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A Patient in the Lobby Refuses to Leave: Medical Emergency, Unhappy Customer or Active Shooter?

By HANS DUVEFELT, MD

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the last few minutes.

I hurried down the hall and unlocked the door to the lobby. I had already noticed the man and the woman standing at the glassed-in reception desk.

“I’m Dr. Duvefelt, can I help you?” I began, one hand on the still partway open door behind me.

The husband did the talking.

“My wife just saw Dr. Kim for chest pain and he thought it was nothing. He didn’t have any of her old records, so how could he know?”

While I quickly considered my response, knowing that Dr. Kim is a very thorough and conscientious physician, the man continued:

“Can we get out of here, and step inside for some privacy?”

My mind raced. This was either a medical emergency or an unhappy customer situation. We had the door locks installed not long ago on the advice of the police and many other sources of guidance for clinics like ours. It was a decision made by our Board of Directors. In this age of school, workplace and church shootings, everyone is preparing for such scenarios. We are always reminded not to bring people inside the “secure” areas of our clinics who don’t have an appointment or a true medical emergency.

I figured I had to find out more about this woman’s chest pain in order to make my decision whether to let her inside again; after all, she had just been evaluated.

“Ma’am, are you having chest pain right now?” I asked.

“A little”, she answered.

“How long have you had it?” I probed.

“A couple of years now.”

“And you just saw Dr. Kim?”

“Yes, and he said my EKG looked okay, but he didn’t bother to ask me about you heart valve operation three years ago in, Boston. He just said ’we’ll get those records’, and he told me I was okay today.”

The husband broke in, “It’s the same everywhere we go, everybody just says it’s not a heart attack, but we need more answers than that. we know what it isn’t, but we need to know what it is!” He added, again, “can’t we go inside for some privacy?”

“Have you been seen elsewhere for the same thing?” I said without answering the request.

“Yes, at the emergency room in Concord, New Hampshire when we lived there…”

“Did Dr. Kim have you sign a records release form so we can get the records from Boston and New Hampshire?” I asked.

“Yes”, the woman answered.

“Then that’s all we can do today,” I said. “I hear you telling me this is an ongoing problem, you’ve already been assessed today and Dr. Kim told you that you’re safe today and we’ve requested your old records. That’s what needs to happen.”

“You mean you’re not going to help us today?”

“You’ve seen Dr.Kim, your records will get here, I don’t know what more we can do for you today.”

“You’ll hear about this”, the husband said as they stormed out. Another man in the lobby introduced himself to them and said “I’ll be your witness.”

I closed the self-locking door and wished I had somehow been more skilled and more diplomatic, and I wished the world wasn’t the way it has become in just a few years, with more concern for bolted doors, gun violence and mass shootings than simple customer relations.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

Announcing the GuideWell Matchmaking Summit

SPONSORED POST

By CATALYST @ HEALTH 2.0

GuideWell Innovation, in collaboration with Catalyst @ Health 2.0, is thrilled to announce the opening of applications for the GuideWell Matchmaking Summit – a new corporate/investor matchmaking event hosted at the GuideWell Innovation Center in Orlando, FL on August 29-30, 2019.

This exciting opportunity connects established healthcare organizations and investors with growing health technology companies. Through professionally curated meetings, the event is designed to encourage synergistic relationships while promoting the testing, commercialization, financing and adoption of innovative digital health tools. Meetings are arranged based on participating organizations’ needs and areas of expertise, allowing for the cultivation of diverse partnership opportunities between digital health innovators, healthcare corporations, and investors that support the growing digital health ecosystem.

The GuideWell Matchmaking Summit is a 2-day event that will be held at the GuideWell Innovation Center in Orlando, FL. The first day of the Summit will be a corporate matchmaking opportunity for invited scale up health technology companies to meet with healthcare organizations that are qualified customer prospects. participants will have a series of meetings that are arranged based on “matched” areas of focus. Innovators will have the opportunity to demo their technology, detail their value proposition, and discuss business avenues with potential partners. Concurrently, healthcare leaders can identify up-and-coming digital health products to utilize at their organizations.

The second day of the Summit will be an investor showcase/matchmaking event for invited health technology scale ups to connect with a national network of venture capitalists. Scale up health technology companies will be competitively selected to attend the Summit based on customer/investor fit with attending corporations and investors.

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Price-Fixing Case Reveals Vulnerability of Generic Drug Policies

By ANDREW MULCAHY

A massive lawsuit filed in May by 44 states accuses 20 major drug makers of colluding for years to inflate prices on more than 100 generic drugs, including those to treat H.I.V., cancer and depression. If true, the alleged behavior is not just a violation of antitrust law, but also a betrayal of the government policies that created and defended the entire generic drug industry. 

Most prescriptions in the U.S. today — 9 in 10 — are filled with generics, which are just as safe and effective as their brand-name equivalent. And yet generics account for only 22 percent of U.S. prescription drug spending. These prices are so low because of competition between makers of different versions of the same generic drug. The more competing generic alternatives, the lower the price, theoretically right down to the marginal cost of manufacturing the pill. 

This success is the result of decades of careful federal and state policymaking, all geared towards introducing competition in prescription drug markets. The entire generic industry has its origins in the Hatch-Waxman Act of 1984. Prior to Hatch-Waxman, a company that wanted to sell a competing version of a drug whose patents had expired had to conduct lengthy and expensive clinical trials to get approval from the U.S. Food and Drug Administration. Hatch-Waxman established a quicker, less-expensive path to FDA approval that leans on the scientific research supporting the already approved brand-name drugs.  

Hatch-Waxman also created incentives for generic drug makers to challenge drug patents that prevent competition. Successful challengers win a 180-day period of exclusivity during which their generic is the only one allowed to compete with the brand-name drug. The floodgates open and additional competition pushes prices down further after the 180-day period.  

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Landmark Results Achieved in Aging and Chronic Disease: Danish Group Extends Disease-free Life by 8 Years

By WILLIAM H. BESTERMANN JR., MD

New Scientific Breakthroughs Can Provide a Longer Healthier Life

Twenty-one years of follow-up comparing usual care with a protocol-driven team-based intervention in diabetes proved that healthy life in humans can be prolonged by 8 years. These results were achieved at a lower per patient per year cost. Aging researchers have been confident that we will soon be able to prolong healthy life. This landmark study shows this ambitious goal can be achieved now with lifestyle intervention and a few highly effective proven medications. These medications interfere with the core molecular biology that causes chronic disease and aging. These same medications will likely produce similar results in patients with congestive heart failure, chronic kidney disease, arterial disease, history of heart attack, hypertension, and angina. Simple medical interventions can extend healthy lifespan today.

Better Chronic Disease Management Can Improve Health and Lower Costs

90% of health care costs come from chronic diseases and aging which are both related. The same biochemistry that causes aging causes chronic disease. Eating processed food, gaining weight, smoking cigarettes, and sitting on the couch accelerate aging and chronic condition development. Those activities switch on genes that should be quiet. Eating real food, avoiding cigarettes, activity, lisinopril, losartan, atorvastatin, metformin, (and spironolactone) are now proven to extend healthy life by 8 years in patients who are at high risk of health catastrophes and early death! These medications all cost $4 a month except for atorvastatin which is $9 a month. The benefits continue even when best practice treatment stops probably because these treatments block signaling from dangerous genes that are inappropriately and persistently turned on.

Progress Will Require Extensive Health System Reengineering

Having better health and reducing health care costs can happen today. Surprisingly, the biggest barrier to progress is our current health care system. It is arranged around catastrophes, organ systems, and hospitals. These concepts are 100 years old. Chronic disease begins decades before the catastrophe, and it is related to aging. Age is the greatest risk factor for a heart attack. The same biochemistry that causes accelerated aging also causes heart attack and strokes. It makes little sense to see a cardiologist for a heart attack and a neurologist for a stroke. They are caused by the same molecular biology. The leading health care systems are beginning to recognize that. The interventions that slow aging and chronic diseases development impact every cell in the body. Every young person who is overweight or smokes has activated genes that make accelerated aging and chronic disease more likely. If these genes are switched on prior to having children, that risk is passed on to the next two generations.

Primary care teams organized to address chronic conditions and more rapid aging will provide lifestyle advice and medication that interfere directly with the biology that is causing the problem. The further upstream these individuals are when identified, the easier it is to slow aging and delay chronic disease onset. The path to better health at lower cost lies in the outpatient setting with primary care teams that are well-versed in molecular biology.

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India’s Mob Problem

By SAURABH JHA, MD

Recently, my niece gingerly confided that she was going to study engineering rather than medicine. I was certain she’d become a doctor – so deep was her love for biology and her deference to our family tradition. But she calculated, as would anyone with common sense, that with an engineering degree and an MBA, she’d be working for a multinational company making a comfortable income by twenty-eight. If she stuck with tradition and altruism, as a doctor she’d still be untrained and preparing for examinations at twenty-eight.

Despite the truism in India that doctors are the only professionals never at risk of starving, the rational case for becoming a physician never was strong. Doctors always needed a dose of the irrational, an assumption of integrity and an unbridled goodwill to keep going. Once, doctors commanded both the mystery of science and the magic of metaphysics. As medicine became for-profit, the metaphysics slowly disappeared.

Indians are becoming more prosperous. They’re also less fatalistic and expect less from their gods and more from their doctors. In the beginning they treated their doctors as gods, now they see that doctors have feet of clay, too. Doctors, who once outsourced the limitations of medicine to the will of Gods, summarized by the famous Bollywood line “inko dawa ki nahin dua ki zaroorat hai” (patient needs prayers not drugs), now must internalize medicine’s limitations. And there are many – medicine is still an imperfect science, a stubborn art, often an optimistic breeze fighting forlornly against nature’s implacable gale.

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A National Patient Identifier: Should You Care?

By ADRIAN GROPPER, MD

The rather esoteric issue of a national patient identifier has come to light as a difference between two major heath care bills making their way through the House and the Senate.

The bills are linked to outrage over surprise medical bills but they have major implications over how the underlying health care costs will be controlled through competitive insurance and regulatory price-setting schemes. This Brookings comment to the Senate HELP Committee bill summarizes some of the issues.

Who Cares?

Those in favor of a national patient identifier are mostly hospitals and data brokers, along with their suppliers. More support is discussed here. The opposition is mostly on the basis of privacyand libertarian perspective. A more general opposition discussion of the Senate bill is here.

Although obscure, national patient identifier standards can help clarify the role of government in the debate over how to reduce the unusual health care costs and disparities in the U.S. system. What follows is a brief analysis of the complexities of patient identifiers and their role relative to health records and health policy.

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HardCore Health Podcast, Episode 2: Consumerism & Privacy

HardCore Health is back and on today’s show Jess & I start by addressing how hard it has become for the health care consumer to navigate the “in-and-out of network” system that exists in health care today, and later discuss how money is being poured into some of the strangest sounding startups ideas in the health tech industry. We have a special interview from the best health data privacy lawyer around, Deven McGraw, from Ciitizen, commenting on the new patient privacy legislation that was released and Jess also speaks to Fred Trotter about how he, Andrea Downing, and David Harlow wrote a letter to Facebook, addressing their concerns over the privacy of Facebook groups. Last, but certainly not least, we have a rant from Ian Morrison about price transparency. Enjoy! —Matthew Holt

Matthew Holt is the founder and publisher of The Health Care Blog and still writes regularly for the site.

Is “Medicare For All (Who Want it)” Enough?

By MIKE MAGEE

In the 2nd night of the Democratic Primary debate on June 27, 2019, Pete Buttigieg was asked whether he supported Medicare-For-All. He responded, “I support Medicare for all who want it.” 

In doing so, he side-stepped the controversial debate over shifts of power from states to the federal government, and trusted that logic would eventually prevail over a collusive Medical-Industrial Complex with an iron lock grip on a system that deals everyone imaginable in on the sickness profitability curve – except the patient.

On July 30, 1965, President Lyndon B. Johnson signed into law “Medicare,” a national insurance plan for all Americans over 65. He did so in front of former President Truman, who 20 years earlier had proposed a national health plan for all Americans, and for his trouble was labeled by the AMA as the future father of “socialized medicine.”

For Truman, there was a double irony that day in 1965. First of all, the signing was occurring at around the same time as our neighbor to the north was signing their own national health plan, also called “Medicare”, but their’s covered all Canadian citizens, not just the elderly.

The second incongruity was that Truman was fully aware that in 1945, as he was being tarred and feathered as unpatriotic by taxpayers for having the gall to suggest that health care was a human right, those very same citizens were unknowingly funding the creation of national health plans as democracy stabilizers in our two primary vanquished enemies – Germany and Japan – as part of the US taxpayer funded Marshall Plan.

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12 Rules for Health Tech Startups

By MATTHEW HOLT

Last week Mark Cuban tweeted out 12 rules for tech startups and Jessica DaMassa challenged a bunch of people to respond for health care. VC and general health care wit Lisa Suennen came out with quite the list (she got to 13) but I thought someone ought to write the real rules…

1. Never start a health tech company if you can sucker someone into giving you a real job

2. When VCs at conferences say raising money isn’t a problem, throw a milkshake at them

3. Never work with a technical co-founder who won’t give you the last M&M in the packet

4. When a clinician wants to quit their job and co-found with you, remember that the good ones could be making $500K a year reading X-rays and be on the golf course at 4pm

5. Do the 50/2 diet. Starve for 50 weeks of the year then eat and drink as much as you possibly can at HIMSS & JP Morgan parties when someone else is paying

6. When the incubator/accelerator/matchmaker says that they “chose you from 700 applicants” remember that there are roughly 700 of them and every company applies to each one

7. When you get the elusive partnership deal with the big hospital system, tech company or corporate, you’re going to expect to work at the speed of the startup and the scale of the corporate. It’ll be the reverse . (I stole this from Michael Ferguson at Ayogo)

8. After your first few clients and funding rounds you’ll be losing money at a exponential rate that matches what you had for revenue on the hockey stick chart in your pitch deck

9. Hopefully you’ll eventually be able to start making the money the health care way, by establishing a monopoly that can arbitrarily raise prices to the moon and stick it to your customers. If not, start prepping for the really big Oscar/Collective/Clover type round. 

10. Pray to whatever God you follow that Softbank is still in business when #9 happens.

11. If after a decade or so of slog, you finally get the IPO, or semi decent exit, try to ignore the fact that the Instagram guys sold for $1 billion 11 months after they founded the company

12. Hope that you can disrupt health care, but remember that UnitedHealth Group’s revenue is $220 billion and CMS spends $900 billion a year and they both appear mostly powerless to make anything better.

Matthew Holt is publisher of The Health Care Blog and advises startups at SMACK.health using these principles and a few others too!

Was the IOM estimate of medical errors correct?

By SAURABH JHA

In 1999, the Institute of Medicine (IOM) in their landmark report – To Err is Human – estimated that the number of deaths from medical errors is 44 ,000 to 98, 000. The report ushered the Quality and Safety Movement, which became a dominant force in all hospitals. Yet the number of deaths from medical errors climbed. It is now touted to be the 3rd leading cause of death. How easy is it to precisely quantify the number of deaths from medical errors? Not many physicians challenged the methodologies of the IOM report. Some feared that they’d be accused of “making excuses for doctors.” Many simply didn’t have a sufficient grip on statistics of measurement sciences. One exception was Rodney Hayward – who was then an early career researcher, a measurement scientist, who studied how sensitive the estimates of medical errors were to a range of assumptions.

Saurabh Jha (aka @RogueRad) speaks with Professor Hayward for the Firing Line Podcast about his research in JAMA published in 2001 – Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer. It was a landmark publication of the time, and its objective methods have stood the test of time.

Rod Hayward a Professor of Public Health and Internal Medicine at the University of Michigan and Co-Director of the Center for Practice Management and Outcomes Research at the Ann Arbor VA HSR&D. He received his training in health services research as a Robert Wood Johnson Clinical Scholar at UCLA and at the RAND Corporation, Santa Monica. His current and past work includes studies examining measurement of quality, costs and health status, environmental and educational factors affecting physician practice patterns, quality improvement, and physician decision making. His current work focuses on quality measurement and improvement for chronic diseases, such as diabetes, hypertension and heart disease.

Listen to their conversation on Radiology Firing Line Podcast here.

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