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Until Death (or Recertification) Do Us Part

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By RICHARD DUSZAK, MD 

The online membership forum of the Society of Interventional Radiology (SIR) blew up this week in response to an email announcement by the American Board of Radiology (ABR) that it will effectively be doing away with lifetime diagnostic radiology certificates for interventionalists whose original certificates pre-dated the introduction of time-limited certificates. Interventionalists were given two choices:

1.     You can keep your lifetime diagnostic certificate if you give up your (earned) interventional subspecialty certification, or

2.     You can keep your interventional certification, if you give up your lifetime diagnostic certification.

Talk about choice.

The ACO Fix

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Kip Sullivan posted an op-ed in “The Health Care Blog,” “On the Ethics of Accountable Care Research,” on August 25, 2017.

Mr. Sullivan’s questioning the ethicality of health system generated research papers touting statistically insignificant results as triumphs, while perfectly valid and well-reasoned, is like questioning the validity of a teacher’s grading curve while missing that the class is gaming the system.

A system ginned up in the only policy factory in the country with policy-makers naïve enough to actually believe that hospital systems would actually cannibalize their core business to split the results with CMS, then split a legally mandated two thirds with the doctors, then pay its costs out of the rest, would ever work. Commercial payers do it, too, but for far more practical reasons.

The Accountable Care initiative, far more vulnerable than Obamacare, is being circled as easy prey for elimination by D.C. policy lions and pundits. It is undeserving of this fate for one, single, compelling reason. The program theory is valid and, with the right partners, is thriving as a win-win.

Its advantaged design partnership to exactly the wrong partners is the ill-conceived – and failing – part.

Who are the right partners? Independent physicians, for example. The ones that are focused on providing better value for their patients and are incentivized because the new money in healthcare is in delivering value. The broad delta between a bloated, wasteful, ineffective system and the improved one you create can restore fiscal stability to primary care physicians, who are on the verge of being price-cut out of business. Primary care physicians are the key because they can be very effective, and less costly, clinical managers for a patient’s overall care.

Should We Fear an Amazon Monopoly on Healthy Food? 

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Two months ago, I wrote about the potential impact of the Amazon purchase of Whole Foods on grocery prices.  Both here and in the Boston Globe, I hoped and predicted that Amazon would use its famed distribution network to drive down prices on the healthy and organic foodstuffs that made Whole Foods famous.

I’m happy to say that I was right. Today, on Day 1 of Amazon’s official ownership of Whole Foods, Americans got to see the first tangible impacts of Amazon ownership and, as predicted, it was lower prices.  As noted by journalists, the chain once derided as Whole Paycheck should now be referred to as “3/4 Paycheck” given deep discounts averaging 25% on a wide range of products ranging from bananas to butter.

Though terrifying for Amazon’s competitors such as Kroger, Walmart and Costco, Amazon’s major foray into brick-and-mortar groceries may end up being a boon for consumers – at least in the short term.  It’s no secret that Amazon retains its web startup mentality in aggressively promoting loss leaders to drive out competition.  And increased competition will better serve consumers who have been squeezed by recovering inflation on food prices.

Soon, Amazon intends to install more of its Amazon lockers into Whole Foods locations, thereby facilitating deliveries for goods bought on the Amazon website while also increasing foot traffic to its stores.  Analysts also speculate that Amazon’s grocery delivery service, Amazon Fresh, may get a much-needed shot in the arm with goods from Whole Foods.  The corporate synergy of this deal is palpable – and just beginning.

This makes people nervous.  Already, journalists and think tanks have sounded alarms about how Amazon’s growing power may make it a monopoly.  They argue that Amazon is an antitrust problem given that it already captures nearly half of U.S. online sales, is the leader in providing cloud computing through Amazon Web Services and has a robust marketing and logistics division.

To bolster their point, it is true that Americans can now spend a large part of their day using Amazon services without even knowing it.  You could wake up on a Saturday, go to Whole Foods for groceries, order supplies off Amazon, read a book with your Kindle, watch TV on Netflix (powered by Amazon Web Services) or catch a movie on Amazon Prime Video.  All of your needs met by Jeff Bezos and company.

Can Self-Driving Cars Stop Attacks Like Charlottesville and Barcelona?

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As if 100+ deaths on U.S. highways every day isn’t horrific enough, we are all too often reading and hearing about cars being intentionally used as weapons and seeing unbelievable images of victims on sidewalks that have been turned into killing fields.

Unfortunately, the list of these instances is growing. The attack Aug. 17 in Barcelona that saw 13 killed was just the most recent; Charlottesville, NC, and Columbus, OH, have been the scene of attacks as well. Since July of last year, vehicle-related assaults have claimed more than 100 lives in Nice, Berlin, Stockholm and London.

It may come as small comfort to know that advanced automotive safety technology, while not eliminating these instances, might be able to reduce the bloodshed. Automatic emergency braking systems monitor what is in front of a vehicle and apply the brakes when collisions appear imminent. This feature already may have saved lives.

To Promote Health Care Excellence, Let’s Recognize Approaches That Assure Value

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A challenge for health care purchasers is choosing vendors whose performance matches their cost and outcomes claims. A 2015 Mercer survey found that only 41 percent of worksite clinic sponsors think that they’re saving money. As Al Lewis and Tom Emerick have detailed, many wellness and disease management companies simply overstate their results. In many cases employers may not realize that they, not the vendor, take the risk for results.

One important answer is the Care Innovations Validation Institute, founded by Intel, that offers health care vendors and purchasers objective validation of vendors’ claims.  The Institute stands behind its work with a money-back guarantee. In the Wild West of the health care marketplace, the Validation Institute is an invaluable resource for purchasers, allowing them to confidently proceed with vendors, knowing that their promises have been vetted by scientists.

Think Different about Patient Engagement: Aetna, Apple, and a Vision of Digital Health’s Future, Part 2

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This is the second post in a series on digital health inspired by Aetna and Apple, whose developing partnership is poised to impact millions of Americans. Part 1 is Mystery Mission in LA.

Getting to Patient Engagement

“Patient engagement” is a popular phrase in healthcare these days, but how do you actually get people to take a greater role vis a vis their own health and healthcare? As the first Director of Consumer eHealth at ONC in the US federal government, I spent several years making the case for strengthening patient engagement with technology, and trying to figure out how to make it happen at scale. With Aetna and Apple working together, I think we’re a step closer.

On the Ethics of Accountable Care Research

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  • Is it ethical for health policy researchers to claim that a Medicare ACO reduced “spending” by 2 percent if the reduction was not statistically significant?
  • Is it ethical for them to do so if they made no effort to measure the cost to the ACO of generating the alleged 2 percent savings nor the cost to Medicare of giving half the savings to the ACO?
  • Does it matter that the researchers work for the flagship hospital within the ACO that was the subject of their study?
  • Does it matter that the ACO and the flagship hospital are part of a huge hospital-clinic chain that claims its numerous acquisitions over the last quarter-century constitute not mere empire-building but rather “clinical integration” that will lower costs, and the paper lends credence to that argument? 
  • Is it ethical for editors to publish such a paper? Is it ethical to do so with a title on the cover that shouts, “How one ACO bent the cost curve”?

These questions were raised by the publication of a paper  by John Hsu et al. about the Pioneer ACO run by Partners HealthCare System, a large Boston hospital-clinic chain, in the May 2017 edition of Health Affairs. Of the eight authors of the paper, all but two teach at Harvard Medical School and all but two are employed by Massachusetts General Hospital (MGH), Partners’ flagship hospital and Harvard’s largest teaching hospital. [1]

How To Prevent Burnout. Frederick This One.

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By MARTIN A. SAMUELS

I posted an essay on The Health Care Blog entitled The Prevention of Physician Burnout: A Nine Step Program. Here is an example of how this works. Recall the wonderful children’s book by Leo Lionni, Frederick. Let me remind you of it.

A family of mice begins to store away food and supplies for the long winter ahead.  Most are practical and gather corn, grains, and straw. One of the mice, Frederick, instead collects rays of sun, colors of the rainbow, and words to remember.  When winter arrives the family begins to use up their practical supplies.  They become irritable and angry and don’t have anything to talk about.  In other words, they become burned out. Frederick shares his stores of sun rays, colors, and a poem which enlivens their spirits and saves their lives.

Ever since reading this story to my own children I have used Frederick as a verb. When a wonderful event occurs, I try to remember to Frederick it…….and save it for a tough day.

About a month ago, a 20 year old woman, previously completely healthy, began to experience twitching of her left hand. Over several days this involuntary jerking worsened and spread to involve the left side of the face as well. Her parents told us that her personality had dramatically changed in that she lost her usual ebullient nature and became almost inert and unreactive. She came to us where it appeared that she was suffering from epilepsia partialis continua (continuous partial seizures).

The MRI was very abnormal in that it showed a very bright signal on T2 weighted images in the basal ganglia bilaterally. An EEG was abnormal in that it was quite slow, but there were no definite cortical correlates to the jerking. 

Confessions of a Healthcare Super User

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On July 17 of this year, I journeyed from Charlottesville Virginia, where I live, to Seattle to have my cervical spine rebuilt at Virginia Mason Medical Center, whose Neuroscience Institute has a national reputation for telling patients they don’t need surgery. It was my fifth complex surgical episode in 29 months, after more than fifty years of great health.  My patient experience has been wrenching, and it made me question yet again the conventional wisdom about doctors and patients that dominates much of our current health policy debate.

None of these interventions was remotely elective: head and neck cancer, nerve grafting surgery to restore use of my right hand and a musculoskeletal trifecta- two hip replacements and cervical spine surgery.   All five surgeries were successful, and I have fully recovered and returned to my busy life. The technical quality of the surgical care was flawless. Only three of the people who touched me were over forty, and three of the procedures were performed by women.   It was stirring to watch and be helped by the remarkable teams and the teamwork they displayed.

In retrospect, it was dizzying how fast the acute phase of these interventions was over. I walked on my new hips an hour after waking up, and spent only three nights in the hospital after my spine was rebuilt! Most of the actual recovery, and large amount of the clinical risk, actually took place out of the hospital, placing a premium on preparing me and my family for the transition.

Healthcare As a Moral Universal

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In mid-July 3 Quarks Daily posted an essay written by Umair Haque, a London-based consultant and frequent contributor to the online Harvard Business Review, that argued “the American experiment is at an end.”   This is because unlike every other rich country the US lacks, Haque stated, essential moral universals defined as “sophisticated, broad and expansive public goods that improve by the year.” These include higher education, a responsible media, transport, welfare and healthcare. Democracies depend on these moral universals available to everyone because these benefits educate, inform and allow us to lead healthy lives. Absent these civilizing mechanisms we are left unable to act morally, democracy breaks down and we are left with our best universities churning out hedge fund managers, are economy recording paper profits and our media, when it bothers, debating climate change. We are left with perverse inequality, a declining middle class and falling life expectancy. Instead of our society producing a sense of “people cooperating by voting to give each other greater prosperity,” we have, Haque wrote, one that takes “prosperity away from one another.”