Year: 2017

Uwe Reinhardt 1937-2017

Nov 14, 2017

Uwe Reinhardt, Princeton economist and one of the best known and best loved personalities in the health policy world died today. I join the rest of the health policy community in mourning the passing of the master explainer and wit that Uwe was.

But I also remember a small act of his kindness. The first time I met him I was a little late joining a crowd trying to get his attention after a keynote. He had talked to many, and had to go. But as he was being hustled off by his handlers, he realized he hadn’t talked to me, and he walked back to do an introduction and share a few words. He was already the biggest celebrity in our little world, and he was clearly running late for his next appointment. He didn’t know me, yet was prepared to spend the extra moment to make me feel included. And in all our future interactions over the next 2 decades, he was the same way.

It’s clear that it was the same for everyone he knew and it’s why the grief and shock in our community is so heartfelt.

John & I are very proud that in recent years Uwe offered to write some original pieces for our little blog, and we will be running a few of them in the next few days.

RIP and thank you Uwe, and we send our condolences to his wife Mae and their daughter and son–Matthew Holt

What Would a Disrupted Health Care Field Look Like?

Nov 14, 2017• 4

By ANDY ORAM

Clayton Christensen, the famous economist who popularized ideas of innovation and disruption, showed up at the recent Connected Health conference in Boston. Although billed as a panelist, he turned up without warning as a guest in a keynote and posed the same question I asked in an article back in July: “The overarching question: whither technology?”

Like my article, Christensen distinguished between incremental improvements that don’t challenge current power structures or sources of revenue, and disruptive change that offers new solutions to old, intractable problems. Disruptive change, as summarized by Christensen, changes processes as well as products.

A similar question came up in a panel, where the moderator asked his guests whether device and app manufacturers were thinking just about the health care field as it is now, or the field as it will be in four or five years. It’s telling that his question went unanswered. I believe that most health care developers are seeking a niche in the current ecology, although hoping to be able to make the evolutionary leap when that ecology changes.

The Next Tech Wave To Impact Personalized Health

Nov 14, 2017• 1

By HEALTH 2.0 SPONSORED POST

The Technology For Precision Health Summit is just around the corner, and it’s the place to discover new digital platforms that will improve the patient experience, and access a deeper insight into the data behind key decisions for treatment and for maintaining health.

Join more than 300 healthcare providers and payers, advocates, developers, investors, entrepreneurs, policymakers, and advocates for the 1-day action-packed summit which includes:

Keynote presentation on quality of patient experience; and initiatives to improve care providers to securely review, analyze and share medical information across the healthcare system by Claudia Williams, CEO of Manifest MedEx; and a presentation by Carlos Bustamante, Professor of Biomedical Data Science, of Genetics at Stanford Medicine on Stanford Medicine’s precision health initiative, and an insight into its Precision Health and Integrated Diagnostics Center.
Presentations and demos from Syapse and Cota focusing on genomics and other omics technologies that are rapidly making their way to clinicians and into Electronic Health Care Records (EHRs) during the Precision Medicine – Decision Support for Clinicians session.
New Diagnostic and Screening Tools session featuring live demos from Helix, DotLab, Ivary, and ColorGenomics.
An in-depth look at funding sources for precision medicine and health as well as insight on how value based medicine and population health incentives and policy are shaping investment with Illumina Accelerator, GE Ventures, Cricket Health, and the California Governor’s Office of Planning and Research during the Business Models and Investing in Precision Health session.

What are you waiting for? Register for the Technology for Precision Health Summit to see healthcare technology demos from some of the most innovative personalized medicine companies, and hear penetrating discussions on precision medicine delivery, innovation in clinical trials, and advances in oncology.

Why Hospitals Are Losing Serious Money And What That Means For Your Future

Nov 12, 2017• 12

By ROBERT PEARL, MD

A strange thing happened last year in some the nation’s most established hospitals and health systems. Hundreds of millions of dollars in income suddenly disappeared.

This article examines the economic struggles of inpatient facilities, the even harsher realities in front of them, and why hospitals are likely to aggravate, not address, healthcare’s rising cost issues.

According to the Harvard Business Review, several big-name hospitals reported significant declines and, in some cases, net losses to their FY 2016 operating margins. Among them, Partners HealthCare, New England’s largest hospital network, lost $108 million; the Cleveland Clinic witnessed a 71% decline in operating income; and MD Anderson, the nation’s largest cancer center, dropped $266 million.

How did some of the biggest brands in care delivery lose this much money? The problem isn’t declining revenue. Since 2009, hospitals have accounted for half of the $240 billion spending increase among private U.S. insurers. It’s not that increased competition is driving price wars, either. On the contrary, 1,412 hospitals have merged since 1998, primarily to increase their clout with insurers and raise prices. Nor is it a consequence of people needing less medical care. The prevalence chronic illness continues to escalate, accounting for 75% of U.S. healthcare costs, according to the CDC.

Practicing Medicine While Black

Nov 9, 2017• 10

By KIP SULLIVAN, JD

The managed care movement thrives on misleading words and phrases. Perhaps the worst example is the incessant use of the word “quality” to characterize a problem that has multiple causes, only one of which might be inferior physician or hospital quality. [1] To illustrate with a non-medical analogy, no one would blame auto repair mechanics if 50 percent of their customers failed to bring their cars in for regular oil changes. We would attribute the underuse of mechanics’ services to forces far beyond the mechanic’s control and would not, therefore, refer to the problem as a “quality” problem.

But over the last three decades it has become acceptable among American health policy experts and policy-makers to characterize any measurement of under- or over-use of medical care, or any measurement of a medical outcome, no matter how poorly adjusted to reflect factors outside provider control, as an indication of “quality.” The widespread, inappropriate use of “quality” long ago set off a vicious cycle. It helped spread the folklore that the quality of America’s doctors and hospitals is awful, and that in turn was used to justify taking even more crude measurements of quality, and so on. [2]Continue reading…

12 Seconds of Placebo – An Outsider’s View of ORBITA

Nov 7, 2017• 3

By SAURABH JHA, MD

The reactions of physicians to ORBITA, a blinded, randomized controlled trial (RCT) from Britain, with a sham arm, comparing percutaneous coronary intervention (PCI) to placebo, in patients with stable angina, are as fascinating as the cardiac cycle. There were murmurs, kicks, and pulsating jugulars. Though many claimed to be surprised, and many unsurprised, by the null results of the trial, the responses were predictably predictable. Some basked in playful schadenfreude, and some became defensive and bisferious.

No shame in sham

The coverage of the trial in the NY Times was predictably jejune and hyperbolic. Predictably, the most nuanced and divergent viewpoints were curated by Larry Husten. Predictably, medical Twitter was set alight. The trial vindicated Vinay Prasad and Adam Cifu who predicted that PCI for stable angina will get placeboed, in their popular book, Ending Medical Reversal. Prasad and Cifu are tireless advocates for using sham control trials to judge the true efficacy of procedures, such as PCI, in relieving symptoms, and reject the notion that invasive placebos are unethical. There’s no shame in sham, they say. They were right.

The Objective Randomized Blinded Investigation With Optimal Medical Therapy in Stable Angina (ORBITA) is an impressive trial, which enrolled 230 patients with stable angina and single vessel stenosis greater than 70 %. The vast majority had class 2 (59 %) and class 3 (39 %) angina. Majority of the patients, 70 %, had LAD lesions. If you look in the appendix, which has pictures of catheter angiograms of all patients, you’ll see scary tight proximal LAD stenosis – yes, even these patients had 50 % chance of getting sham. This takes balls. The trialists deserve applause, as do the Brits who volunteered. These were no snowflakes.

The DNA Tool That You Must See

Nov 7, 2017• 1

BY HEALTH 2.0 SPONSORED POST

Most people have no way of accessing DNA-powered insights about themselves, and no way to store and use their genome in ways that they control. Technology for Precision Health Summit demoer Helix solves that by providing the world’s first online store for DNA-powered products where people can explore diverse and uniquely personalized products developed by high-quality partners. After being sequenced once with true next-generation sequencing, the user can query their data on-demand at any time for a large variety of uses.

The costs of DNA sequencing have dropped rapidly, and our understanding of how DNA influences our lives has increased. For partners in the Helix marketplace, DNA now becomes a software problem, not a hardware problem, where a full clinical-grade exome is accessible through an API. Helix handles sample collection, DNA sequencing, and secure data storage so that our partners can integrate DNA insights into products across a range of categories, including ancestry, entertainment, family, fitness, health and nutrition.

Check out a live demo of Helix’s DNA-powered tool from its co-founder Justin Kao during the New Diagnostic and Screening Tools panel session at the Technology for Precision Health Summit. Hear perspectives about the value of personalization, and lessons learned from being at the forefront of an emerging and exciting new consumer market.

Right to Know: Why the FDA Should Not Be Cut Out of Expanded Access Requests

Nov 6, 2017• 2

By CHAPMAN, KLEIN and McFADYEN

Over the past three years, the libertarian Goldwater Institute–led right to try (RTT) movement has had wind in its sails, propelling the passage of RTT laws in 38 states and counting. The movement, which aims to cut the FDA out of the process by which patients with serious or immediately life-threatening diseases without available therapies access investigational drugs and biologics, hit some choppier waters at the hearing held October 3rd by the Health Subcommittee of the House Energy & Commerce Committee. The House is considering passage of a federal RTT bill, and two potential options were presented at the hearing. S. 204, sponsored by Sen. Ron Johnson (R-Wis.), was passed by unanimous consent in the Senate on August 3. Another RTT bill, H.R. 1020, introduced by Representatives Morgan Griffith (R-Va.) and Dave Brat (R-Va.) in February, was also under consideration. Rep. Andy Biggs (R-Arizona), who in February introduced a third version of a federal RTT bill, H.R. 878, testified at the hearing. Senators Joe Donnelly (D-Ill.) and Johnson have urged the House to pass S.204 “as soon as possible” and “without amendment.” Making any changes to S.204 would require reconsideration of the new version by the Senate.

A Tale of Two Doctors

Nov 3, 2017• 10

By ROBERT MCNUTT, MD

Data is not always the path to identifying good medicine. Quality and cost measures should not be perceived as “scores,” because the health care process is neither simplistic nor deterministic; it involves as much art and perception as science—and never is this more the case than in the first step of that process, making a diagnosis.

I share the following story to illustrate this lesson: we should stop behaving as if good quality can be delineated by data alone. Instead, we should be using that data to ask questions. We need to know more about exactly what we are measuring, how we can capture both the physician and patient inputs to care decisions, and how and why there are variations among different physicians.

A Tale of Two Doctors

“As soon as I start swimming, my chest feels heavy and I have trouble breathing. It is a dull pain. It is scary. I swim about a lap of the pool, and, thankfully, the pain goes away. This is happening every time I go to work out in the pool”.

Her primary physician listened intently. With more than 40 years of experience, the physician, a stalwart in the medical community, loved by all, who scored high on the “physician compare” web site listing, stopped the interview after the description and announced, with concern, that she needed to have a cardiac stress test. The stress test would require walking on a “treadmill” to monitor her heart and would include, additionally, an echocardiogram test to see if her heart was being compromised from a lack of blood flow.

“But, I have had three echocardiogram tests in the last year as part of my treatment for breast cancer and each was normal. Why would I need another”?

“Well, I understand your concern about more tests, but the echocardiograms were done without having your heart stressed by exercise. The echo tests may be normal under those circumstances, but be abnormal when you are on the treadmill. You still need the test, unfortunately. I want to order the test today and you should get it done in the next week”.

The Dunning-Kruger Effect, Or the Real Reason Why the Guys Trying to “Fix” Health Care Are Driving You Crazy

Nov 3, 2017• 2

By HANS DUVEFELT, MD

“The fool doth think he is wise, but the wise man knows himself to be a fool.”
– Willam Shakespeare

I learned about the Dunning-Kruger effect at a medical conference recently. It certainly seems to apply in medicine. So often, a novice thinks he or she has mastered a new skill or achieved full understanding of something complicated, but as time goes on, we all begin to see how little we actually know. Over time, we may regain some or most of our initial confidence, but never all of it. Experience brings at least a measure of humility.

Just the other day I finished a manuscript for an article in a Swedish medical journal with the statement that, 38 years after my medical school graduation, I’m starting to “get warm in my clothes”, as we say in Swedish.

I think the Dunning-Kruger effect applies not only to people who are in the beginning of a career in medicine, but also to people who learn about it for purposes of judging its quality or efficiency or of regulating or managing it from a governmental or administrative point of view.

I think many people outside medicine think “how hard can it be” and then proceed to imagine ways to change how trained medical professionals do their work.

But the Dunning-Kruger effect is also a particular problem in rural primary care. Newly trained physicians, PA’s and Nurse Practitioners are asked to work in relative professional isolation with full responsibility for sizeable patient populations. Unlike the hospital environment, primary care practices seldom have time earmarked for teaching and supervision, and there is little feedback given to such new providers. There is also very seldom collaboration and communication about specific patients or cases. We probably get more feedback from our specialist consultants than we do from the providers in our own clinics, because we are all busy with our own patients.

So, how does a new clinician avoid the newbie hubris Dunning and Kruger describe? Seek out potential mentors and ask them to be yours, start a case conference at your clinic, read the leading journals, NEJM, JAMA, BMJ, The Lancet and ones like them, and read about the history of medicine and the old masters.