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Why Public Health Needs a New Gun Doctrine
I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.
You read that correctly. I am a public health professional.
And I like guns.
This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.
As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.
While that isn’t cause and effect, the association is certainly curious.
In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.
That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.
Can Self-Made Hospital Apps Reduce Healthcare Costs?
Today’s healthcare industry bears a startling resemblance to a Charles Dickens novel. It is the best of times, and the worst of times. In an age where advancements in technology have extended patient lifespans, many healthcare systems are struggling to pay their bills. Deloitte pegs healthcare spending at over $3.8 Trillion in 2014, and providers are desperately searching for any cost-cutting solutions. Many found a means to treat their own symptoms, with a prescription of mobile apps.
It seems to not make sense. How would hospitals save money by spending thousands to build an app? Today, almost 60% of the U.S. population owns smartphones. Patients, especially seniors, are adopting tablets at a rapid rate. Successful hospitals are leveraging branded mobile apps not only to engage their patients and boost HCHAPS scores, but to achieve cost reduction by launching efficient mobile apps.
Waiting For Payment Reform?
The Health Care Blog recently featured our Open Letter to Primary Care Physicians,generating quite a bit of reaction. A commenter made the point that “we cannot expect” primary care physicians “to act differently until and unless they get paid differently.” [Emphasis added]
The comment refers to a doctor in solo practice and notes that “the first step is changing how you are paid, in one way or another. And there are many ways that work better than the current code-driven fee-for-service model.”
Does waiting for payment reform make sense? Or should primary care practices act now to change the way they practice in anticipation of payment shifts?
Moving Toward Value-based Care
Some physicians groups seem somewhat frozen – unsure exactly where health care payment is headed and thus waiting until there is a clearer signal.
But it seems to us that the payment reform signal grows louder and clearer and support for that contention comes in a recent research report* from McKesson, the international consultancy:
We can now say with certainty that healthcare delivery is moving in one direction: towards value-based care.
This is care that is paid for based on results – on measurable quality – as opposed to the traditional fee-for-service approach that pays for volume. McKesson notes that
The affordability crisis is causing unprecedented changes in the healthcare landscape, the most significant of which is the transition from the current volume-based model [fee-for-service] to myriad models based on measures of value.
To remain relevant and competitive, payers, hospitals, health systems, and clinicians must respond now to integrate value-based models into their existing systems.
On the origins of Maintenance of Certification in the National Health Service: A Serial Killer
Britain’s most prolific serial killer was a General Practitioner (GP), Dr. Harold Shipman. He wasn’t England’s most famous murderer. That accolade goes to Jack the Ripper. The Ripper killed five women in the streets of Whitechapel. Shipman might have been responsible for over 200 deaths.
Shipman’s legacy to the medical profession was not just a permanent simmering of mistrust. He triggered the introduction of revalidation, Britain’s version of maintenance of certification (MOC).
During Shipman’s prosecution the media scrutiny on physicians was intense. It’s both a beauty of and curse on our profession that we’re assumed to have such high code of ethics yet not spared the foibles of human nature.
“Homo homini lupus” doesn’t spare physicians. Bashar al-Assad was an ophthalmologist. Ayman al-Zawahiri once had taken the Hippocratic Oath.
This means that outliers, inevitable products of a Gaussian distribution, also get past the gates of medical school.
The government set up an inquiry headed by Dame Janet Smith. How could Shipman have gotten away with murder for so long? What were the systemic failures?
The Shipman Inquiry is 5000 pages long, compiled after interviewing 2500 witnesses. It cost the tax payer nearly 21 million pounds. Its conclusion was stunningly bland even if of military precision: doctors need more policing. This is like concluding that the First World War happened because people aren’t always nice to one another; a truism so uniformly true that it ceases to inform policy.
The report called for the General Medical Council (GMC), the prime regulatory agency for physicians, to work for patients, not physicians.
The solution: Revalidation.
Patient IO Care Plan Platform Announces Integration with Apple HealthKit
Filament Labs announces the integration of its Patient IO care delivery platform with Apple’s newly announced HealthKit, enhancing the ability of health professionals to manage patient health behaviors between doctor visits. The integration will allow providers to automatically pull critical health data from a patient’s HealthKit-supported device and import the details directly into the patient’s care plan.
“We are excited to be one of the first companies to offer a patient engagement platform integrated with Apple’s HealthKit,” said Filament Labs CEO Jason Bornhorst. “Having a patient’s care plan automatically populated with current, accurate and complete data will help providers monitor patient adherence to treatment plans and in turn improve patient outcomes.”Continue reading…
Expecting the Unexpected
The question isn’t whether or not we will have another disaster – it is just a matter of when, where and how severe it will be. The recent earthquake in Northern California, centered near Napa, serves as a reminder that we must be prepared for the unexpected no matter where we live.
Northern California’s largest quake since 1989 happened in a large state where ONC has been working for the past year to ensure health data access every day and especially during disasters. In fact, in April of this year, we issued an assessment on available opportunities to address potential disasters in California and along the Gulf Coast.
Based on those assessments and our expectations of a catastrophic event in California, ONC started working with state emergency medical services officials last year to begin connecting the state’s 35 health information exchange organizations (HIEs) and EMS organizations. This effort was launched to help ensure health data access during emergencies.
The program is working on a pilot project involving several counties in California. However, the Northern California earthquake reminds us that there is much work to do, and it must happen faster statewide and nationwide. We simply cannot make assumptions about how best to prepare for emergencies. In recognition of the importance of this initiative, the HHS Idea Lab awarded a joint ONC/ASPR proposal for the inaugural HHS Ventures Program. The team has been actively engaged in this project as well as other ways technology can improve the routine delivery of care and disaster response – all in an effort to create more resilient communities.
Meet the Apple Watch
Surprise #1. It’s not called the iWatch, as many observers had predicted. Meet the Apple Watch.
Surprise #2. No camera.
Not really-a-surprise: The $350 price tag is now trending on Twitter.
Should Wearables Data Live In Your Electronic Medical Record?
The great promise of wearables for medicine includes the opportunity for health measurement to participate more naturally in the flow of our lives, and provide a richer and more nuanced assessment of phenotype than that offered by the traditional labs and blood pressure assessments now found in our medical record. Health, as we appreciate, exists outside the four walls of a clinical or hospital, and wearables (as now championed by Apple, Google, and others) would seem to offer an obvious vehicle to mediate our increasingly expansive perspective.
The big data vision here, of course, would be to develop an integrated database that includes genomic data, traditional EMR/clinical data, and wearable data, with the idea that these should provide the basis for more precise understanding of patients and disease, and provide more granular insight into effective interventions. This has been one of the ambitions of the MIT/MGH CATCH program, among others (disclosure: I’m a co-founder).
One of the challenges, however, is trying to understand the quality and value of the wearable data now captured. To this end, it might be useful to consider a evaluation framework that’s been developed for thinking about genomic testing, and which I’ve become increasingly familiar with through my new role at a genetic data management company. (As I’ve previously written, there are many parallels between our efforts to understand the value of genomic data and our efforts to understand the value of digital health data.)
The evaluation framework, called ACCE, seems to have been first published by Brown University researchers James Haddow and Glenn Palomaki in 2004, and focuses on four key components: Analytic validity, Clinical validity, Clinical utility, and Ethical, Legal, and Social Implications (ELSI). The framework continues to inform the way many geneticists think about testing today – for instance, it’s highlighted on the Center for Disease Control’s website (and CDC geneticist Muin Khoury was one of the editors of the book in which the ACCE was first published).
Is Healthcare a Business?
In the United States, the question has been asked time and again but never satisfactorily answered. By virtue of publically financed healthcare systems, the rest of the developed world has decided, to a greater or lesser extent, that medicine and healthcare are not pure businesses—that citizens have a right to care, even when they can’t pay all associated costs.
It’s starting to look like Americans won’t be able to duck the question for much longer.
In the last year, the profitability of U.S. hospitals eroded for the first time since the Great Recession, pushing some closer to and others over the solvency precipice. Revenues are down and costs are up. And these issues appear systemic and entrenched, giving rise to a series of important and relevant questions: How can hospitals adapt? If they do, will they still survive? And, do we as a nation think it’s important to make hospitals accessible, even if they lose money?
As recently reported in the New York Times, analysis by Moody’s Investors Service shows that this year nonprofit hospitals had their worst financial performance since the Great Recession. Among the 383 hospitals studied, revenue growth dipped from a 7 percent average to 3.9 percent on declining admissions. For the last two years, expenses have grown faster than revenues, and fully one quarter of all hospitals are operating at a loss.
In a word, Moody’s describes the situation as “unsustainable” because it is the product of what look like enduring realities:
- Private insurers did not increase payments to hospitals.
- Medicare reduced payments due to federal budget cuts.
- Demand for inpatient services declined as outpatient care options rose.
- Retail outpatient options now compete with hospital clinics.
- Patients with higher copays and deductibles chose not to seek care.
- Hospitals are buying up physician practices.
- The costs of electronic medical record systems are impacting the bottom line.
