We are entering the season of presidential politics, of bunting and cries of “What about the children?” and star-spangled appeals to full-throated patriotism.

So here’s mine: Do you count yourself a patriot? Do you care about the future of this country? (And while we are at it, the future of your hospital.) If so, bend your efforts to find ways to care for the least cared for, the most difficult, the chronically complex poor and uninsured.

“But we can’t afford compassion!” Wrong, brothers and sisters, we cannot afford to do without compassion. “But why should we pay to take care of people who can’t take care of themselves?” Because we are (you are) already paying for them — so let’s find the way we can pay the least.

The problem of the overwhelming cost of the “frequent fliers,” people with multiple poorly tracked chronic conditions, has always been that the cost was an SEP — “somebody else’s problem.” Now, increasingly, hospitals and health systems are finding that they are unable to avoid the crushing costs of pretending it’s not their problem, are not being paid for re-admits, and are finding themselves in one way or another at risk for the health of whole populations. They’re also facing more stringent IRS 990 demands that they demonstrate a clear, accountable public benefit.

At the same time, employers and payers are realizing that they end up paying the costs of the uninsured as well as those of the insured who are over-using the system because they are not being tracked. These costs become part of the costs of the system, and the costs are (and must be) shifted to those who do pay. There is no magic money well under the hospital.

Wait, Wait — Save the Country?

Follow the bouncing ball of the logic here: We must do something about deficit spending, right? Austerity budgeting shafts the economy (as has been vividly demonstrated in Europe), so bringing down the deficit needs to be done gradually. But it needs to be done. Over time, the deficit must be brought down into line with the growing economy. With me so far?

Analysis shows that by far the biggest chunk of the deficit is the continuing and projected rise in health care costs. The rise is from the direct costs to the federal budget of Medicare, military, veterans and federal employee health care spending as well as the rising tax costs of private employers’ deductible health plans. Plus, the “health care tax” of putting 18 percent of everything toward medical cost puts a drag on the economy — and a dragging economy means lower tax revenues.

If we spent the same percentage of GDP on health care as Canada, the UK or Germany, we would have no deficit crisis. The deficit would disappear like frost on a sunlit morning. If we do not succeed in lowering health care costs significantly, no amount of cutting National Parks or NASA or education budgets will ever solve the deficit crisis, because those budgets are vastly smaller. It can’t be done. So lowering health care costs is a do-or-die national priority. The health care crisis and the deficit crisis are the same thing.

What are those costs and how do we cut them? Seventy percent to 75 percent arise from chronic conditions. The majority of those arise from behavior, and almost all of them could be better managed to make cases cheaper by making patients healthier.

Who is spending the money, using the health care resources? This follows a Pareto distribution: 20 percent of the people spend 80 percent of the money; 5 percent of the people spend half the money; 1 percent of the people spend 20 percent of the money.

Who are the 1 percent? Some just got prostate cancer or got hit by a bus. This is their year to be expensive. But a substantial portion of that 1 percent and that 5 percent stay in the same category year after year. So a small percentage of the people use a large percentage of the health care resources by crossing your threshold, showing up in the ED and the hospital over and over with the results of their untreated, unmanaged, untracked chronic disease, addictions and mental problems. And recent studies show that people who have health care coverage (and therefore a regular relationship with a primary care doctor and a health care system) cost the overall system half as much as people without coverage.

Bingo! There’s the treasure, because experience shows that getting aggressive with untreated chronic disease can substantially lower costs. Trying to ignore them is costing us dearly. It’s time to change course.

The Treasure Is There

When Rumi said, “Burn down this house! The treasure you seek is beneath the floor,” he presumably was speaking of spiritual treasure. Yet last year in the South Indian state of Kerala, some devotees sued the maharaja running a local temple, concerned that the temple’s treasury was being mismanaged and possibly looted. The Supreme Court of India dictated that the subterranean vaults of the temple, sealed for 125 years, be opened and an accounting made. The official party found gold and jewels in one vault alone valued at an estimated $22 billion — and a second vault has yet to be opened.

Health care’s treasure has been hidden not in some subterranean sealed vault but in plain sight: It is those thousands and millions of cases of poorly treated and untracked chronic disease that flood our EDs every day. We can mine those to reduce health care costs drastically, put our hospitals and health systems on a much more sound economic footing, make people much healthier and, by the way, save the country.

How? Six ways.

Coverage. Push to get everyone covered, one way or another, whether the Affordable Care Act survives or not, including even those whom the ACA does not cover, even the illegal aliens, the homeless and crazy and addicted people wandering the streets. Why? Because they end up in your ED. You’re the dumping ground for the problems society keeps trying to ignore. And this is not just about you getting compensated for your costs. To the extent possible, it should be about health coverage attached to the person. If they are covered, it is much easier to fashion preventive and outreach programs to keep them from your door.

This coverage has to be implemented at the state and local level, both directly through public programs and through “safety net” supplemental insurance programs subscribed by the health plan industry. Get everyone covered, and two things happen: The covered people cost the system less, and less of that cost is an unrecoverable cost to you.

This is a very difficult goal, because people do not understand that this is a way to spend less money not more, that covered people cost the system half as much — and it is the rest of us that end up paying those costs. Health systems must campaign for such truly total coverage at every political level, for their own survival and for the good of the country.

Shift in risk. Work with payers, governments and employers to shift the risk from the Standard Model (fee-for-service, with all financial risk in the payer) to various models in which the provider takes on some risks (as with bundles, warranties, capitation, mini-caps, alternative quality contracts and other models) and the patients take on some risk for making a good decision (going to a clinic or an urgent care provider instead of the ED with a minor matter). Pilots show that when poor people are given coverage in the form of an HSA with deductibles, and when they understand how it works, they treat the money as their own, and conserve it, even when all of it is given to them as a subsidy. So a carefully titrated level of risk works across the spectrum of class.

Incentivized wellness. Work with employers, health plans and public agencies to get as many people as possible into incentivized wellness programs, which give people financial rewards (such as lower premiums) when they participate and meet simple goals. Correctly done, these programs reduce the actual costs for covering the whole population (including those who do not participate) by 10 percent or more.

Targeting. Find and go after that 5 percent, that 1 percent who are costing the most money. Some of the cost will be recoverable, some will not, but go after them anyway, because the costs spiral out of control once they cross your threshold.

Let me teach a technical economic term, in case you don’t know it. The term is bupkis. It’s from Yiddish and means nothing, an inconsiderable sum. Or, as one health care CFO put it to me, “lost in the noise.” That’s what it costs to reach out to someone with some smart prevention, or to treat them in a clinic, rather than treating them when they are hauled in to the ED comatose with something that could have been prevented or caught in an earlier stage. That’s the cost, relatively. Crumbs. Footnotes. Bupkis.

You can target in a number of ways. You can forward-base free or sliding-scale clinics in the parts of town from which you get the most costly cases. You can find ways to help the Federally Qualified Health Centers that may already exist in those parts of town. You can subsidize independent free clinics that already exist.

You can use “big data” from geographic information systems such as Stratasan GIS, Explorys Population Explorer, the Healthy Communities Institute and the free, open-source Community Commons to “hotspot” your community — or you can do a first pass on it just by talking to the cops and EMTs that come into your ED. You can establish a crack Camden-style team to go after the 0.1 percent toughest and most expensive individuals.

Some systems, like Spectrum in southwest Michigan, are setting up special clinics to go after and treat anyone who has shown up in their ED 10 times in one year.

Some doctors will complain that you are stealing their business. By definition, if these people are showing up in your ED with untreated chronic disease, either they are not those doctors’ customers, or those docs are not doing their job. Steal away.

Many people, clinicians and citizens, will tell you that those folks are untreatable, because they are addicts, or you can’t affect their behavior, and this and that. True of some, but it’s a numbers game. When the Camden Coalition of Healthcare Providers began targeting the worst, most complex, most expensive cases, they were able to reduce hospitalization of those they took on by 56 percent. Any way you add it up, that’s a huge saving.

Public health. You must seek partners in all of this. Payers and employers are the best possible partners, since they shoulder a lot of the cost burden with you. But federal, state and local public health officials are equally important. In my years of talking to health care executives, I continue to be astonished at how many of them do not even know the names of local public health officials, much less collaborate with them on a regular basis.

Healthy Communities. Finally, at the furthest remove from your ED threshold is the Healthy Communities movement. There are local groups in most places across the country, supporting programs dealing with everything from effluents to traffic to education to AIDS awareness. The return on investment is always large because the investment is so small compared with the ED visits, surgeries, premature births, and NICU and ICU use that they eventually prevent.

We will save much more money, shore up our finances and help solve the deficit problem when we stop waiting passively for people to cross our threshold and begin aggressively exporting health to those who need it the most.

As a healthcare speaker, writer, and consultant, Joe Flower has explored the future of healthcare with clients ranging from the World Health Organization, the Global Business Network, and the U.K. National Health Service, to the majority of state hospital associations in the U.S. Joe writes at imaginewhatif. This article first appeared in H&HN (Hospitals and Health Networks) Daily.

There’s something compelling about the personal narrative that vast mountains of quantitative data cannot rival. Anecdotes are, quite simply, powerful. They tap into our shared humanity, making something seem somehow more real by putting a face on it. This is why, if you follow politics for very long, you will find numerous cases of policymakers championing issues that have touched their own lives in some way. For example, Senator X doesn’t care about issue Y, until they discover that their son or daughter is affected by it. Then, almost overnight, they seem to care more about issue Y than almost anything else. Such a shift is completely understandable, but often out of proportion to the true scale of the issue in society.

In health policy, the personal narrative can also be very powerful. In fact, the journal Health Affairs routinely runs a “Narrative Matters” section that puts a face on the health care issues of the day. It is absolutely critical that health policymakers, health services researchers, and others, not lose sight of the fact that their work and the subsequent decisions it informs, are based on real people. However, it is equally critical for objectivity to be maintained, and narrative can threaten our work in this regard.

As an example, Tom Perkins recently wrote in the Wall Street Journal about his ongoing battle with prostate cancer in his eighties. His article takes issue with recommendations from the U.S. Preventative Health Service that call for moving away from prostate cancer screening (the PSA blood test). It’s hard to argue with his case, specifically, because he had an aggressive form of prostate cancer that was caught early and is being treated with at least moderate effectiveness. Had he not been screened, the cancer would most likely have killed him. You can see why he would consider the U.S. Preventative Health Service to be a “death panel” (his words, not mine).

The problem is that Tom Perkins is an anomaly. The overwhelming majority of prostate cancer is not aggressive. This is why you may have heard the saying “Most men die with prostate cancer, not of prostate cancer.” One of the greatest things about health services research is the opportunity it affords to step back from the trees and take stock of what is happening to the forest. What we discover then leads us to confront more philosophical questions. For example, are we okay with paying for 100 people to be screened for something that will only help 1 of them? If you were making this decision the way you make decisions about most everything else you buy, you’d want to know some things. For instance, how much does the screening test cost? If the test isn’t done, what else could the money be used for? How accurate are the results of the test? How much will the 1 person be helped? Do I know the 1 person? Am I the 1 person?

These questions represent the continuum from purely objective research to very subjective personal anecdote. They all deserve to be answered, and each answer informs our decision-making in a different way. Unfortunately, when people espouse one extreme or the other, which is admittedly much easier to do than holding the two in tension, something very important gets lost.

D. Brad Wright is postdoctoral fellow at Brown University and  holds a PhD in health policy and management from the University of North Carolina.  He has worked as the Assistant Director of Health Policy for the Association of Clinicians for the Underserved. You can follow him at his blog Wright on Health where this post first appeared.

Under the Patient Protection and Affordable Care Act (PPACA), state governments are expected to set up health insurance exchanges through which individuals will buy their own health insurance, in many cases with substantial subsidies. Should the states comply?

In the following point-counterpoint discussion, Linda Gorman and I give opposing answers to this important question. Leave your thoughts in the comments.

John Goodman: Yes

If the states abdicate their responsibilities under PPACA, the federal government will step in and act in lieu of the state. Under this scenario, states will relinquish all power to make a bad law better. Letting the federal government implement reform almost guarantees bad outcomes.

Linda Gorman: No

Exchanges are required to perform a variety of duties beyond distributing ObamaCare subsidies, and these duties are likely to add significantly to estimated costs. Some of them will damage a state’s business climate by creating new opportunities for crony capitalism. Some require that currently fashionable, but poorly tested, models be forced on health care providers. Some require that state exchanges have expertise equal to private insurers. Others force states to increase the cost of health insurance for people who currently have coverage.

John Goodman continued:

The states should engage in preemptive reform over the next two years. This means enacting responsible, rational reforms — the kind of reforms that they should have enacted all along, in the absence of federal legislation. Where possible, states should try to make their reforms compatible with the new federal law — but only if compatibility does not sacrifice the major goals of the state’s reform.

There are four arguments in favor of preemptive action at the state level:

• If states enact their own reform and if it is achieving most of the goals of the federal law in a reasonable way, they may be able to secure a federal waiver to continue with whatever they are doing.
• There is some possibility that the federal law may be found unconstitutional or it may be repealed altogether. In either case, the states will be able to continue with their good reforms without federal interference.
• There is a high probability that PPACA will be subjected to major modification within the next three years—barring an outright repeal or a finding of unconstitutionality. An amended PPACA will likely grandfather any state reform that appears to be working reasonably well.
• Even if the states are forced to modify their reforms in major ways three years from now, the end result is likely to be much better if the system being modified is a good system to begin with than if a set of perverse federal rules are super-imposed on a pre-existing dysfunction of system.

State Responsibilities under the New Law. States are required to do a number of things under the PPACA. These include:

• Setting up and administering a new risk pool for people who have been denied coverage because of a pre-existing condition.
• Enforcing new health insurance regulations, including no ceiling on annual and lifetime spending, limits on the amount insurers can spend on overhead, enforcing a prohibition on pre-existing condition provisions in child-only policies, etc.
• Beginning in 2013, enforcing a prohibition on adjusting premiums to reflect an individual’s expected health care costs, enforcing guaranteed issue in the individual market—both inside and outside the health insurance exchanges—and limiting the spread of premiums charged to different individuals at different ages and in different occupations.
• Regulating health insurance premiums in the individual market.
• Setting up health insurance exchanges and administering federal subsidies for individuals who purchase their own health insurance, beginning in 2013.
• Managing a major expansion of Medicaid, including families with incomes up to 133 percent of the federal poverty level, beginning in 2013.
• Managing the flow of people who move back and forth between the federal/state-funded Medicaid program and the tax-subsidized health insurance exchanges.

All of these responsibilities are challenging. They are costly and administratively difficult. Hence, it is tempting for the states to dump the problems back in the lap of the federal government.

What if States Do Nothing? More than half the states have already decided not to operate the new federally funded risk pools—which make health insurance available to people who have been denied coverage for a pre-existing condition—for the same premium healthy people would pay. In these states, the risk pool is being operated by federal authorities.

It is understandable that states would have little interest in operating a fund with downside risks and no obvious upside benefits. But for states that take my advice and implement preemptive reform, this decision may have been unwise.

The biggest problem in health reform is the problem posed by people known to have high health care costs. As a result, the greatest help a state can get in transitioning to a new health care system is a pool of money to pay for those costs—even if only for three years.  A well-funded risk pool should be an element of rational state-level reform.

Here is a principle to keep in mind on this and on many other issues: It is in the states’ interest to shift costs to the federal government wherever possible; it is in the federal government’s interest to shift costs to the states. With respect to a risk pool or a health insurance exchange there will be hundreds—even thousands—of decisions made on a day-to-day basis, that are hard to review and even harder to undo. From the state’s perspective, who do you want to make these decisions?

Let’s consider three areas where decision-making authority could be worth millions of dollars to state governments.

First, if state governments abdicate their right to set up health insurance exchanges, the federal government will step in and set up federally regulated exchanges in those states. But the official who stands at the entrance door of the exchange will be the person who will decide whether an applicant is entitled to federally subsidized insurance or whether that person should be getting insurance from an employer or from Medicaid. Consider also that whatever decision is made, no one will know if it was the right decision until an audit is done five years after the fact; and at that point there will not be much that can be done about it anyway.

In principle, there is nothing wrong with a health insurance exchange. What is wrong with existing exchanges is that they give health plans perverse incentives to underprovide to sick people. But an exchange that did not have such perversions built into it could be a valuable institution.

Second, consider the regulation of premiums for plans sold in the exchanges. The Obama administration’s goal for controlling costs in Medicare is immensely transparent. The administration wants to force seniors into super HMOs called Accountable Care Organizations (ACOs). It will then limit the income of the ACO—forcing it to ration care. In doing this, the administration will be following a precedent that has already underway in Massachusetts.

With that in mind, who do you want to regulate private insurance premiums in your state? If the federal government does it, the tendency will be to replicate what is happening in Medicare. The regulators will try to keep the growth of premiums below the rate of growth of health care costs. This will not really control costs but it will limit the size of the subsidies the federal government has to pay. In the process it will force health plans to ration care.

A third area where decision-making authority will be worth millions of dollars is the ability to determine whether an individual or family qualifies for Medicaid or qualifies for insurance in the exchange. Under Medicaid, the federal subsidy is much lower and the state has to pay a good portion of the cost. In principle, eligibility for Medicaid follows in a straightforward way from objective criteria—mainly family income and assets. In practice, however, people’s income and assets are changing all of the time. It’s not unusual for a family to be eligible and then ineligible for Medicaid several times in one year. According to one study of the problem, within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse. Within a year, 50 percent, or 28 million, will.

In the light of all this movement and flux, the ability to make decisions about who should be in the exchange and for how long could be worth an enormous amount of money to the state. Keep in mind that a family at 133 percent of the poverty level will get a benefit in the health insurance exchange in excess of $20,000, according to estimates of the Congressional Budget Office. Medicaid spending will probably be less than half that amount and the federal government doesn’t even pay all of that.

Bottom line: states should at least consider retaining as much decision-making power as they can get.

In a future Health Alert, I will discuss the elements of pre-emptive reform.

Linda Gorman continued:

Once an exchange is established, a state must:

• Reimburse the exchange, but not private insurers, for the cost of any new health insurance mandates.
• Establish a reinsurance program for the first three years of operation. Fees will be collected from health insurers and used to “stabilize premiums” in the individual market. This increases health coverage costs for people who have existing coverage.
• Operate a risk adjustment program that collects risk-related data to determine individual risk scores. Private insurers have historically used experience based rating, not risk scores. Risk adjustment has not worked for Medicare Advantage.

Coverage offered through an exchange must:

• Meet a variety of reporting and document standardization requirements.
• Distribute grants to selected community groups “hired” to replace the services of traditional insurance brokers under PPACA’s “Navigator programs.”
• Establish network adequacy standards that have no minimum requirement except that they cover a “sufficient number” of “essential community providers.”
• Meet a variety of quality improvement requirements that, in pilots, have been shown to increase costs with little improvement in care:
  • Quality reporting.
  • Design new programs for case management, care coordination, chronic disease management, and care compliance initiatives.
  • Implementation the medical home model.
  • Use of evidence-based guidelines.
  • Wellness promotion.
  • Operate programs for community outreach and cultural competency training to reduce health disparities.

We invite you to leave your thoughts in the comments.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

Linda Gorman, Ph.D. is director of the Health Policy Center at the Independence Institute, a free market think tank in Golden, Colorado. A former academic economist, she now focuses on state health care issues.

Today’s Computerworld has a great article about the issues of mixing social media and healthcare.

As hospitals and clinics formulate social networking policies, there are three broad considerations.

1.  Given HIPAA and HITECH privacy and breach rules, how can you best prevent the disclosure of protected healthcare information on insecure social media sites?

2.  Given the distraction factor and productivity loss that can occur with social media, how can you best align the benefits of groupware communication while minimizing the negatives?

3.  How can you reduce the security risks of malware embedded in games and other applications that are downloaded from social networking sites?

To date, Beth Israel Deaconess has focused on #1, ensuring that our employees do not post data to social networking sites in violation of state and federal laws.

We’ve not yet completed a  policy covering #2, although several hospital sites and departments are discussing the issue.

We’re developing a pilot for #3, including blocks on selected websites, Facebook add-on applications, and personal email.

Ensuring we have a suite of social media policies is one of our Internal Audit focuses for 2012.  To formalize our polices, procedures, and guidelines, we’re collecting best practices for healthcare institutions throughout the country and assembling a multi-disciplinary group including Corporate Communications, Legal and IT.

There are many benefits to social networking to foster collaboration and communication.   As we work on developing further policies, I’ll share our lessons learned in future posts.

John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. He’s also the author of the popular Life as a Healthcare CIO blog.

Rewarding quality health plans is an admirable goal for the Medicare Advantage program. Unfortunately, the current system of linking star ratings to bonus payments and rebate adjustments instituted by the Patient Protection and Affordable Care Act (and expanded by the CMS Quality Bonus Payment Demonstration) fails to achieve that goal, and depending on its specific implementation, may even be counterproductive.

Because criteria for evaluation are not published until after the period for which performance will be evaluated, there is no possibility that MA plans will be able to improve their performance to achieve the goals CMS intends to incentivize. Any adjustment plans will be able to make to their bids or plan offerings would have to be aimed at increasing enrollment in counties with the highest bonuses and rebates based on data from performance in previous years, possibly at the expense of improving their performance in the future.

The system rewards beneficiaries for choosing those plans favored by the selected CMS criteria, rather than the plans that best meet their needs. In effect patients whose preferences, health status, and even counties of residence, don’t match the CMS model of a highly rated plan will be at a disadvantage. Simultaneously, the system will likely reduce the scope of choice available to MA-eligible beneficiaries, and reduce competition among MA plans.

Finally, the system rewards beneficiaries for living in counties with low poverty rates (since relatively wealthier counties tend to have more plans with higher ratings), thus adversely impacting poor beneficiaries even more than non-poor beneficiaries.

These impacts are inconsistent with the overall policy purpose. The goal of incentivizing quality health plans is legitimate and admirable; that goal will not be achieved by the rating structure currently being put into place.

The star bonus system could be improved by transforming it to a system in which criteria for performance were announced in advance, and bonuses were paid based on performance during the period in which it occurred. In addition, the system should not tilt the playing field against any particular beneficiaries’ preferences. A star system with these characteristics would ensure that the program goal of incentivizing the achievement of high-quality plan offerings is achieved.

Read the full paper.

Douglas Holtz-Eakin is president of the American Action Forum. He served as director of the Congressional Budget Office from 2003 to 2005. This post first appeared at the American Action Forum.

The numbers are stark. According to the United States Preventive Services Task Force, for every man whose death from prostate cancer is prevented through PSA screening, 40 become impotent or suffer incontinence problems, two have heart attacks and one a blood clot. Then there’s the psychological harm of a “false positive” test result, which is 80 percent of all “positive” tests. They lead to unnecessary worry, follow-up biopsies, physical discomfort and even harm. Final grade: D.

Three men close to me have been diagnosed with prostate cancer late in life. Each was around 70. My dad, already in throes of advancing Alzheimer’s disease, did what the doctor ordered (actually, I suspect my mom told my dad to do what the doctor ordered). He had surgery. And for the last six years of his life, which until his final three months was at home, she cleaned up after him because of his incontinence. My neighbor made the same choice. He quietly admitted to me one day that he suffers from similar symptoms, but he is grateful because he believes his life was saved by the operation. And my friend Arnie? I’ve written about him in this space before. He was diagnosed at 70, and being a psychiatrist with a strong sense of his own sexual being, understood the potential tradeoffs. He decided to forgo treatment. He died a few years ago at 90. I never learned the cause.

So what does it mean that PSA testing gets a D rating?

If you want the test, or your doctor performs it routinely, your insurance company may not pay for the test. It won’t have to since the Affordable Care Act says prevention services must be rated either A or B to warrant automatic coverage. Yet I wouldn’t worry if you’re a symptomless man who is hellbent on getting this unnecessary test. Three insurers told the Washington Post yesterday that they will continue to pay for the test if it is ordered by a physician. I can’t imagine Medicare cutting off payment, either. The wary bureaucrats at CMS have no interest in wading into a fight with the “Evidence? We don’t need no stinkin’ evidence” crowd.

I predict that you’ll see no change in clinical medical practice from this pronouncement by USPSTF. Physicians in community practice will continue to routinely screen men between 50 and 75. Millions will continue to receive unnecessary treatment. A few thousand lives each year will be saved. Will that justify the harm — including premature deaths — caused by the false positives? We’ll never know. Because those who experience those harms will suffer in silence. After all, they’re men.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and The Fiscal Times. You can read more pieces by him at GoozNews.

Dr. Gregory House hung up his stethoscope and cane for the last time last night and shuffled off into eternal life in the Land of Reruns. House — the brilliant, misanthropic, drug addicted, my-way-or-the-highway physician — has been an entertaining presence on FOX television for the past eight years. I enjoyed the series and even learned a little medicine. I also took some pride in the show, since House was television’s first hospitalist, a term I helped coin and now the fastest-growing specialty in modern medicine.

But as entertaining as he was, House was a throwback to an era in which the antisocial tendencies of some physicians were seen as irrelevant to their doctoring. As medical leaders strive to redefine “the great doctor” of today, House’s departure is both timely and welcome.

When I went to medical school in the 1980s, many of us valued nothing more than our autonomy. We saw medicine as an individual, not a team, sport, and interpreted professionalism as unwavering advocacy for our patients. While this was often healthy and noble, in some cases it crossed the line into obnoxiousness, even rage. (Today, we call doctors who cross this line “disruptive physicians.” Dr. House would certainly qualify.)

Hospitals were co-dependent. All too aware of their heavy reliance on the physicians’ control over their revenue stream, hospital administrators learned to coddle doctors, with everything from prime parking spots to a personalized menu of surgical equipment. This kept the doctors happy, but also led to wildly expensive and sometimes risky variations in practice, even within the same institution.

This reliance also made everyone tiptoe around the dysfunctional behaviors that Dr. House so memorably illustrated each week. In one survey of more than 700 nurses, 96% reported seeing doctors engaging in disruptive behavior, and almost half pointed to fear of retribution as the reason such acts went unreported. Another survey found that one in four doctors and nurses believe that disruptive behaviors are associated with preventable deaths. I agree, having seen cases of medical errors in which a scrub nurse or physician trainee suspected that a senior doctor was about to commit a terrible error, but kept quiet rather than risk the physician’s ire.

Former secretary of State Henry Kissinger once observed that “weakness is provocative.” When it comes to taking decisive steps to address the problem of disruptive doctors, we have been both weak and provocative. The reasons are several and knotty. We doctors are not schooled in managing confrontation, and we’re particularly timid when asked to judge the behaviors of our colleagues under our system of “peer review.” Moreover, we worry about being sued if we act decisively against another physician.

But another reason goes to the heart of House’s widespread appeal: patients seem to believe that the Gregory Houses of the world must have terrific clinical skills, whether in performing brain surgery or diagnosing a rare case of strongyloidiasis. While Dr. House did have Sherlock Holmesian diagnostic acumen, the insider’s secret is this: great doctors are skilled at both medicine and teamwork. Patients shouldn’t have to choose one or the other.

Spurred by the patient safety movement, the medical community is finally taking steps to address the problem of antisocial doctors. Gerald Hickson, MD, of Vanderbilt has created a program that begins with a “cup-of-coffee conversation” but escalates to the loss of hospital privileges for physicians who fail to respond to education and counseling. In my own hospital, we have dismissed several physicians over the past few years for behavior that I’m certain would have been tolerated a generation ago. These are wrenching decisions, but ultimately correct ones.

While we’re getting better, we are still not where we need to be. Hospital peer review committees are only partially shielded from lawsuits, which creates a chilling effect. Options for counseling aimed at improving the behavior of disruptive doctors are limited. And doctors released from one hospital for behavioral problems are generally able to continue practicing in other settings, even if their behavior hasn’t changed.

Over the past decade, we have come to realize that, for all its miracles, the American health care system produces uneven, error-prone, and backbreakingly expensive care. These problems are complex and require an array of solutions, ranging from computerization to standardization, from simulation training to patient engagement. But we also need physicians who are smart, well-trained, innovative, intensely focused on delivering the best care to their patients, and who can play well with others. While House had many of these skills, the teamwork part was his fatal flaw. If he worked for me, I would have fired him, somewhere around Season Three.

So rest in peace, Dr. House. Thanks for being in our lives for these past eight years.

And thanks for leaving.

This post first appeared in USA Today.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair-elect of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

One guarantee in the healthcare sector is that when it comes to personal health information (PHI), there is no lack of issues and pundits to discuss security and privacy of such information/data. If one does not jump up and down bleating on about the sanctity of PHI and the need to protect it at all costs, well then you may be labeled a heretic and burned at the proverbial stake.

Now don’t get us wrong. Here at Chilmark Research we firmly believe that your PHI is arguably the most personal information you have and you do have a right to know exactly how it is used. Whether or not you own it remains to be seen for we have seen, read and heard one more than one occasion – some healthcare providers believe that it is their data, not yours, and may only begrudgingly give you access to some circumscribed portion of your PHI that they have stashed in their vast HIT fortress, or worse, scattered in a number of chart folders.

But where we do differ with many on the sanctity of PHI is that the collective use of our de-identified PHI on a community, regional, state or even national level can give us some amazing insights into what is working and what is not in this convoluted thing we call a healthcare system in the US and needs to be strongly supported. Unfortunately, we do a terrible job as a country in educating the populace on the collective value of their data to understand health trends, treatments and ultimately ascertain accurate comparative effectiveness. This leaves the door wide open for others to use the old FUD (fear uncertainty and doubt) factor to keep patients from actively sharing their de-identified PHI.

One of the more popular and edgy online dating sites, OK Cupid, has done some great things with the data they collect on their users. They take the vast amounts of data they collect and do some pretty fantastic and fun (fun is good, fun is engaging) analysis to understand their users and what makes them tick. For some reason, the healthcare industry just doesn’t do fun things with the data – always so morbid!

Imagine if we could collect similar data on health, or heck, even better, imagine taking some of OK Cupid’s findings on body image and sex drive, (see chart 7 & 8) and using that to educate the public on why it may be in their best interest to keep their weight in check. Sure doesn’t seem like the threat of diabetes, heart failure etc. is doing the trick to lower obesity rates, maybe hitting them below the belt will work.

John Moore is an IT Analyst at Chilmark Research, where this post was first published.

Just recently, the New York eHealth Collaborative and the New York City Investment Fund held an awesome information session for the New York Digital Health Accelerator at the chic digs of the TimesCenter in NYC. The Accelerator is a program for early — and growth — stage digital health companies that are developing cutting-edge technology products in the areas of care coordination, patient engagement, analytics and message alerts. The event was open to the public and provided thorough detailing of the accelerator, insights as to the types of solutions that participating providers hope to receive and – of course – some networking. If you missed this exciting event, you can check out the recorded stream. If you are interested in the program, access the application.

Twelve companies will be invited to participate in the nine-month program. A review committee — comprised of hospital leadership, technology experts, clinicians and investors — will select the companies. The committee will evaluate applicants on their product innovation in the four focus areas, the track record of their management team and their company life-cycle stage.

Selected companies will receive up to $300,000 in capital: $100,000 at the start of the program and an additional $200,000 at the four-month checkpoint if the companies meet predefined milestones. The capital will be structured as convertible notes with small warrant coverage. The milestones will be set by participating venture capital and provider organizations.

In addition to funding, the accelerator offers direct access to a unique network of provider organizations. According to New York eHealth Collaborative Executive Director Dave Whitlinger, the program is unique in that it “helps spotlight development companies capable of successfully implementing their solutions in clinical environments and integrating with the SHIN-NY API.” Over twenty provider organizations will play active roles in the program. Each company that is accepted will be paired with a provider, and in some cases multiple providers. Based on user feedback, the organizations will offer clinical workflow and technical guidance.

From Health 2.0’s perspective this is a screaming big deal. It’s the first incubator in health that gets past the “Ramen money” stage and essentially locks in the angel round for the post-3 month stage. Given that not all of the companies coming out of the current 3 month incubators get that funding, these companies will have a chance to really concentrate on product development and work on pilots. The result should be a big leap in productivity.

If you want more information on the New York Digital Health Accelerator, please visit http://digitalhealthaccelerator.com/. But hurry as this is the last call for applications, as the deadline – Friday, June 1 – is just over one week away! So if you fit the desired applicant description, apply now!

Investors just ponied up well over $100 billion for a piece of the social media giant Facebook. While Mr. Zuckerberg and his co-founders deserve a hearty congratulations, I find some eerie parallels between Facebook and accountable care organizations.  The similarity does not bode well for either business model.

1. The users are not the customers: Facebook sells its users to marketeers.  ACOs sells its patients’ health care utilization to insurers.

2. It’s the data and it’s not yours: Facebook’s targeted ads are constructed off of prior usage patterns. ACO’s shared savings calculations are built off off actuarially determined health care utilization patterns.

3. Sovereign hostility: Washington DC views information technology and health care as distractions from the true task at hand: restoring the U.S. manufacturing base.

4. Do you care, really? Now that the wunderkids in charge of Facebook have made their millions, it remains to be seen if they’ll work as hard in delivering value to its users.  Ditto for all the salaried docs working for ACOs, who no longer have to arrive early, skip lunch and stay late.

5. The long term: Yahoo once was the darling of internet investors.  Even if ACOs have initial success, is a better care model being developed as you are reading this?

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.