What if the next time you step into your doctor’s office for an examination, she reaches into her white coat pocket and pulls out an iPhone instead of a stethoscope? That’s the idea behind The Smartphone Physical, a re-imagination of the physical exam using only smartphones and a few devices that connect to them. These include a weight scale, blood pressure cuff, pulse oximeter, ophthalmoscope, otoscope, spirometer, ECG, stethoscope, and ultrasound. Want to know more? I’ve answered some questions here for THCB. And have a few myself.

Years ago, as a family physician in Louisiana, I made house calls. Certain patients were too sick or too hurt to get to my office. Sometimes a condition or injury had worsened, requiring my evaluation bedside. I would visit patients at home for the simplest of reasons: home was where they needed care.

By the mid-1980s, the pressures of time and money prevented most physicians from making house calls anymore. But I kept seeing patients at home until I retired from my practice after 29 years. Home visits enabled me to better detect, diagnose and treat most health conditions. Many of the patients I saw might otherwise have wound up in an emergency room and eventually been admitted to a hospital.

If we hope to rein in health care costs and improve quality, we need, in effect, to bring back the house call. Americans are living longer than ever before and a higher percentage of the population is elderly, with both trends sure to accelerate drastically in the decades ahead. Baby Boomers are now turning age 65 at the rate of roughly 10,000 per day.

As the older demographic expands, so, too, does the number of people who live with chronic diseases, chiefly diabetes, high blood pressure and heart failure. About three in four of Americans age 65-plus suffer from more than one such chronic condition. The single biggest and fastest-growing contributor to healthcare costs is chronic disease. That’s why an estimated, 49% of our health care costs go toward 5% of Medicare beneficiaries.

Yet the U.S. health care system is still based on a massive misconception: that health care for the sickest of the sick, typically the elderly and the chronically ill, should be carried out almost exclusively in institutions, primarily hospitals, but also nursing homes and assisted living facilities. And that health care delivery should consist largely of, say, a trip to the emergency room or a four-day hospital visit for pneumonia. That kind of episodic engagement represents short-term thinking. When it comes to health care, hospitals are essential, but are only a part of the answer.

Rather, health care should be practiced year-round, and even minute-by-minute. Managing chronic disease should involve post-acute care, complete with daily monitoring of vital criteria, including blood pressure, diet and physical activity. Only under such regular oversight can chronically ill patients expect to function well, much less fully. No single approach can do this better than home care. It can shorten hospital length of stay and lower readmissions. And there is mounting evidence that health care delivered at home enables patients to live longer lives and, equally important, better ones.

In the process, home care is doing exactly what’s most needed — increasing quality and driving down costs. An Avalere Health study found in 2011 that health care at home improved outcomes and saved $2.8 billion among patients with diabetes, congestive heart failure and COPD. A 2009 study revealed that home health care reduced hospitalizations and short-term nursing stays, saving Medicare dollars. Indeed, expanding access to home health care for chronic-disease patients could save a projected $30 billion, that same study concluded.

Yet the value of home care remains under recognized. As a result, vast needs are still going unmet. Here’s what has to be done:

Define the discipline better. The medical community, including physicians, medical schools, and hospital administrators must better describe what home care does and why it matters in order to bring it to life for policymakers and family caregivers.

Get in sync. Primary care physicians particularly, but also nurses, therapists, social workers and others, must align better with home-care clinicians to coordinate care, especially during and immediately after the transition from hospital to home.

Physician, educate thyself. Physicians should learn about home-care options and discuss them with patients who could benefit.

Adopt new technologies. More companies in the home-care business should use innovative technology to coordinate care in real time, including point-of-care laptops, telemonitoring devices, and Internet portals for physicians that allow all providers to share a patients’ information.

Remove policy obstacles. Reimbursements from Medicare and private insurers should reflect the true value of home care. But the payment system now in place sees home care, quite mistakenly, as merely an add-on with little clinical benefit. Policymakers should create a payment model that aligns providers’ clinical and economic interests, assigning proper value to good outcomes and recognizing that home care is pivotal to success.

Health care at home is patient-centered, outcomes-driven and truly collaborative, making it a microcosm of how the health care system should function across the board. Only by embracing home care can we truly reform the health care system.

Michael Fleming, MD is chief medical officer of Amedisys, a home health and hospice care company focused on bringing home the continuum of care, and past president of the American Academy of Family Physicians. This post appeared previously in the HBR Blog Network.

The Leapfrog Group has just released its latest report grading the safety of hundreds of individual hospitals, but the real news isn’t the“incremental progress.” It’s how a group started by some of the most powerful corporations in America has quietly devolved into just one more organization hoping press releases produce change.

Amid the current enthusiasm for “value-based purchasing” by employers and possible privatization of Medicare, it is worth examining why Leapfrog’s initial notion that corporations would spearhead a crackdown on crummy care failed and what we can learn from that publicly unacknowledged failure.

Leapfrog was launched with the hoopla of a high-powered initiative. A widely publicized 1999 report by the Institute of Medicine declared that up to 98,000 patients die every year in hospitals from preventable errors and more than one million are injured. In November, 2000, the newly formed Leapfrog Group announced three targeted “leaps” in patient safety that promised to save some 58,000 lives, prevent a half million medication errors and (in calculations that came later) save billions of dollars.

“The number of tragic deaths brought about by preventable medical errors is too striking for those of us in the business community to ignore,” declared Lewis Campbell, chairman and CEO of Textron TXT -0.29%, at the group’s launch.

Campbell was head of a health care task force of the Business Roundtable, an elite group of corporate leaders that sponsored Leapfrog. Wielding the power of the checkbook to enforce “aggressive but feasible target dates” was “a straightforward business approach to tackling a complex problem,” Campbell explained.

As someone who played a small part in that launch, I shared in the optimism of the “Founding Frogs” from big companies like General Electric and GTE, a predecessor to Verizon. But real change requires a sustained commitment to keep up the pressure. Let’s look at what happened to Leapfrog’s three original “leaps”:

Leap No. 1: “Computer physician order entry (CPOE).” Using computers to check the type of medication and dosage before it reached the patient was said at Leapfrog’s launch to reduce prescribing errors in hospitals by “more than 50 percent.” While that may have been true, the cost to hospitals of adopting CPOE turned out to be much higher than anticipated. Corporate America might have been able to force hospitals to become more efficient, but it didn’t.

Although CPOE has finally begun to take hold, even Leapfrog CEO Leah Binder acknowledges it’s because of the government’s “meaningful use” rules, which came I the wake of the 2009 federal stimulus bill giving out billions to hospitals and doctors to buy computers. In return, they had to show they were using the equipment for clinically meaningful improvements, such as safer care.

In other words, the government “carrot” of massive subsidies (bribery) trumped the “stick” of Leapfrog (we’ll tell our health plan to possibly not contract with you).

Leap No. 2: “Evidence-based hospital referral.” Patients should be sent to hospitals whose doctors performed a high volume of a procedure, said Leapfrog, thereby reducing a patient’s risk of dying by “more than 30 percent.” Unfortunately, that volume-outcome link turned out to be more complicated as more research was done. As one review of the medical literature concluded, the relationship between a hospital’s volume and mortality “appears largely to be specific to the procedure being studied.”

In any event, the business community never got serious about “evidence-based” contracting. Whatever the public pronouncements, the private message to health plans remained, “Give us a low price.” And, by the way, don’t stop contracting with any hospital our employees like to use.

Leap No. 3: “Intensive care unit (ICU) staffing by physicians trained in critical care medicine.”

Let’s think about this goal for a moment. At the time it was announced, “virtually no ICU met the Leapfrog standards.” While some research strongly supported the standard, other research found “weak or no scientific evidence.”Even ICU directors who overwhelmingly endorsed it pointed to implementation barriers such as “loss of control, loss of income, and increased cost to hospital administration.”

For Leapfrog to have succeeded, you’d have to believe that top business executives would order mid-level benefits managers to second-guess doctors about a life-and-death staffing decision.

In reality, the Business Roundtable quietly began backing away almost immediately. Worried that if they certified a hospital for being safe, an employee who was the victim of a medical error could sue them, the Roundtable decided to fund Leapfrog for a while but to sever any official affiliation.

And maybe they were right. The federal government has far more purchasing clout than any business coalition can dream of and, with far more at stake both financially and in human terms for its “constituents,” is much readier to wield that influence. The elderly on Medicare and the poor on Medicaid use more medical services, and therefore are at greater risk for poor care, than the working-age population. Big corporations have enough challenges without picking fights with local hospitals often seen as pillars of their communities.

Fortunately, as corporate America copped out, the American government stepped in ­– not as evil regulator but as savvy purchaser. Beginning under President George W. Bush and continuing under President Obama, the feds have set “aggressive but feasible target dates,” as Textron’s CEO put it, for hospitals to either improve care and eliminate “never events” or watch their reimbursement cut. Leapfrog deserves credit for helping push the federal government in that direction, but it was the government that eventually led the way for reasons that made eminent economic sense.

Private insurers followed in the government’s wake, one told me, because of market forces: if they tried to tell a prominent hospital they wouldn’t pay for care related to an error, the hospital could threaten to not sign a contract. But no hospital could afford to drop Medicare; ergo, the big “leaps” in patient safety came from government pressure.

Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, IL; the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management; and a board member of the Society for Participatory Medicine. This post originally appeared in Forbes.

Last week, CMS unilaterally released chargemaster data from 300 hospitals around the country. As David Dranove summed up well in his recent piece, this is an old hat. Yes, there are big variations in hospitals’ chargemasters. And yes, there is a lot of buzz around consumer price shopping.

A Kayak for hospitals is all well and good, but hospitals are cash-strapped as it is and there is only so much money to be saved by driving down the costs the hospital charges the health care plan unless the waste within the hospital is addressed. I would like to highlight perhaps one of the most exciting things going on under the radar in US healthcare today: using price transparency data within the hospital.

Hospitals are now reimbursed a capitated amount according to each patient’s diagnostic-related group. Capitated payment means, essentially, that the hospital receives a set amount of dollars for each patient that walks through its doors with a given diagnosis — say, $X for a patient with pneumonia or $Y for a patient with MI. Regardless of how many drugs, tests, or scans the hospital uses for the patient, it will still get the same compensation from the insurance company.

Yet, the physician up until now still acts as a kid in a candy store, running up a bill without awareness of cost or value. This is largely because the doctor is ordering from a menu without prices. I have talked to many physicians, in both out-patient and in-patient settings across seven health care systems around the country — they want a menu with prices.

I have seen firsthand the motivation for this, as pay-for-performance model is beginning to take over with my own practice. Gone are the days where doctors’ salaries are unhitched to the cost-effectiveness of care. Everyone is now in the same boat.As a neurologist, I want to share a few examples regarding stroke care that illustrate the potential savings available from educating physicians regarding cost, and also some pitfalls to avoid that could compromise patient care.

CTA and MRA are two imaging methods of diagnosing clogged arteries in acute stroke patients. CTA can be used in most cases, and is more timely and detailed in showing arterial status than the roughly equivalent MRA. This makes it preferable as a diagnostic tool in acute stroke cases. However, MRA provides similar information and is frequently ordered in conjunction with an MRI since it utilizes the same machine, and the MRI test is being done anyway to obtain different and necessary data.

The piece of information that physicians do not often consider is that CTAs are thousands of dollars cheaper for the health system than MRAs. This saving holds true even if an MRI is done and then a CTA is done separately. Having a comparison price tag at the point of ordering informs the physician to think twice about the routine selection of a vastly more expensive test, and leads to savings for all stakeholders, including the health system.

Likewise, in treating hemorrhagic stroke, doctors frequently order Factor VIIA to control bleeding which not only costs $10,000 a dose, much more than the alternative — fresh frozen plasma — but also carries a higher risk of clotting complications. There are specific indications for preferred use of Factor VIIA, but 97% of the time it is used inappropriately.

The good news is that physicians are getting on board with the new model. I know this from my own experience as a stroke director for a hospital administering “Get With the Guidelines”, a nationwide computerized tracking program of stroke care that includes a physician-accountability component. This initiative has led to dramatic improvement in the screening and treatment of elevated cholesterol in the acute stroke patient.

At the same time, we must be careful of being penny-wise and pound-foolish. For instance, TPA is an anticoagulant that is used to treat stroke shortly after it occurs. Although it is very expensive, TPA is critical for post-stroke care, and discouraging its use due to its cost would be inappropriate. Not to mention, it would actually raise overall costs because the hospital would have to deal with sicker patients for longer.

Whether it is prescribing pricey Plavix instead of the equally effective aspirin, giving redundant blood tests, or ordering hypercoaguable workups in older patients, there is so much room for improvement. The trick is in large part to inform physicians — the ones whom the burden of value is being put on in the post-reform world — at the point of care about the relative prices and value of their options, enabling them to make optimal medical decisions, while not sacrificing quality. We are already seeing the impact of putting price transparency in the doctor’s hands in studies emerging form Johns Hopkins (FN) and other leading thought leaders such as University of Pennsylvania Health System and CHOP, where price transparency is being brought not to patients’ iPhones, but to the point of order.

Dr. David Halpert is the Stroke Director for the 200-bed Arnot Medical Services, a regional hospital serving upstate New York. Dr. Halpert is also the Chief Medical Officer of MemberRx, a company sponsored by Penn Medicine, Independence Blue Cross, and DreamIt Health and working with health systems around the country to transition successfully value-based care models.

I always believed that, if we could harness the entrepreneurial spirit of the American physician, we could be capable of great things. Physician decisions drive much of what is good and bad about our health care system. Their pens are the biggest driver of cost and their vigilance is the most significant driver of quality. It is a shame that physician-owned hospitals are accelerating the creation of a two-tier system by cherry-picking healthy, well-insured patients.

There are overwhelming monetary incentives for physician-owned hospitals to market to the healthiest and wealthiest, who seek a narrow list of procedural interventions. But then those physicians are rewarded with value-based payments for high satisfaction scores and low readmission rates as mandated by the Affordable Care Act.

What happens to the rest of the patients—the ones with one if not several chronic conditions and minimal if any insurance?

They find their way to teaching hospitals, which treat a disproportionate number of “dual eligibles” (seniors so poor they need both Medicare and Medicaid support), the disabled, and nonwhite patients. Teaching hospitals can quickly become underfunded and over-stretched, offering opportunities for physician-owned hospitals in the market to deliver better quality, albeit more expensive, health care to those who have the ability to choose. In spite of that, many teaching hospitals deliver excellent service and care.

In a May 14 Wall Street Journal article, Alicia Mundy wrote, “Doctor-owned hospitals are largely privately held, so it’s difficult to know their profit margins, despite the law’s growth restrictions. According to the American Hospital Directory, a private firm that provides data about some 6,000 U.S. hospitals, many physician-owned hospitals have enjoyed 20 to 35 percent profit margins in recent years.”

American community hospitals’ margins averaged 7 percent in 2010 and those of teaching hospitals are lower yet, at 5 to 6 percent. “In 2011, the first year ACA restrictions were in effect, more than half of the 30 largest doctor-owned hospitals showed operating margins that either matched or surpassed 2010 figures, and some had operating margins of more than 40 percent,” Mundy noted.

You can argue that we have had a two-tier system for a long time. “Are you having trouble finding a doctor who will see you? If not, give it another year and a half. A doctor shortage is on its way,” writes John C. Goodman.

When demand is high, doctors tend to see those patients who have the best insurance coverage. In a study of dermatologists in 12 metropolitan areas, half of dermatologist respondents offered appointments for Botox injections with a wait time of 8 days. This is in stark comparison to previous work that showed wait times of 26 days for evaluation of a skin cancer (a changing mole) in these same communities. (Resneck et al., Journal of American Academy of Dermatology, Volume 57, Issue 6, December 2007, Pages 985–989). A New York Times reporter interviewed practitioners and revealed, “For patients in need of services covered by Medicare, the typical wait to see a doctor was two or three weeks, and the appointments were made by answering machine. However, for Botox and other treatments not covered by Medicare (and for which patients pay the market price out of pocket), appointments to see those same doctors were often available on the same day, and they were made by live receptionists.”

Sounds like the same situations patients encounter in physician-owned and for-profit hospitals.

The tragedy is that most docs in physician-owned hospitals are delivering a level of service and quality that they could not muster in other settings. It is a testimony to the physicians, nurses, and staff at teaching hospitals that, in spite of the financial challenges facing their organizations, they respond so impressively to situations like the Boston Marathon bombings or the shooting in Arizona that injured Congresswoman Gabrielle Giffords; while purposely blind to the insurance status, color, or ethnicity of their patients.

I don’t think the architects of the Affordable Care Act envisioned their legacy to be one in which only the very affluent have prompt access to the kind of high-quality health care that historically has been available to the vast majority of Americans, while the rest endure long waits for appointments, poor quality, and rationing.

Joanne Conroy, MD, is Chief Health Care Officer at the Association of American Medical Colleges. She blogs at Wing of Zock. Follow her on Twitter @joanneconroymd.

ONC and the National Cancer Institute (NCI) are challenging app developers to create new tools to help cancer survivors. The new Crowds Care for Cancer: Supporting Survivors Challenge is asking app developers to create new tools meant to help survivors manage their care after they have completed cancer treatment.

HHS has had a series of developer contests that have spawned the creation of tools and apps to help patients and doctors better manage care. Some past app challenges include:

• the Million Hearts Risk Check Challenge
• the Blue Button Mash Up Challenge, and
• the Ensuring Safe Transitions Challenge.

Cancer patients need more care coordination

The number of cancer survivors in the United States is currently estimated at 14 million people. With improvements in cancer screening, diagnosis, and treatment, as well as the aging of the United States, this number is expected to rise.

While celebrating advances in cancer care, there remains a need to help patients manage their health after they have completed their primary treatment. Cancer survivors experience a host of physical and psychosocial long-term and late effects of the disease, and it’s the treatment of this that requires coordinated follow-up care.

Despite significant progress in cancer treatment, the complex and often fragmented state of end-of-treatment care may lead to harmful breakdowns in patient-provider communication. This can result in unmet health care needs. Better communication, data exchange, and care coordination have been shown to help the patients.

Participate in the developer contest to help improve communication for cancer survivors

ONC and NCI are calling on app developers for innovative solutions to address specific challenges that cancer survivors encounter when managing their care.

The following examples illustrate just a few potential ideas that an app could address:

• Help survivors use information from their providers and survivorship care plans to improve communication within their care teams (i.e., families, friends, and members of their primary and specialty care teams)
• Address follow-up care needs such as helping patients track their medications and medication adherence, upcoming appointments, and healthy lifestyle recommendations
• Implement key sources of health data and interoperability standards such as Blue Button+ (http://www.bluebuttonplus.org/).

We also encourage all app developer applicants to consider different ways to seamlessly integrate tools and information into the daily lives of patient. The intention is to help them in the communication and coordination of care with all members of their care team.

Win up to $30,000 in the Crowds Care for Cancer: Supporting Survivors Challenge
The Challenge will consist of two phases.

• Applicants will submit wireframes and supporting documentation that details the proposed functionality of their tool or application, and how these address the goals of the Challenge. At the end of Phase I, up to three applicants will be awarded $5,000 and will receive feedback and support to optimize their application proposal for promotion on MedStartr’s crowdfunding portal as they transition to Phase II.
• Phase I finalists will post relevant details of their application on MedStartr for public feedback and support. At the end of Phase II, the finalists will submit a functioning application to be judged for the $25,000 grand prize.

Enter this developer contest

To learn more about the Challenge and to enter a submission, please visit http://challenge.gov/ONC/529-crowds-care-for-cancer-supporting-survivors.

“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.

Case Study: Wal-Mart as Powerhouse

But when it comes to potentially reshaping care access and delivery, Wal-Mart is still just scratching the tip of the surface. To understand the company’s scale and ability to disrupt traditional market dynamics, look no further than last year’s Center of Excellence program.

The company decided to directly contract with Mayo Clinic, Cleveland Clinic, and four other leading hospitals. As a result of the COE program, more than 1.1 million Wal-Mart employees and dependents can now travel, at no cost, to those leading hospitals for certain cardiac and orthopedic procedures.

(For perspective, consider that CMS’s much-discussed accountable care organization effort last July, which involved 88 hospitals, affected about 1.2 million Americans.)

“Love them or hate them, Wal-Mart has a huge ripple effect,” Dave Chase wrote at Forbes. “Overnight, every facility in America that does cardiac, spinal, or transplant procedures is now competing with Mayo, Cleveland Clinic and other top providers.”

Opportunity: Wal-Mart as Destination

One reason that Wal-Mart partnered with those hospitals: lowering its health care costs.

“We literally spend billions of dollars” on employees’ health care insurance alone, Osborne noted.

Still, there’s a distinction between contracting with providers to tamp down your own health care costs and competing with those providers by offering services like retail clinics or even primary care.

So why would Wal-Mart get into broader health care services? It starts with “the obvious financial opportunity,” as Osborne alluded to in one talk

U.S. spending on health care is poised to surpass spending on retail — the only developed economy where that’s the case — and Wal-Mart has natural advantages like foot traffic and scale. About 150 million Americans visit a Wal-Mart every week, spending about 50 minutes on average.

Could Wal-Mart Positively Reform Care?

That ease of access could be transformative if Wal-Mart elected to expand its primary care services, experts note, given that many patients struggle to simply get in the doors of a doctor.

And many of Wal-Mart’s customers are especially affected by the burdens of health care. As Osborne noted, roughly one in ten Wal-Mart customers identifies as a caregiver. And the average Wal-Mart customer is losing about $6,000 in income because of that caregiving, he added.

Meanwhile, the company’s $4 generic drug program has appeared to boost adherence to certain medications and reduce costs for some low-income Americans.

One unique element that Wal-Mart could bring to health care access, Dave Chase told California Healthline, is the company’s presence in rural markets. That’s where there’s “the biggest shortage of primary care doctors, and it’s not getting any better,” Chase noted.

That ease of access could be transformative if Wal-Mart elected to expand its primary care services, experts note, given that many patients struggle to simply get in the doors of a doctor.

And that plays into one unique element that Wal-Mart could bring to its health care strategy, Dave Chase told me: the company’s presence in rural markets. That’s where there’s “the biggest shortage of primary care doctors, and it’s not getting any better,” Chase noted.

Meanwhile, many of Wal-Mart’s customers are especially affected by the burdens of health care. As Osborne noted in one speech, roughly one in ten WalMart customers identifies as a caregiver. And the average Wal-Mart customer is losing about $6,000 in income because of that caregiving, he added.

And there’s some evidence that Wal-Mart’s emerging presence in health care has already been a boon. For example, the company’s $4 generic drug program has appeared to boost adherenceto certain medications and reduce costs for some low-income Americans.

A Sleeping Giant

But great things have been predicted of Wal-Mart’s role in health care before — even by Wal-Mart itself.

In 2007, the company’s then-CEO Lee Scott predicted that Wal-Mart would have 2,000 retail clinics in place by 2012.
Today? Wal-Mart has closer to 130, and is “closing locations faster than it’s opening them,” Renee Dudley noted at Bloomberg BusinessWeek.

One of the challenges facing the company: For all of Wal-Mart’s advantages, officials are still feeling their way in the health care space.

“Wal-Mart has developed a great deal of expertise at how to buy and sell products at a discount price,” Ateev Mehrotra, a physician at the University of Pittsburgh Medical Center and a researcher at the RAND Corporation, tells California Healthline. “Providing health care is different” and much more complex, ranging from developing the needed expertise for a broader strategy to hiring practitioners to deliver care, he speculated.

And the speed bumps of launching the retail clinic program may have slowed down Wal-Mart’s plan to launch broader health care services.
“I think Wal-Mart is still going to” move into the health care market, Chase said, although “they’re not on the fast track.”

“But they could be formidable.”

Dan Diamond (@ddiamond) is Managing Editor of the Daily Briefing, a CaliforniaHealthline columnist, and a Forbes contributor. An earlier version of this post appeared in California Healthline.

Dear Ms. Jolie,

Thank you for your bravery and leadership in the battle against breast cancer. In a small way, through my patients, I understand the challenge and pain it took not only to undergo prophylactic mastectomies, because you carry the BRCA1 cancer gene, but also to reveal this deeply personal part of your life to the world (NYT, 5/14/13; My Medical Choice). You had no obligation to open your soul; your selfless act leaves those of us that treat the dread disease, in awe.

Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years. By opening up the conversation, by educating and by boldly stating that beauty, strength and health are possible, even when radical choices are made, you open up life saving opportunities for many. Mastectomies may not be the answer for all women, but the very idea that cancer can be prevented, instead of simply waiting in fear, is earth shattering.

Women and men will now better understand the genetic risks for cancer, be exposed to the different options which are available in the prevention of cancer and know that it is possible, whatever path is taken, to continue with full lives. You have made it easier for patients, their families and physicians to have vital discussions.

The announcement of your surgery coincides with a critical legal battle, the deliberations of the United States Supreme Court regarding BRCA genetic testing. You have put pressure on the Court to find against Myriad Genetics Corporation in the company’s attempt to protect their expensive monopoly of the breast cancer genetic assay. Thus, the Court will have the opportunity to reduce the cost of testing, which as you note, can run thousands of dollars per patient.

Your action changes the war against breast cancer. You have prevented the suffering of thousands and given them the opportunity to go on with life and be part of what is truly important, families and communities.

Thank you for your remarkable sacrifice.

Humbly,

James C. Salwitz, MD

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

A woman’s mother dies at age 56. A blood test is done. The woman finds out she has a genetic pre-disposition to cancer. She takes what action she thinks she needs to take. A familiar story repeated over and over again every day. I’ve met many women who have made this choice. While not “normal”, it is a familiar situation. These women’s difficult choices go unheralded. But not Angelina. She has a voice and she’s not afraid to use it.

I am of two minds about Ms. Jolie’s announcement. Unlike double mastectomies for ductal carcinoma in situ (DCIS), which isn’t necessarily a cancer and can be treated with a lumpectomy, BRCA1 gene mutations can’t be treated any other way. Unless I hear differently from my breast surgeon friends, I’d say she probably did the right thing. Her decision to talk about it is probably encouraging to women who have or will have to make that choice. It raises awareness of the gene mutation. It puts breast cancer on the front page of the New York Times. Again.

Here’s my problem: double mastectomy is not a benign procedure. Ms. Jolie seems to have had a remarkably easy time of it. Yes, she says she was right back to her normal life soon after, but since Jolie’s life is not normal that’s hard to generalize. The truth is there is significant pain involved, a long period of waiting while the tissue expanders do their work, then there’s further procedures for the implants, which can develop capsules around them, or rupture, or get infected. If Angelina had chosen breast reconstructive surgery there would be the risk of the flap losing blood flow, multiple drains, overnight stays in recovery rooms or ICUs, and many many surgeries for revision, nipple creation, etc. And the results are not always beautiful. I understand that it is not Ms. Jolie’s role to scare people, but to encourage them. I would just warn against falsely rosy expectations.

I am not trying to discourage double mastectomy. Sometimes it is necessary. I do think that people who have extraordinary access to public attention must pay extraordinary attention to what they say. I wish Angelina all the best for a complete, and beautiful, recovery.

Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at medicine for real.