practices of routine scheduled primary care visits and mass influenza vaccination clinics, but gaps still exist in pharmacies’ ability to effectively transmit immunization records securely and provider willingness to embrace these “alternative immunizers.“

via Healthcare Economist · Comparison of Pharmacists and Primary Care Providers as Immunizers.

Filed under: Comparative Effectiveness Rearch, Drug Policy, Health Law, Pharmacy, Primary Care, Quality Reporting, Reform, Risk Management, , ,

Attack Of The Zombie Biotechs – Forbes.com

Interesting commentary in Forbes.  Obviously alluding to the downturn’s fears of “zombie” banks and automakers, propped up by government bailout, they, instead, discuss small biotech firms, a small number of whom are sitting on R&D for the next generation of breakthrough drugs and biotech therapies.   The start-ups, however, are starved of cash due to the recession and credit crunch’s impact.

Without a major change in the investment environment, most of these companies will either go out of business, be gobbled up by large pharmaceutical firms where their technology will languish or exist only as Zombie Biotechs, a term used by insiders to describe companies with enough cash to exist on paper but not enough to conduct meaningful research and development. These zombie companies tie up capital, hold on to technology that could be developed elsewhere and discourage investors.

via Attack Of The Zombie Biotechs – Forbes.com.

The authors call for:

[A] meaningful tax incentive would be beneficial to the biotech industry, would eventually benefit the larger pharmaceutical industry, would yield more breakthrough drugs for sick people and would foster continued U.S. leadership in pharmaceutical R&D. This small investment through preferential tax treatment would yield tremendous return for individuals, investors and the economy as a whole.

In addition to the Forbes article, New York Time’s Deal Book had a similar article entitled Small Medical Companies Feel Recession’s Pinch on

In relatively recent op-ed peices, Thomas Friedman of the New York Times has been calling for similar stimulus focus.   Here’s what he said on 2/21/2009:

You want to spend $20 billion of taxpayer money creating jobs? Fine. Call up the top 20 venture capital firms in America, which are short of cash today because their partners — university endowments and pension funds — are tapped out, and make them this offer: The U.S. Treasury will give you each up to $1 billion to fund the best venture capital ideas that have come your way. If they go bust, we all lose. If any of them turns out to be the next Microsoft or Intel, taxpayers will give you 20 percent of the investors’ upside and keep 80 percent for themselves.

via Op-Ed Columnist – Start Up the Risk-Takers – NYTimes.com.

Filed under: Biotech, Health Law, Reform, , , , ,

AMNews: March 23, 2009. Doctors increasingly close doors to drug reps, while pharma cuts ranks … American Medical News

In the March 23, 2009 AMA News, a consulting firm reports that the heyday of the pharma detailer may have already peaked and is headed into decline:  “At its peak in 2007, the American pharmaceutical industry fielded 102,000 sales reps, said Chris Wright, managing principal for the consulting firm ZS Associates’ U.S. Pharmaceuticals Practice. Drugmakers have slashed the number to 92,000 since then, and ZS projects the number will fall to 75,000 by 2012 at the latest, saving the industry $3.6 billion.”

According the article and the survey, fewer physicians are spending less time with the detailers.  More types of providers are requiring advance appointments.

The article and survey reports that “[p]hysicians’ openness toward visits by pharmaceutical company detailers varies by practice ownership and size.

Refuse
to see
Require
appointments
Practice size
1 to 2 doctors 14.3% 32.5%
3 to 5 16.7% 36.1%
6 to 10 23.1% 45.0%
More than 10 44.0% 45.5%
Practice ownership
Non-hospital 22.1% 37.8%
Non-health system 22.3% 37.5%
Hospital 31.2% 44.6%
Health system 34.7% 52.0%

Source: “Physician Access: U.S. Physicians’ Availability to See Drug and Device Sales Reps,” SK&A Information Services Inc., released February”

The article also reports significant decreases in detailing staff.  “Experts estimate the U.S. pharmaceutical sales rep force eventually will be cut 25% from its 2007 peak of more than 100,000. Here are some of the biggest layoffs announced in the last year.

Drugmaker Sales rep cuts
GlaxoSmithKline plc 1,800
Merck & Co. Inc. 1,200
Wyeth 1,200
Schering-Plough Corp. 1,000
Sanofi-Aventis 650

Source: News accounts”

via AMNews: March 23, 2009. Doctors increasingly close doors to drug reps, while pharma cuts ranks … American Medical News.

Filed under: Conflicts of Interest, Health Law, , , , , ,

Running a hospital: Final budget decisions

Running a hospital: Final budget decisions.

Running a hospital: Good progress in budget deliberations.

In his “Running a Hospital” blog, Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, writes two particularly remarkable posts concerning the decision-making process leading to budgetary cuts in these lean times for his hospital.  The posts are note-worthy due to the steps taken, the transparency through which the cuts are communicated (effectively to the world), and what appears to be the level of buy-in generated by the hospital management, personnel and medical staff.

Mr. Levy also posts that the accolades he is receiving are misplaced.  The process and the values demonstrated by the budgetary cuts, according to him, are more a reflection of the hospital’s community, then necessarily, his leadership.  Of interest to me, he references, in current events, a quote (that I also took) from Thomas Friedman’s recent op-ed, although focuses this, again, more on the institution’s own values as merely reflected by leadership, rather than leadership instilling the leader’s values on the organization.  Truth is probably somewhere in between.  Very much worth a read.

Filed under: Health Law, Personal Posts, , , ,

New York Medicaid Provider Self-Disclosure Process

As reported in the March 13, 2009 BNA Health Law Reporter, The New York State Office of the Medicaid Inspector General (OMIG) on March 12 announced the release of the Provider Self-Disclosure Guidance.  According to the the OMIG, this will “enabling health care providers to identify, reveal, and return to the OMIG overpayments they have received from the Medicaid program.”  BNA reports that the guidance is significantly more expansive in scope than the Department of Health and Human Services Office of the Inspector General’s Self-Disclosure Protocol.   OMIG reports that it hopes to save up to $820 million in Medicaid costs in the 2009-2010 fiscal year.  The OMIG also “highly discourages” providers from attempting to avoid the self-disclosure process when circumstances warrant its use and it will not accept full and final payments for self-disclosed violations before the investigatory process is finalized. See  http://www.omig.state.ny.us/data/images/stories/self_disclosure/omig_provider_self_disclosure_guidance.pdf for the new guidelines and http://www.omig.state.ny.us/data/images/stories/self_disclosure/voluntary_disclosure_form.pdf for the disclosure form.

Filed under: AKS, Fraud and Abuse, Health Law, Medicaid, , , , ,

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