My father, sister and I sat in the near-empty Chinese restaurant, picking at our plates, unable to avoid the question that we’d gathered to discuss: When was it time to let Mom die?
It had been a grueling day at the hospital, watching — praying — for any sign that my mother would emerge from her coma. Three days earlier she’d been admitted for nausea; she had a nasty cough and was having trouble keeping food down. But while a nurse tried to insert a nasogastric tube, her heart stopped. She required CPR for nine minutes. Even before I flew into town, a ventilator was breathing for her, and intravenous medication was keeping her blood pressure steady. Hour after hour, my father, my sister and I tried talking to her, playing her favorite songs, encouraging her to squeeze our hands or open her eyes.
Doctors couldn’t tell us exactly what had gone wrong, but the prognosis was grim, and they suggested that we consider removing her from the breathing machine. And so, that January evening, we drove to a nearby restaurant in suburban Detroit for an inevitable family meeting.
Continue reading “How Mom’s Death Changed My Thinking About End-of-Life Care”
Filed Under: OP-ED, THCB, The Vault
Tagged: Charles Ornstein, Dartmouth Atlas, Death panels, Elliot Fisher, End of Life Care, ICU, Medicare, Medicare spending
Feb 28, 2013
A recent article in Time magazine by Steven Brill, “Bitter Pill: Why Medical Bills Are Killing Us,” is a brilliantly written expose of the excesses and outrages of health care pricing. In reaction to the story, some have suggested the price controls are the appropriate (or the only) way to rectify the situation. A recent story in the Washington Post’s Wonkblog, “Steven Brill’s 26,000-word health-care story, in one sentence,” suggests that US health care costs and cost growth are so high because we do not use rate setting, i.e., price controls.
In fact, I think it’s not easy to establish whether that is indeed the case. We don’t get to use randomized controlled trials for health policies or systems, so it’s difficult to figure out how effective a policy like rate setting is. Let me start with some simple examinations of patterns in data to see if something jumps out that strongly supports (or contradicts) the assertion that price controls reduce health care costs.
Continue reading “Are Price Controls the Answer?”
Filed Under: OP-ED, THCB
Tagged: Costs, Economics, health economics, Managed Care, Martin S. Gaynor, Massachusetts, Medicare, Price controls, rate settings, Steven Brill
Feb 27, 2013
Same story, different week: A governor who opposed the Affordable Care Act changes course and announces plans to opt into the Medicaid expansion.
Supporters of the ACA rejoice, conservatives grumble, and a new number gets tacked on the board – 24 states opting in, at last count.
Yet there’s more to the story than governors’ speeches. In at least eight of those states, lawmakers are warning that they may not go along with expansion plans.
Those legislative logjams — and what governors need to do to circumvent them — vary state by state , but the fights are falling out along party lines.
In Missouri, two GOP-led House committees this week voted down Medicaid expansion plans, despite Democrat Gov. Jay Nixon’s pledge to opt into the measure last year. Republican lawmakers in Arkansas, Montana and Washington have similarly been skeptical of their Democratic governors’ expansion positions. Meanwhile, four GOP governors who have backed the expansion are having difficulty corralling members of their own party.
Continue reading “How Many States Are Really Opting In?”
Filed Under: THCB
Tagged: Dan Diamond, Medicaid Expansion, The ACA, The States
Feb 27, 2013
A bureaucracy-centric governing philosophy is spreading in health care, and with it comes heavy reliance on “experts” to determine how to curb costs outside the normal legislative and democratic process. This was embodied at the national level by the Affordable Care Act (ACA), and most recently at the state level in a new Massachusetts growth-capping law. (Supporters refer to the law as cost control and payment reform or Health Reform 2.0; the legal name is Chapter 224 of the Acts of 2012).
The new Massachusetts law was discussed by Mechanic, Altman and McDonough in a past Health Affairs issue, and on the blog by Turnbull and Lee. Yet, the unintended consequences of using this method to reform health care have not been fully explored.
What’s In The Law?
Promising savings of $197 billion over 15 years, Chapter 224 sets a cap on statewide health care spending growth by tying it to state growth, enforced by a flat $500,000 civil penalty if health care entities don’t meet reporting deadlines or take reform efforts seriously enough. The law grants strict preference to alternative payment methods (capitated or bundled payment contracts) and accountable care organizations (ACOs).
Continue reading “Now For The Rest Of The Story On Massachusetts Cost Control”
Filed Under: THCB, The Business of Health Care
Tagged: Josh Archambault, Massachusetts
Feb 27, 2013
Happtique has been spending a lot of effort cataloging all the health, clinical and fitness Apps in the Apple App Store, Google Play and more. Their goal is to create prescribable apps, and proprietary app stores for providers. The idea is that a hospital or clinic can help its physicians suggest the right apps to patients by giving them a select group to choose from, and by having them cataloged in a way that is far more detailed than Apple or Android can do.
That in itself is a big advance, but even though they’ve cataloged 15,000 of the approx. 40,000 health apps out there, they don’t think it’s enough. Happtique is introducing a new certification program today. The idea is to have all apps assessed both for technical proficiency and also for content. Happtique will be reviewing the applications for technical, security and privacy–in other words, where any data goes and whether the app does what it says it does. In addition it’ll assess whether the app links properly to a particular devices or a particular EMR–something that presumably is pretty important to users. (I had an Android phone once which a major tracking device could not link to, even though the device had an Android app!). Here’s the release.
Happtique’s partners (academic med center group AAMC, nurse credentialers CGFNS International & testing lab Intertek) will provide clinicians and other experts who will review the apps for content. The idea here is not to rate or review the content but to see whether the content is from a valid source, and is true to what it says it is.
Continue reading “Certifying apps? Happtique’s big new idea”
Filed Under: Health 2.0
Tagged: Happtique, Health 2.0, Matthew Holt
Feb 27, 2013
I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).
Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”
Continue reading “The HIT Job”
Filed Under: Tech, THCB, The Vault
Tagged: Allscripts, Bob Wachter, Cerner, EHR, Epic, HIT, HIT adoption curve, HITECH Act, Julie Creswell, New York Times
Feb 26, 2013
Say “employee benefits” and pensions and health care will jump to most people’s minds. Maybe life and disability insurance will pop up as well. But employers in Silicon Valley are going way beyond that. They’re providing housekeeping, cooking, babysitting and a host of other services as perks for their employees. According to The New York Times, here is what some California companies are doing:
At Evernote, a software company, 250 employees — every full-time worker, from receptionist to top executive — have their homes cleaned twice a month, free.
Stanford School of Medicine is piloting a project to provide doctors with housecleaning and in-home dinner delivery.
Genentech offers take-home dinners and helps employees find last-minute babysitters when a child is too sick to go to school.
To hear the employer representatives tell it, companies are providing their workers with services that make it easier to balance home and family life in an age when there are few stay-at-home spouses and work is stressful.
But a more likely explanation is economics.
Continue reading “Employee Benefits Gone Wild”
Filed Under: The Business of Health Care
Tagged: California, employee benefits, Employees, Employers, flat tax, John Goodman, Laurence Kotlikoff, marginal tax rates, Silicon Valley
Feb 26, 2013
It feels like part of me is dying. I am losing something that has been a part of me for nearly 20 years.
I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996. My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization. I saw electronics as an excellent organization system for documents. Templates could make documentation quicker and I could keep better track of labs and x-rays. I could give better care, and that was a good enough reason to use it.
But the EMR product we bought, as it came out of the box, was sorely lacking. Instead of making it easier to document I had to use templates generated by someone else – someone who obviously was not a physician (engineers, I later discovered). So we made a compromise: since it was easier to format printed data, we took that data and made a printed template.
Continue reading “Death of an Evangelist”
Filed Under: OP-ED, Tech, THCB
Tagged: EHR, Physicians, practice management, primary care, Rob Lamberts
Feb 25, 2013
“Make it work.”
This advice on health reform to Democrats earlier this month illustrates that President Clinton knows what the opponents of Obamacare also know: success is the best political revenge.
As the health reform law moves off the drawing board into the real world, its opponents are doing their best to make it not work — by shifting their energies from fulminations about the boogeymen they imagine in the law to hampering, complicating or outright obstructing its implementation.
For openers, half the states have announced they will probably not expand their Medicaid programs under the law — though there have been defectors, most notably Florida. This will leave a large segment of the uninsured priced out of even the subsidized insurance markets created under Obamacare, while adding enormous complexity and uncertainty for small businesses and multi-state employers who want to comply with the law and cover their lower-income workers.
The same states, more or less, are also refusing to establish health insurance exchanges — online marketplaces where small businesses and individuals can purchase private health insurance — the fulcrum of the law’s provision for those not covered by Medicaid. As of last Friday’s deadline, 24 states and the District of Columbia were going ahead with exchanges and 26 were not.
Continue reading “Praying For Obamacare to Fail”
Filed Under: THCB
Tagged: GOP, HIEs, J.D. Kleinke, The ACA, The States
Feb 24, 2013
Several email lists I am on were abuzz last week about the publication of a paper that was described in a press release from Indiana University to demonstrate that “machine learning — the same computer science discipline that helped create voice recognition systems, self-driving cars and credit card fraud detection systems — can drastically improve both the cost and quality of health care in the United States.” The press release referred to a study published by an Indiana faculty member in the journal, Artificial Intelligence in Medicine .
While I am a proponent of computer applications that aim to improve the quality and cost of healthcare, I also believe we must be careful about the claims being made for them, especially those derived from results from scientific research.
After reading and analyzing the paper, I am skeptical of the claims made not only by the press release but also by the authors themselves. My concern is less about their research methods, although I have some serious qualms about them I will describe below, but more so with the press release that was issued by their university public relations office. Furthermore, as always seems to happen when technology is hyped, the press release was picked up and echoed across the Internet, followed by the inevitable conflation of its findings. Sure enough, one high-profile blogger wrote, “physicians who used an AI framework to make patient care decisions had patient outcomes that were 50 percent better than physicians who did not use AI.” It is clear from the paper that physicians did not actually use such a framework, which was only applied retrospectively to clinical data.
What exactly did the study show? Basically, the researchers obtained a small data set for one clinical condition in one institution’s electronic health record and applied some complex data mining techniques to show that lower cost and better outcomes could be achieved by following the options suggested by the machine learning algorithm instead of what the clinicians actually did. The claim, therefore, is that if the data mining were followed by the clinicians instead of their own decision-making, then better and cheaper care would ensue.
Continue reading “Data Mining Systems Improve Cost and Quality of Healthcare – Or Do They?”
Filed Under: Tech, Uncategorized
Tagged: Artificial intelligence, CDOI, client-directed outcome informed assessment, Costs, Data, data mining systems, HIT, Informatics, Physicians, Quality, William Hersh
Feb 24, 2013