Check out Xerox Blog Talk Radio to learn about protecting personal health information. This morning, Mark Tripodi, chief innovation officer, government healthcare solutions group for ACS, A Xerox Company, explained why data can easily be put at risk and what can be done to ensure organizations meet privacy standards. You can access the recording here: http://bit.ly/eyv65U. For more on Xerox: http://xrx.sm/news.
John Irvine
The Value of a Life
A recent NYTimes article on how to value a life drew almost two-hundred heavy-handed comments. It discussed how different governmental agencies such as the Food and Drug Administration (FDA), the Environmental Protection Agency (EPA) or the Department of Transportation (DoT) place a monetary value on each life saved.
In many public policy areas, Cost-benefit Analysis (CBA) is being used to assess whether an investment in a particular area is worthwhile. CBA uses an “exchange rate” in which the consequences are monetarized.
The article mentioned the following values: The DOT value each life saved at or around $6 million 2010 USD$; $9.1 million 2010 US$ was the corresponding value of the EPA; and the FDA put a figure of $7.9 million 2010 USD$ (increased from $5 million in 2008 USD$) on eachlife saved from cancer death caused by cigarettes.
I did not know that the FDA considered efficiency measures such as money per life saved at all.
What I find fascinating is how arbitrary the approach of the different agencies can be. They could have just funded certain policies by how cheaply they can save a life up to a certain threshold (e.g. when thebudget is exhausted).
Instead, the EPA uses a methodology derived from logging industry (yes, you heard right). $1,000 worth of extra-work for the lumberjacks each year is generally accepted to save 1 in 1,000 lumberjacks. This was apprently developed by a Professor Viscusi who wrote his firstpaper on CBA as an undergrad at Harvard in the 1970s.
Other governmental agencies seem to survey citizens. In economics, this could actually be considered a valid approach if done right.
There were interesting comments by the readers. Some did not want to put any value of life. It was controversial if the value was too high or too low. One reader mentioned that the Federal Aviation Administration might have had a value of $450,000 per life in the late 1970s.Continue reading…
The Triumph of Fear, Uncertainty, and Doubt
According to a new poll, half of all Americans say they are “confused” about healthcare reform. And boy howdy, are they right!
Take a look at this new Kaiser Family Fund poll: http://www.kff.org/kaiserpolls/upload/8156-C.pdf
Scan down to Slide 9: Almost a quarter of all Americans think that ObamaCare has been already been repealed. More than a quarter aren’t sure. Barely half are paying attention enough to realize that it’s still law.
What about the idea that the reform law is wildly unpopular, and most people want it repealed? Slide 4 shows that 39% want it repealed, and 50% want it kept or expanded. But take a look at slides 7 and 8. The only major provision of the law that a majority of Americans want repealed is the individual mandate—the part that says you have to buy healthcare insurance or be fined. Even those who want the law repealed agree, except that a majority also think it’s unfair to make the wealthy pay a heftier Medicare tax.
Think about that: Even those who will tell pollsters that they want the law repealed say that, well, yes, they think it’s a good idea to give tax credits to small business to help them give health insurance to their employees. And to close the Medicare “doughnut hole.” And to subsidize low and moderate income Americans to buy health insurance. Or to provide voluntary long-term care insurance (the CLASS Act). And to tell insurance companies that they have to take all comers (“guaranteed issue”).
So 39% want health care reform repealed, but 30% want it expanded. And a majority across the spectrum want insurance companies to be forced to sign up all comers, but they don’t want to be forced to sign up if they don’t feel like it.
What are we to make of this?
1. What most Americans think about healthcare reform is somehow not exactly what you would hear on Fox News or on the red side of the House of Representatives.
2. Most Americans aren’t exactly paying attention anyway.
3. If Americans have a strong suit, it’s not arithmetic.
The Obamacare Shift
A colleague pointed this out to me recently, and I think he has it right: While more people will have health insurance as a result of the federal health care reform act, a side effect will be to reduce the number of people insured through the employer-based insurance plans that have characterized the US health care system. These people will either be insured as individuals through the state exchanges that are to be established or, if eligible, through Medicaid. There are three aspects of economic hydraulics that are likely to lead to this result.
First, the penalty to be assessed against employers for not offering coverage — $2000 per year — is dramatically below the cost of providing insurance. If you are an employers and can save, say, $5,000 by paying $2,000, why wouldn’t you do that? And the $2000 is not even indexed to inflation, while the annual charge for an employer-sponsored plan is likely to go up over time. Hence the differential will grow every year.
In the past, the provision of a health care benefit was viewed as competitive factor in hiring and retaining a firm’s work force. But for the vast majority of businesses, that may be a less important factor than saving a few thousand dollars per employee and being able to offer a portion of those savings in higher wages and/or improving the profitability of the firm. Sure, some businesses might still want to attract workers by having their own semi-customized insurance benefit, but the power of that is likely to diminish over time.
A second factor is that the so-called “Cadillac” tax will make employer-sponsored health care even more expensive if you have a plan with generous benefits. Health coverage in excess of $10,200 for individual plans and $27,500 for family plans will be hit with a 40 percent excise tax on the amount in excess of the floor. The tax is indexed for inflation plus 1 percent.
Finally, to help avoid the excise tax, employers are going to “dumb down” plan designs by raising deductibles and co-pays. As they do so, the substantive difference between their own plans and the ones that will be offered through state exchanges or Medicaid will diminish. Even if you have a residual concern that your workers may want an employer-based plan, their desire might be diminished as you make your plan less attractive, so you lose little in competitiveness by referring them to the non-employer based plans.
There are those who believe that there was an ideological basis for this construct, that the Administration and a majority of Congress wanted people to move away from employer-based health insurance as part of an eventual movement to a federally chartered single-payer regime. Others say that it is just an natural extension of a bill that created important protections — benefit mandates, a floor for medical loss ratios, guaranteed issue, restrictions on medical underwriting — all of which act to increase the cost of insurance products.Continue reading…
Regression to the Mean
You may have heard about the Sports Illustrated Effect, the notion that people who appear on the cover of the magazine are likely to experience bad luck, failure, or a career spiral.
Over the 30 years of my own professional life, I’ve watched many colleagues become famous, receive significant publicity, then fail to live up to the impossible expectations implied by their fame. They regress to the mean. Nature seems to favor symmetry. Things that rise slowly tend to decline slowly. Things that rise rapidly tend to drop rapidly.
Fame is usually a consequence (good or bad) of invention, innovation and accomplishment. Fame itself is generally not what motivates a person to accomplish their feats. An Olympic athlete is usually inspired because of a highly competitive spirit. An inventor is usually inspired because he/she believes there is a better way. Fame that is the consequence of a feat can affect future behavior. It can become an intoxicant and motivate someone to strive for accomplishments that keep the fame coming.
I’ve thought about my own brushes with fame.
When I was 18 and started at Stanford, I realized that my scholarships would only cover the first year of tuition. I visited the Stanford Law library, read the US tax code and wrote software for the Kaypro, Osborne 1, and CP/M computers that calculated taxes. The software shipping from my dorm room generated enough income to start a small company. When the PC was introduced, we were the first to provide such software to small businesses seeking to compute their tax obligations. By the time I was 19, I moved into the home of Frederick Terman, former Provost of Stanford, and the professor who first encouraged William Hewlett and David Packard to build audio oscillators and form a new company called HP. The story of a 19 year old running a software company and living in the basement of founder of HP was newsworthy at the time. I did interviews with Dan Rather, Larry King, and NHK TV Japan.Continue reading…
HIMSS11 Recap
“We just need to do it.” That’s the comment I heard from a hospital CMIO on a HIMSS shuttle bus Thursday morning. He, of course, was talking about “meaningful use,” the standard by which providers will qualify for federal Electronic Health Record (EHR) subsidies. This year’s edition is the first HIMSS conference since the incentive program started in October (for hospitals) and January (for individual providers).
Yet, HIMSS11 was not all about meaningful use. “Meaningful use in some ways fell off the radar,” another CMIO said on the same bus ride. The new buzz—and source of anxiety—is about Accountable Care Organizations.
The healthcare world is waiting nervously for HHS to release its proposed ACO regulations. HHS Secretary Kathleen Sebelius was on hand for a keynote address Wednesday morning, but gave no hint of when the regs might come. Instead, Sebelius and departing national health IT coordinator Dr. David Blumenthal mostly stuck to their general stump speeches, perhaps not wanting to stir up political controversy in this time of divided government.
In some ways, Blumenthal’s presence at HIMSS was notable for something he didn’t show up for. Deputy National Coordinator Dr. Farzad Mostashari, likely to be the interim coordinator when Blumenthal returns to Harvard in April, led the ONC town hall on Tuesday. Mostashari caused some seismic ripples through much of the vendor community on Monday by saying that ONC will be working with the National Institute for Standards and Technology and other organizations in the next six months to find ways to measure EHR usability, and that usability likely will be part of Stage 2 meaningful use, starting in 2013.Continue reading…
Conflicts Of Interest In Guideline Development: A Dirty Little Secret Gets Aired Again
By DAVID WILLIAMS
An Archives of Internal Medicine article (Conflicts of Interest in Cardiovascular Clinical Practice Guidelines) is getting a lot of notice this month. In essence, many of the physicians who develop guideline that influence practice patterns and payment decisions have conflicts. The authors recommend only allowing those without conflicts to write the guidelines.
This isn’t a new issue. In 2006 I wrote a piece (Another dirty little secret is out in the open) and am reposting it below because it’s timely:
A year ago in Time to deal with medicine’s dirty little secrets?, I wrote about a variety of practices that are relatively well-known in the health care field but would be shocking to outsiders. Industry often takes the blame for “aggressive marketing tactics,” and no doubt some of that is deserved. But physicians are also culpable.
The open secrets include the ghostwriting of journal articles by industry sponsors, physicians and academic medical centers holding ownership stakes in companies whose products they are researching, the clinical role sometimes played by orthopedic sales reps, and perhaps the most egregious example: physicians who set guidelines having financial relationships with the companies that benefit from how those guidelines are set.
Now we have a new example, which is even more serious than usual. A recent New England Journal of Medicine article blames Eli Lilly for overzealous promotion of Xigris. According to the Boston Globe:
Eli Lilly and Co. funded medical guidelines created for the treatment of [sepsis] in an effort to boost sales of a drug with questionable benefits. The allegation was made by senior scientists at the National Institutes of Health. [They] said Lilly tried to shape the guidelines for use of the drug Xigris by sponsoring a three-pronged marketing campaign
The first two phases are by now almost standard practice in the industry:
- Lilly paid a task force to spread the word that hospitals were rationing Xigris because of its cost, which forced docs “to decide who would live and who would die”
- Lilly “orchestrated” the development of practice guidelines to treat sepsis that called for early use of Xigris (an example of the phenomenon I have described before)
But then Lilly allegedly took a third step, which was a little shocking even to me:
Now, Lilly is sponsoring lobbying efforts to turn the guidelines into quality standards. Hospitals that follow such quality measures receive higher payment from insurers.
What’s happening here? Basically, an influential group of doctors is being lazy and greedy, and Lilly is enabling their behavior. The doctors put their fingers in the cookie jar and Lilly keeps restocking it. The public is paying for the cookies –in the form of higher product sales and sub-optimal health care– and should get fed up!
I have no problem with companies using legal means to promote their products, even if their tactics are “aggressive.” They owe it to their shareholders to maximize return on investment. But it isn’t in their long-term interest to push things as far as the medical profession often lets them.
Industry leans on the reputations of individual physicians (aka “key opinion leaders”), medical societies (aka guideline writers), and journals to legitimize their marketing messages. It’s up to the medical profession to scrutinize industry claims and issue independent guidelines and quality standards. Sometimes these claims hold up and deserve to be propagated. Sometimes they don’t. If the docs and journals don’t do their jobs they deserve to lose credibility.
It’s hard to know the extent to which medical guidelines are already corrupted. The situation is a bit like the incident when the Chinese President’s plane was refitted. In the process of fixing up the plane someone inserted a bunch of listening devices (presumably at no extra charge). When the Chinese checked out the plane and realized it was bugged they had to rip the whole thing up. That’s something like what is going on within the major payers. They’ve stopped treating journal articles and guidelines as objective and have started doing their own analyses. But do we really want to leave health care decisions just to them?
Here’s some free advice to the different players in health care:
- Industry: Feel free to market your products and services aggressively, but don’t take things too far. If you do you’ll end up killing the goose that lays the golden eggs. No one will trust doctors, guidelines or journals anymore
- Physicians: Remember that pharma and device companies are not stupid. If they spend money supporting your research or sending you to conferences or sponsoring continuing medical education it’s because they expect to get a return on their investment. It’s awfully hard to remain objective in such instances. Your job is to adopt the best medical practices and put the patient first –sometimes that requires expensive new treatments and sometimes old, cheap standbys are better
- Payers: Go ahead and challenge the objectivity of journal articles and guidelines. On the other hand, don’t pretend that low cost is always synonymous with best treatment. Expect physicians to keep you in line on that.
- Patients: You need to look out for yourself. Find a good, honest physician. Take a look at who’s sponsoring the educational materials you receive. Ask your physician about alternative treatments and do some research yourself
What’s Yours Is Actually Mine
By LISA SUENNEN
Imagine someone you barely knew came to your neighborhood and took a picture of you playing with your kids at the park and then turned around and used it in an advertisement to promote a product they developed. How would you feel? Presumably you would be highly perturbed. You might even want to sue them for invasion of privacy. Most likely your case would turn on the violation of your right to publicity, which is, according to the Citizen Media Law Project (CMLP): the right of a person to control and make money from the commercial use of his or her identity. It probably wasn’t illegal for that person to take your picture since you were in a public place, but their use of it in a money-making endeavor changes the rules.
CMLP goes on to say that if someone “sues you for interfering with that right [of publicity]” they “generally must show that you used his or her name or likeness for a commercial purpose. This ordinarily means using the plaintiff’s name or likeness in advertising or promoting your goods or services, or placing the plaintiff’s name or likeness on or in products or services you sell to the public.” In order to be a protected use in that advertising scenario, the photographer would have had to get your permission to use the photograph for that purpose.
I bring this up because I got to thinking about the topic after finishing a terrific book called The Immortal Life of Henrietta Lacks by Rebecca Skloot (Amazon’s Number 1 book of 2010). The book is about a poor black woman from Baltimore who, in the 1950’s, has cancerous tissue removed from her body and, while she goes on to die from the cancer itself, the harvested tissue lives on in perpetuity, becoming the first “immortal” human cell line used in medical research, first by Johns Hopkins and later by the worldwide scientific community.
Henrietta’s cells, called the HeLa cell line, were removed from her with her permission (of course she wanted the cancer out), but the subsequent use of her tissue for research purpose occurred without her permission. And now, more than 60 years later, her cells are still in wide use in scientific laboratories worldwide, producing literally billions of dollars in revenues for those who either packaged and sold the cells for commercial use or used the cells themselves to develop drugs and diagnostics. If that ain’t using someone’s likeness in a product or service you sell to the public, I don’t know what is. And yet Ms. Lack’s heirs were never even informed about the tissue repurposing and they certainly never received a dime in recompense. In fact, according to author Skloot, the family members were contacted to provide additional medical tissue samples to augment the research record and weren’t even told that was the purpose of that exercise. They are understandably a bit perturbed.Continue reading…
THCB @ HIMSS11
This week we’ll be reporting live from HIMSS11 in Orlando. We’ll have backstage access to some of the biggest names at the conference, plus posts by surprise guests.
Coverage from the show is underwritten by Xerox Corporation, with areas of focus including meaningful use and EHRs, Health Information Exchanges and Health 2.0.
Find out more about the partnership here: http://bit.ly/f7vdh8.
What’s In a Word?
By MARK FRISSE
The Health Information Exchange (“HIE”) at HIMSS11 appears noticeably different than the “HIE” of HIMSS past. HIE will be ubiquitous. It is not just a topic for a Sunday session any more. Of the 26 sessions that listed HIE as a topic, only eight were specific to the topic. The dedicated Sunday session seemed informative but predictable. Speakers provided perspectives from the federal government, states, and stakeholders. The session also included a Town Hall Meeting, a treatment of consumer engagement, and – my favorite topic – financial sustainability.
Scratch beneath the surface of most topics, and one may find a bit of HIE. It is central to many strategies including Meaningful Use, e-Referrals, workflow management, regional performance improvement, wired BEACON communities, quality measurement, public health, and it will play a growing role as providers and health plans form new relationships.
Each of the more than 20 sessions that place great emphasis on HIE presents an informative perspective very distinct from all of the others. Each presentation is a small chapter in a book describing the far-larger elephant of health care transformation. Confusion is to be expected; the “exchange” in the term “HIE” has many different meanings.
To some, HIE is a “thing” – a regional organization providing exchange services or a state-level organization either providing similar services or fostering exchange through other means – this a bit like a “stock exchange.” To others, HIE is the act of communicating information from one point to another in hope of providing additional value to the point of decision-making or care. (This is more akin to an auto parts swap meet.) To Clayton Christensen, Jason Hwang, and others, exchange is an economic model for commerce – this model – the facilitated user network – is more like Napster.
As a HIMSS attendee or an interested observer, it is important to keep these various models in mind when walking among the vendor exhibits or attending the scientific sessions. It is important to remember that the Electronic Health Record (EHR) is not simply a “computerized record” as much as it is a communications device operating within a vast and increasingly seamless network of commercial and clinical affairs. With or without health care reform, inevitable and consequential reimbursement changes will be taking place.Continue reading…
