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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.”

Tackle The Next Wave Of Healthcare Consumerism

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Value-based healthcare initiatives are great, but on their own won’t be enough to bend the healthcare cost curve.

The focus must move—and move quickly—from treating people who are sick to helping them get and stay healthy. The only way that’s going to happen is by getting patients and populations motivated to do the right things early instead of desperate things late.

The New Consumer World of Tools and Health Models
Health plans, in particular, have shifted responsibility onto consumers.

Kyle Rolfing, President and Co-Founder of Bright Health, and Jackie Auba, Vice President of Cigna’s Customer Adoption and Personalization Strategy, will share this shift during the The New Consumer World of Tools and Health Models panel at the 11th Annual Health 2.0 Fall Conference.

At this session you’ll also check out a demo from health optimization platform Welltok. Through population health management we are learning more about how to create wellness strategies and to stratify patient populations based on their conditions and adjust for nuances in age, race, diagnostic groups, and the like.

What Healthcare Can Learn From United Airlines

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Obamacare repeal and replace is going nowhere, despite seven years of promises by Republican members of Congress. For the foreseeable future, it will remain the law of the land, along with rising insurance premiums and deductibles and fewer plans to choose from. It’s worth remembering the next time someone asks you for money to support Republican incumbents.

What if the airline industry could light the runway toward fixing one of the more onerous aspects of Obamacare? United Airlines has done just that. I don’t mean dragging patients out of hospitals and doctors’ offices as United did earlier this year on an airplane—a physician no less. Instead, United now offers a lower cost option for air travel. Let’s apply it to healthcare.

United recently began offering “basic economy” fares, a lower cost option, compared to its “standard economy” fare. Suppose healthcare insurance companies did the same.

Obamacare requires that all insurance plans cover 10 “essential benefits.” Some of these are common sense, including outpatient, hospital and emergency care. Others are beneficial to only some people—pregnancy, maternity and newborn care, mental health and substance-abuse treatment, and pediatric services.

A 60-year-old man doesn’t need or want pregnancy coverage. A middle-aged couple with adult children can pass on pediatric coverage. A teetotaler won’t want alcohol-rehab insurance. But all are forced to purchase this insurance they neither want nor need. That’s like making Coloradans purchase hurricane insurance.   

United recognized that not all its passengers want the benefits that go along with the higher-standard economy fare. Instead, they offer travelers the option of a lower cost fare with fewer perks. For example, standard fares earn miles toward premier status on United, whereas basic fares do not. For frequent flyers looking to achieve higher premier status, this may be important. Not so for infrequent travelers or those who typically fly another airline. Why make them pay for it?

Another difference is that the basic fare doesn’t allow passengers to choose their seats or sit with their travel companions, unlike the standard fare. For a short flight, if you don’t care where you sit and are OK with your travel companion sitting in a different row, why not save your money?

The idea is that United is giving passengers a choice, offering an alternative to their more expensive fares, the airline equivalent of “essential benefits.” If passengers don’t want or need expensive perks, why not let them opt out and pay less?

An amendment along these lines was proposed by Sen. Ted Cruz during the recent Senate debate on Obamacare repeal and replace. His idea was that insurance companies could sell pared-down, less expensive plans, as long as they also sold at least one plan that provided all the benefits.

For United, that would mean they could sell basic economy fares if they still sold standard economy, economy-plus and first-class tickets. Common sense.

How absurd that the government should tell a business what it can and cannot sell, forcing consumers to purchase what the government commands. United, instead, is offering a discounted fare with fewer benefits that is better able to meet the needs and pocketbooks of many of its travelers.

This could be a stand-alone piece of legislation. Perhaps along with a law requiring Congress and their staffs to purchase Obamacare plans. A simple way to ameliorate one of the more bothersome aspects of Obamacare. Not the repeal and replace we were promised, but at least some relief for Americans struggling to afford ever more costly Obamacare insurance.

How Can I Tell If Medical News Is Fake or Not?

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Is coffee good for you?

A recent headline suggested that people who drink coffee live longer. Sounds great to me. I drink a lot of coffee, so maybe I will be immortal. But, wait, another report links coffee to cancer. Dang.

Estrogens were once touted as a life saving elixir for women of elegant ages, until these hormone supplements were linked to increased cancer risk. Wine will either add to your life expectancy or increase chances of breast cancer. If you are married and have cancer, your outcome is better; you live longer (and can drink more wine). Eggs either kill you (dropping the value of egg futures) or do not hurt you at all, (prompting a financial rebound in chicken-by-product).

Each study and report alluded to above is erroneous.

Indeed, these claims are what I call “fake” medical news. My definition: if a medical report is either wrong or not provable, it is fake.

A Mystery Mission in LA: Aetna, Apple, and a Vision of Digital Health’s Future, Part 1

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It was an invitation too intriguing to refuse: fly to LA to participate in a “top-secret mission” related to digital health. Instructions? Bring workout clothes. Don’t disclose your location. “We can’t say much. Just enough for you to quickly pack your bags, fly to California and participate in an exclusive Apple Watch from Aetna event – all expenses paid.” Generally, I’d file this type of message in the junk mail folder, but knowing that Apple takes secrecy seriously, I did some background sleuthing and decided it looked legit.

The mystery unfolded last week as I stepped into a black car at LAX with a secretive driver who joked that I and his other two passengers (who had received similar invites) would have to cover our faces as we drove through town. (Yikes!) When we arrived at a hip “concept” hotel I felt more at ease, and relaxed into enjoying the so-called mission with a glass of wine and some discussion of trends in the digital health industry. Over the course of a couple of days I was fortunate to join a group of new (and some old) friends to exchange ideas, take a challenging hike to the peak of Runyon Canyon Park, interact with Apple and Aetna execs, try out some new technologies, and get a glimpse of what both Aetna and Apple are envisioning for the future of digital health. I was assigned to one of several teams named after famous movies (in keeping with the Tinseltown theme) a personalized agenda, and some critical tools for the modern adventurer, including a bandana, water bottles, a phone charger, and, naturally, a selfie stick.

For about a year Aetna has used the Apple watch as part of an integrated wellness program available to its 50 thousand employees and those of several partner organizations it insures, such as Hartford HealthCare, which was represented among the participants in the mystery mission. Both companies are poised to expand the program.

The Best Part Of The Health 2.0 Fall Conference Agenda

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There’s still time to secure your ticket before prices increase to this year’s Health 2.0 11th Annual Fall Conference. Whether you’re a Health Provider, Entrepreneur or Investor; the Fall Conference is the place to see the latest health technology, to hear from some of the influential innovators impacting the landscape, and to network with hundreds of health care decision makers. Click here for the full agenda.

Health Providers Agenda Highlights 
Entrepreneurs Agenda Highlights 
  • MarketConnect: A live matchmaking event designed to accelerate the health tech buying and selling process by curating meetings between pre-qualified healthcare executives and innovators.
  • Exhibit Hall: Gain access to 90+ exhibitors, including Startup Alley, is the premier gathering of innovative companies and individuals. The exhibit floor is also home to MarketConnect Live.
  • Developer Day: Expect your day to be filled with strong technical sessions in relation to interoperability and user testing as well as opportunities to network from others in the industry.
  • 2 CEOs and a President Session: Three top health tech executives sit down for separate intimate interviews with a journalist. They will be dishing on both their personal and company journeys.
Investors Agenda Highlights 
  • Investor Breakfast: Bringing together leaders in the Health 2.0 investment community and our innovative startup network for an exclusive breakfast meeting.
  • Investing in Health 2.0 Technologies: Panel experts will address what’s in store for the rest of the year and predict the next big bets in Silicon Valley and beyond.
  • Launch!: Ten brand new companies unveil their products for the very first time and the audience votes on the winner!
  • Traction!: Annual startup pitch competition that recruits companies ready for Series A in the $2-12M range. Teams will compete in two tracks, consumer-facing, and professional facing technologies.

Click here to register for the Annual Fall Conference! Prices increase after September 4th!

A New Pothole on the Health Interoperability Superhighway

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On July 24, the new administration kicked off their version of interoperability work with a public meeting of the incumbent trust brokers. They invited the usual suspects Carequality, CARIN Alliance, CommonWell, Digital Bridge, DirectTrust, eHealth Exchange, NATE, and SHIEC with the goal of driving for an understanding of how these groups will work with each other to solve information blocking and longitudinal health records as mandated by the 21st Century Cures Act.

Of the 8 would-be trust brokers, some go back to 2008 but only one is contemporary to the 21stCC act: The CARIN Alliance. The growing list of trust brokers over our decade of digital health tracks with the growing frustration of physicians, patients, and Congress over information blocking, but is there causation beyond just correlation?

A recent talk by ONC’s Don Rucker reports:

One way to get data to move is open APIs, which the 21st Century Cures Act mandates by tasking EHR vendors to open up patient data “without special effort, through the use of application programming interfaces.”