Access

“Why is Wal-Mart speaking at a health care summit?” the company’s vice president for health and wellness, Marcus Osborne, rhetorically offered up at a conference back in January.

“Wal-Mart’s in retail, we’re not in health care.”

But as analysts, researchers, and other experts who spoke with me. took care to point out, Wal-Mart is in health care, and getting further entrenched by the year. In the past six months alone, Wal-Mart launched a major contracting initiative with half-a-dozen major hospitals, and dropped hints — since retracted — that the company is exploring new services like a health insurance exchange.

Notably, Osborne teased a broader health care strategy for Wal-Mart that would include “full primary care services over the next five to seven years,” in a Q&A at that January conference captured by the Orlando Business Journal.

Wal-Mart has since denied Osborne’s comments — the second time in about 18 months that the company has had to walk back stories about its planned primary care services — and Osborne subsequently stopped talking to the press. (Wal-Mart declined to comment, and Osborne did not respond to an interview request for this story.)
But Osborne’s remarks from that January conference, and his other archived speeches, are still readily accessible. And they paint a vivid picture of a company that’s not just a potential market-mover and disruptive innovator, but an organization that could do a lot to positively reform health care.

Background: Wal-Mart’s Growing Role in U.S. Health Care System

In many ways, this isn’t a new story. Back in 2007, Princeton University’s Uwe Reinhardt suggested to NPR that Wal-Mart could be “taking aim at the entire health care system” by expanding its new discount drug program.

“I think it’s a really fascinating way to come out of the corner and really slug the system,” Reinhardt said at the time. “At the moment, the body blows don’t hurt. But they add up. I’m watching this with great fascination, and expect more from them.”

And in subsequent years, Wal-Mart did grow its health care footprint, from launching retail clinics based within its stores to advocating for national health reform. Considering its history — as recently as 2005, Wal-Mart had little involvement in the health care market and was being pilloried for skimping on its own employees’ benefits — it’s been a significant turnaround for the firm, and has positioned Wal-Mart as one of the leading disruptive innovators in health care. Continue reading “Wal-Mart Could Transform Care–But Does It Want To?”

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In it’s broadest definition, a portal is a doorway from one place to another.  On the internet, a portal is a site that has links to other sites.  In health care IT, the term refers to a feature of an electronic medical record that gives patients the ability to see parts of their medical record.

In each of these definitions there are two important things that are consistent:

1. To access what’s on the other side, a person must find the portal.

2. What is on the other side of the portal is not controlled by the person using it.

This is very important in the area of my concern: health care IT.  Our old friend “Meaningful Use” includes the requirement that the EMR system must “Provide patients the ability to view online, download, and transmit their health information.”

In case you’ve forgotten (deliberately or not), “Meaningful Use” is a program to encourage use of EMR by doctors, paying them real cash money if they meet the prescribed requirements.  The main way EMR vendors accomplish this provision is through the use of a “patient portal.”

So are portals the answer to patient engagement via online tools?  Are they the answer to e-Patient Dave’s demand to “Gimme My Damn Data?” I don’t think so.  They may be a step in the right direction, giving people some of the information they need, but there is still a wide gulf between giving someone a cup of water and ending a drought.

Continue reading “Tool Kit: Why Portals Don’t Work Very Well”

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Currently, India spends about $20 per person per year on healthcare and spending more once seemed like a peripheral concern, taking a back seat to basics like food and sanitation.  However, in the past decade, as the Indian economy has grown and wealth followed, Indians are increasingly demanding access to “high quality” healthcare.  But what does “high quality” mean for a country where a large proportion of the population still goes hungry?  Where access to sanitation is so spotty that the Supreme Court recently had to decree that every school should have a toilet?  What is “high quality” in a setting where so many basics have not been met?

It turns out that “high quality” may mean quite a lot, especially for the poor.  A few weeks ago I spent time in Delhi, meeting with the leadership of the Indian health ministry.  I talked to directors of new public medical schools and hospitals opening up around the country and I met with clinicians and healthcare administrators at both private and public hospitals.  An agenda focused on quality rang true with them in a way that surprised me.

The broad consensus among global health policy experts is that countries like India should focus on improving “access” to healthcare while high income countries can afford to focus on the “quality” of that care.  The argument goes that when the population doesn’t have access to basic healthcare, you don’t have the luxury to focus on quality.  This distinction between access and quality never made sense to me.  When I was a kid in Madhubani, a small town in in the poor state of Bihar, I remember the widespread impressions of our community hospital.  It was a state-run institution that my uncle, a physician, once described as a place where “you dare not go, because no one comes out alive”.

Continue reading “Can Quality Be on India’s Health Care Agenda? Should it Be?”

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Since 2010, when the Affordability Care Act was signed into law, the American mainstream media has insisted that President Obama’s bill provides the most at-risk Americans, low income families and seniors, with better health care. And that must mean, by any logic, better access to doctors, more access to the modern tools of diagnosis and treatment, and ultimately better health outcomes. That poor Americans benefit greatly from the ACA, and that seniors will be more secure under the president’s law, has seemed so obvious to the left-leaning news outlets that this fact has yet to be critically examined by them.

President Obama’s ACA law purports to provide new health coverage to upwards of 16 million low income Americans by way of Medicaid. We already see in the wake of the Supreme Court decision that many, if not most, states simply cannot be burdened with massive increases in their Medicaid outlays, regardless of the promise of financial support from the federal government (itself a financially unsustainable funding source).

But President Obama’s assertion about new insurance for the poor and all it brings is, in fact, a grand deception. We know that 55 percent of primary care physicians and obstetricians already refuse all or most new Medicaid patients (about four times the percentage that refuse new private insurance patients), and only half of specialist doctors accept most new Medicaid patients. Clearly, granting poor people Medicaid is not equivalent to providing access to doctors.

Continue reading “The Moral Case for Romneycare 2.0″

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It was the worst of systems. It was the worst of systems.

For decades, policy analysts have debated how we to strike a proper balance among access, quality and cost in our healthcare system. This debate has missed a crucial point: we do not have one healthcare system, we have two. And both are broken. Fortunately, if we fix one the other may heal itself.

The first system is the one that we encounter when we seek treatment for an illness. This system defines how much we pay out of pocket, which depends which providers we seek and what treatments they deliver. This system also defines how much our providers are paid, including rewards for exceptional quality and penalties for substandard quality. Historically, patients have relied on their physicians to guide them through the complexities of this system. In recent years, supporters of consumer-driven healthcare have argued for a bigger role for patients. They make the important point that patients will never make a serious effort to balance access and quality against cost unless they are responsible for all three.

Continue reading “A Tale of Two Systems”

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In a recent column, Clarence Page ridiculed Republicans who claim that they want healthcare reform but oppose programs that dramatically reduce the number of uninsured. Republicans counter that the PPACA is not true reform because it fails to contain costs. It seems that our political commentators have finally joined a long standing debate among health policy experts. More precisely, they have joined two-thirds of that debate.

The healthcare system is often described as a three-legged stool, supported by access, cost, and quality. Policy makers have usually paid attention to the most “rickety” leg, sometimes to the detriment of the others. During the 1960s and 1970s, access was the biggest problem, and government gave us Medicare, Medicaid, and the community health center movement. These programs triggered a surge in healthcare spending, and by the mid-1970s through the mid-1990s, the emphasis shifted to cost containment. When government price controls and planning laws failed, the private sector stepped in with a “competitive” solution based on HMOs and selective contracting.

Continue reading “Is This Health Reform Which I See Before Me?”

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If conservative Supreme Court justices are determined to overturn the Patient Protection and Affordable Care Act (ACA), then why not look to the Court’s famous ruling on school desegregation for what comes next? Couple the declaration that the signature legislative achievement of the nation’s first black president is unconstitutional with the enforcement urgency that followed Brown v. Board of Education in 1954.

In other words, tell the federal government to dismantle the ACA with “all deliberate speed.” Given the history of how putatively law-and-order Southerners responded, that should give health reform breathing room until at least the middle of the 21st century.

There are similarities between Brown and the ACA case. Both are rooted in controversies over state versus federal power and both, coincidentally, involve Kansas. In Brown, it was the Topeka Board of Education that said the Constitution allowed it to maintain separate schools for whites and blacks. In the ACA, it’s the Kansas state attorney general who has joined with 25 others to say that the Constitution protects state from having to expand the Medicaid program for the poor.

Brown was a landmark ruling that initially prompted little concrete change. When civil rights advocates returned to the Supreme Court in 1955 seeking better enforcement, the Court set a standard of “all deliberate speed” that in effect winked at much deliberate disregard. It wasn’t until 1969, in Alexander vs. Holmes County Board of Education, that the Court ruled that desegregation had to proceed immediately.

Continue reading “Conservative Supremes Can Overturn ACA With “All Deliberate Speed””

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Like waiting outside the Vatican for the puff of white smoke, the nation sits on edge awaiting the Supreme Court’s ruling on the Affordable Care Act. The ruling, which is likely to be announced next week, could toss out the entire healthcare reform bill, chop off one of its limbs (probably the so-called individual mandate), or leave the ACA intact. Whatever the ruling, it will be chum for the blogosophere, particularly in the heat of presidential silly season.

The two fundamental challenges to American healthcare today are how to improve value (quality divided by cost) and how to improve access (primarily by insuring the tens of millions of uninsured people). The bill sought to address these twin challenges in ways that were complex and intertwined. I’ll argue that a decision by the Court to throw out all or part of the ACA will have a profoundly negative effect on the access agenda, but surprisingly little impact on the value agenda. To understand why requires that we focus less on the bewildering details (mandates, insurance exchanges, PCORI, CMMI, IPAB, etc.) and more on some big picture truths and tradeoffs.

The job of any healthcare system is to deliver high quality, safe, satisfying care to patients at the lowest possible cost. Although America certainly does specialty and high tech care like nobody’s business, on all of the key dimensions of value we aren’t very good. The numbers tell the sorry tale: we provide evidence-based care about half the time, there are huge variations in how care is delivered, we kill 44,000-98,000 patients per year from medical errors, and we spend 18% of our gross domestic product on medical care, far more than any other country.

Continue reading “Why the Supreme Court’s Healthcare Decision Will Mean a lot … and Not so Much”

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Not since the earliest days of Deng Xiaoping’s reforms of the iron rice bowl in the 1980s has China faced as great a need for change as the leaders currently face.

Then as now, the government in Beijing recognized a pressing need to reform the means by which social services were provided. But unlike then, today’s reforms must occur in the midst of a society that has already experienced significant economic growth and has already gone through a painful opening of formerly public services to private competition.

For most Chinese, while their economic futures have materially improved since Deng’s painful reforms were enacted, their access to healthcare has actually deteriorated, a point Yanzhong Huang, the Senior Fellow for Global Health at the Council of Foreign Relations, has made eloquently in his recent research.

Beijing’s struggle to reform its healthcare system brings political concerns, social issues and business pressures together on a collision course. While the need for government and industry to collaborate on these matters is obvious, whether China’s pressing concerns in this area will allow it to do so remains to be seen.

The ever-present temptation in China, to simply resort to government-mandated policies absent industry’s guidance, is one the country has already given into at a national level relative to clean technology, and at a provincial level through the Anhui pharmaceutical pricing model.

Continue reading “No Panacea for China’s Healthcare Reform”

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The Pew Internet Project recently issued a short report noting that people living with disability are less likely than other adults in the U.S. to use the internet: 54%, compared with 81%. The first question many people ask when they hear that is, Why? The second is, What can be done? The third is, or should be, What can we learn from this?

Why?

Statistically speaking, disability is associated with being older, less educated, and living in a lower-income household. By contrast, internet use is statistically associated with being younger, college-educated, and living in a higher-income household. Thus, it is not surprising that people living with disability report lower rates of internet access than other adults.  However, when all of these demographic factors are controlled, living with a disability in and of itself is negatively correlated with someone’s likelihood to have internet access.

Just 2% of American adults say they have a disability or illness that makes it harder or impossible for them to use the internet. Eight percent of people living with a disability say this is true. However, this estimate is based on a telephone survey, which does not include people who are not able to use either a landline or cell phone due to hearing loss. If you are interested in more details on this issue, Evans Witt, CEO of our polling firm, Princeton Survey Research Associates International, recommends the following article:

Inclusion of People With Disabilities in Telephone Health Surveillance Surveys,” by Susan Kinne, PhD, and Tari D. Topolski, PhD [PDF]

Continue reading “What People Living With Disability Can Teach Us”

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FROM THE VAULT

The Power of Small Why Doctors Shouldn't Be Healers Big Data in Healthcare. Good or Evil? Depends on the Dollars. California's Proposition 46 Narrow Networking

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Matthew Holt
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Alex Epstein
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Munia Mitra, MD
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Vikram Khanna
Editor-At-Large, Wellness

Joe Flower
Contributing Editor

Michael Millenson
Contributing Editor

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