Here it’s argued that we need to retire the health care fallacy, “We spend more on health care than other rich countries but have worse outcomes.” The fallacy implies U.S. health care is deficient in spite of being costly. Indeed our health care costs too much, but there is little evidence that our care is less effective than care in other countries. On the other hand, there’s plenty of evidence that our social determinants of health are worse.
The argument segues off a recent article by Victor Fuchs. The case is presented by using a simple linear model to explore how life expectancy might change when we substitute the numbers of other countries’ determinants of health for U.S. numbers. After making these substitutions and holding health care spending constant the model predicts U.S. life expectancy is right there with the other OECD countries, 81.6 years compared to their average 81.4 years. This what-if modelling makes clear what should be obvious but the fallacy hides, that health care is only one part of population health.
The Fuchs Essay
Victor Fuchs’s recent essay1 impressed me. He wrote of the lack of a positive relationship between life expectancy and health care expenditures (HCE) in OECD countries. A chart was included for empirical support. I liked the idea behind the chart which demonstrated his point using data from select countries and our 50 states. Professor Fuchs has written on this topic for years (e.g., in his 1974 book “Who Shall Live?”). I posted on the fallacy in March 2013 but was not as nuanced.2
Continue reading “We Spend More on Health Care Than Other Rich Countries but Have Worse Outcomes?”
Filed Under: Economics, THCB
Tagged: Life Expectancy, Population Health, rural health, Social Determinants of Health, Victor Fuchs
Dec 20, 2014
ONC Plans for the Future
The ONC releases an updated five-year strategic plan that stresses interoperability, patient engagement, and the expansion of IT across the care continuum. The document updates the previous strategic plan released in 2011that focused heavily on the Meaningful Use program. Maybe the ONC is not quite dead yet after all.
McKesson Ventures Into Startups
McKesson announces the creation of McKesson Ventures, a venture capital fund that will invest in early-stage and growth-stage healthcare companies attacking healthcare business challenges. Tom Rodgers, who was most recently with Cambia Health, was named managing director of the fund’s investment portfolio.
Stage 2 Attestations Still Lagging
Fewer than four percent of eligible physicians and 35 of hospitals have attested to Stage 2 Meaningful Use, according to the newly released numbers from CMS. The AMA, CHIME, HIMSS and MGMA quickly reiterated the call to shorten the reporting period for 2015 to 90 days. As of November, 2014 CMS has paid $16.6 billion in EHR incentives since the program’s inception. Continue reading “HIT Newser: The Doctor Will Facetime You Now”
Filed Under: THCB
Tagged: Happtique, HIT Newser, Klas, McKesson, Meaningful Use Stage 2, ONC, Phytel, Population Health
Dec 14, 2014
Man looks into the Abyss, and there’s nothin’ staring back at him. At that moment, man finds his character, and that’s what keeps him out of the Abyss. – Lou Mannheim (Hal Holbrook) in the movie “Wall Street”
We hear reform ideas all the time: primary care physicians need to work at the top of license, physicians need to work in teams, healthcare must deliver top-notch customer service, the focus needs to be on creating strong physician/patient relationships, and physicians need to be paid for delivering value.
The question then becomes: how does the healthcare industry implement such ideas?
I believe it would be smart to apply the lessons from other industries.
Specifically, the financial services industry. Continue reading “Primary Care Physicians Need To Be More Like Financial Advisors”
Filed Under: THCB
Tagged: Accountable Care Organizations, Financial Services, Population Health, primary care, Wall Street
Nov 5, 2014
Consider that for the last year or so, we have been treated a deluge of entreaties to reduce our salt intake, with the American Heart Association going so far as to claim that daily sodium intake should not exceed 1,500 mg. This puts it at odds with the Institute of Medicine, and now European researchers whose data indicates that the healthy range for sodium intake appears to be much higher.
Our conversation about sodium, much like advice about purportedly evil saturated fats and supposedly beneficial polyunsaturated fats, exemplifies a national obsession with believing eating more or less of a one or a small number of nutrients is the path to nutritional nirvana.
A few weeks back, an international team of scientists did their level best to feed this sensationalistic beast by producing what’s become known since then as the meat-and-cheese study, because it damned consumption of animal proteins.
Continue reading “Cheeseburger Please, and Make It a Double”
Filed Under: THCB
Tagged: animal-protein vs. plant-protein, Cancer, Diabetes, L-Nutra, Meat and Cheese Study, Obesity, Population Health, Vik Khanna, Wellness
May 14, 2014
It’s a strange business we are in.
Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.
Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.
Funny, then, that in health care there seems to be so little discussion about how a limited supply of doctors can best serve the needs of their patients.
hair-brained novel idea making its way through the blogs and journals right now is to have pharmacists treat high blood pressure. That would have to mean sending them back to school to learn physical exam skills and enough physiology and pathology about heart disease and kidney disease, which are often interrelated with hypertension.
Not only would this cause fragmentation of care, but it would probably soon take up enough of our pharmacists’ time that we would end up with a serious shortage of pharmacists.
Within medical offices there are many more staff members who interact with patients about their health issues: case managers, health coaches, accountable care organization nurses, medical assistants and many others are assuming more responsibilities.
We call this “working to the top of their license.”
Doctors, on the other hand, are spending more time on data entry than thirty years ago, as servants of the Big Data funnels that the Government and insurance companies put in our offices to better control where “their” money (which we all paid them) ultimately goes.
In primary care we are also spending more time on public health issues, even though this has shown little success and is quite costly. We are treating patients one at a time for lifestyle-related conditions affecting large subgroups of the population: obesity, prediabetes, prehypertension and smoking, to name a few that would be more suitable for non-physician management than hard-core hypertension.
It is high time we have a serious national debate, not yet about how many doctors we need, but what we need our doctors to do. Only then can we talk numbers.
Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.
Filed Under: Physicians, THCB
Tagged: doctor/ patient relationship, Hans Duvefelt, Physicians, Population Health, practice of medicine, primary care, Quality
Apr 22, 2014
A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients.
In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.
There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning.
After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.
As my father always said: “There must be a reward for working”.
But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.
A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.
So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.
But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.
Continue reading “How Should Doctors Get Paid? Hourly Wage, Piecework or Quality?”
Filed Under: Economics, Physicians, THCB
Tagged: Cost-Quality Paradaigm, Family medicine, Hans Duvefelt, Medicare payments, Patient Centeredness, Physicians, Population Health, Quality
Apr 17, 2014
I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.
The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.
That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”
Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!
But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”
In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.
It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?
Continue reading “The Medical Home’s Humpty Dumpty Defense”
Filed Under: OP-ED, THCB
Tagged: health care delivery, Michael Millenson, patient centered medical homes (PCMH), patient centered primary care collaborative (PCPCC), Population Health, primary care
Mar 6, 2014
There’s that line about art, “good artists copy, great artists steal.” There’s some debate about if Picasso said it first, but most of us geeks know it from Steve Jobs.
Often, I see things from companies and industries outside of healthcare —processes, products, best practices —which inspire me. I like these little inspirations because they often aren’t rocket science, but nonetheless fuel some creative thoughts about their applicability in healthcare.
The other night, around 9:00 PM on a holiday Monday, I ordered some obscure aviation stuff from Amazon. I needed a new headset, a leg-mounted chart holder, a paper calculating tool called an E6B computer and a portable canister of oxygen.
I have Amazon Prime, their subscription service which provides expedited 2 day shipping, so I expected to see my stuff on Wednesday afternoon. I was blown away when there was an Amazon box outside my door by 9:00 AM the next morning, Tuesday.
A box showed up early, big deal, right?
Here’s what I think happened and why I’m so impressed. I had been browsing for some aviation stuff for a few days. Amazon clearly knows and tracks my window shopping. It’s how they suggest items when you come back to the site.
I believe they preemptively moved some of those obscure aviation items to the closest distribution center in anticipation of my purchase. In fact, Amazon was awarded a patent for exactly that process last week.
By predicting my purchasing behavior, Amazon was able to beat my expectations for delivery – a known threat to their model is the instant gratification of local retail – and get my package to me in 12 hours.
We’ve got a lot of data in healthcare. That’s to the lagging but persistent implementation of electronic medical records, doctors and health systems are beginning to apply some big data science to their patient populations. For instance, any credible EMR can tell a physician how many of her patients have asthma.
More advanced systems, including bolt on solutions can look at disease panels and cross sample against last visit date. Mr. Smith, we see it’s been a year since your last visit, how’s your arthritis? Can we schedule you and appointment with Dr. Jones?
Continue reading “Amazon.com as a Delivery Model for Population Health”
Filed Under: Tech, THCB
Tagged: Amazon.com, Innovation, Nick Dawson, Population Health
Feb 27, 2014
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