Year: 2014

Will the Real Professor Katherine Baicker Please Stand Up?

Dec 31, 2014• 16

By AL LEWIS and VIK KHANNA

Harvard Professor Katherine Baicker is arguably most acclaimed health policy researcher at arguably the most acclaimed (and not even arguably, the best-endowed) school of public health in the country. Her seminal account of the effect of Medicaid coverage on utilization and health status is a classic. As luck would have it, in 2008 Oregon used a lottery to ration available Medicaid slots. A lottery controls for motivation and as such eliminates participant-non-participant bias, since everyone who enters the lottery wants to participate. That meant only one major variable was in play, which was enrollment in Medicaid or not.

Chance favors the well-prepared, and Professor Baicker jumped on this research windfall. She found that providing Medicaid–and thereby facilitating access to basic preventive medical care–for the previously uninsured did not improve physical health status, but did increase diagnoses and utilization. Because of the soundness of the methodology, the conclusion were unassailable – more access to medical care does not improve outcomes or optimize utilization, which is a proxy for spending. (We ourselves reached a similar conclusion based on a similar analysis on North Carolina Medicaid’s medical home model.)

Yet Professor Baicker herself used exactly the opposite methodology to reach the exact opposite conclusion for workplace wellness. And that’s where the identity crisis begins.

She and two colleagues published a meta-analysis in 2010 of participant-vs-non-participant workplace wellness programs. Somehow—despite her affinity for Oregon’s lottery control—she found this opposite methodology to be acceptable. She concluded that workplace wellness generated a very specific two significant-digit 3.27-to-1 ROI from health care claims reduction alone, with another 2.37-to-1 from absenteeism reduction. The title of the article–now celebrating its fifth anniversary as the only work by a well-credentialed author in a prestigious journal ever published in support of wellness ROI—was equally unambiguous: Workplace Wellness Can Generate Savings.

Matthew’s end of 2014 charity & issues letter

Dec 31, 2014• 2

By MATTHEW HOLT

I’ve been posting my personal end of year email on THCB for a few years now–here’s 2014’s edition–Matthew Holt

Dec 31 2014: Last year I claimed laziness and failed to write or send out my End of Year Issues email for the first time since I started in 2000. Perhaps it was the stress of being 50, or the fact that despite having 15,000 of my closest friends follow me on Twitter I cant seem to reach people on email, or people miss my Facebook posts. But this year I’ve been guilted back into it by altogether too many people asking me where it was?!

If you don’t know, this is a letter I write mostly to myself about what happened in the year and what I should do about it–mostly in terms of making donations while it’s still 2014. Obviously a few of you like reading it and hopefully one or two of them that does will put their hand into their pocket (or click on the link and use their Paypal account or whatever the electronic equivalent is). And if you don’t like it, well feel free to hit delete, or go onto the next picture of a cat being cute…and I love comments on the blogs/Facebook/Twitter or by email.

Rethinking The Gruber Controversy: Americans Aren’t Stupid, But They’re Often Ignorant — And Why

Dec 30, 2014• 31

By UWE REINHARDT

M.I.T. economist Jonathan Gruber, whom his colleagues in the profession hold in very high esteem for his prowess in economic analysis, recently appeared before the House Committee on Oversight and Government Reform. Gruber was called to explain several caustic remarks he had offered on tortured language and provisions in the Affordable Care Act (the ACA) that allegedly were designed to fool American voters into accepting the ACA.

Many of these linguistic contortions, however, were designed not so much to fool voters, but to force the Congressional Budget Office into scoring taxes as something else. But Gruber did call the American public “stupid” enough to be misled by such linguistic tricks and by other measures in the ACA — for example, taxing health insurers knowing full well that insurers would pass the tax on to the insured.

During the hearing, Gruber apologized profusely and on multiple occasions for his remarks. Although at least some economists apparently see no warrant for such an apology, I believe it was appropriate, as in hindsight Gruber does as well. “Stupid” is entirely the wrong word in this context; Gruber should have said “ignorant” instead.Continue reading…

2014 A Healthcare Odyssey

Dec 30, 2014• 13

By SAURABH JHA, MD

It might have been the best of times. It could have been the worst of times. But 2014 turned out to be the most mediocre of times. Here’s a recap.

Why did Sebelius resign?

Never make a promise to your kids that you can’t keep. And never project the number of people who will sign up for the exchanges and change your mind, unless you are the CBO. If you have read about the problem of uninsured in the US you might have considered CBO’s original projection that seven million people will sign up on the exchanges within six months of open enrollment a tad conservative. Weren’t there millions and millions, forty million apparently, gagging for healthcare coverage?

The CBO revised the projection to six million in February with the projection date of March 31^st coming tantalizingly close. Towards the end of March you could hear the cheers of “roll baby, enroll” getting louder.

On April Fools’ Day, the ACA remained intact, the country had not descended in to civil war and some eight million had signed up for Obamacare.

Sit. Stand. Stay. Good worker.

Dec 30, 2014• 5

By VIK KHANNA

Example A: The Fitbro

Businesswoman Nilofer Merchant wrote an essay for the Harvard Business Review Blog, which has gone on to become one of the most read posts on the HBR site this year, in which she parrots the convention that sitting too much is killing us, going so far as to equate sitting with smoking. Runner’s World has inexplicably also trod this path, which will not lead us to the land of data, logic, or even common sense.

Capricious furniture vendors, imitating their wellness brethren, have grabbed the theme even though it is demonstrably untrue. Take, for example, Varidesk, which uses this YouTube video to sells its signature product, a desk that adjusts vertically. The theoretical claim, supported by nary a data point, is that workers should stand rather than sit.

On their website, the Varidesk folks also make this claim: “The VARIDESK was developed to address the negative side-effects of being seated for the majority of the working day.”Continue reading…

Has Med School Changed For the Better?

Dec 30, 2014• 9

By KARAN CHHABRA

Every third-year has heard it.

“…When I was in your position, I was taking 24-hour calls every other night. If my resident was there, I was there….”

We’re regaled about the glory days, without shelf exams, without phlebotomists, and—by god—without those work-hour restrictions. The days when medical students wouldn’t dare ask their residents for help, or residents their chiefs, or chiefs their attendings, and so on. I hear a bit of romance: the heroism of providing total patient care, exactly when the patient needed it, unfettered by handoffs or outside interference. I envy the skill required to practice medicine almost-literally in one’s sleep.

As the veteran doc continues his (yes, usually his) soliloquy, he may admit that it wasn’t the safest model for patients, or the most humane for trainees. He may today be a better doctor for it, but he’s a bit ambivalent about whether it should remain exactly the same today. Presumably he wasn’t alone, because since the good ol’ days, the third year of medical school has morphed into something barely recognizable.

HIT Newser: Massachusetts Modifies Meaningful Use Mandate

Dec 30, 2014• 1

By MICHELLE RONAN NOTEBOOM

New Life for ACOs

CMS announces that 89 new organizations were selected to participate in the Medicare Shared Savings program, bringing the total number of participating ACOs to 424. The announcement comes on the heels of a recently released proposed rule that reflects an increased focus on primary care and improved incentives for participation. Were the pundits who predicted an early death for ACOs wrong?

Massachusetts Modifies Meaningful Use Mandate

The Massachusetts Board of Registration modifies a provision requiring providers to attest to Meaningful Use in order to retain their medical licenses. The final regulations establish multiple ways in which physicians can demonstrate proficiency using EHRs, including taking a three-hour continuing education class on EHR or registering with the state’s HIE.

Do We Need Patient Relationship Management (PRM) Systems?

Dec 29, 2014• 5

By JORDAN SHLAIN MD

As a primary care doctor in San Francisco and Silicon Valley, I have been searching for the holy grail of patient engagement for over 15 years. My journey began with alpha-numeric pager and a medical degree. I shared my pager number with my patients along with a pledge to call them back within 15-minutes, 24-hours a day. My communications evolved into email and texting, with the predicate that by enhancing communication, I could carefully guide my patients down the byzantine corridors of healthcare – with a high probability we could avoid mistakes – if they would agree to share the ownership of their treatment plan. My life’s work has been where the rubber meets the road; where doctors interface with patients: office, hospital, home or smartphone.

Technology has washed over almost every industry and transformed it, radically. Healthcare is on the precipice of destiny. The wave is here.

Over the past three decades healthcare has lurched from one existential crisis to another; often manifested by an acronym solution: HMO, ACO, PCMH, P4P, PQRS; each a valiant attempt to reign in costs and solve for aligning incentives. However, we can’t have hospitals, doctors, health systems and payers accountable to healthy outcomes if the 300,000,000 people (patients) are not paramount to the equation.

If you haven’t been paying close attention, ‘patient engagement’ is a white-hot topic in healthcare these days. It wasn’t sexy 5 years ago. In fact, at the keynote speech at HIMSS 13 (the national Health IT conference), it was announced that the “The blockbuster drug of the 21st century is Patient Engagement”.

Stories You Won’t Read In 2015

Dec 29, 2014• 3

By PAUL KECKLEY

The headlines and their storylines that you’re not likely to read in 2015:

Physicians optimistic about their future. They’re wildly enthusiastic about the mandate to use electronic medical records to coordinate patient care more effectively, and see the shift away from volume to value as positive trend for the industry. Increased penalties about unnecessary care and report cards about their clinical performance are welcomed as physicians embrace transparency. NOT!

Facts: Trust in physicians remains high but has slipped in recent years. Their compensation remains high relative to overall population at 5.8:1, but physician discontent is palpable. And the visibility given their business dealings vis a vis the Physician Sunshine Act and Medicare Physician database is unwelcome and discomforting.

The Affordable Care Act repealed. Overcoming a President veto, the Senate and House approved repeal. The newly insured in Medicaid and health exchanges will be easily absorbed into the current insurance system so the ranks of the uninsured will not swell. NOT!Continue reading…

Zen and the Art of Antibiotics

Dec 29, 2014• 2

By HANS DUVEFELT, MD

Jacques Johndreau did not look like his usual self when I saw him in the office a few weeks ago. He looked part retired bank manager and part Disney cartoon chipmunk.

He spoke with hardly any facial movements:

“Holy Boys, my wife said to me this morning, you look like you’ve got the mumps again!”

I was aware that Jacques had an atrophic testicle from catching the mumps as a teenager. This time, it was not likely the mumps, but a bacterial parotitis. He was afebrile, and could open his mouth when asked to. I could not palpate a stone in Stensen’s duct and he didn’t experience any worsening of pain when eating acidic foods, so I wasn’t so sure he had a stone.

This was an early, mild case of parotitis and I thought he had a good chance of beating the infection with oral antibiotics. The majority of these infections are caused by staphylococci, but sometimes gram-negative bacteria are the culprit. Whatever I chose, I needed to consider that Jacques takes a blood thinner, warfarin, which interacts with many antibiotics, particularly ones with gram negative coverage.

I e-prescribed a high dose of Ceftin, or cefuroxime, a second generation cephalosporin with good coverage for both staph and gram-negatives and no effect on warfarin.