OP-ED

OP-ED

The Inconvenient Truth about the Military and Veterans Health Systems? They’re Working Just Fine.

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Lieutenant colonel Justin Constantine USMC

Through the years, I’ve had the honor of speaking to groups after they heard from notables like Michael J. Fox, Sammy Hagar, Jeff Immelt, U.S. Secretaries of Health Tommy Thompson and Mike Leavitt, Warren Buffet and others. They’re the headliners and I usually follow them with a less celebrated presentation about the current issues and future in healthcare. 

Earlier this month, in Arizona, I spoke to 3M’s annual healthcare conference following Lt. Colonel Justin Constantine, a Marine who served from 1997-2013. Justin’s story is profound: he was plying his trade as a military lawyer in the Al Anbar province of Iraq on October 18, 2006 when a sniper’s bullet tore through his head. After an emergency tracheotomy by Navy Corpsman George Grant, scores of surgeries and years of treatment, he survived and now shares his story as an inspirational speaker, crediting the Military and Veterans Health Systems for saving his life. 

His message was riveting: Leaders lead. Never give up. Don’t be afraid. His scarred face and slurred speech commanded the rapt attention of the 250 in the audience. As he concluded, we all stood in a spontaneous expression of appreciation for this man, his message and his courage. 

Later that day, he shared more about his decade-long climb experience as we traveled together back east. And through this week, I found myself reflecting on his ordeal and the roles of our Military and Veterans systems about which I confess I’d given little thought prior. 

The Mysterious Case of Ohio’s Disappearing Price Transparency Law

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When is the last time anyone received an estimate of the cost of a healthcare service upfront?  With premiums and deductibles going up thousands of dollars a year, patients have a need and a right to know the cost of any nonemergent healthcare service to help them make an informed decision.

Meanwhile, the healthcare industry, backed by its powerful lobby and the many politicians it seems to control, obstinately clings to a status quo where we are all kept guessing about the cost of our healthcare.

In June of 2015, a law was passed in Ohio that sought to upend that status quo.  Starting January 1, 2017, the Ohio Healthcare Price Transparency Law requires that patients in Ohio must receive a good-faith estimate of the cost for anticipated healthcare services they are scheduled to receive.  Emergencies are obviously excluded, including hospital admissions for acute issues.  The estimate must provide the amount to be charged, the insurance share and the patient share.  Straight-forward enough one would think. 

Unfortunately, over the year and a half since the Ohio Healthcare Price Transparency Law was passed, the healthcare lobby (led by the Ohio Hospital Association) has vigorously sought to kill the law rather than prepare for its implementation. 

Mirroring honed strategies utilized to defeat transparency laws in multiple states, the healthcare lobby claims it really believes in transparency, but offers disingenuous excuses as to why true transparency is “impossible” to provide.  It offers to support the creation of some difficult-to-navigate and nebulous website, or to provide estimates for only a small number of services or only upon formal request.

What Experts in Law and Medicine Have to Say About the Cost of Drugs

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Pharmaceutical drug costs impinge heavily on consumers’ consciousness, often on a monthly basis, and have become such a stress on the public that they came up repeatedly among both major parties during the U.S. presidential campaign–and remain a bipartisan rallying cry. A good deal of the recent conference named Health Law Year in P/Review, at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School, covered issues with a bearing on drug costs. It’s interesting to take the academic expertise from that conference–and combine it with a bit of common sense–to see which narratives about drug costs hold up.

The Industry Narrative

In defending the ever-growing cost of drugs, the pharmaceutical industry can’t roll out a single, intuitive explanation. Rather, their justification breaks down into many independent but interacting parts. We have to tease these apart before examining their validity.

What Is This Strange & Confusing Healthcare Language We Have Invented?

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Public understanding about how our health system operates is woefully low: surveys show only one in five adults has functional knowledge about how to choose a physician, hospital or insurance plan, or compare treatment options. The lexicon we use in our industry lends to this confusion: powerful words and phrases that convey something different depending on the user’s intent.

As we debate the replacement for the Affordable Care Act, it might be worthwhile to ask lawmakers to clarify what they mean when they use them and examine our own uses in tandem:

Quality: In U.S. healthcare, quality is not defined by a consistent set of metrics that address diagnostic accuracy and clinical outcomes.  Physicians associate it with access to a clinician; insurers associate it with necessary care; employers with provider network scale and premium costs and the public thinks it’s about scheduling and parking, not results. There are a dozen websites where information about the quality of care in hospitals and medical practices is available, but each has its own methodology and results vary widely. As a result, every hospital and every physician affirms they deliver “high quality care” and every insurer tells its enrollees, groups and regulators its plans are “high quality”. Little wonder quality is confusing.

Should Doctors Think?

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It has been suggested that to improve quality in healthcare we must reduce variability in how diseases are diagnosed and treated.

It has been inferred that clinical outcomes would improve exponentially if doctors would only follow established guidelines instead of their own whims.

I take that to mean if doctors didn’t think for themselves so much, the health of our nation would be better. I take that to mean that we may be overqualified for the simple work of delivering “evidence based care”.

That is the fantasy of the non-clinician creators of our new medical world order.

Doctors spend all these years learning biology, biochemistry and physics. We learn about anatomy, physiology and pathology. Eventually we study diseases. Then we learn how to practice what we were taught. Finally, more than a decade after we started, do we earn the right to practice independently, only to become the obedient instruments of a healthcare system that demands conformity and disciplines those who put their training to use by questioning politically motivated health policies and overly simplistic clinical guidelines.  

Should Cleveland Clinic’s Anti-Vax Physician Lose His Medical License?

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Years ago, when I was less inflexible, I took up Pilates. My instructor, Jim, a charming chap with an infectious laughter, was a 911 truther. I’d egg him on to hear about his conspiracy theories. Jim believed that 911 was concocted by Bush and Haliburton so that the U.S. could invade Iraq to capture their oil. He thought that United Flight 93 never took off. Whatever happened after 911 became the motivation for 911. He was the sort of person who would have concluded that Mahatma Gandhi plotted the Second World War to free India from British rule.

I began to suspect that Jim was, to put it charitably, nice but dim. But he wasn’t that dim. He corrected me when I once, innocently, underpaid him. He was also smart at advertising and when he met my wife, he told her that she should join me for Pilates because it would strengthen our marital bond. My wife politely declined the bond strengthening. He was also very cued up with the nutritional sciences and warned me, without leaving a trace of irony, “don’t believe everything you read about diets.”

A Brief History of Why the Republicans Have No Replacement For Obamacare

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There is no conservative replacement health reform plan for Obamacare — because Obamacare is a conservative health reform plan.

After six years of promising to repeal ‘n’ replace the President’s signature domestic achievement, Republican lawmakers have no coherent alternative to the Affordable Care Act for one good reason: because the Affordable Care Act was once the market-based alternative to a real, not imagined, “government takeover” of health care.

What has always made the ACA a political pariah to Republicans, typified by the bizarre claim by House Speaker Paul Ryan (R-WI) on Wednesday that “Obamacare” has “ruined” and “dismantled” our health care system, is the plan’s namesake — far more than its necessarily complex architecture or any of its actual details, unless you count the details they made up.

America’s Health and The 2016 Election: An Unexpected Connection

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Donald Trump’s stunning upset victory has occasioned a lot of searching among political analysts for an underlying explanation for the unexpected turn in voter sentiment. Many point to Trump’s galvanizing support among white working class and middle income Americans in economically depressed regions of the US- particularly Appalachia and the upper middle west “Rust Belt” – as the main factor that put him in office.

While the Democrats concentrated on the so-called “coalition of the ascendant”- voter groups like Hispanics and Millennials that are growing, Trump rode to victory on a “coalition of the forgotten”- working class Americans in economically depressed regions of the U.S. who had been left behind by the economic expansion of the past seven years.

When the Economist searched for a more powerful predictor of the Trump victory than white non-college status, they found a surprise winner: a composite measure of poor health (comprised of diabetes prevalence, heavy alcohol consumption, lack of physical activity, obesity and life expectancy). Believe it or not. this measure of health status predicted a remarkable 43% of the improvement of Trump’s vote percentage compared with the 2012 Republican candidate Mitt Romney, compared to 41% for white/non-college.

A month after the election, the Centers for Disease Control released its 2015 morbidity and mortality trends in the US.  The CDC Report showed that  Americans’ life expectancy actually declined for the first time in 22 years. Except for cancer where we saw continued progress, death rates rose for eight out of the ten leading causes of death, most sharply for Alzheimer’s Disease.  The decline in life expectancy was confined entirely to the under 65 population!

Homme Fatale

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Halfway through the “Bell Curve,” which is an analysis of differences in intelligence between races, I realized what had been bothering me about Charles Murray’s thesis. It wasn’t the accuracy of his analysis, which concerned me, too. It was that he analyzed. The truth, I used to believe, was always beautiful, whether it was what happened in the multiverse at T equals zero, or the historical counterfactual if Neville Chamberlain hadn’t signed the peace accord with Adolph Hitler. After reading Murray’s book, I realized that the truth can be irrelevant, ugly, and utterly useless. Even if the average intelligence of races was truly different, so what? Surely, civilized people must judge each other as individuals, regardless of the veracity of the statistical baggage of their ethnicities.

Murray was castigated, deservedly, for swallowing the bell curve uncritically. But his detractors missed one point. Murray wasn’t just wrong because he was factually wrong or for inquiring. In fact, it was worse, because Murray, it turned out, was wronger than wrong.

Making the Physician-Patient Relationship Great Again

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21st Century Cures is now law. Aside from its touted research and mental health provisions, it’s the most significant health information technology regulation since HITECH, now 8 years ago. A decent summary of the health IT provisions of the bill by John Halamka concludes with “That is just not realistic.” He’s almost certainly right to the extent your perspective is the hospital-centered mega-EHR model. You can’t get there from here.

Halamka and others who think that consolidated institutions will drive interoperability are in denial of the gap between financial integration and clinical integration. This recent post by Kip Sullivan describes some of the wishful thinking. But there’s another reason why HITECH’s institutional EHRs cannot get us to the Triple Aim, and it’s mostly about liability.

Halamka ignored one of the items in 21st Century Cures that could lead to clinical integration around a patient: a longitudinal health record. Section 4006 on page 149 includes:

“(1) IN GENERAL.—The Secretary shall use existing authorities to encourage partnerships between health information exchange organizations and networks and health care providers, health plans, and other appropriate entities with the goal of offering patients access to their electronic health information in a single, longitudinal format that is easy to understand, secure, and may be updated automatically.”

Useful longitudinal health records require curation and, almost by definition, the curators are not going to be affiliated with any single hospital or other institution operating a traditional EHR. Allowing licensed physicians, family caregivers, and the patient themselves to edit an institutional EHR is risky to the point of impossible. That’s why the current initiatives to introduce modern APIs into EHRs like SMART and Sync for Science are read-only.