Month: October 2012

The Organic Medical Home

Oct 23, 2012• 20

By Rob Lamberts, MD

What comes to mind when you hear the term “medical home?” Perhaps you favor the definition put forth by our government (AHRQ):

The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

1. Comprehensive care
2. Patient-centered
3. Coordinated care
4. Accessible services
5. Quality and Safety.

The presence of these five attributes to care should then constitute a medical home, right? It depends on who you get your definition from.

The Wages of Home Care

Oct 23, 2012• 7

By David Glenn

Nearly two million Americans work as home health aides and personal care aides — a number that is projected to climb above three million by 2020.

This is low-paid, low-status, exhausting work. A typical shift might include helping a client bathe, preparing her meals, changing her linens, helping her walk safely to the store, sweeping her floors, and helping administer medications (even though in many cases these aides aren’t licensed to do so). There is also a complex burden of emotional labor: comforting, cajoling, making small talk.

Most home aides are hired and paid by third-party agencies, which are often hugely profitable, in part because domestic workers have lacked minimum-wage and overtime protections under the so-called “companionship exemption” to the Fair Labor Standards Act.

After years of organizing by the National Domestic Workers Alliance, the Paraprofessional Healthcare Institute, and other groups, the Obama administration issued a preliminary regulation late last year that might finally bring an end to that exemption.

Stop Cancer Research?

Oct 22, 2012• 21

By James Salwitz, MD

Now here is a novel idea to save lives and stop the cancer plague; stop trying! Sounds as crazy to me, as it does to you, but this idea actually may have merit. Some smart people are saying that we have spent too much money for little gain, thus it is time to give up and by retreating win more battles in the war on cancer, than by charging ahead.

The Cancer Prevention and Research Institute of Texas (CPRIT) is the second largest cancer research agency in the United States, after the National Cancer Institute, controlling a pot of $3 billion dollars, most of which funds basic science and clinical research. At recent hearings, university scientists and leaders in biotech proposed that CPRIT cut back on the money it is pouring into laboratories. As Professor John Hagan of the University of Texas proclaimed, “If people didn’t get cancer in the first place, CPRIT would accomplish much of its mission.”

This radical idea was echoed in a scary article in the September issue of Lancet Oncology, entitled “First do no harm: counting the cost of chasing drug efficacy.” This editorial reviewed data, which shows that between 2000 and 2010 many new cancer drugs produced marginal extensions in survival and simultaneously increased risk of treatment associated death and side effects. The Lancet authors emphasized the vital need as we develop new therapies to carefully measure both benefit and harm before FDA approval and for careful post-marketing follow up after drugs are released to the general population.

Now in reality no one is saying that we should shut down cancer research labs and simply hope for the best. Eventually we will completely cure this disease and basic science, as well as the development of new therapies, is key to that future. Perhaps what we should hear from these words is an idea about a different balance in health and healthcare.

Dr. Yes

Oct 19, 2012• 10

By David Dranove

Last week I attended a conference on health policy at the University of Chicago, where I moderated a panel that examined implementation of the Affordable Care Act. For much of our time, the panel focused on Accountable Care Organizations. Panelists and attendees wondered whether ACOs would meet the same fate as Integrated Delivery Systems of the 1990s. Some in the audience mentioned that when it comes to integration, electronic medical records could be a game changer. EMRs could be used to monitor and reward cost saving decision making, for example. But most ACOs are still figuring out how to use EMRs for clinical decision making; their use in helping managerial decision making remains far off.

As more and more speakers expressed skepticism about the future of ACOs, a physician in the audience offered a truly fresh perspective, one that makes me feel much more optimistic. I never learned this physician’s name, so I will call him Dr. Yes. Before I summarize Dr. Yes’ argument, it is helpful to turn back the clock to the late 1990s, when IDSs were taking the health industry by storm. Perhaps the defining feature of IDSs in the 1990s was the integration of hospitals and primary care physician practices. This strategy failed in large part due to classic agency problems. In a nutshell, an agency relationship can fail because of incentive problems (the principal is unable to effectively motivate the agent) or selection problems (the principal employs the wrong type of agent.) IDSs suffered both. When hospitals acquired physician practices, they converted entrepreneurs into employees who resisted any kind of incentive payments. As employees, primary care physicians did not work as hard or show as much commitment to their practices. Moreover, those physicians most eager to give up their autonomy were those looking to dial down their practices and lead the “quiet life.” In these ways, IDSs experienced both incentive and selection problems, with devastating results.

The Day After

Oct 18, 2012• 6

By Rob Lamberts, MD

There is nothing exciting or glamorous about doing what I am doing: building a new practice from scratch. It’s a slow and often mundane process that takes far longer than it looks like it should. There are a thousand questions I need to answer: Where will my office be? What will my logo look like? Does it matter what my logo looks like? Can I get the video of my presentation done? Why is it taking so long? Which EMR system will I use? Will I use and EMR at all, or will a PHR product suffice? Who will I hire? What will I pay them? When will I start? How many patients will I accept at the start? What will I do about my website? Who should design it? Can I do that myself? Who should run it? What about a phone system? Each day uncovers a new set of questions that need answering, and each day passes with most of them left unanswered.

There are two things I’ve been doing which have kept me from becoming discouraged or overwhelmed by this process. The first thing is something called Centering Prayer, which is well-described in the book Into the Silent Land by Martin Laird. Whether from the tradition of the middle ages or from eastern religious practice, meditation is upheld by many in science as a sound life-practice. What makes centering prayer, a form of meditation out of the Christian Tradition, different from other forms is the way one deals with distractions or worries. I’m not an expert on eastern meditation, but my understanding is that the goal is to clear the mind from any thoughts and worries, coming to a place of peace and rest in the mind. Centering prayer, however, does not push away worries or distraction, it changes the perspective on it.

Walmart Moves Health Care Forward Again

Oct 18, 2012• 64

By Brian Klepper

Walmart’s sheer size makes almost any of their initiatives newsworthy. That said, despite being a lightning rod for criticism on employee benefits and health care, they have introduced initiatives with far-reaching impacts. Their generic drug program began in September 2006 – more than 300 prescription drugs for $4/month or $10 for a 90-day supply – and was widely emulated, disrupting retail drug markets and generating immense social benefit. Imagine the difference it made to a lower middle class diabetic who had been paying more than $120 per month for medications, and suddenly could get them for about $24.

Yesterday Walmart announced that “enrolled associates” – covered workers and their family members – needing heart, spine or transplant surgeries could receive care with no out-of-pocket cost at 6 prominent health systems around the country: Mayo Clinics (Rochester, MN and Jacksonville, FL); Cleveland Clinic (Cleveland, OH); Geisinger Clinic (Danville, PA); Mercy Hospital Springfield (Springfield, MO); Scott & White Memorial Hospital (Temple, TX); and Virginia Mason Medical Center (Seattle, WA).

Walmart’s Center of Excellence (COE) program builds on its own and other organizations’ pioneering efforts with similar programs. Walmart developed a relationship with Mayo Clinics in 2007 for transplant and lung volume reduction surgeries. In March 2010, Lowes reached a similar arrangement with Cleveland Clinic for heart surgeries and, last December, Pepsico announced a global pricing deal with Johns Hopkins for cardiac and joint replacement surgeries.

The Stockholm Syndrome and EMRs

Oct 18, 2012• 9

By Paul Levy

First the definition:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Now, the health care connection. As a result of the billions of dollars allocated by Congress to health information systems as part of the stimulus program, those companies who had a head start in implementing electronic medical records quickly found themselves in demand. Of all those companies, Epic is the most successful. Forbes notes, “By next year 40% of the U.S. population–127 million patients–will have their medical information stored in an Epic digital record.” Here in Massachusetts, the biggest convert was Partners Healthcare System: “System development and implementation will occur over a 10-year period and represent a capital investment of approximately $600 – 700 million.” Elsewhere, notes Forbes: “The biggest win: a $4 billion project to digitize medical records for health care giant Kaiser Permanente.”

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems. The company also “owns” its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced. And yet, large hospitals sign up for the system, rationalizing that it is the best. For example, Partners said, “The new health care landscape will challenge us to engage in population health management, improve the coordination of health care, and accept financial risk for the care of our patients. This new system will enable us to meet those challenges.”

Alvin Roth Receives Economics Nobel For Flawed Residency Match System

Oct 18, 2012• 3

By David Whelan

There’s a larger question here about why the scholarly world allows itself to be judged by secretive Scandinavian committees sitting on endowments funded by money made selling explosives. But let’s put anti-Nobel polemics aside.

The announcement today that Alvin Roth and Lloyd Shapley won this year’s award in economics came with the explanation that they had devised systems for matching buyers and sellers that led to more rational outcomes than existing markets.

Shapley, a contemporary of “A Beautiful Mind’s” John Nash, introduced an elegant theory 50 years ago to explain the (relative) stability of marriage pairings despite the fact that individuals have complicated preferences when choosing a mate. Shapley’s idea is that the person you end up with is the best match given everyone else’s preferences.

You might prefer someone else more than your current mate, but that person has you lower on her list, and so on. Imagine Larry. If he could Larry would have definitely married Elizabeth Taylor. But she was taken so now Larry is happy with his actual wife. (To sum it up in a way that would make an economist cringe.)

Alvin Roth built on that early theory. He designed actual markets that used the matching principle, also known as the deferred acceptance algorithm, as a guiding principle. The most famous example of a Roth market is the Residency Match.

Medical residency is a job that lasts three to seven years, depending on the program, and follows graduation from medical school. It is required for a doctor to complete a residency in order to be licensed to practice.

In the “old days” medical students would apply to hospitals and rank their preferences in a way that was visible to those institutions. A hospital would first review those applicants who had indicated them as the first choice. If spots remained to fill, a hospital would then look at those who had picked it second, and so on. You can quickly see how this system punished people who shot high and missed. They would end up at one of their last choices because the best places would fill up quickly.

Health 2.0 Berlin Code-a-Thon Sponsored by Aetna International

Oct 17, 2012

By Health 2.0 Staff

Health care stakeholders join forces with developers to build new apps for health and wellness

On 3-4 November 2012 web and mobile developers meet health professionals, patients and other health care stakeholders at the Health 2.0 Berlin Code-A-Thon 2012 to create innovative solutions and build brand new prototype applications for improved health and wellness in only two days.

Berlin, October 18, 2012 – What if a smartphone app could check for signs of sleep apnea and help patients and their families sleep more soundly? Or what about an app that lets Parkinsons patients take standard motor skill tests at home instead of in the doctors office? Sound too good to be true? And how long do you think it would take to develop a working prototype? The answer is as few as 48 hours.

These are just some of the many excellent prototypes that have been developed by Health 2.0 Code-A-Thon teams in the past. Find out on 3-4 November 2012 what brilliant health care solutions will be created at the Health 2.0 Berlin Code-A-Thon. For this two-day event, sponsored exclusively by Aetna International, gifted coders and health professionals will come together in Berlin to compete to develop the most innovative solution to improve health and wellness. The event is part of the Health 2.0 Code-a-Thon series, which includes a range of developer-focused events happening in the United States, Europe and Asia.