Month: August 2018

Is Medical Imaging a Ricardian Derived Demand?

Aug 30, 2018• 7

By SAURABH JHA

Medical Imaging and the Price of Corn

After the Napoleonic wars, the price of corn in England became unaffordable. The landowners were blamed for the high price, which some believed was a result of the unreasonably high rents for farm land. Economist David Ricardo disagreed.

According to Ricardo, detractors had the directionality wrong. It was the scarcity of corn (the high demand relative to its supply) that induced demand for the most fertile land. That is, the rent did not increase the price of corn. The demand for corn raised the rent. Rent was a derived demand.

Directionality is important. Getting directionality wrong means crediting the rooster for sunrise and blaming umbrellas for thunderstorms. It also means that focusing on medical imaging will not touch healthcare costs if factors more upstream are at play.

Medical imaging is a derived demand. The demand for healthcare induces demand for imaging. Demand is assured by the unmoored extent to which we go for marginal increases in survival.

Why Cochrane is Wrong About Hypertension. Very Wrong.

Aug 29, 2018• 6

By SWAPNIL HIREMATH MD, MPH

Archie Cochrane and the Cochrane Collaboration

Archie Cochrane was born in Scotland, educated in London (King’s College, University College and London School of Hygiene and Tropical Medicine) and worked in Cardiff, Wales. His work as a doctor during the Spanish Civil War and World War II, especially in a prisoner of war camp in Salonica, is credited with his push towards generating higher quality evidence. In his description of the clinical trial he conducted, he mentions James Lind as his hero. Ironically, that clinical trial – with weak randomization, open allocation, non-blinding of investigator or participants, and use of surrogate outcomes, would rate poorly in the Cochrane risk of bias tool.

But the scientific method of measuring stuck with him, and among many other achievements, he did perform a proper randomized clinical trial (RCT) a few decades later. He continued to be a strong supporter of RCTs and pushed for the Medical Research Council (MRC) to move from purely fundamental research towards applied clinical research. As an aside, the first proper RCT in the modern era was funded by the MRC and was published in 1950 – on the use of Streptomycin vs para-aminosalicylic acid, or a combination, in tuberculosis. Far more influential was his paper (and later book) published as part of the Rock Carling Fellowship, available here freely and worth a read. It’s where he puts forward the vision for RCTs in moving towards what he termed an ‘effective, efficient health service’.

Health in 2 Point 00, Episode 46

Aug 29, 2018• 1

Jessica DaMassa asks me about single payer polling high, big VC for women’s pelvic floor digital therapeutic Renovia, 23andme cutting off API access to its data, plus guest mentions for Shafi Ahmed and Glen Tullman. All in 2 minutes (more or less!)–Matthew Holt

Prior Authorizations: Will They Become Damocles Sword?

Aug 28, 2018• 29

By NIRAN AL-AGBA MF, FAAP

In July 2009, the family of Massachusetts teenager Yarushka Rivera went to their local Walgreens to pick up Topomax, an anti-seizure drug that had been keeping her epilepsy in check for years. Rivera had insurance coverage through MassHealth, the state’s Medicaid insurance program for low-income children, and never ran into obstacles obtaining this life-saving medication. But in July of 2009, she turned 19, and when, shortly after her birthday, her family went to pick up the medicine, the pharmacist told them they’d either have to shell out $399.99 to purchase Topomax out-of-pocket or obtain a so-called “prior authorization” in order to have the prescription filled.

Prior authorizations, or PAs as they are often referred to, are bureaucratic hoops that insurance companies require doctors to jump through before pharmacists can fulfill prescriptions for certain drugs. Basically, they boil down to yet another risky cost-cutting measure created by insurance companies, in keeping with their tried-and-true penny-pinching logic: The more hurdles the insurance companies places between patients and their care, the more people who will give up along the way, and the better the insurers’ bottom line.

PAs have been a fixture of our health care system for a while, but the number of drugs that require one seems to be escalating exponentially. Insurance companies claim that PAs are fast and easy. They say pharmacists can electronically forward physicians the necessary paperwork with the click of a mouse, and that doctors shouldn’t need more than 10 minutes to complete the approval process.

Comprehensiveness is Killing Primary Care

Aug 24, 2018• 20

By HANS DUVEFELT, MD

Dr. Hans Duvefelt

In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.

Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.

A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well-established patients.

A Cross-Party Win: Empowering Consumers Through Digital Health

Aug 23, 2018• 1

By LYGEIA RICCIARDI

These days Americans are more politically divided than ever, disagreeing vehemently about everything from guns to the role of the press. Despite the distrust and inflammatory rhetoric, there are examples of cross-party, trans-Administration collaboration and success. Let’s celebrate them and be motivated by what happens we put differences aside and focus on shared long-term goals.

Using digital technology to empower healthcare consumers is one example of a cross-party win, a still-developing success story that has been cultivated for more than a decade by the efforts of public and private sector leaders from a wide variety of affiliations and political perspectives.

The UN’s Extreme Poverty Report: Further Evidence US Healthcare Is Divorced From Reality

Aug 22, 2018• 5

By DAVID INTROCASO, Ph.D.

Skid Row in Los Angeles

In May Philip Alston, the United Nation’s Special Rapporteur on Extreme Poverty, and John Norton Pomeroy Professor of Law at New York University Law School released his, “Report of the Special Rapporteur On Extreme Poverty and Human Rights on His Mission to the United States.” The 20-page report was based, in part, on Alston’s visits this past December to California, Georgia, Puerto Rico, West Virginia and Washington, D.C. After reading the report and the response to it, one is again forced to question how legitimate is our concern for the health and well being of the poor, or those disproportionately burdened with disease.

The UN report found over 40 million Americans live in poverty, or upwards of 14% of the population. Those living in extreme poverty number 18.5 million and 5.3 million live in 3^rd World absolute poverty. Among other related statistics, Alston cites the fact the US has the highest comparable infant mortality rate, 50% higher than the OECD mean, due in part to an African American mortality rate that is 2.3 times higher than that of whites. The US has the highest youth poverty rate in the OECD. In 2016, 18% of children were living in poverty comprising 33% of all people in living poverty and 21% of those were homeless. These facts are explained in part by the report noting between 1995 and 2012 there was a 750% increase in the number of children of single mothers experiencing annual $2-a-day poverty. US poverty, the report explains is due in part to the continuing growth in income and wealth inequality. The report found in 2016 the top 1% possessed 39% of the nation’s wealth while the bottom 90% lost 25% of its share of wealth and income. Since 1980 annual income for the top 1% has risen 205% and for the top .1% by 636% while annual wages for the bottom 50% have stagnated. The report reminds us the US has approximately 5% of the world’s population but 25% of its billionaires. The US in sum ranks 18^th out of 21 wealthy countries in labor markets, poverty rates, safety nets, wealth inequality and economic mobility.

Seema Verma Hyperventilates About Tiny Differences Between ACOs Exposed to One-and Two-Sided Risk

Aug 21, 2018• 8

By KIP SULLIVAN, JD

There is no meaningful difference between the performance of Medicare ACOs that accept only upside risk (the chance to make money) and ACOs that accept both up- and downside risk (the risk of losing money). But CMS’s administrator, Seema Verma, thinks otherwise. According to her, one-sided ACOs are raising Medicare’s costs while two-sided ACOs are saving “significant” amounts of money. She is so sure of this that she is altering the rules of the Medicare Shared Savings Program (MSSP). Currently only 18 percent of MSSP ACOs accept two-sided risk. That will change next year. According to a proposed rule CMS published on August 9, ACOs will have at most two years to participate in the MSSP exposed to upside risk only, and after that they must accept two-sided risk.

That same day, Verma published an essay on the Health Affairs blog in which she revealed, presumably unwittingly, how little evidence she has to support her decision. The data Verma published in that essay revealed that one-sided ACOs are raising Medicare’s costs by six-one-hundredths of a percent while two-sided ACOs are cutting Medicare’s costs by seven-tenths of a percent. [1] Because these figures do not consider the expenses ACOs incur, and because the algorithms CMS uses to assign patients to ACOs and to calculate ACO expenditure targets and actual performance are so complex, this microscopic difference is meaningless.

“Two beellion dawlers”

Even if the difference is not meaningless – even if two-sided ACOs actually save a few tenths of a percent for Medicare – the impact on Medicare spending will be barely noticeable. Verma assures us, without a hint of embarrassment, that her new rule will cut Medicare spending by $2.2 billion over ten years. “The projected impact of the proposal would be savings to Medicare of $2.2 billion over ten years,” she declares in her blog comment.

Dr. Evil from Austin Powers

I feel like we’re in a scene from the Austin Powers movie where Dr. Evil announces he will hold the world ransom for “one meellion dawlers.” Dr. Evil’s sidekick, Number Two, has to advise him that a million dollars is peanuts. Verma’s estimate of 2.2 “beellion dawlers” is essentially zero percent of the trillions of dollars CMS will spend on Medicare in the next decade.

Health in 2 Point 00, Episode 45

Aug 21, 2018• 1

In this episode a not-too-happy Jessica DaMassa asks me about who’s on the Inc5000 list (Modernizing Medicine, Health Recovery Solutions, Definitive Healthcare, EngagedIN & uBiome), about Klara’s $11m round, and what I’ll be doing in NYC at the DHMP Matchmaking session on Thursday. Why so grumpy Jessica? Maybe it’s because this episode has the same number as our very grumpy President?–Matthew Holt

Biomedical Knowledge Must Be Mobilized to Save Lives, Not Privatized in the “Last Mile”

Aug 20, 2018• 3

By JOSHUA C. RUBIN JD, MBA, MPH, MPP

Last week, Facebook’s unprecedented stock price collapse triggered by concerns over personal data privacy, as well as same-day commentary regarding GlaxoSmithKline’s investment in 23andMe to gain access to its customers’ genomic data, reignited a national dialogue vis-à-vis our rights to our data, especially our health data. Three years ago, our nation’s first National Coordinator for Health IT foresaw an impending “gold rush” for valuable personal health data. Myriad headlines such as Bloomberg’s “IBM Buying Truven for $2.6 Billion to Amass More Health Data” proved him right and fueled this national dialogue.

However, there has been far less discussion about the flip-side of this coin: accessibility of knowledge gleaned from people’s data, by the people whose experiences contributed to its development and the people who need it to save lives. Policymakers have noted that, “We must develop a communications system so that the miraculous triumphs of modern science can be taken from the laboratory and transmitted to all in need.” Unfortunately, that statement, attributed to Senator Lister Hill and inscribed on a wall inside the U.S. National Library of Medicine (the world’s largest biomedical library), was made in 1965! That predates by a year Dr. Martin Luther King Jr.’s observation that, “Of all the forms of inequality, injustice in health is the most shocking and inhuman.” Indeed, inequitable access to knowledge, resulting from society’s failure to realize Senator Hill’s vision over half a century later, exacerbates such injustices while costing lives.