At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.
But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.
It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.
Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.
So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.
And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?
Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.
Continue reading “If Gun Violence is a Health Epidemic, Can We Quarantine It Like a Virus?”
Filed Under: Uncategorized
Tagged: at-risk youth, crime, gun violence, Mike Weisser, Population Health, public health
Oct 20, 2013
Having been supported by several small business grants from the National Cancer Institute to create online interventions for cancer patients, I have been learning gradually about commercialization models to get our work out to the public. I am dismayed about the major disconnect between eHealth entrepreneurs and eHealth intervention researchers (my personal reference group).
Last year I attended Stanford Medicine X and last week I did a demo of one of our web sites at Health 2.0 in Santa Clara. Both times, I was struck by the assumption in the IT developer and consumer community that giving people realtime feedback about their health will automatically result in major positive changes in behavior, not to mention cost savings for insurers.
The Connected Patient movement seems particularly naïve to me. Psychologists have been using self-monitoring, i.e. recording behaviors such as smoking, eating, and exercise, for at least 30 years to promote behavior change. First we used paper-and-pencil diaries, but researchers like Saul Schiffman quickly adapted the first handheld computers to prompt people to record their behaviors in realtime, greatly increasing the accuracy and power of self-monitoring.
As technology has advanced, so have our means of self-monitoring. Overall, however, the technology matters far less than the procedure itself. For most people, tracking their smoking, calories, mood, or steps does change unhealthy behaviors somewhat, for a limited period of time. A small group of highly educated, motivated people is more successful in using self-monitoring to make larger, more lasting changes.
I was reminded of this last year in a seminar on tracking at Stanford Medicine X, when a concierge physician from San Francisco and several of his patients talked about being empowered to change their health by using feedback from various types of sensors. One had paid out of pocket for a continuous blood glucose monitor since his insurance would not cover the costs to use it for his Type II diabetes.
Another doggedly demanded access to the data from his cardiac defibrillator. They believed their experiences heralded a sea change in health care in the United States. I am all for empowering patients with knowledge, tracking tools, and social support.
However, if knowledge and feedback was all it took to change unhealthy behaviors, psychologists would be superfluous in the world.
Continue reading “Healthcare’s Tech Disconnect: Why Aren’t We Building the Products Patients Really Need?”
Filed Under: Tech, THCB
Tagged: Apps, behavioral psychology, Health 2.0, HIT, Leslie R. Schover, mHealth, Patients, Population Health, Stanford Medicine X, Wellness
Oct 11, 2013
I am known in the disease management and wellness fields as a naysayer, critic, curmudgeon, and/or traitor…and those are only the nouns that are allowed to be blogged across state lines. This is because I am driven not by wishful thinking but rather by data. The data usually goes the wrong way, and all I do is write down what happened. Then the vendors blame me for being negative — sort of like blaming the thermometer because the room is too hot — because they can’t execute a program.
However, the nonprofit Iowa Chronic Care Consortium (ICCC) apparently can execute a program. They reduced total diabetes events by 6% in the rural counties they targeted. This success supports a hypothesis that in rural (presumably underserved) areas, disease management fulfills a critical clinical gap: it provides enough basic support that otherwise would not be provided even to those who actively seek it to reduce near-term complications and exacerbations.
This result will likely produce its own unanticipated consequence: because many people now believe (thanks, ironically, to some of my own past work) that disease management doesn’t produce savings, there will be widespread skepticism about the validity of this study. Quite the opposite: this “natural experiment” is as close to pristine as one could hope for in population health, for five reasons:
- There was no participation/self-selection bias because outcomes were measured on all Iowa Medicaid members.
- The program was offered in some Iowa counties but not others, so there was no eligibility or benefits design bias, Medicaid being a statewide program.
- The program encompassed only one chronic condition (diabetes) rather than all five common chronic conditions normally managed together (asthma, CAD, CHF, and COPD being the other four). Since all five conditions were tracked concurrently, whatever confounders affected the event rate in one of those conditions should have affected all of them. And event rates in the four other conditions did indeed move together in both the control and study counties. Just not diabetes.
- The data was collected exactly the same manner by the same (unaffiliated) analysts using exactly the same database so there is no inter-rater reliability issue.
- Both groups contained hundreds of thousands of person-years and thousands of events.
As one who has reviewed another high-profile “natural experiment,” North Carolina Medicaid, and found that the financial outcomes were the reverse of what the state’s consultants originally claimed (incorrectly, as they later acknowledged by changing their answer), I can also say that natural experiments in population health don’t harbor some as-yet-unidentified confounder that causes the study population to outperform the control population.
Continue reading “Stop the Presses: A Disease Management Program Worked”
Filed Under: THCB
Tagged: Al Lewis, Disease Management, Iowa Chronic Care Consortium, Medicaid, Population Health, prevention, Wellness
Jul 30, 2013
Since 1973, when Jack Wennberg published his first paper describing geographic variations in health care, researchers have argued about both the magnitude and the causes of variation. The argument gained greater policy relevance as U.S. health care spending reached 18 percent of GDP and as evidence mounted, largely from researchers at Dartmouth, that higher spending regions were failing to achieve better outcomes. The possibility of substantial savings not only helped to motivate reform but also raised the stakes in what had been largely an academic argument. Some began to raise questions about the Dartmouth research.
Today, the prestigious Institute of Medicine released a committee report, led by Harvard’s Professor Joseph Newhouse and Provost Alan Garber, that weighs in on these issues.
The report, called for by the Affordable Care Act and entitled “Variation in Health Care Spending: Target Decision Making, Not Geography,” deserves a careful read. The committee of 19 distinguished academics and policy experts spent several years documenting the causes and consequences of regional variations and developing solid policy recommendations on what to do about them. (Disclosure: We helped write a background study for the committee).
But for those trying to make health care better and more affordable, whether in Washington or in communities around the country, there are a few areas where the headlines are likely to gloss over important details in the report.
And we believe that the Committee risks throwing out the baby with the bathwater by appearing, through its choice of title, to turn its back on regional initiatives to improve both health and health care.
What the committee found
The report confirmed three core findings of Dartmouth’s research.
First, geographic variations in spending are substantial, pervasive and persistent over time — the variations are not just random noise. Second, adjusting for individuals’ age, sex, income, race, and health status attenuates these variations, but there’s still plenty that remain. Third, there is little or no correlation between spending and health care quality. The report also effectively identifies the puzzling empirical patterns that don’t fit conveniently into the Dartmouth framework, such as a lack of association between spending in commercial insurance and Medicare populations.
Continue reading “Making Sense of Geographic Variations in Health Care: the New IOM Report”
Filed Under: Economics, OP-ED, THCB
Tagged: ACOs, Costs, Dartmouth Atlas Project, Economics, Elliot Fisher, Geographic variation, IOM, Jonathan Skinner, Medicare, Population Health, Quality, The Affordable Care Act, Triple Aim
Jul 24, 2013
You’d be forgiven if, after reading last month’s Health Affairs, you came to the conclusion that all manner of wellness programs simply will not work; in it, a spate of articles documented myriad failures to make patients healthier, save money, or both.
Which is a shame, because – let’s face it – we need wellness programs to work and, in theory, they should. So I’d rather we figure out how to make wellness work. It seems that a combination of behavioral economics, technology, and networking theory provide a framework for creating, implementing, and sustaining programs to do just that.
Let’s define what we’re talking about. “Wellness program” is an umbrella term for a wide variety of initiatives – from paying for smoking cessation, to smartphone apps to track how much you walk or how well you comply with your plan of care, and everything in between. The term is almost too broad to be useful, but let’s go with it for now.
When we say “Wellness programs don’t work,” the word work does a lot of, well, work. If a wellness program makes people healthier but doesn’t save lives, is it “working”? What if it saves money but doesn’t make people healthier?
Continue reading “Wellness Programs Aren’t Working. Three Ideas That Could Help.”
Filed Under: THCB, The Business of Health Care
Tagged: automated hovering, Employees, Employers, gamification, Health Affairs, Mike Miesen, Population Health, prevention, Quantified Self, Readmissions, The Affordable Care Act, Wellness
Apr 1, 2013
“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health.
Health care is a proper subset of population health. For example, longevity is determined by more than just health care. Using a specific recent estimate (Appendix Exhibit A6 – gated), an average 20-year old U.S. white male who did not graduate high school will live 10.5 fewer years than a similar man with a college degree. That’s over ten years of life related to educational attainment. Sure, there are many reasons for the difference, and health care or the lack of it is only one of them.
Continue reading “Health Care Shibboleth”
Filed Under: OP-ED, THCB
Tagged: Art Kellermann, Costs, Frank de Libero, Health Affairs, Health care spending, health-care-is-health-fallacy, Institute of Medicine, Outcomes, Population Health, Tom Daschle
Mar 24, 2013
Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over “population health.”
This correspondent says the article is what is muddled and that the readers of JAMA deserve better.
According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing “population health” for an entire geography.
Between the here of “improving chronic care” and the there of “population health,” Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term “population health” in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.
Continue reading “Accountable Care Organizations Can Change Everything, But Only If We Get the Definition Right”
Filed Under: Hospitals, OP-ED, THCB, The Business of Health Care
Tagged: ACOs, Care Continuum Alliance, Douglas Noble, Jaan Sidorov, JAMA, Lawrence Casalino, Outcomes, Patient-centered care, Population Health, Quality, The Affordable Care Act
Mar 20, 2013
The US healthcare system’s myriad of problems again seized the headlines recently with the release of an Institute of Medicine report, which found that 30 percent of healthcare spending in 2009 – around $750 billion – was wasted. Citing the “urgent need for a system-wide transformation,” the report blamed the lack of coordination at every point in the system for the massive amount of money wasted in healthcare each year.
One critical area in particular need of transformation is the business and operating model that drives healthcare in the US. There is broad-based agreement across the healthcare industry that the current fee-for-service model does not work, and needs to be changed. The sweeping health reform law enacted in 2010 included a range of more holistic, value-based payment structures that are now being referred to as “population health.”
Population health is an integrated care model that incentivizes the healthcare system to keep patients healthy, thus lowering costs and increasing quality. In this value-based healthcare approach, patient care is better coordinated and shared between different providers. Key population health models include:
· Bundled/Episodic Payments – This is where provider groups are reimbursed based on an expected cost for a clinically defined episode of care.
· Accountable Care Organizations (ACOs) – This new model ties provider reimbursement to quality and reduction in the total cost of care for a population of patients.
Continue reading “How Using a ‘Scorecard’ Can Smooth Your Hospital’s Transition to a Population Health-based Reimbursement Model”
Filed Under: Hospitals
Tagged: ACOs, avoidable readmissions, bundled payments, coordinated care, Data, Fee-for-service, IOM, Population Health, reimbursements, Russ Richmond, Scorecards, The Affordable Care Act
Dec 4, 2012
Healthcare: The Journal of Delivery Science and Innovation, a new journal promoting cutting edge research on innovation in health care delivery, has launched. The questions is, do we really need yet another journal? The short answer is yes. The longer answer is, absolutely yes. Here’s why.
The Need for New Knowledge on Healthcare Delivery
There is an urgent need to improve our mess of a health care system. Healthcare will consume about $2.8 trillion in 2012 – that’s an astronomical amount of money. To think of it in another way: spending in Intensive Care Units will make up 1% of all economic activity in the U.S. In a broader context, about 1 in 5 dollars in the economy will be spent on healthcare.
How will we actually spend the $2.8 trillion? Over a million doctors and nurses will see patients in hundreds of thousands of clinics, hospitals, nursing homes, and countless other settings. They will see patients who are sick and suffering and will make decisions about how to help them get better. These intensely personal decisions will be made in the context of a broader healthcare delivery system that is mindboggling diverse, complex, and fundamentally broken. We are probably wasting more on healthcare than we are spending on education. Yet, despite all this money and excess (or may be because of it), tens of thousands of Americans are dying each year because of poor quality, unsafe care. We can do so much better.
Continue reading “Healthcare: The Journal of Delivery Science and Innovation”
Filed Under: The Business of Health Care
Tagged: Ashish Jha, delivery innovation, Population Health, The Journal of Delivery Science and Innovation
Dec 3, 2012