Year: 2014

What Do Millennials Want from the Healthcare System?

Mar 18, 2014• 54

By Paul Keckley

The 18-34 year old segment of our population is large, growing and important in our society. They are 80 million strong. Their attitudes, beliefs, values and actions are re-shaping the way every organization, business and institution thinks about its future.

According to a Pew Research report released last week, Millennials are independents and skeptics: 50% have no political affiliation, 29% no religious affiliation, and 19% say they do not trust established institutions to do the right things (versus 40% for Baby Boomers).

Millennials worry about money. A study by the Investor Education Foundation of the Financial Industry Regulatory Authority concluded that their concerns about their auto, credit card and school debt trump other issues.

Most think economic stability should come before marriage and family life. Half who went to college have a student loan to repay, and one third moved into the homes of their parents at some point to make ends meet.

And they worry about the future. Paul Taylor’s The Next America: Boomers, Millennials, and the Looming Generational Showdown predicts economic battle between Millennials and Baby Boomers:

“Every family, on some level, is a barter between the generations…If I care for you when you’re young so you’ll care for me when I’m old…But many Millennials won’t be able to afford that…The young today are paying taxes to support a level of benefits for the old that they themselves have no prospect of receiving when they become old.”

Pew survey data supports his contention:

51% of Millennials do not think there will be any money for them in the Social Security system by the time they retire.
39% believe they’ll get reduced benefits

So what do Millennials want from the health system? Their view is likely to disrupt how industry leaders operate their businesses and how policymakers make laws that govern its commerce.

Why Bad Research Makes It into Good Medical Journals

Mar 18, 2014• 4

By Josh Herigon

Last week, a study in the New England Journal of Medicine called into question the effectiveness of surgical checklists for preventing harm.

Atul Gawande—one of the original researchers demonstrating the effectiveness of such checklists and author of a book on the subject—quickly wrote a rebuttal on the The Incidental Economist.

He writes, “I wish the Ontario study were better,” and I join him in that assessment, but want to take it a step further.

Gawande first criticizes the study for being underpowered. I had a hard time swallowing this argument given they looked at over 200,000 cases from 100 hospitals. I had to do the math. A quick calculation shows that given the rates of death in their sample, they only had about 40% power [1].

Then I became curious about Gawande’s original study. They achieved better than 80% power with just over 7,500 cases. How is this possible?!?

The most important thing I keep in mind when I think about statistical significance—other than the importance of clinical significance [2]—is that not only does it depend on the sample size, but also the baseline prevalence and the magnitude of the difference you are looking for. In Gawande’s original study, the baseline prevalence of death was 1.5%.

This is substantially higher than the 0.7% in the Ontario study. When your baseline prevalence approaches the extremes (i.e.—0% or 50%) you have to pump up the sample size to achieve statistical significance.

So, Gawande’s study achieved adequate power because their baseline rate was higher and the difference they found was bigger. The Ontario study would have needed a little over twice as many cases to achieve 80% power.

This raises an important question: why didn’t the Ontario study look at more cases?

Why the Creative Destruction of Healthcare May Not Be Such a Good Idea

Mar 18, 2014• 12

By BILL CROUNSE, MD

From childhood most of us remember the sage parental advice on how to deal with bullies–“sticks and stones can break my bones, but words can never hurt me”.

Of course, we all know that words do hurt, maybe not physically, but they certainly take a toll on our psyche.

These days in planning meetings at my own company, in articles I read on the web and at various tech industry conferences, I come across words and language that I know feel hurtful, or are at least disrespectful, to the health industry and the people who work there. I hear cavalier talk about the need to disrupt the healthcare industry.

Some thought leaders even say we will creatively destruct the healthcare industry. Consumers armed with technology will rise up, they say, and disrupt everything about the current state of healthcare.

Now imagine for a minute that you are a hospital executive, a doctor, a nurse or other clinician and you hear people who work outside your industry talking about disrupting or destructing it.

Imagine being told that consumers, patients, and tech companies will rise up and destroy your business.

There you are doing the best you can to make it through each day keeping your hospital or practice economically sound, dealing with the barrage of patients at your door, staying one step ahead of ever-increasing rules, regulations and rising costs, while those who’ve never worked a day in your world tell you they are going to disrupt and/or destroy it.

Even if there is a need to disrupt healthcare (and even many who work in the health industry might agree), nobody appreciates being told by some outsider that they know your business better than you do.

I don’t imagine my colleagues who work at Microsoft (or Google, or Apple, or Amazon) would appreciate being told by a hospital administrator or a doctor that they knew better how to run a tech company, or what ails the tech industry.

Nor do I think that most patients and consumers can really appreciate the amazing complexity of our healthcare system or the unbelievable pressures under which it operates these days.

Mixing Politics and Science Is Injurious to Public Health

Mar 18, 2014• 9

By Saurabh Jha, MD

If Obama’s nominee for the position of Surgeon General, Vivek Murthy, is not endorsed by the Senate because Senate Democrats from conservative states are too scared to vote for him for fear of losing votes from a population, egged on by the National Rifle Association (NRA), that passionately supports firearms, the first words that come to mind are ‘unfortunate,’ ‘tragic’ and ‘daft,’ although not in that particular order.

Words that do not come to mind are ‘surprising’ or ‘unprecedented.’ This is the natural result of decades of actively encouraging science to mix with politics.

In an ideal world, or I should say reasonable world, noting that perfection is not a pre-requisite to being reasonable, it would scant matter what Murthy thought about firearms.

He would be judged on his (impeccable) credentials, (unmistakable) leadership, and (imaginative) entrepreneurship not to mention his gumption in standing up for what he believes.

It would, of course, be utterly naïve to believe that in the real world his politics do not matter.

I doubt Murthy would have advanced so precociously, let alone been nominated for the position of Surgeon General, if he were a second amendment absolutist, an implacable limited government advocate or had written extensively about the role of free market in healthcare, all things else being equal.

We applaud him for standing up for his convictions not just because of his standing up but for the nature of his convictions.

This is not to suggest that Murthy’s worldview is expedient. There’s no reason to doubt its sincerity. It’s to suggest that a certain weltanschauung is incompatible with progress in academia and beyond.

That’s because despite living in an age of unprecedented reason we have been unable to render unto science what is unto science and render unto politics what is unto politics, a distinction our species has made little progress in making in the last two thousand years.

Silly Republican Insurance Reform Ideas

Mar 17, 2014• 5

By Robert Laszewski

There are news reports indicating Republicans will be proposing such longstanding health insurance reform ideas as selling insurance across state lines and association health plans.

These ideas have been around for some time and have served Republicans as convenient talking points out on the campaign trail positioned as common sense alternatives to Obamacare.

When I discuss these ideas with people in the insurance industry––people who know how their market really works––these ideas generally command plenty of snickers.

Selling Insurance Across State Lines
Presumably, Republicans are targeting the many state benefit mandates that drive health insurance policy prices up. The idea is to allow the sale of policies from states with the fewest benefit mandates to be able to be sold in a high mandate state––thereby encouraging the state with more mandates to curtail them.

There are a number of problems with this idea:

IF it did attract new carriers to a market, it would be a great way to blow up an existing health insurance market––for example, the high market share legacy Blue Cross plan whose business is in compliance with all of the existing state benefit mandates. A new carrier could conceivably come into the market with much lower rates––because it is offering fewer benefits––attracting the healthy people out of the old more regulated pool leaving the legacy carrier with a sicker pool.Stripping down a health plan is a great time tested way for a predatory insurance company to attract the healthiest consumers at the expense of the legacy carrier who is left with the sickest.
It’s a 1990s idea that that fails to recognize the business a health plan is in in 2014. Health plans don’t just cross a state line and set up their business like they did decades ago when the insurance license and an ability to play claims was a all a carrier needed to do business. This idea was first suggested by the last of the insurance industry cherry pickers back in the 1990s and it has long outlasted its relevance.Continue reading…

Computer Security as an Exercise in Public Health

Mar 17, 2014• 3

By CORY DOCTOROW

In a recent column, security expert Bruce Schneier proposed breaking up the NSA – handing its offensive capabilities work to US Cyber Command and its law enforcement work to the FBI, and terminating its programme of attacking internet security.

In place of this, Schneier proposed that “instead of working to deliberately weaken security for everyone, the NSA should work to improve security for everyone.” This is a profoundly good idea for reasons that may not be obvious at first blush.

People who worry about security and freedom on the internet have long struggled with the problem of communicating the urgent stakes to the wider public. We speak in jargon that’s a jumble of mixed metaphors – viruses, malware, trojans, zero days, exploits, vulnerabilities, RATs – that are the striated fossil remains of successive efforts to come to grips with the issue.

When we do manage to make people alarmed about the stakes, we have very little comfort to offer them, because Internet security isn’t something individuals can solve.

I remember well the day this all hit home for me. It was nearly exactly a year ago, and I was out on tour with my novel Homeland, which tells the story of a group of young people who come into possession of a large trove of government leaks that detail a series of illegal programmes through which supposedly democratic governments spy on people by compromising their computers.

I kicked the tour off at the gorgeous, daring Seattle Public Library main branch, in a hi-tech auditorium to an audience of 21st-century dwellers in one of the technology revolution’s hotspots, home of Microsoft and Starbucks (an unsung technology story – the coffee chain is basically an IT shop that uses technology to manage and deploy coffee around the world).

I explained the book’s premise, and then talked about how this stuff works in the real world. I laid out a parade of awfuls, including a demonstrated attack that hijacked implanted defibrillators from 10 metres’ distance and caused them to compromise other defibrillators that came into range, implanting an instruction to deliver lethal shocks at a certain time in the future.

Commentology: Actually, High-Tech Imaging Can Be High-Value Medicine

Mar 17, 2014• 3

By Robert McNutt, MD & Nortin Hadler, MD

Our comments regarding this interesting blog, and the comments to the blog, may seem tangential to the author’s points.

The blog and comments point, we think, to a confusing set of principles being considered, perhaps, out of context?

Those comments range from: ACOs will lead to better figuring out what is best (impossible) – to mismatched information regarding a specific clinical case (reasonable). What is striking is that we have medical students worrying about costs of care.

Instead, shouldn’t we be teaching them to understand the value of information for decision-making? Shouldn’t we be teaching them the concepts of co-dependent testing leading to all tests being less useful than we think?

Shouldn’t we be teaching students the concepts of decision-analysis, and thresholds, and patient’s being involved in the decisions? Shouldn’t we be teaching that it is better to know than to think we know? Shouldn’t we be doing studies rather than scratching at the “tragedy of the commons” (so many physicians feasting on the grassy fields of a sick patient)?

The ACO Hypothesis: Farzad Mostashari Responds

Mar 17, 2014• 7

By THCBist

Farzad Mostashari’s post last week provoked a heated (to put it mildly) discussion between supporters and critics of the ACO model.

Farzad writes:

Commenters have raised several points regarding the early results of the Medicare Shared Savings Program that bear further discussion and clarification:

-The need for more details on the participants by name, along with their characteristics, actions, and outcomes.

I agree. We strongly encourage CMS to release more detailed information about the results of the program to date. As someone who’s been on the other side, I can attest however, that lack of transparency can occur despite the intentions of leadership, and even when there’s nothing to hide. CMS has taken great steps towards open data in recent years- unparalleled in its history (or in comparison to private sector payors and most states), but there is more work to be done to overcome institutional inertia, and concerns regarding the “privacy of providers”.

How is the MSSP different from an HMO?
A major similarity between managed care and “shared savings” programs is that physicians that make decisions about treatment, diagnostic, and referral options do have an incentive to reduce cost. I was trained in an era where we were not supposed to think about (or even be aware of) the cost implications of our care recommendations. I now believe that we need physician engagement in addressing the truly unsustainable rise in healthcare costs that threaten to bankrupt our nation.

However, policymakers have learned a few lessons from the backlash against managed care:

Quality Matters
Reducing cost cannot be the only outcome. In the MSSP, in the first year only can you qualify for savings simply by reporting quality measures. In future years, ACOs will have to not only reduce total cost but also perform well on measures of patient satisfaction, clinical quality, and utilization (such as ambulatory care sensitive admissions) to collect shared savings payments.

What about patient choice?
If the patient doesn’t like the care they’re getting, they can get care elsewhere. This is a sore point for many ACOs, especially those that have been successful in managed care arrangements, but the current regulations in no way limit patients’ ability to seek care elsewhere. MSSPs are required to notify patients that they have formed an ACO, and patients have the option of opting out of the sharing of their claims data with the ACO.

Shared Savings versus capitation
Finally, the MSSP program is indeed layered on top of fee-for-service payments (versus prospective payments/ capitation), and most MSSPs have opted for the “upside only” track for the first three years. We acknowledge that where the ACO includes a hospital sponsor, they must contend with “demand destruction” on their fee-for-service lines of business if they reduce procedures, admissions and emergency department visits. However, physician-led ACOs are not similarly encumbered, and this model provides them with a “safe” transitional path towards taking risk. It is also worth noting that “one-sided risk” during the riskiest early transition period would tend to reduce the likelihood of a physician having to choose between limiting needed care and going bankrupt.

Can Hospitals Survive? Part II

Mar 14, 2014• 29

By JEFF GOLDSMITH

In 1980, while working at the University of Chicago Pritzker School of Medicine, I wrote an article for the Harvard Business Review entitled “The Health Care Market: Can Hospitals Survive?”. This article, and the book which followed, argued that hospitals faced a tripartite existential threat:

1) ambulatory technologies that would enable physicians to compete successfully with hospitals at lower cost in their offices or freestanding settings, 2) post-acute technologies that would enable presently hospitalized patients to be managed at home and 3) rapidly growing managed care plans that would “ration” inpatient care and bargain aggressively to pay less for the care actually provided.

I predicted a significant decline in inpatient care in the future, and urged hospitals to diversify aggressively into ambulatory and post acute services. Many did so. A smaller number, led by organizations like Henry Ford Health System of Detroit and Utah’s Intermountain Health Care, also sponsored health insurance plans and became what are called today “Integrated Delivery Networks” (IDN’s).

In the ensuing thirty years, US hospital inpatient census fell more than 30%, despite ninety million more Americans. However, hospitals’ ambulatory services volume more than tripled, more than offsetting the inpatient losses; the hospital industry’s total revenues grew almost ten fold.

Ironically, this ambulatory care explosion is now the main reason why healthcare in the US costs so much more than in other countries. We use far fewer days of inpatient care than any other country in the world. But as the McKinsey Global Institute showed in 2008 ambulatory spending accounts for two thirds of the difference between what the US spends on healthcare and what other countries spend, far outstripping the contribution of higher drug prices or our multi-payer health financing system.

Med School: Can the Lecture!

Mar 14, 2014• 4

By James Salwitz, MD

Medical students frequently see patients with us in our office. Their presence is welcome, if for no other reason than it makes us think young.

A second year student has been coming to our office for over a year and is excited about a future taking care of cancer patients. She just completed the Hematology and Oncology section of lectures at the med school. I asked her how it went. “Frankly, “ she said, in the articulate way of the highly educated, “it sucked.”

I was astonished. How could such an exciting, complex and rapidly evolving field, yield teaching that would cause a motivated student to take such umbrage? Too much information? Too complex a topic? Too much difficulty in the exams? “No,” she said, it lacked “too” of anything.

It was not organized, not at the appropriate level, rambling and incomplete. Without reviewing the critical information in texts and online, she would have learned little and the entire class would have failed the subsequent tests.

In a huff, wanting to assure that we not lose a crop of budding oncologists, I swore to find the cause of this didactic discord. Surely, it must be possible to put together a set of clear, complete, cancer and blood lectures, so that the students were not only taught, but inspired. Somehow, we would fix those lagging lectures. But, then it occurred to me, why?

There are 141 medical schools in the United States, 2372 in the world. They teach 20,055 students in North America and hundreds of thousands around the globe. In every school, every state, and country, they all teach about cancer. In every school, cancer is the exact same disease. On every continent, the possible treatments are the same.

Therefore, why in the world do students listen to different lectures by different teachers on the exact same subject?

Why use the lecture hall format in medical school? Why not find a few super-experts to write one perfect lecture, and then record that lecture one perfect time, given by a brilliant, inspiring, articulate educator (with translations)?