prevention

flying cadeucii“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”

I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes.  For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.

After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked.  I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative.  It doesn’t exist.

It turns out that while the law does require that an annual wellness visit be covered (sec. 4103. “Medicare coverage of annual wellness visit providing a personalized prevention plan”), this requirement is specific to Medicare beneficiaries and does not apply to individual or group plans. Beyond this particular section you won’t find any mention of a requirement within the ACA.

So what gives?  Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?

Continue reading “Does the ACA Actually Mandate Free Checkups?”

flying cadeuciiA predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?

How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize. Continue reading “The High Cost of Free Checkups”

flying cadeuciiMeaningful Use and Pay for Performance – two of the most talked about programs in healthcare IT over the past several years. They are both based on the premise that if you want to drive behavior change among providers and improve quality of care, you need to offer financial rewards to get results.

But what about the consumer? We have now entered a new era in healthcare where the consumer is rightfully front and center – AHIP is even calling 2014 the “Year of the Consumer.” Payers, and other population health managers, who until recently viewed consumers as claims, now want to “engage,” “motivate” and “delight” them.

The challenge, however, is that we are giving consumers more responsibility, but not making them accountable for the quality of care they provide for themselves.

As a country we have spent tens of billions of dollars on Meaningful Use incentives and Pay for Performance programs for clinicians. Providers need to demonstrate they are making the best choices for patients, being efficient and coordinating care.

They need to educate patients and give them access to information based on the belief that if patients are informed, they will take responsibility and action. Unfortunately, this seems like a “Field of Dreams” spinoff – “If we say it, they will act.”

However, that movie has a different ending. The intentions are good, but the flaw is that consumers don’t simply need more information. They need personalized guidance and support, and they need to feel like they have a financial stake in the game.

So the big question is – why aren’t we spending more time thinking about how the concepts behind “meaningful use” and “pay for performance” could be used as a way to get consumers engaged in their health? Yes, clinicians are important as they direct approximately 80 percent of the healthcare spend in our “sick-care” health system.

However, what most people do not realize is that 75 percent of healthcare costs are driven by preventable conditions like heart disease and type-2 diabetes. And while some consumers may throw up their hands and blame genetics for the majority of their health issues, it’s a fact that 50 percent of what makes us healthy is under our control – as opposed to 20 percent for genetics.

So what if we made wearable technologies such as FitBit more “meaningful” for the consumer?  Instead of just tracking steps, what if consumers were financially rewarded for taking steps to improve their health (pun intended) through health premium reductions, copay waivers or even gift cards?

Consider a scenario where an individual who was identified as being pre-diabetic and then took action to prevent the onset of diabetes. What if we required that proactive person to pay less in premiums than someone who was not taking any initiative to improve their health? That would clearly be very motivating.

Continue reading “Should Health Consumers Be Paid for Performance Too?”

Two weeks ago, Vik wrote a column for the The Health Care Blog on the now infamous meat-and-cheese study done by a team of researchers led by folks from USC. You can read the column, and the hilarious comments, here. I sent the column to one of the researchers, using the messaging available at LinkedIn. Here is that researcher’s response in its entirety:

I feel no need to get into a debate with someone who doesn’t understand basic statistics, how research is conducted, and has written a statement that is blatantly wrong. It does worry me that you are propagating yourself as an “expert” when you can’t seem to critically evaluate or understand a study. I know that this study is not perfect, hardly any are, especially in epidemiology, but the points you bring up in your blog are completely misconstrued and show very poor understanding of research methodology.

If you had actually read and understood the paper you would see that we controlled for waist circumstance [sic] and BMI. Also, this isn’t some random population of fat, low educated, American smokers, it is a nationally representative sample–unfortunately this is what the American population looks like. Finally, the idea that you think our supplemental tables house the real results illustrates your lack of understanding about statistics or how mortality models are run.

That being said, if you come up with a legitimate critique, I would be happy to engage in a friendly debate. When you attack something, I would suggest you make sure you understand it first, otherwise it is hard to legitimize anything else you say. I find it ironic that most of the push back from this paper has been from the general public who don’t have experience doing these types of studies, while for the most part, the scientific community (at least from people at R1 universities) has been fairly receptive.

We are glad to offer this legitimate critique, beginning with what we find in the very first sentence of the Results discussion that is not in the paper itself, but in the supplementary materials: “Using Cox Proportional Hazard Models, we found no association between protein consumption and either all-cause, CVD, or cancer mortality (Table S2).” Table S1 makes the point even more clearly: all-cause mortality in the low protein group was 42.9%. All-cause mortality in the high protein group was 42.9%, meaning that there is ZERO impact on overall mortality from protein variation at the extremes.

Continue reading “The Cheeseburger Study”

David Katz MDOn Tuesday of this week (4/29/14), I was on the Katie Couric Show to discuss Integrative Medicine.

Somewhat ironically, I returned from Manhattan that same day to a waiting email from a colleague, forwarding me a rather excoriating critique of integrative medicine on The Health Care Blog, and asking me for my opinion.

The juxtaposition, it turns out, was something other than happenstance. The Cleveland Clinic has recently introduced the use of herbal medicines as an option for its patients, generating considerable media attention.

Some of it, as in the case of the Katie Couric Show, is of the kinder, gentler variety. Some, like The Health Care Blog — is rather less so. Which is the right response?

One might argue, from the perspective of evidence based medicine, that harsh treatment is warranted for everything operating under the banner of “alternative” medicine, or any of the nomenclature alternative to “alternative” – such as complementary, holistic, traditional, or integrative.

One might argue, conversely, for a warm embrace from the perspective of patient-centered care, in which patient preference is a primary driver.

I tend to argue both ways, and land in the middle. I’ll elaborate.

Continue reading “A Holistic View of Evidence-Based Medicine”

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There’s a war being waged on one of America’s most revered institutions, the Emergency Room. The ER, or Emergency Department (ED for the sake of this post) has been the subject of at least a dozen primetime TV shows.

What’s not to love about a place where both Doogie Houser and George Clooney worked?

Every new parent in the world knows three different ways to get to the closest ED. It’s the place we all know we can go, no matter what, when we are feeling our worst. And yet, we’re not supposed to go there. Unless we are. But you know, don’t really go.

Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is ok, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.

But its true. I hear ED physicians openly express disappointment in people who came into the ED and shouldn’t have.

It’s just a stomach bug, you shouldn’t be here for this… Or, it’s not my job to fill your prescriptions…

Some history

The Emergency Department is a fairly modern invention. The first EDs were born of two separate, though similar, aims. At Johns Hopkins, the ED began as the accident room, place where physicians could assess and treat —wait for it —minor accidents.

Elsewhere, in Pontiac Michigan and Northern Virginia early EDs were modeled after army M.A.S.H. field hospitals. They were serving more acute needs.

Today, billing for emergency department visits is done on the E&M Levels where level 1 is the least acute (think removing a splinter) and level 6 is traumatic life saving measures requiring hospitalization (think very bad car wreck). Most EDs, and CMS auditors, look for a bell curve distribution, which means there are more level 3 and 4 incidents than most others. While coding is unfortunately subjective, solid examples of level 3 visits include stomach bugs requiring IV fluids, a cut requiring stitches, and treatment of a migraine headache.

Continue reading “Stop the War on the Emergency Room!!! (Fix the System Failure)”


Jennifer Anyaegbunam is a Fellow at The American Resident Project. Her post appears on THCB as part of The Health Care Blog’s  partnership with ThinkWellPoint.  Stay tuned for more. Follow the American Resident’s Project on Twitter @Amresproj.

I’ve spent the past four weeks learning about primary care on my Family Medicine rotation. A significant portion of patient care in this setting is focused on “health maintenance” or disease prevention.

Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.

According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.

Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?

I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.

This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.

Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.

Continue reading “The Flu Shot and a Patient’s Right to Choose”

We don’t make a lot of New Year’s predictions, but we are happy to make this one: 2014 will be the year the get-well-quick mentality driving corporate and individual health choices implodes…and people start taking genuine steps to be healthy. The way to ensure that 2014 is your year for good health?  Start with a double negative:  (a) wellness industry advice is almost always wrong; and (b) most people don’t keep their New Year’s resolutions. Hence, making the New Year’s resolutions recommended by the wellness industry is not the best way of ensuring your good health in 2014.

For simplicity, we’ll divide this list into individual and corporate wellness industry resolutions, and start with individual ones.

  1. Take more health advice from celebrities. Whether it’s hoping that Kim Kardashian’s personal trainer can help you or pining for Dr. Oz to cure what ails you with green coffee bean extract and raspberry ketones, a good way to put off doing worthwhile things is to do worthless ones.

  2. Start a weight loss program. The medical establishment could not head off the obesity dilemma at the pass, and they have no solution for it now, other than to crow about more drug companies diving into this expanding market. There is zero evidence that weight loss programs can produce sustainable long-term weight loss (and much evidence that they don’t), and we don’t know of a single one shown to improve fitness. That will not, however, prevent weight loss companies from trying to claim their little piece of the wellness landscape because they are losing so many individual customers to free dieting apps, such as LoseIt.com. Improve the quality of your diet first, and weight loss may follow, which is a bonus.

  3. Give yourself a cleanse. America’s obsession with cleanliness is now running smack into the reality of evolution and human physiology.  Surely if bacteria in your colon were bad for you, mankind would have died out eons ago.

  4. Stock up on supplements. The only things better than raspberry ketones and green coffee bean extract: all the other vitamin and mineral supplements on the market that fail to make sick people better or healthy people healthier. Who’s left to try to help, Martians? Never mind that risk is not endlessly reducible and the four most important things you can do for your health don’t come out of a bottle of magic jujubes: exercise, don’t smoke, eat well, and keep as close to a healthy weight as you can.

  5. Remove saturated fat from your diet. Just like in the 1960s, when we all traded in “the high-priced spread” for sticks of partially hydrogenated vegetable oils fit for a king to avoid saturated fat, we may be mis-demonizing this longstanding and naturally occurring component of our diet.   The entire nutrition dialectic in our culture over the past 20 years has focused on a string of individual no-nos: fat, saturated fat, cholesterol, and now refined grains and sugars (because we bought the government’s wrong advice to eat low-fat). It’s time to revive the notion of healthy eating patterns, not healthy eating isolates. In fact, here is the world’s simplest diet advice for 2014: eat less junk. That alone would be a landmark nutritional achievement for Americans.

  6. Eat organic and stay away from Starbucks. Within a week of each other, the New York Times published an account of a woman damaging her health eating an obsessively healthy and organic diet, and USA Today wrote of  another who ate exclusively at Starbucks for a year, with no apparent ill effects and no weight gain.

  7. Continue reading “Ten Health and Wellness Resolutions Not to Make in 2014″

Here is a thought experiment. Assume that every hour you run you extend your life by an hour.

I have chosen a one-to-one ratio between the increase in longevity from running and the time running because higher ratios lead to the immortality paradox. Lazarus aside, the all-cause mortality for Homo sapiens is 100 % and will remain so for the foreseeable future.

This arithmetic means that at one point you will literally be running for your life: your life being extended precisely by the time spent running. But ignore this logical fallacy.

You run an hour every day for 40 years. Your life is extended by 1.67 years. Your costs are a new pair of running shoes every three months, which might even be covered at zero co-payment by insurance if USPSTF gave running a grade A or B recommendation.

A back of the envelope calculation, assuming the shoes cost $ 80, yields cost per life year of roughly $7664. There is, of course, more nuance. I am not including injuries that may result from running. I am not discounting time: I am assuming we value an hour now the same as an hour 40 years from now.

I am also not factoring the costs avoided of treating late stage cardiovascular disease, which must be balanced against the additional social security checks that the individual will draw because of living longer, not to mention the costs of treating diseases of extended longevity such as cognitive impairment, Alzheimer’s disease, recurrent falls.

But please continue to indulge my approximation. The point is not precision of economic calculations but a principle.

$7664 for an additional life year. Compared to the benchmark of $50, 000 per quality-adjusted life year that’s a bargain!

Was it worth it then?

Continue reading “Healthism: The New Puritanism”

It’s been clear for more than a decade that trans fat is a dangerous substance that increases the risk of heart disease.  Denmark banned its use in 2003.  Several American cities and states have followed suit, but the use of trans fat is still widespread despite the availability of suitable substitutes.

Over the past 10 years, trans fat consumption is thought to have contributed to an estimated 70,000 needless American deaths. Given  that universal, voluntary cooperation to eliminate trans fat hasn’t happened, the Food and Drug Administration (FDA) is justifiably seeking to designate trans fats as unsafe.

A nationwide ban on artery-clogging artificial trans fat is a long-overdue first step toward improving American diets, fighting obesity and limiting the risk of chronic disease. But it is just the first step in what should be a far broader campaign to help consumers make healthier choices at mealtime.

Public lack of awareness of the impact of prepared foods on individual health is not limited to trans fat.   When dining out, even in establishments that avoid trans fats in preparing food, Americans face a range of health risks often without realizing it. People are routinely served far more calories than they can burn.

They are routinely served too many low nutrient foods and insufficient quantities of fruits, vegetables, and whole grains.  What should become routine instead is the availability of menu options that put people’s health first.

Hopefully, the FDA’s trans fat initiative will succeed – previous city/state bans and labeling improvements have already managed to cut daily consumption by Americans from 4.6 grams in 2006 to 1 gram in 2012 – and pave the way for the creation of other standards and regulations regarding the quantity and quality of food that is offered to diners in restaurants.

The lack of such standards makes it difficult, if not impossible, for most people to recognize when they are being put at risk for a chronic disease.   If people are served too much of something (like calories), they would have to compensate by eating less later; conversely, if they are served too little of something (like vegetables), they would have to eat more later to neutralize the risk of chronic disease.

But most people lack the information they need to judge or track the quantity and quality of the nutrients they consume.

Continue reading “The FDA Ban on Trans Fat Should Be Just the Beginning”

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